ASHE members use their voices to create code change

Regulations, codes and standards aren’t bureaucratic rules created to satisfy “just in case” scenarios. They are often based on the lessons of past catastrophic incidents and informed by the people who lived — and learned — through the experiences.

The serious implications of regulations, or a lack thereof, in the health care field warrants undivided attention from facilities professionals both in enforcing the rules and creating them.

But health care regulations can’t become static. The field is dynamic and ever-changing, and its codes and standards need constant review and modification to check if new procedures, technologies and methods of care conflict with current rules or create a need for new ones.

The American Society for Health Care Engineering’s (ASHE’s) Regulatory Affairs Team has been leading this mission for the association, and throughout the year has been helping shape numerous codes, standards and regulatory rulemaking that could significantly alter the operations of health care facilities.

Top issues to watch

An overview of the top regulatory issues for health care facilities professionals to watch midway through 2024 — as well as how they can take action in shaping their future — is discussed here:

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Centers for Medicare & Medicaid Services (CMS) potential update to the 2024 editions of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, and NFPA 101^®, Life Safety Code^®. The biggest regulatory change on the immediate horizon is the mounting call for CMS to update its required editions of NFPA 99 and NFPA 101.

For years, CMS has required health care facilities to follow the 2012 editions of the codes under its Conditions of Participation and Conditions for Coverage, even though newer, more modernized versions of the code sets have been released since the 2012 editions.

ASHE has led the push to convince CMS to update to the 2024 versions of NFPA 99 and NFPA 101, saying the change will better align compliance efforts with other, more updated requirements, incorporate vital industry updates and reduce regulatory burden, says Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director of regulatory affairs at ASHE.

“The burden on health care facilities management professionals is mounting as we try to comply with older standards. It’s essentially like being stuck in 2012,” Beebe says. “A lot of things have happened over the last decade and a half that impact the codes.”

For example, changes in technologies and updates in infection prevention strategies used by health care facilities now conflict with the older codes. The 2024 editions incorporate important lessons learned from the COVID-19 pandemic, including adjusted design strategies and amenities to protect patients from infectious diseases.

Numerous changes also have been made to the NFPA codes since 2012 to make health care facilities safer, including additional exterior sprinkler requirements and interior protections that are currently not required by CMS using the older code set.

The 2012 edition of NFPA 99 used by CMS refers to the 2008 edition of the American National Standards Institute (ANSI)/ASHRAE/ASHE Standard 170, Ventilation of Health Care Facilities — which has been updated numerous times since 2008. There are several conflicts within the 2008 standard, such as misalignment with current pharmacy compounding standards and endoscopy pressure differential requirements, that could adversely impact staff and/or patients.

The latest 2021 edition of Standard 170 also allows health care facilities to adjust their ventilation requirements based on facility type and implement unoccupied turndown protocols, which supports sustainability efforts by saving energy. Under the 2008 edition of Standard 170, all facility types need to meet the more stringent ventilation requirements of hospitals, which wastes resources.

“We want the flexibility to embrace the additional safety requirements, sustainability adjustments and general lessons learned that have been worked into the 2024 editions of the codes,” Beebe says. “We have tracked about 600 changes to the codes over the last 12 years, and nearly all were implemented to make the facilities management job easier and more predictable and provide better patient outcomes.”

How to take action. Facilities professionals are encouraged to send letters to CMS asking them to update to the 2024 editions of the codes, outlining the burdens they’ve faced by following the 2012 editions.

Facility Guidelines Institute (FGI) Guidelines for Design and Construction update to 2026 edition. FGI is currently updating its Guidelines documents that, when adopted by authorities having jurisdiction (AHJs) like state departments of health, dictate how health care facilities must be designed and constructed. The creation of the 2026 editions of FGI’s Guidelines for Design and Construction of Hospitals and Guidelines for Design and Construction of Outpatient Facilities will have a significant impact on how health care facilities are not just built but also eventually operated.

ASHE officials have growing concerns that facilities management and operations considerations are not being voiced or incorporated into the updates — which can lead to major issues if facilities are constructed and then can’t be properly maintained according to requirements. For example, some proposed Guidelines updates aimed at mitigating Legionella and other infection issues could require increases in maintenance costs that outweigh the benefits, Beebe says.

A total of 1,400 proposals were submitted for the Guidelines’ 2026 edition. While ASHE advocacy representatives are reviewing the proposals and serving on FGI committees, help is needed from the field to ensure any changes adversely affecting facilities management are identified and advocated against. New editions of FGI Guidelines are created every four years.

“It is extremely important that our members comment on these proposals — they are the people who will be responsible for operating the buildings constructed to these requirements for years to come,” says Leah Hummel, AIA, CHFM, CHC, CHOP, SASHE, senior associate director of regulatory affairs at ASHE and a member of FGI’s Health Guidelines Revision Committee. “The design and construction of health care facilities is one small part of the entire life cycle of a building. Facilities professionals have a unique role to play in evaluating these updates. What might sound good in design and construction might not make sense in operation and maintenance.”

How to take action. Facilities professionals should review the first draft of the FGI Guidelines released July 1 on FGI’s website. Comments are open to all members of the public. Once released, ASHE will issue an “Advocacy Alert” email highlighting a list of the most contentious and impactful changes for members.

“We want facilities professionals to keep an eye on the development of FGI changes, and get involved in the process by reviewing draft guidelines and submitting comments on changes that would create a burden in health care operations,” Beebe says. The comment period is open until Sept. 30, and is the last opportunity for public comments before FGI committees vote on the updates.

New sustainability initiatives. Several sustainability regulations and certification programs have entered the health care field in recent months that have caught the attention of health care facilities professionals.

In March, for instance, the Securities and Exchange Commission (SEC) adopted rules that require all publicly-traded entities — including publicly-traded hospitals — to account for and disclose Scope 1 and Scope 2 carbon emissions starting in 2025.

The SEC rules only impact a small percentage of health care organizations. But for hospitals that are impacted, ASHE’s Energy to Care^® program offers a free resource to track their energy and water use, both of which are part of Scope 1 and Scope 2 emissions, says Kara Brooks, MS, LEED AP BD+C, senior associate director of sustainability at the American Hospital Association (AHA). The AHA Sustainability Roadmap for Health Care™  also offers resources for hospitals to identify emissions sources and provides ideas on how to reduce emissions.

The Joint Commission in March issued its first voluntary Sustainable Healthcare Certification to four hospitals in the Hackensack Meridian Health organization, based in New Jersey. Launched in January, the certification program is available to The Joint Commission-accredited hospitals and aims to advance decarbonization in health care by recognizing organizations working to reduce their greenhouse gas emissions. The certification provides a framework for setting priorities, creating baselines, and measuring and documenting greenhouse gas reduction. The certification marks a significant milestone for health care sustainability initiatives given it is issued by one of the field’s largest accrediting agencies.

CMS also recently launched its own sustainability program that largely mimics The Joint Commission’s program. In April, CMS announced the Transforming Episode Accountability Model (TEAM), a voluntary decarbonization and resilience initiative to support health care organizations in monitoring, assessing and addressing hospital carbon emissions and their effects on health outcomes, costs and quality.

The initiative, which is scheduled to start Jan. 1, 2026, would invite acute care hospitals participating in TEAM to identify how they can reduce greenhouse gas emissions and improve patient outcomes. The program includes two elements:

• Voluntary reporting on emissions, which align with metric areas collected by The Joint Commission for its Sustainable Healthcare Certification.
• Technical assistance on reducing emissions from CMS, which includes benchmark comparisons of their emissions and an individualized assessment of the effectiveness of their decarbonization strategies.

How to take action. Facilities professionals should start their sustainability efforts now so they can address future regulations. While many of these initiatives are voluntary, the SEC ruling shows there is a growing movement toward mandatory tracking and reduction of energy use and emissions.

Beebe recommends taking a proactive approach to sustainability before it is too late. Instead of waiting for regulations to be required, facilities should start taking small steps toward sustainability efforts. For example, when replacing equipment, they can evaluate if a more energy-efficient option exists that will help them move toward decarbonization. Participating in the Energy to Care program, which charts sustainability data, will also help ASHE establish reasonable benchmarks that the association can point to as it works to ensure any regulations that are created are done so in a feasible way.

“The sustainability regulatory train is coming down the tracks whether you agree with it or not,” Beebe says. “Facilities professionals need to look at all their resources and work toward better efficiency. If you stick your head in the sand and don’t participate, someone else will step up — and you may soon find yourself reporting to them.”

Guideline 43 expected in late 2024. After years of development, ASHRAE/ASHE Guideline 43, Operations Guideline for Ventilation of Health Care Facilities, is expected to be released by the end of the year. Jointly produced by ASHRAE and ASHE, the guideline builds on ANSI/ASHRAE/ASHE Standard 170 by offering a consistent and universal standard for the operation and maintenance of heating, ventilating and air conditioning (HVAC) systems in health care facilities.

To date, health care facilities professionals could only look to the manufacturer’s recommendations for HVAC operations, which in most cases are so broad that they don’t align with the way health care facilities staff run their HVAC systems, says Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, senior associate director of regulatory affairs at ASHE and chair of the Guideline 43 subcommittee.

“The way you operate a system is not always aligned to how it is designed. Our challenge is that AHJ surveyors have been using the HVAC design standard as their guide and forcing us to operate the system that way — which often doesn’t align to care needs,” Flannery says. “Guideline 43 will resolve a long-standing issue of surveyors surveying to a design standard, and instead survey to an operation standard utilizing a ventilation management program based on risk assessment.”

For example, operating room HVAC systems are designed to operate between 68 F and 75 F. “But if we have a burn victim in the operating room, the surgeon may request to turn the temperature up to 85 F to help the patient, or if there is another procedure that requires the surgeon to wear extra garb, it may be necessary to run the system colder than 68 F to help the surgeon,” Flannery says. “Guideline 43 will allow organizations to establish a valid program that addresses clinical needs and patient comfort, supporting the healing environment and helping patients heal quicker. Why should we put a patient in a room and require them to wear three blankets to stay warm just so we can tell surveyors we are following Standard 170?”

Guideline 43 states that health care facilities should organize a multidisciplinary team (e.g., medical staff, infection control, environmental services, administration and facilities management) to develop their own ventilation management program that adjusts the temperature based on risk assessments and also addresses excursions. Surveyors can then evaluate a facility based on their documented, Guideline 43-driven ventilation management program.

The guideline is expected to be finalized in late 2024. After it is released, ASHE plans to propose the inclusion of ventilation management programs in the 2027 edition of NFPA 99 to further promote this concept.

How to take action. Facilities professionals should start using Guideline 43 in their facilities once it is published, Flannery suggests. They can also participate in the NFPA 99 edition update process and encourage the adoption of ventilation management programs.

Get involved and be heard!

Less is often more when it comes to codes, standards and regulations, especially in the current health care environment of reduced resources and downsized staffing. As one of the most heavily regulated fields, health care professionals must ensure any regulation on the books is effective and continuing to provide value. This is especially important as health care operating margins shrink and operating costs increase.

“The outcome of any regulation should be the safety of our staff, the safety of our visitors and our patients, first and foremost,” Hummel says. “By getting involved, you can help ensure these standards meet that objective, but also do so in a way that isn’t overly burdensome and still allows us to provide high-quality health care to our communities. We must be smart about how we regulate our facilities so we can meet the growing challenges facing the field.”

Getting involved in advocacy comes down to two things, Flannery says: removing overly burdensome requirements and instituting rules that help keep patients, visitors and staff safe inside health care facilities.

“Take the 2012 edition of NFPA 101, which is the version currently adopted by CMS,” Flannery says. “How in the world is looking at an LED exit sign light every month that is guaranteed to work for 20 years keeping people safe? It isn’t. We are the ones this impacts, so get involved and make a difference.”

Related article: Additional issues being monitored by ASHE

In addition to the top regulatory issues discussed in the accompanying main article, there are several other issues that the American Society for Health Care Engineering’s (ASHE’s) Regulatory Affairs Team is monitoring. They include:

• In-progress 2027 editions of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, and NFPA 101^®, Life Safety Code^®. Though many in the field are calling for the Centers for Medicare & Medicaid Services to update to the 2024 editions of NFPA 99 and NFPA 101, work is already underway on even newer versions of the codes. Operating on a three-year update cycle, NFPA has actively begun working on developing its 2027 editions.
• ASHE representatives have been providing input on the next code set and encouraging the public to send any concerns about the proposed changes to the ASHE Regulatory Affairs Committee so it can track and support issues over the next several months of code development. “We want to monitor future editions and ensure new technology is addressed by the code,” says Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director of regulatory affairs at ASHE.
• Overregulation is also a consistent concern in facilities management, and ASHE has been supporting relaxing codes that are not effective or worth the effort given the low risk of failure.
• Electric vehicle charging in parking garages. Insurance carriers have voiced growing concern about placing electric vehicle charging stations inside parking garages given their increased risk of fire. Some insurers have started requiring facilities to either remove the stations or increase the sprinkler density in the garages, Beebe says.
• Cybersecurity breaches. While many may see the recent rise in cybersecurity attacks on health care organizations as an information technology issue, a growing number of major security breaches are occurring through building systems, Beebe says. ASHE is supporting an NFPA Research Foundation project to review cybersecurity protections and potential weaknesses in fire protection systems, which may inform future versions of NFPA codes.
• International Code Council (ICC) I-Codes on alcohol-based hand rub (ABHR). For years, the I-Codes prohibited storing over 30 gallons of ABHR due to fire concerns — which presented an issue during the pandemic as hand sanitizer use skyrocketed in health care facilities. The ICC Committee on Healthcare recently reviewed a thorough analysis that showed storing more than 30 gallons of ABHR had no impact on fire safety, and it is currently advocating that ICC revise the code to a more reasonable requirement.
• ICC International Plumbing Code proposal on tepid water. A proposal being considered by ICC in October would change the required temperature range of tepid water delivered to handwashing sinks. The ICC Committee on Healthcare proposes changing the code to state that water be delivered to sinks either higher than 110 F or lower than 85 F, given the ideal temperature range for waterborne pathogen growth is between 85 F and 110 F, says Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, senior associate director of regulatory affairs at ASHE. 

Chris Dimick is content development and communications manager at the American Society for Health Care Engineering and production editor of  Health Facilities Management magazine.