After a major collaborative effort on the part of more than 100 healthcare practitioners, building designers, and code officials, the industry is now reaping the benefits of the Facility Guidelines Institute's updated 2010 Guidelines for the Design and Construction of Health Care Facilities, available at www.fgiguidelines.org.

“This is the most comprehensive single source for state-of-the-art design guidance for healthcare facilities,” declares Roland M. Binker, AIA, NCARB, LEED AP, principal, planning director, Ellerbe Becket, Washington, DC, who served on the 2010 revisions committee. Published by the American Society of Healthcare Engineering, the 2010 Guidelines represent a major upgrade since the document's last 2006 edition.

“I think each version is a work in progress in an ongoing attempt to keep up with technologies, research, and regulatory shifts,” explains committee member Shannon Kraus, senior vice-president/healthcare practice leader, HKS, Washington, DC. “In this regard, I think 2010 made drastic strides in creating a document that, to date, is the easiest to navigate and works to give guidance on several challenging issues facing us including patient handling, patient safety, and infection control.”

Similarly, Clay Seckman, PE, executive vice-president, Smith Seckman Reid, Nashville, and revisions committee member states, “The 2010 Guidelines took a big step forward in terms of responding to evolving issues such as bariatric care and what's actually happening in the healthcare environment.”

Other major new sections include design guidelines for acoustics and telecommunication rooms, and the adoption of ASHRAE Standard 170 for indoor environmental conditions. Furthermore, a number of specific facility types are addressed including cancer treatment, ambulatory care, renal dialysis, outpatient rehabilitation, senior care, and gastrointestinal endoscopy facilities.

Bariatrics

Getting into some particulars, because existing bariatric design literature is not very extensive, a new section addressing design criteria for bariatric patients is a most welcome addition to the Guidelines.

“Not only is there a section that covers the unique needs of the bariatric unit, but it also outlines bariatric needs in emergency, surgery, and other departments where bariatric patients may be found,” explains Kraus. “The guidelines also reflect the need to accommodate the patients’ path of travel, i.e., door to bed to exit, as well as unique toilet room provisions.”

For example, 200 square feet is the established minimum for patient room size with 5 feet of clearance around the bed. And at least one bariatric patient room must be equipped with a built-in mechanical lifting system.

According to Binker, who served on the bariatrics focus group that drafted the new section, extensive research, discussions, and informal beta testing were involved in this effort due to the uncharted nature of bariatric design recommendations. “As this new section becomes used more widely, and as additional treatments and equipment items evolve, we expect the bariatric design criteria to be refined.”

Acoustics

Based upon the results of an extensive 4-year study, specific noise criteria for different spaces within healthcare facilities have been included in the new Guidelines and mark a major jump from “judgement calls” to recommended acoustic levels culled from empirical data, says Kraus.

“These criteria were developed in an effort to reduce clinical errors, insure patient confidentiality, enhance decision making by clinicians, lower stress, and improve patient outcomes,” reports committee member Roger Brown, PE, senior project executive, Gilbane Building Company, Cleveland. “Particular attention was paid to neonatal intensive care units, patient and exam rooms where noise has been shown to have a direct impact on clinical outcomes.”

Although the committee admits there is still work to be done to more accurately establish these standards, this updated section is considered to be a significant step in the right direction. “Now that we have established this in a more robust way, future editions will be able to fine tune and adjust as we continue to learn more about the environments we create,” says Kraus.

Patient handling

Another significant addition to the 2010 Guidelines is a new requirement that the healthcare organization performs a Patient Handling and Movement Assessment (PHAMA) as part of the preliminary design process. The institution is then expected to clearly communicate PHAMA findings and subsequent expectations to the architects and engineers.

The assessment process itself models an Infection Control Risk Assessment and aims to ensure that adequate funding and space is allotted to address these issues during design, explains Kraus.

“In addition,” says Brown, “the purpose of this process is to reduce injuries to staff and patients during transportation and movement activities.”

At the same time, while not required, a Patient Safety Risk Assessment is recommended. While the revisions committee has recognized the importance of patient safety as it pertains to building design, there is still much development happening in this arena, so for now, the group decided to include this information in the appendix with the hope that the next four-year cycle will upgrade this recommendation to a requirement, reports Brown.

Telecommunications

Yet another major Guidelines change was a significantly updated telecommunications section. Whereas the 2006 edition hardly touched upon low voltage, new prescriptive, detailed requirements are now included.

In particular, a separate, dedicated telecommunication distribution closet is required on each floor, and a central telecom service entrance room and separate technology equipment center must be included. The Guidelines also provide an uninterrupted power source, ventilation, temperature and humidity standards, and all equipment rooms must be located above the floodplain and secured with locking systems.

Also a work in progress, the committee plans to revisit telecommunications in the next cycle to formulate some performance-based guidelines, says Kraus.

ASHRAE Standard 170

While all the updates and changes to the 2010 Guidelines are too numerous to list, one other noteworthy developments, as mentioned, was the decision to adopt ANSI/ASHRAE/ASHE Standard 170-2008 for ventilation rates and indoor environmental conditions. Dropping previously established criteria, Standard 170 increases operating room air changes per hour, for example, from 15 to 20.

Overall, this move represents a win-win situation with the Guidelines capitalizing on the American Society of Heating Refrigerating, and Air-Conditioning Engineer's expertise and ASHRAE, in turn, watching its standard be promoted from recommendations to code enforceable in the states that have adopted the Guidelines as such.

“As the ongoing Guideline review/update process continues, I think this will also bring some different perspectives to the 170 standard that haven't previously been brought,” observes Seckman.

Sustainable design

Interestingly enough, one area which has intentionally been left somewhat vague is sustainable design, in line with the committee's approach to avoid duplicating other standards and rating systems, and the decision to leave sustainability options up to the institution.

“Right now there are state, community, and federal laws being enacted that cover sustainable requirement issues, so for now, and not without significant debate, we require that facilities follow those requirements with regards to sustainability. Having said that, I think you can look for more research-informed changes to be woven into the guidelines with regards to sustainability,” projects Kraus.

Of course, the same holds true for all areas of healthcare design with the FGI and other entities promoting ongoing research to provide more informed, science-based healthcare design recommendations and requirements in the coming years.

Health guidelines: Setting the bar

Since its very first publication 63 years ago, the Health Guidelines have evolved to become a code or reference standard in 42 states for reviewing, approving, and financing plans, in addition to surveying, licensing, certifying, or accrediting newly constructed healthcare facilities.

Originally appearing in the 1947 Federal Register, the then-named General Standards were formulated to help implement regulations established by the Hill-Burton program. Passed during the Truman administration, this legislation sought to bolster the nation's hospital infrastructure, which created a need for such guidelines.

Naturally, the publication has evolved significantly over the past several decades into a thoroughly researched guide for recommended minimum program, space, and equipment needs for clinical and support areas of hospitals, ambulatory care facilities, rehabilitation facilities, and nursing and other residential care facilities. In addition, the Guidelines, managed and revised by the Facility Guidelines Institute and published by the American Society of Healthcare Engineering, provides important engineering criteria including plumbing, electrical, and heating, ventilation, and air-conditioning system design.

To FGI's credit, the revisions committee is an all-star line-up of more than 100 architects, engineers, administrators, medical practitioners, and representatives from authorities having jurisdiction, who actively pooled their expertise, carefully reviewed 1,142 change proposals and 1,688 comments on proposed changes to the 2006 edition.

“In a world with an overabundance of ‘information,’ the ‘evidence’ submitted as substantiation for change to the Guidelines is vetted by this interdisciplinary committee,” explains revisions committee member Roland M. Binker, AIA, NCARB, LEED AP, principal, planning director, Ellerbe Becket, Washington, DC. “As such, committee members spend much time between meetings running calculations, reviewing research, and testing alternative wording to validate proposed changes.”

Used today by the Joint Commission, and many federal agencies and authorities, the Guidelines also serve as an important resource to design professionals and healthcare providers for best practices and emerging trends.

For the updated Guidelines please visit www.fgiguidelines.org

Barbara Horwitz-Bennett is a frequent contributor to publications and organizations dealing with building and construction. She can be reached at http://www.bhbennett.com or bbennett@bezeqint.net.

Healthcare Design 2010 September;10(9):36-39