The final touches on the 2010 Guidelines for Design and Construction of Health Care Facilities are finished and the document will be ready for delivery this month.
Known as the "FGI Guidelines," this health care industry standard is administered by the Facility Guidelines Institute (FGI) and developed by the all-volunteer, 116-person multidisciplinary Health Guidelines Revision Committee (HGRC) with representation from nurses, surgeons, anesthesiologists, neonatologists, infection preventionists, administrators, architects, facility managers, consulting engineers, safety and security professionals, risk managers and over 25 state, federal and private enforcing authorities.
The 2010 edition had more than 25 focus groups reviewing specific sections of the 2006 document or working on the development of new sections. Two specialty subcommittees were formed to take on major projects on acoustic design and patient handling and movement. Expertise on these specialty subcommittees was bolstered by contributions from outside technical and subject experts. The HGRC reached a consensus at its final meeting and unanimously endorsed the revised guidelines to be sent out for letter ballot, which was then unanimously approved.
The 2010 HGRC took on numerous challenges to modernize the document and meet the needs of the enforcing, design and owner communities. Major new sections on acoustics, patient handling and movement, bariatric accommodations, cancer treatment/infusion therapy services, freestanding cancer treatment facilities and telecommunications areas were added by the committee, along with new material on wayfinding, patient safety assessments and outpatient rehabilitation facilities.
To make the usability of the Guidelines more consistent with other national standards, a further reorganization of the document was undertaken for the 2010 edition. The time-intensive reorganization effort has resulted in a book presented in six parts, including a common elements chapter at the beginning of Part 2 (Hospitals), Part 3 (Ambulatory Care Facilities), and Part 4 (Residential Care Facilities) and a new Part 6 (Ventilation of Health Care Facilities) that incorporates the 2008 edition of "Standard 170: Ventilation of Health Care Facilities," which was developed by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) and the American Society for Healthcare Engineering (ASHE) and adopted by the American National Standards Institute (ANSI).
To assist users of the Guidelines, significant changes are marked throughout the book with a vertical line beside the text. The glossary also has been expanded to include definitions of commonly used terms and moved to the front of the book.
Additions and revisions
Major additions and revisions that resulted from the 2010 revision cycle include the following:
Part 1: General. Chapter 1.1 provides a useful introduction to the document, including information about how to use the Guidelines and request interpretations of its recommendations. It further explains how the Guidelines are applied to renovation projects and outlines federal requirements for protecting patient privacy. A list of publications referenced in the Guidelines concludes the chapter.
Chapters 1.2 (Environment of Care) and 1.5 (Planning, Design, and Construction) from the 2006 edition have been combined into a new Chapter 1.2 (Planning, Design, Construction, and Commissioning). Text on the functional program—a key document used to identify a provider's goals and objectives for the environment of care—has been expanded, including text on projected operational use and demand and on short- and long-term planning considerations.
A new appendix section (A1.2-4) on performing a patient safety risk assessment of a project's design elements has been added as well as a new section (1.2-5) requiring a patient handling and movement assessment (PHAMA). A PHAMA will be a major element of all new designs as more and more portable and permanent patient handling and movement equipment is being added to the health care environment. A new section (1.2-6.1) has been added on acoustic design as a result of six years of development and the issuance of a white paper. This text and accompanying appendix language provide design guidance for addressing exterior noise and interior sound. The text on commissioning continues to expand, with additional sections on newly installed or modified HVAC and fire alarm systems in patient care areas.
Part 2: Hospitals. Part 2 contains chapters on general hospitals, small primary care hospitals, psychiatric hospitals and rehabilitation facilities in addition to the new Chapter 2.1 (Common Elements for Hospitals). New and significantly revised material that appears in Chapter 2.1 as common elements includes:
- A new section on self-contained medication dispensing units;
- New language on soiled holding rooms;
- A requirement that patient room windows be at least 10 percent of the clear floor area;
- New language on hand-washing stations and sink design;
- A new section on furnishings;
- New language on ventilation for airborne infection isolation (AII) rooms;
- A revised section on nurse call systems; and
- A new section on technology and medical communication systems.
The text of Chapter 2.2 (General Hospitals) includes the following completely new and significantly revised material:
- Patient bathing facilities need to be assessed for meeting the needs of mechanical lifting devices;
- The protective environment section has been rewritten to include combination AII/protective environment (PE) rooms and a new section on bone marrow/stem-cell transplant units, including new ventilation language;
- New sections on oncology nursing units and cancer treatment/infusion therapy services;
- Revised language for neonatal intensive care unit (NICU) noise control;
- A new section on bariatric nursing units;
- Revised material on obstetric units;
- New dimension requirements for pre- and post-operative patient care areas;
- Revised language on magnetic resonance imaging (MRI) and positron emission tomography (PET) suites; and
- The emergency services section has been updated to include new language on emergency services reception, triage and control stations; new language on emergency services examination/treatment rooms or areas; updated language on emergency services observation units; and a new section on fast-track areas.
Chapter 2.5 (Special Requirements for Psychiatric Hospitals) includes a new section on psychiatric hospital perimeter security and updates to other material. For the most part, changes in Chapter 2.2 (Specific Requirements for Small Primary Care Hospitals) and Chapter 2.6 (Specific Requirements for Rehabilitation Hospitals and Other Facilities) were made to correlate them with changes in Chapters 2.1 and 2.2. Chapter 2.4 is a placeholder for a chapter on critical access hospitals, which was
developed too late to be included in the 2010 edition.
Part 3: Ambulatory Care Facilities. The significant changes to Part 3 occurred during the reorganization of the 2006 edition, when individual facility information was pulled out of the general outpatient facility chapter and placed in separate chapters, leaving the common elements in Chapter 3.1. For the 2010 edition, the chapters on Mobile, Transportable, and Relocatable Units and Freestanding Birth Centers have been moved to Part 5 (Other Health Care Facilities).
The text of the chapters in Part 3
(Ambulatory Care Facilities) includes the following completely new and significantly revised material:
- New language for hand-washing stations and sink design;
- A revised section on flooring;
- A new section on waste management;
- A revised section on medical waste disposal;
- Clarified use for unrestricted, semi-restricted and restricted areas in outpatient surgical facilities; and
- Revised language for pre- and post-operative holding areas in both outpatient surgical and gastrointestinal endoscopy facilities.
New chapters in this part of the Guidelines cover cancer treatment and outpatient rehabilitation facilities.
Part 4: Residential Care Facilities. Part 4 includes chapters on health care facilities that provide a residential environment, such as nursing, hospice and assisted living facilities. The chapter on adult day health care facilities has been moved to Part 5.
Chapter 4.1 (Nursing Facilities) was not extensively revised, but some significant changes include the following:
- A new "household" resident unit layout and care concept;
- Revised resident room space requirements;
- A new section on resident food areas;
- New language on dining and recreation areas;
- Revised and new language on flooring; and
- A new section on furniture.
No major changes were made to the chapters on hospice or assisted living facilities.
Part 5: Other Health Care Facilities. This new part includes facilities in which the length of stay is generally less than 24 hours but cannot be characterized as outpatient care because of the services being provided. Included are adult day health care facilities and freestanding birth centers. Mobile, transportable and relocatable units are also included because the requirements in the chapter relate more to the type of unit than to the specific medical services provided.
Significant changes made to Chapter 5.1 (Mobile, Transportable, and Relocatable Units) include the following:
- A new section on factors that affect the location of the unit;
- Revised language on MRI unit site considerations;
- A new section on support areas;
- A new section on exterior finish materials;
- New language on air-handling units; and
- A new section on emergency electrical service.
Significant changes also were made to Chapter 5.2 (Freestanding Birth Centers). These changes include:
- Further defined in the functional program are size and layout, transfer and service affiliations and proximity to hospitals;
- Revised language on capacity and size of rooms;
- New language on support areas for staff, mothers and newborns;
- New sections on medication preparation locations, soiled and clean workrooms, and service areas; and
- Use of portable medical gas equipment is permitted.
Very minor updates were made to Chapter 5.3 (Adult Day Health Care Facilities).
Part 6: Ventilation of Health Care Facilities. To avoid having two standards addressing identical design issues, the FGI board of directors approached ASHRAE in 2007 with a proposal to include Standard 170 as part of the Guidelines. Both organizations saw this as a great opportunity and have worked closely together to make it a reality. As a result, Standard 170 is presented in its entirety as a new Part 6 of the Guidelines, making it the primary document on health care ventilation systems.
With any merger, the gain doesn't come without some interim adjustments. The 2010 Guidelines has retained all sections and paragraphs not covered by Standard 170, which may give some sections of the document an unfinished look. Further, Standard 170 has what ASHRAE terms "continuous maintenance" project status. A newly formed maintenance committee, composed of a mix of HGRC and ASHRAE members to give it broad health care expertise, will keep Standard 170 current with practices in the field.
By having the standard under continuous maintenance, the committee can meet and develop proposed changes at any time rather than waiting for the end of the three-year revision cycle. The official addenda prepared by the committee will be published free of charge on the ASHRAE, ASHE and FGI Web sites at www.ashrae.org, www.ashe.org and www.fgiguidelines.org, respectively. It is hoped that state agencies will adopt these addenda as they are issued.
Otherwise, significant ventilation changes from the 2006 Guidelines include the following:
- Ventilation for Class B and C operating rooms has increased to a total of 20 air changes per hour (ach) and four outside ach;
- If the total cooling capacity for the facility is greater than 400 tons, reserve cooling capacity is required to meet the "facility's operational plan";
- A single filter bank for Class A operating rooms (ambulatory surgery);
- Variable air volume (VAV) permitted for AII and PE rooms (pressure differential must be maintained); and
- Newly installed ductwork must be cleaned before space is occupied.
Those seeking more information on the 2010 Guidelines can take advantage of a series of workshops being presented by FGI and ASHE. The workshop schedule and other information can be accessed at www.ashe.org/ashe/education/guidelinesworkshop.
Moreover, the 2014 revision cycle is already starting. Health care professionals are encouraged to help in this process by submitting proposals and comments for the next edition of the Guidelines.
Douglas Erickson, FASHE, CHFM, HFDP, is deputy executive director of the American Society for Healthcare Engineering; vice president of the Facility Guidelines Institute (FGI); and Health Guidelines Revision Committee (HGRC) chairman of the 2010 and 2014 Guidelines. His e-mail is firstname.lastname@example.org.
Joseph G. Sprague, FAIA, FACHA, FHFI, is senior vice president and director for health facilities at HKS Inc., Dallas; president of FGI; and HGRC chairman emeritus. His e-mail is email@example.com.
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