Healthcare facility development, hospitals, medical office buildings, ambulatory surgery centers, imaging centers, and specialty clinics, is the most technically complex category of commercial construction. The regulatory oversight is more extensive than any other building type. The MEP systems are more sophisticated. The infection control requirements during construction create operational constraints that are specific to the healthcare environment. And the consequence of error, a facility that doesn’t function correctly when patients are in it, is more serious than in any other development category.
The healthcare owner’s representative or construction manager who has direct experience with healthcare facility standards, ICRA protocols, and the regulatory approval process brings value that no amount of commercial construction management experience in other building types can replicate. Healthcare is a sector where the relevant experience is non-transferable.
The Regulatory Framework
Healthcare facilities are regulated at the federal, state, and local level in ways that standard commercial buildings are not. The primary frameworks:
State health department licensure. Most healthcare facility types, hospitals, ambulatory surgery centers, skilled nursing facilities, assisted living facilities, require state health department licensure to operate. The physical plant must meet the state’s licensing standards, which typically reference the Facility Guidelines Institute’s Guidelines for Design and Construction of Health Care Facilities as the technical standard. The FGI Guidelines are comprehensive, they specify room dimensions, ventilation requirements, plumbing fixture counts, lighting levels, and dozens of other physical plant requirements for each healthcare space type.
Before a licensed facility can open, the state health department conducts a survey, an inspection of the completed facility against the licensing standards, and must issue a license before patients can be served. A facility that doesn’t meet the licensing standards cannot open. The construction team that delivers a facility with deficiencies that fail the state survey creates a financial problem for the owner that extends beyond punch list into licensing delay.
Joint Commission accreditation. Many hospitals and ambulatory surgery centers seek Joint Commission accreditation, a voluntary but effectively required certification for facilities that want to accept Medicare and Medicaid reimbursement (which is most of them). The Joint Commission’s Environment of Care standards impose requirements on the physical plant that must be maintained throughout the facility’s operation and that are evaluated at accreditation surveys.
Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Facilities that receive Medicare and Medicaid payment must meet CMS’s Conditions of Participation, which include physical environment standards. CMS certification surveys evaluate the physical plant against these standards.
ICRA: Infection Control During Construction
The Infection Control Risk Assessment (ICRA) is the framework through which healthcare facilities manage the infection risk created by construction and renovation activities in or adjacent to occupied clinical spaces. Construction dust, airborne particles, and disruption to air pressure relationships between construction zones and occupied clinical areas create infection risk for immunocompromised patients that can be fatal.
ICRA requirements during construction include: physical barriers (temporary walls and barriers with negative pressure) that contain construction dust and prevent it from migrating into clinical areas; HEPA filtration of air in construction zones; shoe cleaning mats and worker attire requirements for workers entering or exiting construction zones; specific protocols for moving materials and debris through the facility; and real-time air quality monitoring in adjacent clinical areas during certain construction activities.
Healthcare facility construction managers and GCs who have not worked in occupied healthcare settings regularly underestimate ICRA compliance costs and schedule impacts. A renovation project in an occupied hospital floor that takes 12 weeks in a vacant building can take 18 to 22 weeks in an occupied building with ICRA compliance requirements. Contractors who bid renovation projects in occupied healthcare facilities at rates calibrated to vacant commercial renovation will underbid the project and either seek change orders to recover the ICRA compliance cost or cut corners on compliance to protect their margin.
Specialized MEP Systems
Healthcare facilities require MEP systems that have no equivalent in standard commercial or multifamily construction:
Medical gas systems. Piped oxygen, nitrous oxide, medical air, and vacuum systems are required in most clinical treatment spaces. These systems are installed by specialty contractors, tested to NFPA 99 standards, and verified by independent testing before they can be placed in service. A medical gas leak or contamination in an occupied clinical area is a patient safety emergency.
Critical power systems. Healthcare facilities are required to maintain specific critical functions, life safety systems, critical care equipment, lighting in critical areas, during utility power outages. The emergency power infrastructure (generators, transfer switches, UPS systems for critical equipment) is both more extensive and more complex than commercial building emergency power.
Enhanced HVAC with pressure control. Clinical spaces require specific airspace pressure relationships, operating rooms at positive pressure relative to adjacent spaces (to prevent contamination from entering), isolation rooms at negative pressure (to prevent airborne pathogens from escaping). The HVAC system must maintain these pressure relationships continuously, and the commissioning process must verify that they are achieved under the full range of operating conditions.
Owner’s Representation in Healthcare Projects
The healthcare owner’s representative serves as the owner’s technical expert and project advocate in a development process where the technical complexity is high enough that an uninformed owner is at a systematic disadvantage relative to the GC, the design team, and the regulatory agencies.
Specific value the experienced healthcare owner’s representative provides: review of programming and design documents against FGI Guidelines standards before the documents are finalized; contractor prequalification that specifically evaluates ICRA experience and healthcare project references; construction phase quality oversight that includes verification of medical gas, critical power, and HVAC commissioning; and coordination of the state health department survey process to ensure that the facility is prepared for licensure at delivery.
Innergy Integral provides these services in Houston, TX and across our six-state footprint.
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