Ask an expert: Hospitals, health care facilities: Codes and standards

Health care facility designers are expected to keep pace with increasingly complex, advanced engineered systems and features

By Consulting-Specifying Engineer November 20, 2019


Neal Boothe

TLC Engineering Solutions

Boothe has more than 24 years of experience in the health care industry. As Principal/Senior Electrical Engineer, he has led numerous projects, including new greenfield hospitals and additions and renovations to existing health care facilities.

Mark Chrisman

Henderson Engineers

In his role as Vice President and Health care Practice Director, Chrisman coordinates strategy for the company’s health care projects nationwide. His areas of technical expertise include fire protection and code consulting.

Tom Divine

Johnston, LLC

As Senior Electrical Engineer, Divine has spent 21 years in the consulting engineering field, with the past 17 years designing and engineering health care facilities. He is responsible for power, lighting and fire alarm design for hospital and health care projects.

Roger Koppenheffer

Certus Consulting Engineers

As a founding Principal of Certus Consulting Engineers, Koppenheffer brings 24 years of experience in the MEP consulting engineering industry specializing in health care facilities. He has a range of expertise in mechanical and plumbing engineering.

Nick Martin

Affiliated Engineers Inc.

As principal, Martin oversees multidiscipline engineering teams with a focus on national and international health care markets. He originally joined the firm as an electrical project engineer.

Michael Phillips

Southland Industries/Envise

Phillips works with consulting engineers, customers and internal business development staff. He is responsible for educating them on the solutions offered through controls and building automation.

Jose Torres

RMF Engineering

As Health care Team Leader in the company’s North Carolina Building Systems Division, Torres works with organizations such as Duke Health, UNC Hospitals and Rex Health care. He has been with RMF since January 2001.

April Woods


As vice president and mechanical department head of Florida building systems for the company, Woods has played a key role in engineering mechanical solutions for major health care projects. She has facilitated sustainable design for several successful green building projects.

CSE: Please explain some of the codes, standards and guidelines you commonly use during the project’s design process. Which codes/standards should engineers be most aware of?

Woods: Luckily, nationwide we are seeing more states continue to adopt the Facility Guidelines Instituteguides, which allows engineers the ability to standardize and implement more consistent best practices into their designs. However, it is important that engineers continue to do their due diligence with code research to ensure that the local enforceable codes are still being maintained. Many jurisdictions still have local amendments that must be adhered to.

Divine: NFPA 99: Health Care Facilities Codespecifically addresses the requirements of health care facilities. NFPA 110: Standard for Emergency and Standby Power Systemshas broad application to hospitals. The usual array of building codes also applies. Typically, those include NFPA 70: National Electrical Code, the International Building Codeand NFPA 101: Life Safety Code. An energy code will also apply, usually either the International Energy Conservation Codeor ASHRAE 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings, though some states have developed their own energy codes.

Koppenheffer: The primary documents when beginning the health care design process are NFPA 99 and FGI. These are considered the enforceable codes by most jurisdictions. Outside of these primary codes and standards, there are other key codes and operational standards that are crucial in designing health care facilities. Among these include ASHRAE 170: Standard for Ventilation of Health Care Facilities, which is now referenced in FGI. USP 797 and 800are pharmaceutical compounding standards and handling of hazardous drugs that are essential for hospital pharmacy designs. There are even operational standards that are not construction codes but contain strict temperature and humidity requirements that the hospital must adhere and report on such as Association for the Advancement of Medical Instrumentation, which comes into play for designing sterile processing departments.

Boothe: Well the easy answer would be “all of them,” however, there are three codes that specifically address issues that make health care unique from other projects and include requirements for hospitals that help make them unique. These are codes that require work, materials, etc. that differ from other building types and therefore may not be obvious to owner, contractors, designers, equipment vendors, etc. These codes include Article 517 in the National Electrical Code (this article in the NEC is specific to health care), NFPA 99 and Guidelines for the Design and Construction of Hospitals(often known as the FGI Guidelines).

Chrisman: The better option might be to state which of the few codes and standards that don’t apply within health care occupancies. With each city/state adopting a set of building, fire and mechanical/energy codes as well as the health department having a set of guidelines/standards and following the requirements of U.S. Centers for Medicare and Medicaid Services, the list is fairly extensive. Additionally, how a hospital bills a particular service or department can have bearing on what occupancy the space will be enforced too by regulatory bodies like The Joint Commission, DNVor Healthcare Facilities Accreditation Program. While knowledge of the adopted building codes is great, knowledge of how NFPA 101 and NFPA 99 (adopted by Medicaid/Medicare) work is a must. There are many referenced standards from these two codes and the ability to navigate between multiple codes as well as conflicting and duplicative criteria is critical for compliance.

Torres: The beautiful part of working on health care projects is the opportunity to bring in so many different codes, standards and guidelines to serve and protect the patient. In general, any health care project would require all state building codes, NFPA 99, NFPA 90A: Standard for the Installation of Air Conditioning and Ventilating Systems, NFPA 101, FGI Guidelines for Design and Construction of Hospitals and/or FGI Guidelines for Design and Construction of Outpatient Facilities and ASHRAE 170. Depending on the complexity of the project other codes and guidelines would apply to the project, such as NFPA 50: Standard for Bulk Oxygen Systems at Consumer Sites.

Martin: ASHRAE, FGI, International Building Codeand NFPA are codes/standards that every design engineer should be aware of. A working knowledge of the LEED system is also important.

CSE: What are some best practices to ensure that such buildings meet and exceed codes and standards?

Chrisman: Have a good fire protection engineer/life safety consultant on call and on each project design team. These folks typically spend a significant amount of time researching/applying the codes as well as on-site with the regulatory/accreditation organizations. Beyond that, having a good program/process to regularly assess compliance in existing buildings is helpful. This may also help with system inventory and keeping abreast of capital infrastructure needs.

Woods: A solid quality assurance/quality control process continues to be the best strategy to ensure that designs not only meet and exceed codes and standards, but also achieve the requirements set out by the owner. Having a deep bench of thought leaders allow companies like WSP to ensure designs are both consistent in approach while also adhering to both the stringent requirements set forth by the applicable codes and owner requests. Engaging key subject matter experts allows for project teams to thrive and guarantees that the latest codes and technologies are being implemented properly.

Koppenheffer: Three best practices that can be used to ensure compliance with codes and standards include continuous review, early energy modeling and understanding the business operations of the hospital. Continuous review provides multiple benefits including higher quality design with fewer mistakes or coordination issues. It also allows for better coordination with other engineering disciplines, architects and other consultants such as medical equipment or food service. Early energy modeling leads to successful code compliance but more importantly allows for system enhancements necessary for better energy performance. It also helps ensure a more cost-effective implementation of strategies as multiple approaches can be evaluated while the design is in its earlier stages. Understanding the business operation of the hospital allows for system design to address more than just that required by the code and standards. In some cases, a hospital may wish to exceed minimum code requirements such as requiring lower temperature spaces and a greater number if air changes like operating rooms. These examples can require additional enhancements that must be accounted for to deliver a code compliant building.

Martin: Stringent quality control protocols by experienced engineers has proven to be one of the most effective practices in ensuring codes and standards are aligned with project design and delivery.

CSE: How are codes, standards or guidelines for energy efficiency impacting the design of such projects?

Woods: Increased energy efficiency standards continue to push the envelope for how hospitals are required to be designed and operated. While often these guidelines are requiring a higher capital outlay for owners to swallow, many technologies and controls implementation strategies that are being used to meet these energy benchmarks have a proven and appealing return on investment. Engineers should continue to use energy modeling software and calculations to validate overall building performance when analyzing energy cost savings measures. This strategy also allows for different building components and technologies to be evaluated rather than just blindly applying prescriptive requirements that may not be the most advantageous for the building performance.

Martin: Every year codes and standards are being updated at some level with a focus on energy efficiency for new and renovated facilities. We’ve come a long way over the past 15 years and it is only reasonable to expect that these codes and standards will continue to become more stringent with respect to energy requirements.

Chrisman: On most new health care facilities and large renovations/additions, energy codes continue to play a major role in design and construction. While not every project is following the full LEED accreditation process, every project does have major discussions about energy, equipment, options, etc. While many items like LED lighting have become standard, there are many details related to heating and cooling that require fine tuning early in design.

Koppenheffer: Codes and standards consistently and correctly drive requirements for higher system efficiencies. The fact that hospitals are inherently inefficient due to their very nature of simultaneous heating and cooling necessary to maintain proper air changes and pressure relationships requires special attention to energy saving measures. Control strategies such as operating room airflow setback, static pressure and discharge air temperature reset, as well as differential and chilled water temperature reset are viable energy savings strategies in hospitals. Implementing these strategies, even where they are code required, can be more challenging and more difficult in hospitals and must be weighed against clinical requirements.

CSE: What new or updated code or standard do you feel will change the way such projects are designed, bid out or built?

Chrisman: While energy codes will continue to be a major driver in building design and construction, it will be interesting see how much of a role WELL Building Standardwill play in health care facilities moving forward. Both the WELL Building Standard and health care are converging on providing an impactful healing environment and this allows for a method to determine if healing is taking place through the life of the building.

Koppenheffer: In the summer of 2016, the Center for Medicare & Medicaid Services (CMS) adopted the 2012 edition of NFPA 99 requirements and the design community continues to evaluate best practices for implementation. With this adoption, along with similar changes to the International Energy Conservation Code, came the requirement for commissioning of building systems. We are a strong advocate in commissioning building systems, especially in a hospital. Commissioning means another set of eyes during design and construction, then testing the performance after installation to uncover operational issues before owner occupancy. This enhances the overall delivered quality of a project. Fortunately, in the health care world, owners tend to be savvy enough to understand the importance of commissioning and its value to a project, but as the industry moves more toward the smaller specialized facilities that are sometimes developer, first cost and schedule driven, commissioning is not always a top priority. With commissioning now being code required, it can change the way projects of this nature are delivered and ultimately make them safer for the occupants.

Boothe: There are new requirements in health care codes that now require more communication rooms throughout hospitals and also require that these communication rooms be of a substantial minimum size. These updated codes are reacting to the proliferation of more and more systems and technologies commonplace in modern health care. The FGI guidelines requires that all communication rooms be a minimum of 12×14 feet. Furthermore, NFPA 99 dictates a new communication room for every 20,000 square feet of construction.

Martin: ASHRAE Standard 189.3: Construction, and Operation of Sustainable High-Performance Health Care Facilitieswill likely change the way sustainability solutions are developed for real-world patient care conditions.

Woods: ASHRAE Standard 170 will continue to be the “bible” for health care mechanical engineers. As ASHRAE and other industry leaders continues to invest in R&D, this standard will continue to evolve to allow for best practices to be implemented and enforced. Design requirements are continually being tested through these efforts, which allows for the validity of the standard to be evaluated.

CSE: What are some of the biggest challenges when considering code compliance and designing or working with existing buildings?

Koppenheffer: The key to this is early due diligence and open communication with the authority having jurisdiction. As engineers, we have the responsibility to do the right thing. This does not necessarily mean designing the absolute ideal solution as it may not fit in the project budget, but also does not mean designing the absolute minimum or pushing for “grandfathering” of existing conditions. We may know of upcoming codes that are not yet adopted but will be and may currently be considered standard of care. Examples of this in the past decade are the early versions of USP 800 and ASHRAE 170. We need to educate and inform our clients and communicate with the AHJ to determine as a team how far we take the design for compliance with current and future codes. Where do we stop?

Torres: The biggest challenges with working on an existing facility are patient safety, infection control and limiting the impact of a renovation to adjacent areas. In the design phase, the biggest challenge is verifying existing conditions in the proposed renovation area. Typically, the proposed renovation area is used throughout the day and there is limited availability to perform fieldwork. Once access is provided to the area, the design team must comply with the infection control guidelines when accessing the spaces above the ceiling. In the construction stage, the construction team balances the need to maintain the egress in corridors open and maximize the amount of renovation that can be completed.

Martin: When renovation work needs to be completed so that it complies with current energy requirements, there can be a lot of hidden costs and unknowns associated with bringing the existing space up to current standards. In some cases, to achieve this, more invasive work is required, which isn’t always captured in a project budget.

Woods: Having complete evaluations of existing systems early in design is wise to be able to identify potential code deficiencies upfront. Early engagement with the local AHJ may be required to discuss these deficiencies and how they relate to the project system being altered. This is important as some code deficiencies may have a big impact to project budget and scope. These items should be identified early to the owner to reduce costly change orders that could occur later in construction.

Chrisman: Most of the health care industry is struggling with aging facilities and infrastructure in some shape or form. Many of these ageing facilities have portions that may require or already have an equivalency or waiver for an existing system or condition that cannot be corrected without a major renovation or capital. Similar to the discussion on best practices on code compliance, having a regular program/process in place that regularly assesses existing buildings is important. This can be accomplished through several methods including environment of care rounding or hiring a consultant to help with this. When a deficiency is identified that cannot be resolved quickly or cheaply often a consultant will be required to assist with the plan for resolution and timeline.

CSE: What codes or guidelines have you used to enhance the security on such a project?

Chrisman: While we have not used NFPA 3000:Standard for Active Shooter/Hostile Event Responseyet on a project, our internal security group has developed some similar physical security/campus risk and vulnerability assessments and management programs to assist with this process. There is also great guidance in the security management chapter in NFPA 99. Security continues to play a major role in most of our health care projects and crosses many disciplines, users and contractors. Most projects will include several specific meetings on security, risks and how we are going to maintain code compliance while meeting the needs of the staff and patients.