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Hospital facilities managers are facing challenges on all fronts this year, from pandemic-related threats to long-term infrastructure concerns. Fortunately, the American Society for Health Care Engineering (ASHE) is leading advocacy efforts to address these issues.

“We have more clarity on a lot more advocacy issues now than we did six months ago,” says Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, ASHE’s deputy executive director. “The pandemic brought some things into focus that need to be addressed, and there are issues from before the pandemic that still require attention.”

Among the advocacy issues ASHE leaders are dealing with include making sure lessons learned during the pandemic are applied locally and nationally; unifying and improving the codes and standards that affect health care facilities; and responding to President Biden’s call for a national infrastructure plan.

Pandemic lessons

COVID-19 presented a tremendous challenge to hospitals. It also uncovered a number of issues that require advocacy.

The ASHE COVID Response Tactics Sharing (CRTS) survey, completed by 1,440 respondents in health care engineering, revealed that 87% of hospitals created additional care spaces during the pandemic, something that involved facilities managers at every stage. 

“The No. 1 finding of the survey was that facilities managers didn’t stop doing their normal work; they did everything,” says Lisa Walt, ASHE’s senior researcher and methodologist. “While they were doing their normal jobs, they were involved in all the steps involved in surge preparation, including maximizing clinical space. They created operating room anterooms, reconfigured patient rooms and prepared complete floors for the surge.”

The creation of extra care spaces has prompted health care facilities leaders to consider how to define a “temporary” structure and what the life safety requirements for such structures should be.

For example, one-third of the respondents to the survey deployed tents during the pandemic, and many of them are still there. When they were set up, the situation seemed urgent, and inspectors may not have been concerned about strictly enforcing codes. But now that situation is changing.

“Now we need a game plan to deal with these,” Beebe says. “I just got off a call with the International Code Council (ICC), and there were several building officials and fire officials saying, ‘Hey, I need to get these tents off these sites. They said they were temporary, but we’re going on 18 months now. This isn’t temporary anymore.’”

Beebe notes that tents may have egress issues or other life safety concerns, so if a hospital intends on keeping one for the long term, procedures should be established for a fire watch or other safety precautions. That requirement and others related to the temporary measures hospitals took to deal with the pandemic or surge need to be ironed out before the next pandemic hits, he says.

Creating those extra spaces touches on another key issue that may result in advocacy efforts: How much should hospitals be expected to expand during a crisis? While it seems intuitive that a hospital will do everything it can to meet the needs of its community, the physical limits need to be properly understood and acknowledged, says Brad Pollitt, AIA, vice president for facilities at the University of Florida Health Shands Hospital.

“One of the things I observed during the pandemic was that every hospital has a natural surge capacity,” Pollitt says. “That capacity is a combination of space and utilities and staff. And during the pandemic, many hospitals that became overwhelmed went beyond their natural surge capacity. When you start placing twice as many patients to a nurse, or twice as many patients in a space, you have exceeded a safe surge capacity.”

Pollitt estimates that every hospital can safely add 25% to 50% of its normal capacity in a crisis. But when a situation requires greater capacity, the community cannot rely on the hospital alone to fill the need.

“Hospitals can take the initial surge, but they can’t take the long-term sustained surge,” he says. “My argument is that every community has a civic center, a gym or some other building that could be turned into surge capacity. We need to let communities step up when it’s time to pick up these surges.”

Beebe adds that the role of hospitals in a pandemic perhaps should be subject matter expertise. The hospitals could guide communities in dealing with the surge but not necessarily offer to handle the entire surge themselves.

“The community may need to step up to handle the surge,” he says. “This pandemic surge could have been a million times worse than it was, and we would never have the capacity to deal with it.”

From an advocacy standpoint, the issue of surge capacity may require educating and lobbying officials at various levels, Beebe says.

Improving codes

An ongoing advocacy issue for ASHE is the unification of the codes that affect health care facilities. And in that area, a significant victory may be imminent.

The issue in question is the designation of lay-in ceilings as smoke-tight construction. These types of ceilings are convenient for facilities managers because they provide easy access to plumbing, sprinkler heads, electrical wiring and other utilities above the ceiling. 

The International Building Code (IBC) states that lay-in ceilings are prohibited in hospitals because they are not considered adequate to stop the passage of smoke. On the other hand, the National Fire Protection Association’s NFPA 101®, Life Safety Code®, permits them.

“Most times, we would build it with the lay-in ceiling and take the heat from the jurisdiction, because we know the Life Safety Code accepts it and it’s easier to manage over the life cycle of the building,” says Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, ASHE’s senior associate director of advocacy. “For three code cycles, we have proposed that a lay-in ceiling should be considered a smoke-tight construction, and it’s been turned down each cycle. But we actually got it approved at committee this time.”

Jeff O’Neill, AIA, ACHA, CHFM, co-chair of the ICC Committee on Healthcare and senior director of facilities at Penn Medicine’s Pennsylvania Hospital, explains that ASHE advocacy staff members documented the smoke-stopping abilities of lay-in ceilings by noting the weight of the tiles and the properties of smoke in corridors. The ICC accepted the proposal at the spring 2021 committee action hearings.

“It was impressive that we got this one. It’s a huge part of aligning the IBC and the Life Safety Code,” O’Neill says. “But we’re only halfway there. The next step is the public comment hearings in the fall. We need to have testimony on all of the science and other issues we raised to support our position.”

This particular issue was perhaps the last major difference between the IBC and the Life Safety Code, Flannery says. But that doesn’t mean ASHE advocates can afford to stop paying attention. Jim Peterkin, PE, LEED AP, SASHE, chair of the ASHE Regulatory Affairs Committee and a principal of TLC Engineering Solutions, explains that managing differences in the codes is an ongoing advocacy issue.

“The codes are both constantly changing, so we have to be on top of them to make sure we’re continuing to align them,” Peterkin says.

Another advocacy concern ASHE has undertaken is helping to ensure codes are as effective as possible without being overly burdensome. This can take several forms. In some cases, ASHE addresses misinterpretations by authorities having jurisdiction. In other cases, ASHE supports an addition to a code. And finally, in some cases, ASHE works to prevent needless additions to codes.

An example of the first situation involves The Joint Commission’s interpretation of the number of spare sprinkler heads hospitals must have. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, as referenced by the Life Safety Code, requires that hospitals keep a minimum of six spare sprinkler heads on hand. Recently, The Joint Commission interpreted that to mean hospitals needed six spare heads for every type of sprinkler in the building. This is a misinterpretation, Peterkin explains.

“Hospitals might have dozens of different types of sprinkler heads,” Peterkin says. “The NFPA standards require one spare head of each type, and then they say the minimum number the hospital needs on hand is six or more depending on the total number of sprinklers in the facility. So, if you have all the same type of head, you would have six spare heads for that type; but if you have different types, you just need one spare for each type, as long as you have the minimum required based on the total number of sprinklers within the facility.”

The ASHE Regulatory Affairs Committee received a clear interpretation of the standard from NFPA — confirming that hospitals do not need six spares per type of head — and presented that to The Joint Commission. At the time this article was written, the committee was still awaiting a response.

An example of ASHE advocating an addition to a code involves the width of aisles in hospital care suites, such as intensive care units and emergency departments. Because such suites are considered one large room, the Life Safety Code does not specify aisle width. But having reasonably wide, clear aisles in these suites is important.

“Someone put in a proposal to say that the minimum aisle width in a suite should be 36 inches,” Flannery says. “When you’re trying to move a bed or a wheelchair or something like that, that just makes absolute sense. That’s just good code. So ASHE supported the proposal, and it was approved by the committee.”

Finally, an example of ASHE working to avoid needless additions to codes involved a proposal to require a particular type of protective door in front of elevator shafts in hospitals. An individual proposed this during an ICC code hearing, but there is no science indicating that such doors would solve any known problem, Flannery says. 

“There are occasions when individuals submit proposals to try to establish their product in the code,” Flannery says. “When we see these types of proposals, we testify against them. Our members need to know that we’re there for them, and we’re doing that. When a proposal has the science behind it and it makes sense, we’re all behind it, absolutely. But we are also opposed to proposals that bring unnecessary costs or requirements to codes.”

Infrastructure plan guidance

A forward-looking advocacy effort that ASHE is currently undertaking is to provide guidance to the Biden administration on the proposed national infrastructure plan.

“The opportunity with the new administration’s infrastructure plan is probably the most pressing thing at the moment,” Flannery says. “We know the administration is working on an infrastructure funding bill, and we want to make sure that health care facilities are in that. We’re pushing hard to figure out what is a good number and to advocate for that.”

Flannery explains that he and Beebe are using two monographs about infrastructure investment that were prepared during the previous presidential administration as foundational documents for the new proposal. 

One of those monographs, called the “State of U.S. Health Care Facility Infrastructure” and accessible at, used data from an ASHE survey. 

Flannery says ASHE may do another survey to gather more up-to-date data for the new infrastructure document.Flannery and Beebe’s current effort is focused on the presidential infrastructure proposal, but for the long term, they hope to create a database that helps hospital facilities leaders determine how much money to invest in their own facilities and in which areas.

“How much do we need to invest in our health care facilities that maintains our infrastructure in a way that’s appropriate without wasting money?” Flannery asks. “That’s our long-term goal: to come up with something that is logical, that can be supported, that can be banked on. So that a facility manager can go to their CEO and CFO and chief medical officer and say, ‘I know we need to extend surgeries, we need to do this, we need to do that. There are a million things that need to be done, and there’s never enough money. But, folks, if we don’t spend X on a recurring basis, the infrastructure is going to fail, and it will not matter what services you are offering or not offering. Because we won’t be offering services.’” 

Ed Avis is a freelance writer and frequent Health Facilities Management contributor based in Chicago.