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ASHE works with the International Code Council Ad Hoc Healthcare Committee on such issues as building code proposals.


One of the most important responsibilities of a health care facility manager is keeping the physical environment in compliance with the various codes and standards that regulate hospitals.

The advocacy team at the American Society for Healthcare Engineering (ASHE) works in two ways to help members meet their responsibilities to help create and maintain safe, healing environments.

ASHE works directly with code development and enforcement organizations to help create more unified codes and standards, and also provides compliance resources and tools to help members keep their hospitals in compliance.

Advocacy update

By becoming involved with a variety of regulatory agencies and standards-writing bodies, ASHE’s advocacy team continuously works to improve the regulations and codes affecting health care facilities. ASHE’s work with the following four key organizations provides some examples:

Federal Communications Commission. In August, the Federal Communications Commission (FCC) adopted new rules that will allow unlicensed devices to operate on the same Wireless Medical Telemetry Service (WMTS) frequencies (TV Channel 37) as thousands of WMTS devices used to monitor patient health. More than 3,500 hospitals use WMTS devices, and more than 200,000 devices are registered to use Channel 37, which is the only band that supports fetal monitoring.

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ASHE is concerned that these devices, which are critical for patient health, could be subjected to interference from unlicensed devices under the new FCC rules. ASHE and the American Hospital Association will continue to work with the FCC to help provide protection for hospitals under the new rules.

As the details are sorted out to determine exactly how the new rules will work, ASHE is encouraging hospital facility members to create a current inventory of the WMTS system and devices in their facilities, and make sure those devices are registered and up-to-date with ASHE. To check the status of WMTS devices in a facility, log on to or call ASHE’s technical partner, Comsearch, at 703-726-5711. For additional information, facilities professionals should contact

American Society of Heating, Refrigerating and Air-Conditioning Engineers. The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) published its long-awaited standard on legionellosis this summer. ASHRAE 188, Legionellosis: Risk Management for Building Water Systems, outlines risk management requirements intended to prevent Legionella, a bacteria that can cause Legionnaires’ disease and a less-severe illness called Pontiac fever. ASHE worked closely with the 188 Committee to align the standard with current accrediting organization requirements for utility management. The health care facility requirements are based on a risk management plan developed by a designated team. The standard has not been adopted into code yet, and ASHE will keep members informed on this issue.

International Code Council. ASHE continues to work with the International Code Council (ICC) Ad Hoc Healthcare Committee (AHC) to help align the ICC family of codes with other health care codes and standards. The AHC again has submitted several proposals for the International Building Code as well as existing building, plumbing, mechanical and fuel gas codes. These proposals were voted on by various ICC standing committees during hearings held in April and May, and were voted on by ICC members at the public comment hearings in September and October. The 30 proposals focused on updating health care requirements in the International Plumbing Code and improving the language of current health care requirements in the other codes. The AHC will continue working on the rest of the ICC family of codes over the next year. Facilities professionals who are interested in assisting should contact ASHE’s Jonathan Flannery, CHFM, FASHE, senior associate director of advocacy, at

National Fire Protection Association. It’s still two years away, but facility managers should plan now to attend the 2017 National Fire Protection Association (NFPA) Conference & Expo in Boston.

While all NFPA technical meetings are important — this is where code changes are voted on — the 2017 meeting is especially important because NFPA 99, Health Care Facilities Code, and NFPA 101, Life Safety Code, will be on the same code cycle. Changes made to these important documents in 2017 will be incorporated into the 2018 editions. NFPA 99 often is incorporated into the International Building Code, so the ramifications of this meeting could be even more far-reaching should an unnecessary or overly burdensome requirement be approved.

During these technical meetings, every vote counts. For example, ASHE recently tried to align the Life Safety Code with the International Building Code, which just revised its long-standing smoke compartment size limitation from 22,500 sq. ft. to 40,000 sq. ft. ASHE successfully lobbied to have this changed in the Life Safety Code. Despite a massive campaign by ASHE to call members into action and attend the 2014 technical meeting, not enough hospital members attended the meeting and voted, and an appeal was upheld to revert the code to 22,500 sq. ft. The Life Safety Code and International Building Code now conflict on this important size limitation.

In another example, ASHE advocated hard at meetings regarding the 2012 edition of NFPA 99, but did not have the membership to support final floor actions. One provision dealt with wet locations. ASHE testified against the new provision to make all operating rooms (new and existing) wet locations unless a risk assessment is performed. Only a handful of people were there to testify and vote, so the provision was adopted despite ASHE’s concerns. The investment of $1,500 to $3,000 it would have taken for a hospital facility manager to attend the technical meeting could have prevented $20,000 or more hospital spending per operating room to add isolated power systems.

To attend the 2017 NFPA technical meeting in Boston, facilities professionals should make sure their NFPA membership is up-to-date so they can be present and cast their votes.

Compliance resources

In addition to those breaking advocacy efforts, ASHE also has made many resources available to health facilities professionals to help them deal with existing compliance challenges. They include two programs developed in conjunction with the Joint Commission and others.

Focus on Compliance. This summer, ASHE and the Joint Commission launched a collaborative project targeting the top causes of life safety and environment of care citations in hospitals and health care facilities. By providing specific information and resources for each compliance area, the project aims to reduce physical environment citations.

The approach has proven to have worked before. The Joint Commission, ASHE and several other groups worked together to provide education and resources on barrier management. Barrier management symposia were held around the country, helping hundreds of facility professionals to get a better handle on maintaining smoke and fire barriers. Since the symposia began, citations have dropped in this area.

ASHE and the Joint Commission wanted to repeat the focused approach on all of the most challenging standards related to the health care physical environment. Information and tools for each topic will be housed on the ASHE Focus on Compliance website ( as well as the Joint Commission’s Physical Environment Portal (

Every two months, ASHE and the Joint Commission will focus on a new standard, with the previous information archived on the page to create a library of compliance resources, including:

• August/September 2015: Utility systems (EC.02.05.01);

• October/November 2015: Means of egress (LS.02.01.20);

• December/January 2016: Built environment (EC.02.06.01);

• February/March 2016: Fire protection (EC.02.03.05);

• April/May 2016: General requirements (LS.02.01.10);

• June/July 2016: Life safety protection (LS.02.01.30);

• August/September 2016: Automated suppression systems (LS.02.01.35);

• October/November 2016: Hazardous materials and waste management (EC.02.02.01).

Barrier Management Symposium. Fire and smoke barriers installed in health care facilities are an important part of the structure. They protect patients, staff and visitors, and are used for the horizontal evacuation of compromised areas in case of a fire. Fire and smoke barrier management is critical to maximize patient safety and property protection; minimize death and injury; and facilitate entry and movement for emergency responders. But maintaining these barriers and their features is often challenging.

To improve the awareness of these issues, ASHE collaborated with the Joint Commission, Underwriters Laboratory and the Firestop Contractors International Association in the development of the barrier management symposium. The one and a half-day symposium addresses the design, installation, inspection and maintenance of barrier systems.

Hundreds of facility professionals have attended the various symposia presented in several ASHE regions. The number of citations in this area is declining. Still, there is a need to increase awareness of this issue. The next symposium is scheduled Nov. 16–17 in Bristol, Tenn. For more information about the program, go to

Getting involved

ASHE’s advocacy team is dedicated to codes and standards — and spends most of its time on the road working to develop, update, improve and explain the codes and standards regulating hospitals.

But it takes multiple voices to move closer to the goal of unified codes. To get involved with ASHE’s advocacy work, contact Deputy Executive Director for Advocacy Chad Beebe, AIA, SASHE, at

Deanna Martin is communication manager for the American Society for Healthcare Engineering. She can be reached at

More regulatory tools and tips

In addition to the resources included in the accompanying article, the American Society for Healthcare Engineering (ASHE) has created many other tools to help health facilities professionals keep their hospitals compliant. They include:

CMS waiver tools. ASHE has compiled a comprehensive list of all the categorical waivers offered by the Centers for Medicare & Medicaid Services (CMS). A sample waiver template also is available for ASHE members to download and edit for use in their facilities. The documents are available in the ASHE Resource Library.

RPT tools and guidance. CMS is offering waivers that allow power strip use in patient care areas in certain circumstances. Resources for ASHE members include a comparison of guidance from various organizations on relocatable power taps (RPTs), a chart explaining the differences between RPTs and special-purpose RPTs, and a sample RPT policy that can be adjusted to fit a facility’s needs. These documents also are found in the ASHE Resource Library.

NFPA 99 risk assessment tool. This tool can help health care facility professionals comply with the risk-based approach required by the 2012 edition of NFPA 99. The 2012 edition includes a major change to previous editions of NFPA 99. Previously, NFPA 99 applied different requirements based on occupancy type rather than on the risk to patients. The 2012 edition gives the same requirements for a procedure no matter where it takes place. This new approach gives hospitals more flexibility while maintaining safety. This approach may seem more complex because it involves determining risk for multiple areas and multiple pieces of equipment, but risk assessment tools can help health care facilities to keep track of the risk categories. ASHE created a Microsoft Excel-based risk assessment tool that tracks equipment, system and emergency management categories. This tool can be found in the online ASHE Resource Library.

FSES tool. ASHE created this tool for hospitals that want to use a fire safety evaluation system (FSES) utilizing the alternative compliance approach under NFPA 101A. This tool also can be found in the online ASHE Resource Library.

HVA tools. ASHE published two tools last year to help hospitals assess and weigh potential hazards and their effects. Performing a hazard vulnerability analysis (HVA) is an important part of emergency preparedness, and these tools can help organizations to refine their facility’s emergency preparedness plans. The HVA tools are in the online ASHE Resource Library.