Navigating code conflicts in health care facilities

Codes and standards do not always align. For example, both the 2012 edition of the National Fire Protection Association’s NFPA 101^®, Life Safety Code^®, and the 2012 International Building Code (IBC) require shafts connecting four or more stories to be 2-hour fire rated. However, IBC requires combination fire/smoke dampers when exiting the shaft, and NFPA 101 references the 2012 edition of NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, which only requires a fire damper. 

Another example involves the placement of a duct detector on an HVAC unit producing more than 2,000 cubic feet per minute. NFPA 90A requires placement on the supply, while the 2012 International Mechanical Code^® requires placement on the return. These conflicts often result in teams meeting all criteria to limit potential liability, adding time and cost to projects. 

But unification is possible. For example, the Association for the Advancement of Medical Instrumentation (AAMI) ST79, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare, used to conflict with ANSI/ASHRAE/ASHE 170, Ventilation of Health Care Facilities, for humidity requirements. However, the AAMI ST79 developed an ad-hoc committee recognizing that regulating environmental conditions is complex. They concluded that sterile processing and facilities management work collaboratively to establish policies and procedures for monitoring and maintenance based on ANSI/ASHRAE/ASHE 170.

How do facilities navigate these conflicts? It ultimately comes down to what’s adopted. Centers for Medicare & Medicaid Services has adopted NFPA 101 (2012) and NFPA 99 (2012); however, your state or local authority having jurisdiction (AHJ) might have adopted a different guiding code or standard. 

When you find a conflict, you could comply with the most stringent requirement. However, another course is to request a meeting with state and local AHJs, gather background on the conflict, build a business case and present the request for a determination. AHJs likely won’t permit cherry-picking requirements from codes, but they may permit following one code when conflicts arise.

Joshua Brackett PE, SASHE, CHFM, system special project manager at Baptist Health.