Designing health care facilities and medical campuses: Codes and standards

Hospitals, clinics, and similar facilities are among the most demanding an engineer can tackle—technology is evolving rapidly, hospital managers are increasingly budget-conscious, and assist in saving lives. It’s also vital to comply with the necessary codes and standards.

By Consulting-Specifying Engineer November 21, 2018


  • Andrew Flanagan, PE, GPD, LEED AP, Associate, Senior Plumbing Engineer, Interface Engineering, Portland, Ore.
  • Mikhail Fuks, PE, HFDP, Engineering Group Leader, P2S Inc., Long Beach, Calif.
  • Gary Hamilton, PE, LEED AP, CxA, EDAC, SASHE, Senior Vice President, WSP, Arlington, Va.
  • Alex Harwell, Client Manager/Project Manager, Dewberry, Raleigh, N.C.
  • Ted Hood, Senior Project Manager, TLC Engineering for Architecture, Brentwood, Tenn.
  • George P. Isherwood, PE, Vice President, Peter Basso Associates Inc., Troy, Mich.
  • Jeremy Jones, PE, LEED AP, EDAC, Healthcare Market Leader, Affiliated Engineers Inc., Chapel Hill, N.C.
  • Brian Kannady, PE, Principal, ME Engineers, Golden, Colo.

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

Flanagan: For HVAC systems, ASHRAE 170: Ventilation of Health Care Facilities and ASHRAE 189.1: Standard for the Design of High-Performance Green Buildings Except Low-Rise Residential Buildings are commonly used above and beyond the commercial building standard of care that ASHRAE 62.1: Ventilation for Acceptable Indoor Air Quality and ASHRAE 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings provide. In addition, ASHRAE Guideline 12: Minimizing the Risk of Legionellosis Associated with Building Water Systems and ASHRAE 188: Legionellosis: Risk Management for Building Water Systems require the design community to both design aspects of HVAC/plumbing systems to mitigate legionella as well as inform the owner/facility manager of the ongoing maintenance, testing, and reporting aspects associated with piping systems.

Harwell: Hospitals are typically under the jurisdiction of myriad overlapping regulatory standards and agencies, which varies from state to state. Designers worth their salt should know the following:

  • Current state building codes and editions applicable to their projects.
  • Current licensing-agency rules for state hospitals or health care facilities and regulations adopted or referenced. These can vary from no additional requirements to adoption of national health care standards, such as Facility Guidelines Institute (FGI), to unique local rules codified in the state’s administrative codes.
  • Local state and county health department rules.
  • The currently enforced edition of NFPA 101: Life Safety Code and NFPA 99: Health Care Facilities Code by the Centers for Medicare & Medicaid Services (CMS) and the local state agency (which can differ).
  • The particular facility’s third-party CMS accreditation organization’s rules (e.g., The Joint Commission’s Environment of Care standards).
  • Any additional clinical body standards that the facility enforces (e.g., Association for the Advancement of Medical Instrumentation (AAMI), Association of perioperative Registered Nurses (AORN), etc.). These often have additional or more stringent aspects affecting engineering systems.

Isherwood: Most states’ building codes relate to the International Building Code and the American Institute of Architects (AIA) Health care design guidelines.

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

Fuks: You should regularly communicate and understand what is coming next in the world of codes for health care facilities. Our team’s approach is to get involved in the standards and guidelines development for our industry so that we can effect change in the code cycles to come. For example, participate in standards and technical committees at the national ASHRAE level that feed into the California codes in the coming decades.

Jones: The best way to ensure that buildings meet or exceed the standards to which they are designed is through a rigorous commissioning process by a qualified commissioning agent. A longtime staple of high-end laboratory construction, commissioning has recently become more prevalent in health care projects. A commissioning agent will field-verify control sequences and equipment installation to prove that design intent is met.

Harwell: In-house staff should stay up to speed on the current local regulatory rules, environment, and interpretations. This is critical for hospitals, as much of their oversight is beyond the typical building code-enforcement agencies most firms encounter and are familiar with. Engaging with and attending The American Society for Health Care Engineering (ASHE) educational events and state chapter organizations, such as North Carolina Healthcare Engineers Association, Inc, Virginia Society of Healthcare Engineers, etc. is important. These often provide face-to-face engagement with state regulators, FGI, Centers for Medicare & Medicaid Services (CMS), and NFPA representatives, as well as direct and current training on topics related to hospital regulatory aspects.

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

Fuks: California is always pushing facilities to, at minimum, improve in energy efficiency. Health care facilities have been long exempt from these performance levels but soon will be under similar guidelines. This is driven by industry demand and a drying up of energy hogs out in the current marketplace.

Flanagan: As the industry’s understanding of a healthy environment evolves, energy efficiency standards and guidelines require more comprehensive solutions. This has created the need for a deep level of coordination between building siting, the building envelope, ceiling space, and HVAC systems earlier in the process to ensure an integrated solution. Passive strategies, such as increasing exterior insulation and shading while employing daylight harvesting, coupled with selective additional thermal massing allow new buildings to meet and exceed energy efficiency requirements.

Jones: Jurisdictions vary widely in their adopted energy efficiency requirements and the resulting aggressiveness of the strategies required to comply, but the common denominator is that they’re all getting more stringent and will continue to do so into the foreseeable future. MEP engineers can either decide that this is restrictive or exciting. I choose to consider it to be exciting because we are being forced to innovate and improve upon the stale design strategies of the past.

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

Jones: The first one that comes to mind is ASHRAE Standard 188. This has been adopted by CMS, which means that any hospital accepting Medicare patients must comply. It requires hospitals to have a documented plan on hand for their plan to control and mitigate a potential legionella outbreak. It requires hospitals to have piping drawings and schematics on hand so that they can understand their layout and potential for legionella triggers. It requires hospitals to monitor chlorine levels. It severely limits dead-legs and distances between plumbing fixtures and their water mains. Finally, it contains an increased focus on the cold-water side. Designers have gotten very proficient at forcing constant recirculation on domestic hot-water systems, but cold-water systems are traditionally uncirculated.

Isherwood: Humidity in the health care environment seems to be under a significant amount of discussion. There are studies that indicate higher humidity levels in health care environments are better for the success of patients, yet energy savings is trying to drive down the humidity levels.

Harwell: FGI’s facility guidelines for hospitals and outpatients are moving to the forefront of the code-consolidation effort, pulling in resources from CMS, AORN, ASHRAE, and the accreditation organizations to try and build a singular standard for hospital and outpatient design.

Flanagan: ASHRAE 188 provides an industry standard built to require the ongoing maintenance, testing, and reporting of all water-piping systems within a facility to mitigate legionella and other waterborne pathogens. However, health care owners and facility managers are not experts in ASHRAE standards and rely on their mechanical engineer consultants to inform them of any required compliance. ASHRAE 188 provides a framework for the health care facility to document and execute a management plan for their water-piping systems, and the mechanical engineer needs to integrate various control points and testing ports into these systems.

Fuks: California’s Energy Code, Title 24, will start to apply to more acute health care facilities in the coming code cycles. This will greatly change some design practices and force engineers to think in a more creative manner to meet the energy-consumption rates without lowering the outcome of a patient’s health.

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

Kannady: A common code challenge lately has been deciding how, where, and when to apply a specific design standard and code to a project. For example, it has been our experience that a state-level authority will typically review or have jurisdiction over a facility only if the facility is licensed with that state. Some state authorities use NFPA and FGI as the code and design standards, while many local authorities use IBC as the code. As these codes can contradict each other, it’s important to determine which code is used as a first step in the design process.

Harwell: Projects with existing conditions that may not have complied at the time of construction but were ostensibly accepted by the approving official at the time of original occupancy are a challenge. They require careful assessment and determination of the potential risk or impact of the deficiency and then review and negotiation with the authority having jurisdiction (AHJ) and the client to determine what path is acceptable. Equally important is defining the boundaries of corrective actions with the AHJ. When a specific controversial condition may exist, it is often best tackled early in the review phase with the assigned reviewer.

CSE: What are some of the challenges that exist between what the building owner wants, how the building needs to accommodate occupants, and complying with particular codes and standards?

Harwell: This comes up most often when the purpose of the existing facility changes. For example, a department wants to change the function of what a particular room or area is providing; however, the area may be in an older section of the facility with older, limited-capability systems requiring significant upgrades outside of the scope of work expected by the client. This often results in negotiations between the client and regulator on what will be allowed and what can be afforded.