ASHE spells success in its work to unify conflicting codes.

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The American Society for Health Care Engineering’s (ASHE’s) Advocacy Team maintains a wide range of initiatives affecting innumerable aspects of health care facility design, construction, engineering and operations.

Whether pursuing sustainability goals, monitoring and unifying many overlapping codes and standards, working to revamp outdated regulations, or addressing emerging and long-standing issues, the advocacy team’s work allows health care facilities to optimize their physical environments and focus more of their valuable resources on patient care. 

This month, Health Facilities Management looks at some of the ASHE Advocacy Team’s key initiatives and areas of focus for the new year.

Focus on decarbonization

The urgency of climate change, the global focus on decarbonization and the U.S. government’s ambitious agenda to tackle the climate crisis are pressuring health care — one of the biggest contributors of carbon emissions — to take a serious approach to sustainability in the new year. 

As a field, health care contributes almost 9% of total carbon emissions in the U.S. T

o put it in perspective, if the health care sector was a country, it would be the fifth-largest emitter of greenhouse gases on the planet, according to the group Healthcare Without Harm. Decarbonization refers to reducing the amount of carbon-based fuel that buildings use.

With no time to spare, sustainability will be a primary focus of ASHE advocacy in 2023, says Chad E. Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director at ASHE. 

“Sustainability needs to be a main focus right away,” says Beebe. “Health care has one of the largest carbon footprints. We have a responsibility to improve our community’s health, and our patients’ health, by providing a better environment. Health care is often one of the largest employers. And communities look to health care to lead the way.”

“Health care is in a unique position,” says Kara Brooks, MS, LEED AP BD+C, senior associate director of sustainability at ASHE. “The impact of climate change affects the people we care for, yet health care is a contributor to the problem. Those factors are converging at the same time.”

Developments in 2022 have laid the foundation for the new year. Available capital is shifting toward companies that embrace energy efficiency initiatives. The 2022 Inflation Reduction Act expanded tax credits for U.S. companies that adopt energy-saving renewable technology. And, for the first time, these credits are available to nonprofits, which includes more than half of U.S. hospitals.

While sustainability measures are primarily voluntary, down-the-road mandates may be necessary to meet U.S. goals to cut greenhouse gas emissions by as much as 50% by 2030. In 2022, the Securities and Exchange Commission proposed a new rule that would require public companies to disclose greenhouse gas emissions they produce, which would impact roughly 25% of U.S. hospitals. At press time, no decision had been made. 

Depending on emerging regulations, facilities departments now responsible for energy accounting may one day be tasked with calculating how much carbon dioxide and other greenhouse gases the hospital emits, according to ASHE leaders. To help, ASHE recently added the ability to track carbon abatement to its Energy to Care Dashboard tool.

Whether or not the hospital’s CEO develops a sustainability strategy, facilities managers need to be proactive about making changes.

“Energy savings has traditionally gone to the facility manager, and the facilities team will have a major role in expanding sustainability in a broader way,” says Brooks. “The biggest challenge is achieving decarbonization, which might include transitioning to renewable energy and other efforts, such as tackling embodied carbon. For facilities departments, that should start with the low-hanging fruit, which is an easy way to make a big impact. Once you optimize the facility, the next step is to transition to an electrified building.”

“There are so many things a facility manager can do that don’t require CEO approval,” Beebe says. “Electricity is still the biggest piece of sustainability, so things like putting in occupancy sensors, trading out light fixtures to LED, turning lights off on vending machines. All of it adds up quickly.”

Beebe also suggests hospitals negotiate with their local utilities to improve energy efficiency. As one of their largest customers, hospitals have leverage with utility companies.

ASHE will advocate for sustainability throughout 2023 with education, resources and tools, including a comprehensive sustainability guide that helps managers take a proactive approach to sustainability, no matter how far along they are in the process (see sidebar on page 23).

ASHE advocates including Brooks, Beebe and Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, ASHE’s senior associate director of advocacy, represent facilities managers on sustainability committees for ASHRAE, the National Fire Protection Association (NFPA) and the International Code Council (ICC). Brooks is co-lead of an American Hospital Association policy team working to develop a sustainability agenda.

Updating CMS standards

Sustainability also ties into another ASHE priority: getting the Centers for Medicare & Medicaid Services (CMS) to adopt updated standards that would allow health care to move forward with critical, resilient sustainability measures that will improve energy efficiency and lower energy costs.

In 2016, CMS adopted the 2012 editions of NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities Code, which hospitals are still operating under. The federal government updates CMS standards every 10 to 15 years.

NFPA codes have long overseen microgrids that have traditionally been part of health care energy systems in the form of diesel generators. Microgrids operate independently of the main power grid and provide backup power during outages.

For the first time, a 2021 NFPA standard references a “health care” microgrid, a more sophisticated system that relies on renewable energy like fuel cells, photovoltaics, wind and geothermal, providing additional redundancy and resiliency beyond a traditional system. In referencing a health care microgrid, NFPA acknowledges the specific electrical requirements unique to health care.

“When you have all of these potential energy sources, you can switch between them to provide constant power,” Beebe says. “That means the whole concept of backup power with a diesel generator no longer makes sense. Hospitals could use a health care microgrid as part of the essential electrical system.”

Considering the urgency of sustainability, the rapid advancement of technology and the lengthy process for approving new codes, Beebe says CMS should treat these NFPA updates as evergreen provisions, meaning they would be adopted as they are released.

ASHE is pushing CMS to update its standards overall to help hospitals improve efficiency across the board, reach budget goals and prepare for the next generation of health care.

Code unification and improvement

ASHE continues to lead the effort to unify codes that affect health care facilities, including those from NFPA, CMS, the ICC and ASHRAE. Conflicting codes can be a major roadblock for hospitals, says Leah Hummel, AIA, CHFM, CHC, ASHE senior associate director of advocacy.

“Hospitals are often held to standards from different regulating bodies that require different things,” Hummel says. “For example, a hospital could be required to build a construction project under local laws that don’t align with CMS standards. When that happens, hospitals are held to the most restrictive code. ASHE is constantly advocating for codes and standards to be written in a unified way.”

While it took years, ASHE scored a victory in aligning two different standards for regulating lay-in ceilings. 

The International Building Code (IBC) limits the usage of lay-in ceilings in hospitals because they are not considered adequate to stop the passage of smoke, while NFPA 101 considers lay-in ceilings to be adequate. “Fire marshals want the hard ceilings, which are better when it comes to protecting from smoke migration, but for maintenance operations, hard ceilings are much more difficult to work with,” Flannery says. “They make it difficult to access things like plumbing, HVAC systems and electrical wiring above the ceiling.” The IBC requirement was eventually changed.

ASHE also works to improve codes, which sometimes can mean changing just a few words in the standard. For example, ASHE felt that an NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, code regulating sprinkler pipes above ceilings was overly restrictive. 

The requirement said that nothing could rest on a sprinkler pipe above the ceiling, which is unrealistic, Flannery says. “Above the ceiling, there are thousands of cables and wires, so it’s really difficult to not have a single thing touch the sprinkler pipe,” he says. “A lot of hospitals were getting cited for this.”

ASHE lobbied NFPA for two code cycles, and the request to change the regulation in a small but critical way was recently approved. “The wording now says the sprinkler system cannot ‘support’ anything versus ‘touch’ anything,” Flannery says. “This will go a long way in reducing the burden on facilities managers.” The change will be included in the NFPA 2023 edition but won’t be effective until CMS adopts updated life safety codes.

In previous editions of the codes, ASHE scored another win related to alcohol-based hand rubs (ABHRs), which soared in use during COVID-19 and have been permitted in health care settings for over a decade — a change advocated by ASHE. Nevertheless, ABHRs, which are regulated by NFPA 101 as well as NFPA 1, Fire Code, were once prohibited in businesses because it is believed that the fire risk outweighed the use risk.

ASHE used data with computer modeling to demonstrate that installed ABHR dispensers present far less fire risk than the potential infection control issues related to not having the dispensers.

ASHE worked with the ICC Committee on Healthcare and other organizations to develop a proposal that will provide guidance on how to properly place, use and store ABHRs for all occupancy types. Flannery says the proposal has been approved. “ASHE has knowledge in this area, and we are working to share that as part of a unified code effort,” he says.

ASHE also got a change to a recent International Fire Code (IFC) proposal that would require carbon monoxide (CO) monitors in all sleeping rooms in buildings. Unlike other buildings such as hotels, Flannery says CO detectors aren’t necessary in every patient room, which already have strict ventilation requirements. The IFC Committee on Healthcare updated the proposal for health care, stating, “In health care facilities, where carbon monoxide detection is provided in the space containing the CO source, and the carbon monoxide alarm signals are automatically transmitted to an approved location, carbon monoxide detection is not required in each sleeping unit.”

Infection control role

Infection control remains central to ASHE’s advocacy efforts in 2023 as it continues to build on its guidelines for an infection control risk assessment (ICRA) process, which is required during hospital design and construction projects. 

While hospitals are laser-focused on patients in terms of infection control, ASHE is recommending a more comprehensive approach to ICRAs going forward, Flannery says, broadening its focus to include not only contractors and construction workers, but also in-house hospital staff.

“We’ve known for decades that the health care physical environment impacts infection control, through construction that stirs things up and exposes people to mold or germs carried in dust,” Flannery says. “We focus on sealing construction areas off from occupied areas to protect patients, but we might have employees who are going into patient-occupied areas as well. We need to make sure the ICRA process [also] focuses on them and that we are doing proper mitigation strategies for our own employees’ work.”

Hospitals can assess infection control risk in maintenance, renovation and construction projects with the updated ASHE ICRA 2.0™, which includes tools and resources. 

Finally, ASHE continues to work on the massive job of incorporating infection-control lessons learned during COVID-19 into a unified, industrywide strategy.

ASHE plays a key role on an ICC task force created in conjunction with the National Environmental Health Association with the goal of developing best practices for infection control based on COVID-19 experiences. The task force includes 24 members representing a cross-section of the industry, including the American Institute of Architects, ASHRAE and the National Association of Home Builders. Flannery and Beebe serve on the committee for ASHE. 

“Infection control is an extremely complicated issue, and it takes a lot of time to dig through all the information we have related to COVID-19,” Flannery says. “As an advocacy team, we are working to make sure these changes are part of a unified code effort.”

Thinking ahead 

Because codes and standards are constantly changing, unification will always be a major part of ASHE’s advocacy work. Along with code alignment, it has never been more important that codes and standards are written in a way that puts hospitals on a solid trajectory for the next generation of health care, Hummel says.

“Looking ahead, we want our codes and standards to allow health care to take advantage of the new technologies and improvements from every perspective, especially in terms of sustainability,” Hummel says. “There is such a lag time from when the code is written versus adopted, we need to think ahead to the future when we are developing regulations, considering how difficult they are to update or change.”