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The world’s concern over COVID-19 ebbs and flows as infections fluctuate and variants emerge, but from the perspective of American Society for Health Care Engineering (ASHE) advocacy experts, the illness continues to dominate conversations. 

The pandemic touches so many aspects of hospital facilities that its impact will be felt for decades. “We’ve realized that there are always going to be COVID-19 patients now,” says Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, ASHE’s senior associate director of advocacy. “It’s something facilities managers are going to have to continually be addressing.”

COVID-19’s impact on ASHE advocacy efforts reaches into several areas. Primarily, the organization is working to make sure that pandemic-related code changes are feasible and not overreaching, and that the changes made in various codes can ultimately be unified. In addition, an ASHE task force that emerged to deal with COVID-19 issues continues its regular meetings, but its mission has become broader and now encompasses all physical environment-related issues.

But, of course, ASHE’s advocacy efforts also reach beyond COVID-19. “Some advocacy initiatives that would have been big issues in past years almost seem trivial in 2022, with all of the impacts and changes from COVID-19,” says Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, ASHE’s deputy executive director. “But we still can’t take our eyes off of those.”

An unrelenting effect

COVID-19 affected hospitals in many ways and, as things slowly settle into a new normal, the long tail of the pandemic becomes evident. One long-term effect is how codes and standards are changing to deal with potential future pandemics.

“As you can imagine, we’ve had lots of focused conversations over the past 20 months about how people are responding to the COVID-19 event. In the building code world, there were a number of reactions that you kind of could have predicted,” says John Williams, an executive director at the Washington State Department of Health who chairs the International Code Council’s (ICC’s) Committee on Healthcare. “When there is a big event, a disaster or a pandemic, people look to codes and standards and ask, ‘How could we have prevented this? What can we design into new buildings to make them more resilient?’”

For example, the ICC, Facility Guidelines Institute (FGI) and National Fire Protection Association (NFPA) are working on guidance related to alternate care sites. 

In the early months of COVID-19, hospitals around the world had to set up tents in parking lots, turn lobbies into triage centers, and otherwise use areas of facilities or even entire facilities that were not traditionally designed or built as patient care space. The code authorities want to provide information related to such situations should they arise again.

“The ICC pulled together a work group to look at temporary surge facilities and develop some appendix language,” Williams says. “That way, jurisdictions faced with turning a convention center into a temporary hospital, or a hotel into a temporary quarantine location, have some guidance. The idea is to make these responses happen quickly, and this effort explores what the ‘temporary’ minimum is. That way, we give both designers and facilities a little direction to maintain occupant safety and give authorities having jurisdiction the permission to do a little less than the traditional minimum.”

The proposed appendix creates a tool that authorities can use during a disaster to ensure that temporary structures are safe but also allows them to relax the standards they may apply during normal conditions, Williams explains. The appendix was not accepted on its first opportunity, but Williams is nevertheless pleased with the potential.

“The first time you bring something completely new before an ICC committee or the membership, there are a lot of questions. This is a pretty comprehensive appendix they’ve built,” he says. “Those are always hard to get through the first time because it’s a new concept and people are responding to it. There’s all sorts of detail there that needs to be worked out, but I think there’s support for the concept.”

The NFPA also is working on this issue and has created the first draft of an annex to NFPA 101®, Life Safety Code®, to clarify requirements for alternate care sites. 

“Representatives from the U.S. Army Corps of Engineers spearheaded this effort because they were responsible for setting up alternate care sites and faced numerous challenges from local authorities,” says Gregory Harrington, PE, principal fire protection engineer at NFPA. “They were looking to get something into the code that would provide guidance on this.”

Harrington says the annex will define alternate care sites and then discuss planning and design, site assessment, and how to provide alternative means for safety and protection when the conventional standards can’t be met. For example, a health care provider using a hotel as an alternate care site could find guidance in the annex on how to establish and maintain a health care facility in the hotel properly and safely. 

“The annex is designed to help people create these sites and use the criteria of the Life Safety Code when that is practical and alternatives where the strict requirements of the code can’t be applied,” Harrington says. The proposed annex will open for public comment in March 2022.

Not all of the proposed code changes that emerged during COVID-19 will ultimately succeed. For example, another idea that was born during the pandemic was to install equipment to bathe hospital spaces in ultraviolet radiation, with the hope that doing so would kill airborne pathogens. The individuals who proposed the idea asked that such technology be required for all public spaces, including restrooms and lobbies. But the code makers decided — after being lobbied by ASHE advocates and other interested parties — that requiring such technology would be an overreach.

“We didn’t think that’s the right thing to do,” Flannery says. “Adding technology like that should be based on a risk assessment. Does a public toilet room on my first floor waiting area need ultraviolet germicidal irradiation? Maybe, or maybe not, but performing a risk assessment is the best way to determine what the best approach would be.”

However, the ICC did propose guidelines on how to deploy such technology safely, if a hospital were to choose to use it, Williams says. The guidelines indicate the specifications of such equipment and how it should be installed.

Keeping codes unified

The flood of potential code changes due to COVID-19 has exacerbated another perennial concern: keeping the codes that affect hospital facilities unified. ASHE advocacy staff has made big strides in this area over the past few years, but COVID-19 put those efforts temporarily on the back burner.

For example, on the issue of temporary structures, which is fresh ground for code writers, making sure the various codes do not contradict one another is an important challenge. “Neither the FGI nor ICC have something on the books that comprehensively deals with temporary health care structures,” Williams says. “Now we’ve got two similar concepts developing on parallel lines, and we’re trying to link those two conversations up so that we’re approaching it with the same sensibility. We’ve got folks involved in both the ICC Committee on Healthcare and FGI emergency conditions white paper development. As these drafts solidify and gather support, we need concentrated attention to make sure they align.”

Flannery adds that the ICC Committee on Healthcare also will be watching the changes to NFPA codes to ensure alignment. “We’ll do our absolute best to try and align them as they go forward in all of those areas,” Flannery says. 

Rapid response

The pandemic also provided an opportunity for ASHE members to get more involved in dealing with key issues. 

One avenue for that was the COVID-19 Response Team, which ASHE established at the outset of the pandemic to help the association keep tabs on the situation and, when appropriate, disseminate information on how to best deal with it. The team, which was made up of ASHE members from across the country, conversed via the internet weekly. Flannery estimates that 90% of the information on ASHE’s COVID-19 resources site emerged from those calls. The team still exists but now covers other urgent issues, not just COVID-19, Flannery says. And its name has changed to the Rapid Response Team. Among the regular participants in the call is Kathryn Quinn, MHS, CHSP, safety officer at Saint Alphonsus Health System in Boise, Idaho.

“Initially we focused on pandemic-specific issues due to the crisis, and many other regulatory or operational concerns were pushed to the back burner,” Quinn says. “But, nonetheless, those issues were persisting in the background. And, so, the Rapid Response Team has really helped to integrate the ongoing COVID-19 concerns with other leading topics in facilities engineering.”

Among the issues the Rapid Response Team dealt with during the pandemic was whether hospital ventilation systems were adequate for safely managing the pathogen, especially when patient care surge locations were needed in unique spaces, Quinn says. The group discussed their respective HVAC systems, air filtration capabilities and the adjustments needed. They also considered how to manage oxygen supply and other operational needs in an alternate care location.

And when the Occupational Safety and Health Administration issued an emergency temporary standard (ETS) on vaccination and testing, the Rapid Response Team looked at how hospital facilities managers should respond, says Richie Stever, CHFM, CLSS-HC, LEED AP, vice president of real estate and property management at the University of Maryland Medical System, another regular participant in the calls.

“Learning what others were doing [regarding the ETS] was helpful in guiding us on how we should do things,” Stever says. “Not that we weren’t doing it already, but just having a partner out there going through the same thing with maybe a slightly different lens was helpful in our journey to compliance.”

The discussions during the calls are helpful for the team members themselves but, ultimately, the information derived from the meetings is disseminated through ASHE publications, Flannery says.

“After we discuss a topic, often we’ll say, ‘Yeah, let’s do an article on that,’ or ‘Let’s put a tool together for that,’” Flannery says. “Then I’ll get it back to an individual who had input or something like that on a call and we’ll create something.”

Participation in the Rapid Response Team is by invitation only, but Flannery welcomes inquiries from ASHE members who would like to join when a spot opens. He can be contacted at

Advocacy evolution

As COVID-19 normalizes and hospitals become more accustomed to the challenges of the pandemic, ASHE’s advocacy efforts will continue to evolve.

“COVID-19 is still impacting our work, and probably will for a while, but we also need to focus on other advocacy issues in 2022,” Beebe says. “There is a lot going on that needs to be addressed.”

Ed Avis is a Chicago-based freelance writer and regular Health Facilities Management contributor.