Health care facility plans and policies

Management plans and policies are critical in hospital facilities departments.

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Author's note: Environment of Care management plans previously required by Joint Commission were not discussed in this article because they were not included in the updated Physical Environment Standards published in July 2025.Management plans and policies are critical in hospital facilities departments because they provide a structured, consistent and legally sound foundation for operations.

Well-developed plans demonstrate that the hospital is meeting codes and regulations, helping to avoid fines, citations or accreditation issues. Written plans also can help protect the hospital from litigation or insurance claims by showing due diligence in safety, maintenance and compliance.

Policies can promote consistency in how tasks are performed, especially across shifts or locations. They ensure that all team members follow the same procedures for maintenance, emergencies and safety practices.

In crisis situations (e.g., fires, power outages and inclement weather), policies and plans provide step-by-step instructions for response and recovery. They reduce confusion and response time, helping facilities departments react quickly and effectively under pressure. New employees can be trained with existing policies and plans, ensuring they learn best practices. They also serve as a point of reference for ongoing training, audits and performance evaluations.

Policies and management plans aren’t static. They are required to be reviewed and updated regularly so that they align with current hospital practices and regulatory standards.

Planning essentials

Developing an effective management plan within a health care facilities department begins with a focused assessment of specific risk areas, such as water systems and utility dependencies. A water management plan (WMP) and the various loss of utilities plans are critical to ensuring patient safety, regulatory compliance and continuity of care.

The first step is to evaluate current infrastructure and processes through a risk-based approach, identifying potential failure points, historical incident data and compliance gaps with Centers for Medicare & Medicaid Services requirements and standards such as the American National Standards Institute (ANSI)/ASHRAE Standard 188, Legionellosis: Risk Management for Building Water Systems; the National Fire Protection Association’s NFPA 99, Health Care Facilities Code; and other accreditation standards.

Clear, goal-oriented planning is essential. For example, a WMP should include control measures for Legionella prevention, risk mapping of building water systems, routine monitoring protocols, corrective action plans and documentation requirements. Similarly, loss of utilities plans must define response protocols for electrical, water, medical gas or heating, ventilating and air-conditioning (HVAC) failures, detailing backup systems, prioritized loads, internal communication workflows and vendor coordination.

Cross-departmental collaboration is crucial during development. Infection prevention, clinical services, biomedical engineering, emergency management and information technology all should be involved in shaping these plans. Their input ensures operational feasibility, identifies dependencies and promotes alignment across departments. Once drafted, loss of utilities plans should be validated through tabletop exercises, scenario-based walk-throughs or drills. For example, simulating a normal power outage can test the readiness of emergency generators and facilities staff response.

Implementation must be structured and well-communicated. Initial and periodic training is essential to ensure that everyone understands their roles and specific locations of the equipment. Job action sheets, laminated quick-reference guides and signage at the equipment location site can support rapid decision-making during incidents.

Formal reviews should occur at least annually or after any real-world event, with updates made as needed to reflect lessons learned, regulatory changes or infrastructure modifications. Each update should be documented and recommunicated to stakeholders. Announcing plan updates during the environment of care committee meetings would likely be an efficient and effective way to communicate any updates to multiple parties at once.

Water management

Creating and implementing a comprehensive WMP is required for meeting the Environment of Care requirements in Joint Commission’s hospital accreditation standards. The primary goal of the plan is to minimize the risk of waterborne pathogens, particularly Legionella, in patient care environments.

Writing the plan begins with assembling a multidisciplinary water safety team that includes representatives from facilities, infection prevention, environmental services and clinical operations. This team is responsible for drafting the plan based on the unique infrastructure and risk profile of the patients in the facility.

The first section of the written plan should clearly identify all water sources and systems within the building, including potable water (e.g., sinks, showers and drinking fountains), non-potable systems (e.g., irrigation or cooling towers), and any emergency backup water supplies. It also should identify any decorative fountains or water features in and around the building.

Each system should be mapped to understand how water flows through the facility, with special attention to areas where water can stagnate or temperatures can support bacterial growth. The plan should outline control measures at each critical point, such as monitoring temperature and disinfectant residuals, establishing flushing protocols for low-use outlets and ensuring proper design and maintenance of plumbing components. It also should reference relevant standards and resources, including ANSI/ASHRAE Standard 188 and applicable city water quality reports.

Once the plan is written, the implementation phase involves putting those control measures into action. This includes training facilities staff to take regular temperature and disinfectant readings, flushing systems on a defined schedule and documenting all activities in the work order system.

Clear procedures for responding to out-of-range results should be documented, and the plan should include predefined corrective actions, such as re-flushing, hyperchlorination or taking fixtures or areas offline. Implementation also means communicating and gaining approval for the plan through periodic meetings with the water management committee. Facilities teams should record in minutes the approval of the plan and any recent findings or issues with the water system.

The WMP must be reviewed and updated regularly. The plan should include evaluation procedures such as routine water sampling in high-risk areas. If water samples reveal elevated bacterial counts, the team must reassess flushing frequencies, control points or remediation procedures, and those changes must be documented within the written plan. Updates should be reviewed at least annually or following any significant change to the water system.

Ventilation management

Similar to the WMP, a comprehensive ventilation management plan (VMP) is essential to ensuring indoor air quality, patient safety and regulatory compliance across health care environments. The written plan should begin by clearly defining ventilation requirements for each type of hospital space, such as operating rooms (ORs), isolation rooms, patient rooms, sterile processing areas and laboratories, among others.

Each space type should have documented requirements for air changes per hour, pressure relationships (positive or negative), temperature and humidity ranges and filtration levels (e.g., HEPA filtration in critical zones). The plan also should include a description of all HVAC systems in use, including air-handling units, exhaust fans, filters, monitoring equipment and the associated areas or spaces that the equipment serves.

Once the plan is written and approved, implementation involves ensuring that all ventilation systems are properly configured, maintained and monitored. This includes calibrating and verifying pressure differentials, especially in critical areas like negative pressure isolation rooms or positive pressure ORs, maintaining required air exchange rates and performing timely filter changes.

Facilities teams should be trained to perform routine inspections of air-handling units, check for proper sealing of ductwork and ensure automated building systems are accurately monitoring airflows, humidity and temperature. The use of building management systems can help automate real-time monitoring and alert staff to potential deviations from setpoints.

Ongoing evaluation is required to keep the plan updated because hospital space usage is consistently changing. The written VMP should include schedules and procedures for regular testing, including airflow pressure testing, air exchange testing, and temperature and humidity validations. Documentation should show that air balancing has been completed and that any areas not meeting standards are being actively addressed.

Filter replacement logs, HVAC maintenance records and any corrective actions should be kept current and easily accessible for internal reviews and accreditation surveys. Additionally, the plan should establish a process for reviewing regulatory updates and incorporate those changes into future revisions. (This is discussed further in the related article below.)

Fire response

A well-developed fire response plan is a critical component of a health care facility’s overall emergency preparedness strategy. Writing the plan begins by defining the roles and responsibilities of responding staff during a fire event and ensuring alignment with the facility’s broader fire safety policies and local fire codes.

The plan must incorporate specific procedures for fire detection, alarm activation, communication with emergency responders and coordination with the local fire department. It also should include how staff throughout the facility are trained to respond to a fire event.

The plan should outline fire response details for areas with special requirements, such as helipads or specific medical procedure rooms. Business occupancy buildings also should be specified in the plan and include the location of the evacuation meeting point outside the building.

Once written, the implementation phase focuses on training all staff and ensuring everyone understands how to locate and operate fire extinguishers, fire alarm pull stations and evacuation routes. Fire drills must be conducted regularly, with documentation of staff participation, response times and any identified areas for improvement.

After each drill or real event, an after-action review should be held, and the fire response plan should be updated to reflect lessons learned and any procedural changes. The overall plan should be evaluated periodically or as building or code changes occur, and the updates should be relayed to staff.

Loss of utilities

Loss of utilities policies are essential emergency preparedness plans that ensure continuity of operations in case of an infrastructure failure. Writing the policies begins with identifying all critical utility systems, such as normal/emergency power, water supply, HVAC, steam and medical gases, and developing detailed contingency plans for temporary outages or complete system failures.

For example, the loss of normal/emergency power policy should include priority lists for areas requiring backup power (e.g., intensive care units and ORs), strategies for manual operation of medical gas systems and backup water supply sources. The loss of oxygen plan should identify an emergency vendor where additional oxygen can be obtained and delivered quickly. A loss of water plan should detail vendors who can provide an emergency water supply.

Facilities teams should develop detailed, utility-specific response procedures that clearly define roles, responsibilities and step-by-step actions for staff.

To implement each loss of utility plan, facilities staff should incorporate communication protocols to alert internal teams and external partners, such as utility providers and emergency services. Staff training and drills should be conducted frequently to build confidence and ensure readiness.

Combining emergency management tabletop drills with loss of utility drills can be an effective way to train staff, identify gaps and meet regulatory requirements. The loss of utility plans should be evaluated and updated based on lessons learned from exercises, real incidents and evolving hospital infrastructure to ensure they remain effective and aligned with regulatory requirements.

Inclement weather

An inclement weather plan is usually required by a hospital’s insurance agency. It helps facilities remain operational and safe during severe weather events and can help protect occupants and equipment. Writing this policy starts with assessing regional risks, such as hurricanes, blizzards, flooding and tornadoes, and identifying their potential impacts on staffing, transportation, infrastructure and supply chains. It should address heating and cooling needs and equipment kept on-site to handle inclement weather.

Facilities teams should consider assigning a priority to certain areas for snow or ice removal so staff know where to begin clearing. The driveway and sidewalks leading to the emergency department should be a high priority and cleared off as soon as possible. Staff parking and hospital entrances also should be high priorities. Helipads should be treated before snow and ice is expected, and continued as necessary.

Implementation focuses on ensuring all departments understand their responsibilities, that communication tools (e.g., mass notification systems and radios) are functional and that prearranged transportation and lodging options are available for essential staff.

Evaluation involves conducting tabletop exercises to simulate responses to specific weather threats, reviewing past weather-related incidents for performance insights and refining the plan to improve logistics and response times. 

Related article // Implementing a ventilation management plan

With the recent approval of the ASHRAE/American Society for Health Care Engineering’s Guideline 43, Operations Guideline for Ventilation of Health Care Facilities there is a growing focus on how health care facilities maintain ventilation requirements in their health care spaces.

A ventilation management plan (VMP) helps organizations ensure compliance with all regulatory standards. Similar to a water management plan, a VMP is developed by a multidisciplinary committee and aims to maintain and manage heating, ventilating and air-conditioning systems effectively. The development process includes:

1. Form a multidisciplinary committee, ideally as a subcommittee of the established environment of care committee, to oversee the VMP.
2. Select a primary code reference to unify conflicting ventilation requirements. Requirements can differ based on location, local authority having jurisdiction and when the building was built. The committee also should ensure that other hospital clinical policies do not reference other ventilation standards.
3. Create a master list of facility spaces with ventilation needs. This list should be updated periodically to ensure spaces have not changed usage and to incorporate building additions.
4. Risk-rank spaces based on the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, categories to prioritize testing and maintenance.
5. Establish an excursion response plan to address out-of-range conditions promptly. These may be from equipment failure, extreme weather or patient needs.
6. Educate committee members on key ventilation concepts and risk levels using visual tools like ventilation maps.
7. Draft a formal VMP policy detailing committee structure, definitions, code references, testing frequencies and response plans.
8. Obtain committee approval for all aspects of the VMP.
9. Maintain the plan through ongoing monitoring, updates to space usage and adapting to evolving codes and standards.

An extended discussion of these steps is available in the "Nine steps to developing a ventilation management plan article." 

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Taylor Vaughn, MBA, CHFM, CHC, SASHE, is a facilities manager at Children’s Health in Dallas. She can be reached at 
taylor.vaughn@childrens.com.