Designating med gas facilities authorities

The 2021 edition of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, identifies clear duties of the responsible facilities authority (RFA) for medical gas systems. At Children’s Hospital of Philadelphia (CHOP) the role of the RFA is largely governed by the senior director of building systems operations (BSO) and the plumbing supervisor with support from CHOP’s plumbing, BSO and infrastructure staff, key vendors and contractors. This column discusses some of our procedures.

The BSO team is responsible for core supply, controls and bulk systems, and plumbing is responsible for distribution and terminal units. Our plumbing and BSO managers are ASSE 6040 certified for medical gas maintenance. Our maintenance department worked with a qualified vendor to develop in-house training so that all plumbing staff receive equivalent ASSE 6040 training and certification.

We also performed a risk assessment to inform inspection requirements. Core systems are inspected and maintained by BSO staff and vendors in accordance with the code and manufacturer’s recommendations. Plumbing staff inspect distribution equipment annually, and inspect and test operating room med gases quarterly. Additional risk and vulnerability assessments were led by emergency preparedness staff to create system failure plans.

At CHOP, the RFA is essential to the design and construction of new or renovated medical gas systems. Infrastructure staff lead the design phase with input from BSO and plumbing staff. Vendors and contractors are added as key team members for complex projects.

The permit-to-work process requires input from plumbing, BSO, infrastructure, safety and infection control staff and the contractor. We review medical gas utility interruption requests weekly.

The responsibilities of the medical gas system RFA are a critical regulatory component that requires planning and dedication to patient safety. 

Beth Lorenz, senior project manager, Children’s Hospital of Philadelphia.