Open to change

The Facility Guidelines Institute (FGI) has announced the opening of the public proposal period, the first major step toward revising the 2010 edition of the Guidelines for Design and Construction of Health Care Facilities.

Widely used throughout the United States by health facility managers, medical professionals, architects, engineers, interior designers, and federal, state, and local authorities having jurisdiction (AHJs), the Guidelines publication long has been a critical resource for keeping new and renovated health care facilities up-to-date, while supporting the needs of those they serve and employ.

The document is a vital resource that profoundly affects the nation's health care community and patient standard of care. Input from all Guidelines stakeholders is essential to maintain the document's relevance and importance in providing physical environments that meet the needs of a minimal level of patient care and support.

A little history

The Guidelines has been aiding in the design and construction of hospitals for more than six decades. As it was originally known, the General Standards appeared in the Federal Register, the U.S. government's "official daily publication for rules, proposed rules, and notices of federal agencies and organizations," on Feb. 14, 1947.

These standards were created to implement regulations for the Hill-Burton Act, which directed grant funds and loans for the improvement and modernization of hospitals. For many years, the General Standards document was maintained and revised by various government agencies as needed. It eventually evolved from a congressionally mandated program to a self-sustaining industry code.

Over the years, many organizations have played a vital role in keeping the Guidelines current and valuable for design and health professionals. They include such government agencies as the National Institutes of Health and the Centers for Disease Control and Prevention as well as the American Institute of Architects/Academy of Architecture for Health, the American Society for Healthcare Engineering (ASHE), the Association for Professionals in Infection Control and Epidemiology and the FGI, which is the nonprofit organization created specifically to support the Guidelines revision process and ensure the document is updated regularly using a public, multidisciplinary process.

More than 20 other organizations also participate in revising and updating each edition of the Guidelines.

The Guidelines today

Overseen by FGI, today's Guidelines for Design and Construction of Health Care Facilities has been adopted by the Joint Commission as well as many federal and state authorities having jurisdiction for the planning and design of hospitals, outpatient facilities and residential health care facilities, providing minimum recommendations for new construction and renovation.

The current Guidelines addresses patient and support service space, functional programming, acoustics, patient handling, infection prevention, architectural detail, and surface and furnishing requirements. It covers hospitals; rehabilitation facilities; ambulatory care facilities; residential care, including nursing homes, hospices and assisted living facilities; birth centers; and adult day care facilities.

In addition, the Guidelines details minimum design requirements for plumbing, medical gas, electrical, low-voltage, information technology, HVAC and medical support systems related to the built environment. In the 2010 edition, the American Society of Heating, Refrigerating and Air-Conditioning Engineers' "ASHRAE 170: Ventilation of Health Care Facilities" standard was incorporated into the document, providing guidelines for ventilation, humidity and temperature in various areas of health care facilities.

Independent and objective

The Guidelines is now updated by the independent Health Guidelines Revision Committee (HGRC), a volunteer group of 130 clinical, health care administration and design professionals appointed by FGI that reviews public proposals to change the document and public comments on a draft of the next edition.

The HGRC strives to maintain its independence as an objective, multidisciplinary committee that supports the public interest and isn't swayed by vendors or special-interest organizations.

The multidisciplinary nature of the committee ensures that it weighs textual revision suggestions fairly and always considers the impact of changes to patients, their families and health care facility staff. Costs inherent in changes to the document also are considered.

The committee's goal is to guide the revision process candidly, fairly and knowledgeably through open consensus, and to ensure that the process continues to improve with each passing cycle. Ongoing goals include the following:

• Seek public input from a wider base, not only from professionals, but also from patients and other consumers.
• Encourage and sponsor research projects to support development of changes influenced by evidence.
• Work constantly to improve the revision process and the content of the Guidelines to maintain a dynamic document that truly reflects the state of the art.
• Have the courage and wisdom to adopt requirements that are forward-looking and address the needs of the future of health care, looking backward only to discover what not to do.
• Strive for a document that is credible, reasonable and knowledge-based with a cost-benefit statement, and will maintain the tradition of the American health care physical environment as the role model for other countries.
• Work with state agencies to adopt the most recent edition of the Guidelines so that health facility projects are regulated using current industry concepts.

The next edition

After the first HGRC meeting for the current revision cycle in April, FGI announced the opening of the proposal period for the 2014 edition. Until Oct. 31, architects, consulting engineers, administrators, facility managers, interior designers, medical professionals, patient advocates and other interested parties are encouraged to submit proposals that recommend changes to the 2010 edition of the Guidelines.

Topics the HGRC highlighted for attention during the 2014 revision cycle include functional programming, the patient-safety risk assessment, operating room requirements, imaging facilities, ambulatory surgery centers and other outpatient facilities and residential care facilities (nursing home, assisted living and hospice).

Also considered will be hot water piping size, temperature and insulation criteria (including infection-prevention concerns) and identification of differing requirements for new construction and renovation projects. The HGRC members also have been tasked to consider patient and staff safety costs and benefits of all proposals submitted.

Functional programming. The 2014 HGRC focus group on planning, design and construction (PDC) identified the need to improve term consistency and clarity of deliverables, citing confusion in feedback from Guidelines users. In addition, AHJs have requested the inclusion of an executive summary of requirements because, as health care facility projects expand in size and complexity, AHJs have less time to devote to each project.

Patient-safety risk assessment (PSRA). The PDC group also questioned the need for the PSRA, noting overlap between it and the infection-control risk assessment. The group will consider the feasibility of consolidating the ever-increasing number of assessments that must be completed by health care facilities. Feedback will be solicited from patient advocacy groups to help the group understand end-user perspectives and better address consumer concerns.

Operating room requirements. The 2014 HGRC specialty subgroup on operating room requirements is considering removing the "ABC" operating room classifications from the outpatient surgery center chapter. The group also cited the need for flexibility in OR services and questioned whether anesthesia workrooms still are relevant.

Imaging facilities. The focus group on diagnostic and treatment facilities has determined that comprehensive revisions are needed in the Guidelines sections on imaging facilities because of the vast and frequent technology improvements in this aspect of health care. The group is also considering whether interventional imaging services should be provided in a surgery suite rather than an imaging suite.

Ambulatory surgery centers and other outpatient facilities. The specialty subgroup on ambulatory care is considering consolidating chapters on some facility types because of nearly identical requirements. The group also cited the need for flexibility in outpatient facilities, recognizing that applying common requirements to all health care facilities offering outpatient services sometimes can be too restrictive.

Residential care facilities. The specialty subgroup on residential health care facilities cited as its first priority the creation of a Guidelines volume that is specific to residential care. Many states make distinctions between acute and ambulatory care and long-term care and do not adopt the Guidelines as the standard for long-term care facilities. The subgroup's second priority is to refine the current text, checking for relevance and reviewing barriers to adoption.

Water use for health care facilities. The focus groups on infection prevention (IP) and facility management both highlighted the need for guidelines that address access to clean water and disposal of contaminated water during an emergency. The IP group also is considering the most effective location for hand-hygiene sinks during renovations, and weighing the effectiveness of water and soap versus sanitizing gels at those locations. In addition, they're evaluating the relative cleanliness of electronic and manual faucets.

Critical-access hospitals. Also included for review and proposals during the period is a new chapter with requirements for critical-access hospitals. A critical-access hospital section was prepared as a white paper at the end of the 2010 Guidelines revision cycle — too late for inclusion in that edition — and posted on the FGI website (www.fgiguidelines.org/interim_pubs.html) as draft guidelines. The 2014 HGRC voted to place the new chapter in the proposal system, making the text available for public proposals.

Moving forward

At the April HGRC meeting, Chairman Douglas Erickson, FASHE, CHFM, HFDP, CHC, who is deputy executive director of ASHE, charged the committee with focusing on four key criteria throughout the multiyear revision process. He challenged them to do the following:

• Reflect on the language currently in the Guidelines to ensure the requirements remain relevant for current practices in medicine and patient care.
• Think about how health care will be delivered in 2020 and how the physical environment will need to be designed and constructed to support innovative delivery methodologies.
• Write minimum requirements rather than lofty best practices.
• Consider the initial, life-cycle, and patient and staff safety costs and benefits of each major change being considered for the 2014 edition.

The six-month proposal period is merely the first step in the lengthy revision process. Once proposals have been received by FGI, they are reviewed by the HGRC, incorporated into the text of the 2010 Guidelines, and then made available for public review and comment as the draft 2014 Guidelines.

Only after completion of the subsequent public comment period, which will occur in 2012, will the full HGRC body determine final revisions and additions for the next edition of the document.

Although the HGRC is essential to maintaining the document's continuity and standard of excellence, Erickson says the committee is seeking wide input.

"The Guidelines publication needs to be publicly driven by quality input generated through the public proposal and comment periods," he says. "While the HGRC is made up of experts representing all aspects of patient care, design, administration, safety and authorities having jurisdiction, it is the multiplicity of Guidelines users who need to engage in submitting quality proposals for change if the current content does not fulfill patient and staff needs."

All individuals and organizations wishing to propose an addition, deletion or revision to the 2010 Guidelines for Design and Construction of Health Care Facilities should visit the FGI website at www.fgiguidelines.net/proposals, where instructions for submitting a proposal in an electronic form can be found.

Heather Livingston is an editor for the 2014 edition of the Guidelines for Design and Construction of Health Care Facilities.