|Assessment||Facility Type/Area||Project Scope||Guidelines
|Infection control risk (ICRA)||AII||
1. New construction
2. AII renovations
|Patient handling and movement (PHAMA)||Areas where patient handling, transport, transfer, and movement occur||
1. New construction
2. Major renovation and renovations changing functional use of space
3. Minor and minimal renovations where patient handling occurs
|Fall prevention||Any area to which a patient or family member has access||
1. New construction
2. Major renovation and renovations changing functional use of space
3. Minor and minimal renovations where patient falls may occur
|Medication safety||Medication safety zones||
1. New construction
2. Major renovation and renovations changing functional use of space
3. Minor and minimal renovations where medication preparation, processing, and distribution occurs
|Behavioral and mental health risk||Any area where behavioral health patient care is provided||
1. New construction
2. Major renovation and renovations changing functional use of space to include care of behavioral health patients
3. Minor and minimal renovations where behavioral health patient treatment occurs
1. New construction
2. AII renovations
|Infection control risk||Patient handling and movement||Fall prevention||Medication safety||Behavioral and mental health risk||Security risk|
|Clinicians from services affected by the project|
|Facility management staff|
|Performance and/or quality improvement experts|
|Architects, interior designers, and/or engineers|
|Human factors specialists|
|Other appropriate individuals based on nature of the project||As needed||As needed||As needed||As needed||As needed||As needed|
|Exterior Site Noise Exposure Category||A||B||C||D|
|Distance from nearest highway (ft.)||> 1000||250—1000||60—249||< 60|
|Slant distance from nearest aircraft flight track (ft.)||> 7000||3500—7000||1800—3499||< 1800|
|Distance from nearest rail line (ft.)||> 1500||500—1500||100—499||< 100|
- The multidisciplinary project team should be assembled as early as possible in the design process.
- The multidisciplinary team may include administrators, clinicians, infection preventionists, architects and other design professionals, facility managers, safety officers, security managers, users of equipment, and support staff relevant to the areas affected by the project as well as those with knowledge of the organization's functional goal for the project. Inclusion of patient advocates/consumers, A/E consultants, and construction specialists should be considered.
- For small outpatient facility projects, the project team is likely to include fewer participants than listed in paragraph a. An individual participant may provide expertise in multiple categories. The frontline provider of the health care services and facility owner or care provider leadership (if that is someone different) may be the only person(s) in addition to the architect(s) or other design professional(s) on a very small project. The goal is to include the key stakeholders responsible for care delivery and determine if additional outside expertise is necessary (e.g., infection preventionist, ergonomist).
- The health care environment should enhance the dignity of the patient through features that permit privacy and confidentiality.
- Stress can be a major detriment to the course of a patient's care. The facility should be designed to reduce patient, family, and staff stress wherever possible. Research and evidence-based materials are available to support these goals and should be referred to during design.
- As technology changes, flexibility is in the best interests of quality care.
- Health care economics continuously apply pressure to management. Therefore, every effort should be made during the design process to enhance the performance, productivity, safety, and satisfaction of staff to promote a safe environment of care.
- Creativity should be encouraged in the design process to enhance the environment of care.
|Design Element||Facility Type/Room Type||Guidelines Section|
|HVAC Systems||Outpatient surgery facilities Endoscopy facilities||Part 3 (ASHRAE 170)|
|Imaging facilities with Class 2 and 3 imaging rooms Infusion centers Renal dialysis centers||Part 3 (ASHRAE 170) for room types listed in the "Design Parameters" table for outpatient facilities|
|General and specialty medical services facilities Birth center Urgent care center Imaging facilities with Class 1 imaging rooms Outpatient psychiatric centers Outpatient rehabilitation facilities||State and local building codes|
|Dental facilities||Part 3 (ASHRAE 170) for rooms where anesthesia is provided|
|Hand scrub facilities (scrub sinks)||Outpatient facilities||2.1-184.108.40.206, 2.1-3.8.6, 2.1-220.127.116.11|
|Hand-washing stations and hand sanitation dispensers||Outpatient facilities||2.1-2.5, 2.1-18.104.22.168, 2.1-3.8.7, 2.1-22.214.171.124|
|Ice-making equipment||Outpatient facilities||2.1-3.8.10, 2.1-126.96.36.199|
|Potable water supply systems||Outpatient facilities||2.1-188.8.131.52|
|Heated potable water distribution systems||Outpatient facilities||2.1-184.108.40.206|
|Drainage systems (piping, floor drains, condensate drains)||Outpatient facilities||2.1-220.127.116.11|
|Showers and tubs||Outpatient facilities||2.1-18.104.22.168|
|Clinical sinks||Outpatient facilities||2.1-22.214.171.124|
|Emergency eyewash and emergency shower stations||Outpatient facilities||2.1-126.96.36.199|
|Hydrotherapy facilities||Outpatient facilities||2.1-188.8.131.52|
|Hemodialysis water distribution||Renal dialysis centers||2.10-184.108.40.206|
|Hemodialysis water treatment equipment area||Renal dialysis centers||2.10-8.4.2|
|Surfaces and Furnishings|
|Surfaces||Renal dialysis centers||Based on the ICRA|
- All projects, large and small, require a functional program to guide the design. The length and complexity of the functional program will vary greatly depending on project scope. The functional program for a small, simple project might consist of a simple sketch or a description of a few sentences.
- The functional program can be used as a supplement to the construction documents; it is not intended to be approved by the authority having jurisdiction.
- The functional program shall be completed as part of the project planning phase and updated, as needed, throughout the design and construction phases.
- Following its approval, the functional program shall serve as the basis for the project design and construction documents.
- A description of construction type(s) for the proposed project
- A description of proposed occupancy(ies) and, if applicable, existing occupancy(ies)
- A description of the existing construction type and construction type for any proposed renovations or additions
- A general description of existing engineering systems serving the area of the building affected by the proposed project
- Gross floor area for the project should be aggregated by department, and multiplying factors should be applied to reflect circulation and wall thicknesses within the department or functional area. This result is referred to as department gross square footage (DGSF).
- DGSF for the project should be aggregated, and multiplying factors should be applied to reflect circulation patterns, exterior wall thicknesses, engineering spaces, general storage spaces, vertical circulation, and any other areas not included within the intra-department calculations. This result is referred to as building gross square footage (BGSF) and reflects the overall size of the project.
|Exterior Site Noise Exposure Category||A||B||C||D|
|General description of category||Minimal||Moderate||Significant||Extreme|
|Outdoor average sound level during occupancy hours (Leq) (dBA)1||< 65||65-69||70-74||≥ 75|
|Outdoor average hourly nominal maximum sound level (L01)1 (dBA)||< 75||75-79||80-84||≥ 85|
|Design Criteria for Exterior Shell Sound Isolation in New Construction2|
|Minimum exterior shell composite sound transmission rating3, 4, 5||OITCc: 25 |
|OITCc: 30 |
|OITCc: 35 |
|OITCc: 40 |
|Patient Care and Diagnostic Areas|
|Class 2 imaging room||0.15|
|Class 3 imaging room||—3|
|Medication safety zone||0.15|
|Waiting area (near patient care areas)||0.25|
|Corridor (near patient care areas)||0.15|
- Underlying conditions include the physical environment, organizational and social factors, and task characteristics that can be affected by the design of a space, including the following:
- -Visual distraction and disorganization of space
- -Light type, quality, and quantity for each location
- -Surface characteristics for different spaces
- -Indoor air characteristics for different spaces
- -Sources of infection
- -Staff fatigue
- -Space required to accommodate functions
- -Standardized locations for equipment (e.g., medical gas outlets, emergency call buttons)
- -Opportunities for, and barriers or disincentives to, mobilization of patients
- -Impediments to movement, maneuvering, and flow
- -Communication systems
- -Visibility of patients
- -Automation (where possible)
- -Support for family involvement in outpatient care
- -Multi-use areas (e.g., a clinic located within a retail grocery store)
- The multidisciplinary project team should carefully consider how outpatient facilities are sited, particularly as venues for outpatient care become more diverse and integrated with other functions. Retail settings provide additional opportunities and challenges that should be studied during the planning phases. For example, when designing a clinic within a larger retail environment, the project team should consider how access to the location might impact patients and other users. Venues with incongruent features (e.g., a site adjacent to a tobacco products display) should be avoided.
- For additional information, see the Center for Health Design report "Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process," which identifies 10 environmental factors as "latent conditions that can be designed to help eliminate harm." Such "built environment latent conditions [holes and weaknesses] that adversely impact patient safety" should be identified and eliminated during the planning, design, and construction of outpatient facilities. The report can be found on the Center for Health Design website.
- Written records shall remain an active part of the project documents for the duration of design, construction, and commissioning.
- The records shall include the SRA recommendations report and any documentation completed as part of the SRA process.
- The SRA team shall provide updates to the planners and designers for compliance with additional levels of detail generated during the project for all safety components listed in Table 1.2-1 (Safety Risk Assessment Components).
- Changes to the original design plans shall be documented, updated, and continually shared between the SRA team and the designers, planners, governing body, and contractor.
- Identify and plan safe design elements, including consideration of long-range infection prevention.
- Identify and plan for internal and external building areas and sites that will be affected during construction/renovation.
- Identify potential risk of transmission of airborne and waterborne biological contaminants during construction and/or renovation and commissioning.
- Develop infection control risk mitigation recommendations (ICRMRs) to be considered.
- Design recommendations generated by the ICRA
- Infection control risk mitigation recommendations (ICRMRs). See Section 1.2-220.127.116.11 (Infection control risk mitigation recommendations).
- Characteristics of overall HVAC system design as well as design for specific sensitive areas, including components, capacity, filtration, air changes, pressure relationships, and directional flow
- Ease of access for HVAC system maintenance
- Ease of general maintenance activities and system cleaning
- Selection of air distribution devices that allow for minimal or easy cleaning
- Location of air intakes and exhaust outlets to prevent cross-contamination
- Redundancy in equipment and systems
- Plan for HVAC system outages and maintenance (both planned and unplanned)
- Airflow into the construction zone from occupied spaces should be maintained by means of a dedicated exhaust system for the construction area.
- Locations of exhaust discharge relative to existing fresh air intakes and filters, as well as the disconnection and sealing of existing air ducts, should be reviewed as required by the ICRA.
- If the existing building system or a portion thereof is used to achieve this requirement, the system should be thoroughly cleaned prior to occupancy of the construction area.
- Outpatient facility construction barriers for projects in high-risk areas should be maintained at a pressure differential of at least 0.03-inch water gauge (7.0 Pascals), with airflow from facility clean areas to construction dirty areas. Construction barriers in high-risk areas should have visual display of airflow direction. (High-risk areas include freestanding emergency facilities, outpatient surgery facilities, areas serving pediatric patients, pharmacies, post-anesthetic care units, areas serving immunocompromised patients, Class 2 and Class 3 imaging rooms, central sterile supply, airborne infection isolation rooms, cancer treatment facilities, and dental treatment areas.)
- The governing body should provide a written plan for what will happen in the event of a water outage. This should include location of supplies, who is responsible for what, and who is to be notified.
- The governing body should provide a written plan for what will happen in the event of an air shutdown. This should include who is responsible for what and who is to be notified.
- The governing body should provide a written plan for what will happen in the event of a water leak. This should include who is to be notified.
- Construction materials should be kept clean and dry, as appropriate.
- Ductwork should be kept capped/clean during demolition and dust-generating construction.
- Drywall installation should not proceed until exterior protection against rain damage has been installed.
- The governing body shall provide monitoring plans for effective application of ICRMRs during the course of the project.
- Provisions for monitoring shall include:
- Written procedures for emergency suspension of work
- Protective measures indicating the responsibilities and limitations of each party (i.e., governing body, designer, contractor, and monitor)
- The PHAMA has two distinct yet interdependent phases: Phase 1: A patient handling, movement, and mobility needs assessment is performed to identify appropriate patient handling and movement equipment for each patient care area.Phase 2: The space, structural, and other design requirements needed to accommodate patient handling and movement equipment and to facilitate patients' weight-bearing and physical activity are determined.
- Information and guidance for conducting a PHAMA can be found in the FGI white paper titled "Patient Handling and Movement Assessment: A White Paper" posted under the Resources tab at www.fgiguidelines.org. The white paper also explains the rationale for considering patient handling equipment during the design and construction process, information (including illustrations) about various types of patient-handling equipment, the business case for implementing patient handling and movement programs, and strategies for implementing such programs.
- Caregivers repositioning and transferring patients cannot lift more than 35 pounds manually without putting themselves at risk for back injuries. As a consequence, caregivers are one of the groups at highest risk for injury of any industry, and manual patient handling and moving are the primary causes. If caregivers are not equipped to perform these necessary physical tasks safely, patients may not receive adequate care and may remain inappropriately immobile. Equipment is now available to facilitate necessary clinical work while significantly reducing the risk of caregiver and patient injury from patient handling, moving, transfer, transport, and mobilization activities. By better supporting appropriate levels of care and reducing risk of injury to caregivers, use of such equipment and related architectural accommodations will improve outcomes and reduce the overall cost of care.
- The following definitions apply to text in Section 1.2-4.3 (Patient Handling and Movement Assessment):
- -Whenever the term "equipment" is used, it refers to patient handling and movement equipment.
- -"Fixed" equipment refers to equipment with track systems attached at some point within the room. Fixed equipment includes overhead (ceiling-mounted or wall-mounted) lifts and other lifting devices with fixed tracking. An alternative would be a demountable track that may be fully or partially disassembled and removed from the space.
- -"Portable" or "mobile" equipment is floor-based equipment that moves on the floor surface, such as floor-based sling lifts and sit-to-stand lifts. These may be moved horizontally manually or with the assistance of motorized wheels. When the term "portable" is used in connection with ceiling lifts, it may also refer to a lift motor and hoist that can be removed from the track system in one room and attached to the track system in another room.
- In addition to the factors listed in the main text, recommendations for patient handling, movement, and mobility equipment are also based on the following:
- -Patient dependency levels. This information is critical in determining patient handling and movement needs. To simplify determination of dependency levels, patients are usually grouped into categories based on physical limitations (not clinical acuity). Recommended categories include total dependence/extensive assistance, partial assistance, and independent.
- -Consideration of the weight and size of patients of size. This is important to assure equipment with appropriate capacities is provided.
- -Patient handling, movement, and mobility tasks for which equipment is used to minimize risk. These should include the following:
- • Vertical and lateral transfers (from/to an exam table, gurney, stretcher, chair, commode, toilet, or wheelchair)
- • Repositioning in chair
- • Lifting appendages
- • Transporting patients
- • Assisting patient ambulation
- To correctly identify all high-risk patient handling tasks and impediments or hindrances to patient mobility in an area, analyze injuries in the area for common task involvement, conduct walkthroughs, and interview and/or survey frontline staff (e.g. nursing, rehab, therapists) for their perceptions of high-risk tasks.
- Many types of patient handling and movement equipment are available, but only those that affect building design need be considered in a PHAMA. New equipment designs will need to be evaluated for building design impact as they become available. Presently, equipment that significantly influences design includes, but is not limited to, exam tables/stretchers/trolleys/gurneys, wheelchairs, and lateral transfer devices. Fixed patient lifts (i.e., ceiling- and wall-mounted lifts) and portable patient lifts (e.g., sit-to-stand lifts and floor-based sling lifts) are further described below, as their design impact may be significant. Other transfer devices and accessories in addition to those mentioned above (e.g., slings, transfer sheets and boards, and trapezes) influence design to the extent that storage is required.
- -Sit-to-stand lifts are used to assist a patient who requires partial assistance and who possesses some weight-bearing ability. Sit-to-stand lifts assist in vertical transfers, toileting, dressing, peri-care, and ambulation.
- -Floor-based sling lifts and ceiling-mounted lifts are used for patients who are completely or substantially unable to assist caregivers. Patients requiring these levels of care are often described as "dependent" or requiring "extensive assistance." The utility of these lifts for this population includes-but is not limited to-vertical transfers, lateral transfers, repositioning in bed and chair, lifting appendages, and lifting patients from the floor. These lifts can also be used for assistance with ambulation rehabilitation or mobilization of patients with some weight-bearing capability.
- The average percentage of "dependent/extensive assistance" patients should be used to determine the number and placement of fixed lift systems and/or the quantity of floor-based sling lifts.
- Installation of fixed lift systems will reduce, but not eliminate, the need for floor-based lifts since most fixed lift systems do not provide complete coverage of patient use areas.
- The number of patients who need partial assistance should be used to determine the number of sit-to-stand lifts needed. A ratio of one lift per 8 to 10 patients may be used.
- Peak patient handling times may increase the quantity of lifts required.
- For portable lifts. Battery-charging areas with electrical services should be provided in storage rooms for portable, floor-based lifts and other assistive devices.
- For fixed lifts. Access to both electrical power and emergency control features (often suspended from the motor housing) should be provided for fixed lifts.
- Accessibility of patient-handling equipment is critical to assuring it will be used. Storage needed for the type and quantity of equipment identified during the project planning phase should be incorporated during project design.
- Storage will be needed for patient handling equipment accessories such as lift slings, hanger bars, and trapezes as well as for other patient-handling equipment. Operational considerations when determining storage space requirements include:
- -Surplus slings should be stored in the same location as portable lifts.
- -In storage areas, large hooks should be installed for hanging slings or shelving should be provided for storage of folded slings.
- -Standard shelving should be provided for storage of an assortment of slings for lifts, extra lift hanger bars, and other patient-handling equipment, such as friction-reducing devices and air-assisted lateral transfer aids with motor(s).
- -Storage alternatives: For small areas, centrally located storage may be provided. For large or small areas, storage may be provided in alcoves or storage areas interspersed throughout the unit.
- Flooring. See 2.1-18.104.22.168 (Flooring and wall bases) and their appendices for information.
- Equipment. See appendix section A1.2-4.3 (Patient Handling and Movement Assessment) for a description of equipment to support patient handling and movement and reduce the risk of patient falls.
- Standards for barriers and other protective measures required to protect adjacent areas and susceptible patients from clutter and construction dust on flooring
- Protection from demolition debris on flooring
*1.2-4.6 Behavioral and Mental Health Risk (Psychiatric Patient Injury and Suicide Prevention) Assessment
- The governing body should develop a detailed assessment of the level of risk for each program area where mental health patients will be served (e.g., freestanding emergency facilities, clinics). See appendix table A1.2-a (Safety Risk Assessment Team Member Expertise) for areas of expertise needed on the behavioral and mental health assessment team.
- Each area should be evaluated to identify the architectural details, surfaces, and furnishings and exposed mechanical and electrical devices and components to be addressed in the risk assessment. Examples of areas to be included in a mental health risk assessment include the following:
- -Highest level
- • Seclusion rooms (where patient acuity poses an increased risk)
- • Patient toilet rooms
- • Psychiatric emergency department (comprehensive psychiatric emergency program, or CPEP, an area under good supervision but dealing with unpredictable patients under initial evaluation and often under heavy medication)
- -Moderate level
- • Activity spaces, group rooms, and treatment spaces (supervised with good visibility)
- • Dining rooms and recreation spaces, both indoor and outdoor
- • Corridors (always visible)
- -Lower level
- • Exam rooms and private offices
- • Staff and support areas (not accessible by patients)
- -Highest level
- This patient environment shall be designed to protect the privacy, dignity, and health of patients and address the potential risks related to patient elopement and harm to self, others, and the care environment.
- The design of behavioral/mental health patient areas shall accommodate the need for clinical and security resources.
- Security considerations for project design
- -Parking and exterior spaces. Outpatient facility surroundings may include open space, parking facilities, and private roadways and may border other businesses, residential properties, or major transportation routes. Lighting design should be provided for parking and exterior spaces.
- -Buildings and interior spaces. Outpatient facilities may include non-patient care areas such as academic and research space. These areas may present specific risks or security concerns. The physical design of buildings and integration of electronic security systems in the built environment are important components of the facility protection plan and the patient, visitor, and staff experience.
- • Security plan. The project design should include a comprehensive security plan that indicates a layered approach to access control, including zones, control points, circulation routes, and required egress paths.
- • Protected health information. The design of outpatient facilities should address all forms of confidential patient information commonly referred to as protected health information (PHI). The design should address the ways in which this information could be compromised and should apply integrated physical and electronic security systems (e.g., access control and audit features) to locations such as registration, interview, clinical, storage, and waste areas as well as in data systems.
- • Utility and mechanical systems and other infrastructure. The risk assessment should address the need to secure spaces and systems that provide for system reliability and, as required, redundancy. The design of utility, mechanical, and infrastructure-related spaces in outpatient facilities should include the recognition that such spaces and the mechanical, electrical, plumbing, and information technology (IT) systems in them are critical assets for the provision of uninterrupted patient care, basic building comfort, and extraordinary emergency response capabilities.
- • Biological, chemical, and radioactive materials. Areas in outpatient facilities containing highly hazardous materials are frequently regulated and should be designed accordingly. Their design should also address the unique security risks presented by highly hazardous materials (e.g., biological, chemical, and radioactive materials) that may be present in patient care, laboratory, hazardous waste storage, or other locations.
- Emergency management security considerations. Some outpatient facilities may provide both scheduled and emergency services, serve as part of local emergency response networks, and be expected to be functional, safe, and secure for patients, visitors, and staff while remaining prepared for natural and man-made emergencies 24 hours a day.
- -The design of the facility should address the facility's role in responding to internal and external emergencies on its own or in coordination with local emergency response or public health authorities based on assessed risks. All other regulations for emergency operations should be considered when developing the design.
- -An all-hazards approach to design should be applied to help the facility prepare for, respond to, and recover from man-made events and natural disasters.
|ROOM TYPE||NC/RC(N)/RNC2, 3, 4||dBA|
|Patient Care and Diagnostic Areas|
|Multiple-occupant patient care area||45||50|
|Class 2 imaging room||40||45|
|Class 3 imaging room5||50||55|
|Medication safety zone||40||45|
|Testing/research lab, minimal speech||55||60|
|Research lab, extensive speech||50||55|
|Group teaching lab||45||50|
|Corridors and public areas||45||50|
|Auditorium, large lecture room||30||35|
- Access to natural light should be provided no farther than 50 feet from any patient activity area, visitor space, or staff work area. To the extent possible, the source of such natural light should also provide opportunities for exterior views.
- Access to natural light should be available without entering private spaces. Examples of such access include windows at the ends of corridors, skylights into deep areas of the building in highly traveled areas, transoms, and door sidelights.
- Artificial lighting strategies. The Illuminating Engineering Society (IES) has developed two publications that apply to health care facilities. ANSI/IES RP-29: Recommended Practices for Lighting for Hospitals and Health Care Facilities addresses lighting for the general population and special lighting for medical procedures. ANSI/IES RP-28: Recommended Practices for Lighting and the Visual Environment for Seniors and the Low Vision Population addresses the special lighting needs of older adults.
- Color rendering properties should be addressed in lamp selection.
- Finish selection should address light reflectance values (LRV) in conjunction with lamp selection.
- Indirect lighting should be considered to reduce glare.
- Ideally, the design for an outpatient facility would include direct physical access to the outdoors as well as views of nature and indoor gardens/atria. When direct access is not possible, suitable alternatives could include indoor gardens with natural light (atria) and visual access to nature, as defined by Green Guide for Health Care Environmental Quality Credit 8.2 and Sustainable Sites Initiative Credit 6.7.
- Separate outdoor respite areas for medical and support staff should be provided. For practical guidelines for the percentage of space allocated for these areas, refer to LEED for Health Care and Green Guide for Health Care requirements as well as Sustainable Sites Initiative Credit 9.1.
- Outpatient facilities should provide a garden or other controlled exterior space that is accessible to building occupants. Consider specifically designed therapeutic and restorative gardens for patients and/or caregivers, as appropriate. Exterior spaces should be located to accommodate staff observation. Therapeutic and restorative gardens should be designed by landscape architects with knowledge and experience specific to health care design as part of the interdisciplinary design team.
- Opportunities for active as well as passive interaction with nature in outdoor space(s) should be provided (e.g., opportunities for exercise and play or other types of physical activity and for physical, occupational, horticultural, or other therapies).
- Signage, other wayfinding features, and/or views of outdoor garden(s) and/or atria should be provided to encourage their use.
- Access to both sun and shade, with trees and/or built shade structures, should be provided. Shady places are particularly important for patients who are photosensitive.
- When access to outdoor space is not restricted, automatic door openers, flat door thresholds, and other physical connections between indoors and outdoors that facilitate easy access should be provided.
- Use of harmful and poisonous plants should be avoided, especially in gardens for children, the developmentally disabled, and people with dementia.
- Outpatient facility entry points should be clearly identified from all major exterior circulation modes (e.g., roadways, bus stops, vehicular parking).
- Clearly visible and understandable signage, icons, universal symbols, visual landmarks (including views to the outside), and/or cues for orientation (including views to the outside) should be provided.
- Boundaries between public and private areas should be well marked or implied and clearly distinguished.
- A system of interior "landmarks" should be developed to aid occupants in cognitive understanding of destinations. To be effective, landmarks should be unique and used only at decision points. Landmarks may include sealed water features, major art, distinctive color, or decorative treatments. These features should attempt to involve tactile, auditory, and language cues as well as visual recognition. When color is used as a wayfinding device, it should support the primary wayfinding system elements and be clearly distinguished from color palette decisions unrelated to wayfinding.
- Signage systems should be flexible, expandable, adaptable, and easy to maintain. Signage should be consistent with other patient communications and supporting print, Web, and electronic media.
- Lighting in patient and staff areas should allow for individual control and provide variety in lighting types and levels.
- Building systems design should address individual control over the thermal environment through carefully considered zoning of mechanical systems that permits control of heating and cooling to achieve thermal comfort for individual patients and for staff in staff areas.
- Noise has been proven to be an environmental stressor for patients, families, and staff; therefore, the effects of noise should be a high priority in the design of the physical environment and the selection of operational systems and equipment.
- -Where feasible and clinically safe to do so, patients should be able to have some control of their acoustic environment. Staff should be able to switch medical alarms and communication equipment such as paging and nurse call systems to staff communication devices and/or to an acoustically protected room or area under caregiver supervision.
- -Use of personal mobile devices should be considered in place of overhead paging systems.
- -Patients and staff should be able to activate sound-masking technology to help mask unwanted sounds that affect the patient environment.
- -Noise-canceling headsets or hearing protection devices should be available for patient use.
- -In waiting areas with television, alternate listening devices should be available to offer patients a choice of quiet.
- Personal storage. When length of stay is extensive, accommodations for patients' personal belongings should be provided. Staff should have a place to secure their personal belongings.
- Public circulation and staff/patient circulation should be separated wherever possible.
- Waiting areas for patients on stretchers or in gowns should be located in a private zone within the plan, out of view of the public circulation system.
- Private alcoves or rooms should be provided for all communication concerning personal information relative to patient illness, care plans, and insurance and financial matters.
- Provision of readily accessible and visible external access points to the facility should be balanced with the ability to control and secure all access points in the event of an emergency. Factors such as adequate exterior lighting in parking lots and at entry points to the facility and appropriate reception/security services are essential to ensuring a safe environment.
- Since the strict control of access to an outpatient facility is neither possible nor appropriate, safety within the facility should also be addressed through the design of circulation paths and functional relationships.
- Provisions should be made for securing the personal belongings of staff, visitors, and patients.
- The physical environment should be designed to support the overall safety and security policies and protocols of the institution.
- Security monitoring, when provided, should respect patient privacy and dignity.
- Organizational culture is defined by the history of the organization, leadership philosophy, management style, and caregivers' dispositions. Also consider the clinical functions being served (e.g., pediatrics, geriatrics, oncology).
- Regional culture is defined by the physical location and demographics (including age, nationality, religion, and economics) of the communities served. Cultural responsiveness to community-specific issues such as demographic density in urban, suburban, and rural communities should be considered.
|Patient Care and Diagnostic Areas|
|Examination room||Corridor (with entrance)||353|
|Examination room||Examination room (with electronic masking)||404|
|Examination room||Examination room (no electronic masking)||50|
|Examination room||Public space||50|
|Examination room||MRI room||605|
|Treatment room||Corridor (with entrance)||353|
|Treatment room||Treatment room||50|
|Operating room||Operating room||50|
|Operating room||MRI scanner room||605, 6|
|Consultation room||Corridor (with entrance)||353|
|Consultation room||Public space||50|
|Toilet room||Public space||45|
|Public space||MRI room||50|
- The definitions of acoustics terms used in this publication most often are based on ANSI S1.1: Acoustical Terminology. See "Sound & Vibration: Design Guidelines for Health Care Facilities," the Acoustics Research Council white paper coordinated with the FGI Guidelines and available through the Facility Guidelines Institute website (www.fgiguidelines.org), for the glossary of acoustic terminology used in this document.
- Limits set by codes often are expressed as maximum A-weighted sound levels in dBA. Separate limits are typically set for day and night periods, with the nighttime limit typically 5 to 10 dBA lower than the daytime limit. Daytime limits typically vary between 55 and 65 dBA.
- Following are some acoustic design codes, regulations, and guidelines that should prove useful for outpatient facilities:
- -U.S. Department of Health and Human Services regulations (including HIPAA)
- -Federal Aviation Administration (FAA) guidelines for helipad design, construction, and operation
- -Building code used by the local or state jurisdiction
- -Local and state limits on environmental sound
- -Occupational Safety and Health Administration (OSHA) regulations for worker noise exposure in areas where sound levels exceed 85 dBA
- -Professional society design guidelines for noise (e.g., ASHRAE guidelines for mechanical system sound and vibration control)
- -American National Standards Institute (ANSI) guidelines for sound in building spaces and special spaces (e.g., booths for measuring hearing threshold)
- -Manufacturers' guidelines for medical equipment that is sensitive to sound and vibration or equipment that produces sound and/or vibration
- Exterior noise exposure for the project site shall be classified according to the categories shown in Table 1.2-3 (Categorization of Outpatient Facility Sites by Exterior Ambient Sound).
- The exterior noise classification category(ies) identified for a project site shall be used to determine the degree of sound attenuation required in the building façade due to sources of exterior noise, including sources being added by the facility.
- The building façade shall have a sound isolation rating (which depends on the site noise classification category) that complies with minimum exterior shell composite sound transmission ratings, either OITCc or STCc, as shown in Table 1.2-3 (Categorization of Outpatient Facility Sites by Exterior Ambient Sound).
- The sound levels for noise exposure categories A through D provided in Table 1.2-3 and appendix table A1.2-b should be used to evaluate required health care building envelope sound isolation and may differ from other such categorizations of community noise made elsewhere in this document. Category A-Minimal environmental sound. As typified by a rural or quiet suburban neighborhood with ambient sound suitable for single-family residences sound produced by transportation (highways, aircraft, and trains) or industrial activity may occasionally be audible but is only a minor feature of the acoustic environment.Category B-Moderate environmental sound. As typified by a busy suburban neighborhood with ambient sound suitable for multifamily residences sound produced by transportation or industrial activity is clearly audible and may at times dominate the environment but is not loud enough to interfere with normal conversation outdoors.Category C-Significant environmental sound. As typified by a commercial urban location, possibly with some large apartment buildings sound produced by transportation or industrial activity dominates the environment and often interferes with normal conversation outdoors.Category D-Extreme environmental sound. As typified by a commercial urban location immediately adjacent to transportation or industrial activities, sound nearly always interferes with normal conversation outdoors.
- Environmental noise on Category B, C, and D sites generally may be evaluated using the methods given for documenting site ambient sound levels using continuous sound monitoring over a minimum one-week period in ANSI/ASA S12.9: Quantities and Procedures for Description and Measurement of Environmental Sound, Part 2: "Measurement of Long-Term, Wide-Area Sound." This information should be used to determine detailed environmental noise control requirements for building design. Sites where ambient sound is influenced by airport operations may require additional monitoring as suggested in the ANSI standard to account for weather-related variations in aircraft sound exposure on site. In lieu of performing such additional monitoring, aircraft sound level contours available from the airport (if available) should be used to determine the day-night average sound level on-site produced by nearby aircraft operations. Sound-level monitoring on-site will still be needed to determine sound levels produced by other sources.
- Table 1.2-3 and appendix table A1.2-b present general descriptions for exterior sound exposure categories A through D, including distance from major transportation noise sources, ambient sound levels produced by other sound sources, and corresponding design goals for the sound isolation performance of the exterior building shell. The outdoor sound levels, expressed as A-weighted day-night average sound levels, are provided in the context of exterior building shell design. Outdoor patient areas may require lower sound levels, typically not exceeding a day-night average level of 50 dB. To achieve this may require accommodations such as exterior noise barriers or location of outdoor patient areas where the building structures provide shielding from noise sources.
- In most cases, following the requirements in Table 1.2-3 will result in interior day-night average sound levels (Ldn) from exterior sources that are less than or equal to 45 dBA. Actual results will vary depending on how well the sound-blocking ability of the shell at various frequencies matches the sound spectrum of the outdoor sound and other factors, such as the area of the exposed façade and sound absorption in the room. Some rooms require lower sound levels, such as assembly spaces, clinical spaces, quiet rooms, and similar noise-sensitive rooms. These room types should be carefully evaluated to reduce the contribution of outdoor noises transmitted inside while considering the noise levels from the building systems (see Table 1.2-5: Maximum Design Criteria for Noise in Interior Spaces Caused by Building Systems). Assemblies meeting the minimum OITCc requirement will typically provide better performance when the outdoor sound is dominated by sources with strong low-frequency sound (e.g., locomotives or slow-moving heavy trucks). Assemblies meeting the minimum STCc requirement typically provide better performance when strong low-frequency sound is not present.More detailed evaluation should be considered to identify which sound isolation rating (OITCc or STCc) is preferred to meet the exterior shell acoustic requirements and potentially provide a more cost-effective design.
- Alarm fatigue. In 2011 the Joint Commission and the U.S. Food and Drug Administration designated "alarm fatigue" a top priority in health care facilities. FDA incident reports demonstrate that alarm fatigue can cause dangerous and potentially life-threatening behaviors, including willful deactivation of clinical alarms; increased error rates due to impaired communication; disorientation, distraction, and elevated stress that induce fatigue; and-for patients-heightened anxiety and increased sedative use. Room conditions contribute to alarm fatigue, which is caused by multiple, frequent, uncorrelated, and highly arousing noises from alarms and other sources mixing and reverberating in enclosed spaces with surfaces that are highly sound-reflective (i.e., do not absorb sound reverberation). Table 1.2-4 (Minimum Design Room Sound Absorption Coefficients) specifies the sound absorption coefficients needed to reduce the potential for alarm fatigue.
- Operating rooms. The acoustic environment of operating rooms should be designed to reduce reverberation, noise buildup, and noise-related fatigue. The design room sound absorption coefficient in operating rooms should be at least 0.10.
- A "demising wall assembly" is a partition that separates one occupancy or health care service from another occupancy/service or a corridor. Partitions within the same occupant space or health care service space are non-demising partitions. For example, the partition between two exam rooms is demising.
- Appropriate steps should be taken to assure the composite STC performance of demising wall assemblies in Table 1.2-6 (Design Criteria for Minimum Sound Isolation Performance Between Enclosed Rooms) is achieved after consideration of perimeter leaks due to lack of sealing, flanking due to continuous surfaces extending from one room to the other, sound passing through a plenum above a wall, or penetrations in the wall or ceiling. Particular attention should be given to intersection and sealing details of demising wall assemblies.
- Federal legislation requires that facilities protect patient information privacy. This includes speech privacy in all health care venues or wherever patient health information is discussed, either between staff, on the telephone, or during dictation.
- Speech privacy in open-plan spaces. People working in open-plan spaces are most productive when distraction from voices, equipment, etc. is minimal. Therefore, the acoustic environment should be designed to minimize such distractions. One option for achieving speech privacy in open-plan spaces is provision of a separate room where conversations may take place in private.
- Criteria for the AI (Articulation Index) metric were originally defined in ANSI S3.5-1969: Methods for the Calculation of the Articulation Index, but are now defined in ASTM E1130: Standard Test Method for Objective Measurement of Speech Privacy in Open Plan Spaces Using Articulation Index. This metric has been in use since the mid-1950s and is still considered a current practice.
- Criteria for the SII (Speech Intelligibility Index) metric are defined in ANSI/ASA S3.5: Methods for Calculation of the Speech Intelligibility Index.
- Criteria for the SPC (Speech Privacy Class) metric are defined in ASTM E2638-10: Standard Test Method for Objective Measurement of the Speech Privacy Provided by a Closed Room and "ASTM Metrics for Rating Speech Privacy of Closed Rooms and Open Plan Spaces," an article from the September 2011 edition of the Journal of the Canadian Acoustical Association.
- Criteria for the PI (Privacy Index) metric for converting AI values into percentages are defined in ASTM Standard E1130-08: Standard Test Method for Objective Measurement of Speech Privacy in Open Plan Spaces Using Articulation Index.
- Building vibration refers to vibration produced by building equipment and activities, not vibration produced by earthquakes.
- Vibration levels to which occupants are exposed should not exceed those in ANSI/ASA S2.71: Guide to the Evaluation of Human Exposure to Vibration in Buildings.
- Vibration produced by building mechanical, plumbing, and electrical equipment; footfalls; and medical equipment should be considered in the design of an outpatient facility.
- Mechanical, electrical, and plumbing equipment vibration
- All fixed building equipment that rotates or vibrates shall be considered for vibration isolation.
- Equipment bases, isolators, and isolator static deflections shall be selected based on the proximity of the supported equipment to vibration- and noise-sensitive areas, structural design of the facility, and type and operating point of the equipment.
- The recommendations in the ASHRAE Handbook-HVAC Applications shall be considered when selecting types of bases, isolators and isolator static deflections.
- More stringent requirements shall be considered for equipment impacting sensitive areas.
- Structural vibration
- Footfall vibration in the building structure shall be evaluated using properly substantiated methods of analysis, including:
- For steel floor systems: American Institute of Steel Construction (AISC) Design Guide 11: Vibrations of Steel-Framed Structural Systems Due to Human Activity
- For concrete floor systems: Concrete Reinforcing Steel Institute (CRSI) Design Guide for Vibrations of Reinforced Concrete Floor Systems
- If neither document in paragraphs (i) and (ii) is applicable, use of finite element analysis (FEA) or modal superposition analysis shall be considered.
- The structural floor shall be designed to avoid footfall vibration levels that exceed the peak vibration velocities in Table 1.2-8 (Maximum Limits on Floor Vibration Caused by Footfalls in Outpatient Facilities).
- More stringent vibration criteria shall be considered for locations where medical and laboratory instrumentation sensitive to vibration is housed.
- Footfall vibration in the building structure shall be evaluated using properly substantiated methods of analysis, including:
- Structure-borne sound
- Structure-borne transmitted sound shall not exceed the limits for airborne sound presented in Section 1.2-6.1.4 (Design Criteria for Room Noise Levels).
- Where necessary, vibration isolators shall be used to control potential sources of structure-borne sound.
- A growing body of knowledge is available to assist design professionals and health care organizations in understanding how buildings affect human health and the environment and how these effects can be mitigated through a variety of strategies.
- LEED® Green Building Rating System. This U.S. Green Building Council has established this third-party certification framework for the design of sustainable buildings. LEED® for Building Design and Construction (BD+C) includes health care.
- Green Guide for Health Care, a voluntary self-certification metric tool that specifically addresses the health care sector
- Green Globes® assessment and rating system. This interactive green building design tool provided by the Green Building Initiative (GBI) incorporates an integrated project management approach and offers third-party certification. GBI tools are available for New Construction (NC) as well as Continual Improvement for Existing Buildings (CIEB) for health care facilities. GBI has has developed ANSI/GBI 01: Green Building Assessment Protocol for Commercial Buildings to inform the development of Green Globes rating systems.
- Energy efficiency goals. Health care organizations should set energy efficiency goals (e.g., application of ASHRAE 90.1; design to earn ENERGY STAR®, Green Globes, or LEED certification) and consider energy efficiency strategies that include, but are not limited to, the following examples.
- -On major new projects, consider the use of energy modeling early in schematic design to assist in developing and assessing energy efficiency strategies and opportunities.
- -Reduce overall energy demand. Sample strategies for this purpose include using a high-efficiency building envelope; passive and low-energy sources of lighting (including daylighting); advanced lighting controls integrated with daylighting strategies; high-efficiency equipment, both as part of building mechanical and electrical systems (e.g., chillers and air handlers) and for plug loads (e.g., EnergyStar copiers, computers, medical equipment, and appliances); heat recovery; and natural ventilation.
- -Optimize energy efficiency. Mechanical/electrical control systems should optimize consumption to the minimum actual needs of the building. Consider using multiple modular HVAC equipment units or variable-speed drives for variable loads. Consider co-generation systems for converting natural gas to both heat (or cooling) and electricity. Select equipment with improved energy efficiency ratings.
- -Reduce environmental impacts associated with combustion of fossil fuels and refrigerant selection. Consider various renewable sources of energy generation, including purchase of green power, solar and wind energy, or geothermal/ground source heat pumps.
- Measurement and verification plan. In new construction, a measurement and verification (M&V) plan should be developed and implemented. Metering that provides consistent and reliable data should be considered for the electrical and mechanical systems applicable to the scope of the project, which may include:
- Main gas line to the site
- Each natural gas boiler
- Kitchen gas
- Consumption (kWh) and demand (kW) for each source of electricity to the building
- Output from each automatic transfer switch
- Energy consumption for pump and fan for each motor with a variable frequency drive (VFD)
- -Thermal energy
- All steam purchased from off-site sources, including recovered condensate
- Steam produced by each steam boiler
- Hot water produced by each hot water boiler
- Chilled water output for each water chiller
- -Energy source (fuel oil, propane, etc.) for each device listed
- Each steam or hot water boiler
- Each generator used for non-emergency purposes
- The site design shall be developed to minimize negative environmental impacts associated with buildings and related site development.
- The orientation of buildings on the site shall be evaluated to assess how solar and wind effects can be harnessed to minimize energy consumption.
- Site development considerations include the following:
- -Land use
- -Storm water management
- -Habitat preservation
- -Landscape design and irrigation systems
- -Natural ventilation
- -Renewable energy use
- -Effects from heat islands
- The orientation of buildings on the site should be evaluated to determine how to make appropriate use of daylighting based on the care population. Evaluate the net effect of planned daylighting on energy consumption and operating cost. See appendix section A1.2-22.214.171.124 (Energy efficiency) for information.
- The location of the buildings should also be evaluated in regard to the impact of site exterior noise, acoustics, and the care population. See Section 1.2-6.1 (Acoustic Design) for additional information.
- Many states and local jurisdictions have begun to mandate various waste management targets for commercial facilities, including health care facilities. As well, many health care facilities have realized financial rewards from managing their waste streams. Therefore, health care organizations may want to consider the space needs associated with environmentally preferable purchasing and recycling programs to facilitate achievement of such savings.
- Construction waste management. A construction waste management plan in keeping with local recycling resources should be developed and implemented.
- -Materials should be identified that can be recovered, reused, and/or recycled and a plan made to divert them from disposal in landfills or incinerators.
- -The disposal method should be identified for each material, and whether materials will be sorted or co-mingled on-site.
- Potable water quality and conservation strategies shall be evaluated in all phases of facility development or renovation.
- Design for water conservation shall not adversely affect patient health, safety, or infection control.
- Plumbing fixtures and fittings for water reduction shall comply with ANSI/ASHRAE/ASHE 189.3: Design, Construction, and Operation of Sustainable High-Performance Health Care Facilities.
- Reducing water use. Potable water consumption can be reduced by:
- -Selecting low-consumption plumbing fixtures and controls.
- -Designing low-consumption irrigation systems.
- -Using landscape design such as xeriscaping.
- -Replacing items such as pumps and compressors cooled using potable water sources with equipment that uses non-potable water sources such as graywater or with non-evaporative heat rejection equipment (air-cooled or ground-sourced).
- Medical equipment. Except for backup systems, potable water should not be used for primary once-through cooling for any medical equipment.
- Measurement and verification plan. To provide for long-term continual measurement of potable cold water uses in the facility, a measurement and verification plan may be developed and implemented. The following water uses (as applicable to the project) may be metered:
- -Main water to site
- -Special deduct meters, including those for cooling tower makeup, boiler system makeup, boiler blowdown, other hydronic loop makeup, irrigation, and emergency medical equipment cooling
- Irrigation water
- -Use of irrigation systems to establish landscaping when first planted should be permitted.
- -Irrigation systems should be designed to use only captured rainwater, recycled wastewater, recycled gray water, or water treated and conveyed by a public agency specifically for non-potable uses for irrigation.
- -Use of xeriscaping should be considered to avoid the need for irrigation.
- The impact of building design and construction on indoor environmental quality shall be addressed.
- Impact from both exterior and interior air-contamination sources shall be minimized.
- During the functional programming process, input from frontline staff, facility managers, visitors, families, and patients should be sought regarding wayfinding. This should include evaluation of the most common and problematic scenarios to identify shortcomings and help develop design criteria to address them. Consideration should be given to the following:
- -Needs of first-time users
- -Stress experienced by patients and families while finding their way to unfamiliar areas in a facility
- -Populations served (e.g., the elderly; children; and cognitively impaired, visually impaired, and other particularly vulnerable populations, including those with Alzheimer's and dementia)
- -Needs of limited English proficient (LEP) individuals, speakers of other languages, and those with limited reading ability. Where possible, use the Universal Symbols in Health Care.
- -Use of unique landmarks (e.g., design elements such as color, artwork, texture, change in architecture, exterior views, plants)
- -Varied presentation of the same information to accommodate different cognitive processes (e.g., those used by different individuals or by the same individuals at different points during the wayfinding process)
- -Integration of the wayfinding plan with relevant security plans
- Input from staff, visitors, families, and patients as described in Section 1.2-2 (Functional Program) should be integrated into the development of a systems approach to wayfinding. Planning for wayfinding should begin with the goal that the average visitor or staff member can easily find his or her way throughout the facility. Outside wayfinding should be considered for those walking and for those driving to the facility. If public transportation is available, directions and signage to and from transportation sites should be provided.
- General sign recommendations:
- -Exterior and interior approaches to wayfinding should be coordinated.
- -Nomenclature should be consistent and understandable to the general public, and signs generally should be written at a sixth grade level.
- -Information (a destination hierarchy) should be developed to ensure the right information is presented at the right time.
- -A family of signs should be developed for consistency within the wayfinding system. This should include directional and orientation signs (e.g., overhead and wall-mounted signs and maps), destination signs, room identification signs, regulatory signs, and provisions for a multitude of facility-specific policy and information signs.
- -Each sign should be accurate, legible, and functional:
- • Letters should contrast with the background to conform to ADA requirements. For signs in areas that primarily house the elderly, letters should contrast with the background by a minimum of 90 percent.
- • Colors should be differentiable by those who are color-blind.
- • When used, symbols and pictographs should be recognizable to the general public and the community served. (The Universal Symbols in Health Care have been tested for usability and comprehension.)
- • The number of symbols used on a single sign should be limited and indicate primary destinations only.
- • Destination hierarchies should manage the number of symbols by building, zone, or floor. Users have difficulty differentiating more than 16 unique symbols in one set.
- • Where health care symbols are combined with other universal symbols used in transportation or accessibility, the different sets of symbols should be clearly differentiated.
- You are here (YAH) map recommendations:
- -YAH maps should be oriented so that forward is up.
- -It is preferable to use a perspective view. Where vertical navigation is required, consider illustrating the relationship between levels and which elevator cores serve which areas, especially where floors are not contiguous.
- -Inset maps should be used to locate details within the overall map where appropriate.
- Exterior signage (general)
- -Directional signs should be easily viewed from the street and located and sized so that drivers can read them when traveling at the local speed limit.
- -Consistency should be used in the nomenclature of buildings.
- -Directions should be clear to all users.
- -Signage should be within an individual's 60-degree "cone of vision," whether the person is walking or driving.
- -Exterior directional signs should be visible at night.
- -Signage should be located where it is easy to see.
- -Where applicable, emergency departments should be clearly distinguished from other destinations.
- Exterior signage (parking)
- -Directions should be provided to various parking locations, where applicable.
- -Directions should be provided from the parking structure to the entrance of the facility.
- -Signage should clearly indicate short-term and long-term parking rates, where applicable.
- -Valet parking, if provided, should be clearly marked.
- -Directional signage should be provided for automobile and pedestrian traffic.
- -Floor numbers or sections should be marked clearly.
- Interior signage (entrance and exit)
- -A well-designed and located set of interior signs and clearly labeled directional maps should be located near the entrance. Symbols used on directional signage should be used in orientation maps for consistency and to assist users in finding primary destinations.
- -Signage should clearly identify all publicly accessible functional areas of the facility.
- -Where symbols are used, a single symbol should be used to represent a single primary destination.
- -There should be adequate signs to direct people out of the facility back to parking and public transportation.
- Interior wayfinding (room numbering)
- -Room numbering should be consistent from floor to floor and area to area.
- -The numbering system should be simple and continuous.
- -Design of the numbering system should be flexible to allow for future expansion and renovation.
- -Room numbering should consider the need for sequential strategies for public wayfinding that may be different from operational and maintenance numbering.
- -Signs should differentiate between those spaces used by patients/visitors and those used by staff.
- Interior wayfinding (sign placement)
- -Signs providing directions should be placed at major decision points, including the following:
- • Major intersections
- • Major destinations
- • Changes in buildings and/or patient care areas
- -If there are no major decision points, reassurance signs should be placed approximately every 250 feet (76 meters).
- -Signs providing directions should be placed at major decision points, including the following:
- Interior wayfinding (signage maintenance). Fabrication should be in a manner that allows messages to be changed.
- An integrated system that coordinates elements such as visible and legible signs and numbers
- Verbal directions, paper information, and electronic information
- The patient's weight, the distribution of the patient's weight throughout the body, and the patient's height are involved in identifying a patient who requires additional assistance, expanded-capacity equipment, and larger space for patient care, moving, handling, and mobilization. Such patients are not necessarily receiving bariatric care; therefore, the term "patient of size" is often used. The most commonly accepted method for clinically identifying patients of size is the body mass index (BMI).
- Creating health care environments that can accommodate patients of size requires attention to issues that significantly affect design, such as the nature of the clinical area, current codes, and local regulations. In addition to the requirements in the Guidelines, useful information is provided in the Joint Commission monograph "Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration, and Innovation."
- Average number of patients heavier than 300 lbs. served in a specific clinical area each week
- CDC obesity prevalence future projections by geographic area
- Average number of patients heavier than 600 lbs. (or facility threshold) served in a specific clinical area each week
- CDC obesity prevalence future projections by geographic area
- Accommodations for patients of size and the equipment needed to care for them require more operational space and more storage space than a traditional patient care environment. The need for increased square footage will be determined by the space needed for caregiver assistance and equipment to accommodate patients of size, both mobile (e.g., gurneys, lounge chairs, wheelchairs, patient lifts) and fixed (e.g., large bore MRI/CT equipment, larger surgical tables and exam tables). Another primary space driver is the staffing-per-patient ratio and associated maneuverability needed in environments where patients of size are served. In most instances, additional caregivers are recommended for patient handling.
- Other design issues to consider when planning to accommodate patients of size include ingress/egress to primary treatment and service areas. The rooms and/or destinations at the ends of these traverses also need special consideration to accommodate patients of size:
- -Surgical suites. The design should address issues that relate to patient transfer, lifting and holding for an extended period, proper and comfortable positioning, and the most efficient positioning for the implementation of surgical processes.
- -Imaging suites. Many of the same issues found in a surgical environment, especially patient transfer and positioning, are also present in the imaging environment. It should be noted that much of the equipment associated with imaging is not designed for patients of size. Careful evaluation to ensure selection of appropriate imaging equipment needs to be exercised.
- -Exam rooms. Exam rooms should be programmed and sized to accommodate the patient of size and the associated care team.
- -Waiting rooms or areas. Appropriately sized elements with capacity adequate for patients of size should be interspersed with more traditional furnishings to avoid confining patients of size to specific areas of the waiting environment.
- -Additional staff/patient interaction areas. These areas include cashier/registration, patient assessment, physical rehabilitation, and family interaction areas.
- Wind- and earthquake-resistant design for new buildings
- -Facilities should be designed to meet the requirements of ASCE/SEI7: Minimum Design Loads and Associated Criteria for Buildings and Other Structures or building codes with substantially equivalent requirements. Particular attention should be paid to seismic considerations in areas where the classification of a building would fall into seismic design categories C, D, E, or F as described in ASCE/SEI 7.
- -Seismic construction inspection. The governing body should complete the testing described in Section 11A.2 and special inspection during construction of the seismic systems described in Section 11A.1.3 of ASCE/SEI 7.
- -Roof considerations
- • Roof coverings and mechanical equipment should be securely fastened or ballasted to the supporting roof construction and provide weather protection for the building at the roof. If ballast is used, it should be designed so as not to become a projectile.
- • In addition to the wind force design and construction requirements specified, particular attention should be given to the design of roofing, entryways, glazing, and flashing to minimize uplift, impact damage, and other damage that could seriously impair building function.
- Flood protection
- -In accordance with Executive Order 11988 (Floodplain Management), possible flood effects should be considered when selecting and developing the site.
- -Insofar as possible, new facilities should not be located on designated floodplains.
- -Where locating a facility on a floodplain is unavoidable, consult the U.S. Army Corps of Engineers' regional office for the latest applicable regulations pertaining to required flood insurance and protection measures.
- -Helipads should be located a minimum of 3 feet above the 100-year-flood elevation on campuses constructed on designated floodplains. A path of travel above 100-year-flood elevation should be provided between health care facilities and the helipad to facilitate evacuation.
- Infrastructure assessment. The assessment should consider performance of structural and critical nonstructural building systems during an adverse event and the likelihood of loss of externally supplied power, gas, water, and communications from such a disaster.
- Facility planning. Ideally, the emergency preparedness assessment results will be used to implement practices and plans that will help the health care organization prevent, mitigate, and expediently recover from an event. Facility master planning should consider mitigation measures required to address conditions that may be hazardous to patients and conditions that may compromise the ability of the health care organization to fulfill its planned post-emergency medical response. Resiliency requires a plan to absorb and recover from adverse events by preparing, preventing, protecting, mitigating, and responding. The plan should outline a health care facility's ability to:
- -Adapt to changing conditions
- -Recover from disruptions
- -Resist probable deliberate attacks
- -Improve technical and organizational capabilities
- -Focus on reducing damage and disruptions to public health and safety
- Space where patients, staff, and visitors can be safe in an emergency should be identified.
- Provision of space for resources needed to respond in an emergency, such as medical supplies, materials, pharmaceuticals, communications equipment, transportation, food, water, utilities, and waste storage should be considered during project planning and design. Some of these resources could be accommodated through mutual aid agreements between the health care organization and other local providers or vendors. Such storage capacity or plans should be sufficient for at least four continuous days of operation.
|Speech Privacy-Closed Plan||PI||AI||SII||SPC|
|Defining standard||ASTM E1130||ASTM E1130||ANSI S3.5||ASTM E2638|
|Speech Privacy-Open Plan||PI||AI||SII||SPC|
|Confidential||Special consideration required3|
|Defining standard||ASTM E1130||ASTM E1130||ANSI S3.5||ASTM E2638|
- Subsurface conditions (e.g., soil testing reports, soil type identification, known water table information, active/abandoned utility locations)
- Foundation and superstructure information, including the ability of the structure and equipment (elevator) to handle the movement of heavy and/or large loads from one location to another
- Types of fire suppression, detection, and alarm systems, including whether the building is fully sprinklered
- Communications systems (including telephone, nurse call, overhead paging, telemetry, dictation, electronic imaging systems)
- Plumbing systems (e.g., domestic water, treated water, wastewater, medical gases/vacuum systems)
- Existing airflow of affected areas
- Main electrical service and electrical service affected by construction, including rating and actual load/peak and feeder sizes as applicable, and power factor
- Emergency power system, including rating and actual load/peak and feeder sizes, as applicable, for life safety, emergency/critical, and equipment branches
|Space Type||Structural Framing
Footfall Vibration Peak Velocity (micro-in/s)
|Patient Care and Diagnostic Areas|
|Class 1 imaging room||8000|
|Class 2 imaging room||4000|
|Class 3 imaging room||4000|
|Public and Administrative Areas|
|Public circulation areas||8000|
- Higher vibration criteria are less stringent and vice versa.
- The vibration criteria in this table do not apply to renovation projects unless new equipment being installed has more stringent vibration limits.
- The vibration criteria in this table do not apply to mobile/transportable medical units.
- Health facility commissioning. Many organizations, including NEBB, BCA, and ASHE, have published commissioning manuals, guidelines, standards, and handbooks. The ASHE Health Facility Commissioning Guidelines is structured to foster a successful transition from planning, design, and construction to high-performance operations (i.e., operations that are code-compliant, safe, and energy-efficient and that support positive clinical outcomes and high patient and visitor satisfaction).
The ASHE commissioning process includes the following unique features:
- -Establishment of a project energy efficiency goal
- -Involvement of health care facility operations and maintenance staff in the design review process
- -Development of a utility management plan (UMP) during the design process instead of during the postoccupancy period
- -Comprehensive training of the operations and maintenance staff, including pre-testing to assess training needs and post-testing to ensure competency
- -Testing of fire and smoke dampers prior to occupancy
- -Measurement and verification of actual energy performance as compared to the energy efficiency goal
- Total building commissioning (TBC)
- -Objective. TBC is a process whereby the governing body (i.e., the owner) is assured that all building systems and components (not just the HVAC system) will function according to design intent, specifications, equipment manufacturers' data sheets, and operational criteria. Because all building systems are integrated and validated during commissioning, the owner can expect the commissioning process to improve occupant comfort, energy savings, environmental conditions, system and equipment function, building operations and maintenance, and building occupants' productivity.
- -Feedback. The TBC process should include a feedback mechanism that can be incorporated into the owner's postoccupancy evaluation process to enhance future facility designs.
- -Acceptance building testing. Facility acceptance criteria should be based on the commissioning requirements specified in the contract documents. These criteria specify the tests, training, and reporting the owner must complete to validate that each building system complies with the performance standards of the basis of design before final acceptance of the facility.
- -Systems and components included in TBC. Key systems and components that should be tested and validated, at minimum, during the TBC process include design and operations of the HVAC, plumbing, electrical, emergency power, fire protection/suppression, telecommunications, nurse call, intrusion and other alarm device, and medical gas systems as well as specialty equipment.
- • Air balancing, pressure relationships, and exhaust criteria for mechanical systems should be clearly described and tested to create an environment of care that provides for infection control.
- • Areas requiring emergency power should be specified and tested.
- • Special plumbing systems should be certified to support the chemicals scheduled for use in them.
- • Water lines, taps, showers, and ice machines to which service has been disrupted or stagnant should be flushed before use by building occupants.
- Areas to be included in commissioning. While all areas of an outpatient facility are included in the commissioning process, areas of particular concern are surgical services; isolation rooms, including those used for airborne infection/pathogens; and pharmacies and other areas containing hazardous substances.
- Building envelope
- Lighting controls and levels
- Communication systems
- Normal power systems
- Plumbing systems
- Acoustic measures
- Energy efficiency