2022 FGI Guidelines: Flexible Design Encouraged

More than 2,500 years after philosopher Heraclitus noted, “The only constant in life is change,” the observation remains relevant. Change is apparent everywhere in issues as broad as geopolitics, economics, equality, technology, medicine and design. Ensuring that the Guidelines for Design and Construction standards evolve with these changes was a priority consideration for the Facility Guidelines Institute’s 2022 Health Guidelines Revision Committee.

From the beginning of the 2022 Guidelines revision cycle, the HGRC focused on the need to encourage design flexibility to support emerging technologies in the health and residential care industries. The committee considered where technology improvements may have reduced overall spatial needs, which patient care spaces can be adjusted to better support multiple functions and/or patient populations, and how the Guidelines language could be modified to ensure designers and facility owners are encouraged to embrace new technologies.

Support for alternate concepts

The Facility Guidelines Institute and members of the HGRC receive countless inquiries every year. Frequently, designers and owners want to know if an equivalent solution would be an acceptable alternative to a fundamental requirement in the Guidelines. The HGRC has long held that the Guidelines should allow the use of new or alternate concepts “when the requesting organization demonstrates an equal or higher operational goal is achieved and safety is not compromised.”

For the 2022 edition, the HGRC strengthened the Guidelines language to explicitly permit use of new or alternate concepts and encourage authorities adopting the standards to approve plans and specifications that contain deviations as long as the intent of the standard has been met. It is important to remember that FGI is not an authority having jurisdiction and, although we provide interpretations, the final authority is the federal or state agency.

Safety risk assessment

As COVID-19 spread across the U.S. in 2020, FGI received a torrent of requests for guidance on building alternate care sites, adapting public and administrative areas to support patient care and reducing the spread of the coronavirus through improved ventilation and infection prevention practices. FGI’s 2021 white paper “Guidance for Designing Health and Residential Care Facilities that Respond and Adapt to Emergency Conditions” (posted at https://fgiguidelines.org) was assembled to respond to those requests and provide timely guidance for designers and owners needing quick solutions.

From that effort, a new component of the safety risk assessment was incorporated into the 2022 Guidelines documents: the disaster, emergency and vulnerability assessment, or DEVA. Built on the hazard vulnerability assessments many healthcare organizations already perform for CMS, the Joint Commission and other agencies, the DEVA requires organizations to assess and document potential weather and manmade vulnerabilities during the planning phase and incorporate identified disaster and emergency-related design features in the project design documents. Addressing risks and vulnerabilities during project planning provides the best opportunity to incorporate spaces and systems that can adapt during emergency conditions.

Infection prevention

After decades of FGI not requiring the airborne infection isolation room to have an anteroom, the infection prevention topic group recommended — and the HGRC approved — the infection control risk assessment as the determining factor on whether an anteroom is required for an airborne infection isolation room.

A new appendix section gives guidance to designers and facility owners as they decide where an anteroom is needed. The infection prevention topic group also reviewed existing methods and devices for disposing of human waste and championed the addition of more options for bedpan management.

Electrical receptacles

After receiving a request for a formal interpretation on the Guidelines requirement for a duplex receptacle on every wall of a medical-surgical patient room, revisions were made to Table 2.1-1 (Electrical Receptacles for Patient Care Areas in Hospitals) to allow more flexibility in patient room design. The interpretation committee agreed that the minimum number of receptacles required at the bed location is intended to agree with NFPA 99: Health Care Facilities Code. Beyond these requirements, the Guidelines now states receptacles must be “located to support clinical function and patient and visitor needs.”

Critical access and other small hospitals

Although the 2014 and 2018 Guidelines permit small hospitals to follow the requirements in the critical access hospital chapter rather than the general hospital chapter, this allowance wasn’t common knowledge. To encourage adaptable design in small hospitals, the critical access hospital chapter has been revised to explicitly include small hospitals with 35 beds or fewer. Other revisions support increased flexibility in room use and provision of a universal care room.

Emergency facilities

Three significant changes were introduced to chapters addressing emergency facilities in the Hospital and Outpatient documents. First, fundamental requirements for low-acuity patient treatment stations have been added for emergency facilities. Intended for treatment of walking well patients, low-acuity treatment stations may supplement but not replace traditional treatment spaces.

Second, trauma/resuscitation rooms may now be subdivided to create two treatment rooms when not in use by a trauma patient as long as the room can support the needs of two patients, and quickly be reverted to a trauma room. Finally, a flexible secure treatment room that can be easily converted from a single-patient treatment room to a secure holding room, and a treatment room for behavioral and mental health patients, has been added.

Other notable changes that support design flexibility

• New hospice and/or palliative care rooms can be located independent from or in a hospice unit to provide care where the need is greatest.
• A new neonatal couplet care room was added to the Hospital document to support care for a hospitalized mother and baby in the same room.
• New text in the Hospital and Outpatient documents addresses universal design concepts, providing guidance for owners and designers on creating environments that can be accessed, understood and used to the greatest extent possible by all people, regardless of age, size or ability.
• Modular or prefabricated laminar flow ceiling systems are now permitted for the center array over the surgical site in lieu of monolithic ceilings in operating rooms and Class 3 imaging rooms. Where these ceiling systems are used, they must be constructed with a structural frame engineered and rated for the systems supported and have continuously gasketed seams and access doors.
• For Class 2 and Class 3 imaging rooms that have a control room, omission of the control room door is permitted where the control room serves only one imaging room and has the same architectural details and environmental controls as the imaging room.
• In the Outpatient document, where inhalation anesthesia (including nitrous oxide) will be used, a waste anesthetic gas disposal system is required per NFPA 99. However, use of portable delivery and scavenging equipment is permitted in some outpatient facilities in lieu of a permanently installed WAGD system.
• The Outpatient chapter for urgent care centers offers design flexibility through sharing of spaces. For example, the triage area, a patient care station or a consultation room can be used for initial patient interviews.
• Changes to support flexibility in the outpatient surgery facility chapter include permission to omit a clinical sink in a soiled workroom where an alternative method of fluid waste disposal is provided, and to provide storage for clean equipment and clean and sterile supplies in one room or area or a combination of the two.

Given that first and operational costs of healthcare facilities perpetually increase, the 2026 HGRC will undoubtedly continue to champion flexibility as a means of reducing the cost impacts of new construction and renovations on the delivery of care.

When the proposal period for the 2026 Guidelines revision cycle opens next spring, FGI and the HGRC encourage healthcare organizations and design professionals to note these opportunities for improvement and recommend changes that foster flexible design.