E7 – Is Part 1 of the Guidelines Optional? —John Williams and Bridget McDougall

Acronyms mentioned

AHJ: authority having jurisdiction

DEVA: disaster emergency and vulnerability assessment

ICRA: infection control risk assessment

PHAMA: patient handling and mobility assessment

Mentioned in this episode

Good Charts: The HBR Guide to Making Smarter, More Persuasive Data Visualizations by Scott Baranato

The Home Place: Memoirs of a Colored Man’s Love Affair with Nature by J. Drew Lanham

Crime and Punishment by Fyodor Dostoevsky

ASHRAE Standard 170

PHAMA white paper

Ken Cates: Guest of episode 2 and co-founder of Northstar Management Company

Tony Ruebsam: Guest of episode 3 and a mechanical engineer at Northstar Management Company

Lela Luper: Guest of episode 4 and manager of infection prevention and control at the Chickasaw Nation Department of Health in Ada, Oklahoma

“Skip to My Lou” by Neal Caine Trio

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Show notes (download transcript)

Bridget McDougall: It would be like if you offered me a grilled cheese sandwich. I love grilled cheese. Maybe I’m just hungry right now. And you’re like, great. And you gave me just like a piece of cheese on some bread. You’re missing the whole kind of critical part of what makes it a grilled cheese sandwich—which would be the other piece of bread. I’m not sure if that’s a good analogy, but that’s what came to mind. It’s essential is what I mean—Part 1. 

John: It’s essential. 

Bridget: Absolutely.  

Bridget and John talk introductions and forwards 

Bridget: Hey, John. 

John: Hey, Bridget. 

Bridget: So, before we hit record, I asked you to grab a book that you’re currently reading. 

John: I’ve got one right here. Good Charts by Scott Baranato. I apologize to Scott if I mispronounced your name. 

Bridget: That’s OK. Hi, Scott. I hope he’s listening. So, tell me, does that particular book have an introduction or a forward? Anything like that? 

John: It does. It’s got an author’s note and then it’s got something called the introduction. 

Bridget: Did you read it? 

John: The Introduction had pictures, so I did read it. I was captivated by the pretty, pretty pictures, but I did not read the author’s note. 

Bridget: I think I was telling you I’m reading The Home Place. It’s amazing. [It’s written] by J. Drew Lanham. It also has an intro with pictures. And so, I read all, every single word [of it], and his writing is so amazing. I couldn’t stop. However, I also read Crime and Punishment every year. And that introduction [has] many, many, many, many pages before you get to the actual page one. And I skipped that for a good 25 years. It’s just, no, didn’t want it. If it, basically, if there was a Roman numeral on the bottom of the page, I didn’t want to read it. [Do] you know what I mean? 

John: [Laughs.] 

A misunderstanding about Part 1 of the Guidelines 

Bridget: So, a lot of people skip over those parts, and some people read every little bit, but the bottom line is that, and this is the connection with the Guidelines document, the Guidelines documents are divided into three parts and there’s a common misunderstanding—I’m not sure how common—but there is a misunderstanding I’ve heard from some that Part 1 is akin to the forward in a book or something that has interesting information, but it’s not critical to understanding, or in this case, using the Guidelines. 

John: Right. And that misunderstanding that we hear is certainly not mine. I have always started with Part 1, and I encourage people to start with 1. So, before we dispel that myth, we thought it would be good to just familiarize ourselves and our listeners with a bird’s eye view of what the three parts of the Guidelines actually are, and then zoom in on what’s in this mysterious Part 1—maybe not so mysterious—and why it’s critical for designers, architects, facility planners, AHJs not to skip over it. 

Bridget: Right. OK. So, there’s three books: we have one for design and construction of hospitals, one for outpatient facilities, and one for residential care and support facilities. 

John: And to keep this discussion simple, we’re going to focus in on the structure of the hospital and outpatient Guidelines. Residential has a similar structure, but there’s enough nuances there that we don’t want to confuse folks. So, we’re just going to go with hospital and outpatient. 

Understanding the three parts of the Guidelines 

Bridget: Exactly. OK. So that bird’s eye view of the sections inside. The document is broken up into three parts. As we said, Part 1 is general, it’s called “General,” and that’s what we’re going to be looking at today. Part 2 [contains] specific facility chapters, like in the outpatient book, for example, there’s a chapter on urgent care centers or one on infusion centers. Or in the hospital book, there’s a chapter for general hospitals, another one for children’s hospitals, that sort of thing. And then Part 3 is a reprint of the ASHRAE Standard 170, which are ventilation requirements. 

John: Three parts. So, typically what I’ve noticed a lot of new users do is they zoom into Part 2. They find the thing that sounds most like them and go directly there. And to be sure, specific requirements for those facilities are listed over there in Part 2. But the Guidelines does several things to make sure people don’t skip over Part 1.  

So, the requirements in Part 1 are not optional. They’re not like the intro of the book that you would just skip over or gloss over. They’re part of the required minimum standards set forth by the document itself. And actually, in some ways, kind of set up the sandbox that we play in, so to speak. 

All facility chapters lead back to Part 1 

Bridget: That’s a good way to put it. OK. So, each of those facility chapters that we talked about, they start off with a requirement that tells folks they have to meet what’s been laid out in Part 1. Here’s an example. OK. So here’s the chapter for general hospitals. It’s on page 153, if you’re looking at a book. Don’t do that while you’re driving, by the way. So, the requirement is: “The general acute care hospital shall meet the standards described in this chapter and the standards in Part 1 of the Guidelines.” 

John: And here it is again on page 253 at the beginning of the children’s hospital chapter: “The children’s hospital shall meet all the Guidelines in this chapter and standards in Part 1 of the Guidelines.” So, another signpost pointing you back to Part 1. 

Bridget: Yep, we got it over in the outpatient document, page 165: “The urgent care center shall meet the standards described in this chapter and the standards in Part 1 of the Guidelines.” 

John: Yeah. I sense a trend. 

Bridget: A definite trend there. So, every facility chapter starts out in this way, telling you to go back to Part 1.  

You can also look in the part in the beginning of the Guidelines document that tells you how to use the document. This truly, truly is in that kind of beginning front matter, we call it, before you get to the body. And it’s under a description of fundamental requirements. It says, “The main body is composed of three parts.” And that goes on to describe Parts 1, 2, and 3, like we’ve just done. 

John: Right. Keywords here being “main body.” Part 1 is part of that main body. And I think some folks think of it as a forward [to] Part 2, you know, those facility chapters that have really concrete definitive standards as the main body. 

Bridget: I imagine our listeners are falling into three camps right about now. The, the first camp being of course, like “Part 1, I can’t even imagine skipping over Part 1! That’s part of our process!” There might be a second, much smaller group of people that say, you know, “Well, yeah, we do kind of skip it,” and we’ll point out what you’d be missing if you were to do that. And then there might be a third group of you that are like, “What is, what is the Guidelines? What’s FGI? Where are we? Where did we land?” Welcome. You know, we’ll take you on this ride with us. 

What is Part 1, why is it so important, and what’s the harm of skipping over it? 

John: Now that we made a pretty good case for the intent and that intent being that each facility being built, the requirements in Part 1 are the starting point, let’s dive into a little bit of what’s in there. So, what is Part 1? Why is it so important? And what is the harm of skipping over it? And you know, honestly, when I heard this, it was kind of a surprise because so many of the things that are touch points in the Guidelines that everybody knows, like the ICRA or the safety risk assessment or the functional program, every one of those live in Part 1.  

Bridget: So, to start with the super bird’s eye, just looking at the document itself, Part 1 actually starts on, I mean like the title page—that is technically page one of the Guidelines—but the text you’re going to see is on page three and it goes all the way into page 73. So, we’re talking about 73 pages of content and material here that encapsulates Part 1. Where do you want to start in there, John? 

Section 1.2 (Planning, Design, Construction, and Commissioning) 

John: Why don’t we start with 1.2? Let’s skip over 1.1 for now because it’s kind of overarching and probably makes more sense at the end. 1.2 is about planning, design, construction, and commissioning. So, if you think about it, kind of in the phases of a project, it identifies a couple of things that good projects have and have always had, which is a discussion of what the goals, what the risks, and what the mitigations are. So, that’s where we find things like the functional program, the safety risk assessment, which includes the infection control risk assessment—things like that.  

Bridget: Yeah. It’s kind of, I think of this section, the planning, design, construction, and commissioning section, like the getting ready before you go on a trip, you know? It’s really like, where are we going to go? What do we need in the suitcase? Is it sunny? Do you need sunscreen? Do you have your suit? Do you have your towels? Do you have your medications? Do you have everything you need? It’s, it’s those conversations and making sure that we get the right thing for the right type of facility you’re trying to build. And we already had some, uh, really good episodes. If you haven’t listened to the earlier episode on the functional program, we did that with Ken Cates and again with Tony Ruebsam. 

And then we also had an episode that touched on the infection control risk assessment with Lela Luper. But all of those kind of deep dives into these considerations and conversations that should be happening before a facility is even put down on a blueprint that lives here in 1.  

Setting the table for the project 

John:  Yeah, it’s setting the table for the project. A clear understanding with the important parties involved. What are we doing? What’s the goal? What are we planning for in this entire project? And what should that end project look like? And as an AHJ, I really love all of these things because it helps me understand how to interpret the document that we’re about to jump into in Part 2. All of these planning things help me understand which chapter I should be using in Part 2 based on that functional description. It helps me understand how to look at aspects of the built environment because of the safety risk assessment, the patient handling and movement assessment. So many of the questions that come up in Part 2 are answered by a really focused, purposeful conversation that’s described in Part 1. 

Part 1 includes the functional program 

Bridget: You know, I was at a conference some years ago, so I’m sure more hands would go up now than they did then. But the question was asked, how many people, write a functional program or do a functional program? And [there] was a spattering of hands. First of all, the Guidelines point to this section and say that you have to do it. But then there’s the actual practical in real life, why you would want to do this. 

John: Yeah, that’s an interesting question actually. Could you do a project without a functional program? And I think probably a lot of people do this automatically as they go through a design process, and they step through a set of user meetings to understand what a facility needs, what an owner needs, how they want it to function. In health care though, probably true in a lot of different types of organizations, the amount of change that happens, not only [with] people on a particular project, but the actual scope and goals of a project itself. If building a brand-new hospital takes two years, somewhere between that two-year construction process, we will have changed something about the project—either decision makers or actual programmatic elements of the project itself. So, having that narrative that said, hey, we made this decision because of X, Y, and Z, and that’s why this particular set of drawings look that way. I think that’s important. 

Bridget: And again, I’m going to put a plug in for those earlier podcast episodes about the functional program. I learned so much about what it is, how it functions, what the reason for having one is that I just want to send everybody there, honestly. 

John: Yeah. And on the other side, could you review a project, you know, for compliance with the Guidelines without a functional program? You probably could. You would open up the drawings and you would look at rooms and make a fair bit of assumptions about what goes on in those rooms and the condition of patients in those rooms. And it would be kind of a longer discussion between you, the designers, and the facility to understand truly what the function is and truly what the risk levels are inside of a facility. So, I would encourage folks to start with that functional program, get that deep understanding of what’s actually happening from the facility’s perspective, and then start applying the Guidelines based on that understanding rather than what might be an assumption in cases. 

Part 1 includes the safety risk assessment 

Bridget: That’s good. So, functional program, big part of Part 1, section 1.2, as you talked about. The next section there I see in here is about the safety risk assessment. What kind of things are people assessing and why would Part 1 be a way to help them out through that process? 

John: The safety risk assessment is really kind of a compendium of a bunch of different smaller risk assessments that look at. Risks from different lenses. [A] classic example [is] infection control risk assessment. And like in our previous episode, we know a lot of people assume this is just infection control risk elements in construction. So, renovation inside of an existing building kind of risk assessments. But it’s also, do you have an anteroom in front of your airborne isolation room? How many handwash sinks do you have? Where do you put them? That kind of assessment. 

In addition to that, we’ve got, a risk assessment that looks at it from the lens of patient handling and movement. Where are there fall risks? Where are there a need for lifts and how does that work? How does that happen? 

Bridget: Updated to the “patient handling and mobility assessment,” also known as, the PHAMA white paper, which is amazing. We’ll drop a link in the show notes you want to do a deeper dive on the patient handling and mobility assessment. 

Part 1 includes the behavioral and mental health risk assessment 

John: We also have the behavioral and mental health risk assessment which is a broad look at all of those locations where there may be risk related to behavioral and mental health. And while the Guidelines is very clear that we’re not operational, and we don’t prescribe operational components, we do understand that a lot of times people operationalize a safety component that may not require the exact same built environment kind of mitigation. So, identifying those risks and then deciding how you’re managing that risk during the planning process really kind of informs what the building needs to do. 

Bridget: And then we’ve got the security risk assessment which takes into account security measures. We’ve got the DEVA, which I love. It’s one of my favorite things in the Guidelines, the DEVA, for obvious reasons of just I imagine Diana Ross just popping out of this document. But it actually is an acronym for Disaster Emergency and Vulnerability Assessment. 

So, to your point, there’s just a whole host of assessments and considerations to take into account before a facility is built. It’s the good stuff, the good stuff in Part 1 right there, I think. 

But wait, there’s more 

Bridget: But, that section before we leave it, Section 1.2, Planning, Design, Construction, and Commissioning, there are, other things in there, too. We’ve got environment of care, acoustic design considerations—that comes with a table, there are tables in this part—sustainable design requirements, design considerations for individuals of size, renovation. I mean, man, what does this one particular section in Part 1 not have? Besides a grilled cheese?  

John: Yeah. The planning design consideration and requirements are those things that are probably more overarching over the entire facility and entire structure. So, instead of saying, all right, let’s look at acoustics in this particular room or this particular type of facility, we say, here’s an overarching approach to look at some facility-wide or maybe even building-wide considerations around acoustics or security or wayfinding or whatever it may be, that’s a little bit more systemic. It’s high-level, I believe, for a purpose. 

Bridget: Which is probably why it was put in the front of the book, you know, as Part 1, because it is meant to apply to all of these different facilities. And instead of repeating this information in every single specific facility chapter, we’re telling them to go back to Part 1. 

Part 1 includes tables 

John: So. before we leave this section, let’s look at the tables. 1.2 has a lot of associated tables with it, and, if you look at the first one, safety risk assessment components, this is a list of all of the different things that should be inside of the safety risk assessment and where you can find that reference in the Guidelines. The infection control risk assessment, these are associated parts of, you know, often Part 2, which is where those really specific and kind of prescriptive requirements are that you should go consider when you’re building a safety, um, infection control safety risk assessment so that you’re covering all of the prompts in Part 2 to put something into the infection control risk assessment. Then, after that, we quickly get into a lot of pretty, pretty prescriptive things; charts and tables associated with acoustic design of the entire facility. So again, this is kind of an umbrella approach [to] acoustics where we look at not only the exterior wall, but what’s going around you on the site and the different types of rooms. 

John: So. there’s a host of tables here that range from pretty performance-based and, you know, often sometimes just signposts to things that are actual requirements that have numbers and prescriptive criteria associated with them. 

The small but mighty site section  

Bridget: OK, then we hop over to probably the smallest part of Part 1, which is the section on site. It’s small, but mighty, And it covers topics like security, parking, landscape, environmental pollution control. And again, these are all requirements that are listed in there as opposed to, you know, just considerations there. You can find real bones in Part 1. 

John: Right. And you know, that’s a really good point. When you say bones, probably what to many people “bones” means is actual numbers, dimensions, or square footages or numbers of things that we can count and we can either, you know, check off a checklist that says, hey, we’ve got that in the design, we’re compliant, or a plan reviewer would go through and check because you have a very specific number to compare to. So, a lot of what’s in Part 1 is that performance side of regulation, which is you should document the good discussions that you have during the design process so that we know what we’re looking at and we know what we’re holding you accountable to. That may be why it’s easy sometimes to gloss over parts of Part 1 of the Guidelines, because there aren’t a whole lot of really concrete numbers there. 

Bridget: I’m going to ask you this as your role as an AHJ: Do you think terms in here like “shall be evaluated” or “shall be revised” make some folks feel like the bones are a little squishy? And here’s an example. “Paved walkways shall be provided for pedestrian traffic.” That seems like a pretty solid bone. But then we’ve got, “Parking needs shall be evaluated.” Is that tough for you as an AHJ to have a requirement that says that something shall be evaluated? How do you enforce whether something was evaluated or not? How would you approach that? 

John: You know, it’s a really good question, and I think a lot of the things that we put in there are acknowledging that sometimes in some locations, there’s an absence of like a parking study requirement in zoning criteria, or there isn’t a really prescriptive way to assess parking needs, or whatever the case may be, whatever is being evaluated; though, in my personal experience from looking at the document, [people] tend to be aware of zoning restrictions and local parking requirements and things like that. 

So, to me, that much more specific process that may exist in a state or a local or even a federal regulation is evidence of compliance with what is, you know, ostensibly a more performance-based question that really prompts us to ensure that a good conversation is being had; a purposeful conversation is being had. 

Guidelines written for AHJs? Designers? 

Bridget: To that point, do you feel like some of the requirements in the Guidelines are written more for an AHJ and some are written more for new designers? [Do] you know what I mean? Like . . . 

John: Yeah, you know, honestly, I think it’s true for both. Because there are some things that are foundational that need to be a reminder for new people starting out or experienced people starting out because, you know, as someone with a little bit of experience under my belt, often I forget things. And those reminders and those prompts to validate whether somebody has looked at that particular component of design with purpose is valuable. 

Bridget: And then I guess for the authority having jurisdiction, let’s say you show up to a place and parking is just totally wacky and wonky or not there. You can come back to this and say, “Well, did you evaluate? Show me how and where you evaluated your parking needs to help that facility.”  

John: The absence of something really prescriptive I think, you know, points us to validating whether people are having good conversations about it as opposed to trying to overlay a real specific prescriptive set of requirements. And I don’t think that’s inconsistent with what we do. 

Addressing equipment  

Bridget: OK, we have this little section on equipment, you know, this little baby section, and it’s really just kind of what to put in the equipment list and how to classify the equipment. So, if I was somebody who thought I could fly through Part 1 because it didn’t lay out requirements and minimum standards, this might be the section where I’m like, “Is this needed?” Point to that. Tell me why it is [included]. 

John: I think it’s incredibly valuable because if I were to go into a set of plans and not have a clear understanding of what equipment goes in one particular space, I wouldn’t have a good understanding of clearances, space needs, infrastructure needs, things like that. If I had a set of plans without a clear set of equipment drawings that showed me where that item is that’s connected to the plumbing, I wouldn’t understand, you know, the criticality of maybe what branch of the essential electrical system that would apply to. And that whole conversation about branches of the essential electrical system are covered in another code, but being able to see it, understand it, and understand the function of it, you know, where that important piece of gear plugs into a wall or plugs into the plumbing system, I think is key to understand the content of the project and how to apply not only the Guidelines, but, a couple of other codes. So, to me, it’s really kind of a handshake between the staff who are actually going to work in the space and the contractor and the owner. What are we planning? What are we buying? Where is it going to be? And how are we going to be able to interact with that piece of equipment? 

Bridget: One of the things in this section 1.4, the equipment section, is about documentation requirements. Are those the documents that you’re asking for or looking at or reviewing when you do a review of a space? 

John: So, typically when I go into a set of drawings, I’m going to look for what type of equipment it is and what the infrastructure connections are. Whether it’s, you know, plumbing, electrical, or medical gas, what have you. If it’s not there, this is the section that I would go back to say, “I need to see this. Here’s the section of the standard that would tell you to provide it.” 

Applicability of the Guidelines: The fine line between minimum requirement and allowance of flexibility 

Bridget: So, this last bit, the one that we saved for last is innocuously named “Introduction,” but what it does is it kind of tells you about the applicability of the Guidelines document in general. It talks about the difference between new construction and renovation. It’s got some sections in there about government regulations, exceptions, equivalency concepts, [a] tiny bit about whether you should use the English or metric measurement system—get on with it, U.S.—that’s just my own personal opinion. But, what would you like to say about this section, John? 

John: So, I mean, this is one of the key sections to the Guidelines. And I think for people who are familiar with codes and standards, it’s a really common one because it sets up the core concepts of scope and applicability. So, what, does this particular document cover? Is it about, seismic risk or is it about explosion risk? You know. What’s it here to do? What is it here to mitigate? Then it talks about that difference between all the different contexts that we might use this particular code on. So, if you think about projects that could be a new project, greenfield project, where, you know, we’re building something from scratch and we’ve got a whole lot of ability to make decisions about what goes into that building, or it’s a renovation project where you’ve already got an existing building and a whole lot of existing stuff. 

And the question comes up, well, where would you apply this particular document? Do you only apply it to the stuff that’s changed, or do you apply it to the rest of the building? So, in a way, this sets up kind of the sandbox for how we have good conversations about the regulation itself. 

And this is highly charged. It’s one of the core things that I think we discuss and hash over, either in projects or in the rule-making process, is how do we have good conversations? How do we provide flexibility? How do we maintain a minimum of public safety? 

I’ve also heard this described as a way to, or a structure of having good conversations about how to apply the Guidelines because you know, I think practically there are times when we want to give flexibility based on the particular risk and the particular project. And how do you go about structuring a conversation around that? And that’s what it’s there to do. I think if you were to boil the Guidelines down to a simple sentence, it would be: Don’t make decisions in a vacuum. Look at all of these risk assessments, the functional program, the safety risk assessments, and have good conversations over a broad body of people. 

Bridget: It’s something that I find so fascinating about the Guidelines in as much as it’s, you know, have three feet around this piece of equipment, it also comes back to time and time and time again, to that point that you made about having these discussions, having the right people at the table, getting all of your information there as you’re making decisions on these facilities. 

John: So, that in a nutshell is Part 1. 

John: That sounds like a plan! And I’m going to go read all of those proposals that tweak Part 1 of the Guidelines and see what people think today. 

Bridget: All right, John. I’m going to go finish reading all of the front matter for Crime and Punishment. That’s my to do. And then, after that, I’m gonna read Part 1 of the Guidelines with my morning coffee. 

Bridget: Oh, good idea. We’re gearing up for the comment period, putting that draft together. So, this is great. All right.  

Outro

Bridget: Thanks for joining us for another episode of Between the Lines with FGI. Do you have an idea for an episode or a question you’d like us to answer? Please get in touch by writing to us at [email protected]. 

John: Also, if you’re interested in becoming a sponsor for one or a series of episodes, you can reach out to us at the same address. It is [email protected] 

Bridget: Many thanks to Neal Caine and the Neal Caine Trio for the use of his song “Skip to My Lou.” It’s from the album of the same name. 

John: All right. Join us next time as we go between the lines with FGI. Bye, everybody! 

Bridget: See you next time! 

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Special thanks to Neal Caine and the Neal Caine Trio for the use of his song “Skip To My Lou” by the album of the same name.

Find the album on Spotify or Apple Music.

Visit Neal Caine’s website here.