ASHE's Advocacy team is uncovering the best ways to enhance pandemic preparedness and sustainability.

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Hospital facilities managers faced countless challenges during COVID-19, and now the American Society for Health Care Engineering (ASHE) and other organizations are striving to make sure that the next time a pandemic hits, it won’t be quite as tough. How? By uncovering the lessons of COVID-19 in white papers, reports and other documents.

But, for ASHE, a key part of that “lessons-learned” process is ensuring that these documents don’t create new burdens for health care facilities professionals and that the code changes that result from the process do not conflict with each other. ASHE advocacy staff is accomplishing those goals by sitting on various committees that are working on these documents and by monitoring the results closely.

“We are helping these committees make the best possible suggestions from the facilities perspective,” says Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, senior associate director of advocacy for ASHE. “And, as far as code unification is going, our efforts are doing very well. We’ve put together a crosswalk that compares the National Fire Protection Association (NFPA) codes, the International Code Council (ICC) codes and the ASHRAE codes. And we add in the Centers for Medicare & Medicaid Services (CMS) standards. We feel right now that if the latest edition of each code was adopted, we’d be right around 98% unified.”

While COVID-19-related issues are still on the forefront, ASHE advocacy staff also is keeping a focus on code overreach, sustainability and other issues.

COVID-19 lessons

Numerous efforts are underway to put into writing the lessons of COVID-19. For example, the ICC is preparing an appendix to the International Existing Building Code that aims to provide guidance related to temporary health care occupancies. ASHE’s Senior Associate Director of Advocacy Leah Hummel, AIA, CHFM, CHC, who joined ASHE in February after seven years at The Joint Commission, is on the committee assisting with that appendix.

“The COVID pandemic has really brought to the forefront the need for temporary facilities to be used for health care in response to needing additional surge capacity within our facilities,” Hummel says. “But organizations were wanting to open up these temporary facilities in buildings or portions of buildings that weren’t really designed for that use. And so, organizations were challenged by their authorities having jurisdiction (AHJs) to meet their requirements for health care that are pretty stringent and that these buildings weren’t necessarily designed for. So, by having some levels of safety defined or maybe eased up in some cases while still providing a level of safety, the changes will really help organizations — not just in this pandemic, but in other situations in the future where they will have the need for surge capacity.”

Other efforts to capture COVID-19 learnings are underway from NFPA, ASHRAE and others. Each of these groups is focusing on its area of specialty, which means there could be overlap or conflicting recommendations. To help alleviate that, the ICC has created a task force to examine all the efforts and create one holistic document that incorporates the best ideas from each.

The ICC’s task force formed in December 2020 in conjunction with the National Environmental Health Association (NEHA). The task force includes 24 members representing a broad cross-section of the industry, including individuals from the American Institute of Architects, the National Association of Home Builders, ASHRAE, the National Center for Healthy Housing and several others. ASHE is represented on the committee by Flannery and Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director.

The group’s first task was to review the pile of documents currently available, explains Jim Cika, director of plumbing, mechanical and fuel gas technical resources at ICC. The 24 task force members formed four working groups — architectural/structural, fire service, mechanical-plumbing-electrical and remote operations.

“This task force is attempting to look at the situation holistically,” Cika says. “They are figuring out how all these things intertwine when you’re looking at a building as a whole. Because they all tie together, you can’t just change something without it potentially snowballing somewhere. That’s what the task force was targeted with, trying to look at this with a holistic approach.”

The second phase, which has been underway since the end of 2021, is developing best practices from all the disparate pieces. Each working group is reporting to the body with their recommendations and, by the end of 2022, those should all be assembled into one document, Cika says.

The final phase will be to incorporate those recommendations into the ICC codes as appropriate.

“The end goal is to look at all these best practices and determine if the building codes need to be changed or modified based on our findings,” Cika explains. “So, we will, as the third phase, take all of our learnings and come up with lists of proposed changes for the building codes as we go through our code development process for 2024, which will actually be for the codes that are published in 2027.”

Preventing overreach

The creation of these documents regarding pandemic situations will help AHJs decide if proper precautions are being taken when temporary structures are built or other pandemic-related actions are taken, of course, but ASHE advocates are ensuring that the documents do not create needless burdens.

For example, one concept in the ICC appendix on temporary health care occupancies relates to the structural durability of tents, modular buildings and other structures that were commonly erected in hospital parking lots during COVID-19. John Williams, an executive director at the Washington State Department of Health, who chairs the ICC’s Committee for Healthcare, explains that the draft of the appendix was revised to address the on-the-ground reality of such structures.

“Temporary structures are typically rolled out quickly, and there is always some risk of an additional environmental impact like a windstorm or an earthquake aftershock that could compromise the structure,” Williams says. “While it’s a good idea to interrogate the durability of those temporary structures, there also needs to be a conversation about what realistically happens if a tent falls down. There would be immediate consequences to the people inside of it, but if making the tent or modular building more robust prevents it from being deployed within the time frame needed, we have a gut check to do. We need to strike a balance between being safe enough and meeting the needs of the situation.”

Another example of an effort to ensure that requirements are manageable relates to a proposed requirement in the ICC appendix that the means of egress of a temporary structure meet the requirements of a normal health care occupancy, Flannery notes. That would completely wipe out the potential use of hotels as temporary health care facilities, because hotel hallways are typically much narrower than the 8 feet required by code.

“We were able to get that changed to say that you wouldn’t reduce the means of egress of the existing facility,” Flannery says. “So, if the existing egress of that facility was not as good as a hospital, it doesn’t matter, as long as you don’t reduce the egress opportunities.”

Another issue ASHE is pushing back on is a proposed requirement to include carbon monoxide (CO) detectors in health care facility sleeping rooms. This idea is being put forth for the International Fire Code. The scenario is that a CO buildup could indicate an increased risk that the ventilation is not adequate. Flannery explains that ASHE opposes this provision because there is no evidence that CO is a problem now, and since health care sleeping rooms are required to be well ventilated already, the increased requirement would not provide a reduction in risk.

Beebe notes that obviously ASHE is not opposed to a life-saving device, but there’s no evidence that CO detectors in hospitals would save lives.

“It needs to be in a scalable approach because, in many hospitals, we wouldn’t have fuel-burning appliances that would give off carbon monoxide on the patient floors or attached to the sleeping areas,” Beebe says. “So, the whole concept of requiring carbon monoxide detectors in every single patient room is an overreach. I think the money could go to better patient care options over that.”

Improving the codes

In addition to preventing code overreaches, ASHE has been advocating to improve existing codes and unify them as appropriate.

For example, Beebe reports that an error was discovered in the 2018 edition of NFPA 99, Health Care Facilities Code, that technically limits health care facilities from using oxygen above the fifth story of a structure. The section in question is called “Maximum allowable quantity of hazardous materials.” Because oxygen is an oxidizer, it is considered a hazardous material, and the regulation states that the amount of hazardous material allowed above the fifth floor drops by 25% per floor.

“That limitation would, of course, basically eliminate the ability to do health care on higher floors because we depend on oxygen too much,” Beebe says.

Beebe says ASHE advocacy staff is trying fix this error for the 2024 edition, but he also hopes to affect a correction to the 2018 and 2021 editions. CMS is still using the 2012 edition, so the rule doesn’t apply to hospitals yet, but it’s unknown which edition CMS will adopt next.

Getting the situation changed is not a slam dunk, Beebe says.

“The NFPA 99 committee feels there’s a hazard that exists, but we have not seen any data that would suggest that there is a hazard,” he says. “We have a long history of medical gases being used throughout high-rise floors without incident in the U.S.”

A code alignment issue that ASHE advocacy staff is dealing with regards the usage of alcohol-based hand rubs (ABHRs) in business occupancies. ABHR usage went through the roof during COVID-19, but building codes prohibit it in business occupancies because it supposedly could explode during a fire.

Flannery notes that computer modeling has revealed that ABHR dispensers will not blow up in a fire and, in fact, they don’t really even catch fire. Additionally, there is no documented case of a fire made worse by ABHR. Health care occupancies are already permitted to have ABHR dispensers, and aligning other codes to allow ABHR usage in business occupancies simply makes sense.

“We worked with several other folks and made changes in the International Fire Code and the International Building Code, and those same groups work with NFPA for the Life Safety Code,” Flannery says. “So, in the end, we’ll have it all aligned and the codes will allow for proper ABHR usage anywhere.”

Sustainability is key

COVID-19-related issues are not the only focus of ASHE advocacy staff. Another key issue is sustainability, particularly the drive to decarbonize health care buildings. This refers to reducing the amount of carbon-based fuel these buildings use.

Naturally, ASHE supports decarbonization efforts thoroughly, but advocacy staff works to make sure patient needs are not jeopardized in the drive to decarbonize.

“ASHE supports the changes health care facilities make to their utilities, infrastructure and their facilities to reduce carbon usage, but it’s important that they still support patient safety and don’t go so far in the other direction that patient safety is impacted,” Hummel explains. “For example, we need to make sure hospitals still have ventilation that ensures infection control concerns are met, water systems that effectively limit the growth of Legionella or other waterborne pathogens, and electrical systems that provide the redundancy that’s needed to make sure that all of the things that are required to be on essential power, like life safety components and critical utilities and equipment, may remain operational whenever a facility is occupied. We want to work out some of those challenges and really provide a blueprint for organizations to meet the challenges to decarbonize, but also meet the requirements for patient care.”

As with other issues, ASHE is helping the decarbonization effort by contributing to committees focusing on the topic. For example, several ASHE representatives are working on a program of the National Academy of Medicine called the Grand Challenge on Climate Change, Human Health and Equity.

The Grand Challenge has four objectives: to communicate the climate crisis; develop a roadmap for systems transformation; catalyze the health sector to reduce its climate footprint; and accelerate research and innovation on the topic.

Kara Brooks, MS, LEED AP BD+C, ASHE’s senior associate director of sustainability, sits on two subcommittees of the Grand Challenge — one focusing on policy financing and metrics, and one on supply chain and infrastructure.

“The collaborative is kind of a public-private partnership,” Brooks says. “They are looking at lots of different areas within health care and learning what can be done. They’re really digging into all aspects.”

Brooks also serves on an ASHRAE work group on decarbonization. She explains that the two groups have somewhat different focuses on the same topic. “ASHRAE is looking at the planning and design of health facilities, while the National Academy of Medicine effort is higher level; it’s really trying to inform policy and regulations,” she says.

Long-term focus

As noted above, ASHE advocacy staff members have full agendas on a wide range of issues. However, sustainability is an issue that will outlive COVID-19 and continue to affect health care facilities perpetually, Beebe predicts.

“Sustainability is going to be a big factor in everything that we do going forward,” he says. “When we do our advocacy, we’ll continue to look at ways that we can improve the codes to acknowledge newer technologies in a quicker fashion. These will often address advancements in sustainability.” 

Writing a procedural document for ANSI/ASHRAE/ASHE 170

American National Standards Institute (ANSI)/ASHRAE/American Society for Health Care Engineering (ASHE) Standard 170, Ventilation of Health Care Facilities, is widely used by facilities managers working to maintain their systems. However, it is a design standard, not an operational standard, which limits its use in that regard. An ASHE/ASHRAE work group began efforts late last year to remedy that situation by creating an operational standard based on Standard 170.

Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, senior associate director of advocacy for ASHE, leads the working group. He explains that an operational standard based on Standard 170 will provide more flexible parameters for several real-world issues. For example, Standard 170 specifies that the temperature of an operating room be 68 to 72 degrees, which is manageable from a design standpoint. But, in day-to-day operations, that range could easily be exceeded.

“A surgeon may want it cooler or, if you have burn victims in there, the space needs to be hotter,” Flannery says. “When you’re doing surgery on burn victims, you want to have the room around 85 or 90 degrees, actually. So that’s why we’re in the process of writing an operations guide.”

Another reason the committee is developing the operational standard is that the Occupational Safety and Health Administration (OSHA) is seeking to adopt ANSI/ASHRAE/ASHE Standard 170 as a retroactive standard for the safety of health care workers, explains Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director of ASHE.

“We are opposed to OSHA’s adoption of ASHRAE 170 because it is not an operational standard, it’s a design standard,” Beebe says. “It’s not intended for an organization to maintain exactly to those standards 100% of the time. For example, there might be a temperature called out for a certain room, or a certain number of air changes, but anything in the environment can change that at least momentarily.”

Beebe says it would be preferable if OSHA did not use any version of Standard 170 as its standard, because that would mean one more adoption that would need to be coordinated to keep unified with the Centers for Medicare & Medicaid Services’ Conditions of Participation. But if OSHA persists in that effort, having it adopt an operational standard instead of a design standard makes more sense.

Flannery predicts the work group will have a draft ready for public review by summer 2023. 

TJC resumes survey activity with new occupancy standards

The Joint Commission (TJC) has resumed its health care facility surveys in practically the entire country, reports Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, senior associate director of advocacy for the American Society for Health Care Engineering (ASHE). TJC paused surveys during COVID-19. These surveys are the first since the organization released new standards related to business occupancies last summer.

Not surprisingly, the new standards have raised some questions. “A lot of questions have come up from our members about application of the new TJC standards,” says Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director of ASHE. “We know that TJC is revising those standards, and we look forward to the requirements becoming more clear.”

Leah Hummel, AIA, CHFM, CHC, senior associate director of advocacy at ASHE, was employed by TJC when the new standards were issued and she worked on some of those revisions, which have not yet been published.

“For example, there is an element of performance regarding protection of hazardous areas in business occupancies,” Hummel explains. “Within the Life Safety Code, the requirements for hazardous areas in business occupancies are a little bit unique compared to health care occupancies in that, if the building is sprinklered, you don’t have to have the room protected with a smoke partition and a self-closing door. But the wording of TJC element of performance requires that the room, even if it is sprinklered, also is protected with smoke partitions and a self-closing door. So that was one of the elements of performance that was questioned, by not just ASHE but also other organizations. So, it needed to be revised.”

Hummel praises the thoroughness of the process of revising TJC standards: “Having been on that side of the fence and really seeing what goes into evaluating a question from an organization or a clarification that’s submitted after survey, I have a lot of appreciation for the complexity of those decisions and really having to parse the wording of the code and understand what’s required by the Centers for Medicare & Medicaid Services. It’s complicated, and there’s a lot that goes into it; it really requires a thoughtful evaluation and response.” 

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