Pending letter ballot, the revised 2006 Guidelines for Design and Construction of Health Care Facilities by the American Institute of Architects (AIA) and Facility Guidelines Institute (FGI) will be completed and available in March 2006.
Formerly known as the Guidelines for Design and Construction of Hospital and Health Care Facilities, the new revision is the result of countless hours spent by the health guidelines revision committee (HGRC), a group of leading architects, engineers, authorities having jurisdiction and health care professionals that have been considering revisions, additions and clarifications to the 2001 version.
While the process was still under way at press time, the revisions are certain enough to provide this overview.
New for 2006
Among the most notable changes in the 2006 edition, the single-bed modification for general medical-surgical units is a major accomplishment for patient advocates, infection control professionals and clinicians and will certainly attract a great deal of industry attention. This new guideline does not apply to behavioral health, pediatrics, intensive care, rehabilitation and similar units, which can maintain multibed configurations.
The FGI, parent organization of the HGRC, funded research prior to the HGRC proposing a minimum standard of single-bed patient rooms. The HGRC looked at issues such as initial costs, operating costs, infection control, privacy, patient falls and therapeutic impact.
The final proposed language reads as follows: “In new construction, the maximum number of beds per room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement. Approval of a two-bed arrangement shall be obtained from the licensing authority.” In this context, “necessity” means considerations such as therapeutic value, economic issues or practicality issues such as rural or limited urban site conditions, any of which require approval from the authority having jurisdiction. “Where renovation work is undertaken and the present capacity is more than one patient, maximum room capacity shall be no more than the present capacity, with a maximum of four patients.”
In this context the design of a major renovation of an existing floor could continue to include multipatient rooms even though other aspects of the design would need to meet new construction requirements. This permits the organization to update patient units without losing existing licensed beds.
There are also significant changes aimed at helping professionals navigate the guidelines. Specifically, the revised edition will be divided into four parts: “General Considerations,” “Hospitals,” “Ambulatory Care Facilities” and “Other Health Care Facilities.” Health care programs covered will be placed in a section with similar facility types, rather than presented in the order in which they were added to the book.
The reference also includes additional infection control risk assessment guidelines. This risk-defining and reduction chapter encourages multiagency/provider cooperation for better patient care in acute general hospital or outpatient settings. New language clearly makes the owner responsible for monitoring and evaluating the renovation or new construction. Language has also been added to mandate the assessment of existing mechanical systems prior to adding ductwork.
The HGRC also added language to reflect several other key issues for hospitals, including patient safety, Leadership in Energy and Environmental Design (LEED), privacy and confidentiality, safety and security. The guidelines still require handwashing stations to be placed in all patient bathrooms and bedrooms; however, in renovation, if existing spatial (clear floor area) conditions prohibit the installation of a sink, waterless cleaners may now be substituted.
In addition, some units now fall under expanded guideline recommendations. For example, in new construction of critical care units, bed clearances for adult and pediatric areas shall be a minimum of 4.5 feet at the foot of the bed to the wall, 5 feet on the transfer side, 4 feet on the nontransfer side and 8 feet between beds. In-hospital skilled nursing units require spaces for living, dining and recreation at 25 square feet per bed. In new construction of LDR and LDRP rooms, the guidelines increase the clear floor area from 250 to 300 square feet. There were also minor changes made to intermediate care units, surgical suites, PACUs, phase II recovery rooms and observation units.
The guidelines on outpatient facilities include changes to space requirements as well. The size of typical exam/treatment rooms for general purpose is 80 square feet, special purpose (such as eye, nose, etc.) is 80 square feet, treatment rooms are 120 square feet and observation rooms are 80 square feet. A Class A operating room is increased from 120 to 150 square feet with 12 foot clear dimension. Additional changes include rewriting the standards for endoscopy suites, and changes to outpatient PACUs and requirements of phase II recovery rooms.
A “Small Inpatient Primary Care Hospital” chapter has also been added to the guidelines. The purpose of the small inpatient primary care hospital is to provide a community-focused, short-term overnight stay environment designed to provide primary care to the patient population within a designated rural or underserved community.
An evolutionary process
The guidelines change to keep pace with evolving health care needs and in response to requests for up-to-date guidance from providers, designers and regulators. It is recognized that many health care services may be provided in facilities not subject to licensure or regulation, and it is intended that these guidelines be suitable for all health care providers. It is also intended that some latitude be granted in complying with these guidelines when used as a regulation as long as the health and safety of the occupants of the facility are not compromised.
In some facilities, areas or sections, it may be desired to exceed the guidelines standards for optimum function. For example, door widths for inpatient hospital rooms are noted as 3 feet 8 inches, which satisfies applicable codes to permit the passage of patient beds. However, wider widths of 3 feet 10 inches may be desirable to reduce damage to doors and frames when beds and large equipment are moved frequently. The decision to exceed the standards should be made part of the health care facility’s functional program.
The guidelines and the methodology for revising them have been, and still are, an evolutionary process. When first published, they were a set of regulations developed by a single department of the federal government as a condition to receive a federal hospital construction grant under the Hill-Burton Act. Even in those early days, the document was highly respected and influential throughout the world. From the time it was first issued and enforced, U.S. hospitals have become the ideal and the goal to be achieved by professionals building hospitals in all nations.
Gradually, state hospital authorities and other federal agencies were added to the HGRC, then private, nongovernmental health care professional societies, practitioners and designers.
Educational programs and seminars were introduced in the 1980s to inform the public about the subjects addressed in the guidelines and the reasons behind inclusion of certain requirements. Over the past three editions, public input was requested by the committee in the form of proposals and comments on proposed changes. This public review process has now exploded into the current avalanche of proposals and comments. In each succeeding cycle, the committee membership has been expanded to increase the base of expertise and to allow for more public representation. Further, the consensus procedure was adopted for all decision-making.
The need for a more formal and expeditious process became mandatory as the process became more complex, the committee grew larger, more public input was used and health care delivery began to change at an increasing rate. Adding to the complexity was the expansion in the scope of the document from exclusively covering acute-care general hospitals to including nursing homes, rehabilitation centers, ambulatory care facilities, psychiatric hospitals, mobile health care units, hospice care, assisted living and other facilities.
It is the desire of the HGRC to continue working in its relationship with the AIA and for FGI to make certain the guidelines and the revision process continues in a responsive manner. The HGRC does, however, wish to maintain its independence as an objective, multidisciplinary committee, operating without pressure from any organization and arriving at conclusions candidly, fairly and knowledgeably through the consensus process.
The American Society for Healthcare Engineering (www.ashe.org) and the AIA Academy of Architecture for Health (www.aia.org/aah) will be sponsoring several workshops on the guidelines and the 2006 revisions beginning in June 2006.
Joseph G. Sprague, FAIA, FACHA, FHFI, is senior vice president and director of health facilities in the Dallas office of HKS Architects Inc., an international design firm specializing in health care facilities. He is the chairman for the AIA 2006 Guidelines for Design and Construction of Health Care Facilities and is president of the Facility Guidelines Institute. He can be contacted via e-mail at firstname.lastname@example.org.
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