ASHE executive provides look at regulatory issues

The Beebe File

CV

• Deputy executive director for regulatory affairs, American Society for Health Care Engineering (ASHE).
• Associate director of advocacy for ASHE.
• Former authority having jurisdiction for the State of Washington.
• Architect and certified building official.

Appointments

• Trustee of the Fire Protection Research Foundation.
• National Fire Protection Association committee positions include executive board member of the Health Care Section, chair of the Health Care Section Codes and Standards Review Committee and a member of more than 20 technical committees.

Chad E. Beebe, AIA, CHFM, CFPS, CBO, FASHE, the American Society for Health Care Engineering’s (ASHE’s) deputy executive director for regulatory affairs, discusses important advocacy and compliance issues facing health care facilities professionals in the new year and beyond.

What issues are the ASHE Regulatory Affairs Team working on as we move into the new year?

We will persist in advocating for updated Centers for Medicare & Medicaid Services (CMS) Conditions of Participation. With numerous technological advancements and regulatory improvements enabling hospitals to operate more efficiently and prioritize patient care, it’s unfortunate that CMS mandates adherence to outdated codes. Increasingly, our members are finding themselves in a compliance gap, where modern state and local requirements clash with the obsolete CMS rules.

We are also developing a variety of tools and resources for our members. By leveraging our core competency framework, we have aligned current best practices with the key job tasks of health care facilities managers and are creating resources for each area. We recognize the emergence of a new generation of facilities managers and aim to provide them with trusted resources to maintain strong operations. Additionally, we will continue to advocate for the profession, ensuring that those who keep the lights on and the buildings operational have the same access to institutional resources as their clinical colleagues.

On the technical side of our advocacy efforts, we have partnered with ASHRAE to develop a companion to ANSI/ASHRAE/ASHE Standard 170, Ventilation of Health Care Facilities. Our members have clearly expressed the need for relief from the operational burdens of complying with Standard 170.

The new companion, ASHRAE/ASHE Guideline 43, Operations Guideline for Ventilation of Health Care Facilities, addresses this need. As a guideline, we will advocate against its mandatory adoption, but we will support the idea that hospitals should have the flexibility to create their own ventilation management plans (VMPs). These plans may or may not align with the design requirements of Standard 170, allowing hospitals to determine what best suits their patients, document their plans, adhere to them and be evaluated based on their own VMPs rather than a design standard that doesn’t fully consider their daily operations.

The ASHE Regulatory Affairs Team has been working within the National Fire Protection Association process to encourage the use of remote damper inspections. Can you talk about that?

ASHE fully supports the concept of remote inspections, especially above the ceiling. Minimizing ceiling access is crucial because each infiltration increases the risk of exposing patients to harmful particulates. Despite efforts to protect patients from these hazards, mortality rates remain unchanged. We’ve seen an increase in citations from surveyors regarding ceiling barrier integrity and improper use of containment units. 

Many consultants contracted for routine hospital work lack specialized health care training and don’t fully understand the implications of their actions or the safety measures they bypass. This issue is particularly evident with those inspecting and testing fire/smoke dampers above the ceiling in hospitals. The most efficient solution is to eliminate the human element and move to remote damper inspections.

Is sustainability still a high priority for the ASHE Regulatory Affairs Team?

We understand that sustainability may not be a top priority for some organizations. While it might not be ASHE’s primary focus either, providing resources for our members who prioritize sustainability is certainly important to us. Our commitment is to offer valuable resources that meet the diverse needs of all our members, so we will continue to prioritize developing more resources for those who currently need them.

Regardless of a hospital’s impact on the climate, these sustainability resources have the potential to save money and reduce the burden on facilities staff. For example, nitrous oxide systems contribute significantly to greenhouse gas emissions. Anesthesiologists have indicated that they no longer use much nitrous oxide and don’t need bulk systems. In areas where the installation of such systems is mandated, we advocate for rule changes to lift that requirement, allowing health care organizations to decide for themselves. If the absence of such a system eliminates the need for facilities staff to inspect, test and maintain it while also reducing the initial cost and the expense of purchasing bulk gas, we consider that a win-win situation.

How can sustainability give ASHE members a chance to play a more proactive role within their organizations?

For hospitals embarking on a sustainability journey, it would be wise for the facilities manager to step up and lead the effort. Eventually, the hospital will need someone to take charge, and it makes sense for facilities to take the lead. Much of the sustainability effort falls within the facilities department’s domain, including the building, lighting, utilities, maintenance and waste management. For those who don’t volunteer to lead, it will add an extra layer of complexity, as the facilities manager will likely have to coordinate with a sustainability lead on every project, purchasing and maintenance activity.

What will some of your priorities be later in 2025?

As I mentioned earlier, we need to intensify our efforts to keep people out of our ceilings, especially contractors without specific health care training. ASHE has developed the Health Care Physical Environment Worker Certification, which should be a minimum requirement for every subcontractor and written into every contract. Not requiring this certification can expose a hospital to liability if a contractor’s actions lead to patient infection.

However, that certification alone isn’t enough. We are responsible for the subcontractors working in our hospitals, and their performance reflects on us. We’ve observed misuse of containment units, often by third-party contractors who may be skilled in their trade but lack health care experience. We need to take control and change the culture in our facilities, ensuring that only those with extensive training and demonstrated competency breach the ceiling barrier.

While we will always need to access our ceilings for various reasons, we should employ technology wherever possible to minimize physical access.

What advice would you give to ASHE members who are interested in getting involved in codes and standards issues?

I often hear the question, “Who writes this stuff?” The answer is, technically, anyone reading this interview. Those who work in these environments every day are the ones committees rely on to submit proposed changes. I highly recommend that whenever you encounter a code you disagree with, find confusing or don’t understand its purpose, you submit a code change proposal through the appropriate body.

The worst-case scenario is that the committee doesn’t accept it. But, in a consensus code-making process, they are required to explain why they didn’t accept it. You couldn’t ask for a better interpretation. If you still disagree, refine your argument and resubmit it. You never know what could happen!

The time involved in this process is usually less than an hour or two, and you might end up fixing something that saves you dozens of hours each year in compliance or saves your organization money. Plus, if it’s an issue you’ve observed, there likely are others with the same concern, and you could be helping your colleagues as well.

Michael Hrickiewicz is editor-in-chief of Health Facilities Management magazine.