Clarifications Part 4

I continue my series on clarifications of surveyor findings that I have written for a client.

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Clarification for EC.02.06.01, EP 13

EC.02.06.01, EP 13: The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment and services provided.

Surveyor finding:

During a tour of the operating rooms it was noted that the temperature in a recently used operating room was 59 degrees. Nursing and medical staff noted that there were occasions when physicians asked that the temperature in a room be lowered below 68 degrees for personal comfort rather than patient care.

The Soiled Utility room number 6630 has airflow coming out of the room instead of flowing into the room.


Who: The Director of Facilities is responsible for the implementation and compliance of the utility management program at XYZ Hospital.

What: The ventilation requirements for the operating rooms are based on design recommendations from the Guidelines for Design and Construction of Health Care Facilities, as written by The Facilities Guidelines Institute (FGI), and published by the American Society for Healthcare Engineering. These guidelines are not regulatory requirements, as stated in the preface of the FGI document, and as indicated in the Joint Commission standard EC.02.06.05, EP 1. Another Joint Commission standard, EC.02.05.01, EP 1, specifically states: “The hospital designs and installs utility systems that meet patient care and operational needs.”  While the FGI Guidelines were used during the design of the operating rooms, it was fully understood and planned by the hospital with careful input from the medical staff for ventilation settings outside the range that the FGI Guidelines recommended. There are legitimate reasons to have the air temperature lower than the minimum FGI recommendations, such as the operational needs during the surgery. (See “Why” below).

When: Ventilation settings in operating rooms are carefully monitored by Surgery and Plant Operations staff. Normal temperature ranges are adhered to, with the exception when a surgeon makes a request to have the operating room temperature set outside of the recommended range.

How: Operating room staff is educated in the normal ventilation requirements of surgical procedures. New-hires are orientated on all policies and procedures in the Surgery department, and any changes or updates to policies or procedures are communicated to all staff in the Surgery unit.

Why: The request to have the temperature setting in the operating room lower than what is recommend by the FGI Guidelines is not just for surgeon personal comfort, as the surveyor wrote in his finding. This is an operational need for a successful surgical procedure based on the many layers of surgical attire worn by the surgeon and the procedures required during surgery. The layers of attire worn by the surgeon during the procedure include:

  • Undergarments;
  • Surgical scrubs;
  • Sterile surgical gowns;
  • A hooded mask.

The hooded mask is similar to a Hazmat hood and has little air flow. The procedure is performed underneath high wattage intense surgical lights which produce heat, and the procedure requires physical manipulation of the patient’s limbs during prosthetic replacements. The many layers of attire, the heat from the surgical lights, and the physical assertion required during the surgery ultimately requires a lower air temperature in the operating room in order to have a successful surgery, which ultimately is the mission of the organization to provide excellent patient care. Without the lower temperature setting, the surgeon would suffer from physical exhaustion and fatigue, which would jeopardize the success of the surgery and the care provided to the patient.

The decision to set the operating room temperature below a recommended range is not taken lightly, and only done so under the direction of the attending surgeon. Surgery Department policy #12375-2.30 specifically allows for the operating room temperature to be set lower than the 68° to 73°F range at the request of the surgeon for certain surgical procedures.

Therefore, since the 68 degree temperature range is based on guidelines and recommendations and not regulations; since Joint Commission standards permits the operation of utility systems that meets operational needs; and since the air temperature setting that the surveyor observed was permitted in accordance with hospital policy; XYZ Hospital respectfully requests that The Joint Commission vacate this finding under EC.02.06.01, EP 13, and consider this standard to be ‘Compliant’.


Result? The accreditor did not accept this clarification…. and I think I know why. We made a very good argument that the temperature settings are recommendations only and not regulations, and the hospital had a great reason to have air temperature set lower than recommended. Had that been the only finding the surveyor wrote under this standard I think the accreditor would have accepted the clarification. But there were two findings: the other was improper air pressure relationship for a soiled utility room. We had nothing for that finding. So we decided to argue on the OR temperature setting issue and hope that they would overlook the soiled utility finding.

They didn’t. Oh well… It is what it is.

If you’re keeping track, the score is:   Accepted 1: Not Accepted 3