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Table of Contents

Articles
Inside HFM
2
Advocacy Adviser
4
My Ashe Messenger
5
Design Discoveries
6
Architecture Showcase
7
Upfront
8
Interview
12
Solutions
14
The new normal
18
Centralized operations yields efficiency upgrade
24
Architecture and bioethics
28
Financing hospital energy sustainability
32
Building automation expands for hospitals
37
Compliance help for ASHE members
40
Developing an EVS compliance plan
44
Advertiser Index
47
HFM Online
48

Advertiser Index

ATG, a JLL Company
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Fire Door Solutions
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National Grid USA Service Company
Page 3
PDC Summit
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STARC Systems
Page BC

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Table of Contents Articles

Articles
Inside HFM
2
Advocacy Adviser
4
My Ashe Messenger
5
Design Discoveries
6
Architecture Showcase
7
Upfront
8
Interview
12
Solutions
14
The new normal
18
Centralized operations yields efficiency upgrade
24
Architecture and bioethics
28
Financing hospital energy sustainability
32
Building automation expands for hospitals
37
Compliance help for ASHE members
40
Developing an EVS compliance plan
44
Advertiser Index
47
HFM Online
48

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Inside HFM

Article header image here

Shadie (Shay) R. Rankhorn Jr. SASHE, CHFM, CHC, ASHE President

Greetings , my fellow health care facilities management leaders. I am humbled to write to you as the 2022 American Society for Health Care Engineering (ASHE) president. You might already know me from the ASHE Advisory Board, committees or affiliated chapters. Whether we’re already acquainted or soon will be, I support you in your professional and organizational goals. I am committed to ASHE as our trusted resource for education, advocacy, guidance and certification.

The recent impacts on health care systems across the U.S. have significantly reduced organizational funding for professional memberships and education. Still, we need to continue learning and connecting to operate efficient hospitals, stay current with regulatory changes, and maintain our professional designations or licenses.

On the ASHE Advisory Board, I championed the creation of easy-to-access, affordable education. This year, the Advisory Board, ASHE staff and I will work to further meet your needs. We’ve worked hard on our new three-year strategic plan, which is expected early this year. The primary focus of the plan is to serve ASHE members with every opportunity to continue creating safe, efficient facilities and advance our careers.

When I first got into this field, somebody told me I needed to join ASHE to be successful in my role and to benefit from networking with our community. I have benefited tremendously from being an ASHE member and getting involved as a volunteer and leader. Now, I offer you the same advice. Become a member and get involved. Invest in your career by engaging in our education and conferences. I can testify that ASHE experiences will stay with you throughout your life.

Qualified facilities staff are in high demand, and we need to work together to identify and equip incoming team members and leaders. Please consider supporting your team with membership as we prepare the next generation for this essential work.

To quote Steve Jobs, “Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do.”

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Generator battery inspection requirements

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Jordan Plyler CM-Lean, facilities manager, Baptist Health Medical Center of Arkansas

Many health care facilities are making theswitch from wet lead-acid or “flooded” emergency generator batteries to sealed or “maintenance-free” batteries. While sealed batteries come with a major perk of saving some time and hassle related to inspections, testing and maintenance (not to mention eliminating the risk of spillage or exposure to harmful chemicals), there are still inspections that must be conducted to measure the condition of the battery life. Regardless of whether your batteries are flooded lead-acid, sealed lead-acid or nickel cadmium, you are required to test for either electrolyte levels or battery voltage weekly. The 2010 version of the National Fire Protection Association’s NFPA 110, Standard for Emergency and Standby Power Systems, states that “storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer’s specification”(section 8.3.7). 

However, monthly inspections may differ depending on your battery type. 

The next section of NFPA 110-2010 states, “maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted” (section 8.3.7.1).

Using a hydrometer, a specific gravity test will compare the ratio of the weight of a solution versus the weight of an equal volume of water to determine the solution’s density. A low-density reading shows that the battery has lost some of its electrolyte solution and must be replenished.

Sealed lead-acid batteries eliminate the ability and need to perform specific gravity tests; however, the requirement to test the battery’s state of charge still applies even if you are unable to perform a specific gravity test. Determining how much charge the battery has left is accomplished by measuring the conductance of the battery, or the ability of a battery to conduct current. This will likely require purchasing a special device designed for conductance testing. Knowing the conductance measurement of your battery is helpful to predict when the battery is approaching its end of life. HFM

 

My Ashe Messenger

Article header image here

 

The My ASHE Messenger column contains excerpts of topics from My ASHE, the member-only community for the American Society for Health Care Engineering. To join the discussion, visit my.ashe.org.

 

QUESTION: I was asked to look at our badging process for contractors providing facilities or clinical work. I would appreciate some insight from other hospitals.

Contractors in our hospital must meet all requirements regarding vaccines and safety training — basically what any staff must have for onboarding. Then, they are issued a photo ID that identifies them as a contractor with access privileges only to areas in which they are working.

 

QUESTION: We have a hydrotherapy pool with a treadmill. The maintenance staff keeps bromine in an automatic dispenser, and the physical therapy staff tests the water. I have concerns about who has responsibility for the water chemistry. I would appreciate any advice.

First, you should ensure the pool is part of your overall water management program. One of the most important facets is making sure that you have an engaged multidisciplinary team that touches all aspects of the program. Infection control leadership should weigh in on water treatment as well. Second, a pool is a high-risk area, so it and associated equipment also should be assessed in your utility management and medical equipment management programs. Installation documentation for the filter system and other equipment should be reviewed for chemical maintenance, water changes and filter changes. Finally, the ventilation system should be assessed to ensure it is functioning properly . Keep in mind that a new Joint Commission standard for water management went into effect Jan. 1. HFM

 

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JOIN THE Q&A ONLINE!

ASHE members can go to my.ashe.org to ask or answer questions from colleagues. If we choose your question or answer for this column, we’ll send you some ASHE swag as a token of our appreciation for contributing to the My ASHE online community.

 

How design supports health care wayfinding

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Melissa Piatkowski research associate, The Center for Health Design

Wayfinding is the process of orienting yourself in space and finding your way from point A to point B. Health care facilities are notoriously complex spaces, especially facilities where growth and expansion often create misalignment between new circulation and existing routes. As a result, wayfinding in health care facilities can be challenging, especially when people are not feeling well, or have physical , cognitive or visual impairments.

And we all can relate to the stress involved in visiting a new doctor, arriving for a procedure at a different facility or visiting a loved one in an unfamiliar hospital environment. While you may not get lost, the stress of figuring out how to get somewhere can impact the rest of the experience.

The Center for Health Design’s Knowledge Repository includes numerous studies on wayfinding, three of which arehighlighted here. A narrative review by Jamshidi and Pati provides a good overview on the foundational theories behind wayfinding in health care and explains why there is still such a great need for research in this area. The authors propose four ways to categorize the different aspects of wayfinding : theories of perception, theories of spatial knowledge development, theories of mental representation of spatial knowledge and theories of spatial cognition. While visual perception is an obvious component of navigation, this review explains the more nuanced cognitive processes that play a role.

Understanding the cognitive processes involved in wayfinding is especially pertinent in design for dementia-friendly environments. A two-part study from the Netherlands by van Buuren and Mohammadi first examines the theories behind wayfinding for seniors with dementia, then assesses several different inpatient residential care facilities using wayfinding design criteria. The researchers were able to identify certain floor plan typologies that facilitate wayfinding, highlighting how different characteristics of the corridor play a key role in the wayfinding experience.

Several methods have been used over the years to better understand how humans navigate an unfamiliar route. In their study, Ghamari and Goshany used “gaze tracking” with a mobile eye-tracking device to capture where users were looking as they navigated through a health care facility. This technology allows researchers to map the points where the visual gaze moves — they could essentially see through the users’ eyes as they traveled different routes. They found that users looked at signs and architectural features longer and more frequently than other types of information (e.g., maps or artwork) during wayfinding tasks. It’s also interesting to consider these findings in the context of the cognition aspects of wayfinding discussed by Jamshidi and Pati.

The design of the health care environment can either help us find our way or literally send us down the wrong path. A better understanding of the cognitive processes we go through when navigating the health care environment can help us design spaces that ease wayfinding, reducing unnecessary stress and irritation for patients, visitors and even health care staff. To read more on wayfinding and other health care design topics, visit the Knowledge Repository. HFM

 

Research used for this column

The following citations from The Center for Health Design’s Knowledge Repository of health care design resources were used by the author when writing this column:

• S. Jamshidi and D. Pati, “A Narrative Review of Theories of Wayfinding within the Interior Environment,” HERD: Health Environments Research & Design Journal 14, no. 1 (2021): 290–303.

• L. P. G. van Buuren and M. Mohammadi, “Dementia-Friendly Design: A Set of Design Criteria and Design Typologies Supporting Wayfinding,” HERD: Health Environments Research & Design Journal, 2021, in press.

• H. Ghamari and N. Golshany, “Wandering Eyes: Using Gaze-Tracking Method to Capture Eye Fixations in Unfamiliar Healthcare Environments,” HERD: Health Environments Research & Design Journal, 2021, in press.

 

ABOUT THIS COLUMN

“Design Discoveries” highlights research from The Center for Health Design’s Knowledge Repository, a user-friendly library of health care design resources. This research effort is supported by the American Society for Health Care Engineering, the American Institute of Architects, the Academy of Architecture for Health Foundation and the Facility Guidelines Institute. It can be accessed at www.healthdesign.org/knowledge-repository.

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Advancing care in its region

Article header image here

 
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FACILITY // The Center for Advanced Healthcare at Brownwood

LOCATION // The Villages, Fla.

ARCHITECT // ESa

Part of a 32-acre development that includes a boutique hotel and spa, The Center for Advanced Healthcare at Brownwood was designed to meet local needs, including those of a large continuing care retirement community. The timeless design reflects its community while appearing to have always been a part of it. Inspired by the nearby Brownwood Town Square, which is reminiscent of an early Florida cattle town, the design utilizes a warm, rustic interior and exterior material palette to create an exceptional patient experience.

Designed for future expansion, The Center for Advanced Healthcare at Brownwood is a four-story facility that is the first phase of a long-term ambulatory care program. Featuring two main entrances with a central lobby and space to accommodate multiple medical specialties and retail tenants, the building provides direct patient access, simple wayfinding and convenient parking. Influenced by hospitality elements, all lobby and patient waiting areas are filled with natural light and feel more like living rooms than waiting rooms.

The team prioritized the patient experience by focusing the design on the aging population in The Villages. The stylistic theme of the health care center is the spirit of the Floridian cowboy, consistent with the hotel and the entire Brownwood town center. It is conveyed through the use of rustic wood accents in flooring and lighting.

The collaborative design process included stakeholder interviews, evidence-based design research and detailed review of operational processes. As a result, the goal was to maximize physician consultation time, while decreasing travel distances and redundant registration processes. The design eliminated trip hazards, including sidewalks that taper to paving edges near key entrances and raised edges or trim strips at flooring transitions. To eliminate falls, ample walk space was created between seating and other furniture and steady chairs without wheels were placed across the facility.

In addition to diagnostic imaging, radiation oncology and outpatient lab testing/processing, the first floor also includes an audiology testing and retail center, Medicare resource center, retail pharmacy and a coffee shop. Tenants include Aviv Clinics, which provides groundbreaking hyperbaric oxygen therapy treatment aimed at improving physical and cognitive performance. An ambulatory surgery center and medical oncology are located on the second floor, while the third floor contains ophthalmology, a rehabilitation suite and a multispecialty procedural suite. Floors three and four house physician offices for 13 different specialties.

The Center for Advanced Healthcare is adjacent to a new 150-room hotel and spa, connected to the specialty center on the second floor, with 30 dedicated rooms for surgery and elective procedure patients to stay overnight. An activated courtyard located between both projects provides outdoor event space in addition to a gathering place and retail dining for patients, families and guests. HFM

 

LEARN MORE

View more projects like this by visiting ASHE’s Architecture for Health Showcase at archshowcase.org.

 

COVID-19 creates obstacles in health care construction projects

BY BETH BURMAHL

Heading into 2022, the health care construction industry faced the daunting challenge of planning for the coming months in the midst of an unstable, unpredictable COVID-19 economy.

Active construction projects forced to shut down when COVID-19 hit in 2020 began bouncing back in 2021 as the country regained some of its footing. Unfortunately, the economy had not yet recovered from the serious blow leveled by COVID-19, creating significant obstacles to getting hospital construction projects back on track.

Labor shortages, supply chain disruptions , rising prices and increased demand are just some of the major challenges facing health care systems across the country, according to Chris Harmon, system director of facilities, construction and renovation at Baptist Memorial Health Care, Memphis, Tenn.

“Construction projects are getting done, but it often means adding time and money ,” Harmon says. “The volatile economy has also changed how we assess projects against revenue. Because financial factors are constantly changing, some projects may no longer be feasible.”

According to 2021 data from the Associated General Contractors, the cost of building materials rose nearly 13% from April 2020 to February 2021, but project bids did not reflect the increased cost. Data shows this increase is 10% higher than the average 3% yearly inflation prediction that is usually included in most construction project bids.

Harmon, who oversees 22 hospitals in the Baptist Memorial Health Care system, says capital budgets have been disrupted to the point that many hospitals are essentially playing catch-up with funding projects that were postponed.

For example, a construction project to build a new hybrid operating room (OR) at Baptist Memorial Health Care began with design in December 2019.

Construction was slated to start in early 2020. When Harmon was ready to bid the project out, COVID-19 shut it down. The project was pushed to 2021 when supplies and labor were in short availability, driving the cost far beyond the amount initially allocated.

The project price tag jumped from $850,000 to $1.4 million, not including the loss of potential revenue the hybrid OR would have generated if completed on time. Extended by a month, the hybrid OR was planned to open in December 2021, as of press time.

 

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“When we started the fiscal year, we needed to reallocate 2021 dollars to this project,” Harmon says. “There is only so much money in the capital budget each year, so that money has to come from some other project or from contingency funding. Getting back on track is extremely challenging.”

Many building projects are being sidelined by a lack of general laborers who are not returning to the construction market in pre-pandemic numbers, due in part to government compensation under the CARES Act.

A lack of workers has created a shortage of supplies such as wood, hardware and copper, and hospitals are scrambling to find alternatives to products that stopped or significantly scaled back production during COVID-19. Another alternative is paying exorbitant prices to get the supplies they need.

In an already volatile COVID-19 economy , an extreme weather event in Texas last year forced some manufacturers to stop producing polyvinyl chloride, a plastic commonly used in electric utility work, spiking the price by 270% from March 2020 to March 2021.

The impact of the unpredictable economy also is being passed down to subcontractors facing construction supply and labor shortages.

Before the COVID-19 pandemic, a guaranteed 30-day pricing hold for bids barring an unforeseen increase in the cost of materials was common. Now, some subcontractors are drastically reducing the length of pricing holds.

For example, the vendor for a small project underway at Baptist Memorial Health Care who previously guaranteed prices for 90 days decreased the time frame to just five days.

Tighter price holds are one of the factors forcing designers, architects and construction managers to significantly expedite hospital construction projects in an effort to keep projects on schedule as much as possible.

Where does that leave hospitals planning projects for the year ahead? Because the issue comes down to a matter of simple economics, Harmon doesn’t see circumstances improving until the economy recovers from the impact of COVID-19.

“With material supplies depleted and labor shortages continuing, construction cost will continue to rise as the market establishes a new equilibrium price point. Owners will need to continue projecting project cost escalations until the labor crisis is resolved and material supplies are replenished,” Harmon says. //

 

Examining the benefits of predictive maintenance

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BY DAVID STYMIEST, PE, CHFM, CHSP, FASHE, AND MITCH ALLEN, FASHE

Predictive maintenance (PdM), also sometimes called condition-based maintenance, has been around for a long time, just not by these specific names. Workers often used simple tools of the trade (e.g., a screwdriver, a short pipe, human hearing and sense of smell) to assess unusual equipment sounds, unexpected vibrations and pending failures.

PdM then further evolved during scheduled equipment inspections and testing by sampling oil or other fluids, using hand-held technology such as infrared scanners and ultrasonic condition monitoring. The results of scheduled inspections and testing are useful, providing that the results are assessed in time to permit completing necessary corrective action before a pending failure actually occurs.

More recently, many original equipment manufacturers have been providing new equipment with built-in sensors tied by the Internet of Things to software that is capable of diagnosing problems and creating work orders. Installed predictive technology has the benefit of continuous monitoring to determine and alarm staff of pending failures regardless of a testing calendar. The PdM sensor monitoring outputs, when acted upon to prevent pending failures, result in a much more reliable infrastructure.

The PdM sensor applications apply to equipment with moving parts such as fans, air handlers, pumps and other mechanical or plumbing equipment. Numerous types of sensors can fill those needs. Electrical equipment PdM sensors also can include partial discharge monitoring (a subset of ultrasonic condition monitoring ) and internal monitoring of physical operating conditions and other types of devices.

What is the benefit to a health care facility? The Department of Energy’s (DOE’s) “Operations and Maintenance Best Practices, Release 3.0 — A Guide to Achieving Operational Efficiency” projects an 8% to 12% reduction in maintenance costs over a typical preventive maintenance program. The DOE document also states that, depending on a facility’s reliance on reactive maintenance and material condition, those savings could exceed 30% to 40%. According to that publication, industry studies also have indicated 70% to 75% decrease in breakdowns, and 35% to 45% reduction in downtime.

An American Society for Health Care Engineering tool provides stepwise guidance for implementing PdM and recommends using reliability-centered maintenance to prioritize new PdM projects. Members can visit the link on the left side of this column to access it. // 

 

Apprenticeship program develops employee pipeline

BY MEGAN HEADLEY

Advocate Aurora Health (AAH) St. Luke’s Medical Center in Milwaukee is celebrating the third year of its health care facilities apprenticeship program and preparing three of its four apprentices to graduate this spring. Upon completing the 5,200 hours of training required by the state-sanctioned program, the individuals will receive a journeyperson’s card.

As Cory Majszak, MSOL, CHFM, CHOP, director of operations for facilities at St. Luke’s Medical Center, says, “Now our workforce is hitting the cusp of retirement , so our strength is turning into a liability.”

It’s a liability hitting the entire industry , and AAH capitalized on that fact by securing help from other local health systems in building its apprentice program.

“Our biggest fear was to build an employee with skills that no one else would want,” Majszak says.

 

article ImageSt. Luke’s Medical Center’s current apprenticeship class is set to complete the program in the second quarter of 2022.

 

So AAH connected with peers through the Wisconsin Healthcare Engineering Association. Through this collaboration, Majszak aimed to build a program that other health systems would recognize, making the opportunity more enticing to potential recruits. While Majszak acknowledges it may seem counterintuitive to create candidates for competitors, he says, “The burden, and opportunity, is on us to retain them.”

AAH also secured assistance from the Milwaukee Area Technical College (MATC) and former American Society for Health Care Engineering President Dean Pufahl, CHFM, CHC, in transforming an early AAH intern program into something more comprehensive that aligned with requirements set by the Wisconsin Department of Workforce Development. With this assistance, AAH created a curriculum that tied specific steps and hour milestones to compensation increases and documented the hours put into building key skill sets.

Individuals were recruited through MATC, word-of-mouth outreach and AAH’soriginal facilities internship. Apprentices train alongside AAH team members to become well-rounded jacks of all trades. However, current facilities employees went through their own training sessions, learning how to serve as mentors.

“We saw team members take a sense of pride in showing what they know. They had a chance to leave their legacy by passing on that tribal knowledge,” Majszak says.

Once these individuals transition to journeypersons for AAH, they will have responsibility for training the next generation of apprentices in a sustainable recruitment cycle. // 

 

 

Study looks into COVID-19 surface contamination

BY JAMIE MORGAN

A new study published in the Infection Control & Hospital Epidemiology journal looked into possible associations between surfaces contaminated with SARS-CoV-2 and health care worker COVID-19 infection rates. The study was conducted from September 2020 to January 2021 at the Hospital of the University of Pennsylvania in Philadelphia. Surface samples were collected weekly from staff breakrooms and bathrooms, and nurse workstations in four patient care areas: a medical ward, an intensive care unit (ICU) for COVID-19 care and two nondedicated ICUs.

Samples specifically were collected from high-touch surfaces such as refrigerator handles, microwave handles and tables; staff bathroom surfaces, comprising toilets, sinks and doorknobs; and floors. Weekly sampling also was performed in nurse workstations on computer mice and floors.

In total, 640 samples were obtained from staff common areas over the 20-week study time frame, during which there were 18 incidents of SARS-CoV-2 infections among the study unit nursing staff. Sources of infection included patient exposure (1), unspecified workplace exposure (2), community exposure (1) and unknown (14).

Researchers detected a borderline significant association between increased relative incidence of health care worker infection with increasing common area surface contamination. Although the numbers were no longer statistically significant after being adjusted for community incidence, the study authors say the data provide key insights.

“Common area surface contamination did not predict health care worker COVID-19 [infection rates] after adjusting for community incidence,” the study authors wrote.

“However, increased surface contamination was observed as the COVID-19 patient census increased over time, underscoring a need to ensure adequate staffing, resources and efforts for environmental disinfection,” the researchers added. // 

 


 

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VALUABLE RESOURCES AVAILABLE FROM ASHE

Visit ashe.org to learn more about the following resources available for health care facilities professionals:

COVID-19 resources for facilities management

As new variants emerge and hospitals grapple with COVID-19-related patient surges, ASHE is continuing to update its COVID-19 Resources for Health Care Facilities page. Recently added content includes an article on pandemic-resilient hospital design, guidance on ventilation and an article about hospital incident command operations.

Energy to Care posts conservation resources

ASHE’s energy conservation measure (ECM) resources cover everything from how to establish baselines for energy consumption to reevaluating HVAC schedules. These unbiased resources can help organizations integrate sustainable practices into the health care environment . Visit energytocare.org and click on Educational Tools to access the ECMs.

ASHE creates “how-to” YouTube series

ASHE has partnered with Legacy FM to create and host a new publicly available series of “how-to” videos for health care facilities managers. The short videos review everything from how-to set goals and implement action plans to optimizing chiller and HVAC performance. The series is now available on ASHE’s YouTube channel, which can be accessed at youtube.com/asheaha.

 

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VALUABLE RESOURCES AVAILABLE FROM AHE

Visit ahe.org to learn more about the following resources available for health care environmental services (EVS) professionals:

COVID-19 resources for EVS managers

AHE’s continually updated COVID-19 Resources for EVS Professionals webpage includes information from the Centers for Disease Control and Prevention on the COVID-19 variant omicron. The site also features training tools such as Project Firstline, Pathways to Clean and the COVID-19 EVS Cleaning Essentials Refresher Training Toolkit as well as resources to help health care workers deal with stress brought on by the pandemic.

Resources address EPA compliance

AHE has developed several resources to help health care EVS departments comply with the Environmental Protection Agency’s hazardous waste pharmaceutical regulations. Resources available to members and nonmembers include a webinar detailing updates to the rule, a white paper that gives a deep-dive explanation of the rule and the science behind the regulations as well as a helpful infographic detailing three key points.

Interactive tool helps develop EVS skills

The Competency Model for Health Care Environmental Services Professionals is an interactive competency model tool for the entire EVS team, from technicians to directors . The tool can be used to create job descriptions, assess performance, guide professional development, self-assess skill levels and training needs, and set goals.

 

BayCare Health engages patients with Alexa devices

BY MEGAN HEADLEY

BayCare Health has deployed Amazon’s voice assistant (Alexa) devices across 2,600 patient rooms in 14 Tampa Bay, Fla.-area hospitals , one of the largest such deployments for a U.S. health system. The devices connect with Aiva, a voice-powered virtual health assistant that works with Alexa and Google solutions.

Today, Aiva allows patients to control the hospital room television via Alexa as part of BayCare’s phase one deployment. Where the facility’s infrastructure allows, the health system is adding in-room voice control for lighting, powered blinds and room temperature. However, the next priority is to connect patients directly to care teams through Alexa for improved service and communication.

 

article ImageThe Aiva voice assistant integrates with Amazon’s voice assistant to improve communication between patients and care teams.

 

“We are in the process of developing and rolling out additional features to enhance communication between patients and our care teams,” says Craig Anderson, BayCare director of innovation. “Our plan is to standardize these offerings and deploy them across all hospitals early next year.”

The Aiva platform is able to interpret requests and send them to the right person, connecting the patient to their care team through their workplace smartphone . “The patient can simply ask Alexa for things they need like a blanket or a glass of water,” Anderson says.

The voice-powered solution was piloted at St. Joseph’s Hospital and Winter Haven Hospital in 2019 before being deployed across St. Joseph’s Hospital-North. Through these pilots, the health system was able to address potential hurdles as they arose.

“A key step to implementing new technology is educating all levels of the organization to be sure everyone understands how patients will benefit from the innovation ,” Anderson says. “And while we were excited to move forward, we have had to proceed with extra caution due to the COVID-19 pandemic. It took careful planning to be sure our work was done safely as patient rooms were available.”

To ensure patient privacy and network security, the rollout also required the information services team to move the devices onto a reserved portion of the BayCare network.

Patients were highly satisfied with the technology in surveys during the pilot, Anderson says. As he puts it, “This is bringing consumer-friendly technology into the medical space.” // 

 

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New water management requirement goes into effect

The Joint Commission’s new standard for water management went into effect Jan. 1. The standard was approved last year to address Legionella and other waterborne pathogens. Previously, EC.02.05.01, Element of Performance (EP) 14 (for hospitals and critical access hospitals) and EP 6 (for nursing care centers), required organizations to minimize pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems. These two EPs were deleted Dec. 31, 2021. The new requirement falls under EC.02.05.02, EPs 1–4, and is a more comprehensive standard applying to hospitals, critical access hospitals and nursing care centers.

CMS ends process for temporary hospital status

Although the Centers for Medicare & Medicaid Services (CMS) continues to review the need for existing waivers and flexibilities issued in response to the COVID-19 public health emergency (PHE), it has decided to end the flexibility of a streamlined process to allow ambulatory surgery centers (ASCs) and licensed independent freestanding emergency departments (IFEDs) to temporarily enroll as hospitals during the PHE. Effective upon issuance of the memo, no new ASC or licensed IFED requests to temporarily enroll as hospitals will be accepted, the agency states. However, facilities that are temporarily enrolled as hospitals under this flexibility can continue providing inpatient and outpatient hospital services until the health care facility voluntarily ends the program or CMS deems that the program is no longer necessary.

HHS launches web resource on cybersecurity

The Department of Health and Human Services launched a central web resource for information on cybersecurity best practices recognized by its 405(d) program. A legislative provision (H.R. 7898) enacted by Congress this year allows the Department of Health and Human Services’ Office for Civil Rights (OCR) to recognize certain recommended security practices when making determinations related to Health Insurance Portability and Accountability Act audits, fines and resolution agreements associated with a cyberattack, including practices recognized by the 405(d) program. The American Hospital Association has urged OCR to quickly initiate rulemaking for the legislative provision, and strongly advocated for regulatory relief for hospital and health system victims of cyberattacks in testimony before a Senate hearing last year.

Correction

An article in the March 2021 edition of Health Facilities Management magazine titled “Ventilation management plans” suggested readers may want to adopt newer versions of ASHRAE/ASHE/ANSI Standard 170, Ventilation of Health Care Facilities, than those used by surveyors. The American Society for Health Care Engineering does not encourage such actions, and the suggestion was subsequently removed from the web and digital versions of the article.

 

Working on the local and national levels

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BY JAMIE MORGAN

Sean Goings, CEM, CHSP, SASHE, president of DAC Inc. in Houston, received the 2021 American Society for Health Care Engineering (ASHE) President’s Award for his dedication at the national and local levels. This month, he talks with HFM about what inspires him in health care facilities management and strategies to train new leaders.

 

How does it feel to receive the 2021 ASHE President’s Award? It’s a gigantic honor to be considered for such a prestigious award. ASHE has given me so much more than I’ll ever be able to give back, and I’ll forever be indebted to the Advisory Board, the staff and its members. It’s provided me some of the greatest moments in my life and professional career as I’ve made deep friendships that will span a lifetime. I’ve grown to love the field of health care and the people who work within it. I’m truly humbled to receive this acknowledgment.

Tell us how you started your career and how it has led to where you are today. Like many of my colleagues in health care, I unknowingly started my career. It was through a summer job working for Landis & Gyr on the Texas A&M campus while in college. Cleaning up on construction sites eventually led to installing building automation systems, running conduit and pulling wire. That company was acquired by Siemens and I continued working for them all over Texas to pay for college.

After earning my degree, I continued my career with Siemens in Houston, working on construction and technical renovation projects with some of the country’s largest medical institutions. I wanted to make a bigger difference, so I convinced management to hold an internal competition for a customer-facing sales role. Winning that role propelled me into other roles where I became heavily involved in ASHE and its Texas chapter.

With a focus on health care and leveraging my experiences with ASHE, I was recruited to take on a business development role with Schneider Electric. Soon afterward, I assumed responsibility for developing the U.S. health care segment across all business units. I visited hundreds of facilities around the country in that role and learned about the common challenges health care facility professionals faced, and got a dose of what drives them to execute their jobs with passion.

In late 2014, I was provided the opportunity to take 20 years of diverse experience and apply it to leading a small business with the simple goal of growing it into something great. We’ve spent the

past seven years nearly quadrupling our business, tripling our headcount and growing to serve nearly every major health system in Texas. I’m proud of what the people of DAC have been able to accomplish and excited about the experiences in front of me.

What role has ASHE played in your career development? Spending personal time with passionate individuals is contagious, no matter what you’re doing. I’ve found passion and purpose at every step of my involvement of progressing in the health care facility management profession and working to advance the organizations that support it.

I’ve never really looked at my service to organizations like ASHE, the Texas Association of Healthcare Facilities Management or the local groups as a volunteer role, nor did I look at them as an extension to my job. I’ve always approached them like an employee of the organization willing to do what it took to make it successful.

I’ve been blessed with some of the greatest mentors imaginable, whether they knew they were serving that role or not. Health care is a tough field. Managing facilities as core components of the mission is exhausting with the relentless regulatory environment and continuous financial pressures. When you really spend time with the people who make it all work, you realize it is purpose that drives them, and it’s awesome when you see it in action. The most powerful weapon on earth is the human soul on fire.

Over the years, I’ve tried to soak up every bit of positive influence I could from the great people I’ve served with. I truly believe I wouldn’t be where I am today without it, and I give a lot of credit to ASHE and the people I’ve met along the way for opening my eyes to a purpose-driven career.

 

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How have you seen ASHE evolve in its service to associate members? ASHE has made great strides in recognizing the value of the associate members and taking advantage of the expertise, knowledge and effort they are willing to contribute to the profession and mission . The picture of ASHE today and tomorrow is vastly different than it was just a decade ago. It’s clear our associate

membership is a key component of ASHE’s future success. However, we still have a long way to go. Mutual value in membership is different for every associate member, and every company and organization. Each requires a return on investment, and it’s up to all of us to find what that means.

Where do you feel local chapters fit into the overall ASHE strategy? Chapters are the lifeblood of ASHE and its success. It’s where ASHE’s strategies come to life, where standards are employed and enforced, where education finds value and where community exists.

There is no area of the health care community more critical for associate member involvement and volunteerism than the chapters. And it’s the highest area of mutual return on investment. I’ve proudly served the board of the

Texas chapter for 15 years and have worked with other chapters all over the U.S. in various stages of development, support and consultation. Any success and involvement I’ve had with ASHE has been born at the chapter level, and it’s been a major contributor to my career.

Are there other opportunities in the field that ASHE and its members are well-suited to address? I’ve always had a passion for succession planning and where we can find the next leaders to take our places. Health care facilities management is not alone in that challenge, but the challenge is particularly difficult in this profession.

Being a health care facility manager is not a sexy job. To solve the issue, we default to our impressions of the next generation. How do we entice them? How do we restructure or better market these roles to appeal to their wants and desires? How do we develop a social media plan so they can see us? ASHE, and its chapters and volunteers, have worked tirelessly to develop solutions to create pathways for young professionals. However, as a community, we have to do a better job matriculating the staff that currently exists in the rank and file, developing the trades and providing all of them a better path to leadership. That’s how most leadership got to where they are now. With an infinite number of potential solutions, this is an unconventional area where business partners and associate members can help.

Associate members also can help by embracing the Certified Health Care Physical Environment Worker credentials for their team members. I created an initiative within my company to have all of our customer-facing employees certified regardless of their day-to-day interactions in health care facilities. It has helped them understand the requirements of working in a health care environment , their impact on the physical environment, and the purpose we serve to facilities and their occupants. Over 120 employees have achieved the certification , and the mutual benefit is clear. HFM

 

Jamie Morgan is editor of Health Facilities Management magazine.

 

Solutions

 

On Our Radar

 

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1. PROTECTIVE COVERING // Nanoshield can be applied to keep surfaces sanitized between cleanings. The protective covering is able to destroy viruses and bacteria 24/7 for up to 12 months. It is proven to eliminate SARS CoV-2, influenza , E. coli, Staphylococcus aureus and norovirus. It is available in a polyethylene terephthalate or polyvinyl chloride film that can be custom sized and applied to a variety of surfaces. Nanoshield

2. COMPLETELY DRY // The Ventaire scope drying and tracking cabinet provides real-time tracking capabilities and online scope monitoring. It features an automated system that continuously delivers HEPA-filtered pressurized air to keep scopes dry and avoid reprocessing. The line also includes a scope tracking cabinet, retrofit scope drying and more. InnerSpace

3. PRIVACY PLEASE // LC Privacy Glass can help reduce the spread of contagions throughout health care facilities and provide much needed doctor and patient privacy. It also provides flexibility in how a space functions. Doors, walls and partitions with the patented PowerTrack power transfer system can be configured in multiple ways. Innovative Glass Corp.

4. TABLE FOR TWO // The Flo Chair and Table Series for behavioral health is where comfort meets durability. The line’s flowing design and soothing color palette provides a calming aesthetic that invites users to relax while dining safely in an intensive-use space. The line is stain-resistant, seamless and easy to clean. It features tamper-resistant hardware and a laminate top surface. Stance Healthcare

 

Medical Gas

 

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1. SOUND THE ALARM // The Alert-4 LCD Ethernet area alarm displays medical gas information on a 10-inch LCD screen. Capable of handling up to eight gases, the alarm fits all areas of the hospital. Because it is Ethernet ready, an exact replica of the alarm screen also can be displayed on a computer screen. In addition, an exact image of the alarm can be displayed on a mobile device connected to the local network via Wi-Fi. Amico

2. ON-THE-GO // The Walk-O2-Bout+ family of products provides an innovative solution to problems that health care practitioners face when providing respiratory care. Each cylinder’s streamlined design incorporates everything needed into one integrated, easyto-use unit. A large knob with an arrow indicator on top shows flow direction and helps users easily turn on the cylinder to a precise flow rate. Airgas Healthcare

3. EASY SWITCH // CryoEase Service offers the advantages of bulk supply to smaller volume users of nitrogen, oxygen and argon. With this gas supply solution, hospitals can eliminate swapping full for empty cylinders and the inconveniences that come with it, including reducing exposure to pressurized and cryogenic gases and the potential risk of cross-contamination with dedicated containers. Air Products Inc.

4. SPACE SAVER // Vertical Zone Valve Box for medical gases is a space-saving solution. The design features the gas inlets and outlets positioned vertically to dramatically reduce the wall space required for installation, with a space savings of 50% or more compared to a traditional horizontal layout. The new vertical valve box keeps the installation contained to a single bay, avoiding costly routing of pipes through multiple bays. BeaconMedaes

 

Plumbing

 

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1. TWO-IN-ONE // The Halo swing-activated faucet and eyewash has an innovative dual-use design. The convenient, compact faucet and eyewash solution is designed for any health care or laboratory environment . The product combines a gooseneck faucet for regular use, such as handwashing, with a built-in emergency eyewash featuring Halo technology to deliver effective eye washdown coverage. The durable ceramic valve limits wear and tear on moving parts. Bradley Corp.

2. POWER CYCLE // Hydro·X Power technology has been integrated into a touchless sensor faucet portfolio. Hydro·X Power efficiently generates and stores energy from the source. Once the faucet is activated, the turbine system transforms flowing water into energy. A few activations each day harvests enough power to extend the battery life by at least 10 years. Zurn Industries LLC

3. A STEP AHEAD // Flood Buzz is a line of easy-to-use, low-cost, loud and effective small water-leak alarms. The alarm warns of impending water leaks before it sounds a loud alert up to 110 decibels when it senses a leak. The alarms are simple to install by placing them next to any potential leak location and walking away. Flood Buzz Inc.

4. TIGHT GRIP // Dearborn grab bars with concealed flanges are designed for health care facility restrooms. The grab bars are essential for patient safety. The product is not only Americans with Disabilities Act-compliant but also meets ASTM F446. The bars are available in two sizes and two finishes (satin and peened) so that users can customize the solution to their unique needs. Oatey

 

Patching job delivers thorough results

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Damaged fireproofing that is not patched properly can lead to life safety and liability issues. Jaime Almeida, vice president at CFM Construction Corp., Glastonbury, Conn., was facing such an issue that involved a large renovation project at MidState Medical Center, Meriden, Conn.

MidState is a 156-bed, acute-care hospital with more than 1,200 employees and 350 affiliated physicians. The hospital is a member of Hartford HealthCare, Connecticut’s largest health care system, and has been serving its community since 1998. The medical center’s services include surgery, emergency medicine , oncology, wound care and more.

Almeida and his crew were retrofitting an existing space within MidState Medical Center to build out a new pharmacy with a clean room at the hospital. The project called for the removal of fireproofing from existing steel beams to allow for the connection of clips to frame new steel members.

“At the end of the day, all of the fireproofing needs to be intact,” Almeida says. “When the right fireproofing solution is not used, the integrity of the building is compromised.”

Kurt Martin, health care facilities manager at MidState, adds, “The condition of the fireproofing must be compliant. Code requires any repair of fireproofing to match the existing fireproofing that is on the beam.”

Exposed beams during a fire event are subject to failure. This becomes a life safety issue for occupants and a liability for building stakeholders.

Heat from a fire will raise the temperature of steel to approximately 1,500 F in a relatively short period of time. At approximately 1,100 F, steel loses about 65% of its strength. Failure can occur when just the portion of the structure left exposed reaches this temperature.

Traditionally, fireproofing repair has been accomplished using spray equipment. Often, however, missing fireproofing goes unnoticed and untreated . Spraying a patch comes with many challenges. For example, spray-applying a small patch can be cost-prohibitive when factoring in the equipment and labor for multiple workers.

To help ensure the proper patch is made, CFM Construction uses Universal Fireproofing Patch (UFP) on all of its fireproofing patch jobs.

UFP is a do-it-yourself patch solution that can be applied by a single worker. It mixes with water and can be applied with a trowel. Developed by Tim Vellrath, a 40-year fireproofing contractor and engineer, the product makes the process of patching fireproofing fast and simple , and it has been fully vetted to perform beyond performance regulations.

The MidState Medical Center project included 75 connection points that needed patching. Typically, such a patching job would require bringing in spray equipment and a two-person crew to operate it. The approximate cost for this hospital’s fireproofing patching job using traditional means would total approximately $5,600. However, because UFP can be applied with a single worker and does not require any equipment, the cost to MidState was approximately $2,200, more than 50% less than traditional patching.

The other primary benefit of using UFP over spray equipment was that UFP has been tested specifically as a patch solution and tested to be compatible with both fiber and cementitious applications. It also has been tested as a trowel-applied fireproofing patch. UFP has been ASTM E- and UL-tested, and is certified by Intertek and VTEC Labs. The product’s adhesion and cohesion make it five times stronger and significantly denser than existing fireproof patch alternatives, according to Almeida.

“UFP is key to patching fireproofing for a number of reasons,” Almeida says. “It is very easy to use. You simply mix it, and then apply. Furthermore, it adheres really well to the substrate.”

This is important because spray-applied fireproofing tends to provide less adhesion during a patch application because the spray material contains a slip agent to help it move through the hose.

“Using UFP gave us the flexibility to bring one worker in to do patch jobs,” Almeida says. “I didn’t need to hire a crew and bring in equipment. And this made scheduling the work much easier.” HFM

 

The New Normal

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By Ed Avis

Navigating compliance in the pandemic era

The world’s concern over COVID-19 ebbs and flows as infections fluctuate and variants emerge, but from the perspective of American Society for Health Care Engineering (ASHE) advocacy experts, the illness continues to dominate conversations.

The pandemic touches so many aspects of hospital facilities that its impact will be felt for decades. “We’ve realized that there are always going to be COVID-19 patients now,” says Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, ASHE’s senior associate director of advocacy. “It’s something facilities managers are going to have to continually be addressing.”

COVID-19’s impact on ASHE advocacy efforts reaches into several areas. Primarily , the organization is working to make sure that pandemic-related code changes are feasible and not overreaching, and that the changes made in various codes can ultimately be unified. In addition, an ASHE task force that emerged to deal with COVID-19 issues continues its regular meetings, but its mission has become broader and now encompasses all physical environment-related issues.

But, of course, ASHE’s advocacy efforts also reach beyond COVID-19 (see sidebars on pages 19, 20 and 21). “Some advocacy initiatives that would have been big issues in past years almost seem trivial in 2022, with all of the impacts and changes from COVID-19,” says Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, ASHE’s deputy executive director. “But we still can’t take our eyes off of those.”

An unrelenting effect

COVID-19 affected hospitals in many ways and, as things slowly settle into a new normal, the long tail of the pandemic becomes evident. One long-term effect is how codes and standards are changing to deal with potential future pandemics.

“As you can imagine, we’ve had lots of focused conversations over the past 20 months about how people are responding to the COVID-19 event. In the building code world, there were a number of reactions that you kind of could have predicted,” says John Williams, an executive director at the Washington State Department of Health who chairs the International Code Council’s (ICC’s) Committee on Healthcare. “When there is a big event, a disaster or a pandemic, people look to codes and standards and ask, ‘How could we have prevented this? What can we design into new buildings to make them more resilient?’”

For example, the ICC, Facility Guidelines Institute (FGI) and National Fire Protection Association (NFPA) are working on guidance related to alternate care sites.

In the early months of COVID-19, hospitals around the world had to set up tents in parking lots, turn lobbies into triage centers, and otherwise use areas of facilities or even entire facilities that were not traditionally designed or built as patient care space. The code authorities want to provide information related to such situations should they arise again.

“The ICC pulled together a work group to look at temporary surge facilities and develop some appendix language,” Williams says. “That way, jurisdictions faced with turning a convention center into a temporary hospital, or a hotel into a temporary quarantine location, have some guidance. The idea is to make these responses happen quickly, and this effort explores what the ‘temporary’ minimum is. That way, we give both designers and facilities a little direction to maintain occupant safety and give authorities having jurisdiction the permission to do a little less than the traditional minimum.”

The proposed appendix creates a tool that authorities can use during a disaster to ensure that temporary structures are safe but also allows them to relax the standards they may apply during normal conditions, Williams explains. The appendix was not accepted on its first opportunity , but Williams is nevertheless pleased with the potential.

“The first time you bring something completely new before an ICC committee or the membership, there are a lot of questions. This is a pretty comprehensive appendix they’ve built,” he says. “Those are always hard to get through the first time because it’s a new concept and people are responding to it. There’s all sorts of detail there that needs to be worked out, but I think there’s support for the concept.”

The NFPA also is working on this issue and has created the first draft of an annex to NFPA 101®, Life Safety Code®, to clarify requirements for alternate care sites.

“Representatives from the U.S. Army Corps of Engineers spearheaded this effort because they were responsible for setting up alternate care sites and faced numerous challenges from local authorities,” says Gregory Harrington, PE, principal fire protection engineer at NFPA. “They were looking to get something into the code that would provide guidance on this.”

Harrington says the annex will define alternate care sites and then discuss planning and design, site assessment, and how to provide alternative means for safety and protection when the conventional standards can’t be met. For example, a health care provider using a hotel as an alternate care site could find guidance in the annex on how to establish and maintain a health care facility in the hotel properly and safely.

“The annex is designed to help people create these sites and use the criteria of the Life Safety Code when that is practical and alternatives where the strict requirements of the code can’t be applied,” Harrington says. The proposed annex will open for public comment in March 2022.

Not all of the proposed code changes that emerged during COVID-19 will ultimately succeed. For example, another idea that was born during the pandemic was to install equipment to bathe hospital spaces in ultraviolet radiation, with the hope that doing so would kill airborne pathogens. The individuals who proposed the idea asked that such technology be required for all public spaces, including restrooms and lobbies. But the code makers decided — after being lobbied by ASHE advocates and other interested parties — that requiring such technology would be an overreach.

“We didn’t think that’s the right thing to do,” Flannery says. “Adding technology like that should be based on a risk assessment . Does a public toilet room on my first floor waiting area need ultraviolet germicidal irradiation? Maybe, or maybe not, but performing a risk assessment is the best way to determine what the best approach would be.”

However, the ICC did propose guidelines on how to deploy such technology safely, if a hospital were to choose to use it, Williams says. The guidelines indicate the specifications of such equipment and how it should be installed.

Keeping codes unified

The flood of potential code changes due to COVID-19 has exacerbated another perennial concern: keeping the codes that affect hospital facilities unified. ASHE advocacy staff has made big strides in this area over the past few years, but COVID-19 put those efforts temporarily on the back burner.

For example, on the issue of temporary structures , which is fresh ground for code writers, making sure the various codes do not contradict one another is an important challenge. “Neither the FGI nor ICC have something on the books that comprehensively deals with temporary health care structures,” Williams says. “Now we’ve got two similar concepts developing on parallel lines, and we’re trying to link those two conversations up so that we’re approaching it with the same sensibility. We’ve got folks involved in both the ICC Committee on Healthcare and FGI emergency conditions white paper development . As these drafts solidify and gather support, we need concentrated attention to make sure they align.”

Flannery adds that the ICC Committee on Healthcare also will be watching the changes to NFPA codes to ensure alignment . “We’ll do our absolute best to try and align them as they go forward in all of those areas,” Flannery says.

Rapid response

The pandemic also provided an opportunity for ASHE members to get more involved in dealing with key issues.

One avenue for that was the COVID-19 Response Team, which ASHE established at the outset of the pandemic to help the association keep tabs on the situation and, when appropriate, disseminate information on how to best deal with it. The team, which was made up of ASHE members from across the country, conversed via the internet weekly. Flannery estimates that 90% of the information on ASHE’s COVID-19 resources site emerged from those calls. The team still exists but now covers other urgent issues, not just COVID-19, Flannery says. And its name has changed to the Rapid Response Team. Among the regular participants in the call is Kathryn Quinn, MHS, CHSP, safety officer at Saint Alphonsus Health System in Boise, Idaho.

“Initially we focused on pandemic-specific issues due to the crisis, and many other regulatory or operational concerns were pushed to the back burner,” Quinn says. “But, nonetheless, those issues were persisting in the background. And, so, the Rapid Response Team has really helped to integrate the ongoing COVID-19 concerns with other leading topics in facilities engineering.”

Among the issues the Rapid Response Team dealt with during the pandemic was whether hospital ventilation systems were adequate for safely managing the pathogen, especially when patient care surge locations were needed in unique spaces, Quinn says. The group discussed their respective HVAC systems, air filtration capabilities and the adjustments needed. They also considered how to manage oxygen supply and other operational needs in an alternate care location.

And when the Occupational Safety and Health Administration issued an emergency temporary standard (ETS) on vaccination and testing, the Rapid Response Team looked at how hospital facilities managers should respond, says Richie Stever, CHFM, CLSS-HC, LEED AP, vice president of real estate and property management at the University of Maryland Medical System, another regular participant in the calls.

“Learning what others were doing [regarding the ETS] was helpful in guiding us on how we should do things,” Stever says. “Not that we weren’t doing it already, but just having a partner out there going through the same thing with maybe a slightly different lens was helpful in our journey to compliance.”

The discussions during the calls are helpful for the team members themselves but, ultimately, the information derived from the meetings is disseminated through ASHE publications, Flannery says.

“After we discuss a topic, often we’ll say, ‘Yeah, let’s do an article on that,’ or ‘Let’s put a tool together for that,’”

Flannery says. “Then I’ll get it back to an individual who had input or something like that on a call and we’ll create something.”

Participation in the Rapid Response Team is by invitation only, but Flannery welcomes inquiries from ASHE members who would like to join when a spot opens. He can be contacted at jflannery@aha.org.

Advocacy evolution

As COVID-19 normalizes and hospitals become more accustomed to the challenges of the pandemic, ASHE’s advocacy efforts will continue to evolve.

“COVID-19 is still impacting our work, and probably will for a while, but we also need to focus on other advocacy issues in 2022,” Beebe says. “There is a lot going on that needs to be addressed.” HFM

 

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Ed Avis is a Chicago-based freelance writer and regular Health Facilities Management contributor.

 

Sustainability to the fore in ASHE advocacy efforts

The American Society for Health Care Engineering (ASHE) advocacy staff has spent much effort on sustainability, particularly how to define the terminology commonly used in that field.

For example, the concept of minimizing carbon emissions is connected to terms such as “carbon neutral,” “carbon zero” and “carbon negative.” All of these terms mean somewhat the same thing but, without clear definitions, it’s difficult for a hospital to meet a particular carbon-related goal.

Furthermore, ASHE advocates want to make sure that the definitions for those terms relate to goals that hospitals can feasibly achieve. Hospitals consume a great deal of energy, so getting to a point where a hospital can meet a carbon-related goal requires the goal be set with reality in mind. This is especially true considering that some technology that could help a hospital reduce carbon emissions — such as a microgrid, which can use renewable energy and could feasibly replace a fossil-fuel emergency generator — is not permitted in currently adopted Centers for Medicare & Medicaid Services Conditions of Participation.

“I think that with hospitals’ reliance on fossil fuels, it’s going to be difficult to get to ‘carbon negative,’ but we support it in a way that would be feasible [and] reasonable that we can actually get there,” says Kara Brooks, MS, LEED AP BD & C, ASHE’s sustainability program manager. “I think that there is an enthusiasm for going big and going bold, but it’s just a matter of trying to keep in mind really what can be done within our current codes and where the technology is right now.”

Brooks says ASHE is building tools and other resources to help hospitals reach their sustainability goals. Two examples are ASHE’s Energy to Care program and its sustainability “treasure hunts,” which help facilities managers discover ways to improve efficiency and reduce emissions.

Furthermore, ASHE is making sure the viewpoints of hospital facilities managers are included in discussions of sustainability goals by having advocates — including Brooks; Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, ASHE’s senior associate director of advocacy; and Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, ASHE’s deputy executive director — on the responsible committees, including those in ASHRAE, the National Fire Protection Association and the International Code Council.

“We have representation on all of those,” Brooks says. “It’s so that we can help influence these topics because not everybody understands them. It’s pretty easy to say, ‘We want to do something,’ without understanding how feasible it is to get there. So, we work with them to make sure that whatever targets or goals they’re setting are achievable under current conditions.” ■

 

Member tools task force establishes top priorities

American Society for Health Care Engineering (ASHE) members contribute to association priorities in many ways; one key avenue is by being part of the ASHE Member Tools Task Force (MTTF). This group met via conference call in September to discuss priorities for 2022. About 100 members were on the call, says Jonathan Flannery, MHSA, FASHE, FACHE, ASHE’s senior associate director of advocacy.

“Based on the call, we come up with a list of the 30 top items that we’ll address in the coming year,” Flannery says. The items are placed into three categories: Those that warrant a full article in Health Facilities Management (HFM); those that can be handled with a short article; and those that will be Advocacy Adviser columns. Some of the articles include tables or tools that help members deal with the issues.

For example, the Advocacy Adviser column on page 4 of this issue of HFM focuses on the requirements for generator battery inspections. “That’s a real hot topic right now,” Flannery says. “People are concerned about it.”

Another example is a full article scheduled for May on the differences between the Life Safety Code and the International Building Code. The article will clarify the differences in nomenclature. “A lot of people struggle or fail to understand the differences between the two,” Flannery says. “For example, what’s the difference between a ‘smoke barrier’ and a ‘smoke wall’? Fundamentally they are the same thing, but there are small differences in what you call them in the Life Safety Code and the International Building Code.”

Other planned articles for the year include an Advocacy Adviser column on maintaining egress corridors, a short article on asset life-cycle maintenance and a full article on building a case for in-house maintenance.

Readers may turn to page 40 of this issue of HFM for an in-depth look at ASHE’s MTTF project. ■

 

Focusing on water issues through ASHRAE standard

A new standard is being developed by ASHRAE to help minimize the risks associated with building water systems. Standard Project Committee (SPC) 514P, Risk Management for Building Water Systems: Physical, Chemical, and Microbial Hazards, is designed to “establish practices to minimize the risk of disease and injury from physical, chemical, and microbial hazards associated with water systems in buildings,” according to ASHRAE.

The standard began its life as NSF/ANSI 444, Prevention of Injury and Disease Associated with Building Water Systems, which was transferred to ASHRAE in 2019. ASHRAE Standard 514P is built on the foundation of NSF/ANSI 444 and ANSI/ ASHRAE Standard 188, which focuses on legionellosis.

“The intent of Standard 514P is to address chemical, physical and biological hazards ,” says Heather Platt Gulledge, senior project manager at Dewberry in Raleigh, N.C. Gulledge is an American Society for Health Care Engineering member and sits on the ASHRAE technology council. “The standard refers to ASHRAE Standard 188 for Legionella . The intent is to evaluate each of the hazards so that facility teams know what those hazards are, and they can be prepared to expand their facilities management plans to minimize these identified risks.”

Among the areas addressed are requirements for potable water systems, ornamental fountains, and public pools and spas.

“It’s to help facilities look at water hazards holistically,” Gulledge says. “Is the treatment you’re using the right treatment for your system? Are you aware of other waterborne pathogens or chemical risks that could be in the water? Standard 514P also includes guidance for microbial, physical and chemical hazards; potable and process building water systems; designers; testing strategies; and additional resources.”

ASHRAE Standard 514P underwent an advisory public review in early 2021 and is expected to be open for public review early this year. ■

 

 

Centralized operations yields efficiency upgrade

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By Erik J. Martin

Banner Health receives ASHE annual award for excellence in health care facility management

Seven years ago, Banner Health, a Phoenix-based nonprofit health system serving patients in 32 hospitals across six states, identified a big opportunity. It had implemented retrocommissioning at several of its facilities but saw potential for savings deteriorate over time because of changes and overrides made to its building automation system (BAS).

Challenges maintaining operating room temperature, humidity and pressure requirements followed. Its decentralized efforts in previous years were triggering other significant negative consequences, too. It was time for a more efficient strategy and operating model that swiftly and successfully leveraged the organization’s scale and skills.

Banner Health embarked on a datadriven facilities operations initiative in 2015 that aimed to consolidate decentralized technology, processes, procedures and policies; implement monitoring-based commissioning; merge computerized maintenance management systems (CMMSs) to a single platform; and develop universal protocols designed to improve building equipment operations. It would accomplish these goals and others by creating an innovative remote operations center (ROC) and forming a highly skilled team that, together, have decreased energy spending by nearly $12 million per year. But these achievements paid off in more ways than bottom-line savings. For its exemplary efforts, Banner Health won the American Society for Health Care Engineering’s 2021 Excellence in Health Care Facility Management Award, which recognizes individuals or facilities management departments that implement new or innovative programs or processes to optimize the physical environment and improve patient care.

 

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Tracing the timeline

Shawn Mathiesen, CEM, construction and engineering senior consultant at Banner Health, explains that the organization was at a crossroads a few years back and needed a better strategy to improve facilities operations.

“Monitoring and maintaining critical spaces is challenging for all major medical centers. We needed a standardized approach to not only ensure regulatory compliance but to optimize environment of care areas as well as enhance patient safety, efficiency and operational responsiveness ,” he says.

Previous efforts through retrocommissioning and other energy initiatives resulted in high levels of savings drift across three to five years.

“We recognized that we were making facility-level decisions, not system-level decisions, and we didn’t have the team or expertise that could support each facility as a dedicated full-time equivalent (FTE) employee,” Mathiesen says. “That’s when we determined that changes were needed, including the creation of a new, centralized ROC.”

Adding extra pressure to this initiative was the fact that Banner Health was expanding, most notably via a merging in 2015 with the University of Arizona Health Network in Tucson; eventually, the health system would serve patients in facilities spanning Arizona, California, Colorado, Nebraska, Nevada and Wyoming.

“The growth and diversity of Banner Health facilities challenged our leadership in 2015 to explore a more efficient facilities organization and operating model,” says Mark Barkenbush, vice president of facilities services for Banner Health. “This ultimately led to a centralization of facilities operations in 2017 organized by geographic area rather than the previous model, which was a more siloed, single facility-based approach.”

In 2015, the organization began alpha and beta testing a monitoring-based commissioning program at two Banner Health facilities, the findings of which suggested this would be an effective strategy. Buoyed by those desirable results, the facilities management team launched Phase 1 of this program across one-quarter of its hospitals (recently, it completed Phase 4).

But the centerpiece of the organization ’s initiative to shift facilities management practices to data-driven decision processes was the development of the new ROC and dedicated team, which started in 2015. Two years later, the ROC was up and running.

“Originally, we didn’t have the expertise in-house, so we partnered with a vendor that played a much heavier role in the beginning,” says Brandon Conway, CEM, senior manager for the ROC. “But we later agreed that our team would do some of the ROC creation work internally because it was a much more sustainable model for us long term. The organizational design of our ROC team included building management system technicians, coordinators and energy analysts that today has grown to a group of 12.”

Before the centralization of the ROC, each facility was acting as an independent department working with local staff and focusing on local issues, repairs and initiatives.

“The consolidation of technology, policies , processes and procedures allowed our teams to create universal protocols to ensure the best approach was applied to the operation of all building equipment . This ensured that we could more easily identify anomalies in equipment operations across our facility portfolio ,” says John Miller, CHFM, CLSS-HC, senior director of facilities operations for Banner Health.

“A great example of a big issue that all of our facilities faced was chiller surging,“ Conway says. “Through many conversations with the various manufacturers and engineers to identify the key characteristics for early identification and through proving the concept through several model iterations, we can now accurately predict a chiller surge before it occurs.”

Addressing other priorities

Aging infrastructure and critical utility infrastructure projects were high on the to-do list as well. Using data gathered from the centralization of its facilities operations department and implementation of the ROC, the team was able to secure a dedicated budget for a systemwide infrastructure renewal program.

Meanwhile, Banner Health had to address another serious impediment to progress: multiple BAS, CMMS and preventive maintenance (PM) tasks being used across its network of hospitals.

Before long, it began consolidating and supporting software to enable centralized maintenance and compliance activities and unified processes and procedures.

 

article ImageRemote operations center technicians cross-checking local chiller data against the building management system to ensure data integrity.

 

“As we continue to grow and bring other hospitals into our system, we convert them over to our new consolidated systems , policies and procedures within the first few months of operation,” Conway says. “And, for our BAS platform, we’ve converted to an open-ended and nonproprietary version of Niagara building management software. Standardizing on the Niagara platform allows Banner to align all our sites with a standard sequence of operations, hardware and graphics. This standardization reinforces best practices and ensures data consistency.”

However, the push for progress didn’t stop there. Banner Health also worked hard over the past seven years to standardize contracts, improve building management system and construction standards, fine-tune precision PM tasks and procedures, increase regulatory compliance and transition more efficiently to updated operation plans.

“This is the beauty of fostering a culture of continuous innovation and improvement . We are not afraid to admit when something is wrong or needs tweaking, and our team works together on it to figure out how to solve the problem so that everyone can benefit — patients, visitors and staff alike,” says Phil Dauge, executive director of facilities operations at Banner. Conway echoes those thoughts. “Our culture from the top down resonates continuous improvement with a strong focus on our patients. Our facilities operations department continually strives to do better for the benefit of our patients and staff, and our ROC and the centralization of our department is an extension of that.”

Fruits of their labors

Banner Health’s efforts over the past several years weren’t foolproof or without setbacks, of course. The ROC team encountered difficulty implementing standardized engineering and operational practices, achieving consistent communication with all facilities, and with manufacturers balking at service contract liabilities and limitations.

Despite these challenges, what the organization was able to accomplish is impressive, especially considering its size.

article ImageA visual representation of a massive data set that clearly illustrates where the remote operations center should focus its team’s efforts.

 

“We learned that, when we centralize and standardize on data-driven decision-making processes, we can create a significant benefit for the communities we serve, which is the ultimate goal,” Miller says. “We found that with the right team, including key internal staff assigned to the project as well as crucial external vendor support, our initiative could be successful.”

In particular, the gathered unified data allowed the team to observe trends at the system level, empowering them to make better-informed decisions and work toward a common cause. “These are issues that every hospital and health system are struggling with today,” Conway says.

Banner Health’s focus on using data to drive decisions has significantly increased staff productivity and efficiency.

“We have decreased diagnosis and repair times, decreased the number of hot and cold calls due to advanced analysis and remote resolution, and allowed for expertise in advanced control system logic to be housed internally ,” Miller says. “We have also been able to reduce deferred maintenance and repairs using data and collaboration.”

Banner Health has shared its lessons learned and paths to success with other health care organizations. “What we’ve told them is that the effort to get to the finish line requires an awesome team. It also demands a well-designed plan based on data that can be sold to senior leadership — a plan that can and will change as variables are firmed up. Above all, the effort must be a collaboration, not an edict, in which every involved party is encouraged to provide feedback and suggest improvements,” says Phil Dague, RPA, executive director of facilities operations.

’Greatly impressed’

Gary Hamilton, PE, LEED AP, FASHE, the Arlington, Va.-based chair of the task force that chose the 2021 Excellence in Health Care Facility Management Award, says Banner Health’s project ticked all the boxes as a top-class submission.

“We were greatly impressed by their ROC and their ability to manage and augment different tasks, from maintaining equipment and ensuring energy efficiency within a building to commissioning and monitoring,” Hamilton says. “The ROC really pushes the envelope when it comes to what a systemwide control center should look like and how it should perform. It needs to be nimble enough to expand to other facilities, which is exactly what Banner Health did.”

He notes that being short-staffed and needing to operate facilities remotely were major challenges faced by hospitals during the pandemic, as was the ability to proactively monitor every patient room and temperature setpoints to reduce nuisance calls.

“Banner Health overcame these and other challenges with their facilities operations initiative and ROC, which they replicated across several facilities. In my several years of judging this award, this was one of the strongest submissions I’ve seen,” Hamilton says.

Barkenbush commends everyone involved with the initiative. “I’m so proud of the innovations my team has implemented over the past few years. We have made a positive impact on our patient care environment and our bottom line,” he says. “The recognition by ASHE of this work confirms our belief that we are on the right path.”

Conway adds, “Seeing our program mature year over year while continuing to improve patient care and yield energy and operation savings is extremely gratifying. Getting our facilities colleagues in the field to acknowledge our efforts is icing on the cake.”

Importantly, the initiative meshed with and supported Banner Health’s mission statement: Making health care easier so life can be better.

“It all ties back to providing a safer, healthier and better patient healing environment ,” Miller says. “If our team wasn’t laser-focused on this mission, we may have each had great ideas, but we would have been running in different directions.” HFM

 

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Erik J. Martin is a freelance writer based in Oak Lawn, Ill.

 

Exceeding performance objectives through remote operations center

From the start of its initiative, Banner Health, Phoenix, identified areas of improvement and set ambitious objectives, including collective energy cost savings across its facilities.

“We as an organization continually set goals for ourselves and our team for each effort that we take on. These include a graduating scale of minimum to maximum performance expectations,” says Shawn Mathiesen, CEM, construction and engineering senior consultant at Banner Health. “Remote operations center (ROC) goals have been addressed annually when evaluating our performance improvements and have continually met or exceeded expectations.”

To improve Banner’s operating margin through cost savings, it created adjusted energy value targets: $0 to $1.4 million in annual energy savings was judged as not meeting the goal; $1.4 million to $1.7 million didn’t fully meet the goal; $1.7 million to $2.053 million met the goal; $2.053 million to $3 million exceeded the goal; and greater than $3 million in savings greatly exceeded the goal.

It’s safe to say that the latter target has been reached: Since 2016, the ROC team has reduced annual energy spending by almost $12 million. And every year, the ROC team avoids $3.85 million in utility spend drift alone made possible by continuous monitoring of faults and performance anomalies across systems.

The new ROC also has met or exceeded patient healing environment aspirations, including proactive monitoring of patient room temperature setpoints to ensure a comfortable environment of care; aggressive measures to reduce health care-associated infections via operating room and negative pressure isolation room dashboards containing real-time pressure, humidity and temperature data; and lowering avoidable operational spending by monitoring key building equipment to predict failure before it occurs.

“Our outcomes have far exceeded original expectations and have delivered a unified team with a single focus on utilizing data to drive decisions and improve the performance of our facilities services,” says Phil Dague, RPA, executive director of facilities operations. “The ROC specifically has become known as a systemwide resource whose expertise is used by our front-line teams, finance, construction and anyone else looking for answers to questions that were never readily available before.” ■

 

Architecture and bioethics

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Health care facilities such as this suburban hospital are akin to medical interventions, and they require the same research depth and overview as pharmaceuticals or other therapies.

BY WILLIAM J. HERCULES, DIANA C. ANDERSON, STOWE LOCKE TETI AND DAVID A. DEEMER

A new value proposition for health care facility designers

Johann Goethe, the 18th century polymath, once remarked, “Architecture is frozen music,” by which he meant architecture interprets and expresses the values of its time — sometimes in a general epoch and sometimes at a very precise point. Experienced health care architects will appreciate this phenomenon, as current project drivers may have eclipsed those of decades past. It is in precisely this context that designers are studying the decisions and trade-offs that result from these normative preferences.

In health care architecture, design is being increasingly employed to affect patient outcomes, alter specific behaviors and mediate the interactions of those within health care spaces. The advances in design science have progressed to the point that the built environment in health care can be considered akin to medical interventions. And, as with medical interventions, the nature, risks, benefits and alternatives should be disclosed to patients and caregivers.

The ethics of buildings and construction typically involve environmental impacts and social equity of the built environment. And while these are important, the focus of this article is on the health care setting itself and how it affects patients, families and health care teams. While some of these effects bear on individual patients, such that an informed consent process may be sufficient, others have a population-level impact that will persist for generations, well after the designer’s direct influence.

Focused work in medicine, neuroscience and psychology is being employed to several ends but, to date, there has been little investigation of these practices. This is because the elements affecting control are neither providers nor medications , but the health care facility building itself. Broadly, this raises issues about the nature of the built environment, what constitutes a medical intervention, what architecture is expected to do and, importantly , what obligations emerge from designers’ choices.

To preview the impact of this argument , many facilities directors and design firms have built strong reputations in the architecture’s “ability to heal.” However, the truth and power of that proposition remain largely unexplored opportunities. While medical care itself forms the lion’s share of the healing enterprise, environmental factors can enhance or detract from those effects. Taking seriously the moral obligation to be knowledgeable and intentional about the powerful effects of the built environment in health care would enable architects and facility directors to validate such claims in the same way medical therapies are validated.

State of research

One consistent theme in the following examples is the demonstrable need for more research into the effects of these interventions, some of which are described below. Consider that roughly 5,000 articles in the Center for Health Design’s Knowledge Repository serve as the foundation that informs health care architecture. Compare that number to the 30 million peer-reviewed articles in PubMed that serve as the foundation of medical care. And yet, architecture has been linked to myriad physical, psychological and social effects, many of them in the health care setting.

The profession of architecture lacks the machinery that medicine or bioethics can call on for longer-term, project-spanning research enterprises. Therefore, evidence-based design requires a multidisciplinary approach involving changes at each level — at the bedside, in the project team room and in the executive suite. Some examples include:

• Design interventions coupled with health outcomes. Several significant examples of the utility of some research-informed architectural interventions include intensive care unit (ICU) room visibility, treatment intensity, patient falls, infection control and the perpetual debate related to centralized versus decentralized nurses stations. Nowhere is the need for more research more apparent than architecture being used intentionally to affect outcomes.

Roger Ulrich’s pivotal but small 1984 retrospective study examined hospital stays in postoperative patients in which one group’s hospital window faced a brick wall and the other faced a park. The group facing the park had shorter hospital stays and took fewer doses of pain medications. This study launched the field of evidence-based design, as architects claimed professional validation by evidence to support what they had instinctively believed. In the ensuing decades, many studies examined nature’s role, with findings supporting the hypothesis that access to nature and views of nature reduced stress, lowered blood pressure and diminished the need for pain medication.

Other research has found that facility design can affect the care choices made by physicians and medical teams. A Harvard lab investigated different rates of caesarian sections that correlated with elements of the building’s design. A small number of labor and delivery suites and a larger number of surgical recovery bays prompted providers to move from natural birth to surgery more quickly than in other facilities. In effect, the building plan profoundly affected the care that went on inside it.

• Nudging and illusion for cognitive impairments. The bioethical connection between architecture and dementia is neurological; for example, the brain regions affected in the early stages of Alzheimer ’s overlap with the areas important for spatial navigation. Research into these impacts has revealed perceptual disabilities in persons with dementia (PWD) that in certain settings may limit the navigation of PWD while not affecting others. Instead of managing the disruptive behaviors through traditional methods (e.g., locking exterior doors, physical restraint or the use of medications), design-based approaches may utilize these perceptual differences of PWD to decrease disruptive behaviors.

For example, PWD often avoid shiny floors and surfaces with extreme glare, grid patterns on floors and black areas on floors. Even though these design interventions do not slow or halt the progression of dementia, they are effective at decreasing the use of traditional methods of behavior management in PWD, such as chemical or physical restraint.

Across the world, dementia facilities are increasingly employing design-based approaches to similar effects. However, these interventions rely on creating a misperception of the space. The natural progression of this illusory approach is complete immersion. For example, De Hogeweyk, the original “Dementia Village” set in the Netherlands, does not limit resident wandering but promotes permissive wandering to combat the confusion and spatial disorientation experienced by PWD through a created reality. In the Dementia Village, residents are free to visit amenities such as shops, a café and a pub; and purchases are made with fake money, lending a sense of realism to transactions.

Anecdotal reports from De Hogeweyk note less agitation and behavioral disturbances in addition to fewer doses of psychotropic medications, although no formal studies to date have attempted to quantify the village design on outcomes, nor have those outcomes been defined. Is the absence of medications or restraints alone the correct metric, or should any effects on a resident’s primary health and well-being also be considered? Do these interventions temporize the behavioral symptoms of dementia or even other unknown consequences?

• Using design to segregate patients and staff. Health care facilities typically separate staff, patients and families. For example, private patient rooms are special spaces that allow for critical communication under controlled conditions. However, the practice of medicine is actively moving toward improved transparency and promotion of patient autonomy , diverging from the traditional architecture of hospitals, which often reinforces a clinical process that remains opaque to patients.

Recent design approaches borrowed from the hospitality industry to deliberately segregate staff activities from patient- and public-facing activities. While the intent is to improve patient satisfaction (a managerial metric), staff often become isolated from the spatial benefits otherwise afforded to patients. This trend is likely to intensify in the coming years, as contagion considerations add weight and volume to calls for separate spaces in a post-COVID-19 world looking to avoid another pandemic. Additionally, staff caregivers are already demanding better working conditions to support work-life balance (see Figure 1 on this page).

 

article ImageFigure 1: Staff are prohibited from accessing a hospital garden amenity to be used for public only, resulting in space that is often unoccupied.

 

Physician burnout and moral distress have been linked to poorly designed workflows and systems, which include chaotic environments, interruptions and distractions. Frequently, the hospital lobby, waiting areas and public eating zones are enhanced with art, color and amenities. But, as one crosses the consumer-design threshold into the off-stage portions of the building, the walls often become colorless, lighting becomes harsh and views of the outdoors are reduced. The resulting fragmentation, decentralization and concealment of clinical spaces create class disparities between staff and patients, a condition at odds with the current social discussions around equity and a stressor to human resource directors filling and retaining staff roles.

Ramifications for architects

If one accepts the basic notion that health care architecture is itself a medical intervention — as is often claimed by many designers and researchers — the responsibilities of their effects carry direct ethical obligations.

This is completely new territory, and many design firm attorneys will immediately claim that the standard of care is being extended. However, a high standard already exists in the research demonstrating generalizable or even specific effects. All involved in design do not have the luxury of being complacent, but these realities already demonstrate a higher order of knowledge, practice and even outcomes.

Similarly, all health care enterprises accumulate enormous amounts of data through their own internal research initiatives. As a matter of the design process, architects should be asking for specific data to develop metrics and demonstrate the value of their work in clinical efficacy, operational benefit and outcomes. The implied value proposition is significant and allows for a deeper demonstration of cause and effects regarding better patient and community outcomes, which have the potential to reduce clinical and operational costs or even enhance value for health systems.

 

article ImageFigure 2: This ICU sketch indicating visibility percentages per room was part of a study that found a correlation between room visibility and patient morbidity and mortality.

 

• Obligations to inform about architectural effects. With increasing knowledge of how architecture impacts patient well-being and outcomes comes the responsibility to be transparent about those effects. Health care organizations regularly conduct institutional and quality control surveillance to optimize various behaviors and policies known to affect outcomes; for example, the use of checklists to minimize surgical site infections, moving high-risk procedures to specialized services and promoting cultures of safety.

However, institutions less commonly perform design-based interventions to optimize outcomes . While the impact of behavior has a role to play, physical design is often overlooked as one of the most powerful motivators of behavior, as an ICU study examining patients placed in rooms with poor nursing visibility demonstrates (see Figure 2 on this page).

Because designers know the built environment has profound effects on those within a space, and designers have a duty of care to its occupants, all of those involved in making decisions with this knowledge must not just be transparent about those effects but also be intentional about how one uses that power. If there are concerns that poorly visualized ICU rooms tend toward poorer outcomes, those in the architectural, medical, bioethical and public health professions should address the benefits and harms of differing designs directly.

Design and health care teams should work to maximize both outcomes and fairness to all patients, regardless of which ICU room those patients find themselves in. This has a current corollary with how health facility risks are assessed with an infection control risk assessment or a disaster, emergency and vulnerability assessment, or even more deliberate oversight that is required in the development of pharmaceutical trials. Whether the cause of the disparity or potential harm to patients is the building itself or a medical treatment, it should be addressed during design.

• Weighing the benefits and harms. The harms and benefits of different design options depend on one’s perspective . Some argue that creating artificial realities such as dementia villages is an affront to their dignity. Others argue the benefits of design-based interventions, which diminish disruptive behaviors by using such illusion and deception, are justified by limiting stress, conflicts with staff and the indignities of being sedated. The potential for harm in traditional dementia care facilities that employ physical restraint and sedation might further outweigh the harms of the illusion and deception. On the other hand, the means of these interventions are at odds with principles of respect for individual autonomy and truth-telling . In the end, careful consideration of these issues and deliberate decision-making by all stakeholders is a high road forward into this unexplored terrain.

Architects are ideally suited to take a leadership role in the advancement and selection of these techniques. However, to be leaders in this new space, architects will not only need to collaborate with the physicians, bioethicists and scientists doing this research but also become versant in the ethical questions and issues that emerge.

By synthesizing the research and value considerations, architects are ideally positioned to assert a new level of professional authority beyond being an educator exclusively into a professional domain that may extend beyond health, and which pushes the envelope of how the built environment can improve the human condition.

Expanding the discussion

A way forward may recognize that health care environments are what Donald Berwick recently described as a “moral determinant of health.” The researching, designing and construction of these environments can have as much impact as the best therapeutic intervention or the worst ethical breach of a patient’s rights. All involved with health care design need to preserve and assist all stakeholders ’ abilities to act intentionally or make deliberate choices about relinquishing freedoms. The issues raised here are distinctly architectural and bioethical, and they actively invite discussions about these issues with project teams, hospital-based ethicists, institutional review boards and executive leaders.

The value proposition offered is substantial for the future of health care design in general, and for architects to engender and assert professional authority . This may be done through responsible consideration of applied research, engaging with concurrent research studies conducted within their client’s domains, and advocating for longitudinal research related to sustained outcomes. HFM

 

 

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William J. Hercules, M.Arch, FAIA, FACHA, FACHE, is an architect and the CEO of WJH Health; Diana C. Anderson, M.D., M.Arch, ACHA, is a health care architect and physician who is a principal at Jacobs and a clinical fellow at the VA Boston Medical Center; Stowe Locke Teti, HEC-C, is a clinical ethicist with Inova Health System who teaches ethics to Georgetown University and University of Virginia medical students and is editor-in-chief of the bioethics journal Pediatric Ethicscope; and David A. Deemer, M.D., MA, is a bioethicist and internal medicine resident at the University of Wisconsin. They can be reached at Bill@WJH-Health.com, diana.anderson@dochitect.com, stowe.teti@inova.org and ddeemer@wisc.edu.

 

Basic recommendations on interventional hospital design

The health care built environment should in many cases be considered a medical intervention, and it should therefore be subject to the same research depth and overview as medical interventions.

This is especially true when design elements utilize knowledge of cognitive impairments to influence behavior, associate with relevant medical outcomes, and become a source of burnout or inequity for staff.

While this work just begins to discover the full scope, impact and ethics of the built environment as a medical intervention, several basic recommendations can be drawn:

• The development of architectural interventions intended or known to have effects on patients compared to other medical interventions should be rigorously reviewed.

• The question of design standard of care should be openly and honestly discussed, recognizing the legal implications and potential increased value of design services.

• Informed consent should disclose any design interventions aimed at modifying behavior, whether as part of the hospital admission process or when moving to a longterm care facility.

• Surrogate consent to long-term care involving deception or illusion, particularly when against the patient’s wishes, should be subject to additional oversight and scrutiny.

• Hospital quality improvement departments may consider monitoring the effects of their built environment on relevant patient outcomes and examine more architectural interventions to improve outcomes.

• Health care institutions should strive for spatial quality parity; high-value spaces are community assets that can build a sense of comradery, solidarity and trust between staff, patients and their families.

• Health environments research needs suitable and substantially more funding to create a credible research infrastructure to demonstrate clear cause-and-effect relationships , akin to those afforded medicine or other therapies.

• Organizations could reconsider contractual relationships to include longitudinal data collection and research. ■

 

ABOUT THIS ARTICLE

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This feature is one of a series of articles published by Health Facilities Management (HFMmagazine.com) in partnership with the American College of Healthcare Architects (healtharchitects.org).

 

 

Financing hospital energy sustainability

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BY BEN WALKER AND MARK MININBERG

Three steps for assessing potential savings opportunities

Hospitals are intended to serve without end regardless of the circumstances. For this reason, they must look at sustainability as the ability to remain resilient in perpetuity.

However, figuring out how to fund the necessary equipment, staff and infrastructure to achieve this is no small feat. To help, the American Society for Health Care Engineering (ASHE) recently released a new monograph called “Best Practices for Financing Energy Sustainability ,” from which this article was excerpted and edited.

Building on the previous ASHE monographs “Energy Procurement: A Strategic Sourcing How-To Guide” (2017) and “Best Practices in Business Planning for Energy Resiliency” (2018), the document sets forth best practices for financing energy sustainability.

Financing projects

There are two main pathways to reducing scope 1 and scope 2 emissions (see sidebar on page 33 for scope definitions): reducing the need for dirty energy (a demand-based approach) and ensuring the energy being used is coming from increasingly cleaner sources (a supply-based approach). Neither should be ignored at the expense of the other.

There are three categories of action that will allow facilities professionals to reduce a hospital’s scope 1 and scope 2 greenhouse gas (GHG) emissions. They usually are taken in the following order:

Step 1: On-campus energy reduction. Reducing the demand for energy is one of the best understood solutions for reducing campus emissions. There are a variety of ways to reduce the need for energy, including more efficient equipment and software as well as architectural and design choices.

To ensure a hospital has a high-quality project or portfolio of projects, professionals can follow the guidelines discussed in the sidebar on page 34, which addresses problematic analyses. Assuming a project has a well-performed analysis that accurately states the savings potential, what are ways to successfully finance the project?

Health facilities professionals usually are trained to identify projects that produce a return on investment (ROI) in less than three years. They may assemble a list of these projects and become frustrated when they are repeatedly turned down by the chief financial officer (CFO). The reasons are found in the details of health care finance and accounting.

First, ROI analysis is suited to projects funded via capital expenses and designed to answer: How long is the payback? This helps determine whether to invest capital in the proposed project or to invest capital elsewhere. Short payback time frames of less than three years may gain momentum within an institution, while projects with longer break-even horizons can be difficult to move forward.

These ROI or simple payback analyses are popular with engineers because they are relatively straightforward. However, ROI calculations rarely convince the CFO to approve a project. ROI only compares the new project to current operating conditions and costs. From the CFO’s perspective, energy is not reimbursed by Medicare and thus does not contribute to top-line revenue.

As a supplement to ROI, engineers should consider how a project impacts the hospital’s financial situation or, more specifically, its gross margin and net operating margin (NOM).

When hospital profit margins are low, even modest decreases in NOM can affect the institution’s ability to borrow. In more extreme cases, low NOM can reduce the hospital’s credit rating. Thus, hospital CFOs are wary of the ramifications of taking on even small indirect expenses and debt, despite a relatively short ROI.

Facilities professionals must look at their organization’s overall priorities and trace how the energy equipment impacts the larger operation. Then, they should ask what happens to the organization ’s revenue and NOM if the project is installed. Does it allow for decreased staff time, increased patient revenue or improved regulatory compliance? Are there other financial benefits like deferred maintenance, delayed equipment replacement and increased uptime?

Additionally, it is worth noting that $1 saved on a bottom-line energy expense at a 2% operating margin is worth $50 billed in top-line Medicare revenue.

Next, facilities professionals can reverse the analysis and consider what might happen to the organization if the project is not completed. At times, such as for regulatory compliance, the cost of leaving the project undone is unacceptable . In other cases, it would be cheaper to avoid the proper maintenance required of backup generation and equipment.

However, what happens if a major boiler failure occurs in winter? Under resiliency requirements established by the Centers for Medicare & Medicaid Services, this could entail evacuation of patients and cancellation of medical procedures, which leads to lower revenue and reduced community confidence.

Another important financing strategy is to operationalize the capital costs, moving them off the hospital’s balance sheet. There are a variety of options for achieving this. While each has important nuances, the objective is the same: An external party bears the capital cost, while the system pays for the project out of its operational budget.

If the project is classified as an operational cost, it may be viewed as a “direct” cost rather than a “financed” cost, and it will not affect the hospital’s cost of borrowing.

Operational strategies also can offer immediate cost reductions. With another party taking on the capital cost, the hospital can enjoy lower energy rates as soon as the project is completed, with no capital outlay. Operational strategies can be deployed in several forms, including energy as a service (EaaS) agreements, operating lease structures and on-bill financing.

Another financing option is an energy savings performance contract (ESPC). These agreements shift operational responsibility to a third-party equipment operator, but the hospital still pays the capital cost of the equipment. Under this model, an energy services company (ESCO) installs and operates the equipment that may continue to be owned by the hospital or transferred to the ESCO at some point.

The equipment delivers a specific amount of savings via reduced energy bills, ensured by a contractual “performance guarantee.” If the operation does not produce the savings, the ESCO pays the customer the difference.

ESPC performance contracts are well-suited to combining multiple projects or technologies into one agreement. They also ensure savings and relieve hospital staff of operational responsibility. Due to their similar “pay-for-service” structure, ESPC performance contracts often are compared against EaaS contracts. Both can offer significant operational savings, but there are key differences.

If the ESPC contract will place capital costs on the hospital balance sheet, it may reduce the project’s appeal to administrators. Also, performance contracts often require the hospital to make a fixed monthly payment, which is adjusted later based on a monthly calculation of savings. The additional scrutiny required by ESPCs in terms of auditing and verification of savings may erode the saved staff time coming from the shift in operational duties.

Under the EaaS model, the project asset is not owned by the hospital and therefore is not placed on the hospital’s balance sheet. In addition, the EaaS service provider must confirm energy and financial savings before billing monthly energy costs to the hospital. Thus, EaaS contracts often are marketed to hospitals as being “paid for directly out of savings.”

One factor to consider is inertia: Will the hospital become locked into a particular solution or supplier with little chance to change in the future? Any situation in which the hospital must pre-commit for decades merits extra scrutiny.

Another consideration is matching the contract type to the project type. Energy services agreements (ESAs), a form of EaaS, fit well for projects that reduce a facility’s energy use, especially if those projects also reduce energy demand charges. If the project is instead generating power, an ESA option might still be used, but it is more common to utilize a power purchase agreement (PPA).

The approaches share similarities, but the savings protection of an ESA may be more necessary for energy efficiency projects. PPAs are well-suited to procuring renewable power generation either on-campus or off-campus.

Once a project has been completed, it often will yield recurring cost savings. In general, the savings are returned to support patient care. In some cases, a system may choose to devote the savings that have been created to fund future equipment needs.

Those that reinvest savings from initial successes into future projects have a “rolling green fund.” This provides for an easier approval process, increased organizational savings, better equipment performance and higher staff productivity.

Without a rolling green fund, each project has its own process and internal communication , and alignment can be more difficult. If a facilities professional must operate without a rolling green fund, they should aggregate projects as much as possible to mitigate these challenges.

Utility rebates create an excellent alternative revenue stream for energy-reduction projects. Facilities professionals should develop a dialogue with the utility or find an external consultant to do so to maximize the potential benefit of the projects being considered.

Nonprofit hospitals often are unable to take advantage of tax incentives. However, for-profit partners often can do so. Thus, an external financing option may have a lower effective cost of capital than an internal debt service, even if the internal option had a lower interest rate. Similarly , external partners can have a lower effective cost of labor or equipment.

All hospitals have a treasury management function to ensure sufficient cash to meet financial obligations. Health care treasury funds are intended to provide long-term financial stability. This means that investment strategies must balance obtaining high returns while not taking unreasonable risks. A certain portion of the fund income may be used each year to support operations.

“Impact investing” means making investments that provide a significant financial return and a positive social impact. As investments in renewable energy are becoming more profitable, opportunities are opening for facilities to engage in impact investing. One way to encourage impact investing is to identify projects that benefit the hospital and community and to engage the finance and treasury departments in a dialogue.

Lastly, tying a project to new or increased revenue sources can be a strong argument for it being approved.

Step 2: Buying clean energy produced off campus. If reducing the need for energy is the typical starting point for hospitals, looking to procure clean energy follows closely behind. The benefits of starting with off-campus renewable procurement rather than on-campus projects are that it:

• Does not interfere with existing infrastructure such as rooftops and parking facilities.

• Avoids locational constraints such as tree cover or utility interconnect limitations.

• Allows access to larger aggregations and improved economies of scale.

• Offers purchasing that fits into existing procurement frameworks of market hedging.

The costs of renewable generation have decreased dramatically. Many types of renewable power generation, including wind and solar, have now become cost competitive with fossil fuel alternatives in many parts of the country. But how can a hospital benefit from these trends?

PPAs are among the most flexible contract agreements available to energy developers and buyers. Under a PPA, a hospital would engage with a renewable energy developer and agree to buy a specified amount of power produced by a specific energy asset at a certain rate for a certain length of time.

There can be other contract terms that distinguish projects, such as an energy production guarantee, which internal supply chain and legal professionals may help to analyze. PPAs have become common for procuring on-site and offsite generation. However, there are some distinctions between how electrons flow based on where the generation is located.

Under an on-site PPA, the energy produced by the asset will typically flow directly into the facility to power on-campus equipment. Because the hospital is supplying some of its own power, the utility provides less power to the campus. Therefore, from the utility’s perspective , the energy load is reduced. Under an off-site PPA, the energy produced is being delivered to the grid on the hospital ’s behalf. The energy that flows off the renewable asset goes into the pool of electricity that all energy users access. From the utility’s perspective, the campus energy needs are unchanged.

Two common types of off-site PPAs are physical PPAs and virtual PPAs (VPPAs).

Under a physical PPA, the generation asset connects to the utility grid that serves the hospital campus. Under a physical PPA and a VPPA, the generating asset delivers power to the grid at large.

However, under a physical PPA, the hospital is said to take ownership of the electricity once it enters the hospital ’s utility load zone. Hence, while the agreement is financial, money is being exchanged for a commodity: electricity. Physical PPAs are typically available only to hospitals that operate in jurisdictions with competitive electricity markets.

A VPPA is open to hospitals regardless of location. Under this agreement, the transaction is purely financial, and the buyer never takes ownership of the electricity . It also is known as a contract for differences, a financial PPA, a synthetic PPA or a fixed-for-floating swap. These function similarly to wholesale PPAs, but the settlement is only financial and under a separate invoicing structure.

VPPAs are especially great options for hospitals that want renewable energy but do not have access to a competitive market. They are generally used to purchase energy from a renewable energy project at a fixed price and, like all PPAs, that price may or may not include the project’s renewable energy certificates (RECs). The power is sold in an energy market that could be in another state or jurisdiction from the hospital making the purchase.

The VPPA is an investment in renewable energy that can create revenue (but also risk potential losses) for the hospital. VPPAs are treated as financial instruments under generally accepted accounting principles. Thus, the hospital must calculate the VPPA’s fair value based on current forward energy pricing and report that value on the hospital’s balance sheet as either a profit or loss. This is different from ordinary energy market purchases for electricity or natural gas, which are operating expenses and are not on the balance sheet.

Perhaps the most important concept when entering a PPA is how the project is “shaped.” This means comparing the project’s energy generation profile with the corresponding grid pricing profile. This comparison must be made at an hourly level for each month in a shaping analysis.

Another consideration when entering into an agreement to procure off-site renewable energy is whether to take ownership of the RECs. Each renewable energy project creates RECs, which take the form of a certificate verifying the source and quantity of the renewable power generated. RECs come in different types or vintages, depending on the year, generation technology and location from which they were produced.

While the REC and the renewable electricity are generated at the same time, the electricity and the REC are separate things. The electricity and the REC can each be bought and sold separately — and often are sold to different parties.

Just as there is a market for electricity, there is a market for RECs. Private and nonprofit organizations buy and sell RECs. Many states also allow (or even require) utilities to purchase RECs to comply with renewable generation targets.

One newer option is called “community solar,” though each state might provide its own name for its program. Community solar can be considered a hybrid of on-campus and off-campus generation. The solar panels are installed off campus , but they operate under many of the on-campus rules.

In addition to being a hedge against utility delivery rates, community solar can, if contracted correctly, offer guaranteed savings. This is possible through a “fixed-discount” contract type.

One type of community solar contract structure that should be avoided is when the hospital is offered a fixed discount that also includes a price floor. These are not structured as true fixed-discount contracts and do not offer the same savings profile.

Step 3: Producing on-campus clean energy. When considering on-campus generation, it is important to assess how the project would impact daily operations , who will maintain and own the asset, and how the location would impact long-term campus planning.

On-campus clean energy production often takes the form of solar panels on a rooftop or carport or via ground mount. This is called “behind-the-meter” (BTM) solar because the electricity flows from the solar panels directly into the facility. Any financial analysis should treat energy and demand charges separately.

On-site BTM solar can offset the energy and delivery rates found on both the hospital ’s utility bills and on any third-party energy supplier invoices as well. However , a solar project is limited to hours when the sun is shining and therefore cannot be relied upon to consistently deliver savings during more expensive peak energy demand.

By pairing a solar project with battery storage, the hospital may be able to discharge the stored energy at peak hours and reduce demand rates as well. In some areas, discharging storage for non-demand services such as energy arbitrage or ancillary services is also lucrative , in which case those revenues should be accurately stated in any analysis.

In some states, a hospital may be allowed to sell excess energy produced on campus through self-generation equipment . This is commonly called “exporting energy to the grid.” State regulations and utility tariffs governing the exported energy — including the rates a hospital is paid for energy — will vary based on location.

The financial benefit of on-campus renewable power generation depends in part on the available resource (e.g., hours of sunshine). The benefit also varies based on building constraints, local utility incentives and state support.

Another factor is the readiness of the space: the less alteration and construction a site needs, the more cost-effective the solar installation will be. Hence, it is important to consider on-campus generation during any project design phase.

On-site solar generation tends to make the most sense when the health system is in a utility zone with high electricity delivery rates. If the delivery rates have high demand charges, it is worth examining solar plus battery storage. If the local utility includes high energy charges in its delivery rate, it is typically worth exploring stand-alone solar.

The most common payment structure for on-site solar is a PPA. On-site PPAs have many of the same price risks as off-site PPAs. However, on-site PPAs replace a different set of costs than offsite PPAs and therefore have a higher cost-to-compare. While off-site PPAs only provide energy and not the non-energy costs provided by traditional energy market suppliers or the delivery rates charged by the local utility, on-site PPAs will offset charges on both the supplier and utility delivery bills and should be analyzed accordingly.

Any on-site project may introduce the need for additional compliance efforts. To produce RECs that a hospital can monetize or retire, the project needs to be registered with the appropriate entity.

Some sort of maintenance contract or EaaS is typically necessary for the system to derive the maximum benefit from an on-site project. In many cases, this is included in the PPA, but if the system were to purchase the panels outright, a separate agreement would be necessary.

Many of the financing strategies appropriate for on-site energy efficiency also are appropriate for on-site supply. BTM solar can be financed directly through a loan, a lease or through an EaaS agreement.

On-bill financing through the hospital’s energy supplier is uncommon, primarily because this type of financing works best for short-term loans. As a result, most hospitals prefer a third party to provide solar energy charged as an operational cost rather than paying upfront to own the installation.

For hospitals seeking to own the solar directly, federal tax incentives will provide 20% or more of the project’s value as a tax write-off. Thus, monetizing that tax credit is beneficial in completing a BTM project. Assuming a nonprofit health system does not have a need for the tax credits, it is worthwhile to find a partner.

One unique way to participate in on-campus generation is to act as a landlord for a solar developer.

 

Getting started

While many health care organizations wish to begin the transition to a more sustainable energy future, financial constraints often prevent progress.

These three steps offer methods for getting started and for continuing this important work. HFM

 

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Ben Walker is director of market analytics and Mark Mininberg is founder and president at Hospital Energy, Manchester, N.H. They can be reached at bwalker@hospitalenergy.com and mark@hospitalenergy.com.

 

Developing a successful program

The best way to obtain the necessary knowledge and support for a strong sustainable energy program is to form a multidisciplinary team that brings together the expertise of several disciplines within the health system, including facilities staff, finance, supply chain/purchasing, public health professionals and a sustainability director.

With this committee or green team in place, a hospital will have the necessary internal experts aligned to set its sustainability targets and to make sound decisions about how to finance the pathways needed to meet the organization’s objectives.

An important early step is to create a baseline and develop an understanding of initial conditions. From there, facilities professionals can classify their emissions reduction strategies and quantify the benefits.

If a hospital is just starting out on its sustainability journey, the first action may be an accounting of current emissions. When creating a greenhouse gas accounting report, it is helpful to distinguish between scope 1, scope 2 and scope 3 emissions.

• Scope 1 emissions describe those that come from campus operations.

• Scope 2 emissions are associated with electricity delivered to the hospital through the grid.

• Scope 3 emissions come from the supply chain. Scopes 1 and 2 are the easiest to measure and reduce, while scope 3 (which is beyond the focus of this article) takes more time and effort to address. To be successful, it is important to first identify and articulate what the facility is trying to achieve.

The best strategic investment follows aspirational goals. It also is process oriented , because the desired destination may take several steps to achieve and involve solving and financing other projects along the way. The strategic outcome will impact not only current operations but the care environment as it evolves.

The process of determining the best strategic investment will ideally identify the most vital energy projects that impact the delivery of care, reduce energy costs and eliminate carbon emissions.

Once a list of projects has been developed, it is vitally important to appropriately prioritize that list according to the organization’s highest value. As the number of available projects changes, the list should be continually reranked and prioritized to the highest value. ■

 

Avoiding financial analysis pitfalls

It is important to accurately analyze projects under consideration for financing. To avoid common problems, health care facilities professionals should avoid the following pitfalls:

• Analytical pitfall 1: Not incorporating knowable market information. Energy sustainability planning requires professionals to consider current and future conditions. A common developer approach to selling a project to a hospital is to create savings calculations that look back at energy costs over the past 12 months, then project consistent 2% to 3% growth (also called an “escalator”) for the next two decades. However, while volatile, the energy markets produced a long-term decrease in costs from 2008 to 2021. Thus, projections should be independently analyzed.

• Analytical pitfall 2: Using escalators blindly. A hospital should be skeptical of any proposal that requires them to pay a monthly rate for energy that will escalate at a fixed rate each year. Compounding the problem, generic fixed escalators often are applied to every cost component. The longer a project’s expected life, the more skepticism a fixed escalator deserves. Similarly, if any project’s savings value depends on the energy market escalating significantly, the hospital should be very skeptical.

• Analytical pitfall 3: Comparing apples and oranges in project cost analysis. Accurately analyzing a long-term energy project requires professionals to avoid combining costs that are not relevant to the ultimate project value. For example, many hospitals have a natural gas utility delivery bill and a natural gas supplier bill. These two components ought to be modeled separately in any financial analysis. Sometimes bill components from one source need to be separated even further. For instance, electricity delivery bills have “energy” components and “demand” components. The hospital will pay both costs, but different projects may impact only one component or may impact both together.

• Analytical pitfall 4: Not accounting for all the correct costs and benefits. While many analyses attempt to capture the savings associated with “option A” versus “option B,” it is important to make sure the underlying scenarios are appropriately described by creating a “value stack” for each one. Properly accounting for all cost items is called “total cost of ownership.”

• Analytical pitfall 5: Ignoring likely regulatory change. The movement toward decarbonizing buildings is very active. Along with regulatory requirements, there also is an increase in how government incentives are being allocated. Cities, utilities and states are considering requirements and incentives for building electrification. A good energy sustainability business plan will review these regularly.

• Analytical pitfall 6: Ignoring how projects impact other projects. One challenge is deciding how to move forward when presented with multiple project options. When there are relatively few options, and the options have little interplay, each project can be approved or denied separately. A challenge arises when projects have significant overlap. Therefore, hospitals should adopt the “prioritizing the highest value” method discussed in the sidebar on page 33. ■

 

 

Building automation expands for hospitals

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INFORMATION RICH // Metasys presents information from multiple building systems to help hospital facilities teams quickly identify and troubleshoot issues. Johnson Controls

BY NEAL LORENZI

Capabilities continue to grow while new applications multiply

Building automation system (BAS) providers are tasked with helping health care facilities find ways to reduce their costs, increase staff efficiency and provide secure operational systems, all while ensuring resiliency and redundancy.

Many challenges

Hospitals pose many challenges to BASs, ranging from external factors such as changing regulatory requirements to internal factors such as resource constraints and staff shortages.

Aging infrastructure, including outdated legacy system equipment, and slim profit margins mean that hospitals often lack both the digital and financial resources to support BAS initiatives, according to Drew Byrd, buildings segment leader at Schneider Electric, Boston . “A general lack of familiarity with the technology among even hospital information technology (IT) staff can create roadblocks for these deployments.”

Cybersecurity is another challenge. Security incidents can include data breaches as well as disruptions to IT operations and business functions. To combat this challenge, BAS providers must partner with hospital IT departments to understand their specific network facilities requirements, says Ken Gilbert, regional technical consultant for Automated Logic, Atlanta. “Hospitals should perform risk assessments with the assistance of BAS providers to make decisions on the network architecture and security controls, such as with defense-indepth and incident response plans.”

The growing number of smaller, off-site facilities poses additional challenges for BAS providers. Many smaller facilities lack technical support and, even when they are within the network of a larger care provider, they may not receive proper communications or support for installing new systems within their own facility. This also poses challenges when each of these off-site facilities is running different systems, which requires a central IT team to manage logistics.

Smaller health care facilities often have a limited number of spaces that need to act as multiuse areas — ranging from patient rooms to operating rooms to imaging rooms — and quickly adapt to serve various use cases. “A well-integrated BAS helps by providing the appropriate space conditions and lighting required for each use case,” says Robert Harland, Metasys brand manager at Johnson Controls, Milwaukee. “Also, these types of buildings don’t always have an experienced or fully dedicated facilities staff, so having remote access to these buildings is important.”

Many health systems are acquiring smaller health networks, resulting in a potpourri of BASs, according to Ayana Nathan, head of health care at Siemens Smart Infrastructure USA, Buffalo Grove, Ill. “Operationally, they have systems of various ages, little integration capabilities and limited remote access, coupled with staff shortages. Hospitals are looking for BAS providers to find innovative ways to help solve these challenges,” Nathan says. “Overall, it is difficult to find skilled facilities staff to manage these remote locations. This presents a challenge for BASs to support remote connectivity, which is difficult to achieve from a central location.”

 

article ImageTAKING CHARGE // Desigo CC with the Powermanager extension module allows facilities managers to promote actionable responses, simplify root cause analysis, and develop key performance indicators for tracking and reporting. Siemens

 

article ImageURGENT ACTION // EcoStruxure Building Operation provides actionable insights to better manage buildings, improve engineering efficiency, and meet cybersecurity and compliance demands. Schneider Electric

 

article ImageCOMPLETE CONTROL // The MyWay app provides a touchless experience for hospital staff to adjust room temperatures in real time. Automated Logic

 

Data collection

Data collection is a key component of the latest BASs. “Data collection provides the information needed to make thoughtful decisions about how to operate the physical plant to provide healing environments for patients in a cost-effective and sustainable manner,”

Gilbert says. “The ability to identify and detect trends in data streams frequently reveals outliers and anomalies that can impact operational costs or patient and staff comfort.”

The energy budget is one of the largest costs a facilities department must manage, Gilbert says. “Thus, it is important to be able to quickly identify deficiencies and mitigate the cost impact of nonperforming equipment or systems, and to create efficiency with the maintenance and contracting teams,” he says. “Being able to trend and record environmental and equipment operating characteristics over time provides a baseline from which future analysis can be predicated against.”

Harland says that data collection allows facilities managers to tap into the foundational role that a well-integrated BAS plays in a building management strategy. A BAS collects data from not only HVAC systems, but also from fire, security, lighting, and even business and specialty systems to make informed building management decisions.

“An effective BAS will present this data in a clear, intuitive way to identify issues before they become costly repairs; seamlessly connect with cloud-hosted analytics to turn data into insights and corrective actions; and support data searching and filtering required for various compliance reporting issues,” Harland says.

Data collection is essential to improving and refining BASs, and there are three areas where it is especially important , according to Byrd:

• Reliability-centered maintenance. Health care facilities need to prioritize their workforce and capital, and data helps to remove the added stressors of unexpected maintenance demands. By adopting more connected solutions, hospitals can regulate energy resources throughout the facility, which increases efficiency, sustainability and resiliency while providing cost-cutting opportunities that won’t affect patient satisfaction.

• Centralized control. An intelligent facility orchestrates all the critical data elements that are shared across equipment , and controls the facility holistically , to keep all of these operations organized and easily accessible in one location. By integrating connected technology systems, resources on both the IT and operational technology (OT) sides can be deployed efficiently.

• Better outcomes. Hospitals are focused on improving care for patients, and that extends to their facilities. Data on outcomes and trends analysis allow facilities managers to create strategies that improve patient safety. Interoperable BAS connectivity avoids the need to acquire systems from multiple vendors. A connected system with reliable data output simplifies regulatory compliance and improves financial performance, staff productivity, safety and security.

Expanding capabilities

BAS vendors have expanded their health care-related BAS applications and functions in recent years. For example , Schneider Electric has expanded its offerings to include BAS analytics to better monitor and diagnose problems in mechanical operations and then feed those insights into computerized maintenance management systems (CMMSs) to make improvements. “Our solutions facilitate the secure exchange of data from both Schneider Electric and third-party energy, lighting, HVAC, fire safety, security and workplace management systems while leveraging digitization and big data for greater visibility,” Byrd says.

Automated Logic continues to see an increase in the diversity of delivery models of care, especially in urgent care and localized health delivery services. In response, the company has expanded its distributed and cloud solutions for enterprise applications, along with remote site monitoring and analysis. “With an increased focus on indoor air quality (IAQ), we have seen a significant demand in technologies that can communicate IAQ posture to the patient and staff community ,” Gilbert says.

“These include touchscreen displays, innovative metrics and quick response (QR) codes that link to IAQ content, foster confidence in the healing environment and enhance patient outcomes,” Gilbert says. “These visualizations can be created and displayed on lobby kiosks, internet protocol links or patient devices. Machine learning and artificial intelligence (AI), along with rich analytic tool sets, allow us to monitor, report and use feedback and control loops that can act on environmental deviations.”

Siemens has expanded its BAS solutions for health care by creating more opportunities to satisfy more use cases with integrated data from operational and clinical systems. For example, its BAS solutions can give patients the ability to control their room environments and can integrate with smart beds to reduce the likelihood of patient falls. Siemens also has deployed solutions that reduce the impact of lighting on a patient’s circadian rhythm.

Health care offerings

Schneider Electric offers EcoStruxure Building Operation, a cloud-based BAS. EcoStruxure offers greater interoperability between systems running in health care facilities and allows field controllers to feed up to the cloud and reduce server loads. “It also provides access to building data anytime via smartphones, tablets or laptops; visibility into large campuses and global enterprises in one convenient view; and time- and labor-saving features ,” Byrd says.

Automated Logic has developed the MyWay mobile app, which extends the power of the WebCTRL BAS from the facilities manager to building occupants, putting them in control of their own comfort . The app is designed to provide staff with touchless entry at all security points, adjustment of room temperature and lighting scenes, and booking of conference rooms in real time. “Building occupants now can personalize and streamline their everyday experience in the buildings where they work,” Gilbert says. “From temperature control to conference room bookings, the MyWay mobile app empowers occupants by connecting them directly to their building environment.”

Johnson Controls offers Metasys Release 11.0, which includes a new fault detection and fault triage feature suite that identifies building system-related faults in order of severity, and provides suggested possible causes and corrective actions to help operators quickly identify and troubleshoot issues to keep systems running optimally and building occupants comfortable. It also features FIPS 140-2 Level 1 compliance for Metasys network engines and application servers, which provides a strong cybersecurity technique to help prevent unauthorized access to customer systems and data.

In addition, the expansion of the Metasys next-generation hardware platform includes a new supervisory network controller series model with an onboard interface. It gives operators the ability to quickly monitor equipment status, view alarms, see trends, issue overrides, and change setpoints and parameters.

Powermanager from Siemens is a Desigo CC extension module that delivers real-time monitoring and analysis throughout the electrical infrastructure of a facility. An extension module of the Siemens Desigo CC BMS, it integrates a building’s infrastructure and electrical monitoring into one system. This enables facilities managers to promote actionable responses, simplify root cause analysis, develop key performance indicators for tracking and reporting, and manage alarming.

Another upgrade, Siemens’ Desigo CC with Advanced HL7 integration capability , can help facilities managers reduce clinical workloads and improve operational performance. One example of this integration uses admission, discharge and transfer data to place patient rooms in occupied or unoccupied mode, which ensures consistent arrival experiences. It also can be used to incorporate surgical scheduling information, resulting in reduced clinical workloads and improved energy savings.

Technology moves forward

Byrd predicts that BASs will continue to see new advances in mobile applications and touchless communications options. This will make them faster and easier to operate in hospital environments, while minimizing contact and potential contamination.

For his part, Gilbert sees significant growth in digital services and the ability to aggregate massive data sets through machine learning and AI. “This will produce site-specific, innovative strategies that will mitigate waste, increase efficiency and extend equipment life cycles.”

BAS integration needs will continue to increase, Nathan says, resulting in more interaction and partnering with IT organizations . “To drive operational efficiency, there will be more integration between OT and IT systems, expanding the ability to integrate and manage more operational components of the hospital.”

Harland notes that a more cyber-secure version of BACnet was recently approved. “This version will gain more popularity in BAS device networking applications in hospitals.” HFM

 

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Neal Lorenzi is a Mundelein, Ill.-based contributor to Health Facilities Management.

 

Compliance help for ASHE members

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BY FRANK D. RUDILOSSO

Member tools task force offers resources for health care facilities managers

 

The American Society for Health Care Engineering (ASHE) represents professionals who design, build, and operate hospitals and other health care facilities.

The ASHE advocacy team monitors and works to unify the overlapping codes and standards regulating the health care physical environment. Revamping codes and reducing code conflicts allows health care facilities to optimize their physical environments and focus more of their valuable resources on patient care.

The ASHE team also advocates for ASHE members through professional development and credentialing opportunities as well as providing up-to-date tools and resources to help keep health care facilities in compliance.

Because the wide range of codes and standards regulating health care facilities is complex and often difficult to understand even for experts, ASHE members are likely to need some help keeping pace with the quickly evolving regulations.

To assist, ASHE established a member tools task force (MTTF) to evaluate the compliance issues most important to members and create online tools accessible on the ASHE website and discussed in a series of articles in Health Facilities Management (HFM) magazine. The MTTF is a group of knowledgeable ASHE members who create and develop content and tools as resources for the ASHE membership.

Historical roots

In 2015, ASHE collaborated with The Joint Commission (TJC) to provide resources and tools to help hospitals comply with life safety and environment of care requirements. TJC identified its top eight physical environment standards that were frequently cited during surveys of hospitals and other health care facilities , which included the following:

  • Utility systems (EC.02.05.01).
  • Means of egress (LS.02.01.20).
  • Built environment (EC.02.06.01).
  • Fire protection (EC.02.03.05).
  • General requirements (LS.02.01.10).
  • • Life safety protection (LS.02.01.30).
  • Automated suppression systems (LS.02.01.35).
  • Hazardous materials and waste management (EC.02.02.01).

Through their collaboration, ASHE and TJC provided resources that helped health care facilities managers keep their organizations in compliance with these challenging standards. TJC created an online physical environment portal to house its resources related to these issues. Additionally, ASHE developed a website called “Focus on Compliance” that included tools, best practices and technical documents.

Each year, TJC identifies the top physical environment standards frequently cited during surveys while ASHE looks for ways to assist organizations to continue to drive for compliance. And, each year, ASHE selects hot topics in the health care physical environment and supports the development of tools and articles written by members, for members.

MTTF growth

Formed in 2017 as a spinoff of Focus on Compliance and a result of the merger between ASHE and HFM, the MTTF has expanded its library of tools and resources . At its start, the group used ASHE’s top 20 advocacy topics, then decided which issues would be addressed through the task force. Once those topics were finalized , the task force identified subject matter experts to author articles and develop related tools.

In late 2021, the MTTF leadership team put together a survey to collect topics , which were evaluated by the ASHE regulatory affairs committee, advocacy liaisons and MTTF members at the annual planning meeting to identify top areas of concern for the health care physical environment. What started in 2017 as a discussion of 20 topics has ballooned to the most recent review of 86 topics that were submitted by ASHE members.

Each year in October, the MTTF leadership team holds the annual MTTF planning meeting in conjunction with ASHE advocacy and sustainability liaison training . The purpose of the planning session is for the MTTF to prioritize the topics submitted for the following year to determine the top 30 that would become articles . Some topics are combined, as they could be included in the same article.

Further meetings are held to establish the final top 30, and discuss combined topics, volunteer assignments, article types, tools to be included and the article schedule. Each year the process becomes more refined, with an increase in the number of articles written and tools developed.

A full-length article consists of 2,000 words in addition to a 300-word sidebar article for a total article length of 2,300 words; a short article consists of 350 words and a tool; and an advocacy column is a 350-word piece.

The MTTF, holds monthly meetings to review schedule deadlines, discuss comments on draft articles and provide feedback on proposed tools.

The process continues to grow and evolve. The use of Smartsheet for tracking article and tool deadlines, content and task force comments has eliminated the need for sending and tracking emails. In addition, the use of Smartsheet automation features for reminders has allowed the task force to focus more time on reviewing content and tools.

Previously, eight of the top 10 TJCcited standards centered on the physical environment. However, for 2020 (last year of full data), there were only three in the top 10: EC.02.05.01, EP 15; EC.02.06.01, EP 1; and EC.02.02.01, EP 5. The three that remain were in the top 10 in 2014, so the field still has work to do. However, there have been tremendous accomplishments that are proven by the reduction in the physical environment standards in the top 10.

 

article ImageA year-by-year look at MTTF articles published and tools developed since 2018.

 

article ImageAn example of a short MTTF article (in the foreground) and an excerpted partial image of the tool to which it links (in the background).

 

Sample topics

Following are just a few of the more than 80 articles and 40 tools developed by ASHE through the MTTF that can be accessed at ashe.org/mttf:

• Complying with door locking requirements. Decoding requirements of the 2012 Life Safety Code and the 2018 International Building Code.

• ASHE e-tool brings clarity to life safety risk assessments. A matrix helps to determine physical environment risk tolerance and document necessary interim life safety measures (ILSMs). Available tool: Life Safety Risk Assessment Tool, a matrix of risk tolerance, allows a health care organization to document the severity of occurrence and the impact of a deficiency. By cross-analyzing these factors, whether the deficiency has the potential to cause major injury or death and whether it is facilitywide or a short duration, the organization can determine if the deficiency is a high, medium or low risk, or whether no ILSM is required.

• Tracking and documenting physical environment compliance. How to prepare for accreditation surveys well ahead of time. Available tool: Environment of Care Documentation Checklist.

• Demystifying life safety decommissioning processes. Help to clarify which life safety features are no longer required and can be removed. Available tool: Life Safety Decommissioning Tool breaks down several life safety features no longer required by code, as well as recommendations to either decommission or maintain these features.

• Maintaining safety of holiday décor. Tips for health care facilities managers on maintaining physical environment compliance during the holiday season. Available tool: YouTube video, “How the Safety Guy Made the Holidays Safer.”

Those responsible for the hospital’s environment of care may dread the winter holiday season. It is the time of year in which wanting to celebrate and decorate for the season often clashes with the rules and regulations that facility and safety staff are responsible for upholding. The video teaches facilities managers to work with hospital staff members to ensure a joyous — and safe — holiday season.

• Handling indoor air quality concerns. A layered approach to ensuring safety moves from design and installation to routine hazard surveillance. The performance of hazard surveillance rounds, as it relates to indoor air quality (IAQ), provides a key opportunity to identify IAQ issues. Available tool: The Indoor Air Quality Checklist Tool can be used to supplement hazard surveillance rounds and incorporate items related to IAQ.

• Readiness for accreditation surveys. A health care facility perspective on managing the accreditation process. Available tool: The Survey Guide for Internal Mock Audits, including TJC standards and elements of performance.

• Varying time for fire drills. A hospital fire drill matrix that assists code compliance. Available tool: ASHE has updated its Fire Drill Matrix Tool to reflect new interpretation and knowledge of fire codes. Facilities must meet the +/- 10-day criteria per the quarterly fire drill requirements; locations and device types must be different ; certain locations must be specifically considered; and they must ensure they are covering doctors, transient staff and others. MTTF modified the Excel version of TJC’s fire drill matrix planning tool to automatically turn cells red if the proposed drill does not meet the time criteria.

• Water management plan action levels. Developing a water management plan of action. Available tool: “Water Management in Health Care Facilities: Complying with ASHRAE Standard 188” provides guidance on ASHRAE Standard 188 compliance and Legionella risk management . This monograph offers a summary of the threat of legionellosis; gives an overview of ASHRAE 188 requirements ; outlines recommended steps for compliance, including the creating of an overall water risk management plan; addresses maintenance procedures, monitoring strategies and emergency responses ; and provides additional information on potential pathogens and possible response methods.

 

article ImageA list of MTTF articles planned for 2022.

 

• Operating room temperature/ humidity code variations. Managing operating room temperature and humidity. Available tool: An ASHE advocacy video offers clear understanding of minimum relative humidity requirements. This training video provides a brief explanation on how temperature and relative humidity affect one another.

• The definition of “monthly.” Advice on dissecting the definition of monthly compliance. When it comes to life safety frequencies, each inspection, testing and maintenance (ITM) preventive maintenance (PM) task is very well defined. Carrying out these ITM PM tasks per defined methods and at defined intervals is crucial for establishing and maintaining compliance. A number of these tasks are required monthly. Available tool: A helpful table provides monthly tasks necessary to stay in compliance.

• Clear interpretation of special locking. Designing and installing new special locking arrangements can be challenging, and assessing existing locking arrangements for compliance is often even more challenging. Available tool: The Special Locking Arrangement Worksheet tool was developed to assist in designing and documenting special locking arrangements.

• Managing nitrous oxide use outside the operating room. Help in managing the increased use of portable nitrous oxide systems. Available tool: ASHE created a tool to help users perform a risk assessment and develop a safety protocol to manage nitrous oxide use outside the operating room.

• Risk assessment for eyewash stations. Taking a good look at eyewash station requirements. Available tool: Risk assessment template that can help to determine when and where to place eyewash stations in health care facilities.

• Master planning to secure funding. Creating an easy-to-follow health facility master plan dividing spaces into subcategories can help to make the master planning process more manageable. Available tool: Sample facility master planning outline breaking a health care facility into subcategories can help to simplify the master planning process. This outline provides a list of subcategories that organizations can use as a starting point as they customize their own plans.

• Plant operations and maintenance labor recruitment, training and continuity (retention). This article is for labor recruitment, training and continuity , and integrating training into staff culture to help with job satisfaction and operational continuity.

• Maintaining life safety drawings. Life safety drawing updates and accuracy are keys to managing living documents and successfully performing facility inspections. Available tool: A sample drawing showing the required life safety building features.

Educating and engaging

ASHE members can access MTTF’s growing roster of articles, spreadsheets, tools and other resources at ashe.org/mttf. These include an increasing number of videos that are related to codes and standards compliance.

Additionally, ASHE members can download numerous compliance tools that were developed independently of the MTTF by ASHE staff, volunteers and partners at ashe.org/tools. These include handbooks, guides, books, videos, monographs, spreadsheets and more. Titles include Developing Code-Compliant Integrated Fire Protection and Life Safety Inspection, Testing and Maintenance Programs ; Introduction to Health Care Facilities Management; Resource Scheduling Tool; Infection Control Risk Assessment Guide 2.0; Health Care Facility Manager Guide to Smoke Control; Sustainability Guide; and Health Care Facilities Management Data Nomenclature Standards, among others.

Along with educating ASHE members, these compliance resources promote engagement with the code process, which can sometimes feel overwhelming . Designed to be easy to follow, the resources provide education, guidance, code interpretations and tools that support the implementation of solutions and processes. HFM

 

 

article Image

Frank D. Rudilosso, PE, CHSP, SASHE, is director of facilities regulatory readiness, NewYork-Presbyterian Hospital, New York City. He can be reached at frr9035@nyp.org.

 

Volunteering for MTTF and other ASHE programs

American Society for Health Care Engineering (ASHE) volunteers play an important role in helping the organization to move forward on various initiatives that support the mission of optimizing the health care physical environment. Getting involved in volunteer work can provide personal and professional rewards.

In the case of the member tools task force (MTTF), volunteers can author, co-author and/or provide much-needed feedback and comments on articles and tools drafted by the MTTF. This can be helpful for those looking to apply for a Senior ASHE (SASHE) or Fellow ASHE (FASHE) designation. One of the requirements under publishing is to write articles published in a national magazine and/or journal specific to the health care engineering or facilities management field. Volunteering with MTTF and writing a full article can help meet this requirement.

Those interested in volunteering for the MTTF should reach out to ASHE’s Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, senior associate director of advocacy, at jflannery@aha.org. Additionally, those interested in volunteering for other ASHE projects should go to ashe.org/volunteer to reap the personal and professional benefits volunteering can provide. ■

 

article ImageASHE’s top 10 most downloaded compliance tools with MTTF tools highlighted in blue.

 

ABOUT THIS ARTICLE

This is one of a series of monthly articles submitted by members of the American Society for Health Care Engineering’s member tools task force.

 

Developing an EVS compliance plan

Article header image here

BY LLOYD DUPLECHAN

Using accreditation requirements as a template for a program

 

It ’s no secret that the health care field is rigorously regulated. It is incumbent upon the effective environmental services (EVS) manager to continually demonstrate compliance with a plethora of ever-changing laws, codes and standards.

Hospitals are responsible for ensuring their programs satisfy practically every legal provision or risk running afoul of the regulatory community (e.g., Centers for Medicare & Medicaid Services [CMS] 42 Code of Federal Regulations [CFR] §482.11, TJC LD.04.01.01).

Statutes, regulations and standards provide the foundation upon which quality health care is built, and beneath which no program should fall.

Compliance challenge

In the words of Charles Kettering, former head of research at General Motors, “A problem well stated is half solved.” So, simply put, the challenge of compliance is developing a program designed to essentially manage practice and operations in a manner prescribed by or conforming to the law.

To help frame a general structure that can reinforce an effective compliance program, EVS managers should consider borrowing the basic outline that underpins The Joint Commission’s (TJC’s) Environment of Care (EC) standards chapter, which includes (EC 1) planning (including risk assessments, policies, plans and evaluations ); (EC 2) program implementation; (EC 3) staff training; and (EC 4) monitoring , performance improvement and statistical analyses.

Planning considerations

The first signpost on a compliance journey is developing a sound plan. It’s impossible to play a sport without knowing the playing field and the rules. Thus, it is imperative that EVS managers become familiar with statutory, regulatory and standards-based requirements.

It is important to understand that the thousands of pages of rules, regulations and standards were penned by different people at different times, often to solve different problems. This can create frustrating overlaps, inconsistencies and gaps.

Before managers attempt to carve through the inextricable kudzu of words and esoteric parlance of the legal provisions , they should seek first to understand the intent of these provisions.

This should allow for a deeper level of understanding of the “why,” recognition of levels of risk and priority, a better blend of the provisions and a more pragmatic approach.

Within this context, managers can consider the following six habits of getting to the intent of legal language:

1. Pay attention to TJC’s rationale and icons.

2. Read the appendices and annexes (e.g., the National Fire Protection Association ’s NFPA 101®, Life Safety Code®).

3. Pay attention to the applications and scope as well as exceptions and exemptions.

4. Study the Conditions of Participation regulation’s supplemental interpretive guidelines and CMS survey procedures.

5. Invest in regulatory handbooks.

6. Assiduous managers also may want to research preambles, congressional or legislative findings, House of Representatives and Senate bill introductions, and historical language.

EVS managers at TJC-accredited facilities should pay particular attention to TJC’s rationale, which is furnished at the beginning of the standard. It provides additional background, justification and text that describes and explains the purpose of the requirement.

TJC chapter structure also provides icons that accompany the standards, particularly specific standards that require a document are demarcated with an encircled letter “D” icon positioned to the immediate left of the element of performance (EP).

As part of the compliance program risk assessments and establishment of priority, TJC’s current National Patient Safety Goals® (NPSGs) should not be overlooked. Each year, TJC collects “… information about emerging safety issues from widely recognized experts and stakeholders …” This forms the basis for the NPSGs, which are tailored for each specific program.

This pre-planning exercise is designed to group the various codes and standards by subject matter buckets to find common themes and overlaps. For example, the intent and objectives of certain codes pertaining to cleaning can be the maintenance of a sanitary environment, infection prevention and patient safety, proper waste management and worker safely.

Within these subject matter buckets, EVS managers should place the enforcement agencies and governmental organizations , and associated regulations and standards. Common examples include:

• The management of waste. This includes how the Occupational Safety and Health Administration (OSHA) addresses worker safety as it pertains to managing red bag and sharps waste within the bloodborne pathogen regulation (29 CFR 1910.1030); the Environmental Protection Agency (EPA) regulates the management of regulated chemical waste and solid municipal wastes as it pertains to the environment under parts D and C of the Resource Conservation and Recovery Act; and applicable Department of Transportation (DOT) regulations pertain to the packaging of regulated medical waste (49 CFR §173.197).

• Infection prevention. By reference, CMS recognizes and expects EVS programs to conform to organizations and agencies such as the Association for the Advancement of Medical Instrumentation ®, Association of periOperative Registered Nurses (AORN) and the Centers for Disease Control and Prevention (CDC). Within the interpretive guidelines of 42 CFR §482.42, there is an expectation that hospitals develop and implement hospitalwide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines.

Overlapping and common thread topical themes should almost organically manifest themselves to the EVS manager working through this exercise. They should consider connecting the dots by using a crosswalk linking agencies and standards organizations such as TJC, OSHA, EPA, CDC and AORN to each general subject as illustrated on page 46.

EVS managers should identify and evaluate risks to understand not only potential hazards and deleterious conditions but, from a compliance perspective, current governmental priorities, agency enforcement schemes and liability risks.

TJC’s EC.02.01.0, EP 1, note states that risks may be identified from “… credible external resources such as Sentinel Event Alerts.” According to TJC literature, Sentinel Event Alerts “…identify specific types of sentinel and adverse events and high-risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes.”

In any health care institution, EVS plays a pivotal role in infection prevention and safety in the patient care environment . According to the CDC, hospitals should integrate EVS into the hospital’s safety culture.

Thus, EVS managers should develop management plans, policies and procedures from a platform of interdependence and teamwork to address risks and frame management systems. This includes identifying standards and setting specific protocols for cleaning and disinfection, including the use of technologies and products (per the CDC).

Additionally, using the crosswalk ensures that these standardized policies and procedures align with applicable standards, such as the fundamental EC.02.06.01, EP 20, areas used by patients are clean and free of offensive odors; and IC.02.01.01, EP 6, the hospital minimizes the risk of infection when storing and disposing of infectious waste (also see OSHA 29.CFR §1910.1030).

EVS managers should consider cross-referencing applicable laws and standards within the reference section of the policies and procedures. This goes a long way toward showing surveyors that the department’s policies are in lockstep with their requirements.

 

article ImageA crosswalk can connect the dots by linking agencies and standards organizations to each general subject.

 

One of the basic principles of a high-reliability organization is “deference to expertise.” In light of this, EVS managers should strongly consider involving frontline EVS staff in the development and/or review of policies.

Implementation steps

EVS managers should institute programs and procedures that are predicated on principles and strategies gleaned from the various agencies and standards-based organizations, such as the CDC’s Guidelines for Environmental Infection Control in Health-Care Facilities.

Within this literature, the CDC recommends that strategies for cleaning and disinfecting surfaces in patient-care areas should consider potential for direct patient contact, degree and frequency of hand contact, and potential contamination of the surface with body substances or environmental sources of microorganisms (e.g., soil, dust and water).

The implementation of the EVS compliance program is the nexus of continuous compliance efforts, where the program must delve into the details and get granular to better ensure alignment with requirements. Once intent of the law and standard is discerned, and policy is structured by subject matter similarities and common thread themes, the next signpost is to implement the directive of policy statements and standardized instructional protocols and practices that are in lockstep with the prescriptive details of mandates and literature. This is where the program literally defines compliance : conformity in accordance with rule or order.

Developing checklists and critical task lists are essential to ensuring standardized and consistent processes, minimizing variation and driving accountability.

One example of program implementation that matches rule and order is where the CMS survey procedures for 42 CFR §482.42 instructs surveyors to “…. observe the sanitary condition of the environment of care, noting the cleanliness of patient rooms, floors, horizontal surfaces, patient equipment, air inlets, mechanical rooms, food service activities, treatment and procedure areas, surgical areas, central supply, storage areas, etc.” Given this, the EVS manager would be advised to make every effort to implement inspection check sheets that specifically address patient rooms, patient equipment, procedural areas, sterile supply and food services.

Managers should ensure the implementation of policies and procedures designed to address employee worker safety in accordance with OSHA regulations and applicable accreditation standards. At the very least, EVS compliance policies should incorporate the following OSHA requirements:

• Bloodborne pathogen safety and regulated waste handing (29 CFR §1910.1030).

• Personal protective equipment regulations (29 CFR §1910.132).

• Respiratory standard (especially in light of the pandemic) (29 CFR §1910.134).

To help prepare for the actual survey or agency site visit, EVS managers should create a compliance-evidence binder to assemble, organize and house critical compliance documentation such as staff training sign-in sheets, competency evaluations , policies, permits and certifications , and completed plans of correction from previous surveys.

Training staff

The next step is providing education, orientation and training based on policy, procedure, plans and needs assessments (i.e., making sure staff is packing the right gear). Some, such as the details of required DOT training for EVS staff managing regulated waste and/or tracking documents, can be easily overlooked.

Staff training should address the following required elements according to 49 CFR §172.704:

• General awareness/ familiarization training.

• Function-specific training.

• Safety training.

• Security awareness training.

• In-depth security training.

Additionally, EVS managers should document staff competency assessments in accordance with TJC’s HR.01.04.01, EP 1: “Staff participate in ongoing education and training to maintain or increase their competency…” Examples include the process of terminal cleaning, patient room turnover and operating room cleaning between procedures and terminal cleaning.

Monitoring compliance

Finally, performance monitoring includes assessments, performance improvement, statistical analyses and follow-up. To help implement verification procedures designed to enable EVS managers to monitor compliance, managers should simply inspect what they expect; in other words, round the floors and units with a view to validate compliance with policies , regulations and standards, as well as identify any discernable gaps or opportunities for systematic improvements.

During rounding and huddles, EVS managers should take the opportunity to directly observe and verify compliant practices and ask questions related to policy and standardized work processes conducive to consistency, safety and compliance.

EVS managers should actively participate in the facility’s EOC committee and make every effort to utilize the proper statistical analysis tools and methods to demonstrate identifying and taking action to improve the environment. Evaluations of EVS compliance programs should be data driven, illustrate trending analysis over time and determine whether things are getting better, worse or staying the same.

As part of the periodic performance reviews, EVS managers should provide feedback on adequacy and effectiveness of cleaning and disinfection to all responsible health care professionals as well as relevant stakeholders (e.g., infection control and hospital leadership) per the CDC.

EVS managers should present data to their personnel regarding their adherence to cleaning, disinfection, infection prevention and safety procedures by determining the best method to clearly disseminate the information and foster shared accountability. HFM

 

article Image

Lloyd Duplechan is CEO of Duplechan & Associates Healthcare Consulting and a retired hospital COO. He can be reached at duplechanlloyd@gmail.com.

 

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