Fire Department Accreditation 1
Running Head: FIRE DEPARTMENT ACCREDITATION
Fire Department Accreditation
Reynold Mateo
Yokota Air Force Base, Japan
Fire Department Accreditation 2
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: ________________________________________
Fire Department Accreditation 3
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.
Fire Department Accreditation 4
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 5
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
Fire Department Accreditation 6
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
Fire Department Accreditation 7
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-
Fire Department Accreditation 8
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)
Fire Department Accreditation 9
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)
Fire Department Accreditation 10
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.
Fire Department Accreditation 11
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.).
Fire Department Accreditation 12
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
Fire Department Accreditation 13
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.
Fire Department Accreditation 14
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
Fire Department Accreditation 15
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
Fire Department Accreditation 16
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
Fire Department Accreditation 17
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
Fire Department Accreditation 18
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.
Fire Department Accreditation 19
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
Fire Department Accreditation 20
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.
Fire Department Accreditation 21
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
Fire Department Accreditation 22
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
Fire Department Accreditation 23
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.
Fire Department Accreditation 24
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
Fire Department Accreditation 25
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
Fire Department Accreditation 26
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
Fire Department Accreditation 27
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
Fire Department Accreditation 28
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
Fire Department Accreditation 29
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.
Fire Department Accreditation 30
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.
Fire Department Accreditation 31
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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
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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
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accredited/reaccredited status. Retrieved September 22, 2010 from
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Locke, S. (2010, December). The benefit of becoming a CFAI peer assessor. Navy Fire &
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Fire Department Accreditation 33
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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___________________________________________________________________
Fire Department Accreditation 35
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.
Fire Department Accreditation 36
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