Bronchoscopy Procedure Rooms

Q: Are Bronchoscopy procedures to be performed in negative pressure rooms under all circumstances, or can they be performed in OR suites? Does the negative pressure rule only apply to new construction, or does it apply universally to all facilities old and new?

A: According to the 2010 FGI Guidelines for Design and Construction of Health Care Facilities, ventilation requirements for a Bronchoscopy procedure room requires negative air pressure relationship to the surrounding area, and a minimum of 2 outdoor air exchanges per hour and a total of 12 air exchanges per hour. This ventilation requirement must be met regardless where the Bronchoscopy procedure is conducted, which includes the operating rooms. So, to answer your first question: Yes, this requirement applies to all circumstances.

The ventilation requirements found in the 2010 FGI guidelines applies to new construction or renovated areas. It is not a standard, and it does not apply to existing conditions. However, the ventilation requirements for Bronchoscopy procedures have been consistent since the 1996-1997 edition of the guidelines, and perhaps even before that (I only have records back to the 1996-1997 edition). So, if you have constructed or renovated the Bronchoscopy procedure room since 1996-1997, then these ventilation requirements must be complied with.

Some authorities will allow deviance from the FGI guidelines as they are guidelines and not standards. So, if you have extenuating circumstances that requires you to deviate from the FGI guidelines, then contact your AHJ to determine what their expectations are.

Which Edition of FGI Guidelines Do We Use?

Q: We were using the 2006 edition of the FGI Guidelines for Design and Construction of Health Care Facilities but we have both the 2006 and the 2010 version of this document. The guidelines are different related to air pressures in Endoscopy and Bronchoscopy procedure rooms. We are trying to determine if air flow should be positive or negative. Can you tell us which edition of this book we are to be using as the current guideline?

A: The ventilation requirements for Bronchoscopy procedure rooms have stayed consistent through the many recent editions of the Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities. There have been no changes in the requirement for negative air pressure in relationship to the surrounding areas, and a minimum of 2 outdoor air changes per hour with an overall total of 12 air changes per hour.

However, the same cannot be said for Endoscopy procedure rooms. From the 1996-1997 edition to the 2014 edition, the ventilation requirements seemed to change every edition:

Edition Air-Pressure Requirement Outdoor Air Changes

per Hour

Total Air Changes

per hour

1996-1997 No Requirement 2 6
2001 Negative 2 6
2006 No Requirement 2 6
2010 Positive 2 15
2014 No Requirement 2 6
[It is noted that the 1996 – 1997 edition was written and published by the American Institute of Architects (AIA), and the 2001 and 2006 editions were written by the FGI and AIA together. All subsequent editions are written by FGI and published by the American Society for Healthcare Engineers (ASHE).]

So, depending on when the Endoscopy room was designed, the ventilation requirements fluctuated. You authorities having jurisdiction usually state which edition of the FGI guidelines they are using as a guide. The interpretive guidelines for the Centers for Medicare & Medicaid Services (CMS) standard 482.41(c)(4) says acceptable standards such as the FGI guidelines should be incorporated into the hospital’s policy, but the standard does not say which edition. Likewise, the HFAP standard 11.07.03 says virtually the same thing, but The Joint Commission standard EC.02.06.05, EP 1 does reference the 2010 edition of the FGI guidelines.

For CMS and HFAP purposes, the assumption is clear that they would require the most recent edition, which would be the 2014 edition. For Joint Commission purposes, George Mills, Engineering Director for the accreditor recently stated during a regional ASHE meeting they would allow a health care organization to use the more recent 2014 edition.

The current edition of the FGI guidelines is the 2014 edition, which has no requirement for air pressure relationship to surrounding areas, and requires 2 outdoor air changes per hour and 6 total air changes per hour. But please check with you state and local authorities to determine what their requirements are.

CMS Enforces Different Time-Description

I received the following comment from a reader:

During a recent CMS life safety survey a surveyor stated that my kitchen hood suppression testing intervals were out of compliant even though they’re we’re clearly within The Joint Commision’s plus or minus 20 day window for semi-annual testing. He said CMS goes by the NFPA code (not JC) and that, that window is not in the code so therefore the testing must be completed before the 6 month anniversary. However, he stated that the quarterly inspections and testing can be done in a calendar basis and not by the revised quarterly interval parameters that JC has implemented (every 3 months, plus or minus 10 days).

This is an example where the accreditation organization has developed a thoughtful and practical interpretation of the NFPA standards regarding frequency of inspections and tests. Then CMS comes along and denies the practicality of the interpretation because it is not permitted in the NFPA codes or standards. That’s one of the problems with the NFPA standards is they don’t define time, such as what “semi-annual” or “every 6 months” means.

I’ve heard some state agencies surveying on behalf of CMS actually require the annual inspection or testing activity to occur exactly on the same date as the previous activity, one year later. So if it was last tested on April 15, it had to be next tested on April 15 of the next year, regardless what day of the week that landed on. That was extreme and I hope responsible people came to their senses.

But part of the problem is the people who are interpreting these rules have never worked in a hospital. They seem to not understand that hospitals need a reasonable window of opportunity to schedule these inspections and tests. Facility departments have decreasing resources available to them and it would sure be helpful if the government would just give them a little help now and then by interpreting issues with a little kinder attitude.

Wouldn’t it be nice if all of the authorities having jurisdiction (i.e. CMS, accreditation organizations, state fire marshals, etc.) were on the same page for critical issues like this?









The following comment is a result of an article that I ran last September on decorations (search: Decorations or Communications?). This comment is from a representative from a state agency that performs surveys on behalf of CMS.

I recently read your article on Decorations. I thought the advice was really good information. I was contacted by a facility not too long ago that asked me if a large, homemade tapestry brought to a resident’s room would need to be fire retardant if it was hung up. The question from the engineer was valid as it was to be hung as a “decoration”, was made of flammable material and the family wanted to hang it in the corridor. He wanted to know if it should be fire-treated. His argument was focused on not allowing the family to bring it in at all, mostly because he found it objectionable. I related to him the code; how it could be both stringently and loosely interpreted and suggested, as you pointed out, to err on the side of caution and either treat it or suggest to the family it wasn’t allowed by the standard. The main issue was that the family wanted to hang it in the corridor, which I pointed out could potentially affect safe egress. I then asked him what he felt would be a surveyor’s opinion if this same decoration was hung inside the room, or used as a blanket.

I pointed out that many times I am in a facility where the family has brought in a blanket, or other homemade decoration to make their loved ones feel at home during their stay, or possibly their final hours. I stated I view those items based upon the possible risk, and the intent of the standard. More often than not I find they pose no greater risk to the facility’s other occupants than the same person’s bathrobe knitted by their aunt (when solely used or displayed inside their respective room).

Point being that speaking for myself, I view it solely based on each individual situation: If the facility is providing it and it poses a possible risk to the safe housing or evacuation of all occupants, I will look at that risk and evaluate the issue, citing it if it is apparent and substantiated. I will not unnecessarily burden a resident, patient, client, family or staff member for the purpose of removing something that falls within the letter of the rule for the sole purpose of demonstrating that rule. As always, “it depends”.

I find it refreshing that a state surveyor would have compassion and evaluate issues on a case by case basis. But if this is not done carefully, it can lead to inconsistent interpretations and cause problems when AHJs do not agree on the same issue.

I think hospitals have too many AHJs conducting inspections and surveys in their facility, as it often leads to differences of opinion on how an issue should be interpreted by the AHJs. Ultimately, the hospitals often have to ‘do-over’ a construction project because they receive poor advice from an architect, or an incorrect interpretation from an AHJ.

No wonder healthcare costs so much…

A Follow-Up to “Comments on Corridor Clutter”

The following comment is a result of an article that I ran last August on corridor clutter (search: Comments on Corridor Clutter), which quoted Randy Snelling, the Chief Physical Environment Officer for DNV.GL Healthcare, Inc. This comment is from a representative from a state agency that performs surveys on behalf of CMS.

First, I totally agree with both Randy and you. Both in principle and standard we should be  more up to date and facilities should know what the standard is and how to  follow it. Oddly, I spend more time assisting facilities on this issue even when I cite it. I tend to smile when they announce I have arrived and wonder “Were you in compliance yesterday?”

As a surveyor doing checks on all occupancies, I have found none ever seem to not have some issue with space and where to place those items needed for patient/resident care. Having worked in a healthcare facility, I can also fully relate that focus being first and foremost.

That being said, the standard is there for a reason and has been for some time.  Even though my initial peek into 2012 finds some increasing awareness of how clutter is viewed, I still believe that we have a wide arrangement of options if, as both you and Randy point out, senior management buys into it and
supports either their Safety Manager or Maintenance staff.

Inevitably, these are the ones who take it very personally when I cite a facility for a blocked or obstructed corridor. Administrators, Chief Nursing Officers on down need to understand the reasoning behind the code and what steps it takes to stay in compliance. I feel a majority of the time the facility management thinks “Oh we clear everything when the drills happen”. Now imagine those corridors filled top to bottom with smoke. The scenario will change considerably. I hope all who read your article and Randy’s comments take it to heart.

I think this representative for a state agency makes a very good point: The healthcare industry needs better education on the need to keep the corridors clear from clutter. I suspect we have become insensitive to this issue because the frequency of fires in hospitals has dropped dramatically since the mid-1980’s, when smoking was restricted in hospitals.

But fires still occur in healthcare settings as documented in either this blog or in the HCPro’s Healthcare Life Safety Compliance newsletter. And it is the belief of Randy and I (and this representative from a state agency) that corridor clutter still needs to be taken seriously.

In my opinion, it did not help that the NFPA Life Safety Code technical committee decided to allow certain unattended items in corridors of 8 feet as described in the 2012 edition. It also didn’t help that CMS decided to endorse this section of the 2012 edition last year as a categorical waiver. The decision on the technical committee to do this was not unanimous, as a representative from a state agency who surveys hospitals (not the same individual quoted above) enthusiastically opposed the decision. Since he had first-hand observation on how hospitals abuse codes and standards, he did not want to allow them to store items in the corridor.

I suspect corridor clutter will remain a problem until senior leadership decides to take an active role in resolving it.

The FGI Guidelines

fgi[1]Recently, the issue of whether or not the FGI guidelines were enforceable in certain situations came up for discussion. To be sure, the FGI guidelines are guidelines: They are not standards or code requirements. CMS and the accreditation organizations expect hospitals to design their new construction and renovation projects in accordance with the current edition of the FGI guidelines or applicable state and local standards if more restrictive. If there is a physical reason why the hospital cannot meet the FGI guidelines, then that must be discussed with their state and local authorities having jurisdiction over hospital construction, and any variances from the FGI guidelines must be approved by them.

Existing conditions in hospitals do not have to meet the requirements of the most current edition of the FGI guidelines, including the ventilation and air-pressure requirements. Existing conditions in hospitals must comply with the requirements of the FGI guidelines edition (or the AIA guidelines if older) at the time the facility was designed. So, as an example if an operating room was designed 20 years ago, it would only have to meet the 15 air changes per hour requirement of the guidelines enforced at that time; not the 20 air changes per hour required in the 2014 FGI guidelines for new construction.

I was contacted recently by a hospital that was doing some renovation in their operating rooms, and wanted to know if they had to update their HVAC system to meet the current FGI guidelines on air changes per hour. Apparently, they would have to install a whole-new HVAC system in order to meet the 2010 or 2014 FGI requirements. They said they were updating their medical gases, room lights, installing new floors, and installing some special equipment, but it wasn’t a gut-and-replace job. The FGI guidelines has a section at the beginning of the book that describes when an entire upgrade needs to be done, but this isn’t something that I should be answering for this hospital. They needed to contact their state and local authorities to determine what they would require.

Accreditation organizations like The Joint Commission, HFAP, and DNV do not approve construction or renovation projects. Their job is to assess the hospital for compliance with all applicable codes and standards. The accreditation organization standards do reference the FGI guidelines, but only as a reference; not as a standard. If a hospital has a letter on file from their state and local authorities allowing the deviation from the FGI guidelines, then surveyors should not cite the deviation from the FGI guidelines.

It is critically important for the hospital to retain all documentation from their state or local authorities at the hospital location, and be able to retrieve them during a survey.

Comments on Corridor Clutter

Randy Snelling, the Chief Physical Environment Officer, for DNV-GL Healthcare Inc. spoke at the recent ASHE annual conference in Chicago, and I thought his views on corridor clutter were worth repeating here…

“I read in the ASHE magazine recently an article written by a surveyor who listed the top 5 findings he saw during a survey”, says Snelling. “The first thing he identified was corridor clutter. I threw the magazine across the room. I thought, ‘Man, where are we? This is 2014 and we’re still talking about corridor clutter? Really? Come on!’ Why is corridor clutter still happening in hospitals? Because the senior leadership is not stepping in. The facility manager does not have the clout with those clinicians up on the floors where the corridor clutter occurs. But who does? Senior leadership. And if you’ve got corridor clutter problems, it’s not a life safety problem, it’s a ‘C’ suite problem. And our hospitals know it. I don’t think we’ve had a corridor clutter finding in over a year. Now, what happens? Well, we come in and the hospital makes an announcement overhead welcoming the DNV survey team, and everything gets moved out of the corridor. But that happens with everybody else too, with HFAP and TJC and CMS. So why are we seeing this? I think it is because since we are in the hospital every year our hospitals do not have as much to move out of the corridors as other accredited hospitals. This ends up being a problem with Leadership rather than a problem with the facility manager.”

I consider Randy to be a friend and we talk frequently about accreditation issues. I think his view on corridor clutter on the nursing units is spot on, in that senior leadership needs to back the facility manager (or safety officer) on Life Safety Code issues that are out of their capability. Having been a Safety Officer at a hospital for years I can relate to this problem. I rarely felt the support from the ‘C’ suite and felt I had to struggle with certain basic life safety requirements (such as corridor clutter) on my own.

I did eventually take a different approach by spending time on the nursing units observing the nurses day-to-day operations. This made me realize their needs better and they eventually saw me as one who wanted to help, rather than the enemy who was always telling them to move their equipment out of the corridors. I was able to apportion capital funds to build alcoves in certain locations, and they in turn kept the corridor free from clutter.

But most hospitals probably still struggle with corridor clutter issues and without the senior leadership stepping in and backing the facility manager by insisting items be stored in alcoves and storage rooms, this problem will not go away. I predict it will get worse when the 2012 Life Safety Code is finally adopted, since the new LSC allows certain unattended items to be placed in corridors that are at least 8 feet wide. That will create a struggle for everyone as most staff will not understand what pieces are permitted and what pieces are not permitted.

Critical Access Hospitals vs. Acute Care Hospitals

research[1]I’m no expert on the differences between a Critical Access Hospital (CAH) and an Acute Care Hospital (hospital), but I’m learning. Having been an advisor to American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP) for nearly 3-years now has provided me with an enlightenment that I never expected.

First of all, I learned that CAHs are not hospitals. Well, technically they are not according to CMS, who determines whether a healthcare facility is a CAH or a hospital. If you are ill and need help that a hospital can offer, a CAH healthcare facility will take good care of you and you would not necessarily know the difference. From all appearances, a CAH looks like a hospital, only smaller. Did you know that in 2013, there were 1,332 certified Critical Access Hospitals in the United States, according to reports from CMS? That over 25% of all the acute care hospitals registered in the country.

A new CAH cannot start out by being a CAH. It first must be accredited as a hospital; then it must apply to CMS to become a CAH. There are many qualifying factors that contribute to becoming a CAH, of which this is what I know:

  • CAHs can only have 25 inpatient beds
  • CAH locations have to be more than a 35 mile drive from any other hospital or CAH
  • CAH locations have to be more than a 15 mile drive from any other hospital or CAH in area with mountainous terrain or secondary roads
  • Be located in a rural area
  • Furnish 24-hour emergency care services, 7 days a week
  • Have an average length of stay of 96 hours or less

Why do hospitals want to become a CAH? Mainly for the reimbursement rate that CMS offers to CAHs. Critical Access Hospitals are certified to receive cost-based reimbursement from Medicare. This  reimbursement is intended to improve their financial performance and reduce hospital closures. Each hospital  is responsible for reviewing its own situation to  determine if CAH status would be advantageous. Critical  Access Hospitals are certified under a different set of  Medicare Conditions of Participation that are more  flexible than the acute care hospital conditions of  participation. Since most hospitals (and CAHs) earn the majority of their income from Medicare reimbursements, having the advantage of being a CAH is definitely a benefit. As of January 1, 2004,  CAHs are eligible for cost plus 1% reimbursement, and capital improvement costs are included in allowable costs  for determining Medicare reimbursement. Without the financial advantage of being designated as a CAH, many rural areas in the country would not have healthcare available to them.

There is a story of hospital attempting to become a CAH but they didn’t meet the driving distance from a specialty hospital that did not serve the general public. It took them nearly five years to convince CMS that they qualified as a CAH because the other hospital within their 35 mile radius did not serve the people from that area. Fortunately, CMS finally agreed.

So, you’re wondering why am I telling you all this? Well, Joint Commission recently published the top five findings by surveyors in 2013 for all of the disciplines, CAHs and hospitals alike. Now, from what I understand the same LS surveyors who survey hospitals also survey CAHs. If that is true, then there is one significant difference in the results of those surveys in 2013. Take a look at this:

 Critical Access Hospital

% of Surveys





The critical access hospital maintains fire safety equipment and fire   safety building features.



The critical access hospital manages risks associated with its   utility systems.



The critical access hospital maintains the integrity of the means of   egress.



The critical access hospital reduces the risk of infections   associated with medical equipment, devices, and supplies.



The critical access hospital provides and maintains building features   to protect individuals from the hazards of fire and smoke.


% of Surveys





The hospital maintains the integrity of the means of egress.



The hospital maintains complete and accurate medical records for each   individual patient.



Building and fire protection features are designed and maintained to   minimize the effects of fire, smoke, and heat.



The hospital manages risks associated with its utility systems.



The hospital reduces the risk of infections

The difference that is notable is EC.02.03.05, which is the standard for testing and inspection of fire safety features. For CAHs it is number 1 on the list, cited on 60% of all the surveys. For hospitals it is number 6 on the list and cited on 44% of the surveys. Not sure why there is such a difference, but perhaps it is because CAHs have less resources available to the facility manager to ensure all of the work is actually accomplished.

The rest of the standards are pretty close to being even:

  • EC.02.05.01              54% for CAHs;           47% for hospitals
  • LS.02.01.20              49% for CAHs;           52% for hospitals
  • LS.02.01.30              44% for CAHs;           43% for hospitals

 I think Critical Access Hospitals are neat… especially when you need one out in the rural areas.

Risk Assessment

images[11]A surveyor recently cited an organization for having potential suicide hanging points in a behavioral health unit, in the form of door hinges and other hardware issues in the patient sleeping rooms. While I do not believe that anyone is questioning the reality of the potential suicide hanging points that door hardware may offer, a finding on this issue is not always warranted.

You can’t have a hospital without a certain amount of risk to the patient’s safety. It’s the nature of the beast. It has been said that the process of accreditation is the ability to reduce risk, but not necessarily to eliminate risk. In Joint Commission’s standard EC.02.01.01, EP 1, an organization has the responsibility to identify safety issues in the environment. The note after the EP says: “Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high-risk procedures, and from credible external sources such as Sentinel Event Alerts.”

This note states that risk assessments are “ongoing” and conducted at least annually. Therefore, in the case mentioned above about the door hardware being a potential suicide hanging point, before the surveyor decides to enter a finding in the survey report he/she should ask the organization if they have a Risk Assessment on that particular safety risk. If you do have a documented risk assessment, provide it for the surveyor to review. The surveyor will determine if the mitigation factors identified in your risk assessment are acceptable. This is one of those areas where the surveyor gets to make a judgment, and determines if your risk assessment mitigates the risk to the patient.

If the surveyor determines that your risk assessment does in fact mitigate the risk to the patient (remember: this is their judgment call) then no finding is scored in the survey report. However, if your organization does not have a risk assessment on that issue, or if your risk assessment does not mitigate the risk to the patient (in the surveyor’s opinion), then the surveyor will likely enter a finding under EC.02.01.01, EP 1 or EC.02.06.01, EP 1 for an unsafe environment.

Once your organization has conducted a risk assessment, it is not a “one and done” issue; meaning you need to review the safety risks to the patients periodically. The phrase “ongoing” in the note for EC.02.01.01, EP 1 means you need to do the risk assessment over and over on the same issue, because something in the physical environment may change and the factors that mitigated the risk to the patient may not be present anymore.

How often do you need to do a risk assessment? The note for EC.02.01.01, EP 1 says annually, but a surveyor may expect you to do one more often depending on the severity of the risk to the patient and the mitigating factors.

There is no specific form or template a risk assessment must be documented on. As long as the risk assessment is documented and dated, then it qualifies. Risk assessments can be in the form of a written narrative report of a special task force formed to review the risk; or they may be in the form of a template with specific discussion points. It doesn’t matter what format your organization chooses to use – just that you do assess the risk of a safety issue.[NOTE: To download a free copy of a Risk Assessment template, go to “Tools” and click on “Risk Assessment”.]

It is considered “best practice” that the risk assessment is conducted with a group of stakeholders, such as:

  • Manager of the unit
  • Safety officer
  • Risk manager
  • Facility manager
  • Security manager
  • Administrative representative
  • Environmental services manager
  • Infection control practitioner

The purpose of the multiple individuals is to get a rounded diversified opinion concerning the risk and the mitigation factors. While it is not a requirement, I would advise you to send the completed risk assessment to your Safety Committee for their review and approval, and get the results of the risk assessment entered into their minutes.

Changes to Joint Commission Standards for 2014: Part 1

calendar_quarterly[1]Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define time, and the other…. well we will discuss that in a later posting.

Currently, Joint Commission defines the period of time between required activities, such as testing and inspecting, to be as follows:

  • Weekly, or ‘every 7 days’:   Anytime during the week
  • Monthly, or ‘every 30 days’:   Anytime during the month
  • Quarterly, or ‘every 3 months’:   Anytime during the quarter
  • Semi-annually, or ‘every 6 months’:   6 months from the previous activity, plus or minus 20 days
  • Annually, ‘every 12 months’:   12 months from the previous activity, plus or minus 30 days
  • 3-Years:   36 months from the previous activity, plus or minus 30 days

The change beginning in 2014 involves Quarterly and 3-Year intervals. Now, Joint Commission will define Quarterly as follows:

Quarterly, or ‘every 3 months’:   3 months from the previous activity, plus or minus 10 days.

This change has far-reaching consequences, especially for fire drills. When I was a safety officer at the hospital where I worked, I was responsible for fire drills. Now, I will tell you that I did not enjoy conducting fire drills, as most of the people that participated in the drill, complied only because they had to, and they considered it a major inconvenience to their daily routine. My staff and I understood the importance of doing fire drills, but we were pretty much the only ones. Therefore, since I didn’t enjoy doing fire drills, I tended to ‘put them off’ or procrastinate in doing them, until the last days of the quarter. I was not as organized in doing them as I should have been.

If other hospital safety officers are like me, then this new change in how Joint Commission defines “Quarterly” will be a serious issue. They will have to develop a specific schedule of doing the drills in accordance with the new description, and be disciplined enough to stick with it. This will require organization skills. Make note of this and if you are not the individual responsible for fire drills in your organization, then send this post to the person who is.

Also, this affects all other quarterly testing and inspection activities, such as:

  • Waterflow switches
  • Supervisory signal devices (not tamper switches)
  • Off-premises monitoring transmission equipment (usually conducted with the fire drill)
  • Fire department connections (FDC)

During a recent webinar sponsored by ASHE, George Mills of the Joint Commission explained that this change in how they defined “Quarterly” came from another department and he unsuccessfully argued against the change.

The other change in how Joint Commission defines time between testing and inspection activities is the 3-Year test. It will now read as follows:

3-Years: 36 months from the previous activity, plus or minus 45 days

This is a change from “plus or minus 30 days” and can only be considered a positive for the facility manager. What is strange about this issue, is I heard George Mills says “pus or minus 45 days” for 3-Year testing intervals a couple of years ago at an ASHE annual conference, so I advised my clients as such. Then, last year when one of my clients went 36 months, plus 40 days between the 3-Year generator load test, the surveyor cited them for non-compliance. We wrote a clarification on the finding saying plus or minus 45 days was acceptable, and Joint Commission denied it. So, I’m glad they finally made a decision and let’s hope they stick to it.

Next week’s posting: We will discuss the changes to the monthly generator load testing.