Healthy hospital success: Codes and standards
With hospital projects, it is imperative that engineers get everything exactly right—after all, the lives of patients treated in the health care building may depend on it. Codes and standards, including NFPA and Facility Guidelines Institute, are reviewed.
Richard Heim, PE, LEED AP, Mechanical Project Engineer, RMF Engineering Inc., Baltimore
Tim Koch, PE, LEED AP, Electrical Engineer, HDR Inc., Omaha, Neb.
Nolan Rome, PE, LEED AP, Senior Vice President, ccrd, a WSP | Parsons Brinckerhoff Co., Phoenix
Raymond Schultz, PE, Project Engineer, CannonDesign, Grand Island, N.Y.
Kunal G. Shah, PE, LEED AP, RCDD, President, PBS Engineers, Glendora, Calif.
Tommy Spears, PE, Vice President of Design Solutions, TME, Little Rock, Ark.
CSE: Please explain some of the codes, standards, and guidelines you use as a guide when designing hospitals.
Heim: One of the most important guidelines is the Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities. This guideline provides detailed requirements for many aspects of health care design including ventilation of health care facilities. FGI directly references ASHRAE Standard 170: Ventilation of Health Care Facilities, which is another important standard we follow on all health care projects that defines ventilation requirements. When we get into our energy modeling, we look closely at ASHRAE Standard 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings, which states all minimum requirements for building energy efficiency. Often, this has a large impact when designing U.S. Green Building Council LEED-certified buildings.
Spears: There are very few building types that have more stringent code requirements and standards than a hospital. Just to list a few, in no particular order: NFPA (101, 99, 70, 72, 13, etc.), International Code Council codes (IBC, IEC, IPC, etc.), JAHCO, FM Global, FGI, state codes, city codes, ASHRAE, TIA, VA Design Guides, LEED, hospital standards—and the list goes on. At TME, we familiarize ourselves with the latest codes and standards and work with the local authority having jurisdiction (AHJ) and owner to determine which codes are applicable for each project. In cases where there are conflicts between codes, we work with the local AHJ to discuss the intent behind each code and make sure those intents are satisfied.
Rome: In addition to local codes and standards required by the country, city, or state, we use the design guideline accepted by the Dept. of State Health Services of the state in which the project is located. The national standard is the FGI Guidelines for Design and Construction of Healthcare Facilities. Many states we regularly work in have their own guidelines that replace or supplement the FGI, such as Texas, California, Missouri, etc. In our international work, those countries that do not have a standard typically ask us to use the FGI guidelines.
Shah: For us, the most important codes for hospital design are the requirements of the Office of Statewide Health Planning and Development (OSHPD). These regulations are based on the California Building Standards Code and have their own review process. Understanding their requirements and methods to compliance are imperative to a successful MEP design of a California hospital.
CSE: How have International Building Code (IBC), NFPA, ASHRAE, and other codes affected your work on hospital projects? What are some positive/negative aspects of these guides?
Shah: I don't feel that codes are viewed as positive or negative. They are requirements for our industry. For codes, the intent is life safety, which we as engineers must always consider. Although restrictive at times, having documentation and regulations to protect life is important, and our jobs as engineers is to implement in the most appropriate way. Further, having these standards and regulations allows the designer to have a guide of minimum requirements or preventive measures to prevent life safety issues. In the engineering sport we play, the codes and standards serve as our rules.
Rome: We would not view any of these standards and codes as having a negative impact. Our goal is to always provide the best standard of care for the patients. We let the hospital make decisions on codes for their system or hospital. Sometimes different guides can be in slight conflict, and we have to judge as professionals what we feel is best.
Heim: These codes create a benchmark for what is acceptable in the industry, which is good. However, sometimes the industry changes faster than the associated codes. When this happens, there are new technologies that aren't directly referenced in the codes. This creates a significant challenge when using these technologies. Anytime there is interpretation of the code, there is an opportunity for differing opinions, which creates challenges.
Schultz: Code requirements need to be established early on so details embedded within the code impact design concepts. Overarching mechanical codes are often intended for a wide variety of building types and may not mesh well with health care requirements. For example, hospital-specific codes have comparatively high minimum air-change rates and some spaces (like locker rooms) defer back to the mechanical code's cubic feet per minute per square foot (cfm/sq ft) requirements. Other areas (medical gas storage rooms and hot labs) require independent exhaust that should be established early in the design process. Meeting energy-code requirements can be very challenging for complex institutions such as hospitals. Compliance with heat-recovery and fan-power limitation requirements need to be thought out early in the design. Guideline addendums should be tracked because they often elaborate on the code intent.
Spears: Codes and standards directly impact almost every aspect of the design of any system. They are put in place to help protect the facility, the owner, the patient, the community, etc. The positive side of a code is that it sets a minimum standard that must be obtained to safely occupy the building. Codes provide reassurance that the occupants are safe. However, there are codes that contradict one another, and it takes a collaborative effort involving the engineer of record, AHJ, and owner to determine the ruling code and intent of that code to ensure proper design.
CSE: Meeting codes/standards is often one of the biggest challenges engineers face. What challenges have you recently overcome in a particular jurisdiction or project?
Rome: Most recently, we have been educating owners on the requirement formerly in the NFPA for windowless anesthetizing locations. The NFPA removed it in the 2012 code cycle. Centers for Medicare & Medicaid Services (CMS) has recommended keeping it in health care facilities if the facility believes there is a risk for fire in operating rooms or other anesthetizing locations. Some state health authorities interpret this as a requirement that an evacuation system has to be provided despite being removed from the code. We are assisting many owners' teams to interpret the risk level so they can develop the appropriate plans and response.
Schultz: At the end of construction and prior to occupancy, the Dept. of Health and Human Services walks through the health care facility with the owner to review processes and systems. Prior to the walkthrough, they expect a completed testing and balancing (TAB) report demonstrating that required air-change rates and room pressurization is appropriate. By specifying a TAB report format that summarizes the code-required air-change rates and room pressurization, along with measured airflows and subsequent pressurization in a single table, the Dept. of Health's inspector can quickly scan the information and become comfortable with the airflows.
Spears: One of the biggest and most successful challenges that we have faced is working with state departments of health to allow for patient-room and operating room (OR) setbacks. This allows the facility to decrease the air changes per minute in these rooms, which ultimately greatly reduces utility costs. This has been a very difficult road to traverse, some states are still not allowing it because it's a big change in the industry.
Shah: Interpretation of codes is one of the most difficult challenges we face. The codes are written to account for most types of projects or installations. However, more times than not, we are dealing with a unique case that requires the interpretation of the plan checker or inspector. Most recently, our team has had challenges dealing with recent code changes. We have overcome these challenges by having regular interactions with the inspectors and plan checkers to outline our basis of understandings and how we feel we meet the intent of the code. Further, by developing these relationships with the AHJ, we are able to benefit from their knowledge when they share details of their internal training and how they interpret the code. Knowing what the plan checker and inspectors are looking for allows us to be more effective engineers.
Koch: In 2012, NFPA 99: Health Care Facilities Code introduced the term "wet-procedure location" and defaulted all ORs to wet-procedure locations, unless a risk assessment is conducted by the health care governing body. The code goes on to say that all wet-procedure locations shall be protected by an isolated power system (IPS). Owners are first very interested in understanding what an IPS is, and then in what other owners are doing. Both the code-making panel and professional organizations' (American Society for Healthcare Engineering, ECRI Institute, etc.) positions are discussed, along with the costs, testing requirements, and industry IPS concerns. Based on this information, a decision can be made to proceed with an IPS or completing the risk assessment. Because the distribution and size requirements of an IPS are different, confirming the decision is made early in the project helps with space planning.