Image by Getty Images

Midway through 2023, the American Society for Health Care Engineering (ASHE) is celebrating recent advocacy successes, taking on new challenges and looking ahead to possible changes coming down the line.

The ASHE Advocacy Team is focusing on pressing issues like sustainability, improving operational optimization, unifying codes and standards, pushing for Centers for Medicare & Medicaid Services (CMS) updates, and improving the life and safety codes and standards that protect patients and staff, and streamline operations for facilities managers.

ASHE also continues its work to ensure facilities managers are fully appreciated and recognized for the value they bring to health care as a whole, says Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director at ASHE.

“ASHE advocacy is much more than the work we do on committees,” Beebe says. “We are working with policymakers, code officials, health care administrators and ASHE members to advocate for the field as a whole so that it’s clearly understood that facilities managers play a critical role on the health care team.”

This month, Health Facilities Management looks at some of the ASHE Advocacy Team’s key issues and areas of focus midway through the year.

Sustainability measures

The issue of sustainability looms large for health care, and changes are happening quickly. While sustainability is primarily voluntary, mandates could be on the horizon. Health care, which is responsible for 9% of greenhouse gas (GHG) emissions, including carbon dioxide, has a considerable stake in sustainability. 

Decarbonization — reducing or eliminating carbon dioxide emissions — could improve health for everyone and reduce the costs of care. While the upfront costs are steep, sustainability could also save hospitals millions of dollars in energy and operational costs, Beebe says.

Because of the urgency of climate change and mounting pressure to achieve U.S. goals to cut GHG emissions by as much as 50% by 2030, sustainability measures impacting health care are happening quickly on the local, state and federal level.

Beebe points to a New York City law set to take hold in 2024 that puts carbon caps on buildings bigger than 25,000 square feet, including nonprofit hospitals and health care centers. Hospitals that don’t meet emissions targets could face fines for every ton of emissions above the limit. On the state level, Washington is enacting a similar law requiring businesses that emit over 25,000 metric tons of carbon a year to pay for each metric ton in total. The law takes effect in 2024.

On the federal level, the Securities and Exchange Commission is considering a proposal to require public companies to disclose the GHG they produce, which would impact roughly 25% of U.S. hospitals. In March, The Joint Commission announced it is seeking comments on proposed new requirements to address environmental sustainability for hospitals and critical access hospital programs. The proposed standard focuses on the role of leadership in helping hospitals reduce their carbon footprints.

ASHE is advocating against states and the federal government adopting sustainability standards and targets for health care. Instead, ASHE wants hospitals to voluntarily establish their own carbon reduction goals, Beebe says. 

“We believe that it’s an organizational choice to determine appropriate methods and targets for sustainability,” Beebe says. “Regardless, states are imposing targets that are unrealistic for even the best-performing hospitals. It would be better to have consistency between the states using the same targets so that health care systems don’t have the additional burden of varying standards.”

To help hospitals, incentives are in the works for investing in sustainability. ASHE advocates are waiting for details on expanded tax credits for U.S. companies that adopt energy-saving technology under the Inflation Reduction Act of 2022, says Kara Brooks, MS, LEED AP BD+C, senior associate director of sustainability at ASHE.

“We are waiting for the U.S. Treasury to issue guidance on tax deductions that will be available to hospitals, including nonprofits. Hospitals that qualify will get tax credits for implementing energy efficiency projects,” says Brooks, co-lead of the American Hospital Association sustainability team working to develop an environmental sustainability agenda.

Brooks urges hospitals to take action wherever they can. Transitioning to renewable energy sources, switching to LED lighting, reducing operating waste and integrating sustainability into the supply-chain process are key focus areas. Along with its Energy to Care® Program, ASHE offers extensive education, resources and tools, including a comprehensive sustainability guide.

Alignment and clarification

The ASHE Advocacy Team often devotes years to advocating for code changes or clarifications with the goal of improving patient safety and hospital operations. Halfway through 2023, the team is realizing progress on several fronts. ASHE is making progress in aligning conflicting codes and standards that can cause roadblocks and setbacks in projects ranging from building design to installing carbon monoxide detectors. Because coding bodies, including the National Fire Protection Association (NFPA), the International Code Council (ICC) and ASHRAE are continually updating codes and standards, efforts to keep them aligned are continuous.

“ASHE has spent the past 13 years working to unify codes and standards. They are roughly 97% aligned,” says Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, senior associate director of advocacy at ASHE.

One example: In 2021, the ANSI/ASHRAE/ASHE Standard 170, Ventilation of Health Care Facilities, which provides key guidance on ventilation requirements, was updated to align with the new Facility Guidelines Institute (FGI) classification system for imaging rooms issued in 2018.

“The ASHE Advocacy Team is in a good place now in terms of code unification,” says Leah Hummel, AIA, CHFM, CHC, senior associate director of advocacy at ASHE. “As issues come up in the code process, we always consider the potential impact on other codes.”

Already this year, ASHE scored three wins related to NFPA 101®, Life Safety Code®, and portions of NFPA 70®, National Electrical Code®. The ASHE Advocacy Team serves on the NFPA Healthcare Interpretations Task Force (HITF) representing health facilities management. 

Rather than changes to existing codes, ASHE suggested critical clarifications that were approved by NFPA. “Often hospitals get cited for reasons involving a code interpretation, so clarifying a regulation can have an impact in terms of reducing extra work and improving operations for facilities managers,” Flannery says. 

In the case of spare circuit breakers, facilities managers were bound by a Joint Commission interpretation requiring that spare circuit breakers be in the “off” position even when not connected to electricity. The 2011 edition of NFPA 70 was neutral on whether spare circuit breakers should be in the “on” or “off” position.

After gathering member input and data, ASHE concluded that the decision should be up to the individual facility. This year, ASHE successfully passed a clarification to NFPA 70 specifying that the code does not require properly labeled spare breakers to be kept in any specific position, whether on or off.

Another ASHE clarification helps clear confusion regarding labeled fire doors, which are often located in areas not covered under NFPA but have been held to the same requirements. NFPA approved a clarification to NFPA 80, Standard for Fire Doors and Other Opening Protectives, stating that doors with a fire protection listing label don’t have to be inspected and tested annually if they don’t require a fire-resistance rating. 

“If a door assembly has to be maintained and inspected just because the door has a label on it, this could result in expensive and unnecessary work that has no impact on life safety,” Flannery says.

The NFPA HITF also adopted an ASHE clarification that ice machines are not required to be provided with ground fault protection unless otherwise required by Article 210.8 of the National Electrical Code. 

ASHE has contributed these and many other changes and clarifications to the 2024 editions of NFPA 101 and NFPA 99, Health Care Facilities Code, which will be published later this year. NFPA codes are on a three-year revision cycle that was last updated in 2021.

Code adoption matters

Even when ASHE successfully pushes through changes and clarifications to existing codes and standards, the victory isn’t yet complete. When NFPA publishes updated standards, changes won’t go into effect until CMS adopts them. CMS only updates its standards every 10 to 15 years.

In 2016, CMS adopted the 2012 editions of NFPA 101 and NFPA 99, which hospitals are still operating under. ASHE is continually lobbying CMS to update its standards to incorporate ASHE changes that reflect the quickly changing health care landscape. Technology alone is light-years from where it was a decade — or even five years — ago. 

The lengthy CMS updating process can hinder progress for hospitals working to improve operations, staff performance and safety; patient care; and adopt sustainability measures. 

“In the past decade, ASHE has successfully lobbied for at least 600 positive changes to the codes and standards regulating hospitals,” Beebe says. “Those changes alone justify updating CMS codes. We are continually petitioning policymakers at CMS to go into the rulemaking process to update its standards or consider category waivers to lessen the burden for facilities managers.”

The ASHE Advocacy Team is also working to identify sustainability measures that could be realized if more recent codes were adopted.

“There have been major changes to ANSI/ASHRAE/ASHE Standard 170 since the 2008 edition, which is referenced by the 2012 edition of NFPA 99,” Hummel says. “Particularly in outpatient facilities and nursing homes, the latest changes allow for lower ventilation rates and make it clear that unoccupied turndown is permitted for certain spaces in all health care facilities. This has big potential to lower energy usage anywhere from 10-50% for these facilities.”

The ASHE Advocacy Team uses data from research and hospital surveys to back up proposed changes. For example, ASHE is compiling data from hospitals on fire extinguisher inspections regulated under NFPA 10, Standard for Portable Fire Extinguishers. The average hospital has one fire extinguisher every 75 feet, making inspection a huge job and added expense, especially in large facilities.

While hospitals are required to inspect every fire extinguisher once a month, data shows that less than 1% of inspections fail. ASHE is advocating for a performance-based inspection based on data from individual hospitals. Hospitals that meet a specific percentage of pass rates would be allowed to reduce their inspection rates; or a hospital might need to inspect fire extinguishers more than once a month based on pass/fail rates. “The vast majority of hospital inspections will be reduced,” Flannery says.

Other compliance issues

Updated every four years, the FGI’s Guidelines for Design and Construction has started its 2026 revision cycle. The FGI Guidelines, widely recognized for planning, designing and constructing health and residential care facilities, recently finished its public proposal period.

Hummel serves on the FGI Steering Committee and the FGI Health Guidelines Revision Committee for this revision cycle, which will meet to review and vote on all proposals submitted by the public and committee members.

“Although the documents are called ‘guidelines,’ they are enforceable when adopted by states or referenced in state laws, codes, rules or regulations,” says Hummel. “Forty-three states have adopted some version of the FGI Guidelines, so it’s really important that we advocate for our members in the revision process.”

The ICC is in the beginning stages of its 2024-2026 revision cycle with the first round of code proposals due by Jan. 8, 2024. The ICC has revised its rigorous code development process to create an integrated and continuous three-year cycle. The changes will take effect between 2024 and 2026 for the development of the 2027 International Codes.

Among its updates, ASHRAE recently completed the first draft of its standard for maintaining healthy indoor air quality, with publication planned for the summer.

Getting involved

ASHE doesn’t limit its advocacy focus to codes and standards. It’s also guiding facilities managers in advocating for themselves. ASHE encourages professionals to stay on top of the evolving health care landscape. Navigating fast-moving changes to codes and standards requires up-to-date skills, Beebe says. 

“We are advocating to elevate facilities managers across the board,” Beebe says. “A lot of the process is helping facilities managers connect the dots between best practices and operational optimization.”

ASHE is developing tools and resources to help managers play a role in their own futures. Staying up to date on codes and standards — and participating in the process — is especially important as health care moves into new territory, like sustainability. ASHE encourages members to play an active role in developing and changing the regulations that shape hospital operations and impact their careers. 

“Facilities managers are the ones really impacted by these regulations, so we encourage them to get involved, whether suggesting changes or giving public input on proposed changes,” Flannery says. “It’s really a two-way street, and the ASHE Advocacy Team is just one part of it.”

Beth Burmahl is a freelance writer based in Carbon Cliff, Ill.