About this series

This series of tutorial articles is a joint project of the American Society for Healthcare Engineering and Health Facilities Management.

Hospitals have been working to become more efficient for decades, but these efforts are becoming even more important now as health care organizations face a challenging economy and a seismic shift from volume-based to value-based payment systems.


For facility managers, this turbulent environment provides both pressure to change and the opportunity to bring greater value to their organizations. Commissioning helps facility managers meet these challenges, and the American Society for Healthcare Engineering (ASHE) is stepping up efforts to support its commissioning process developed specifically for health care facilities.

Improving processes

"Health care organizations are increasingly focused on improving processes, becoming more efficient and wringing out waste across all aspects of operations, in part because of continual pressure in the current economic and regulatory climates," says ASHE Executive Director Dale Woodin, CHFM, FASHE. "Facility managers and those responsible for the health care physical environment can be organizational leaders in the movement toward Lean processes."

Facility managers long have been tracking building data as they work to create better-performing facilities. But commissioning offers a thoughtful, comprehensive and accountable approach that ensures buildings — both new projects and existing structures — reach their full potential.

"For years, our profession has understood the power of establishing clear performance indicators and then setting out to improve them, and commissioning furthers this concept," Woodin says. "By commissioning new health care projects and existing buildings, we can ensure that buildings perform as they are intended to and deliver the expected value to support the mission of the organization."

Delivering that value is more important now than ever, and health facility commissioning has a proven track record of success. Consider the story of the University of Arkansas for Medical Sciences (UAMS) in Little Rock, which used a $53 million bond initiative for a central energy plant project.

Commissioning the project produced such enormous savings that additional projects could be funded without lowering the margin: adding 60 new beds, expanding the size of preoperative and post-operative suites, building out a floor of a cancer institute, and buying six acres for future development. It's just one example of how facilities departments can return significant value for their projects and show the value of the department. Imagine telling your hospital's C-suite that you not only conserved energy and saved money, but that you can actually help fund additional projects that advance the organization's mission.

"That's what facilities can bring to the table," says Mark Kenneday, CHFM, FASHE, the vice chancellor for campus operations at UAMS, and the president of ASHE. "We as facilities people can effect significant changes to our institutions at a time when they're clamoring for solutions."

The return on investment is one reason commissioning is becoming more popular. A 2012 construction survey conducted by Health Facilities Management magazine and ASHE found that two-thirds of respondents said they commission projects at their facility.

There are many excellent commissioning processes available in the marketplace, and many return results. The term commissioning stems from commissioning a ship, or getting it ready for active service. A commissioned ship has been tested, operational problems have been fixed and its crew has been trained; similarly, a commissioned building has been tested to ensure that it is operating as it should. The process backed by ASHE — referred to as health facility commissioning (HFCx) — is different from general commissioning processes, because it was developed specifically for hospitals and other health care facilities.

Hospitals face different conditions from those of most commercial buildings. They operate 24 hours a day, 365 days a year. They have a vulnerable population. And they often require different systems from those of typical commercial buildings. So a commissioning process tailored for health care brings greater value and fills in gaps that exist when traditional commissioning processes are applied to health care settings.

The ASHE HFCx process goes further than traditional commissioning, provides greater accountability and more collaboration, tackles the transition-to-occupancy phase with training for maintenance staff, and targets specific systems only found in health care facilities. The HFCx process improves clinical outcomes, improves Hospital Consumer Assessment of Healthcare Providers and Systems scores and increases revenue, Kenneday says.

Resources available

In 2010, ASHE created the Health Facility Commissioning Guidelines to explain the HFCx process. In 2012, ASHE published an accompanying how-to guide called the Health Facility Commissioning Handbook. Both of these resources are available through the online ASHE store at www.ashestore.com. ASHE recently began a new HFCx course being offered in several locations in 2013.

ASHE also offers information on specific projects related to commissioning through the recently expanded Sustainability Roadmap for Hospitals website, www.sustainabilityroadmap.org. The roadmap includes performance improvement measures (PIMs) that show hospitals how to implement sustainability projects. PIMs that relate to commissioning are marked on the website with a blue circle next to the PIM title.

For example, one PIM suggests improving energy-efficiency and reducing the risk of compromised indoor air quality by inspecting and repairing the building thermal envelope. The PIM explains connections to commissioning, and states that the Health Facility Commissioning Guidelines and Health Facility Commissioning Handbook are good informational sources for the project. The HFCx process includes building pressure testing using a six-step process.

Another commissioning-related PIM shows how to schedule baseline thermostat settings to balance comfort and energy-efficiency. The HFCx process explains the importance of trends in managing facilities. When the facility is occupied and systems are subjected to actual load conditions, trend data provide facility managers with information needed to balance comfort and efficiency. And real-time feedback can be seen by integrating trend data into operations and maintenance dashboards.

The Sustainability Roadmap website includes other PIMs related to commissioning, including: establishing baseline energy consumption, evaluating temperature and airflow setbacks at night, evaluating steam traps for repair or replacement, retrocommissioning HVAC controls, and insulating hot water equipment and piping.

Yet, even with all the HFCx resources available and its clear payoffs, there are still barriers to commissioning. Even organizations that support commissioning for some projects do not commission every project. One major hurdle to overcome is cost. Commissioning costs money, and the HFCx process is more involved than traditional commissioning and can come with a higher price tag. Commissioning brings return on investment, however, and the HFCx process brings even greater returns than traditional commissioning. The key to getting commissioning approved and included in a project is showing an accurate representation of the financial benefits and proof of value.

To make it easier to understand the return on investment of commissioning, ASHE has created another commissioning resource — a new educational program that helps to explain the HFCx process and its benefits. The course provides a methodology to develop a business plan that will let a health care executive leadership team evaluate the value and return on investment from the commissioning process. It also includes commissioning case studies and how to develop and implement a measurement and verification plan.

Understanding the differences between conventional commissioning processes and the ASHE HFCx process is key to understanding the return on investment each process brings. ASHE's HFCx process costs more because it includes more. Under the HFCx process, the commissioning agent should have specific experience with hospitals and understand the unique requirements of these facilities. The agent is hired at the onset of the planning, design and construction process — not after the design is complete or construction is under way. The HFCx process includes more systems in its scope, including essential power, medical gas, nurse call, and other systems found only in health care facilities.

Perhaps one of the most significant differences of the HFCx process is that the commissioning agent and the entire design and construction team are held accountable for building performance, says Ed Tinsley, CHFM, CHC, managing principal at TME Inc., Little Rock, and one of the authors of the Health Facility Commissioning Guidelines.

Under the traditional process, Tinsley says, "the commissioning agent literally can walk away at the end of the day and not [be] accountable at all for the actual performance of the building."

"They can always say it was the design or the contractor," Tinsley says. "They're not accountable. Under the ASHE process, the entire team is responsible. They've got skin in the game."

The HFCx process also gets the operations and maintenance (O&M) staff involved with the project early on, collecting comments from them and making changes based on their feedback. This helps to get buy-in from the O&M staff, which is critical for meeting project goals, Tinsley says.

It's a self-fulfilling prophecy, he adds. "If the maintenance staff say it will not work, I can assure you it will not work," Tinsley says. "If they say it's going to work, they're going to work hard to fulfill that prophecy."

Part of every project

ASHE believes that by explaining the business case for commissioning, owners, designers and constructors can move beyond concerns about the direct cost of commissioning and realize that the cost of not commissioning is far higher.

"Commissioning finds ways to achieve performance excellence and brings a return on investment, which is why commissioning should be a part of every hospital project — no matter how big or small," Woodin says.

Deanna Martin is senior communications specialist for the American Society for Healthcare Engineering. She can be reached at dmartin@aha.org.

Sidebar - How health facility commissioning pays off

An interesting session at the 2013 International Summit & Technical Exhibition on Health Facility Planning, Design & Construction (PDC Summit) explored making the business case for commissioning. The session was presented by Mark Kenneday, CHFM, FASHE, vice chancellor for campus operations at the University of Arkansas for Medical Sciences (UAMS) in Little Rock and the president of the American Society for Healthcare Engineering (ASHE), and Ed Tinsley, CHFM, CHC, managing principal at TME Inc., Little Rock. Kenneday and Tinsley are two of the four authors of the Health Facility Commissioning Guidelines.

Kenneday and Tinsley presented the following hypothetical example of how the ASHE health commissioning process brings value to an average project. Kenneday and Tinsley considered a typical hospital project — 164 inpatient beds with 376,000 square feet and a standard payer mix.

By looking at actual commissioning proposals and responses to requests for proposals, they estimated that the ASHE health facility commissioning (HFCx) process would cost about 0.65 percent of the construction budget for the project (about $2.08 per square foot), compared with 0.5 percent of the construction budget for traditional commissioning ($1.60 per square foot). The difference in the two commissioning processes, Tinsley says, would be about $180,000. "There is a premium," he adds.

So what does the hospital gain with that additional $180,000 investment?

The ASHE HFCx process shows cost savings of at least $149,000 a year. The HFCx process also leads to lower infection rates: 1.22 percent of admissions using the traditional process vs. 1.16 percent using HFCx. Fewer patients were transferred under the HFCx process because of more reliable HVAC and other systems: 2.5 transfers per admission for traditional commissioning vs. 2.38 transfers per admission under HFCx. This also saves money.

"The annualized impact using that cost model is a savings [of more than] $787,000 a year — that's $123 per admission," Tinsley says. "That's an internal rate of return of 435 percent. That's the best investment you can make in a construction project today."