Building code consensus

The International Code Council (ICC) is considering code changes that will affect health care facilities across the country — potentially helping facilities with streamlined regulations that keep patients and staff safe.

The end result will be determined by future ICC votes, and those involved in health facilities management are urged to make their voices heard now to give input and help educate building officials about the specific needs of complex health care facilities.

"It's critical for people to get involved while there is still time to influence the codes being considered," says Chad Beebe, AIA, SASHE, director of codes and standards for the American Society for Healthcare Engineering (ASHE). "Those in health care facility management need to speak up while we have a chance to change things. The codes being worked on now will become the 2015 International Codes, and if we don't get it right now, we will have to wait until the 2018 edition to get problems fixed."

Keeping up-to-date

Updating codes and standards is especially important in health care because rapid technological and policy changes have vastly improved health care safety in the decades since many code provisions were written. The widespread adoption of quick-response sprinklers, no-smoking policies and other precautions have made hospitals very safe. Yet, older codes may not recognize these developments, leaving health care facilities to deal with outdated, overlapping and conflicting codes.

ASHE estimates that the health care industry spends billions of dollars a year dealing with these issues, and advocates for more unified codes point out that every dollar spent on unnecessary codes is a dollar not spent on patient care.

"We've plateaued at a level of safety where adding more regulations doesn't necessarily improve patient safety," Beebe says. "In fact, wasting money on unnecessary regulations uses resources that could otherwise improve patient care."

Recognizing this problem, ASHE partnered with the ICC last year in an effort to reduce the complexity and duplication in codes affecting health care facilities while assuring the highest level of safety for patients, employees and others. The ICC created an Ad Hoc Committee on Health Care — a group comprising fire officials, architects, building officials, hospital leaders, facilities managers and engineers — to develop a series of recommended building code changes for health care facilities.

The Ad Hoc Committee worked throughout 2011 to create proposals for codes included in the ICC's 2012 code revision cycle, including the International Building Code. The committee is also working on proposals included in the upcoming 2013 revision cycle, including the International Fire Code. Both the 2012 and 2013 revision cycles will result in the 2015 edition of the International Codes, commonly called the "I-Codes."

ICC's current focus

The ICC's current focus is the 2012 revision cycle. Public proposals for this cycle were due in January and the Ad Hoc Committee submitted several proposals affecting health care.

The proposals were heard at code development hearings from April 29 to May 8 in Dallas, with code committees voting on whether to approve, approve with modifications or disapprove each proposal. The ICC posted a report from the public hearing on June 8 and is accepting public comments until Aug. 1. Final action hearings are scheduled for Oct. 24-28 in Portland, Ore., and the final vote on whether or not to change the code rests with the ICC governmental member representatives.

Many proposals from the Ad Hoc Committee won approval at the code development hearings in Dallas. For example, one proposal from the committee would split the occupancy covering hospitals and nursing homes into two separate classifications — one for short-term care facilities including hospitals and another for long-term care facilities such as nursing homes. The change reflects the differences in care between the two types of facilities that have developed over recent decades, and that change was approved.

In addition to testifying in favor of proposals at the code development hearings, Ad Hoc Committee members also spoke against proposals that would be unfavorable to hospitals. For example, one proposal was aimed at requiring enough shelter space for all building occupants in case of tornadoes or hurricanes. Ad Hoc Committee members noted that the well-meaning proposal would have been nearly impossible for hospitals to comply with — unless they took the unusual and expensive step of building a hospital-sized shelter underground. That proposal was disapproved.

Ad Hoc Committee Chairman John Williams, CBO, plans reviewer for the Washington State Department of Health, says the Ad Hoc Committee had a good success rate for its proposals. But several of the committee's proposals won approval with modifications or were disapproved, so there is still more work to be done. "The process is going well and we're getting a lot of feedback," Williams says.

Committee Vice Chairman Jeffrey O'Neill, AIA, ACHA, senior project manager at the University of Pennsylvania Health System, says comments from the ICC code committee members and from others testifying at the meeting will help the Ad Hoc Committee refine its proposals.

"We've learned a lot from this discourse," O'Neill says. "We're going to get together and go through each proposal and figure out the next steps. We've got a lot more work to do."

Complex environments

Several Ad Hoc Committee members said that one of the biggest challenges to proposals affecting health care facilities is an underestimation of the complex hospital environment and the record of safety success found in health care facilities.

For example, Beebe says that research shows hospitals do not need as many smoke dampers as are currently required, but some representatives from the industry manufacturing these devices are pushing for more smoke dampers or the elimination of exceptions to smoke damper requirements. At the recent code development hearings, the Ad Hoc Committee's proposals to reduce the number of smoke dampers failed, but proposals to expand smoke dampers won approval. Beebe says hospitals need to explain to building code officials the record of hospital success and the extremely limited number of fires that are not contained in their room of origin.

The National Fire Protection Association released a report in January that reported the annual averages of structure fires in various occupancy types from 2006 to 2010. Hospitals, including medical and psychiatric hospitals, made up just 0.3 percent of the total fires reported, and hospitals recorded no fatalities.

Another complicated subject that is not always easily understood is the use of defend-in-place techniques in health care facilities. Hospitals have been using defend-in-place techniques for decades, but it can be an unusual concept to building officials who have little experience dealing with hospitals or other health care facilities.

"Many building officials don't have a hospital in their jurisdictions, and many small jurisdictions don't have a lot of health care projects — if they do it's just once or twice a year," Williams says. "Defend-in-place isn't the first thing on their minds given that it's such a drastic change from traditional procedures."

Williams points out that defend-in-place relies on many different precautions, including active and passive protection, routine inspections and a highly-trained staff that is regularly drilled on emergency procedures.

Beebe says it's imperative for members of the health care community to meet with local ICC members and building officials and explain the concept of defend-in-place and the training that staff members receive to ensure that it works. That way building officials can see that proposed code changes relying on defend-in-place make sense and will keep hospital patients, staff and visitors safe.

At the recent ICC code development hearings, it became obvious that the concept of defend-in-place is not well-known or understood outside of the health care community. One building official compared hospital staff to the Costa Concordia cruise ship captain who was accused of abandoning ship before all the passengers had been evacuated. The building official cited this alleged neglect of duty to question whether hospital staff could be relied on to carry out their duties during a fire.

Everyone in the health care community knows that the idea that hospital staff would abandon patients or flee during an emergency is like insinuating that firefighters would run away from a burning building or police would flee the scene at the sound of shots being fired, Beebe says. Recent emergencies have shown how hospital staff members go above and beyond in following emergency procedures and caring for patients. When a deadly tornado hit a hospital in Joplin, Mo., last year, nurses huddled over patients as windows were blown out, protecting them from harm. When a fire broke out in the basement of a New York City hospital last year, staff followed horizontal evacuation procedures to keep patients — including those in emergency departments and critical care units — safe inside the hospital but away from smoke. In both emergencies, staff intervention helped to save lives.

Ad Hoc Committee member David Howard, director of facilities and construction at Penrose-St. Francis Health Services in Colorado Springs, Colo., says it's up to members of the health care community to see that building officials are educated and up-to-date about precautions taken by health care facilities.

"Defend-in-place is not popularly understood," Howard says. "We've understood it for decades now, but we've got to get out to the authorities in our communities so they can understand how we're constructed, how we operate, and how we train our staff on a continual basis. We're going to be there for our patients."

Getting involved

Health care facility managers are urged to get involved in the ICC code development process so they can help shape the next generation of codes affecting health care facilities.

Deanna Martin is senior communications specialist for the American Society for Healthcare Engineering. She can be reached at dmartin@aha.org