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ASHE Fire Safety
Compliance Toolkit

Resources and best practices from the American Society for Health Care Engineering

By Stanislav Samek, Samektra · 9 min read · Last updated April 23, 2026

What Is ASHE?

The American Society for Health Care Engineering (ASHE) is a professional membership group of the American Hospital Association (AHA) with over 14,000 members. ASHE serves healthcare facility managers, safety officers, plant operations directors, and compliance professionals who are responsible for the physical environment of hospitals, nursing homes, and ambulatory care facilities ASHE Guidelines.

ASHE is the leading source of practical tools, templates, and guidance for healthcare fire safety and life safety compliance. While NFPA writes the codes and TJC/CMS enforces them, ASHE bridges the gap between code language and real-world implementation. ASHE does not write standards or conduct surveys — instead, it provides the resources that facility teams need to meet those standards day-to-day.

Key ASHE Resources for Fire Safety

ASHE publishes an extensive library of templates, guides, and training materials. The following are the most critical for fire safety compliance:

ILSM Templates and Policy Guides

ASHE provides ready-to-use templates for documenting Interim Life Safety Measures. These templates include the 11 ILSMs defined by NFPA 101 §4.6.10, implementation checklists, daily verification forms, and sign-off sheets. The ASHE ILSM policy template is widely regarded as the industry standard and is accepted by both TJC and CMS surveyors as evidence of a compliant ILSM program.

The template covers: ILSM triggers, notification procedures, staff training requirements, fire watch protocols, daily inspection checklists, and resolution documentation. Facilities that adopt the ASHE template and customize it to their operations are significantly less likely to receive ILSM-related citations during surveys.

LSRA Forms and Guidance

The ASHE Life Safety Risk Assessment form provides a structured approach to evaluating life safety deficiencies. It includes a risk matrix (impact vs. severity), deficiency categories, recommended ILSMs for each risk level, and documentation fields. The form is designed to be completed by the facility safety officer or a multidisciplinary safety team.

ASHE guidance emphasizes that the LSRA is not a one-time document — it must be reassessed whenever conditions change, new deficiencies are identified, or construction phases shift. The LSRA should be a living document with regular review dates.

Fire Drill Documentation

ASHE provides fire drill planning worksheets, scenario templates, critique forms, and tracking spreadsheets. Proper fire drill documentation is one of the most commonly deficient areas in healthcare surveys. The ASHE fire drill critique form captures all elements required by TJC PE.02.03.01:

  • Date, time, shift, and building location
  • Scenario description (location and type of simulated fire)
  • Staff response: R.A.C.E. execution, time to alarm, time to contain
  • Participant count and roles
  • Areas for improvement and corrective actions
  • Follow-up training needs identified

PCRA/ICRA Templates

ASHE provides Pre-Construction Risk Assessment and Infection Control Risk Assessment templates that align with TJC PE.01.02.01 requirements. These templates include the ICRA matrix (construction activity type vs. patient risk group), barrier class requirements, daily inspection checklists, and post-construction sign-off forms. The ASHE PCRA packet is considered the definitive resource for healthcare construction risk management.

Healthcare Fire Safety Week

ASHE coordinates Healthcare Fire Safety Week, an annual awareness campaign held each October. The program provides healthcare facilities with turnkey resources to educate staff, conduct drills, and reinforce fire safety culture:

  • Promotional materials: Posters, flyers, digital signage content, and badge cards with R.A.C.E. and P.A.S.S. reminders
  • Training modules: Pre-built presentations and short videos for department-level training sessions
  • Drill scenarios: Realistic fire drill scenarios with facilitator guides and evaluation criteria
  • Quiz materials: Fire safety knowledge assessments for staff competency verification
  • Executive summaries: Templates for reporting Fire Safety Week activities to hospital leadership and boards

Participation in Healthcare Fire Safety Week demonstrates a proactive safety culture — something TJC surveyors look for during accreditation surveys. Many facilities incorporate Fire Safety Week activities into their annual PE chapter compliance calendar.

ASHE-Recommended Compliance Calendar

ASHE recommends a structured annual compliance calendar to ensure no fire safety requirement falls through the cracks. The following schedule covers the major recurring requirements:

FrequencyTask
MonthlyFire extinguisher visual inspections; emergency/exit light 30-second functional test; fire door operational check (close and latch properly)
QuarterlyFire drills (each shift, each building); fire alarm supervisory signal testing; generator load testing (30 minutes); sprinkler valve inspection
Semi-AnnualFire alarm sensitivity testing; fire pump flow test (if applicable); emergency/exit light 90-minute battery test
AnnuallyFire door inspection per NFPA 80; fire alarm system annual testing; sprinkler system annual inspection and flow test; fire extinguisher maintenance; smoke barrier inspection (including above-ceiling); generator 4-hour load bank test; fire safety evaluation
Every 3 YearsBuilding assessment (triennial); generator load-reactive test; fire pump full-flow suction test
Every 4-6 YearsSmoke damper testing per NFPA 105 (every 4 years general, every 6 years hospitals)
Every 5 YearsSprinkler system internal inspection of pipes; fire pump performance evaluation; standpipe flow test

Common Deficiencies and ASHE Best Practices

ASHE tracks the most commonly cited deficiencies from CMS and TJC surveys and publishes best-practice guidance to address them. The top recurring deficiencies and ASHE’s recommended fixes include:

Fire door latching failuresImplement a monthly door rounding program. Train clinical staff to report door problems. Budget for annual NFPA 80 inspections by a qualified inspector.
Corridor clutter and storageEstablish a clear corridor policy with zero tolerance for permanent storage. Conduct weekly safety rounds. Provide designated alcoves or rooms for equipment staging.
Missing or incomplete fire drill documentationUse the ASHE fire drill critique template. Assign a drill coordinator for each building/shift. Maintain a central drill log that is reviewed quarterly by the safety committee.
Above-ceiling penetration deficienciesImplement an above-ceiling permit program for all contractors. Inspect all above-ceiling work before closing tiles. Conduct an annual above-ceiling walk-through of all fire and smoke barriers.
ILSM not implemented during impairmentsAutomate ILSM triggers — integrate with the work order system so any fire protection impairment automatically generates an ILSM assessment. Train all facilities staff on ILSM procedures.
Expired fire extinguishersContract with a licensed fire extinguisher service company for monthly inspections and annual maintenance. Use a tracking system with expiration alerts.

ASHE’s Partnership with TJC and CMS

ASHE maintains active partnerships with both The Joint Commission and CMS to ensure its resources reflect current survey expectations:

  • TJC collaboration: ASHE regularly consults with TJC on PE chapter updates, provides feedback during standards revision cycles, and hosts joint educational sessions at its annual conference. TJC surveyors frequently reference ASHE publications as acceptable compliance documentation.
  • CMS engagement: ASHE participates in CMS rulemaking processes, submits comments on proposed regulations, and disseminates CMS S&C letters with practical interpretation guidance for its members.
  • NFPA technical committees: ASHE members serve on NFPA technical committees for NFPA 101, NFPA 99, and other healthcare-relevant standards, ensuring that real-world facility management perspectives are represented in code development.
  • Education and certification: ASHE supports the Certified Healthcare Facility Manager (CHFM) credential through the American Hospital Association and provides continuing education programs that address PE chapter compliance, life safety management, and healthcare construction safety.

Getting Started with ASHE

ASHE membership is available to individuals and organizations through the American Hospital Association. Members gain access to the full template library, advisory services, webinars, and the ASHE annual conference — the largest gathering of healthcare facility professionals in the United States. Many resources, including basic fire safety templates and Fire Safety Week materials, are available at no cost through www.ashe.org.

Frequently Asked Questions

What is ASHE and who does it serve?
The American Society for Healthcare Engineering (ASHE) is the premier professional society for healthcare facility managers, safety officers, clinical engineers, and construction professionals. ASHE is a division of the American Hospital Association (AHA) and is the authority behind many healthcare-specific compliance guidance documents, templates, and training programs. Membership is open to healthcare facility professionals and affiliates.
Do I need to be an ASHE member to use ASHE templates?
Most substantive ASHE resources (PCRA/ICRA templates, ILSM policies, fire drill documentation, above-ceiling inspection forms, the Health Facilities Management magazine archive) require ASHE membership. Some public-facing guidance, comment letters to CMS, and conference proceedings are available to non-members. The membership cost is often justified by one template that saves a safety officer a week of drafting work.
What are ASHE certifications and how do they rank?
ASHE offers three certifications in progressing depth: CHC (Certified Healthcare Constructor) for design/construction professionals, CHFM (Certified Healthcare Facility Manager) for operations leaders, and CHSP (Certified Healthcare Safety Professional) through IHI/IBHS partnership. CHFM is the most widely recognized credential for healthcare facilities directors and is frequently required for senior roles at CMS-participating hospitals.
What is the ASHE Pre-Construction Risk Assessment template?
ASHE publishes a comprehensive PCRA template that covers the full life-safety-plus-infection-control risk matrix required for healthcare construction. The template includes fire protection impairments, egress impacts, utility shutdowns, ILSM selection guidance, and a signature block for multidisciplinary team sign-off. Using the ASHE template as a starting point is the fastest path to a survey-ready PCRA program.
How is ASHE different from TJC, CMS, or NFPA?
TJC and CMS are REGULATORS — they write standards and conduct surveys. NFPA is a STANDARDS DEVELOPER — it writes codes like NFPA 101 that regulators enforce. ASHE is a PROFESSIONAL SOCIETY — it interprets the regulatory and standards environment for its members and produces practical guidance, training, and advocacy. ASHE publishes guidance on HOW to comply with TJC and CMS expectations; it does not set the requirements.
Does ASHE Fire Safety Week count toward TJC fire training requirements?
ASHE Fire Safety Week (each October) provides staff-engagement materials — posters, quiz sheets, PowerPoint decks — but it does not by itself satisfy TJC fire response training requirements (EC.02.03.03 / LS.01.01.01). The Fire Safety Week content is most effective as a reinforcement layer on top of formal annual training. Document attendance at Fire Safety Week activities as supplemental engagement, not as the primary training record.

References

1. ASHE: American Society for Health Care Engineering — www.ashe.org.

2. ASHE: Healthcare Fire Safety Week Resources, annual program materials.

3. The Joint Commission: Physical Environment (PE) Chapter, Comprehensive Accreditation Manual.

4. CMS State Operations Manual, Appendix I — Life Safety Code Survey.

5. NFPA 101: Life Safety Code, 2012 Edition.

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