Crafting the New Guidelines

Committee members are hard at work on the 2014 edition of the Guidelines for Design and Construction of Health Care Facilities.

• By Jerry Laws
• Sep 01, 2011

An important conference is taking place next month at a New Jersey hospital. The 2011 Designing for Patient Safety Conference (Oct. 11-12 at Virtua Voorhees, a regional medical center that opened May 22, 2011), is being held thanks to funding from the federal Agency for Healthcare Research and Quality. A key goal for the participating experts is to develop the framework for the patient safety risk assessment that will be included in the 2014 Guidelines for Design and Construction of Health Care Facilities.

Douglas S. Erickson, FASHE, CHFM, HFDP, CHC, deputy executive director of the American Society for Healthcare Engineering (ASHE), chairs the Health Guidelines Revision Committee that is now engaged in updating the 2010 edition of the guidelines. These guidelines affect every U.S. hospital in some fashion, influencing new construction and major renovations as they affect patient safety and quality of care, Erickson said.

The guidelines are updated at four-year intervals. The current 2010 edition includes a patient safety risk assessment in an appendix, and it also was the first edition to incorporate the ANSI/ASHRAE/ASHE 170 standard, Ventilation of Health Care Facilities. Infection control has been included in the guidelines since the mid-1990s, he said.

"We continued that by becoming the proponent for putting sinks in almost every location in patient treatment, that being exam rooms, patient rooms -- we've gone back and forth for many different editions of the guidelines, saying is it in the room, is it in the toilet only? In the mid '90s, we bit the bullet and said you've got to have hand washing facilities in the room itself," he explained. "'We've been extremely proactive in hand washing, of course. We're also looking at surfaces."

Adopted in more than 40 states, the guidelines apply to hospitals; ambulatory care facilities of many types; residential health care facilities, including nursing homes, hospice, and assisted living facilities; and birth centers and adult day health care facilities.

Experts among the committee's 130 members are looking at health care facility surfaces, textures, furniture, and fabrics from all angles: durability, infection control, cleanability, glare, and more. "Almost any aspect of the fabric or the surface you can think of. We've been very active in that regard," said Erickson.

A key focus for the committee as the 2014 edition is developed is electronic faucets. Johns Hopkins researchers warned in March 2011 that electronic faucets may cause problems in preventing Legionella infections in hospitals. They reported finding higher bacterial growth in water samples taken from electronic faucets than from manual faucets at The Johns Hopkins Hospital. The researchers surmised that standard hospital methods for disinfecting water systems do not work well with the electronic faucets' complicated valve systems.

"We've got this whole issue with e-faucets right now, all of the more complex water mixer type devices, with biofilms," Erickson said. "You may have seen the Johns Hopkins article that said use of electronic faucets had higher level of biofilms. It wasn't a peer-reviewed article; everyone is up in arms saying, 'Show us the data.'

"We do know that biofilms are growing on the neoprene, or rubber, small intricate pieces within these highly complex sensor faucets and also within the mixing valves of our showers. We'll be working on that along with ASPE, the Society of Plumbing Engineers, to see what we can be doing to work our way around this problem," he continued. "It is going to be a tough nut to crack, and it's going to be tough because you've got energy conservation that you're looking at; you've got the hands-free, which is something that we want within health care facilities, where we're not touching any kind of handles. You've got the whole issue of retroactivity -- so many of these are already installed, what do you do? Do you go back and take them out? How do you clear them?"

ASHE, the Association for Professionals in Infection Control and Epidemiology, and the American Society for Healthcare Engineering announced the formation of a stakeholders group in June to study the issue further. The group will survey the organizations' members about their use of electronic faucets and will work to increase overall knowledge of biofilms in clinical settings.

The committee is looking at hot water as it affects Legionella control, which "is an issue with all of our occupancies," Erickson said. "We're going to be looking at the whole issue of piping hot water to hand washing stations, which is a very interesting concept because the temperature of the water really has nothing to do with the cleaning of the hands. It's the use of the soap and the towels that have something to do with the cleaning of the hands.

"What we are starting to think about is, why are we piping these long, long runs of hot water to these large banks of fixtures, whether it be in a public restroom or up on our patient room floors, and you're not getting the hot water? By the time you're doing washing your hands, you're still not getting any hot water," he said. "You're saying, 'OK, fine, that wasn't a problem.' Now, you don't want ice-cold water. But tepid and natural water that heats itself up because it's in the building envelope, that should not be a problem."

The 'Value Engineering' Problem
Proposals for changes to the 2010 guidelines are due by Oct. 31, with proposals submitted through an electronic system hosted by the Facility Guidelines Institute, a nonprofit organization founded to ensure the guidelines are maintained and updated.

Fifteen working groups within the committee are working on various topics, including medication errors, how operating room environments are classified, and updating the 2010 edition's material on acoustics.

The expected release date for the 2014 draft is June or July 2012.

When the committee first met in April 2011 to begin the task, Erickson challenged the members to:

• examine the guidelines' current language to ensure the requirements are still relevant for current practices in medicine and patient care,
• think about how health care will be delivered in 2020 and how the physical environment should be designed and built to support innovative delivery methodologies
• write minimum requirements rather than lofty best practices
• consider initial, life cycle, and patient/staff safety costs and benefits of each major change being considered

Erickson said the goal of focusing on initial cost versus life cycle costs for all changes began with the 2010 edition. The goal is to eliminate the value engineering aspect of health care construction, where an architect's original design is cut back during the construction phase to save money.

"They value engineer a lot of what we consider the safety features and safety factors out. So it's extremely important," he said. "One of the things we want to be able to do is capture what the anticipated percentage change will be, either up or down. . . . It doesn't cost any more if you do it correctly. It goes back to making sure you get what you pay for in the physical environment and aren't value engineering all of the quality items out."

Much of the focus on how health care is provided a decade from now involves the patient safety risk assessment, which covers areas such as medication errors and patient falls, he added. "We know that we can make a difference if we do a good job in terms of designing our environments. It's not going to cost any more to put the lighting where the lighting is needed in order to be able to read the medication label. It's just a matter of paying attention to those details.

"I think we're going to be ahead of the curve with regards to patient safety," he said. "We work with AHRQ very closely. We're really trying to push the envelope to make it safer for patients."

Building Pace Accelerating
A hospital building boom began to be apparent in some parts of the country this year, but the recession slowed health care construction nationwide, Erickson said. "It had a huge impact. I don't know how many billions we were spending per year, but we dropped 25 to 30 percent [below] what we were doing three or four years ago." He said projects already under way were finished when the economy worsened, but projects still on drawing boards were shelved.

The building pace began to accelerate again in mid-2010, designs are picking up, and major projects are being started, such as the new $1.271 billion Parkland Hospital project being built in Dallas. Critical access hospitals are doing a lot of construction this year. Some health care organizations with aging facilities are finding those physical plants won't support quality care and are building new hospitals, he said.

Erickson said the 2010 edition is the best edition in the series of these guidelines, which are a continuation of hospital construction requirements that came out during the Hill-Burton era in the 1940s and early 1950s. "We're always getting better and are doing a good job of representing the entire health care industry," he said.

This article originally appeared in the September 2011 issue of Occupational Health & Safety.