Hospital facilities have endured a year like none before, and the American Society for Health Care Engineering’s (ASHE’s) advocacy efforts are keeping pace with the challenges. COVID-19 is still dominating the advocacy landscape, of course, but ASHE will be addressing many other issues in the new year as well.
Two key players on ASHE’s advocacy team — Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director, and Jonathan Flannery, MHSA, FASHE, FACHE, senior associate director of advocacy — recently offered insight into upcoming advocacy issues for Health Facilities Management’s readers.
Need for resiliency
The pandemic has strained hospitals to near the breaking point, so resiliency will be the focus of some advocacy efforts in 2021, Flannery says. “I think we’ll see a lot of activity with regard to resiliency in our codes and standards,” he says. “Until we get a vaccine and get people well vaccinated, this situation could continue.”
The codes and standards that govern hospital construction and maintenance deal with resiliency in many areas, ranging from proper care of backup generators to maintenance of HVAC systems to regular inspections of boiler systems. All these areas, and many more, may come under greater scrutiny once the fallout from COVID-19 is evaluated. Hospital administrators will want to know if certain facility areas failed or need thorough reevaluation, and that could lead to changes on which ASHE advocates.
One area that Flannery notes has come to the fore during the pandemic is ventilation. Because the COVID-19 virus is so easily transmitted in the air, hospitals need to have ventilation systems in top shape to minimize the risk. “Is there some additional resiliency we want to build into our ventilation system?” he asks. “We’re definitely going to have to look at ventilation a little more thoroughly.”
Another COVID-19-related issue that may prompt ASHE advocacy in the new year relates to humidity.
“Humidity’s a big issue right now,” Flannery says. “People are saying that, ‘We want higher humidity.’ Well, the higher you make the humidity, the more it costs. And are you really doing any good? Because there are studies out there that clearly show low humidity reduces the chance of the COVID-19 virus spreading, because the moisture that the virus is attached to when you cough or sneeze dries up, and then it dies. But there are also studies that show that in higher humidity, your immune system is stronger. So where is the right line?”
Because the science is not settled in this area, ASHE’s primary role is to keep members abreast of the data. The association will take steps to get the best science incorporated into standards when that’s appropriate.
One advocacy area that is not related to COVID-19 is the determination of appropriate ventilation requirements for an outpatient exam room. This issue arose because the Facility Guidelines Institute separated the Guidelines for Design and Construction into three separate books. This necessitated the creation of guidelines specific to outpatient exam rooms, as distinguished from in-patient exam rooms.
Flannery explains that one element of the requirements will be the option to determine air changes per hour based on the number of people in the exam room.
“For example, if in an exam room you’re expecting a health care practitioner, a patient and at least one visitor — so a maximum of three people in that room — this will determine how many air changes you should have,” Flannery says. “That’s different from the current way, in which we just tell you how many air changes to have per hour for the exam room, period. So, the new requirement will have a prescriptive option and a performance option.”
Improving CMS adoption
The ideas discussed here — improved resiliency for HVAC systems, appropriate humidity controls and outpatient exam room requirements — might successfully make their way into the appropriate codes, such as ASHRAE/ASHE 170, Ventilation of Health Care Facilities, and the National Fire Protection Association’s NFPA 99, Health Care Facilities Code. But even once that happens, getting those improvements implemented is another advocacy hurdle.
Why is that? Because in the hospital environment, the guidelines found in ASHRAE/ASHE 170 and NFPA 99 are only implemented once they are adopted by the Centers for Medicare & Medicaid Services (CMS) as the “conditions of participation” for facilities accepting Medicare, and the CMS has been slow to adopt the latest updates to codes and standards.
In fact, the current CMS standards use the 2012 edition of NFPA 99 and the 2008 edition of ASHRAE/ASHE 170. The most recent version of NFPA 99 available is the 2021 edition, which means CMS is missing nine years’ worth of updates. The situation with ASHRAE/ASHE 170 is more dramatic — the most recent edition is 2017, and the 2021 edition should be ready sometime this year, so CMS is currently missing nine years’ worth of updates and soon will be missing 13 years’ worth. The consequence of this delay is that hospitals are being built, renovated and maintained without the benefit of many years’ experience.
“I’m going to say the one overarching big issue that we ought to really be looking at is advocating that we get the federal entities to update our standards,” Beebe says. “We cannot go on building hospitals that are essentially this old because we’re using standards that are 10-plus years old.”
In the case of ventilation, for example, the version of ASHRAE/ASHE 170 that has been adopted by CMS includes outdated ventilation tables. The 2008 edition recommends that endoscopies be done in a positive air pressure environment. This was in conflict with the requirement for bronchoscopies, which require a negative air pressure environment.
Further research has shown that the air pressure relationship has little to no effect on the environment for general endoscopies, so later versions removed the requirement for air pressure in endoscopies. Consequently, both procedures can be performed in the same room with negative pressure. That newer research is reflected in the most recent version of ASHRAE/ASHE 170 but, because CMS has not adopted that version, hospitals are caught in the uncomfortable position of following the regulations or ignoring the regulations and risking trouble with CMS.
Many changes also have been made to NFPA 99 since the last adopted version. For example, Chapter 5 provides new requirements that allow for the use of oxygen concentrators as central supply sources for piped medical gas systems and allows corrugated medical tubing in medical gas and vacuum systems.
“A lot of improvements also have been made around the regulations for the inspection, testing and maintenance of hyperbaric facilities, and that includes additional protections to patients and people in those areas,” Beebe says.
“Another big addition in the 2021 edition is the definition and acknowledgment of health care facility microgrids. This establishes a number of protections that are required to be in place in order to serve a hospital’s essential electrical system with a microgrid,” he says. “Right now, if you do just a generic microgrid, you could be putting patients at risk, because a generic microgrid has too many single points of failure in it, and that is what is currently allowed in the code that’s adopted by CMS.”
Consequently, ASHE advocacy staff will be focusing on getting CMS to catch up to current ASHRAE/ASHE 170 and NFPA 99 standards in 2021, as they have in many previous years.
Reducing overbearing regs
In addition to advocating for improved regulations, ASHE also works to reduce overbearing regulations. That will probably be an advocacy issue in 2021, since there is a fine line between regulations that maintain a high level of resiliency and safety, and regulations that cause more work or expense than they are worth, Flannery says.
“We need to be resilient, of course. We can’t let our systems fail,” Flannery says. “But yet, do we then require seven or eight backup generators? No, that would be crazy.”
Another example of potentially overbearing regulations regards ground fault circuit interrupter (GFCI) receptacles. There is no current NFPA standard about how often GFCIs need to be tested, but manufacturers recommend monthly testing, so that is the default standard. But ASHE research — based on three years’ worth of data submitted by members — shows that ground fault interrupters have a 0.07% failure rate, so monthly testing is excessive, Flannery says.
Another area that frequently strays into the “overbearing” territory is strict fire and life safety regulations. These are essential to patient safety, of course, but Flannery notes that statistically less than one person per year dies in a hospital fire, so perhaps it’s time to focus some of that effort on other potential killers.
“We continue to pour money into fire and life safety systems to try to make it safer. But compare that one death due to fire to how many people a year who die due to infection,” he says. “The Centers for Disease Control and Prevention says it’s typically 75,000 a year. So, why are we putting so much money into life safety when we clearly have an issue here — infections — that needs to be fixed?”
Flannery explains that ASHE also is currently advocating to loosen NFPA regulations regarding what can come into contact with a sprinkler line. As with the GFCIs, this effort has been supported by data provided by ASHE members. In this case, the data show that some items — such as a single piece of cable — touching a sprinkler line do not pose a risk.
“The code was written to make sure that you don’t hang your duct work off your sprinkler pipe, which would be bad. We don’t want people doing that,” Flannery says, adding that the code says nothing can be “attached” to a sprinkler pipe. “Well, some surveyors see that if something is laying on the sprinkler pipe, it’s attached. Our members provided data with regard to that, and we submitted that data to the committee. The committee has gone along with our proposal at the moment.”
Advocacy by ASHE itself is only part of the story. Beebe and Flannery say that ASHE members should advocate for themselves in 2021, because COVID-19 has revealed that, in many cases, hospital administrators do not fully understand or appreciate the value of the facilities managers.
For example, as COVID-19 hospitalizations began spiking in the spring, many spaces — such as parking lots, lobbies and hallways — were converted to use for triage, testing and other tasks that the spaces were not designed for and which may not have had proper ventilation or engineering systems. Did facilities managers play the essential role in these transformations that they should have? In many cases, no.
“One of the things that we realized during the pandemic is that, in some if not many cases, the facility manager was overlooked when hospitals made changes to deal with the surge of the pandemic capacity,” Beebe says.
Another example of that situation in some hospitals was that bins started appearing in corridors to collect soiled protective clothing.
“Those bins are typically illegal, in terms of the materials they’re made of as well as the obstruction they’re creating in the corridor and a host of infection control-related issues,” Beebe says. “And our facilities managers are typically finding out about them when they discover them on the floor.”
How do facilities professionals advocate for themselves? Beebe says the first step is making sure they study the COVID-19 resources ASHE, NFPA, ASHRAE and other sources provide so that they have the answers available when hospital leaders seek their advice. Next, they should try to get in front of leaders and assert that they are an essential resource in regard to facility usage.
“Explain to them that you’re really there to help, to be part of the solution, not part of the problem,” Beebe says. “The hospital really needs to think of the facility manager as an extension of the clinical team. Just like nobody would push a medication on a patient without consulting the doctors and nurses, nobody should adjust the environment without consulting the facility manager.”
Of course, advocating for the facilities team should not begin with a catastrophe like COVID-19; facilities managers should be building trust within the system at all times, Flannery notes.
“I watched as an information officer became part of the C-suite and everybody turns to them, because they went about it in a way to build the trust so that everybody trusts information technology to do the right thing,” he says. “It should be the same way with facilities. You need to be the voice for the physical environment in a way that everybody can trust you and know that you’re the person to turn to when it comes to questions about the physical environment.”
Ed Avis is a freelance writer and frequent Health Facilities Management contributor based in Chicago.