Healthcare Facility Commissioning: Closing the gap between building performance and code requirements

Building commissioning requirements for commercial buildings are slowly being accepted throughout the country. This progression is occurring through the adoption of energy and green codes, such as the International Energy Conservation Code and the International Green Construction Code. The Joint Commission uses these guidelines, where applicable, to determine the accreditation of hospitals.

The practice of commissioning, however, is excluded from the mandatory requirements in some states, such as California. The following is a deeper look into the gaps between commissioning best practices and minimum code requirements for new facilities.

Codes and Testing Requirements

As an example, The Office of Statewide Health Planning and Development in California has developed the Test, Inspection and Observation Program. The TIO Program covers all of the testing required by the applicable codes but organizes them in a manner more easily visible to the entire project team.

Where these tests are unevenly enforced by varying jurisdictions, OSHPD attempts to strictly and uniformly enforce the testing requirements to the satisfaction of the designated inspector. The testing requirements are focused on OSHPD 1 and OSHPD 2 facilities, with the most tests required for acute care facilities. The number of tests and inspections for structural systems diminishes significantly between OSHPD 1 and 2 facilities, however, the electrical, mechanical and plumbing scope remains exactly the same. These are the systems most frequently targeted for commissioning.

The mandatory tests cover a comprehensive list of items but are generally focused on individual systems such as grounding, boilers, ventilation, isolation rooms and medical gas and vacuum systems. These tests are essential, but do not go beyond factory start-up testing for major equipment. They also cover test and balance for critical constant volume isolation and operating rooms. There are no requirements for testing interoperability between systems and lighting control systems are conspicuously absent from the list.

Superior healthcare facility design and construction professionals find ways to go beyond these minimum requirements, but is it time to mandate commissioning for healthcare facilities in states that have no requirement?

ASHE Healthcare Facility Commissioning Guidelines

The American Society for Healthcare Engineering recognizes the benefits of commissioning. ASHE released the Healthcare Facility Commissioning Guidelines in 2010, which follows general commissioning best practices but includes some specific requirements for healthcare facilities. ASHE’s leadership in providing these guidelines has considerably raised commissioning awareness and many hospital systems voluntarily include commissioning on new buildings and major renovation projects.

The systems covered within ASHE’s HFCx Guidelines are comprehensive and include 15 categories: building envelope, life safety, HVAC systems, controls, plumbing systems, medical gas and other specialty systems, electrical systems, fire alarm systems, information technology, fire protection systems, interior and exterior lighting, refrigeration, vertical transport and materials and pharmaceutical handling. The fact that this list may be too comprehensive to mandate in any code indicates how much work should go into the commissioning of a facility if the owner really wants the new or renovated facility to operate as intended from day one.

The HFCx Guidelines’ procedure for the commissioning process is patently similar to available recommended procedures from leading commissioning organizations but the HFCx Guidelines’ procedure includes two distinct areas not specifically addressed in “typical” commissioning efforts:

Integrated Systems Testing (under emergency power): Provide testing of all critical systems through the transition to emergency power to ensure proper systems start up after loss of power and maintain interoperability with associated systems; e.g., air handling units and exhaust fans to maintain space pressurization.

Transition to Operational Sustainability and Integration of Dashboards: The HFCx Guidelines puts a focus on the development of dashboard tools to help maintenance staff quickly identify areas needing attention. Dashboard tools, along with fault detection and diagnostics tools have continually matured over the last decade to the point of being considered essential parts of the HFCx Guidelines strategies to keep facilities running and operational long after the construction phase ends.

Required system tests share some overlap with pre-functional commissioning checklists and functional performance testing, so an integrated commissioning plan can accomplish both efficiently. One major difference between code-required testing and commissioning is the range of loads considered. Individual system testing is often completed at design conditions and often represented by the peak annual requirement.

Commissioning testing is a dynamic process and should include testing system performance at various load conditions as many issues can occur at minimum loading conditions, such as chiller surging or cycling during cold evenings. Commissioning also includes transitions from primary to secondary equipment, which helps determine the speed of the transition required to ensure the continuous needs of the facility can be met.

ASHE’s HFCx Guidelines may be one of several templates considered if more states and jurisdictions decide to adopt commissioning requirements for hospitals and healthcare facilities. The HFCx Guidelines is steadily gaining visibility and its recommended process is worthy of consideration for any hospital or healthcare facility committed to conducting mandatory or voluntary commissioning for new facilities or major renovations.

Benefits of Commissioning

There is still a significant contingent of hospital owners and developers who choose to forgo formal building commissioning and continue to rely on the code-required testing to ensure a properly operating facility. The main objection to commissioning is the perceived costs, especially in an environment where regulatory requirements are already responsible for significant seismic upgrades to existing hospitals. Additionally, the challenges of healthcare insurance and the hospital reimbursement landscape have led many hospitals to seek every opportunity to reduce costs.

Financial Benefits

The proponents of hospital commissioning understand the initial costs are an investment, which will pay off in the short term with reduced energy costs and less frequent occupant complaints. Commissioning benefits have been well documented in studies, such as the 2009 report “Building Commissioning: A Golden Opportunity for Reducing Energy Costs and Greenhouse Gas Emissions” from the Lawrence Berkeley National Laboratory. The report indicates median energy savings of 13 percent for new buildings with a payback range of 1.1-4.2 years in other commercial sector buildings, which have successfully undergone the process.

Such a study has not been completed specifically for hospitals but it can be reasonably inferred that similar levels of savings and payback can be maintained in the continuous operating environments of hospitals; remember, efficiency savings increase with longer system run time.

Operational Benefits

There are various ways in which the commissioning process can be of great benefit to the hospital’s operations and maintenance staff. Commissioning provides a measured and verified performance baseline. It offers data collection and trending tools to track the ongoing performance of systems commissioned while also offering training for ongoing maintenance and optimization of systems performance. Finally, commissioning ensures that primary and secondary systems work properly in tandem, which saves months or years of troubleshooting. 

Growing Importance of Commissioning

As control strategies for systems gain sophistication and more systems become interdependent, the mandatory testing protocols will no longer suffice to ensure proper hospital operations. More systems are moving away from constant-speed operation, such as operating room airflow control, to variable flow systems that will be dynamic throughout the day based on schedule and specific occupant needs.

Many of these innovations target reliability, staff/patient comfort and energy efficiency. These endeavors show no signs of slowing down and may only accelerate as technological advancements afford more opportunities for systems optimization in the future.