What codes, standards keep hospital designers up at night?

Learn about the key hospital and health care facility codes and standards from ASHRAE, NFPA, FGI and other associations.

Codes and standards insights

• Engineers rely on a wide array of code requirements, including NFPA 99, NFPA 101, ASHRAE 170 and the FGI Guidelines, to ensure safety, performance and regulatory alignment in health care design.
• Because health care projects involve overlapping layers of code compliance from IBC, NFPA, CMS and state authorities, teams must verify applicable editions early and coordinate interpretations with the authority having jurisdiction.

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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?  

Caleb Marvin: Engineers should be knowledgeable of NFPA 99: Health Care Facilities Code as well as the Facilities Guideline Institute guidelines or applicable State hospital codes and standards. These publications dictate many different requirements to ensure the safety of patients in a hospital. Outside of these codes, ASHRAE Standard 170: Ventilation of Health Care Facilities dictates ventilation requirements while the NEC provides the requirements for electrical infrastructure.

Meagan Gibbs: Health care projects bring a unique stack of codes beyond the typical IBC and NFPA requirements. The FGI Guidelines for Design and Construction of Hospitals are foundational and we reference these in nearly every project. Beyond that, the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and Joint Commission standards drive design decisions in ways other building types never encounter. For critical systems, we are also working under NFPA 99 and NFPA 101: Life Safety Code, with ASHRAE 170 (ventilation) and ASHRAE Standard 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings shaping MEP design.  

Jason Butler: In addition to typical building codes, which are in themselves complex and interrelated, key codes to pay attention to are; Facility Guidelines Institute, state DPH/DHHS/etc. and CMS/Joint Commission/etc. There are also application specific guidelines to be aware of such as USP (or state board of pharmacy requirements) and AAMI.

Richard Vedvik: All applicable codes are used, the design team needs to determine which codes, out of hundreds of codes, apply to the project. My advice to engineers is to call the applicable inspectors and other AHJ to build a relationship and verify what codes are being enforced. Engineers may learn about interpretations that the AHJ may use.

Jon Sajdak: The most frequently used codes for the design of health care facilities include the International Building Code (IBC), the Health Care Facilities Code (NFPA 99) and the Life Safety Code (NFPA 101). There are additional NFPA codes and standards that are referenced by these codes in which the buildings and their systems must comply with. Examples include NFPA 13, NFPA 14, NFPA 70, NFPA 90A and NFPA 72. All facilities that are subject to The Joint Commission (TJC) accreditation must comply with NFPA 99 and NFPA 101 in their entirety. At the beginning of each project, prioritize establishing a list of applicable codes and standards with the appropriate editions and also coordinate with the authority having jurisdiction (AHJ) for any local amendments.

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

Caleb Marvin: A structured quality review process is vital to ensuring that the many unique design criteria in health care design are met. Involving senior leadership in design review creates two benefits; it provides an opportunity to teach younger engineers the nuances of health care design and it helps identify the unique, code driven requirements early. By improving the quality of the documents before issuance, the design team reduces avoidable errors and last-minute issues, enabling engineers to focus on delivering well planned, engineering designs rather than reacting to problems under deadline pressure.

Meagan Gibbs: The best practice is to treat code compliance as the baseline. Early in programming, we engage infection preventionists, facilities staff and clinical leaders to map operational risks that are not fully addressed by code. We also use computational modeling and mock-ups to validate that designs not only meet prescriptive standards yet perform reliably under real-world conditions. The goal is to deliver a building which adheres to the necessary and appropriate compliances as well as being truly safe, adaptable and efficient.

Richard Vedvik: Read the applicable codes for each project, do not rely on memory or go off past projects. Instead, conduct thorough reviews with the team and consult the AHJ early to identify any unique interpretations or updates, ensuring compliance and avoiding costly revisions later in the process.

Jon Sajdak: At the beginning of each project, it is essential to perform a robust code analysis. This should include a determination of all applicable codes and standards of the project and typically require input from all design professionals, including both architects and engineers. With health care facilities, there are typically multiple codes and standards that are applicable, some of which have conflicting or varying requirements. It’s beneficial to make a code alignment matrix to ensure the most stringent requirements are being met across the project.

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

Caleb Marvin: Energy codes help drive innovation in design at the plant level. The International Energy Conservation Code includes an exception to remove economizer cycle from air handling units in facilities that operate 24/7 if heat recovery is provided that can manage the lesser of 60% of the peak heating load or preheat the peak domestic hot water load to 85 degrees. Heat recovery chillers can reclaim the heat from the chilled water system and heat these loads that hospitals have a great demand to reduce that power and gas consumption. Items such as these in the energy code help fuel innovation to maximize the energy savings in health care facilities.

Meagan Gibbs: Energy codes are catching up to the reality that hospitals are among the most energy-intensive building types. ASHRAE 90.1 and state stretch codes push systems toward higher-efficiency HVAC, better envelope performance and greater electrification. The challenge is to balance those requirements with the redundancy health care demands. Codes are helping raise the baseline, yet clients are pushing further, asking us to hit systemwide sustainability and carbon reduction targets that exceed minimums.  

Jason Butler: Industry pressure, operational cost efficiency improvement and strategic planning seem to be a bigger driver of energy efficiency and decarbonization, even more so than advancing energy codes. One reason we see for this is the many health care facilities are renovating and modernizing existing building inventory and those projects don’t always trigger mandatory updates to current energy codes. But there is an increasing trend to opt for efficiency improvements that go beyond these code requirements.    

In general, what issues are newer codes and standards working to address?      

Caleb Marvin: The latest codes are working to address the historical differences between the International Building Code and the National Fire Protection Association codes with every edition bringing them closer to alignment. For example, for several editions now, NFPA has not required fire and fire/smoke dampers in walls rated 1 hour. In the 2021 edition, the IBC updated the exceptions where fire dampers can often be omitted in 1-hour walls if the systems are fully ducted of minimum 26 gage steel (including flex duct installed per the IMC) in fully sprinklered buildings.

Meagan Gibbs: We are seeing codes evolve to reflect lessons learned from COVID-19 and from climate resilience. Newer editions of ASHRAE 170, for example, increase focus on airborne infectious disease control and adaptable pressurization strategies. Energy codes are expanding their emphasis on electrification and carbon reduction, signaling a future where hospitals will need to integrate renewables and storage. There is also increasing attention on patient safety through technology integration — for example, requirements around electrical system reliability in spaces with advanced imaging or robotic surgery. Codes are still catching up to how fast health care delivery is changing, yet the trajectory is clear: more focus on resilience, flexibility and decarbonization.   

What considerations are necessary for health care buildings in particular that may go beyond codes and standards for other building types?  

Caleb Marvin: In addition to codes and standards, the design engineer must understand the ongoing operational challenges that a building engineer faces while operating a 24/7/365 facility. Most facilities also have specific protocols and requirements related to infection prevention that the engineer must account for and incorporate into the system designs. These discussions are crucial to have in the early stages of design as some items may significantly affect the project budget. Dedicated air handling units and hands-free plumbing fixtures are a couple items becoming more common in hospital requests to assist in infection prevention that have a direct impact on design and total project cost.

Meagan Gibbs: Health care is about life safety in a 24/7 environment — and codes do not capture everything. Infection prevention, for example, goes far beyond ASHRAE or NFPA minimums. We routinely design redundant air-handling, advanced water treatment and fully separate pathways for patients, staff and materials in ways office or school codes would never require. Behavioral health is another instance: codes cover ligature resistance broadly; however, actual patient and staff safety depends on engineering details such as tamper-resistant systems and maintenance-friendly utilities. In our Behavioral Health Guidelines and projects, we exceed standard ligature guidance to embed resilience and dignity into care environments. These are the kinds of project drivers that codes do not fully address, however, are essential to safe, functional hospitals.         

Jason Butler: The sheer quantity of codes, standards and regulating bodies is challenging, not only for design of health care systems, but operationally for facility staff. The record keeping requirements from regulating bodies make it important the engineering designs do their part to help the facilities staff operate their building successfully.   

Richard Vedvik: NFPA 99 needs to be read, along with the referenced NFPA sections. One common question I get is when NEC Art. 517 applies for buildings that are not I-2 Occupancies but provide patient care in accordance with NFPA 99. One intent of health care codes is to determine the possible impacts of system failures and to assign a Category classification based on possible loss of life.

Jon Sajdak: Health care facilities have more stringent requirements than most occupancy types covered by the IBC and NFPA 101. Some examples include corridor wall construction, corridor width, subdivision of building spaces (i.e. smoke compartments), alignment between sprinkler, fire alarm and smoke compartment zones and pathway survivability for the fire alarm system.

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

Meagan Gibbs: Security in health care is multidimensional — it is about protecting patients, staff and sensitive information. We reference guidelines from the International Association for Health care Security & Safety (IAHSS) alongside standard NFPA and CMS requirements. In projects we have integrated CPTED (Crime Prevention Through Environmental Design) principles with access control systems tied into the hospital’s electronic medical record platform, a level of integration beyond what typical building codes dictate. Security also has a cyber component now requiring engineering teams to coordinate with IT and facilities groups to ensure building automation systems meet cybersecurity standards like NIST SP 800-53, protecting both operational data and patient safety.