Codes and Standards

As health care shifts, so do codes

Lower-cost alternatives to traditional hospitals create code challenges for engineers and designers
By Gregory Hudson, PE, HFDP, RMF Engineering, Charleston, South Carolina July 18, 2019
Figure 2: Inova Fairfax Medical Campus in Falls Church, Virginia, has a labor-delivery center and obstetric care unit that is fully equipped with state-of-the-art technology for patient care. Courtesy: RMF Engineering

Learning objectives

  • Provide an overview of alternative facilities and current building code application for microhospitals and medical office buildings. 
  • Identify what designers and engineers need to look for when designing these kinds of facilities. 

To provide quality health care coverage and services in rural and underserved areashealth care providers are looking for alternative options to traditional, full-size medical facilitiesMicrohospitals and medical office buildings are becoming more relevant as they providthe same high level of service to meet patient needs, but in a smaller footprint 

Microhospitals are facilities that offer many of the same services and at a similar level that a typical hospital provides, but with a smaller bed count. MOBs, typically consisting of administrative offices, exam rooms and support spaces for private practice groups, are now providing supplementary services such as imaging, outpatient procedures and other clinical services that historically were only provided in a traditional hospital environment.  

The challenge that health care facility engineers and designers are now facing is ensuring that these smaller facilities are compliant with the same building codes and standards governing the larger, more traditional health care facilities 

Microhospitals are typically situated in areas that demonstrate a need for services provided in a traditional hospital environment, but lack the population to support large-scale hospital facility that has hundreds of patient bedsMicrohospitals are significantly smallerwith between eight and 15 beds and ranging in size from 15,000 to 60,000 square feet. They are much less costly to construct and generally less expensive to operate.  

This is still a relatively new type of facility. More health care providers are pursuing this new model for areas that are still growing or small communities where constructing a large-scale hospital is not financially feasible.  

MOBs have traditionally been used to house suites of private practice physician groups and were originally intended to provide routine physical examinations, patient checkups, basic laboratory work and some minor outpatient procedures. As health care costs continue to riseproviders are exploring lowcost alternatives. As such, MOBs have begun to take on more of the functions of a hospital. MOBs have expanded their role offering more laboratory services, imaging services and even some ambulatory surgeries.  

The challenges for these facilities lie in their ability to meet current building codes, which were written without MOBs and microhospitals in mind. The goal is to provide a code compliant facility that is safe for building occupants. While working with current building codes will be a challenge, these codes must be applied appropriately.  

Figure 1: The Betsy Johnson Hospital is a 101-bed inpatient nursing care hospital in Dunn, North Carolina, providing critical care services, medical-surgical services, pediatrics, breast care, rehabilitation services, speech therapy and cardiac rehabilitation. Courtesy: RMF Engineering

Occupancy requirements 

When beginning the design for any new facility, the designer or engineer should first reference the International Building CodeChapter 2 of the IBC is dedicated to the “use and occupancy” classifications of different building types based on their use.  

Traditional hospitals are defined as Group I, or institutional occupanciesThese are defined by the IBC as: … the use of a building or structure, or a portion thereof, in which care or supervision is provided to persons who are or not capable of self-preservation without physical assistance or in which persons are detained for penal or correctional purposes or in which the liberty of the occupants is restricted.  

In this case, we are concerned with buildings where “… supervision is provided to persons who are or are not capable of self-preservation, according to IBC-2015. In health care environments, this would apply to patients who may be incapacitated due to anesthesia, in recovery from procedures and cannot move on their own or the elderly who may require assistance when moving around.  

Institutional occupancies are further broken down into three groups, I-1, I-2 and I-3. Medical facilities are group I-2 facilities, defined in IBC-2015 as “buildings and structures used for medical care on a 24-hour basis for more than five persons who are incapable of self-preservation.”  

The IBC provides for two additional conditions to determine if a facility is covered under Group I-2. The first is “facilities that provide nursing and medical care but do not provide emergency care, surgery, obstetrics or inpatient stabilization units for psychiatric or detoxification, including but not limited to nursing homes and foster care facilities.”  

The second condition is facilities “that provide nursing and medical care and could provide emergency care, surgery, obstetrics or inpatient stabilization units for psychiatric or detoxification, including but not limited to hospitals.” This second condition typically is what governs hospitals and any other facilities where patients will remain for a period longer than 24 hours.  

Group I-2 occupancies also have requirements related to the number of people receiving custodial care. Any facilities where five or fewer people are receiving care shall be classified as Group R-3 or “shall comply with the International Residential Code provided an automatic sprinkler system is installed. It would be highly unusual to have a medical facility that would require an institutional type occupancy and only have the capability to accommodate five or fewer patients. Some microhospitals have relatively low bed counts, but typically they are able to handle more than five patients at any given time. 

The IBC also has a class B or business occupancy, which is what is traditionally used for a MOBThe IBC defines the occupancy as “the use of building or structure or portion thereof, for office, professional or service-type transactions, including storage of records and accounts. Each use and occupancy classification provides examples of the facilities that would fall into this category. Group B does include two examples that fall into health care-type facilities: ambulatory care centers and professional services 

The IBC defines ambulatory care centers as “buildings or portions thereof used to provide medical, surgical, psychiatricnursing or similar care on a less than 24-hour basis to individuals who are rendered incapable of self-preservation by the services provided.” This limits the types of procedures that can be performed within these facilities. Any procedure requiring extended observation after the procedure is completed cannot be performed in a business group occupancy.  

Buildings providing professional services are noted to be architects, attorneys, dentists, physicians, engineers, etc. For physicians providing professional services, this typically involves doctor’s offices, private medical practices and some medical specialists. It is not unusual for some MOBs to provide imaging services, minor procedures and laboratory services.  

Given the IBC definitions discussed above, the first step in programming any new facility is to determine what kinds of procedures an owner wants to be able to perform. New facility types, such as a microhospital, can certainly fall into either a Group B or Group I occupancy, depending on the type of procedures being performed. Procedures that would require a patient to stay longer than 24 hours should be designated as Group I occupancy. Any procedure requiring a limited stay, defined as an amount of time less than 24 hours, can be classified as a Group B occupancy.  

Figure 2: Inova Fairfax Medical Campus in Falls Church, Virginia, has a labor-delivery center and obstetric care unit that is fully equipped with state-of-the-art technology for patient care. Courtesy: RMF Engineering

Building design 

Once the occupancy requirement has been confirmed, it will be necessary to determine how the occupancy category will impact the building design. The International Mechanical Code has a specific requirement for ambulatory care facilities and any Group I-2 occupancies. IMC section 407.1 states, “Mechanical ventilation for ambulatory care facilities and Group I-2 occupancies shall be designed and installed in accordance with this code and ASHRAE 170.”  

Given that ambulatory care centers have the capabilities to perform some surgical procedures, any of those spaces would require the same ventilation requirements as needed for a traditional hospital, even if the facility may not be classified as Group I. Surgical and other procedure areas in ambulatory care centers are not treated any differently even though they are in Group B occupancy. There also are several other requirements for Group I-2 occupancies that are also required for ambulatory care centers. Designers and engineers should ensure they are familiar with these additional requirements and how they may impact the project. 

ASHRAE 170: Ventilation of Health Care Facilities on its own is a standard and when referenced by the IBC, it becomes codeASHRAE 170 provides a minimum set of requirements for ventilation of health care facilities. Any facility designated as an I-2, institutional occupancy or an ambulatory care center would be required to comply with this standard per code. The purpose of the standard as defined in ASHRAE 170 … is to define ventilation system requirements that provide environmental control for comfort, asepsis and odor in health care facilities.”  

General scoping information is provided for necessary compliance requirements depending on the project, either new construction or renovation. For renovations, building owners often are concerned with limiting scope creep due to any alterations. Very often in renovations, any areas that the project touches are required to be brought up to current codes. Engineers must be efficient with their designs to accomplish the owner’s project goals, without unnecessarily increasing the project scope and budget. 

The standard also asks for building owners to provide detailed program information for the facility they want to construct. Programs are supposed to provide information on “clinical service expected in each space, the specific user equipment expected to be used in each space and any special clinical needs for temperature, humidity and pressure control,” per ASHRAE 170.  

It is critical for designers and engineers to gather this information from building owners as early as possible in the design process. This information can help determine the occupancy category of the building and will help in identifying other codes and standards that may be relevant to the design. Designers and engineers should ask building owners to advise them of any requirements related to insurance or the owner’s own requirements that may go above and beyond the applicable codes and standards.  

Systems and equipment 

The systems and equipment associated with health care facilities also are discussed as part of ASHRAE Standard 170, including heating and cooling sources such as cooling towers, air handling unit designhumidifiers, air distribution systems, energy recovery systems and insulation systems. Given that health care facility users can have compromised immune systems and can be more susceptible to infection, these systems are more specialized than what is seen in typical commercial buildings.  

Required air change rates, pressurization requirements and space conditions in terms of temperature and relative humidity are provided for hospital spaces, outpatient spaces and nursing home spaces to limit transmission of any infections or spread of contagion and ensure patient safety, staff safety and general occupant comfort.  

There is also an additional detail on specific spaces such as airborne infection isolation rooms, protective environment rooms, critical care units, surgical areas and support areas such as morgue and autopsy spaces, bronchoscopy and psychiatric patient areas.

Finally, the Standard 170 covers general planning, construction and system startup of HVAC systems. Again, since the occupants of health care facilities are more susceptible to infections, special precautions need to be taken when executing a construction project in a health care facility. 

The standard is not intended to be a design guide, but it does provide a set of minimum criteria. Other design guides specific to hospitals are available. ASHRAE’s HVAC Design Manual for Hospitals and Clinics is a great resource for the design of health care facilities 

Another important code is NFPA 99: Health Care Facilities CodeNFPA 99 does not follow the occupancy classifications present in the IBC but does use some of the same language. Per NFPA 99, a health care facility is defined as “… buildings, portions of buildings or mobile enclosures in which human medical, dental, psychiatric, nursing, obstetrical or surgical care is provided.” NFPA 99 also has a definition for an ambulatory care center: 

An occupancy used to provide services or treatment simultaneously to four or more patients that provides, on an outpatient basis, one or more of the following: (1) treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; (2) anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; (3) emergency or urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others. 

Therefore, this code would apply to any Group I-2 occupancy but would also apply to any Group B occupancy designated as an ambulatory care center. Designers and engineers should make sure that owners do not have insurance policies that require facilities to be complaint with this code, even though they may not be a Group I-2 occupancy or an ambulatory care center, but are still providing health care services.  

Figure 3: One of IBM Watson’s 50 Best Cardiovascular Hospitals is part of UNC REX Healthcare providing full-spectrum emergency cardiac care and fast-track treatment for the prevention of severe heart attacks. Courtesy: RMF Engineering

Know the challenges 

To summarize, the first step for designers and engineers is to understand the types of procedures and services being offered in each facility to ensure that the building codes are properly applied. Procedures that will require a patient to remain in the facility for at least 24 hours will require the building to be designated as Group I-2, institutional. Facilities where patients will remain for less than 24 hours can be designated as Group B occupancy, except for any facility designated as an ambulatory care center.  

Ambulatory care centers, though designated as Group B occupancy, are governed by the same requirements as Group I-2 occupancies. Once the building occupancy category has been determined, designers and engineers need to be aware of other codes and standards that may apply, such as ASHRAE 170 and NFPA 99. Designers and engineers also need to be aware of any owner insurance requirements or owner standards that may impact the design of the building above and beyond what is required per code. 

With smaller facilities like microhospitals and MOBs, designers and engineers will be challenged to apply codes appropriately to ensure a codecompliant facility in a cost-effective manner for facility ownersAs health care costs continue to rise, health care providers will continue looking for low-cost options to provide care, especially in smaller markets, while still offering treatment options that were traditionally only available in a full-size metropolitan hospital. As these designs increase in number, having a firm grasp of codes and design requirements will become essential for engineers. 


Gregory Hudson, PE, HFDP, RMF Engineering, Charleston, South Carolina
Author Bio: Gregory Hudson is a mechanical project manager with RMF Engineering. His experience encompasses the design and analysis of HVAC, plumbing and fire protection systems serving health care, educational, laboratory and commercial facilities.