Many fire doors in hospitals have fusible alignment pins, also known as fire pins, that are designed to keep a closed fire door aligned in its frame when exposed to extreme heat. Even though they are intended to make the fire door work better, a decade ago, some fire departments worried that they would trap firefighters and tried to ban them.

“We had hundreds of these things in our facilities, so the financial impact to change them out was big,” says Jeff O’Neill, senior director of facilities, Penn Medicine’s Pennsylvania Hospital in Philadelphia. “So, I made some phone calls to ASHE [American Society for Healthcare Engineering] and various other facilities and AHJs [authorities having jurisdiction] with interest in the topic. This eventually led to our successfully being allowed to keep the pins in the 2012 Code. That little bit of advocacy got me involved.”

Today O’Neill sits on the International Code Council Committee on Healthcare (ICC CHC) and is involved with the effort to unify the various building codes. That phone call years ago to the ASHE advocacy team, and the subsequent effort to alleviate the fire-pin issue, illustrates how ASHE and its members work toward a better code environment for health care facilities.

“Sometimes ‘advocacy’ sounds like a heavy word,” O’Neill says. “But it can be as simple as communicating with an AHJ, and every little bit helps.”

Code unification continues

ASHE’s advocacy efforts take many forms, but it has led in the effort to unify and deconflict the variety of codes that affect health care facilities, from the National Fire Protection Association (NFPA) Life Safety Code to the ICC codes to ventilation standards. This work has succeeded on many levels, but the work continues, and probably always will.

“Our big project at the moment is trying to align the codes and standards with the 2012 Life Safety Code,” says Jonathan Flannery, FASHE, senior associate director of advocacy for ASHE. “When CMS [Centers for Medicare & Medicaid Services] adopted the 2012 edition of the Life Safety Code and Health Care Facilities Code, they updated the K-Tag listings. [K-Tags are the life safety checklist items that CMS requires health care facilities to meet]. The ICC CHC took the latest K-Tags and reviewed them in regard to all the ICC codes and developed a gap analysis.”

Flannery and the other members of the ICC CHC used that gap analysis to determine which codes and standards needed to be unified, then wrote proposals to modify the appropriate ICC codes. The committee also considered a number of code unification issues that are not tied to specific CMS K-Tags, but which still need to be addressed to bring all the codes together.

The ICC CHC, which includes six ASHE members and six individuals from AHJs, met in person three times over the past year, and held regular conference calls. The committee’s work was building up to ICC hearings in April. At those hearings, the CHC committee testified on behalf of 60 proposed changes and earned preliminary approval on 51 of them.

For example, Flannery explains that K-Tag 523 prohibits suspended heaters in patient rooms or means of egress. However, such heaters are allowed by the International Mechanical Code, one of the ICC codes. So, the ICC CHC proposed that the International Mechanical Code be amended to disallow such heaters in hospitals, thus unifying that code with the Life Safety Code.

“That proposal was approved as submitted,” Flannery says.

Another success related to Proposal FS 67, which addressed a fire-safety section of the International Building Code (IBC). Section 717.5.2 stated that a fully ducted HVAC system in which the ducts penetrate fire-barrier walls does not need fire dampers if the ducts are constructed of sheet steel that is at least 26 gauge. However, as written, the section states that the duct “shall be continuous from the air-handling equipment to the air outlet or inlet terminal.” Flannery says the concern is that if the ducts are built that way, they vibrate and make noise that is not conducive to good patient care.

“Nobody builds it that way,” Flannery says. “Instead, they use a dampener where the duct connects to the air-handling equipment and a piece of flex duct to connect to the diffuser in order to absorb the vibration. So, we submitted Proposal FS 67 to allow that, and it was approved.”

This proposal, although not part of the K-Tag gap analysis, brought the IBC into alignment with the NFPA Life Safety Code, which already allowed the use of dampeners and flex duct in a fully ducted system.

When a proposal is accepted by the ICC, it is essentially approved, unless someone makes a formal public comment on the proposal, in which case it will be voted on in a series of “final action” meetings in October. Also, proposals that were rejected or modified by the ICC will be re-evaluated at that October meeting.

One proposal with which ASHE was involved that will be considered at that second meeting, because it was not approved by the ICC, refers to the maximum allowable quantities of oxygen tanks in hospital high-rise buildings.

“The ICC codes are very different from NFPA 45 [Standard on Fire Protection for Laboratories Using Chemicals] on how much medical air you can have higher up in a high-rise,” O’Neill says. “I realized after talking to my colleagues that our change proposal was a little flawed, but rather than withdraw it, I still gave testimony. The fire committee appreciated my testimony — I explained that this is a big issue with hospitals. That change will be modified based on their feedback and will be discussed at the final-action hearings in October.”

Often, code unification requires changing several codes. If a provision is successfully removed from one code, for example, that same provision needs to be removed anywhere else it appears.

“Since they’re all public consensus processes and they’re always being updated, sometimes something is put into one code but not the others,” says Chad Beebe, FASHE, ASHE’s deputy executive director. “So, if we’re successful in addressing a situation in one code, we need to fight for the change in the other codes. Of course, if we’re not successful, then it ends up making it a conflict. It could take years to manage that one particular conflict and get all codes on the same page.”

After unification

On another code front, Flannery notes that the 2018 editions of many of the major standards affecting health care facilities — including the Facility Guidelines Institute, Association of periOperative Registered Nurses, Association for the Advancement of Medical Instrumentation and ASHRAE — are now aligned regarding operating room and sterile process and decontamination areas, room names, temperatures, and humidity requirements, an effort that took more than five years to accomplish. But CMS hasn’t adopted those versions yet, and codes tend to creep apart, so ASHE’s work in this regard will continue.

“Our unified code project is really about streamlining the codes and standards,” Beebe says. “Originally, the project was intended to just make sure all the codes said the same thing. The next level of that is, ‘OK, everybody is now on the same page of music, but are we all singing efficiently? Do we need to step back and relook at things?’”

Beebe notes that codes need regular culling, especially since technology and situations change, making some codes irrelevant or ineffective.

“Something happens, somebody gets hurt, somebody dies and we make sure that doesn’t happen again by implementing a code change,” Beebe explains. “The problem is that we never go back and pull things out of the code that technology has overcome. So, a lot of times we have codes in place that address problems that no longer exist.”

For example, Beebe notes that the Life Safety Code addressed flammable anesthetics for many years after flammable anesthetics no longer were being used.

“It wasn’t until we started our unified code project that I started working on getting those particular provisions removed from those codes,” Beebe says.

Similarly, Beebe notes that ASHE is evaluating codes to see if the documentation requirements need to be adjusted to match current practices. For example, one provision in the Life Safety Code states that every sprinkler head in a facility needs to be inspected monthly. The inspection itself is not problematic, since facilities workers pass by the sprinkler heads constantly, but documenting the inspections can be onerous.

“The Joint Commission has started saying that if it wasn’t documented, it didn’t happen,” Beebe says. “All that extra paperwork and bureaucracy makes it very difficult to show that we’ve complied. It would be much better for people to be actually looking at these things in the field [rather] than sitting at a desk, spending eight hours doing paperwork.”

Procedures during surveys

Another code-related issue with which ASHE is helping is the evolving relationship between CMS and the accrediting organizations (AOs). Two issues have emerged: First, since a couple of years ago, CMS has been publishing validation reports that show the disparity between findings of AO surveys and CMS follow-up surveys; and second, CMS has begun interpreting the Social Security Act such that AOs no longer can waive requirements.

The CMS validation reports are designed to confirm that the AOs, such as The Joint Commission, are catching the same things on surveys that CMS would catch if it conducted those same surveys.

“That has increased the number of citations because it’s essentially become the goal of The Joint Commission and all the other accrediting organizations to cite each K-Tag at least once,” Beebe notes. “If they do that, there’s no way that there could be a disparity rate, right?”

A related situation is a change in CMS policy regarding waiver requirements. Previously, AOs could elect to not cite a deficiency if it appeared that the health care organization was properly managing the situation. Under CMS’s new interpretation of the Social Security Act, it has determined that only CMS itself can make that decision, and all other AOs have to cite every deficiency they find.

Kenneth A. Monroe, director of engineering, Standards Interpretation Group of The Joint Commission, confirms that change. “For years, CMS permitted The Joint Commission, as an AO, to be considered an AHJ and The Joint Commission issued waivers as appropriate for the Life Safety Code. Recently, CMS decided that CMS alone is an AHJ for Medicare-certified organizations,” Monroe says.

As a practical matter, this means more citations, Beebe says. “The classic example is managing your doors,” he explains. “It used to be that if you had a door that didn’t comply for one reason or another, the surveyor would ask the facility manager, ‘Do you know about this condition of the door?’ And if he or she replied by saying, ‘Yes, this is on our list to fix,’ or ‘We’ve got somebody coming through on a weekly basis to make adjustments,’ The Joint Commission used to say, ‘Well, OK, that’s good. You’re managing your program.’”

But that has changed, Beebe says, and now CMS is requiring the AHJs simply to cite every deficiency.

“If they see a door that is not compliant, they have to cite it,” he says. “That’s increasing the number of citations.”

However, Monroe explains that waivers are still possible; it’s just that the AHJs can’t provide the waivers without CMS approval.

“With our changes in survey procedures, equivalencies [as The Joint Commission calls them] or continuing waivers [as CMS calls them] are issued for a three-year period, the time between surveys,” Monroe says. “When the next triennial survey occurs, if the condition the equivalency covered still exists, it will be rescored and the organization must submit another equivalency request. We review the request and if we consider it acceptable, we submit it to CMS for approval. CMS makes the decision to issue the continuing waiver or equivalency to the organization.”

ASHE is working to alleviate these problems by meeting with the appropriate officials. Beebe explains that getting things changed at CMS and the AOs involves researching the topic, gathering data and preparing a justification for the change.

For example, one new CMS policy requires health care organizations to document their monthly inspections of exit signs. Beebe says that ASHE is gathering data about how often an exit sign fails a monthly inspection. If it seems that burned out exit signs are not frequently causing problems, ASHE might suggest that documenting every single inspection — which consumes a great deal of time — is unnecessary. ASHE might also suggest an alternative, such as one monthly report that covers all the inspections.

“We develop that argument, and then send letters and sit down with the accrediting organizations and CMS, essentially to make clear what the intent of the code in that situation was and how it can be dealt with without every individual item being documented.”

Getting involved

Beebe and his colleagues take the lead on these advocacy issues, but it’s essential that ASHE members get involved, too.

“What’s really the most important thing they can do is that if they run into a problem, or a code issue comes up, they should let their local ASHE chapter advocacy liaison know about it,” Flannery says. “The whole purpose of the advocacy liaison is to facilitate the two-way communication between ASHE advocacy efforts and the local membership.”

And for ASHE members with a little time to spare, the ICC CHC conference calls are open to anyone who wants to participate, and members are invited to present testimony at code hearings. “I use my participation in these issues as education time,” O’Neill says. “I equate it with a physician being involved with the American Medical Association or American Hospital Association — it’s professional development.”

Ed Avis is a freelance writer and frequent ASHE contributor based in Chicago.