For years, hospitals have wrangled with conflicting, outdated and unnecessary code requirements that siphon resources from other priorities. And, although there is plenty of room for more continuity, code changes in recent years have helped to align the various codes regulating hospitals. These changes are making it easier for health care facilities to comply with the long list of codes and standards regulating them.

"We've made larger strides than we originally anticipated," says Chad Beebe, AIA, SASHE, director of codes and standards for the American Society for Healthcare Engineering (ASHE). "One of the reasons for the success is that we've been taking a very collaborative approach."


In 2011, ASHE teamed up with the International Code Council (ICC) to create the Ad Hoc Committee on Healthcare, a group that reviews ICC codes and recommends changes. The group includes a diverse membership — including fire officials, architects, building officials, hospital leaders, facility managers and engineers from around the country — which helps to provide a wide variety of viewpoints on various code issues. The group considers input from all interested parties, including manufacturers, product developers, patient safety and advocacy groups, industry experts and associations.

"Probably the greatest thing about the ICC Ad Hoc Committee process is that they bring everybody to the table," says committee member and ASHE Senior Associate Director of Advocacy Jonathan Flannery, CHFM, FASHE, MHSA. "There are some times when we have very lengthy discussions, and sometimes we struggle to reach consensus, but the wonderful thing is that everybody has input."

By considering multiple perspectives during the committee process, the group ensures that its proposals are well-vetted before they move to the ICC for consideration. This has helped the committee to gain wide support for many of its proposals.

During the most recent code development cycle, for example, the Ad Hoc Committee won approval of 38 out of 40 proposals.

For instance, one change will allow existing hospitals that are retrofitted to meet current building code standards to conform to the provisions of current codes. This proposal only applies to hospitals that bring their facilities up to current code standards, including being fully sprinklered. If a hospital built in 1980 is renovated to meet all aspects of 2009 building codes, the facility will be allowed to stop maintaining fire-resistance features that are not required in the 2009 codes.

Another change will increase minimum safety requirements for health care facilities and will bring the International Fire Code in line with other codes.

Specific changes include adding size restrictions on mail-slot, pass-through and similar openings found in hospitals for medication security and other operational needs. These restrictions are included in the 2012 edition of the National Fire Protection Association's NFPA 101: Life Safety Code. The change also states that portions of corridor walls required to have a fire-resistance rating by another code provision must meet that provision. This will help to bring the International Fire Code in line with the International Building Code, which already includes a similar provision. These retroactive requirements will assist code officials and surveyors during the ongoing regular inspection of hospitals. The requirements are consistent with the inspections required by federal laws for certification and reimbursement.

Yet another change details requirements for smoke compartments and also brings the International Fire Code in line with other requirements. This change also will bring noncompliant smoke barriers to at least a half-hour, fire-resistance rating (non-renovated smoke barriers are not intended to be reduced below what was required when these barriers were constructed).

About this series

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

In addition to those recent proposals being accepted, the Ad Hoc Committee also has had previous successes that create more unified, updated codes.

For example, one change increases the maximum smoke compartment size from 22,500 square feet to 40,000 square feet. This proposal reflects the current 200-foot travel distance and accommodates the needs of modern hospitals, where patient rooms have expanded to hold more equipment. Another change exempts hospitals from requirements for duct smoke dampers if the hospital meets certain conditions, such as being equipped with automatic, quick-response sprinklers and a fully ducted HVAC system.

Common understanding

ASHE has learned much during the eye-opening experience of working with the ICC, Flannery says. ASHE members also have helped to explain the unique nature of hospitals to ICC members. Important concepts, such as defend-in-place, which are critical to fire and life safety in health care facilities, typically are not used in other types of facilities, so it takes time to explain, Beebe notes. The role of staff in hospitals also is different than in other buildings. Hospitals have dedicated, well-trained staff that routinely execute drills and take an oath to protect patients.

"There's a much greater awareness of health care issues within the ICC," Beebe says. "We've really changed the understanding."

ASHE also has worked to explain the rationale behind the changes. This may help authorities having jurisdiction understand the reasons why the changes were enacted, which could lead to more unified enforcement of the codes.

In addition to working with the ICC, ASHE is working with other code development organizations to promote unified codes that do not conflict with one another. ASHE has been involved with the NFPA code development process for years with many ASHE members involved in NFPA committees that determine code provisions. In addition, Beebe recently was selected to serve on the NFPA Standards Council, which is responsible for issuing all NFPA codes and standards. Beebe will serve on the council starting this year.

ASHE also has been working with the Facility Guidelines Institute (FGI) to suggest changes on the 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities. Beebe serves on the FGI Steering Committee and has worked with other ASHE members involved in the FGI process to suggest changes that bring the Guidelines in line with other codes.

The changes being made in ICC, NFPA and FGI documents are creating a more unified system of codes for hospitals. But hospitals can't take advantage of the changes until states adopt the latest edition of the codes.

That's one of the reasons why ASHE is working to encourage states to adopt the most recent editions of codes and standards regulating hospitals. Updated codes integrate information learned from real-world situations and reflect changes in the environment and technology. Flannery noted that hospitals routinely go above and beyond code requirements for important measures like emergency planning. Hospitals currently are required to comply with emergency planning regulations that are more than a decade old — and were written before the Sept. 11, 2001, terrorist attacks, Hurricane Katrina and other events. Fortunately, Flannery says, hospitals have incorporated lessons learned from these tragedies into their emergency plans even without code requirements.

"The newer editions of the codes are the best," Flannery says. "We're learning as we go along."

ASHE has sent letters to state regulators urging them to adopt the most recent edition of codes. ASHE is also a member of the Coalition for Current Safety Codes, a group of nonprofit organizations, corporations, governments and individuals advocating for the adoption of current building, sustainability, electrical and life safety codes.

States not only need to adopt updated codes, but they also need to adopt the appropriate codes for the situation, Beebe says. ASHE recommends that states adopt codes that work well with one another, such as adopting the International Building Code and International Fire Code as statewide building codes. These two documents are widely used for the construction of new buildings, including health care facilities, and local building code and fire officials enforce the codes to ensure that new hospitals are built using these requirements. States should not use NFPA 101: Life Safety Code as a fire code, Beebe says, because solely using the Life Safety Code as a fire code would leave a state with inconsistencies and regulatory gaps.

Although the Life Safety Code is an important regulation, ASHE discourages states from adopting it because adoption of this code should remain at the federal level as a condition of participation with the Centers for Medicare & Medicaid Services (CMS). States may consider adopting the Life Safety Code only for facilities that do not participate in CMS programs, but the better way to do this is to reference CMS requirements in general instead of listing the specific edition of the Life Safety Code. By keeping codes consistent across health care facilities, enforcement is easier and hospitals know what to expect.

When states adopt the Life Safety Code separately, it creates the potential for references to be out of sync with the edition of the code required at the federal level (currently the 2000 edition is required). Health care facilities in several states are experiencing this firsthand. CMS recently issued a series of categorical waivers allowing hospitals to take advantage of some provisions of the 2012 edition of the Life Safety Code [see sidebar, Page 46]. But in states that adopted the Life Safety Code separately — without provisions to accept the categorical waiver process — hospitals cannot take advantage of this process. Instead, hospitals would have to follow the routine process of being cited for the provisions and then filing waivers afterward — a time-consuming process that is avoided in states that have not adopted the Life Safety Code.

Plenty of work

The process of creating more unified codes, keeping them updated to reflect the latest developments and encouraging states to adopt the proper codes is a big undertaking. Even with the current successes, there is still plenty of work to do.

ASHE encourages members to get involved in advocacy work, whether it is through ASHE or their local ASHE-affiliated chapter. Members should contact Beebe at for more information on what they can do to help move closer to unified codes.

Deanna Martin is senior communications specialist for ASHE. She can be reached at

Using the CMS categorical waivers

The Centers for Medicare & Medicaid Services (CMS) now offer many categorical waivers for health care facilities, including some outlined in a 2013 memo. Waivers are available for operating room humidity, medical gas master alarms, openings in exit enclosures, emergency generators, door locks, suites, extinguishing requirements, items in the corridor, gas fireplaces, decorations and other topics.

The categorical waiver process as outlined by CMS in an Aug. 30 memo now also covers waivers that were offered by CMS in 2012 and 2013 through other memos. The categorical waiver process does not require citations or individual waiver applications as the traditional process did.

Under the new categorical waiver process, facilities can evaluate and document that all applicable conditions are being met for each elected waiver and can implement the provision without the formal approval process. To use the categorical waivers, the American Society for Healthcare Engineering (ASHE) recommends the following steps after ensuring that a state accepts the categorical waivers:

• Ensure full compliance with the appropriate code reference mentioned in the waiver.

• Document the decision to use the waiver. ASHE recommends creating a letter stating which categorical waivers the facility will use. Facilities professionals should get their safety committees and CEOs to sign off on the letter.
Additionally, the Joint Commission would like to see all Life Safety Code waiver information under the basic building information in the electronic statement of conditions. Facilities professionals should reference or attach the letter outlining the categorical waivers being used. Including the waiver information in the electronic statement of conditions allows surveyors to know the decision was made to use the waivers even before they get on-site.

• Think carefully about which waivers to use. Health facilities professionals should only use the categorical waivers that apply. For example, if a professional is using the waiver on suite size for an emergency room but not for an intensive care unit, the decision should be recorded and the affected suites should be specified. This will show that the facilities professional has done his or her homework, Flannery says, and will save surveyors time because they will know ahead of time which suites will fall under the waiver.

• When the survey team arrives, facilities professionals should notify them of the decision to use the categorical waivers by telling surveyors orally as well as giving them the letter showing the decision to use the waivers.

A full list of the waivers available, along with details of each one, is available at For more information on using categorical waivers, facilities professionals can contact their accrediting organization or ASHE Senior Associate Director of Advocacy Jonathan Flannery, CHFM, FASHE, MHSA, at