TO KEEP PATIENTS, STAFF, AND VISITORS SAFE, hospitals rely on multiple layers of regulations, including codes and standards like those created by NFPA. But the codes used within those various regulatory layers can grind against each other in a variety of ways, a process that can impact a hospital’s operations, including patient care.
Codes that are adopted or made compulsory in a jurisdiction, for example, can contain provisions that differ and sometimes conflict. Additional friction is created when the adopted codes are not the most recent editions of those documents, or if the provisions in those codes are not based on the most recent information related to patient care.
These problems can end up affecting a hospital’s bottom line. Contrary to popular belief, hospitals do not make money hand over fist; according to the American Hospital Association, the average operating margin for a hospital in the United States is 5.5 percent—essentially, 94.5 cents of every dollar earned is spent on direct care to the patient, leaving 5.5 cents available for unanticipated costs and future capital projects. To keep their doors open, hospitals depend on insurance program reimbursements from payers such as the Centers for Medicare & Medicaid Services, or CMS, the federal agency that administers health care financing.
CMS requires health care facilities to comply with an array of regulations to be eligible for reimbursements, which is where hospitals’ slim operating margins can have broad consequences. An unanticipated regulatory expense, such as one actually cited in a jurisdiction—requiring the facility to patch and repair thumb-tack holes in barriers because they were perceived as a penetration, which is a code violation—may cost little to fix; hiring a contractor to repair every wall would cost somewhere around $7,500. Most hospital administrators would not consider that amount worth arguing over with the authority having jurisdiction (AHJ), and would simply proceed with the repairs. But to recover that unanticipated $7,500 cost, the facility would need to bill more than $135,000 in services. Bit by bit, the pressure on the bottom line builds.
Health care regulations need not be tectonic, the layers struggling against one another as we hold our breath, awaiting some cataclysmic boom. Efforts are underway, for example, to address how health care codes work with each other, including reducing the number of regulatory layers and streamlining how codes evolve from edition to edition. Organizations, including NFPA, are undertaking campaigns to educate stakeholders on the value of using the most recent editions of codes, and users are helping initiate research efforts that are resulting in code changes based in the latest science, trends, or care models. With these goals in mind, the overall health care regulatory process can run smoother and have a positive impact on patient care.
The problem of differing or conflicting codes
Codes developed by organizations such as NFPA and the International Code Council (ICC), as well as documents created by related organizations like the Facility Guidelines Institute (FGI), do not set out to create regulations that conflict with one another. For decades, though, numerous codes have been used in the regulation of the health care environment, including some focused on building requirements and others focused on life safety, and by developing codes separately, conflicts have occurred.
By reducing the code conflicts that can occur between documents developed by different organizations, however, hospitals can free more resources to devote to their core missions related to patient care. The organization that I’m a part of, the American Society for Healthcare Engineering, or ASHE, does not advocate the consolidation of various codes into a single master code. Rather, our organization is working to change aspects of the various documents that affect the health care environment so that they are not in direct conflict.
The committees that develop these codes each have expertise that help determine the scope of the regulation. Who knows better about installation requirements for electrical systems, for example, than the members of theNFPA 70®, National Electrical Code® (NEC), committee? Who knows better about designing and the desired performance of electrical systems in health care than the members of the NFPA 99, Health Care Facilities, committee? Who knows better about the best way to protect the patients and staff than the NFPA 101®, Life Safety Code®, Technical Committee on Heath Care Occupancies? And who knows better about the quantity of devices and the access to equipment than the clinical members on the FGI committee?
But codes developed by the same organization can have their differences, too. Newer editions of codes written by an organization will naturally contain different requirements compared to older versions, and codes written by different organizations can conflict with each other. This can lead to rather striking problems. For example, before the first patient enters, a new, state-of-the-art hospital built to comply with the latest local building codes may have to spend hundreds of thousands—if not millions—of dollars rebuilding and making changes in order to comply with previous editions of codes that are still mandated for use at the federal level.
Many people involved with the committees realize that there needs to be more clarity about the jurisdiction and scope of their work. Task groups formed by ASHE have recently begun working more closely together to help prevent, or at least minimize, code conflicts between NFPA, FGI, ICC, the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), and many others.
For example, NFPA 99 sets the performance requirements for electrical systems in health care facilities, and most of this information is repeated in the NEC, which sets all the installation requirements. Regarding essential electrical systems, the specific performance requirements are outlined in NFPA 99; installation requirements can be found in the NEC; and NFPA 110, Emergency and Standby Power Systems, contains the general requirements for emergency generators. NFPA 99 includes requirements for the installation of nurse call and information technology systems, while the FGI guidelines include requirements for both systems, which explains the push to make these two documents consistent with each other. It takes all of these documents working together to complete the package.
With more and better coordination, we can avoid or at least minimize these conflicts. For example, CMS proposed its own emergency preparedness standards at the end of 2013, and many stakeholders encouraged the agency to rely on NFPA 99 instead. By adopting the emergency preparedness chapter in NFPA 99 instead of creating new regulations, CMS would be streamlining the number of codes regulating hospitals and preventing potential conflicts. As this issue of NFPA Journal went to press, CMS had not yet issued a final rule on emergency preparedness.
The New NFPA 99
Risk-based approach puts a new spin on a familiar health care document.
- NFPA Journal looks at NFPA 99, Health Care Facilities, and the changes in the 2012 edition of the document, which moved toward a more risk-based approach.
Read more on the new spin on NFPA 99.
The problem of outdated codes
In addition to conflicting codes, hospitals also face issues in trying to comply with older editions of codes. Codes regulating the health care physical environment are updated every three to four years. Some states have adopted legislation that automatically requires hospitals to comply with the latest versions of required codes, while others revisit legislation periodically and update to newer versions. Some states have started skipping revision cycles, adopting every other new edition, which means that codes reflecting new safety and technological advancements may not be adopted for eight years or more.
Adopting new codes and standards as they are released is important. A code written in 2000 may not seem that old, but it was written before lessons were learned from pivotal events, including the 9/11 terrorist attacks in 2001 and Hurricane Katrina in 2005. Adopting new editions of codes is critical to promoting safety and reducing waste in hospitals.
Waiting to adopt updated codes poses other problems, as well. An updated code may include only a few differences from the preceding edition, but waiting for years to adopt new codes means the number of changes can pile up, making it more difficult to train both code enforcers and those in hospitals responsible for compliance.
Codes also tend to reference other codes and standards, meaning that health care facilities are stuck using older codes in many areas. For example, the 2000 edition of the Life Safety Code references more than 50 other technical codes and standards. Hospitals really have no choice but to use reference codes from as far back as 1995 because they are mandated by the 2000 edition of the Life Safety Code, the edition which is still required by CMS.
Using these older editions of the codes is especially problematic given the speed of advances in safety and technology in recent years. The widespread adoption of non-smoking policies, a variety of code advancements, and other efforts have led to tremendous progress in lowering the number of hospital fires. Older editions do not necessarily reflect the technical advances behind these trends. A significant benefit of adopting newer codes is that they can also contain fewer conflicts with other codes. For example, the ICC Codes have made progress to more closely align with the 2012 edition of the Life Safety Code.
One promising development in the push for updated codes was the recent formation of the Coalition for Current Safety Codes, or CCSC. Founded by NFPA and ICC, the CCSC is a broad-based coalition of nonprofit organizations, code officials, industry leaders, local governments, and others who believe that the use of more up-to-date codes advances safety. ASHE, a member of the Coalition, works on several fronts to encourage the adoption of updated codes and standards. ASHE works closely with CMS, providing information about the advantages of updated codes and the importance of staying up-to-date. ASHE has encouraged CMS to adopt the 2012 edition of the Life Safety Code, for example. At press time, CMS had not issued a final rule on the adoption of that edition.
The need for science-based codes
Another problem with codes regulating health care is that not all of them are based on scientific data. Code requirements are created with the knowledge developers have at the time, but as more scientific and clinical data are gathered, codes must be revisited or they risk becoming outdated and no longer based on the best information available.
The importance of these data can be seen in several codes. For example, the 2013 edition of ANSI/ASHRAE/ASHE Standard 170, Ventilation of Health Care Facilities, a document maintained by ASHE, the American National Standards Institute (ANSI), and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), previously required hospitals to maintain a 35 percent minimum relative humidity (RH) level in operating rooms. In some hospitals, creating and maintaining this level of humidity was expensive, and studies were undertaken to determine whether clinical benefits were obtained by meeting this requirement. A literature search by the National Institutes of Health determined that, in fact, no clinical benefits were obtained, prompting an ASHRAE Project Committee to revise the standard to a 20 percent RH for operating rooms. Other organizations such as the Association for the Advancement of Medical Instrumentation (AAMI) are looking into the performance of certain types of medical equipment at the lower RH levels; AAMI recently reported that certain types of anesthesia equipment, as well as autoclave equipment used to sterilize medical instruments, may not work as intended at those lower humidity levels.
Another example of the importance of science-based codes can be found in smoke compartment size requirements for hospitals. Hospitals are separated into compartments using smoke barriers to limit the number of patients exposed to the effects of a fire. The NFPA Technical Committee on Health Care Occupancies first looked at the distance occupants might have to travel within a compartment affected by smoke to reach a smoke-free compartment. The long-accepted, 150-foot (46-meter) maximum travel distance in a nonsprinklered health care occupancy served as a conservative starting point for discussion. Compartment dimensions of 150 feet long by 150 feet wide were used to establish a maximum compartment size of 22,500 square feet (2,090 square meters). The 1991 edition of NFPA 101 allowed the travel distance to reach another smoke compartment to be increased from 150 feet to 200 feet (61 m) while still maintaining the 22,500 square foot limit. In recent years, the previously mentioned FGI Guidelines recalibrated a fundamental patient care philosophy so as to mandate single patient rooms.
The days of semiprivate rooms with two or three patients per room are being phased out, however, as new hospitals are designed and as existing facilities undergo major renovations. Using the FGI single-bed philosophy, ASHE studied typical patient care floor programs and the space requirements to deliver optimal patient care. The desire to increase the smoke compartment size addresses the ability to limit the movement of hospital staff within the unit, provide staff support areas in a centralized manner, and aid in effective horizontal movement during an emergency. A typical 18-bed unit requires a little over 35,000 square feet (3,252 square meters) to accommodate the average functional program. This change has prompted the technical committee to reevaluate smoke compartment size. Deliberations on nearly doubling the compartment size to 40,000 square feet (3,716 square meters) took place during the revision cycle that produced the 2015 edition of NFPA 101. The proposed change was defeated by the membership and returned to the committee. (See “Input Wanted,” the NFPA 101 piece in this issue’s “In Compliance” department) The technical committee is expected to revisit the subject later this year when it begins its work on the 2018 edition. Connecting NFPA 101 hospital design to FGI Guideline criteria, where the number of patients on a given floor is potentially halved, can provide the science-based justification for larger smoke compartments.
Taking these steps—revising code provisions to more easily harmonize changes between editions, adopting the most up-to-date editions of codes, and basing those codes on the science of patient care—will allow us to reduce waste in hospitals and free up resources for patient care. After all, the construction and operation of health care facilities is an expensive endeavor. Many of those expenses improve patient care and occupant safety, but there remain a number of requirements that either no longer have value, since technology has changed, or in some cases do more harm than good.
Providing a health care facility that offers a careful balance between enough passive fire protection, but not so much that it begins to hinder patient care without markedly improving safety, is a difficult task. The consensus-based committee structures of codes developed by organizations like NFPA can help foster an environment where these issues can be carefully and thoughtfully examined. But the work doesn’t just rest on the committees—it takes input and feedback from everyone.
There is a still lot of work to be done, but by working together on these issues, we can continue to make progress.