Tale of an American Community Hospital: Navigating regulatory ambiguity

What is a hospital?

As today’s healthcare model moves further away from the major metropolitan acute care hospital, the definition of what a hospital is has become a greater conversation among healthcare providers, designers and politicians, alike.

How does the United States define a hospital?

The short answer is: in many ways. The healthcare design industry has been asking the question for years, “What is a micro-hospital/community hospital?” It is a hospital, only a smaller version built for maximum efficiency. The better question is, “What defines a hospital?” And how do federal and state regulations alter that definition from one state to another?

Core versus additional departments

Typically, there are five common departments required to define a healthcare facility as a hospital: 1) emergency department, 2) nursing units/inpatient care, 3) imaging, 4) lab and 5) kitchen. The size and scope of these departments depend on the needs of the community and the specific governing regulations. The departments can be dramatically impacted by the resident state’s adopted code and their interpretations of them. Understanding these requirements will better inform the limitations imposed on the healthcare facility and provide insight into the selection of sites and services.

Many states employ a different definition of a hospital. They all require the five core departments, but each has its own unique set of codes for these departmental functions, while some require additional departments above and beyond these.

As populations grow and the American community’s demand for convenient healthcare expands, medical service institutions are faced with the challenge of understanding what types of hospitals best serve their population.

The type of hospital needed will depend on the service provided and that will dictate additional departments required by both the state and federal hospital regulations. Will this be a special care, general, psychiatric or special hospital? Rural or urban? Government or independent? Nonprofit or for-profit, general or special? All of these decisions will be impacted by these state regulations, as well as federal guidelines from Centers for Medicare and Medicaid Services.

It is also important to recognize that being licensed in a state is not the same as a building code, therefore the definition of a hospital varies from state to state. In Colorado, a hospital must include a surgical department to be officially licensed, while in Texas a healthcare facility without surgery or women’s services can be classified as a specialty hospital and Pennsylvania defines a hospital according to the number of inpatient beds. 

When designing a hospital in a state for the first time, the first step is to understand the governing codes for the state health department. Quickly assess the “if/or/shall than” structure within these codes to understand the additional departmental requirements above the basic five departments. The distinction between licensure and code compliance can be tricky; there is no consistent definition between a license and a code and, again, each state differs. 

Evolution of codes

In the past 10 years, The Facility Guidelines Institute’s Guideline for Design and Construction of Hospitals has become the industry’s most widely recognized guidance for planning, designing and constructing healthcare facilities. While state hospital building requirements can differ, such as which edition of the International Building Code is used, the FGI Guidelines consolidates minimum space program, risk assessment, infection prevention and architectural details. Approximately 42 states have adopted some form of FGI Guidelines as standard code. Although Texas is in the process of adopting a form of FGI Guidelines, some  states have created their own hospital building requirements, such as Texas, South Dakota, Minnesota, Illinois and Wisconsin.

As technology and healthcare trends change, updates to regulations are required and this can be taxing on the state healthcare boards. Many states adopt the current FGI Guidelines after a period of review. It’s always important to work hand in hand with the state healthcare review boards, particularly when the state is in the process of adopting new or updated regulations.

Through our experiences, we have found many states are comfortable with FGI Guidelines because these regulations provide consistency across the country. Many states are adopting FGI Guidelines because it eliminates the burden of writing continual updates needed. Every four years a committee of trained professionals reviews and updates regulations to reflect the latest in healthcare design and building trends. It has leveled the playing field across the country. The beauty of FGI Guidelines is it not only provides the framework — it allows the local clinical experts a way to modify as they see fit — shaping the built environment, while providing consistency across the U.S. 

Some states, such as California, Missouri and Arkansas, have chosen not to adopt FGI Guidelines but have put in place an equivalency. Certificate of need laws have been established in some states in an attempt to control healthcare costs by restricting duplicative services and hoping to ensure a community’s needs are being met. Certificate of need first passed into law in New York in 1964. It then became federal law in 1974. The federal law was later repealed in 1986 and several states began retiring their CON programs.

CON and federal requirements

There are 35 states and the District of Columbia that operate under a CON program. Healthcare providers in CON states must submit major capital expenditures for approval before proceeding. Some CON states’ laws can restrict expenditures to such an extent that it limits the number of facilities that can offer MRI and CT services. Should a healthcare provider wish to build a hospital in a CON state, and it is deemed unnecessary, the provider will not be allowed to license a hospital there.

Not only are designers required to be aware of state regulations, but also how the federal government, through the Centers for Medicare and Medicaid Services, defines a hospital. CMS reimbursement provides the only consistent definition of hospital licensure on a federal level. Any hospital seeking to participate in Medicare and Medicaid programs for reimbursement must meet the definition of a hospital by CMS. This means it is “a facility primarily engaged in providing, by or under the supervision of physicians, to inpatients diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.“ 

CMS further defines a patient as an inpatient if they have been “formally admitted as an inpatient with the expectation that he or she will require hospital care that is expected to span at least two midnights and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not use a hospital bed overnight.” This means surveyors must be able to observe this provision of care by the hospital having at least two inpatients in occupancy at the time of the survey.

CMS has also adopted both the NFPA 101 Life Safety Code and the NFPA 99 Health Care Facility Code as a part of their requirements. When a state has adopted different versions of the LSC, designers must design around the most stringent of the two.

Code is critical to hospital design

In a nation with such a wide variety of geography and political interests, the design of a modern hospital is rightfully being challenged. How we deliver care most effectively and efficiently has become the new approach, whether in a large urban area or a remote rural setting. 

Understanding the core functional programs required by the various codes, as well as the healthcare needs of the local community, is critical to designing the right hospital.