How to design medical buildings: Codes and standards
Hospitals and health care buildings have become very sophisticated. Coordination among all parties, special attention to codes and standards, and a focus on patient comfort have each become highly important to engineers. Adherence to codes and standards is required.
- Randall Ehret, PE, Senior Vice President, Environmental Systems Design, Chicago
- Timothy Larson, PE, LC, LEED AP, Principal, RTM Engineering Consultants, Milwaukee
- Melisa Rodriguez, PE, SET, Director of Fire Protection Engineering, LEO A DALY, Minneapolis
- Matt Volgyi, PE, LEED AP, Principal Engineer, Southland Engineering, Garden Grove, Calif.
- Mike Zorich, PE, LEED AP, Associate Principal, IMEG, Rock Island, Ill.
CSE: Please explain some of the codes, standards, and guidelines you use during the design process. Which codes/standards should engineers be most aware of in their design of engineered systems in hospital, health care, and medical campus projects?
Zorich: The codes that engineers need to be experts in when designing health care facilities are FGI 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities, ANSI/ASHE/ASHRAE Standard 170-2013: Ventilation of Health Care Facilities, and NFPA 99-2015: Health Care Facilities Code. Many federal agencies and states use these three as either a code or a reference standard when reviewing or licensing health care facilities. The intent of all three documents is to enhance the quality of health care while protecting patients and staff.
Larson: There are many codes, standards, and guidelines that govern the design and construction of health care facilities. These include NFPA 99 and the Facility Guidelines Institute’s Guidelines for Design and Construction of Health Care Facilities, which includes ASHRAE Standard 170. Recently, the Centers for Medicare and Medicaid Services (CMS) adopted the 2012 edition of NFPA 101 and all its referenced standards including ASHRAE 170-2008. However, not all AHJs have adopted the 2012 edition, therefore you should always check with your local AHJ as to which applicable codes and standards to follow in your area.
Rodriguez: Health care is unique in that there are multiple standards that overlap including the NFPA 101, NFPA 99, and IBC I2 occupancy requirements. Knowing when one takes precedence over the other can be a task in and of itself. These requirements also vary based on which entity is funding the project. Project teams also need to take note of other AHJ requirements and what is considered for compliance, such as the FGI guidelines or the Joint Commission.
Volgyi: In California, health care design is highly regulated by the California codes, thus thorough familiarity with these codes is a must. The AHJ is the Office of Statewide Planning and Development (OSHPD), which takes an active role in developing and updating all the disciplines of the California codes. In addition, OSHPD has an excellent website that includes additional information for designers, such as CINs (code-interpretation notices) and PINs (policy-interpretation notices). CINs and Pins are, in essence, supplements to the codes with which health care designs need to comply.
Ehret: Compliance with all state and local building codes is mandatory on all projects. For health care projects, the complexity increases exponentially. State health department codes and federal CMS requirements are vital to the ability of a health care facility to be accredited. This adds another level of AHJ review to your project. HIPAA regulations address security and privacy of protected health information. This regulation also highlights acoustic and visual privacy. The American with Disabilities Act applies to all public facilities and greatly impacts building design with its general and specific accessibility requirements. It is also important to understand owner guidelines, for they are becoming increasingly rigorous as hospital systems merge and build outpatient facilities types that are less familiar to them. Additionally, energy codes continue to get more stringent, necessitating owner education and budgeting to implement.
CSE: What are some solutions/best practices to ensure that such buildings meet and exceed codes and standards?
Ehret: We are all human. We all make mistakes. I have yet to see the perfect project. However, a well-documented code search/analysis at the start of a project and a continuous quality assurance process is the best way I have found to develop a good set of contract documents.
Rodriguez: Meeting (and exceeding) codes and standards requires early and open communication channels between the project team, owner, and AHJ, right at the start of the project. It is critical to find out which standards and design guides need to be applied and ensure a thorough understanding of expectations. To ensure a smooth process, preliminary meetings with the AHJ and other stakeholders are recommended.
Larson: Discussing the intended use of spaces with the owner/architect is key to ensuring that the building meets current codes. This includes verifying items such as the occupancy type, whether inpatients will be served, if hospital billing will be used, and what level of anesthesia/procedures will be performed. In addition, discussing the potential future uses of departments, such as the intent for an urgent care to be converted to a future emergency department, can greatly assist in saving the owner money long term by proactively designing power systems and device layouts to accommodate the spaces’ future use.
Volgyi: On our projects, chilled water AHUs worked best for health care buildings. This is due to the relatively high amount of OA and subsequent dehumidification required for the AHU coils. The size of our projects typically justifies a water-cooled chiller system as an energy-efficient and robust solution suitable for hospitals. The central plant building is often designed as a separate structure to reduce the cost of the building, simplify design, and allow better access.
Zorich: It’s important to note that the health care design codes the industry follows are considered minimum requirements. Often, the health care facility may need to exceed these requirements to achieve patient or staff needs. Common items requested that exceed code include higher air changes per hour and lower space temperatures in the operating room; cooling equipment on emergency power; and higher levels of redundancy of MEP systems. The design professionals need to bring these items to the table early in the design to ensure they are understood and addressed. We often hear budgets were established with a “code-minimum” building—this is fine, but it is important for all team members on the project to understand the true meaning.
CSE: How are codes, standards, or guidelines for energy efficiency impacting the design of such buildings?
Volgyi: There is a wide range of projects with significantly different project goals. Hospitals are often exempt from energy codes, so it is the duty of the design professional to provide and deliver an optimum design that not only meets all the code requirements and hospital design safety considerations, but also provides an energy-efficient solution within the project budget. The most common two approaches are first cost and energy savings. In first-cost-driven projects, the first cost is the driver and the goal is to provide the most efficient system within the project budget. The key to the best designs of such projects is to identify energy-saving opportunities, recommend features with reasonable first cost and payback of fewer than 3 years, and find ways to include these features in the project budget.
In energy-savings-driven projects, the project requirements include U.S. Green Building Council LEED certification and/or energy-savings goals requiring a certain percentage better than a reference energy code, such as ASHRAE 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings. To achieve such goals, a wide variety of energy-saving features are considered and prioritized regarding payback period and first cost to achieve the desired goals. A suitable energy model is necessary to evaluate the performance of each of these systems. Finally, the combination of features need to be modeled together because energy-saving measures often overlap and diminish payback when combined, and this effect needs to be considered for finalizing the selection.
Zorich: One of the biggest challenges for health care design in achieving the optimum energy efficiency is how to address the large amount of supply-air reheat. Reheat is ultimately driven by the large amount of OA required by code for a health care facility. The intent of the high quantity of OA is to improve indoor-air quality and mitigate airborne transmission of diseases. Strategies engineers often use to address this challenge include the use of dedicated outdoor-air systems (DOAS) with energy recovery or occupancy sensors for unoccupied setback.
CSE: What new code or standard do you feel will benefit most hospital, health care, and medical campus facilities? This may be a code that your AHJ has not yet adopted, but you feel will directly impact your work in the future
Rodriguez: NFPA 99 recently set health care-specific criteria for systems based on the risk to the patient, staff, and visitors.
Volgyi: An energy efficiency modeling software using ASHRAE 90.1 energy standards to establish baseline energy use and compare it against the proposed mechanical system. The software would need to enable modeling for a reasonable amount of energy efficiency features for the proposed building and generate clear reports suitable to be used for LEED or another required energy-savings submittal. A similar software for the California Energy Code, Title 24, also would be quite useful because local utility companies want to see savings based on Title 24 standards, not ASHRAE 90.1.
CSE: How will updated codes/standards relating to energy efficiency (i.e., ASHRAE 90.1) impact decision making for new and existing facilities?
Volgyi: As codes get more stringent, buildings with higher energy efficiency are being designed and built. However, this needs to be done carefully as the cost of health care buildings are already quite high. Agree that relatively low-cost, high energy-savings alternatives with good payback shall be part of the energy codes to make sure they are provided, though it makes it increasingly difficult to achieve LEED ratings or other project requirements to save beyond ASHRAE 90.1.
CSE: Give an example of a project that conflicted with what the building owner wanted and certain codes and standards. How was this situation resolved?
Zorich: A common conflict that has occurred over the past few years is the disagreement between design (ASHRAE) and operational (AAMI) standards for sterile processing departments. For decontamination rooms, ASHRAE/ASHE 170-2013 states a space temperature range of 72° to 78°F while AAMI recommends operation at 60° to 65°F. To resolve this conflict, we present the two standards to the hospital’s administration and their sterile processing department. We discuss the impact of each option on project budget and building operations and then come to a consensus with the group. Fortunately, ASHRAE, AAMI, FGI, APIC, and AORN are aware of this conflict and have put a joint task force together to establish the HVAC requirements for this space.
Rodriguez: One current LEO A DALY project is a federal health care facility funded by a private developer. Because of this unusual arrangement, there is a potential conflict between the life safety standards of private- and public-sector stakeholders. Conflicts like this may become more common due to the increase in public-private partnerships in health care.
Volgyi: Our most recent example includes a long-term care facility, where the owner wanted to replace the fan coil units with a certain budget in mind. The building was built in the 1960s, and neither the return air nor the OA was ducted to the fan coil units, both taken from the ceiling plenum. This certainly does not meet current codes, which will result in the project costing more than double and likely not allowing the owner to upgrade the facility at a reasonable cost.