Risk assessments for critical utilities

Regular inspections and maintenance are important elements of a successful risk mitigation strategy.

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Critical utilities are foundational to ensuring patient safety, comfort and the overall efficacy of medical services. Without them, the ability to provide appropriate care becomes challenging.

These systems support life, provide infection control, allow for communications and support the equipment and spaces that promote healing.

A comprehensive risk assessment process is essential in identifying vulnerabilities in utility systems, determining the likelihood and impact of potential failures, developing strategies to mitigate identified risks, establishing monitoring and corrective actions, and ensuring compliance with standards such as the National Fire Protection Association’s NFPA 99, Health Care Facilities Code.

Essential functions

Critical utilities provide essential functions in hospitals and other health care facilities, with their own roles, challenges and strategies for effective management. They include:

• Electrical systems. These provide power for lighting, medical equipment and vital systems for patient care. Typically, electrical systems are divided into three branches: the life safety branch, which powers systems that are essential for safety such as fire alarms, egress lighting and other life safety features; the critical branch, which powers systems, lighting and equipment that are essential for patient care and safety; and the equipment branch, which powers mechanical equipment needed for health care operations.
• Essential electrical and emergency power systems. This is the vital portion of the electrical system that ensures critical areas and equipment have a continuous power supply during emergency situations and the continuity of electrical operations during normal power outages.
• Heating, ventilating and air-conditioning (HVAC) systems. These maintain temperature and air quality conducive to patient recovery and comfort. The HVAC system is an essential component of infection control practices within the healing environment.
• Medical gas systems. This is a network of pipes and equipment that supplies gases to patient care areas such as oxygen, anesthetic agents, medical air and vacuum necessary for surgical and respiratory procedures.
• Domestic water supply. This is a network of pipes, valves, control devices and fixtures that provides potable water for hygiene, cooking and patient care. Because of infection control concerns, health care facilities have additional guidance for water quality, often requiring additional management practices. Domestic water systems can consist of several different systems such as hot water, cold water, deionization systems, reverse osmosis systems and sterilization systems, among others.
• Sewage disposal systems. These safely manage and dispose of wastewater, protecting staff and patients from hazards.
• Communication systems. These provide staff the ability to share information and include provider-to-patient or nurse call systems, emergency alert and notification systems, telecom systems, electronic health records and television systems, among others.
• Conveyance systems. These are automated systems that move materials, equipment, supplies or individuals from one place to another. They include elevators, pneumatic tube systems and automated transport systems, among others.
• Fire and life safety systems. These are composed of elements that help ensure the safety of a building’s occupants during an emergency such as a fire, earthquake, security breach, gas leak or power failure. They typically include fire alarms, smoke detection, automated fire suppression and heat detection.

A proactive practice

At its core, risk management is a multidisciplinary, proactive practice that helps mitigate risk. It involves a meticulous analysis of potential threats to safety, security, operations, maintenance and compliance. Through identifying, assessing and prioritizing these risks, health care facilities professionals can tailor strategies to address the most pressing challenges, ensuring resources are directed where they are needed most.

While this process is methodical, it should not be misconstrued as a cold, mechanical exercise. On the contrary, it is a dynamic, multidisciplinary, evolving practice that reflects a commitment to patient care and a relentless pursuit of operational optimization.

The 2012 edition of NFPA 99 provides a framework for maintaining safety and minimizing risks in health care facilities. Key provisions relevant to risk assessment in health care utilities include:

• Risk categories. NFPA 99 establishes four categories for electrical and medical gas systems based on their importance to patient safety, establishing guidelines for their design, installation and maintenance.
• Risk assessment requirements. The standard mandates regular assessments to identify potential risks associated with critical utility failures and to implement appropriate policies and procedures.

Facilities must align with both NFPA 99 and other regulatory standards, such as those of accrediting organizations, the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and local building codes. The American Society for Health Care Engineering’s NFPA 99 2021 Risk Assessment Tool (see related article below) has been specifically designed to help facilities align the risk assessment process with the requirements within NFPA 99 and the CoPs.

Risk assessment process

The risk assessment process enhances understanding and management of critical utilities in health care. It can be broken down into the following six steps:

Step 1: Identification of utility systems. The first step involves compiling a comprehensive inventory of all critical utility systems and detailing the types of systems in place and their specific functions. Components include:

• Electrical systems. These include the main power supply, circuit distribution and emergency power systems.
• Medical gas systems. These include the types of gases used (e.g., oxygen and nitrous oxide), distribution lines, outlets and monitoring systems.
• HVAC systems. These include chillers, boilers, air-handling units, ductwork and control systems.
• Domestic water supply. This includes source (e.g., municipal or well), treatment, storage tanks and distribution lines.
• Sewage disposal. This includes systems for wastewater treatment and disposal, including backflow prevention mechanisms.
• Conveyance systems. These include elevators, dumbwaiters and pneumatic tube systems.

Step 2: System evaluation. The next step is to conduct a detailed evaluation of each utility system using NFPA 99 guidelines to determine current performance levels and identify any deficiencies. Key areas of evaluation include:

• Electrical systems. Inspect for proper grounding, circuit load balancing and compliance with NFPA 70^®, National Electrical Code^®.
• Emergency power systems. Test transfer switches, backup generator functions and fuel supply adequacy.
• HVAC systems. Assess air quality, temperature gradients, humidity control, filter management and ventilation effectiveness.
• Medical gas systems. Review installation compliance, leak testing results and maintenance logs.
• Domestic water supply. Evaluate water quality, pressure levels, treatments and plumbing integrity.
• Sewage disposal. Inspect for blockages, backups and adherence to local regulations governing wastewater management.
• Conveyance systems. Verify intended relationship and operation related to patient care.

Step 3: Risk analysis. This involves assessing the likelihood and potential impact of each identified risk. Techniques such as failure mode and effects analysis can facilitate this process by helping identify points of failure and their consequences. Questions to address include:

• What are the potential failure modes for each utility system?
• What is the likelihood of each failure occurring?
• What would be the consequence or impact on patient care, safety and operational efficiency?

Step 4: Prioritization of risks. Using the information from the risk analysis, this involves prioritizing risks based on their potential impact on patient safety and overall operations.

A risk matrix should be developed to categorize risks, allowing the health care facility to visualize which issues require immediate attention and which can be monitored over time. The risk prioritization framework includes:

• High priority (critical). Issues that require immediate action due to significant potential impact on patient safety or operational continuity.
• Medium priority (serious). Issues that are important to address within a reasonable timeline to prevent escalation.
• Low priority (minor). Issues of minimal impact that should be monitored and addressed as resources allow.

Step 5: Mitigation strategies development. For each high- and medium-priority risk, mitigation strategies should be developed and implemented. These strategies should aim to minimize the likelihood of failure as well as reduce the consequences should a failure occur. Examples of mitigation strategies include:

• Electrical systems. Regular inspection and maintenance of electrical infrastructure; installation of redundant power supplies and automatic transfer switches; and thermographic analysis of switches, race ways and similar elements.
• Emergency power systems. Monthly testing of backup generators and transfer switches; and procedures developed for efficiently refueling generators during emergencies.
• HVAC systems. Regular maintenance of HVAC equipment, including filter changes, coil cleaning and system calibrations; and implementation of a building management system for continuous monitoring and control.
• Medical gas systems. Routine inspections and maintenance checks per NFPA 99 recommendations; and presence of a backup gas supply and emergency shut-off procedures.
• Domestic water supply. Implementation of a water management program to ensure compliance with health regulations; and redundancy in water supply systems, such as additional tanks or alternative sources.
• Sewage disposal. Regular inspections and cleaning of sewage systems and backflow prevention devices; and a contingency plan for sewage leaks or failures, including patient safety protocols.

Step 6: Monitoring and continuous improvement. This involves establishing a continuous monitoring process for all critical utilities and developing feedback loops to assess the effectiveness of implemented strategies. It includes:

• Regular audits. Systematic audits are scheduled for utility systems, checking compliance with established protocols, safety standards and performance benchmarks.
• Training programs. Staff is trained on emergency procedures associated with utility failures, ensuring everyone is prepared to respond effectively.
• Reporting mechanisms. An easy reporting channel is created for staff to report utility failures, deficiencies or near misses, fostering a culture of safety and continuous improvement.
• Update risk assessment. The risk assessment and management plan is reviewed and updated annually or after significant changes to utility systems or operations.

Safety and accountability

A comprehensive risk assessment process for critical utilities is indispensable. This systematic approach not only ensures compliance with NFPA 99 and other regulatory standards but also promotes a culture of safety and accountability within the organization.

Each step must be treated with the utmost diligence to safeguard patient care, enhance operational efficiency and enable health care facilities to thrive in their mission to provide exceptional care.

By embedding these processes into the organizational fabric, health care facilities  can cultivate a more resilient infrastructure capable of withstanding potential challenges in critical utility services. 

Related article // A risk assessment process in action

A hypothetical mid-sized community hospital with a focus on emergency care had long experienced issues with its heating, ventilating and air-conditioning (HVAC) and medical gas systems. Complaints about air quality and inconsistent gas supply led to increased regulatory pressures and patient complaints.

To solve the problem, the hospital’s facilities team implemented a risk assessment process by following the steps explained in the accompanying main article:

Step 1. The facilities management team identified the HVAC system, medical gas system and emergency power supply as critical utilities needing attention.

Step 2. An evaluation revealed that the HVAC system had outdated components, contributing to poor air quality, while the medical gas system lacked redundancy, posing risks during peak usage.

Step 3. The risk analysis indicated the likelihood of HVAC failures during summer peak demand and potential medical gas shortages during surgeries and emergencies.

Step 4. Both HVAC and medical gas systems were categorized as high-priority risks and warranted immediate corrective action.

Step 5. Mitigation strategies included HVAC upgrades, ensuring energy-efficient units were installed and setting a routine maintenance schedule. Additionally, a redundant medical gas supply system was established, and staff received training on gas usage protocols.

Step 6. Regular audits of the HVAC and medical gas systems were established as part of an ongoing monitoring process, with data utilized to fine-tune operations and improve air quality for patients.

The health care facility’s focus on a thorough risk assessment and proactive management of its critical utilities not only enhanced patient care and safety but also ensured compliance with NFPA 99 and other regulatory standards. 

Related article // ASHE’s risk assessment tool

The American Society for Health Care Engineering’s (ASHE’s) NFPA 99 2021 Risk Assessment Tool has been developed to help health care facilities staff comply with the risk-based, patient-focused approach described by the 2021 edition of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code.

This completed risk assessment should be used to determine the steps needed to respond to the identified risks as outlined in NFPA 99, kept as a record of the decisions made and updated annually.

• Prior to implementing the tool, the following steps should be taken:
• Establish a multidisciplinary team with knowledge of the facility’s space use, patient care services, clinical practices and other areas as appropriate.
• Familiarize the team with the risk category definitions found in Chapter 4 (Fundamentals) and Chapter 12 (Emergency Management) of the 2012 edition of NFPA 99. These definitions are included in the category legends on each worksheet; move the cursor over the “Category Legends” box to see them.
• Familiarize the team with ways in which system and equipment operability can affect patient safety.

The risk assessment tool contains the following worksheets:

• The systems worksheet is used to record the level of risk determined for the listed systems in an area (i.e., a room or spaces within a room) of the facility being evaluated and is completed by listing the systems information and indicating the risk level with an NFPA 99 risk category number.
• The equipment worksheet is used to record the level of risk determined for all patient care equipment in the facility by listing the specific equipment information and location and then indicating the risk level based on the area and types of patients served by the equipment with an NFPA 99 risk category number.
• The emergency management worksheet is used to record the building category from NFPA 99’s Table 12.3, Emergency Management Categories, assigned to each building.

Devin Hugie, MBA, CHFM, CHC, FASHE, CRL, is chief executive officer and reliability coach at Forum Reliability in Spencer, Ind. He can be reached at dhugie@forumreliability.com.