Health facilities require a number of unique considerations in their design, construction and operation. To stay abreast of developments in the industry, organizations must maintain and constantly refresh their facilities.

The American Society for Healthcare Engineering (ASHE) is convinced that commissioning, which ensures that the building operates according to design, is critical to the success of every health facility project. So, ASHE began developing the Health Facility Commissioning Guidelines in 2009 to help organizations achieve the results they expect from the facilities they build, with a focus on specific health care issues.

The ASHE process — referred to as health facility commissioning (HFCx) — encourages collaboration among project participants, providing a process and a robust set of tools that improve the project team's ability to deliver a physical environment that meets the goals of the health care organization and the needs of its community. The guidelines establish a standard language and process for commissioning health care facilities that are cost-effective, efficient and deliver the desired return on investment (ROI).

Commissioning defined

The ASHE HFCx guidelines define commissioning as a process intended to ensure that building systems are installed and perform in accordance with the design intent, that the design intent is consistent with the owner's project requirements, and that operations and maintenance staff are prepared adequately to operate and maintain the completed facility.

For optimal outcomes, the HFCx team should be established and engaged at the outset of a project and remain fully involved throughout the planning, design and construction process. This early involvement will optimize the effectiveness of the commissioning process and result in the greatest ROI.

Due to differences in education, training and perspective, C-level executives frequently speak a vastly different language than health facility management professionals.

One of the greatest challenges for any project is cost management. To that end, health facility management professionals must do a better job of developing a business case and value equation to support commissioning activities, demonstrating its value through lower construction and operation costs.

To accomplish this, the HFCx guidelines recommend and provide a model for the development and presentation of a business plan using an accepted convention familiar to the leadership team at a health care organization.

Getting started

The HFCx process begins by defining the project and establishing the commissioning team. In general, this includes the following steps:

Establish the commissioning scope. The commissioning scope is defined by identifying the systems to be commissioned and the tasks to be performed for each of them. The ASHE HFCx guidelines provide a checklist for establishing a comprehensive commissioning scope for a health care facility, which should be tailored to meet a specific project's needs.

Define the HFCx team structure. Achieving desired outcomes from the HFCx process requires a clear definition of individual roles and responsibilities. The ASHE HFCx guidelines recommend the owner designate a health facility commissioning authority (HFCxA) to manage the commissioning process.

The HFCxA serves as the owner's advocate and consultant and should be engaged at the outset of a project to lead the commissioning team, which comprises representatives of the owner, design team, contractor and subcontractors as well as the operations and maintenance (O&M) staff.

The HFCxA fee should be based on the scope of commissioning services and the size of the project. Differences among projects, such as the construction schedule, project phasing, types of systems and sizes of equipment, make it difficult to offer a precise estimating tool for commissioning services. However, there are some rules of thumb that can be used.

The guidelines provide a sample contract for commissioning services to help achieve an agreement between the owner and the HFCxA that is fair to both parties.

Once the health facility commissioning team has been created, it should be empowered with the authority to work with the project team to meet the owner's requirements.

Design phase duties

A predesign conference should be held at the beginning of the design phase to establish the commissioning process for the project and the specific roles and responsibilities of each individual and firm involved.

These discussions should address project goals, scope, team members, delivery process budget, schedule and performance expectations. The commissioning team should establish an aggressive yet attainable and fiscally responsible energy-efficiency goal using the Environmental Protection Agency's Energy Star Target Finder tool at

After the project team has been selected, the owner's project requirements (OPR) and basis of design (BOD) should be developed. The OPR outlines the owner's expectations and requirements for the commissioned equipment and systems, while the BOD documents the means and methods to be used throughout the process. The OPR and BOD are dynamic documents that should be updated periodically throughout the planning, design and construction process.

Key elements of the design phase are outlined in the HFCx guidelines and include the following:

Plan and review process. The ASHE HFCx guidelines require a review of all design phase documents, including schematic design, design development and construction documents. The HFCxA should verify that all documents are consistent with the OPR and BOD and that the proposed design conforms to best practice.

A review should be conducted with hospital O&M staff to document their comments and concerns for review by the owner and the design team. While the other commissioning guidelines restrict the design review to commissionability considerations, the ASHE guidelines require the review to focus on commissionability, completeness, cost-effectiveness, coordination of trades and energy efficiency.

Once the design phase documents have been finalized, the HFCxA develops the commissioning plan describing the process and how it will be executed.

The ASHE HFCx guidelines provide an outline for the components of the plan and the commissioning specifications, which define the specific scope of work, roles, responsibilities and requirements for each member of the health facility commissioning team.

Also during the design phase, the HFCxA should carefully review HVAC control sequencing to make certain it contains adequate detail and incorporates energy efficiency.

As the construction documents near completion, the HFCxA updates the commissioning plan and specifications, and develops the final prefunctional checklists and functional performance tests to be issued with the final construction documents.

Construction phase tasks

The start of a project's construction phase sets off another chain of events in the health facility commissioning process. They include the following:

Commissioning meetings. The ASHE HFCxA guidelines recommend the HFCxA organize a commissioning conference with the team to review the commissioning plan and specifications and ensure all parties fully understand the process and their assigned roles and responsibilities. The commissioning conference should specifically address the process for submittal review and approval that is established in the project manual and commissioning specifications.

During the course of construction, the HFCxA should conduct meetings to facilitate commissioning activities and review the minutes of the regular project meetings, attending as needed to resolve any issues and concerns. The HFCxA should establish and maintain an issues log, which provides a comprehensive list of all commissioning-related issues and their resolution at the close of the project.

Review process. The ASHE HFCx guidelines outline a review process for the construction phase to include: submittal data and shop drawings; O&M manuals; equipment installations, documented through prefunctional checklists; HVAC controls and sequence of operations; a testing, adjusting and balancing (TAB) report; and record drawings.

Start-up and testing. The HFCxA should witness equipment and systems start-up as well as functional performance tests, which assess the performance of the commissioned systems under design, part load and emergency conditions. Additionally, pressure testing should be conducted of all areas requiring controlled-pressure relationships under codes.

O&M project tours. The HFCxA should lead facility O&M personnel on regular tours of the construction site, maintaining a list of their comments and concerns and working with the contractor and design team to respond to these using the standard-issues log format.

Transition to operations

The transition from construction to operations is an often-overlooked part of the commissioning process. Aspects of this transition include the following:

Operational sustainability. As a result of reduced maintenance staffing and budgets, health care facility managers no longer can rely solely upon qualified staff to maintain complex equipment and systems. Rather, they must depend on technology to detect inefficiencies automatically and provide guidance for optimizing operation.

Dynamic O&M dashboards created for the automatic-temperature control system are well-suited for this purpose and should be developed by the HFCxA in conjunction with the design team, contractor and controls contractor. The HFCx guidelines recommend the commissioning team review the individual dashboards for compliance with the OPR and specified requirements and provide an outline of the systems for which dashboards should be included.

The development of a training program should be coordinated with the facility staff to ensure the level of training, scheduling and delivery will meet their needs. The HFCx guidelines provide an outline for training program components to meet accrediting agency requirements.

The HFCxA also should facilitate implementation of HVAC control system trends. These provide critical feedback on space conditions and energy usage. It is vitally important for O&M personnel to have this data to help manage the facility and minimize energy costs.

Construction phase wrap-up. The following documentation and testing outlined in the HFCx guidelines should close out the construction phase activities:

  • The commissioning report. This summarizes and documents the methodology and results of the commissioning process and includes documentation of all commissioning activities.
  • The systems manual. This focuses on operating systems.
  • The maintenance budget. This ensures the health care administrative staff and facility managers have an accurate and thorough understanding of the resources needed to maintain and operate the facility in a cost-effective manner.
  • Smoke and fire damper testing.
  • Statement of conditions. This document is also required by the Joint Commission accreditation process.
  • Building maintenance program.

The ASHE benchmarking tool can be used to determine the staffing level and maintenance budget.

Post-occupancy and warranty

Commissioning remains an ongoing process even after occupancy of the health care facility. Some of the actions that should be taken at that step in the process are:

Review trend data. When the facility is occupied and the systems are subjected to actual load conditions, trends provide the facility manager with critical data to optimize system operations for both building comfort and energy management. The HFCxA can assist the staff in interpreting the trend data and in optimizing performance.

Measure and verify energy performance. After the project is complete, the HFCxA should work with the facility manager to establish a portfolio manager account on the Energy Star website. The facility will receive a baseline Energy Star rating when the account includes 12 months of data.

To ensure that health care facility administrative and maintenance staff remain vigilant regarding energy efficiency, the HFCxA should assist the facility manager in developing an energy-efficiency scorecard to be published each month.

It is necessary to test systems under peak loads within the warranty period and conduct a comprehensive review of the project near the end of the warranty phase to identify and correct any deficiencies.

A first step

The commissioning process outlined here is only a synopsis of the requirements to achieve an accurate document of completion for the owner and cannot begin to cover the breadth of the entire process.

The ASHE HFCx guidelines are the first part of a line-up that will include a handbook, training for health care executives and facility professionals, and a health facility commissioning certification to be developed over the next few years. HFM

Steven R. "Rusty" Ross is the director of commissioning services for SSRCx, a division of Smith Seckman Reid Inc., Nashville, Tenn., and one of the four authors of ASHE's Health Facility Commissioning Guidelines. He can be reached at

Sidebar - Moving beyond LEED requirements
The U.S. Green Building Council's Leadership in Energy and Environmental Design (LEED) green-building certification program recognizes the environmental benefits of a facility commissioning program.

In fact, a minimum level of commissioning activity, referred to as "fundamental commissioning" of building energy systems, is a prerequisite for LEED certification.

However, LEED certification and its fundamental commissioning prerequisite are not sufficient to ensure delivery of a high-performance building.

Additional steps, including ongoing commissioning, often are required to maintain a high level of efficiency.


Sidebar - Guidelines address health care issues
Although there are many excellent commissioning processes and guidelines in the marketplace already, none specifically addresses the complexities of commissioning health care facilities.

The American Society for Healthcare Engineering (ASHE) commissioning process — referred to as health facility commissioning (HFCx) — establishes a standard language and process for commissioning health care facilities that are efficient.

The ASHE HFCx guidelines assign accountability for building performance to the entire project team, including the health facility commissioning authority. The collaboration this approach encourages among project participants improves the project delivery team's ability to deliver a health care physical environment that meets the goals of a health care organization and the needs of its community.

Additionally, the guidelines provide the project team with a process and a robust set of tools to improve initial project commissioning collaboration, continuing commissioning behaviors and retrocommissioning tactics.

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