fire department accreditation

Fire Department Accreditation 1

Running Head: FIRE DEPARTMENT ACCREDITATION

Fire Department Accreditation

Reynold Mateo

Yokota Air Force Base, Japan


CERTIFICATION STATEMENT

I hereby certify that this paper constitutes my own product, that where the language of others is set forth, quotation marks so indicate, and that appropriate credit is given where I have used the language, ideas, expressions, or writings of another.

Signed: ________________________________________


Abstract

The problem was the Yokota Fire and Emergency Services Department (YFESD) had not

investigated the benefits of accreditation by the Commission on Fire Accreditation International

(CFAI). Therefore, the ability to seek accreditation could enhance the department to be more

effective and reduce the risk to injury, death, and property damage. The purpose of this research

was to determine if YFESD would benefit from CFAI accreditation. Descriptive research was

employed for this research project. The following research questions were: (a) what are the

benefits of obtaining CFAI accreditation? (b) what, if any, are the steps other Department of

Defense departments followed to become an accredited department? (c) what, if any, are the

problems that could be encountered in obtaining accreditation by the Commission of Fire

Accreditation International? A literature review, interviews with the Fire Accreditation

Managers, and a survey to other DoD fire departments were conducted. Results indicated that

there are many benefits to being an accredited department; examples were, providing

administrators and directors documentation on what a department is doing and how well it is

doing it to organizational pride and recognition. Time constraints, an unclear purpose, lack of

focus and a high turnover of personnel were some of the challenges when pursuing CFAI

accreditation. The recommendations included: (a) obtain the latest edition of the CFAI Fire &

Emergency Service Self-Assessment Manual, (b) assign an Accreditation Manager and send

senior staff members to accreditation workshops, (c) build a network of other accredited fire

departments, and (d) seek CFAI accreditation.


Table of Contents

Certification Statement 2

Abstract 3

Table of Contents 4

Introduction 5

Background and Significance 5

Literature Review 8

Procedures 19

Results 20

Discussion 24

Recommendations 30

References 31

Appendices

Appendix A Accreditation Questionnaire 34

Appendix B Accreditation Questionnaire Results 35

Appendix C List of Fire Department 36

Tables

Table 1: Advantages of the Accreditation of Human Research Protection Programs

Table 2: Benefits of Accreditation

Table 3: Problems/Challenges Encountered


Fire Department Accreditation

The problem was the Yokota Fire and Emergency Services Department (YFESD) had not

investigated the benefits of accreditation by the Commission on Fire Accreditation International

(CFAI). CFAI accreditation has been a topic of serious discussion and debate for several years

within AF (Air Force) Fire Emergency Services. The AF is the only DoD component that does

not mandate CFAI accreditation for its fire departments; becoming accredited is an option for Air

Force fire chiefs to pursue if desired. The Air Force uses the Fire Emergency Services

Assessment Program (Air Force Civil Engineer Support Agency, 2010) and National Fire

Protection Association 1201 (NFPA, 2010) to evaluate Air Force fire departments. However, in

a recent email to all Air Force fire chiefs, the Air Force Fire Chief, Mr. Warner, mentioned that

“all DoD fire departments will eventually have to become CFAI accredited” (personal

communication, November 15, 2010).

The purpose of this applied research project was to determine if the Yokota Fire Emergency

Services Department would benefit from CFAI accreditation. Descriptive methodology was

employed for this research project. The following research questions were used to guide the

study: (a) what are the benefits of obtaining CFAI accreditation? (b) what, if any, are the steps

other Department of Defense departments followed to become an accredited department? (c)

what, if any, are the problems that could be encountered in obtaining accreditation from the

Commission of Fire Accreditation International?

Background and Significance

The Yokota Fire and Emergency Services Department (YFESD) was legally established by

Department of Defense Instruction (DoDI) 6055.6, DoD Fire and Emergency Services Program

(Department of Defense Fire and Emergency Services Working Group, 2006), Air Force Policy


Directive (AFPD) 32-20, Fire Emergency Services (Office of the Civil Engineer, 2003), and Air

Force Instruction (AFI) 32-2001, Fire Emergency Services Program (Fire Protection Council,

2008). DoDI 6055.6 states, “every DoD component shall establish and maintain an installation

fire fighting, fire prevention and emergency services program” (DoD Fire and Emergency

Services Working Group [F & ESWG], 2006, p. 5). The YFESD is a federal installation and is

required to follow Department of Defense and Air Force Instructions. Department of Defense

Instruction 6055.6 directs fire department programs. DoDI states in regards to accreditation,

“Encourage all DoD Component fire departments to achieve and maintain the Commission on

Fire Accreditation International (CFAI) accreditation” (p. 5). All DoD components, except the

Air Force, has selected the accreditation process for application to its fire and emergency

services departments worldwide.

The Air Force does not mandate fire departments to become accredited. The Air Force fire

chief left it up to the fire chiefs at their respective installation to decide if they want to pursue

CFAI accreditation. In addition, the Pacific Air Forces command Fire Chief, Paveligo, stated, “it

is up to an AF fire chief to decide whether or not to pursue accreditation. …some bases may

have an easier time obtaining accreditation than others and some may benefit more from the

process” (personal communication, October 15, 2010). Paveligo continued, “The AF has a

unique culture with military firefighters and their six to seven month deployments to Afghanistan

and Iraq and the high turnover rate when a firefighter relocates to another assignment makes

obtaining accreditation tough” (personal communications, October 15, 2010). The Air Force has

its own self inspection criterion in the form of an AF Self Inspection checklist (Air Force Civil

Engineer Support Agency, 2010) in addition to utilizing National Fire Protection Association


1201 (NFPA, 2010). An installation inspection of each AF Fire Emergency Services Flight is

accomplished on a two-year cycle.

The author, being a new fire chief at Yokota AB, wanted to explore the benefits of CFAI

accreditation and visit options in addition to the AF self inspection program to make the fire

department a better organization. The Yokota Fire Emergency Services Department has never

pursued accreditation so this research provided the forum for such a step.

Given the Air Force culture of using resources wisely and ensuring compliance with

Department of Defense and Air Force Instruction, this research was focused on exploring fire

accreditation as an evaluation process to identify benefits of accreditation and make

recommendations to possibly pursue fire accreditation.

If the problem was not researched, the future impact would be that the YFESD would not

know if they have measured and defined their effectiveness. If the problem is addressed, the

department will be able to explore a nationally, comprehensive fire service evaluation criteria to

better serve the community and reduce the risk to injury, death, and property.

This research was conducted as a required component of the Executive Leadership course in

the NFA’s Executive Fire Officer Program (USAF, 2006). This research project directly relates

to the United States Fire Administration’s operational objective of “to promote within

communities a comprehensive, multi-hazard risk reduction plan led by the fire service

organization” (U.S. Fire Administration, n.d., p. 18). Fire service leaders are responsible for

evaluating the department’s effectiveness. Knowing how well and how efficiently a department

does its job depends on some sort of an evaluation process. In addition, directly related to this

research is the Executive Leadership Course Goal, “The Executive Fire Officer (EFO) will

develop the ability to conceptualize and employ the key processes used by effective executive-


level managers” (NFA, 2005, p. SM 1-3). When exploring a new program, such as accreditation,

EFOs must analyze what characteristics enable leaders to manage transitions successfully (NFA,

2005, p. SM 6-2). Additionally, the Executive Leadership Student Manual (NFA, 2005)

specifically shows the guidelines for successful transitions:

Raise your awareness of when you are in transition, recognize what to hold on to and

what to let go of as you move from then to now to the future, expect the uneasiness of

the in-between stages of transition, expect to be puzzled by the unknowns of the

transition process, and use your competence, confidence, and creativity as you risk

moving to the new--the unknown. (p. 6-8)

Understanding the guidelines for a successful transition can help an organization maneuver

through a change in the organization, such as possibly working towards achieving CFAI

accreditation.

Literature Review

The Benefits of Fire Service Accreditation

Fire accreditation is a progressive and time-proven way of helping department’s evaluate and

improve their overall performance. Fire accreditation will help the department identify

inefficiencies, build on success and improve service delivery. Additional benefits are:

Demonstrates effectiveness and excellence to the community; promotes future excellence

within the community; identifies strengths and weaknesses in the organization; creates

methods or systems for addressing deficiencies; encourages professional growth for both

the department and its personnel, and fosters national recognition by colleagues and the

public. (Target News Service, 2010)


Other organizations also see the benefits of accreditation. Law enforcement agencies believe

accreditation is a progressive and contemporary way of helping agencies evaluate and improve

their overall performance (Office of Public Safety, n.d.). It provides formal recognition that an

organization meets or exceeds general expectations of quality in the field. Accreditation

acknowledges the implementation of policies that are conceptually sound and operationally

effective (Office of Public Safety, n.d.).

Law enforcement agencies further see the benefits of accreditation. Accreditation establishes

a credible framework for evaluating agency practices and procedures; it reduces agency risk and

exposure to lawsuits; it decreases some liability insurance expenditures; it improves law

enforcement community relations; and, it identifies and highlights the capabilities and

competence of the agency. In addition, accreditation furnishes a solid foundation for the agency

to build upon for further progress and it extends agency accountability to the public and elected

officials. Finally, accreditation develops improved methods for providing services to the

community (What is Accreditation, n.d.).

In a hospital setting, the impacts of hospital accreditation on quality of care are numerous.

For example:

Accreditation enables the improvement of patient care; accreditation enables the

motivation of staff and encourages team work and collaboration; accreditation enables

the hospital to better use its internal resources (e.g. finances, people, time, and

equipment); accreditation enables the hospital to better respond to the populations needs;

accreditation is a valuable tool for the hospital to implement changes; and, the hospital’s

participation in accreditation enables it to be more responsive when changes are to be

carried out. (El - Jardali, 2008)


According to The Joint Commission on Accreditation of Health Care Organizations (JCAHO,

2010) the benefits are:

Accreditation strengthens community confidence in the quality and safety of care,

treatment and services. Achieving accreditation makes a strong statement to the

community about an organization’s efforts to provide the highest quality services. It

improves risk management and risk reduction. Joint commission standards focus on

state-of-the-art performance improvement strategies that help health care organizations

continually improve the safety and quality of care, which can reduce the risk of error of

low quality care. (JCAHO, 2010)

The Association for the Accreditation of Human Research Protection Programs (AAHRPP)

see the benefits with accreditation (AAHRPP, 2010). The accreditation process requires

organizations to take a comprehensive look at their human research protection programs

(HRPPs) – to identify and address any weaknesses and to build on their strengths. Table 1

displays some advantages of AAHRPP accreditation.

Table 1

Advantages of Association for the Accreditation of Human Research Protection Programs

_____________________________________________________________________________

_________Advantage_______________________Description___________________________

Assurance of quality Accreditation is evidence of a quality research program.

Improved efficiency, effectiveness AAHRPP requires organizations to take an unprecedented

view of their research protection programs, to make sure

not just that policies and procedures are in place but also

that they are documented and translated into practice.


Government recognition Federal agencies acknowledge the value of accreditation.

Public trust, confidence Prospective participants and the public in general, are

looking to the research enterprise to take responsibility for

ensuring that research is conducted safely and ethically.

Since accreditation is a voluntary, objective measure of

quality, participants are more likely to choose

organizations that have earned the AAHRPP seal.

Note: Advantages of Accreditation (AAHRPP, 2010)

Additionally, schools acknowledge accreditation benefits in the quality of education

(Accreditation Process and Benefits of Accreditation [APBA], n.d.). Accreditation is the tool

used in the United States and around the world, to monitor, assess, and evaluate the standards

and quality of the education a student receives at a college, university, or other institution of

higher learning. Accreditation status shows that a college, university, institution, or program

meets the standards of quality set by the accreditation organization, in terms of faculty,

curriculum, administration, libraries, financial well-being, and student services.

Furthermore, accreditation is an important factor when a college or university is deciding

whether to accept transfer credits from a student’s previous school. Most colleges and

universities will not accept transferred course credits from an institution that has not earned

appropriate accreditation status from an accredited organization (APBA, n.d.). Finally, most

employers prefer to hire job applicants who have gained their education from a college or

university with the appropriate accreditation status. It is also common for states to require that a

college, university, or program be accredited when allowing students to acquire state

professional licensure (APBA, n.d.).


In summary, there are many benefits to organizations resulting from accreditation. Some

examples mentioned were: continuous improvement; improved efficiency and effectiveness;

government/national recognition, and organizational pride.

Process to Become Accredited

As with any journey, a good road map is essential; heading in the right direction makes the

trip much easier. According to Purcell (2005), CFAI’s map is The Fire & Emergency Service

Self-Assessment Manual, which explains the accreditation process in detail. The book is the core

of the accreditation process and provides a roadmap for any department seeking accreditation. It

provides understanding and information needed to make an informed decision. The manual is

divided into defined sections that explain the process well.

Good record keeping plays a big part in the accreditation process. It is essential and should

be a priority for all departments. Data compiled from departmental reports and records are

necessary to complete this process. An efficient record keeping system will enable achieving

accreditation much easier. Without up-to-date records and documentation, it is impossible to

evaluate successes or failures. Poor recordkeeping shows a systemic problem and must be

resolved.

CFAI accreditation, like any process, requires a point-of-contact. An accreditation manager is

that person to see the project through and is responsible for overseeing everything. The

accreditation manager should know the agency very well and be willing to commit the time and

effort needed to get the job done. The accreditation manager will spend many hours on the

project making sure the process is on track and goals are being met. This person should acquire


as much knowledge as possible about accreditation. The accreditation manager should become

the local expert with the ability to find answers and resolve issues regarding the project.

An accreditation team of interested, knowledgeable personnel is put together to research and

write explanations required during the process. The team should set aside enough time for this

difficult and sometimes challenging work. Team members will take on rather large assignments,

so they will need everyone’s support (Purcell, 2005).

Every department striving to receive accreditation must submit a written document to CFAI

that chronicles its programs, plans, and goals based on its self-assessment (CFAI, 2010). The

format is that of a notebook with enough pages to complete a department’s requirement. The

written explanation includes a description of how the department intends to meet particular

criterion and the subsequent performance indicators, an appraisal of how the department handles

that particular issue, and a plan for future consideration.

Validating information is crucial to the process. CFAI’s control method depends on exhibits

(evidence) to support the facts presented in the self-assessment document. The exhibits are the

proof that gives the system creditability. Diligence in this part of the process is key. This phase

requires a department to stay on track and remain organized. Considering the amount of data the

project requires, it is important to collect and log the evidence supporting findings while building

the self-assessment document (Purcell, 2005).

Any creditable process must be reviewed. CFAI assigns peer assessors to conduct a site visit

to validate the documentation presented in the department’s self-assessment document. Peer

assessors examine fire department activities and processes and compare them to the self-

assessment document. The peer assessors understand the accreditation system and how a fire

department works.


CFAI matches assessors with the departments they will be reviewing. The assigned peer

assessor team leader contacts the local accreditation manager and arranges for the peer visit.

Depending on the size of the department, visits may take three or more days.

The department under evaluation is responsible for the assessor’s transportation and other

expenses incurred during their visit. The number of assessors depends on the size of the

department; CFAI determines the assessor team size.

Agency accreditation is a four-phase process. Each step in the program is carefully designed

to guide the interested agency through four phases: (a) registered agency, (b) applicant agency,

(c) accreditation candidate, and (d) accredited agency.

Once all the accreditation requirements are fulfilled, CFAI reviews the peer assessors findings

and acts on their recommendation. The Formal presentation takes place at the next IAFC Fire

Rescue International Conference (Purcell, 2005).

To ensure success through the accreditation process, fire agencies enroll their accreditation

manager and staff in the CFAI workshops to understand how to complete the self-assessment

manual, standards of coverage, and strategic plan. Additionally, once an individual completes

the CFAI workshops, he or she should serve as a peer assessor. Becoming a peer assessor

provides valuable insight on accreditation. It gives an individual the opportunity to witness the

accreditation process in its entirety and to understand what is truly expected of an agency.

Another benefit of being a peer assessor is working with other people who are passionate about

accreditation and making the fire service a better place. Locke (2010) stated:

Peer assessors are an extremely important part of the accreditation process and serving in

this role will only help to make your own organization more prepared. Every


accreditation manager should serve as an assessor prior to their own department’s site

visit; it is the best way to ensure success. (p. 19)

Another avenue to the accreditation process is through consulting firms. The Technical

Advisor Program (Fagan, 2010) serves agencies in facilitation and support for a price to train,

coach and guide agencies through the accreditation process and document requirements. The

Technical Advisor Program offers three services: Community-Driven Strategic Planning

Facilitation, Standards of Cover Facilitation, and Full Self-Assessment Facilitation. Fagan

(2010) highlighted that, “… the agency receiving this facilitation process in its entirety is ready

to go into Candidate status for accreditation” (p. 24).

The accreditation process for the American Association of Museums (n.d.) is similar to the

fire accreditation process. When a museum is ready to pursue accreditation, the museum

downloads an Application Form from the Accreditation Program section of the AAM website,

completes it, and sends it in. The Accreditation Program staff processes and reviews the

application at the close of the established application period. The staff ensures the museum is

eligible and that there are no factors that may prevent or impede its participation in the program.

The Accreditation Program staff notifies the institution regarding its application. If the

museum’s application is accepted, the museum will be assigned a date to start the self-study

process and sends an invoice for the application fee.

During the established start month, the Accreditation Program staff officially initiates the

museum’s review by sending the museum its Self-Study Questionnaire and other necessary

materials and instructions to complete. The Self-Study is a detailed questionnaire, based on the

Characteristics of an Accreditable Museum (AAM, n.d.). It is designed to gather basic

information about all aspects of operations and programs through objective and subjective


questions and supporting documentation. The museum is assigned one year to complete the

Self-Study.

A site visit is scheduled; the peer reviewers who conduct the site reviews are senior museum

professionals who volunteer their time. While on site, the Visiting Committee’s charge is to

observe the institution’s operations and determine whether the museum meets the Characteristics

of an Accreditable Museum and the Accreditation Commission’s Expectations, verify the

accuracy of the contents of the Self-Study, and communicate its findings in writing to the

Accreditation Commission. At the next Accreditation Commission meeting, the Commission

makes a determination on accredited status (AAM, n.d.).

The accreditation process for The Joint Commission on Accreditation of Health Care

Organization (JCAHO, 2010) follows a similar accreditation process. The on-site survey

consists of staff, resident and family interviews, tours, observations, and review of selected

documentation in an effort to understand how the systems are compliant with JCAHO standards.

JCAHO standards address a healthcare organization’s level of performance in specific areas.

The standards do not simply cover what the organization is capable of performing, but what it

actually does. Standards are based on maximum achievable expectations, and sets forth

performance expectations for activities that affect the quality of resident care.

The JCAHO report is left with the organization at the end of the on-site survey. This is the

final report, and will identify any standards that were scored as partial or non-compliant. For

those standards scored as non-compliant, the organizations will have to submit an Evident of

Standards Compliance (ESC) to the Joint Commission within 90 days of completion of the

survey. ESC includes evidence that the organization is now in full compliance with the standard

and quantifiable Measures of Success (MOS) for all partial or non-compliant Elements of


Performance. The Measures of Success will show that compliance has been sustained over time.

Once the Evidence of Standards Compliance and Measures of Success are approved by the Joint

Commission, the organization moves into the accredited decision status.

After the on-site survey, organizations do not receive an overall score or grid element score,

and no scores are shared with the health care organization. The final accreditation decision will

be made after The Joint Commission receives and approves an organization’s Evidence of

Standards Compliance submission and its Measures of Success (JCAHO, 2010).

In summary, the accreditation process is similar to various agencies where it has a third party

quality endorsement on the agency’s service, assuring high quality, and continuous improvement

performance. In Fire organizations, CFAI workshops, peer assessor training and a Technical

Advisor Program are provided to assist departments in the accreditation process.

Fire Accreditation Challenges

Fire accreditation cannot be taken lightly and is not an easy task. Following the self-

assessment, a team of outside experts conducts a peer review to validate the self-assessment and

make recommendations for improvement. There are ten major categories in the self-assessment

model: (a) Governance and administration, (b) Assessment and planning, (c) Goals and

objectives, (d) Financial resources, (e) Programs, (f) Physical resources, (g) Human resources,

(h) Training and competency, (i) Essential resources, and (j) External system relationships. Of

these categories, several agencies find assessment and planning to be the most challenging

(Jones, 2007).

Standards of response coverage is another area agencies have found challenging. Completing

this part of the process requires the agency to address the issue of service levels. The agency

must be prepared to deliver a level of service equal with its responsibilities, risks and adopted


service-level objectives. The key elements of standards of response coverage include an

overview of the agency’s current legal jurisdiction, responsibilities and deployment capabilities.

Standards of response coverage also require an assessment of response time and on-scene

performance expectations (Jones, 2007). In an article in Fire Chief, IAFC Staff (1999)

explained, “Accreditation takes a lot of work. …It would be foolish to think that a process

covering such a broad range of services and programs would be simple and easily completed”

(¶ 1). IAFC Staff also mentioned, “The largest amount of time required to prepare your

organization for accreditation is the self-assessment process” (¶ 2). Purcell (2005) mentioned,

“Accreditation cannot be taken lightly and is not an easy task. …This unique program is an all-

inclusive evaluation requiring a great deal of team and effort; our department spent more than

600 staff hours in this process” (p. 93). Purcell (2005) continued with, “In our department,

participation was the most important aspect of accreditation…” (p. 93). In an article of the

Navy’s Fire and Emergency Services Newsletter, Fagan (2010) stated, “Because the application

of the CFAI model requires significant work at accomplishing the required criteria for

accreditation, agencies may turn to consulting firms for assistance…” (p. 22). Jones (2007)

continued with, “Standards of response coverage is another area agencies have found

challenging” (¶ 13). The CFAI website also mentioned challenges for some departments which

include: time constraints, lack of focus, high turnover, and unclear purpose (CFAI Accreditation

Process, n.d.).

In summary, fire accreditation is not an easy task. The self-assessment and standards of cover

documents are time consuming. Other challenges identified are time constraints, lack of focus,

high turnover and unclear purpose.


Procedures

This is a descriptive research project to investigate the benefits of fire accreditation by the

Commission on Fire Accreditation International. The research project consisted of interviews

with accreditation managers who have extensive knowledge on the fire accreditation process and

questionnaires to DoD departments regarding accreditation.

Interviews were conducted with Denny Heitman, Fire Chief, Fire and Emergency Services

Department at Charleston Air Force Base, SC (personal communication, September 27, 2010).

Chief Heitman was selected for his extensive background in accreditation. Chief Heitman’s

opinions are important since he obtained accreditation recently. The purpose of the interview

was to obtain the answers to the research questions. Additionally, an interview with Scott Avery

(personal communication, October 19, 2010), accreditation manager at the O’Fallon Fire

Protection District, MO was conducted for his knowledge and understanding of the accreditation

process. Battalion Chief and accreditation manager Mr. Leonard Sarsona (personal

communication, October 2, 2010) Joint Base Pearl Harbor – Hickam Navy federal department

was another interviewee. His department also recently received accreditation status. Their

opinions are important to this research since they have all been involved in the accreditation

process at various levels. The purpose of the interviews was to determine the answers to the

research questions.

Along with the interviews, a questionnaire (Appendix A) was conducted using DoD

accredited departments. The questionnaire was developed by examining the research questions,

and then determining how to appropriately phrase the questions so as to not bias the results. The

reason for selecting these departments was that they were federal fire departments who were

accredited. In addition, the accreditation managers had first-hand knowledge of accreditation


benefits, the accreditation process, and were able to identify any challenges with obtaining

accreditation. The questionnaire was distributed to DoD fire agencies: Air Force, Army and

Navy. The questionnaire was sent to the deputy director of Headquarters Naval Fire and

Emergency Services office with a request that he forward the questionnaire to each accredited

federal fire department. A list of agencies that responded is provided in Appendix C. All

together, seven fire departments provided input to the questionnaire (see Appendix B). The

results of the questionnaire are in Appendix B and presented in the Results section.

Limitations and Assumptions

This research paper has a few limitations. One limitation is that the research is in a military

setting and lacked diversity. Specifically, the questionnaire was limited to only federal fire

departments. In addition, another limitation was that only a small number of federal

department’s are accredited; however, of the questionnaires that were returned, the data captured

was very useful in the research project. Another limitation was the fact that interviews were

conducted with individuals who belonged to accredited departments and were prone to provide

only positive comments on accreditation. Interviewees were not aware of other department’s

culture that could affect a department from becoming accredited.

For this research project, it was assumed that results captured from the interviews were honest

and deliberate in nature since the chief officer’s have a strong interest in CFAI accreditation.

Further, it was assumed that the questionnaires returned were answered objectively and without

bias.

Results

The research questions were answered using interviews of accreditation program managers and a questionnaire to Department of Defense fire departments regarding fire accreditation.


Research Question (a) asked: What are the benefits of obtaining CFAI accreditation? Interviews

were conducted with fire accreditation managers to glean the benefits of accreditation. Chief

Heitman (personal communication, September 27, 2010) from Charleston Air Force Base, SC,

stated: “Being an accredited agency brings credibility to our department, it focuses on evaluating

department performance, and it provides a good model to run any fire department organization.”

Accreditation Manager, Scott Avery (personal communication, October 19, 2010), identified

benefits to firefighters, municipal partners, citizens, elected officials, and to business partners.

Benefits to firefighters were: “better equipment, improved facilities … increased transparency

with communications.” Mr. Avery continued with, “…benefits to our Municipal Partners are

positive grants, budget justification data … provides a clear view of strengths and weaknesses.”

Mr. Avery further explained the benefits to citizens, “improved safety, stability of service …

makes them feel like stakeholders.” In an interview with the Accreditation Manager of Joint

Base Pearl Harbor - Hickam fire department, Battalion Chief, Mr. Sarsona (personal

communication, October 22, 2010), stated, “accreditation brings creditability of our fire

department at the national level and it provides us the recognition as being a top level

department.”

Questionnaires were distributed to DoD fire departments regarding accreditation. The

number of accredited DoD fire departments are low. The Navy is the lead agency in pursuing

accreditation and has funded their departments to pursue and obtain accreditation. On the other

hand, the Air Force is encouraged to pursue and obtain accreditation. Of the seven

questionnaires received (see Appendix B), all seven departments checked the benefits listed on

the questionnaire. In the “Other” block, additional benefits were added by the respondents. A

few examples of the additional benefits are, “accreditation allows other fire chiefs to give your


department a detailed look, a great tool to assess your department and ensure compliance, and

provides framework for anyone to start a department and can be applied to all sizes, types of

departments” (see Appendix B). In Table 2, it is shown that all seven DoD accredited fire

departments see many benefits in being accredited.

Table 2 Benefits of Accreditation Benefits of Accreditation Number Times Item Checked Percentage of Survey Pool Promotes Excellence 7 100% Quality Improvement 7 100% Defined Mission & Objectives 7 100% Detailed Evaluation 7 100% Other(s) Note: Data assimilated from 7 questionnaires received from accredited fire departments In summary, through the interviews and questionnaires, there are numerous benefits for the

firefighters, departments and citizens of an accredited department.

Research Question (b) asked: What, if any, are the steps other Department of Defense

departments followed to become an accredited department? In an interview with Chief Heitman,

“order the current accreditation manual, get department buy in and commitment, and apply to

become accredited” (personal communication, September 27, 2010). Chief Heitman continued

with, “once applied, this will start the time required to complete the process … work all your

documents, and then request a site visit.” In an interview with Mr. Avery, “our process took

about 22 months from registering, applying, becoming a candidate, having a site visit and

eventually becoming accredited (personal communication, October 19, 2010). In another

interview, Mr. Sarsona stated, “…utilize the accreditation manual and follow the process to


register your department and get accredited. … have your accreditation manager and team attend

the Self Assessment, Peer Assessor and Standards of Cover Workshop … it’ll prepare your

agency for accreditation” (personal communication, October 22, 2010).

In the questionnaire, question 2: “What were your steps to become accredited?” All seven

departments checked all the steps listed (see Appendix B) on the questionnaire to become

accredited. Based on the data captured, it is clear that all the departments used the same

procedures to become accredited. However, in the “Other” space, respondents added comments

stating that agencies should pursue the CFAI Self Assessment, Peer Assessor and Standards of

Cover Workshops to assist in becoming accredited. In addition, appointing an accreditation

manager was another comment mentioned in becoming accredited.

Research Question (c) asked: What if any, are the problems that could be encountered in

obtaining accreditation by the Commission of Fire Accreditation International? Chief Heitman

stated, “It is time consuming getting all your paperwork done … you have to get your

department to understand the process” (personal communication, September 27, 2010).

According to Mr. Avery, “The hardest thing was getting the buy-in from the guys the first time

through” (personal communication, October 19, 2010). In an interview with Mr. Sarsona, “…

working towards accreditation is time consuming … lost our focus at times throughout the

accreditation process due to competing priorities” (personal communication, October 22, 2010).

The questionnaire sought to identify the problems/challenges encountered pursuing fire

accreditation (see Table 3). Question #3 of the questionnaire provided some insights into the

challenges accredited departments faced. Table 3 provides a look at how the challenges were

scored.


Table 3 Problems/Challenges Encountered Problems/challenges Number Times Item Checked Percentage of Survey Pool Time Constraints 4 57% Lack of Focus 3 43% High Turnover 3 43% Unclear Purpose 4 57% No Buy-in from Department 2 29% Other (s) Note: Data assimilated from 7 questionnaires received from accredited departments It was shown that time constraints and unclear purpose were the challenges checked the most.

In the “Other” space, respondent’s added additional challenges (see Appendix B). A few

comments mentioned were: lack of effort from department managers, short-term vision, and

limited buy-in.

In summary, the interviews and questionnaires indicated that time constraints, educating

firefighters, unclear purpose, embracing accreditation, and working against competing work

priorities were some of the challenges encountered by the accredited fire departments.

Discussion

Information from the literature review, personal interviews, and questionnaire suggested that

obtaining CFAI has many benefits to the department management, firefighters and the

community. However, there are challenges when seeking to become an accredited fire

department.

The first goal of this research project was to search out the benefits of accreditation. In an

interview with Chief Heitman, “Accreditation provides a good model to run any fire department


organization, it focuses on evaluating department performance, many other progressive

departments are seeking accreditation and being an accredited agency brings credibility to your

department” (personal communication, September 27, 2010). In an article in Fire Chief, IAFC

Staff (1999) listed numerous benefits of accreditation: “promotes excellence … offers a forum

for the communication of organizational needs, both internally and externally, and fosters pride

in the organization when it’s recognized as a department committed to continuous quality

improvement and excellence” (¶ 7). According to Purcell (2005), “…this process will help your

agency identify inefficiencies, build on successes, and improve service delivery. …Achieving

accreditation is an important milestone in an organization’s development and is particularly well

suited for the fire service (p.93). Purcell continued with, “The willingness to open your

department up to outside scrutiny indicates a genuine commitment to excellence and a yearning

for continued improvement. …This journey will make all of our departments better and the

communities they serve safer” (p. 97). In another article in Fire Chief, Jones (2007) stated,

“…any fire service agency can assess itself and support an organizational culture of continuous

improvement” (¶ 3). Bruegman and Coleman (1997) highlighted another benefit of

accreditation, “…provides fire departments the opportunity to take an in-depth look at their

organization and its operations, utilizing a standardized approach. … holds real promise for

enhancing the credibility and professional standing of our fire service” (¶ 8).

Other organizations such as schools and hospitals recognize the benefits of accreditation,

which provides specific evidence of their effectiveness and of the contributions they make to

their communities. In addition, in schools, “Accreditation status indicates that a college,

university, institution, or program meets the standards of quality set by the accreditation

organization, in terms of faculty, curriculum, administration, libraries, financial well-being, and


student services” (Accreditation Process and Benefits of Accreditation, n.d.). Accreditation

benefits are also seen in hospitals. Benefits of JCAHO (2010) accreditation include:

“Strengthens community confidence in quality and safety of care, treatment and services,

provides competitive edge in the marketplace … recognized by select insurers and other third

parties” (p. 2).

The results of the DoD accreditation questionnaire (see Appendix B) supported the benefits of

fire accreditation. Of the four accredited fire departments that responded, all mark the benefits

listed on question #2. In the “Other” space, additional benefits were listed by the respondents

(see Appendix B). As it is shown in the literature review and in Appendix B, there are numerous

benefits to becoming an accredited department; as such, a national accreditation program

provides agencies in becoming goal-oriented, forward-looking, well-organized, properly

equipped and trained and provides a methodology for continually evaluating and improving

services.

The second goal was to look into the steps of becoming an accredited department. In an

interview with Chief Heitman, “Order the current edition of the accreditation manual, apply to

become accredited, work all your documents, and then request the site visit” (personal

communication, September 27, 2010). Purcell (2005) informs us that the CFAI’s Fire &

Emergency Service Self-Assessment Manual explains the accreditation process in great detail.

The book is the core of the accreditation process and provides a road map to achieve

accreditation (p. 94). Purcell (2005) also stated that there are workshops available from the

CFAI to assist those departments pursuing accreditation (p. 96). Purcell (2005) further explained

the four-phase process for agency accreditation. The phases identified were: (a) registered

agency, (b) applicant agency, (c) accreditation candidate, and (d) accredited agency (p. 98). In


an interview with Mr. Sarsona, “attending the CFAI Self-Assessment, Basic Standards of Cover

workshops and becoming a Peer Assessor will help a fire organization achieve accreditation.”

(personal communication, October 22, 2010). Furthermore, Locke (2010) believed peer

assessors are an extremely important part of the accreditation process. Additionally, every

accreditation manager should serve as an assessor prior to their own department’s site visit; it is

the best way to ensure success (p. 19). Fagan (2010) talked about how the Technical Advisor

Program has served to assist numerous agencies in their journey to accreditation. The three

program services offered by the Technical Advisor Program are the Community-Driven Strategic

Planning Facilitation, Standards of Cover Facilitation, and the Full Self-Assessment Facilitation.

The agency receiving this facilitation process in its entirety is ready to go into Candidate status

for accreditation (p. 24). In the September 2010 Navy’s Fire and Emergency Services

Newsletter (Commission on Fire Accreditation International, 2010) Chief Thompson stated,

“…many members from all ranks were involved from the start and were the key to success. …

the Commanding Officer was on-board with the department’s efforts from the beginning and has

supported the accreditation initiative throughout” (p. 16).

The accreditation process in hospitals consist of an on-site survey of staff, resident and family

interview tours, observations, and review of selected documentation in an effort to understand

how the systems are compliant with JCAHO standards (2010). For those standards scored as

non-compliant, the organization will have to submit Evidence of Standards Compliance (ESC) to

the Joint Commission within 90 days of the completion of the survey. ESC includes evidence

that the organization is now in full compliance with the standards and quantifiable Measures of

Success (MOS) for all partial or non-compliant Elements of Performance. The final

accreditation decision will be made after The Joint Commission receives and approves an


organization’s Evidence of Standards Compliance submission and its Measures of Success

(JCAHO, 2010). Schools comply with the following process for accreditation: preparation and

self-examination, peer review, visit and examination, judgment action made by accreditation

organization, and continuous review. Accreditation organizations are held accountable for the

colleges, universities, and other institutions to which they grant accreditation status

(Accreditation Process and Benefits of Accreditation, n.d.). In addition, the questionnaire to the

other federal accredited fire departments reaffirmed the steps of becoming an accredited

department where all respondents checked the steps to become accredited. In the “Other” space,

five departments added attending the workshops offered by CFAI helped them to become more

knowledgeable on their journey to accreditation.

The third goal was to explore the problems and challenges encountered pursuing

accreditation. In an article in Fire Chief, IAFC Staff (1999) explained, “Accreditation takes a lot

of work. …It would be foolish to think that a process covering such a broad range of services

and programs would be simple and easily completed” (IAFC, 1999). IAFC Staff also mentioned,

“The largest amount of time required to prepare your organization for accreditation is the self-

assessment process.” Purcell (2005) mentioned, “Accreditation cannot be taken lightly and is

not an easy task. …This unique program is an all-inclusive evaluation requiring a great deal of

team and effort; our department spent more than 600 staff hours in this process” (p. 93). Purcell

(2005) continued with, “In our department, participation was the most important aspect of

accreditation…” (p. 93). In an article of the Navy’s Fire and Emergency Services Newsletter,

Fagan (2010) stated, “Because the application of the CFAI model requires significant work at

accomplishing the required criteria for accreditation, agencies may turn to consulting firms for

assistance…” (p. 22). In an interview with Chief Heitman, “… initially it is time consuming


getting all your paperwork done” (personal communication, September 27, 2010). Jones (2007)

highlighted that, “…a number of agencies find assessment and planning to be the most

challenging.” Jones (2007) continued with, “Standards of response coverage is another area

agencies have found challenging.” The CFAI website also mentioned challenges for some

departments which include: time constraints, lack of focus, high turnover, and unclear purpose

(CFAI Accreditation Process, n.d.).

The questionnaire to the accredited departments indicated that time constraints and an unclear

purpose were the most challenging; however, lack of focus and a high turnover of personnel

were also a challenge to the accreditation process. “Our process took about 22 months…” (S.

Avery, personal communications, October 19, 2010).

In summary, there are many benefits to accreditation from providing administrators and

directors documentation on what a department is doing and how well it is doing it to

organizational pride and recognition. The accreditation process is the same across the many

professions that have an accreditation program where an external quality review was used for

quality assurance and quality improvement. The challenges can be many when working any new

program; however, staying focused while keeping the momentum going will greatly increase the

chances of achieving accreditation.

The DoD (Department of Defense Fire and Emergency Services Working Group, 2006)

encourages its fire service components to pursue accreditation, all DoD fire departments has

selected the accreditation process for application to its fire and emergency services worldwide,

except the Air Force. The Air Force (Fire Protection Council, 2008) encourages their

departments to pursue accreditation but it is not mandated. The DoD and AF fire departments

that are accredited are proud of their accomplishments and rave about its benefits.


Recommendations

As a result of this applied research project, the following recommendations were made to

consider pursuing CFAI accreditation: First, order the latest edition of the CFAI Fire &

Emergency Service Self-Assessment Manual to enhance understanding and become better

educated in the accreditation process.

Second, assign an Accreditation Manager and visit the CFAI website for workshops being

offered in the near future. Send the Accreditation Manager and senior staff members to the

workshops so key leaders may understand what accreditation is all about and have them

champion the accreditation process to the rest of the department members.

Third, build a network of fire department chiefs that have already obtained CFAI

accreditation. Use the network to communicate with chiefs on lessons learned as they worked

through their journey to accreditation.

Fourth, seek CFAI accreditation. The Navy and Army has mandated their departments to

pursue accreditation and Air Force leadership has encouraged their departments to seek

accreditation. The research showed that there are numerous benefits, and very little negatives,

except for devoting a lot of time, to becoming an accredited department.

In summary, the Yokota Fire Emergency Services Department should take action to

implement the recommendations mentioned. Although the AF has a self-inspection program

becoming accredited with an evaluation program that is nationally recognized should make the

department more credible, stronger and recognizable.


Reference List

Accreditation Process and Benefits of Accreditation. (n.d.). Retrieved July 27, 2010 from

http://www.worldwidelearn.com/accreditation/accreditation-process-benefits.htm Air Force Civil Engineer Support Agency. (2010). AF self inspection checklist. American Association of Museums. Steps in the Process. (n.d.). Retrieved 30 July, 2010 from

http://www.aam-us.org/museumresources/accred/process.cfm Association for the Accreditation of Human Research Protection Program. (2010). The Benefits

of Accreditation. Retrieved July 27, 2010 from http://www.aahrpp.org.www.aspx?PageID=12

Bruegman R. R., Coleman R. J. (1997, March 1). The commission on fire accreditation international: A look to the future. Fire Chief. Retrieved September 21, 2010 from

http://www.fireengineering.com/index/articles/display/59589/articles/fire-engineering/

Commission on Fire Accreditation International. (2010, September). MCLB Barstow F & ES

becomes accredited. Navy Fire & Emergency Services Newsletter, p. 16. Commission on Fire Accreditation International Accreditation Process (n.d.). Retrieved October

22, 2010 from http://www.publicsafetyexcellence.org/agency-accreditation/the- process.aspx

Department of Defense Fire and Emergency Services Working Group. (2006). DoD fire and emergency services program. Department of Defense Instruction 6055.6, p.5 El – Jardali F. (2008, June). The impact of hospital accreditation on quality of care: perception of Lebanese nurses. Oxford Journals. Retrieved September 27, 2010 from

http://www.intqhc.oxfordjournals.org/content/20/5/363.full

http://www.aam-us.org/museumresources/accred/process.cfm�

http://www.aahrpp.org.www.aspx/?PageID=12�

http://www.fireengineering.com/index/articles/display/59589/articles/fire-engineering/�

http://www.publicsafetyexcellence.org/agency-accreditation/the-�

http://www.intqhc/�


Fagan R. (2010, November). Achieve excellence without breaking the bank. Navy Fire & Emergency Services Newsletter, p. 24. Fire Engineering (2010, August 31). Record number of fire departments receive

accredited/reaccredited status. Retrieved September 22, 2010 from

http://www.fireengineering.com/index/Articles/display/0250377134/articles/ Fire Protection Council. (2008). Fire emergency services program. Air Force Instruction 32-2001, p. 9. IAFC Staff (1999, September 1). In accreditation, trip is as important as destination.

Retrieved September 20, 2010, from http//firechief.com/mag/firefighting_accreditation_trip_important/index.html

Joint Commission. (2010, August 16). Benefits of Joint Commission Accreditation.

Retrieved October 9, 2010, from http://www.jointcommision.org/HTBAC/benefits_accreditation.html.

Joint Commission on Accreditation of Health Care Organizations. (April 5, 2010).

Retrieved July 28, 2010 from http://hospaa.org/?p=347 Jones, C. (2007). Credibility check. Fire Chief. Retrieved July 28, 2010 from

http://firechief.com/leadership/firefighting_credibility_check/index.html

Locke, S. (2010, December). The benefit of becoming a CFAI peer assessor. Navy Fire &

Emergency Services Newsletter, p. 19. National Fire Protection Association 1201. (2010). Standards for providing emergency services to the public. Quincy, MA. National Fire Protection Association. Office of the Civil Engineer. (2003). Fire emergency services. Air Force Policy Directive 32-20.

http://www.fireengineering.com/index/Articles/display/0250377134/articles/�

http://hospaa.org/?p=347�

http://firechief.com/leadership/firefighting_credibility_check/index.html�


Office of Public Safety. (n.d.). Retrieved September 27, 2010 from

http://criminaljustice.state.ny.us/ops/accred/index.htm Purcell, W. (2005, March). Understanding the fire department accreditation process. Fire

Engineering, Retrieved July 28, 2010 from http://www.fireengineering.com/index/ Articles/display/227751/articles/fire-engineering/volume-158/issue-3/features/ Understanding-the-fire-department-accreditation-process.html

Targeted News Service (2010, August). Roseville Fire Department is reaccredited by the Commission on Fire Accreditation International. Fire Engineering. Retrieved August 28,

2010 from http://www.fireengineering.com/index/articles/Wire_News_Display/1253472147.html

United States Fire Administration. (2005, October). Executive leadership. Executive Leadership-

Student Manual. p. SM 1-3, SM 6-2, SM 6-8. United States Fire Administration. (2006, October). Executive development. Executive Development-Student Manual. U.S. Fire Administration. (n.d.). Retrieved December 21, 2010 from

http://www.usfa.dhs.gov/downloads/pdf/strategic_plan.pdf What is Accreditation (n.d.). Retrieved September 27, 2010 from

http://www.pachiefs.org/accreditation2.htm

http://www.fireengineering.com/index/�

http://www.usfa.dhs.gov/downloads/pdf/strategic_plan.pdf�

http://www.pachiefs.org/accreditation2�


APPENDIX A Fire Accreditation Questionnaire

1. What are the benefits of accreditation? _____Promotes excellence _____Encourages quality improvement _____Assures organization has defined mission objectives & strives to meet them _____Provides for detailed evaluation _____Others___________________________________________________________________ 2. What were your steps to become accredited? _____Becoming a registered agency _____Becoming an applicant agency _____Becoming a candidate for accreditation _____Achieving accreditation _____Others___________________________________________________________________ 3. What are some of the problems/challenges encountered pursuing fire accreditation? _____Time Constraints _____Lack of focus _____High turnover _____Unclear purpose _____No buy in from department _____Others___________________________________________________________________


APPENDIX B Fire Accreditation Questionnaire Results

1. What are the benefits of accreditation? __(7)___Promotes excellence __(7)__ Encourages quality improvement __(7)___Assures organization has defined mission objectives & strives to meet them __(7)___Provides for detailed evaluation ________Others: Provides a template for effective department management; validates department performance through objective analysis; permits a no-cost option for consultants to provide improvement measures; promotes higher level of confidence from mutual aid partners; great tool to assess your department and ensure compliance; provides framework for anyone to start a department; can be applied to all sizes, types of departments; allows other fire chiefs to give your department a detailed look as well; ensures the organization is being led in a manner consistent with nationally accepted practices for a contemporary fire service agency. 2. What were your steps to become accredited? __(7)___Becoming a registered agency __(7)___Becoming an applicant agency __(7)___Becoming a candidate for accreditation __(7)___Achieving accreditation _____ Others: All agencies must go through these four steps to obtain accreditation; all of the above; appoint an accreditation manager; pursue CFAI self-assessment, peer assessor and standards of cover workshops. 3. What are some of the problems/challenges encountered pursuing fire accreditation? __(4)___Time Constraints __(3)__ Lack of focus __(3)___High turnover __(4)___Unclear purpose __(2)___No buy in from department _______Others: For us, it was time – not having enough time was NOT the issue, instead, making the time for what was important was our perceived obstacle. We overcame that by setting goals and ensuring we maintained momentum (and focus). Lack of effort from department managers, short term vision. Limited buy in, lack of selling knowledge. Look into the process and have your most influential individual sell the program to your department.


APPENDIX C List of Accredited Federal Fire Departments

1. United States Air Force Academy Fire Emergency Services Department, CO 2. Navy Region Northwest Fire and Emergency Services Department, CA 3. Charleston Air Force Base, Fire Emergency Services Department, SC 4. Hill Air Force Base, Fire Emergency Services Department, UT 5. Joint Base Pearl Harbor – Hickam, HI 6. Langley Air Force Base, Fire Emergency Services Department, VA 7. Security and Emergency Services Division, Defense Logistics Agency, San Joaquin

fire department accreditation

Documents