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PART 2: NAVIGATING THE REGULATORY ROADMAP

Healthcare Construction Insights

Whether new construction or renovation, in- or out-patient, facility code compliance is nonnegotiable, but it's also more nebulous than you might think. While every healthcare project is unique in both its program and applicable standards, the end goal remains consistent: In the most cost-efficient manner possible, achieve – and exceed where justified – compliance with compulsory facility code and operational standards to best serve and protect patients, staff, and visitors.

In Part 2 of this five-part series, we'll explore strategies for navigating the current regulatory roadmap with topics including:

Setting Expectations | Defining Occupancy Classification | Integration of VDC for Quality Control & Compliance | Vetting Impacts on Renovations | Consider Future Challenges & Opportunities

In case you missed Part I of this series, The Prescription for Project Success, click here!

The Challenge

Local, state, and federal governing entities and Accrediting Organizations (AOs) have struggled to keep pace with the rapidly changing nature of the healthcare construction environment as hospitals continue to push various care modalities to out-patient settings.

With the rise of function-rich medical offices, ambulatory surgery centers, and microhospitals, the path to achieving the regulatory green light is marred by overlapping, contradictory, and easily misinterpreted codes and standards.

Until greater standardization occurs, how does a project team apply the tangled web of existing codes without incurring the big surprises and big setbacks?

Setting Expectations

Memorizing every code and standard that will govern the construction and/or renovation of a facility is not necessary for owners, but understanding how such codes impact the schedule and budget is crucial.

Establishing budgets and schedules based on “code minimum” construction is acceptable; however, the client's true definition of “minimum” as it relates to their project must be fleshed out and fully understood by all parties (client, design team, contractor, sub-consultants, and targeted end-users) in the earliest stages of planning. This process ensures budgets and schedules are a true reflection of all required scope.

As we learned in Part 1 of this series, involving key participants, including the Authorities Having Jurisdiction (AHJs), before advancing beyond schematic design provides the team with a path to avoid expensive rework and risk of accreditation denial.

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Defining the Occupancy Classification

Generally speaking, all healthcare facilities are designed and constructed according to the widely-accepted ICC IBC model (Group I-2 or Group B). Facilities with an I-2 classification (Institutional-2, the most stringent) serve patients requiring 24+ hour visits (traditional hospitals). Group B occupancy (Business, the least stringent) is reserved for medical office facilities whose occupants require stays of less than 24 hours.

Ambulatory Surgery Centers, classified Group B, are held to the same requirements as an I-2 facility. The type of procedures provided within and the level at which patients are capable of self-preservation in emergency situations (i.e., those incapacitated due to anesthesia) will also impact codes and standards applied.

Why does the classification matter?

Simply, the more stringent the classification, the greater the impacts to the project in terms of additional regulatory approvals, overall cost (short- and long-term), and speed of construction.

The Next Stop...

In addition to ICC IBC standards, facilities must comply with individual state regulations for licensure. While there are exceptions, states generally follow for such purposes the Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Hospital and Guidelines for the Design and Construction of Outpatient Facilities.

The project team must also be aware of other codes and standards that may apply. If a provider intends to bill against Medicare or Medicaid, they must also meet specific accreditation standards (e.g., The Joint Commission, Healthcare Facilities Accreditation Program, etc.) in order to comply with the Centers for Medicare & Medicaid Services' (CMS) conditions of participation.

Outside of these primary standards, other key codes and operational standards make healthcare construction explicitly different from traditional building types (e.g., National Fire Protection Association; The American Disabilities Act; The American Society of Heating, Refrigerating, and Air Conditioning Engineers; and the Occupational Safety & Health Administration, etc.).

Integration of VDC for Quality Control & Compliance

With the integration and widespread use of Virtual Design & Construction technology, project teams can provide AHJs with designs that realistically consider variables such as constructibility, manufacturer specifications, subcontractor practices, and system performance details. This avoids the seemingly endless cycle of redocumentation and reinspection previously typical.

The real-world impacts of VDC technology don't stop at the design stage. Once boots hit the ground, in-field conditions can be regularly documented with 360-degree photos through programs like StructionSite.

From a quality control perspective, this site documentation platform breaks boundaries. Gone are the days of tearing down walls of sheetrock to find a buried outlet. With a smartphone or tablet and StructionSite's app set to X-Ray mode, construction operations personnel can compare previous project images against real time jobsite conditions.

Did you know?

Penetrations above the ceiling, such as those for piping services, are of particular concern during CMS audits. These must be properly sealed to maintain the integrity of fire-rated walls. Passive fire prevention measures (e.g., caulks, putties, sprays, mortar, wrap strips, collars, and fire-rated cable pathways) are designed to contain a fire to its point of origin should more primary systems fail. Why does it matter? Unsealed or improperly sealed barriers can expose needless liability and risk facility accreditation status. Due to the congestion of utilities common in healthcare facilities, proper sequencing ensures a thorough and quality result.

Remote Compliance Audits

The rapid adoption of virtual audits is one positive spurred by the COVID-19 pandemic. With in-person inspections limited, robust and readily-accessible technology has provided an avenue for AHJs to validate completion and compliance more quickly, safely, and effectively.

Drone and video technology can be implemented for cumbersome exterior inspections in lieu of costly lifts for larger, multi-story facilities, and the process itself can also be better documented if desired or required. For instance, Choate employs the Insta360 One X, which provides for 360-degree image and video, as well as a 360-degree live-stream.

Vetting the Impacts on Renovation & Adaptive Reuse Projects

The unknowns – and thus, the hidden costs – of bringing facilities to current standards can become the veritable wrecking ball to any project’s budget and scope. Early engagement of the AHJ and contractor provides for opportunities to determine where code deficiencies exist and where more invasive work might be required.

Adapting a big-box retail structure, for instance, could require significant foundation and structural steel modifications to account for additional rooftop loads for HVAC equipment. Likewise, floor-to-floor heights can be problematic; achieving fire rating and acoustical privacy per code might require expansive and costly interior partitions.

Renovations within occupied facilities provide additional challenges. Infection mitigation based on ICRA procedures should be followed. Additional procedures should be in place to prevent construction crews from having incidental contact with private patient information (HIPPA). Furthermore, if the renovation project or expansion is one which connects to an existing building housing active healthcare services, temporary ADA accommodations might be required.

More coming on this topic in Part III of this series!

Consider Future Challenges & Opportunities

Codes and operational standards are constantly changing as governing entities find better and more consistent approaches for protecting patients, staff, and visitors.

Planning for Infrastructure Upgrades

In cases where ambulatory, in-patient, and outpatient services combine, regulatory agencies are looking more closely at MEPF infrastructure and their suitability for the space. If a higher degree of procedural flexibility is needed, the sophistication level of MEPF systems rises correspondingly.

Understanding where separations between spaces can and should be applied is critical. Determine whether procedural flexibility can be accommodated with an expansion or if the flexibility is an immediate need. Without proper planning, future projects that would otherwise be small and inexpensive could be strapped with the costs of a major infrastructure upgrade.

Did you know?

Inexperienced contractors might see sprinkler piping and envision an easy route for hanging data cables, electrical conduits, or ductwork. Draping the new lines over the piping and/or threading them through the sprinkler system’s supporting structure is a leading NFPA violation. Fire sprinkler piping cannot touch and should not support non-system items.

Better Buildings for Better Healing

Increased energy efficiency standards continue to push the envelope for the design, construction, and operation of healthcare facilities. Depending upon the complexity of the space, MEP systems can average upwards of 40% of total project cost, according to Building Design + Construction. Selecting the right systems means recognizing the potential for significant long-term operational savings and decreased environmental impact.

As such, more healthcare construction projects are also being designed to meet voluntary guidelines (LEED certification for Healthcare, the WELL Building Standard, and FitWel). For instance, while FGI solely focus on the number of air changes in a space, WELL standards focus on the quality of that air both in terms of infection mitigation and patient comfort. We’ll explore this topic further in depth in Part IV of this series.

The Rise of Telehealth & Systems Resiliency

From March to June 2020, there was a 2,632% increase in telehealth visits according to CMS. What this means in terms of HIPAA, HITECH, and CMS regulatory changes remains uncertain, but the rise has highlighted the need for more robust data infrastructure.

Security and uptime for shared Protected Health Information, and resiliency for the functioning of essential systems will remain top priorities for health systems. Owners, operators, and AHJs will need to work in tandem with design and construction teams to determine the correct level of resilience required. Early conversations can avoid unnecessary expenditure on over-specification.

As healthcare costs continue to rise, health care providers will continue to push beyond hospital boundaries to provide hospital-level quality and services in smaller markets. Compliance with regulatory bodies is challenging, but project success is achievable with the right partners, approach, and extensive quality control measures in place.

Now that you have the basics of our approach to healthcare construction, get in touch with one of our experts to learn more. Email us directly or visit our portfolio pages to see more healthcare project experience.

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Choate Construction
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