Using data to fight for better codes

The plethora of facilities data can, does and will continue to change the trajectory of codes and standards for generations.

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There is no question that the health care field experienced significant advancements in the development of codes and standards over the past 100 years.

For decades, professionals who were deeply passionate about the safety and protection of hospital occupants and patients fought tirelessly to usher health care buildings into a new era in which risks from fire and smoke are mitigated thanks to provisions that have been placed into the code.

Health care facilities managers can safely state that they are standing on the shoulders of giants in their current efforts to advance these codes. In the same breath, however, it is now obvious that some of the decisions and stipulations that were placed into the codes were inserted without sound justification or data.

Many of these insertions were driven by a need to change the status quo. The days of the Cleveland Clinic fire of 1929 and the St. Anthony’s Hospital fire of 1949 had to end and, to accomplish this, the codes had to change. Inserting provisions in the code without data was necessary to ensure the safety and protection of those incapable of self-preservation was prioritized.

However, health facilities have advanced from the era when data is not always readily available.

Plethora of data

Fires are no longer prominent. When they do occur, they are contained by passive fire protection and almost always extinguished by fire suppression systems. 

Additionally, many of the risks have been eliminated, such as hospitals no longer using flammable nitrocellulose X-ray film or the conversion of flammable to nonflammable anesthetic gases. Likewise, ignition sources have been limited and contained through no-smoking mandates, noncombustible building construction is the primary construction type, and all new hospitals are required to have automatic sprinkler and fire alarm systems. The list of code enrichments has expanded beyond health care into the entire construction industry.

One of the beauties of the current era is the plethora of data that exists. More data than could ever be processed is available. Technicians now can capture data through a computerized maintenance management system or other digital database, then develop a survey using a standardized format in a matter of minutes. As a result, all this data can, does and will continue to change the trajectory of the codes for future generations.

For example, the American Society for Health Care Engineering’s (ASHE’s) Regulatory Affairs Committee was able to use data to increase the size of smoke compartments to 40,000 square feet in the 2018 editions of the National Fire Protection Association’s NFPA 101^®, Life Safety Code^®, and the International Building Code. The antiquated smoke compartment size of 22,500 square feet was originally placed into the code as a necessary way to compartmentalize hospitals for a defend-in-place strategy. Unfortunately, data was not used to determine the original smoke compartment size and, through the years, the use of egress analysis has provided sound scientific data permitting an increase to align with maximum travel distances within a hospital of 200 feet (200 x 200 = 40,000).

Even with all this data and the opportunities to submit it, it still is not used in the codes and standards nearly as much as it should be. Some of this is due to time constraints of facilities teams gathering the data; and some is due to corruption of data through falsifying or a lack of comprehensive information leading to a lack of trust in the story the data tells. 

Leveraging data

Now more than ever, data standards and data integrity must be at the forefront of the health care facilities field. Hospital facilities teams are under crippling time and cost constraints and being forced to do more with less. Part of the solution is leveraging data to prove certain code inspection, testing and maintenance (ITM) activities are no longer necessary.

A great example of a code requirement that proves to hold very little value because of the growth of data is the monthly inspection of fire extinguishers within a hospital required by NFPA 10, Standard for Portable Fire Extinguishers.

An analysis at Banner Health of more than 5,100 fire extinguishers across 30 hospitals over a five-year period resulted in a 0.1% failure rate for monthly fire extinguisher inspections. That means that every year only five fire extinguishers fail.

Fire extinguishers take approximately three minutes to check with one minute of walking between each extinguisher. This equates to more than 4,000 labor hours to find those five failed fire extinguishers every year. Further, assuming the national average hourly rate of a health care facilities technician is $25 per hour (excluding benefits), this equals more than $100,000 in cost to the system to find those five failed fire extinguishers.

Lastly, using an average national net profit for hospitals of 0.5% (which is unlikely for most health care systems in 2022), a hospital must generate $200 in revenue to cover every dollar it spends. That means to find five failed fire extinguisher failures, almost $21 million in revenue had to be generated.

Taken further, there are 6,093 hospitals in the United States, according to the 2022 edition of the Hospital Statistics report by the American Hospital Association (AHA), of which ASHE is the largest professional membership group. Using the data above as an average and extrapolating, there are over 1,035,000 fire extinguishers across the 6,093 hospitals that take over 828,000 hours to inspect 12 times a year with a total cost of more than $20.7 million. This resulted in more than $4.1 billion in revenue that had to be generated to cover that cost.

All this time and effort is spent to inspect an asset with a 0.1% failure rate. Clearly, the need to perform monthly fire extinguisher checks inside a hospital is simply not justified and a waste of precious time and money, both of which could be reallocated to much more important efforts. Worse, these unnecessary costs are being pushed back to patients and local communities.

Added to this are other unnecessary inspections such as monthly checks of LED exit lights and monthly testing of battery-powered LED task lights. 

In a new era of code reform, this data shows the wastefulness of some of the code and regulatory compliance ITM activities that are costing health care billions of dollars each year.

This data is proof that the codes must change. Further, the data on fire extinguisher monthly inspections is only one example of many that ASHE’s Regulatory Affairs Committee is leveraging to drive code reform. For this specific effort, many other hospitals and health care systems have submitted data to help further support the cause.

In addition to the waste caused by unnecessary codes, part of the barrier that also must be discussed is the code revision cycle and the adoption of new codes. Regarding the code revision cycle, each code and standard organization has different rules and bylaws governing them. 

For example, NFPA has a three-year revision cycle for most of its codes and standards, whereas ASHRAE codes and standards can update more quickly as they use a continuous maintenance methodology.

It is very important to understand the revision cycle and process for each code because it builds the timeline to capture the data and the strategic path forward. For example, the “public input” phase is the first step in NFPA’s code revision cycle. To enact change in the code, either a public input must be submitted to the code, or a “committee input” must be provided. Anyone, including NFPA nonmembers, can submit a public input into the code. This is the easiest way for any individual to enact change.

When inserting a public input, the individual doesn’t need all the data. In fact, submitting the public input allows for additional time to gather the data and submit the information and supporting data during the second phase, the “public comment” period. It is important to understand that this also applies to federal law and the Conditions of Participation managed by the Centers for Medicare & Medicaid Services (CMS), under which most hospitals are held. Active participation is easier than most think, and it buys the necessary time for ASHE’s Regulatory Affairs Committee to continue to build the case.

Regarding the adoption of new codes and standards, it’s no secret that the primary authority having jurisdiction (AHJ) for hospitals is CMS. This is due to the federal funding provided to hospitals to serve patients receiving Medicare or Medicaid, which comprises up to 80% of some hospitals’ total revenue.

The painfully slow process of CMS adopting newer codes must change to allow hospitals to take advantage of the advancements of the code. The primary driver that will lead to success is through consolidation of all hospital data, such as the previously discussed fire extinguisher example, to show the fiscal irresponsibility driven by the adherence to old codes.

Another example of code-triggered fiscal irresponsibility is single data cable touching a sprinkler pipe. Erroneous text regarding this topic was misapplied to health care facilities for far too long by CMS, costing taxpayers, insurance companies and patients millions of dollars.

ASHE and several supporting entities worked diligently by leveraging data to change the text in the 2023 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to correct this injustice. The amendment successfully removed “shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe” and revised the text to state, “Sprinkler piping shall not be used to support nonsystem components.”

Data can also be used to leverage a code and standard committee’s decisions and direction. For example, during the 2022 NFPA Technical Meeting, a certified amending motion was submitted to remove text that was added during the revision cycle that would have required facilities to remove 1% of the cover plates for concealed sprinklers to inspect for leaks and, if one failed, then all heads were to be inspected.

The original text was placed in the standard based on a single instance and did not have sufficient data to support it. ASHE successfully convinced a group comprised of multiple entities to assist with the removal of the text to allow for additional data to be gathered during this next code revision cycle. As a result, facilities managers should keep an eye out for a call to action requesting public data collection on concealed sprinkler heads within the next few months.

Data is critical

Data is critical to helping ASHE and AHA push CMS for faster adoption of better codes and standards. Without it, health care facilities are forced to rely on the previous era of code reform, where a decision must be made without sound justification.

The opportunity to have data-driven codes is here, and it’s going to take everyone to continue to push the codes into this new era. When ASHE asks for data, hospital facilities managers must take the time to respond because the purpose is bigger than one might think.

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.

Joshua Brackett, PE, SASHE, CHFM, is system regulatory director for facilities at Banner Health in Phoenix. He can be reached at Joshua.Brackett@bannerhealth.com.