Historically, NFPA 99, Health Care Facilities, has been the go-to document to help establish the electrical system, medical gas piping system, emergency management, medical equipment safety, and planning concepts for the delivery of health care. Its rules, like those in most NFPA codes and standards, were couched in prescriptive rules and language for the various health care occupancies. But the 2012 edition of NFPA 99 changed that perception as it moved to a risk-based approach.
The current edition represents an important and fundamental shift in the way health care facilities determine which level of safety provisions apply to which situations. Understanding the move from an occupancy-based approach to a risk-based approach is key to successfully applying NFPA 99.
Previously, NFPA 99 applied different requirements based on occupancy type, such as hospitals or outpatient facilities. The 2012 edition moved to a risk-based approach to systems and equipment that has the same requirements for a procedure no matter where it takes place. This approach focuses on the potential risks to patients and staff and allows hospitals to focus safety provisions in areas where they are needed—putting money where the risk is. To use the new risk-based system, familiarity with the procedures and services that support those procedures will be imperative, as will decisions by the facility administration on the risk level they are willing to take.
This new approach provides more flexibility in the design of health care facilities while maintaining the same, if not an increased, level of safety. Many facilities currently have spaces that, simply because of the titles applied to particular rooms, are required to have systems that will never be used. For example, a room labeled as “surgery” in a clinic that only performs Mohs surgery—a micrographic surgery used to treat skin cancer—will have unnecessary requirements. During Mohs surgery, layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains, and the majority of the time in the room is spent examining the removed skin for cancer cells. Previous codes would require the installation of expensive, underutilized medical gas and HVAC systems to create what some would consider a very expensive waiting room. Given the new risk-based approach, the facility can determine that there is no risk of death or injury should a medical gas or HVAC system fail in this space, and therefore more routine systems can be provided.
Other sections of the code apply to all health care facilities regardless of risk, such as the security and fire protection needed in all facilities. Systems and equipment in health care facilities will fall into one of the following four categories based on risk:
Category 1: Facility systems in which failure of such equipment or system is likely to cause major injury or death to patients or caregivers shall be designed to meet system Category 1 requirements as defined in the code.
Category 2: Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in the code.
Category 3: Facility systems in which failure of such equipment is not likely to cause injury to the patients or caregivers but can cause patient discomfort shall be designed to meet system Category 3 requirements as defined in the code.
Category 4: Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in the code.
The risk-based approach may seem more complex than an occupancy-based approach, but the steps to carry out the new NFPA 99 risk models are straightforward: determine what the room, space, or equipment is used for; determine the risk to the patient; select the appropriate risk category; and select the systems or procedures in the code that are prescribed for that risk category.
This process applies to all aspects of health care facilities covered by NFPA 99. This includes spaces such as operating suites and med-surg floors. Risk assessments also cover medical gas systems, HVAC components, plumbing, electrical systems, and communication/information technology systems.
Risk assessment tools can help health care facilities keep track of the risk categories for a vast array of spaces and equipment. For example, my organization, the American Society for Healthcare Engineering, created a Microsoft Excel-based risk assessment tool that tracks equipment, system, and emergency management risk categories. The tool is available at the American Society for Healthcare Engineering's homepage.