ASHE Fire Safety
Compliance Toolkit
Resources and best practices from the American Society for Health Care Engineering
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:
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:
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.
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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Discussion (3)
ASHE membership has been the single best investment for our safety program. The template library alone saved us hundreds of hours — pre-built ILSM policies, PCRA forms, fire drill documentation templates, and above-ceiling inspection checklists. Instead of building everything from scratch, we customized ASHE templates to fit our facility and had a survey-ready program in weeks instead of months.
The ASHE Fire Safety Week materials are incredibly useful for staff engagement. We use their posters, quiz sheets, and presentation decks every October. It gives us a structured way to reinforce fire safety training without our safety team having to create all the content. Staff retention of fire safety procedures jumped measurably after we started using their materials consistently.
ASHE resources combined with facility-specific training create the strongest compliance programs we see. We recommend using ASHE templates as your foundation and then layering in site-specific details like your actual smoke compartment maps, fire alarm zone lists, and evacuation routes to make the training tangible for staff.
The ASHE online learning platform has solid courses on medical gas systems, electrical safety, and emergency power — topics that PE chapter standards require but many safety officers don't feel confident teaching. The CE credits are a bonus. I require all my facilities team members to complete at least two ASHE courses per year as part of their professional development.