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As the eyes and ears of the hospital, front-line employees are best qualified to suggest changes that will improve day-to-day processes in their own facilities. But how do they take those ideas from concept to realization?
One answer: Turn them over to the American Society for Health Care Engineering (ASHE) advocacy team. Some of the most important changes and updates to existing codes and standards in hospitals have come from the ASHE members who see the real-world impact of such regulations on a daily basis, according to Jonathan Flannery, MHSA, FASHE, FACHE, ASHE’s senior associate director of advocacy.
“Member involvement is vital,” Flannery says. “They are the ones most impacted by these rules. And often when one person sees an area for improvement in one facility, many others are dealing with the same thing.”
For example, a suggestion from an ASHE member resulted in an increase in the size of the hospital smoke compartment — a space enclosed by smoke barriers on all sides. Smoke compartments, which create an area where patients can defend in place rather than making a mass exodus toward the exits, are critical to patient safety during fires and other emergencies.
Advocates proposed increasing the maximum size of smoke compartments from 22,500 square feet to 40,000 square feet, which was based on the updated travel distance from 150 to 200 feet. The larger smoke compartments would allow for greater flexibility in design and for more single-patient rooms, which have been proven to decrease infection rates and improve patient satisfaction, according to the ASHE advocacy team.
The proposal was approved by the International Code Council (ICC) for the 2015 edition of the International Building Code and by the National Fire Protection Association’s NFPA 101®, Life Safety Code®, for its 2018 edition. John Williams, chair of the ICC Committee on Healthcare (CHC), says it shows how the advocacy process, which often involves multiple rounds of input, discussion and compromise from all stakeholders, really works.
The proposal is being implemented in hospitals this year. “It is a great example of how ASHE advocates were future-focused rather than backward looking,” Williams says. “This is how the ASHE Advocacy Highway works for health care facilities. Two-way communication is critical to really move the advocacy process forward.”
Codes under development
Such suggestions continue to drive the work of the ASHE advocacy team for the next round of codes for NFPA 101 and the ICC International Building Codes, which are both currently under development. Both sets of standards are developed in an open consensus-based process.
Because codes often can be conflicting, outdated and inconsistent, ASHE remains focused on unifying codes to create consistency among federal, state and local codes and standards. In 2011, the ASHE/ICC CHC was formed with the mission to “assess and amend the current ICC family of codes to ensure that these requirements are appropriate to the special safety risks that exist within hospitals and ambulatory surgery facilities.”
With unity as the main goal, the ASHE/ICC CHC develops hundreds of proposals to help align ICC codes with other codes and standards.
“This is a continuing, well-placed effort to bring federal certification requirements and building codes closer together,” Williams says. “Codes are constantly evolving in response to changes in health care that impact risk management in the built environment. The ICC Committee on Healthcare has fixed the majority of those differences, and we continue to bring local and federal requirements closer together and also move them forward.”
A good example of this progress is the ANSI/ASHRAE/ASHE Standard 170, Ventilation of Health Care Facilities, developed to provide key guidance on ventilation requirements. In the next edition, Standard 170 will be updated to align with the new Facility Guidelines Institute (FGI) classification system for imaging rooms issued in 2018.
“The FGI now labels imaging rooms as Class 1, 2 or 3 in terms of restrictions, and we did not have those categories in the ASHRAE/ASHE 170 standard,” Flannery says. “The FGI went through their cycle, and now we’re making changes that will better align ANSI/ASHRAE/ASHE 170 with their updates.”
Another example is the focus on standards regulating the often-hidden dangers of toxic or flammable refrigerants. While the use of nonflammable refrigerants has been standard in the field for more than 70 years, flammable refrigerants are becoming more necessary to meet global warming regulations.
The 2019 edition updates ASHRAE standards to include a shorthand description for naming refrigerants and assigning safety classifications based on toxicity and flammability, and establishing procedures for operating equipment and systems when using those refrigerants.
“Knowing the ASHRAE standards and how to apply them to your facility will provide the facility manager with the foundation necessary to understand the dangers often hidden within a mechanical system,” says Robert Baird, SASHE, CHFM, facilities director at the University of Florida Health, Gainesville. “Refrigerant phaseouts, new refrigerant compounds and blends will continue to drive change in this field. Keeping abreast of the ASHRAE standards will ensure a defensible and safer environment for your building occupants.”
The ICC CHC continues to work to make sure codes align with CMS Conditions of Participation (K-tags), ASHRAE and NFPA requirements. CMS adopts the NFPA 101 and NFPA 99, Health Care Facilities Code. To help members better understand updates and changes, ASHE has created the Hospital Conditions of Participation/Accreditation Crosswalk, which compares K-tags with Joint Commission, NFPA and ICC requirements. This is just one of a growing roster of ASHE advocacy tools available to members.
What’s new at NFPA?
The NFPA code cycle is a three- to five-year cycle, and the next edition is scheduled to be published in 2020-2021. Changes planned for the next edition include a safety provision that allows the use of fire-retardant plastic sheeting for temporary construction barriers, says Chad E. Beebe, AIA, FASHE, CHFM, deputy executive director for ASHE.
“It is extremely important for us to maintain negative pressure and reduce the potential for infection across patient care areas,” Beebe says. “The allowance for hospitals to do this using fire-retardant plastic has been an issue for some time.”
Updates planned for the 2021 edition of NFPA 99 include a new set of provisions for health care microgrids — a group of interconnected loads and distributed energy resources within clearly defined electrical boundaries that act as a single controllable entity with respect to the grid, Beebe says.
Beyond helping a hospital improve resiliency and guard against the possibility of a grid blackout or power loss, a microgrid can reduce energy costs and maximize the use of renewable energy such as wind and geothermal sources.
As technology improves and costs drop, more hospitals are relying on microgrid solutions to achieve reliable power.
“Standard practice today is that a hospital has primary power supplied by a utility while the essential systems’ secondary source of power is provided by diesel generators,” Beebe says.
The 2021 edition of NFPA 99 would allow microgrids and their various sources to be used as part of a health facility’s essential electrical system. Beebe says this technology could provide additional redundancy and resiliency beyond traditional systems in health care facilities today and could also yield financial benefits.
The new NFPA 99 edition also takes an additional step toward ensuring the safety of medical gas systems, adding language to directly describe the maintenance and labeling of the equipment, as opposed to the design. While hospitals have always identified one person responsible for medical gas systems, the new NFPA 99 edition will increase qualifications and further define the role, Beebe says.
“Medical gas systems are very important to health care and are very vulnerable, and the point person for a potential shut-off really needs to understand the system and what it serves,” Beebe says.
“Technically, this role is mentioned in the NFPA 99 code now, but the new edition will require a person to be officially designated by the facility, and system changes and decisions will have to include that person. This is good for facilities managers who have had experience with staff-initiated system shutdowns and restarts without their knowledge,” Beebe says. There are no additional certification requirements to be designated as the person responsible for the medical gas system, he adds.
While updating and aligning codes to keep up with changes in health care is critical, the process also adds new layers to an already highly complex code system. Winnowing outdated regulations is a huge undertaking, which is often overlooked, Beebe says.
“We are constantly thinking about, ‘How much is enough?’,” Beebe says. “We keep adding regulations on top of regulations and never really go back to see if we need the ones that have been on the books forever.”
In addition, unnecessary codes and regulations can be costly, and the resources spent dealing with them could be put to better use. “We keep driving up the cost with systems and protective features that we often will never use,” Beebe says.
And while the regulations for hospitals are continually evolving, the structures themselves are not as flexible.
Resiliency is becoming more integrated into new health facility design, but it’s harder to effectively apply the same regulations to a hospital built 50 or 60 years ago. This requires a big-picture perspective, Williams says.
“There are only certain things you can change on a structure after it’s built, so we take a backward-looking perspective that acknowledges traditional safety regulations while taking a forward-looking approach to anticipate future needs,” Williams says. “When you renovate a floor, this could be the only time in the next 10-20 years that you get to see what the fire systems look like, so you want to prepare for the future.”
ASHE and the ICC CHC are already working on the next cycle of codes planned for 2024, Williams says.
So far, conversations are centering around building accessibility, including how state codes intersect with the Americans with Disabilities Act (ADA).
“Health care has special scenarios that other buildings do not,” Williams says. “Health care buildings are broad and diverse and house different residents with different needs. We want all health care facilities to align with the federal ADA requirement.”
There continues to be an ongoing conversation about energy savings and how that fits into the regulatory process. “We will also be taking a closer look at delivering care to outpatient and ambulatory facilities to make sure regulations are up to date with how treatment has evolved,” Williams says.
Flannery says the impact of COVID-19 on codes and standards will be a major topic of discussion in the coming months.
In the meantime, Flannery encourages health facilities managers to get involved in the code regulation process.
ASHE members can reach out to their state chapter ASHE advocacy liaison with any suggestions for the next code cycle. Advocacy liaisons within local chapters inform ASHE about policy and legislation affecting the health care physical environment.
“We do a quarterly call with the liaison for state chapters, and they fill us in on what they have accomplished and what their concerns are,” Flannery says.
While participation is vital to the advocacy process, it doesn’t always happen for a number of reasons. Members may lack time, feel the process is too complicated or assume someone else will be the catalyst for change.
However, there are a number of ways for them to get involved. One example: offering a public comment on a proposed code or standard during the public process.
Flannery stresses that member participation is fuel for the ASHE Advocacy Highway, the two-way street of communication on advocacy issues between ASHE and local ASHE-affiliated chapters. A good place to start is the wide array of ASHE tools and webinars on the advocacy process.
“ASHE members are the ones who really understand the facility, about what works or doesn’t work, and how to best take care of patients,” says Flannery. “ASHE stays involved throughout the process, but we rely on input from facilities staff in the field. That’s what drives the advocacy process.”
Beth Burmahl is a freelance writer based in Lisle, Ill., and former associate editor for Health Facilities Management magazine.