Surveyor Notes: Emergency Evacuation Drills

By Rick Miller, CO, FAAOP, Surveyor

As an ABC Facility Accreditation Surveyor for over ten years, I’m often asked by businesses of all sizes for tips on how to be compliant with the most missed accreditation standards. Surprisingly, facility safety standards are often the ones most frequently found to be in ‘Noncompliance’, particularly Emergency Evacuation Drills. Conducting these drills tends to be more of an issue for smaller facilities with smaller staffs, or large facilities with multiple exits. Facility owners frequently brush it off with comments such as, “Why should I worry about conducting and documenting an evacuation drill? It’s just the two of us and there’s the door!” Large facilities sometimes claim they are too busy. Not a great excuse.

I wanted to get an expert opinion on the matter, so I turned to my local Fire Chief, Eric Kerska from the Rochester, MN Fire Department. “To put simply, evacuation drills are important so we can save lives,” says Kerska. I think we can all agree with that! And, that’s why emergency evacuation drills are a critical element of ABC’s accreditation standards.

Since the beginning of the accreditation program, it’s been a required standard for every facility to have an evacuation plan, including posted exit route maps, and to conduct a documented emergency evacuation drill at least once annually that includes all staff on all shifts. Beyond being a requirement, drills can lead to saving valuable seconds in a real emergency, which can ultimately save lives or minimize destruction of property.

If your business has the misfortune of experiencing an actual emergency that results in injury or tragic loss of life, failure to have conducted and documented required emergency procedures can result in additional legal entanglement and financial jeopardy. In short, paying attention to the details where safety is concerned is not only the right thing to do; it’s also good for business. The importance of emergency drills should come as no surprise to anyone, yet some facilities continue to overlook this requirement. Let’s take a look at how creating a good emergency plan can help you stay compliant.

Essentials of an Emergency Evacuation Plan

You should focus on incorporating the following items in your Emergency Evacuation Plan for all of your office/clinic locations.

Communication channels

  • Who will take charge in an emergency situation?
  • How is the order to evacuate given to everyone in the facility?
  • Is there an alarm system, and are there specific instructions regarding its use?
  • Who will make an accurate head count of all persons that should have exited the structure?

It is critical that these questions be considered and answered before an actual emergency, in order to minimize the amount of chaos that would be exacerbated by poor communication in a crisis situation. Knowing how many employees and patients are in an O&P facility is important at all times. The fire department will need to know if everyone is accounted for and has been evacuated. They will need to know if they are putting out a fire or implementing search and rescue to save lives. As you might imagine, those are two very different approaches to an emergency, and seconds count. Chief Kerska adds, “We really need someone who knows the building and knows how many people are inside and any special considerations such as people with mobility issues.” He continues, “We need that person to meet us as we arrive so that we can prioritize where we send our people to do the most good.” Communication channels should be accurately described in your plan, and key persons responsible for an effective evacuation need to be named.

Escape routes

These are the floor plan maps that surveyors expect to see when visiting your facility during an onsite survey. They must be easy to interpret and guide someone with little knowledge of your building to the nearest exit as well as alternative exits. Evacuation maps should be posted inside fitting rooms and restrooms, at major hallway intersections and other locations to help minimize confusion or delay in exiting the facility.

Meeting places

Meeting places are a critical component of a successful evacuation and also takes in to account that your location may have multiple exits. All employees must know the location of the meeting place and the importance of gathering there after evacuation. If anyone is missing from a headcount at the meeting place, it must be assumed that they are trapped inside and in need of rescue.

Emergency lighting and signage

This may vary with the size and type of the building and your local codes. According to Chief Kerska, it is wise to check with your local fire department, who would be happy to assist you in determining proper lighting and signage for your facility.

Coordination of emergency teams

The larger the facility, the more critical this becomes. If the O&P department is part of a large medical complex or hospital, it becomes necessary to function in harmony with others who are responding to the same emergency and possibly following conflicting instructions (such as shelter-in-place). It is important to understand the focus of other departments in an emergency situation, and drills can help identify potential issues that need to be resolved in advance of an actual emergency.

Comprehension of alerts

Your staff should understand and react quickly to the signal to evacuate. It may also be helpful in some settings to alert adjacent tenants in a multiple-use building, such as a strip mall location. Focus on those closest to the risk first, then assist others to evacuate safely.

Emergency equipment

This includes fire extinguishers that are properly serviced and have been recently inspected. Check manufacturer’s recommendations, and always use the proper class of extinguisher for the location. It’s a good idea to check all of the fire extinguishers at your facility, as the fire retardant can settle to the bottom. Simply turn them over and shake well until the key ingredient has been equally distributed. Also, check to make sure that the pressure gauge is in the green range and there has been no breakage of parts around the handle and seal. It is good practice to replace any fire extinguishers that are too old.

In addition, your location may have an automatic sprinkler system. Make sure that you are aware of when it was last serviced and that it is in working condition.

If you have additional equipment such as Automatic Electronic Defibrillators, your staff should be properly trained in its use.


There is never a bad time to conduct an evacuation drill, but some times are better than others. Avoid July in Phoenix and February in Minneapolis, because your staff (and patients) might not appreciate it, and it’s probably best not to conduct an evacuation drill during severe weather. Since all personnel on all shifts must participate in a documented emergency evacuation drill at least annually, it is best to maximize your timing to include all personnel. Use common sense to choose times that will be the least disruptive to your business and a time that will result in a reasonable focus on the evacuation itself.

Nobody expects the worst to happen, yet the simple truth is that emergencies and disasters can strike anyone, anytime and anywhere. Your facility could be forced to evacuate when you least expect it. Having participated in an evacuation drill does not prevent an emergency from happening; but an effective evacuation during an emergency could prevent a tragic loss of life. Be prepared!

For more information and lots of helpful tips, check out OSHA's "How to Plan for Workplace Emergencies and Evacuations." And don’t forget! The ABC Resource Pack includes a Fire/Emergency Drill Form for you to document all of your successful drills.

Special thanks to Chief Eric Kerska of the Rochester, MN Fire Department.

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