Using new tech while adhering to older codes

As noted by Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director of the American Society for Health Care Engineering (ASHE), in a previous article on staying current with code updates, “In the complex world of health care facilities management, staying up to date with the latest codes and standards isn’t just a best practice, it’s essential.”

The ASHE Regulatory Affairs Team strives to assure that evolving codes and standards provide not only a safe environment for patients, staff and visitors but also allow for optimizing the health care physical environment. Health care facilities managers who stay up to date with the most current codes and standards are poised to apply the latest technologies and strategies, sometimes even prior to the adoption of the latest editions.

Embracing new technology within updated codes

Technology in health care evolves rapidly, and certainly at a more rapid pace than codes and standards adoption. While codes and standards currently adopted by the Centers for Medicare & Medicaid Services (CMS) often fail to address new innovations, sometimes newer technology can be implemented before the latest editions of codes and standards are adopted.

For instance, the previous article in this series discussed flexible medical gas tubing as an example of implementing a physical environment change allowed in newer codes prior to their official adoption as the code of the day. This new tubing is a technology not addressed in the 2012 editions of the National Fire Protection Association’s NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities Code. Without updated codes, facilities might not be able to use this product. However, CMS granted a categorical waiver for this technology, allowing for consistent use nationwide.

Another example of newer technology that is not addressed by the 2012 editions of NFPA 101 and 99 are LED exit signs. These devices have been widely available since the early 2000s, and their use had become the norm by 2012, but the true benefits of their usage — increased reliability and durability — were not recognized in the codes. While their use has not been hindered by the failure of regulatory bodies to adopt newer versions of the codes, the true optimization of these devices was not included in writing in the Life Safety Code until the 2021 edition.

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Staying current with code updates

The ASHE Regulatory Affairs Team worked for six years to remove the requirement of monthly exit sign inspections, since the application of LED exit signs clearly showed that the advanced technology being used no longer warranted a monthly inspection. With data from thousands of inspections, ASHE was able to get the monthly inspection requirement changed in the 2021 edition of the Life Safety Code to no longer require monthly inspections, with exit signs backed by battery power as an exception. This underscores the importance of updated codes in enabling the optimization of new technologies.

While CMS has not issued a categorical waiver regarding reducing these inspections, its Hospital Equipment Maintenance Requirements policy does allow hospitals to develop  alternate equipment maintenance (AEM) policies and procedures that they must maintain and document. By providing facility-specific data combined with the changes approved in the 2021 edition of the Life Safety Code, a facilities manager could develop an AEM policy that allows them to reduce their exit sign inspections.

Advocate for change and stay ahead

The health care environment is dynamic, and codes must evolve to reflect new technologies, practices and challenges. ASHE’s Regulatory Affairs Team ensures that these changes are grounded in fact and focused on improving patient care while optimizing the physical environment. By staying current with code updates, health care facilities professionals can avoid confusion, reduce compliance burdens and contribute to a safer, more efficient health care system.

It’s time we all advocate for CMS to adopt current codes more frequently and take full advantage of the opportunities that updated standards provide. One specific way that health care facilities professionals can participate in the advocacy effort is to implement a ventilation management program (VMP) based on the new ASHRAE/ASHE Guideline 43, Operations Guideline for Ventilation of Health Care Facilities.

This guideline, developed over a five-year effort, encourages the optimization of heating, ventilating and air-conditioning (HVAC) systems and their resources through the application of a VMP and the appropriate application of AEM and reliability-centered maintenance practices. As more organizations implement a VMP, accrediting organizations will encourage their usage, thus encouraging CMS to accept this practice.

Additionally, the ASHE Regulatory Affairs Team has been coordinating the efforts of developing Guideline 43 with the application of VMPs for existing HVAC systems within NFPA 99. Proposed changes have been approved by the NFPA 99 Technical Committee on Mechanical Systems that include the application of VMPs to existing HVAC systems. The next step in the process will be to address any notices of intent to make a motion that might be submitted and voted upon during the upcoming 2026 NFPA Technical Meeting.

Facilities managers should keep abreast of these developments via ASHE’s HFM Insider and HFM magazine, ensuring they will not only help keep their organization current with new developments but also gain awareness of how their organization can partner with ASHE in critical advocacy efforts.

Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, is senior associate director for ASHE Regulatory Affairs.