Treat RACE and PASS as policy mnemonics, not code text
Hospital RACE fire response training should operate within the facility’s governing fire-safety program. The federal hospital Condition of Participation at 42 CFR §482.41 addresses the physical environment and life safety from fire. CMS identifies the 2012 edition of NFPA 101 as the Life Safety Code incorporated for covered providers, subject to regulatory exceptions. These authorities—not a mnemonic by itself—establish the controlling compliance framework.
A commonly taught version of RACE is Rescue or Remove, Alarm, Contain or Confine, and Extinguish or Evacuate. PASS commonly means Pull, Aim, Squeeze, and Sweep. The official sources supplied for this draft do not establish those exact words as mandatory code language. Hospitals should confirm the approved wording, sequence, and decision points against their fire response policy, governing authorities, accreditor expectations, and equipment instructions.123
Turn RACE into a hospital-specific response sequence
The training should explain what each RACE step means in the hospital’s actual environment. The rescue or removal step should address immediate danger without directing employees to enter conditions beyond their training. The alarm step should identify approved alarm activation, internal notification, and escalation methods. Containment should address actions such as closing doors when safe. The final step must resolve whether the hospital uses “extinguish,” “evacuate,” or both and explain when each action is appropriate.
A role matrix can prevent the mnemonic from becoming an unrealistic one-size-fits-all instruction. Clinical staff, security personnel, facilities teams, operators, and designated responders may have different responsibilities. The matrix should identify who initiates patient movement, who communicates with responders, who manages building systems, and which personnel may attempt extinguisher use. Those assignments require confirmation from hospital leadership and applicable emergency procedures.138
Set safe boundaries for PASS extinguisher use
PASS describes a commonly taught operating sequence: pull the pin, aim at the base of the fire, squeeze the handle, and sweep from side to side. It should not be taught as an instruction that every employee must fight a fire. The hospital must define who is expected or authorized to use an extinguisher and when evacuation, containment, or another response takes priority.
Before attempting extinguisher use, training should require staff to apply hospital-approved stop conditions. Practical criteria to validate include whether the alarm has been initiated, the person has received applicable training, the extinguisher is appropriate, the fire remains within the limits defined by policy, and a safe exit path remains available. Equipment-specific instruction should be checked against the extinguisher manufacturer’s directions rather than inferred from the acronym alone.
Extinguisher education should also connect to the hospital’s broader fire-protection inspection and testing checklist so staff understand the difference between operating equipment during an emergency and maintaining or documenting the fire-protection program.138
Connect RACE to the hospital’s compartment strategy
NFPA 101 addresses new and existing health care occupancies through Chapters 18 and 19 of the CMS-incorporated 2012 edition. Hospital fire response may depend on compartments, protected openings, horizontal exits, suites, and means-of-egress arrangements. RACE training should therefore reflect the approved life safety drawings and emergency procedures rather than assuming immediate whole-building evacuation.
Staff should know the initial movement destination assigned to their unit, which doors support the response strategy, and how occupants needing assistance will be moved. Units with different clinical or physical conditions may require different procedures. Those procedures should be coordinated through documented life safety planning and validated against the building’s current configuration.3529
Teach alarm, door, and locking interfaces
The alarm step should cover the hospital’s approved activation and notification process, including what staff are expected to do after receiving a signal. Training should match the installed system and local policy; it should not assume that every building, campus, or unit has the same alarm sequence or notification method.
Containment instruction should explain why doors may be important to the fire and smoke strategy while avoiding unsupported claims that every door has the same rating or function. Where a unit uses special locking, delayed-egress, or sensor-release arrangements, staff training should match the approved system response and emergency release procedures. A separate guide to healthcare delayed-egress and sensor-release locking systems can support that system-specific instruction.358
Separate fire response from impairment and fire-watch duties
RACE addresses immediate fire response, while an impairment is a condition in which a required feature, system, utility, or item of equipment cannot perform its intended function. Hospitals should teach these subjects separately so employees do not mistake routine RACE knowledge for authorization to initiate, supervise, or discontinue an impairment procedure.
A fire watch is a temporary compensatory measure using assigned personnel to patrol affected areas when directed by applicable procedures and authorities. Personnel assigned to this role need instructions covering their area, communications, escalation, documentation, and termination authority as locally defined. The hospital’s temporary fire-protection impairments and fire-watch decision path should be incorporated into role-specific training rather than compressed into the RACE acronym.3589
Measure competency through hospital scenarios
Attendance alone does not show that an employee can apply the procedure. A scenario-based competency check can ask participants to identify the immediate hazard, select the approved alarm method, describe containment actions, state whether extinguisher use is appropriate, and identify the correct movement or evacuation route.
Scenarios should reflect the hospital’s actual policies without creating unverified facility facts. Useful variables can include an occupied patient area, a closed door, an alarm notification, an impaired fire-protection feature, or an obstructed preferred route. Observers should use an approved checklist and record missed steps, coaching, and any required reassessment.
The supplied evidence does not establish a universal RACE or PASS training frequency. Initial orientation, refresher training, drills, and reassessment intervals should be set using the hospital’s governing requirements, accreditation program, risk assessment, and policies.1689
Maintain survey-ready training and corrective-action records
CMS Life Safety Code survey procedures include preparation, information gathering, analysis, and post-survey activity. A defensible training record set can identify the policy version taught, intended audience, completion date, instructor or delivery method, competency method, scenario results, exceptions, remediation, and approval history. This is a recommended governance structure, not a claim that every listed field is universally mandated.
Records should connect training to the underlying hospital procedure and any affected life safety drawings, alarm instructions, impairment plans, or unit-specific movement plans. If a survey finding results in retraining, the hospital should link that action to the applicable deficiency, plan of correction, responsible party, completion evidence, and follow-up monitoring. Form CMS-2567 is used to record deficiencies and cross-reference the provider’s plan of correction.6579
Frequently asked questions
Is the RACE acronym specifically required by CMS for hospitals?
The supplied federal and CMS sources establish hospital fire-safety and Life Safety Code requirements but do not identify RACE itself as the mandatory acronym. A hospital may use RACE as a training tool, provided the approved wording and actions match its governing requirements, emergency procedures, and jurisdictional expectations.123
What do RACE and PASS commonly stand for?
RACE is commonly taught as Rescue or Remove, Alarm, Contain or Confine, and Extinguish or Evacuate. PASS is commonly taught as Pull, Aim, Squeeze, and Sweep. The supplied authorities do not establish these exact expansions as controlling code language, so the hospital should verify its approved terminology and equipment instructions before publication.138
How often should hospital staff complete RACE and PASS training?
The supplied evidence does not establish one universal interval for these mnemonic-based courses. The hospital should determine initial, refresher, drill, and reassessment frequencies from applicable regulations, the adopted code, current accreditation requirements, local authority instructions, risk assessments, and organizational policy.1298
Should every hospital employee be trained to use a fire extinguisher?
Do not assume every employee has the same extinguisher role. The hospital should define role-based expectations, authorized users, stop conditions, evacuation priorities, and competency methods. PASS training should not imply that an employee must attempt suppression when conditions or policy call for containment, movement, or evacuation.138
Can a hospital use the 2024 edition of NFPA 101 to update its training?
A hospital may review a newer edition as a source of recommendations, but it should not represent the 2024 edition as the CMS-incorporated requirement unless the governing authority has adopted it for that purpose. CMS identifies the 2012 edition for covered providers, subject to regulatory exceptions. State, local, and accreditation requirements must also be verified.2341
What records should support RACE fire response training during a survey?
A practical record set may include the approved policy and version, assigned audience, completion records, competency method, drill or scenario results, remediation, and links to relevant emergency procedures. Survey teams may gather and analyze facility information, but the exact requested documents depend on the survey authority and current program requirements.659