Why we must persevere with electrical code changes in Healthcare


Photo by Ashes Sitoula on Unsplash

Early in my career, I used to get frustrated when something in some code stopped a client from doing something better. I learned that, when you are working on a project, you never have the time or the budget to clear all of the hurdles involved in fixing these obstacles. At the time, I worked for a mentor, Mr. Hugh Nash, well known in the engineering world for his commitment to working in the, often tedious, world of codes and standards. Hugh taught me that it was possible, with patience and persistence, to make a difference outside of projects, as well as through use of projects.

Another thing that Hugh taught me was that the codes, as written, tend to result in electrical systems that are significantly larger than the loads they will experience. Now, sizing isn’t just about the loads you measure – there are issues of safety factors and what happens during power outages, and motor starting – but today’s systems are often three and four times larger than the loads they are serving.

In recent years, healthcare organizations have begun to employ LEAN techniques. LEAN is a process derived from Toyota and the Japanese, focused on improving value by removing waste. That philosophy, it seems to me, is highly appropriate to thinking about how we size healthcare electrical systems. It seems to me that, in an era where we are concerned about rising healthcare costs, anything we can do to eliminate waste is something we should pay attention to.

Moreover, eliminating waste is a huge opportunity for sustainability. If we can reduce the size of our electrical systems, without changing needed functionality, we will reduce the amounts of copper and other metals we need; we will improve the efficiency of equipment that does not run well when lightly loaded; we will reduce the amount of stuff that must ultimately end up in landfills.

I spent much of the last two weeks in various meetings with other volunteers, thinking through modifications to the National Electrical Code. I sit as an alternate on the group called Code Making Panel 15 (CMP 15), which has jurisdiction over healthcare facilities, but I also represented a team of volunteer engineers from my company and from around the country, who are conducting research to eliminate some of this waste.

Changing codes can be a tedious, often frustrating process. Changes are often incremental. But over time, the aggregate of incremental changes makes a difference. We’ve seen this in new “standards of care” becoming more acceptable, including the use of fuel cells for emergency power generation, right-sizing emergency generator loads, and even displacement ventilation, as evident in the recently opened (Stanford) Lucile Packard’s Children’s hospital, considered to be one of the most sustainable and technologically advanced hospitals in the U.S.

How does this effect you, our clients?

When you work with Mazzetti, you have the opportunity to help us identify inefficiencies inherent in code and thus, opportunities for change. You get to play a critical role in creating that positive change with us… 

I encourage you to continue reading to hear more about the specific work of this committee, but more importantly, how you can get involved too…

CMP 15 had spent a lot of time in four work groups over the last several months in 2017, reviewing a large number of public proposals to update this critical code. At the meeting, we reviewed all of the recommendations from the committees and took final action. The NFPA will publish these results for the public to comment on later this spring. In the meantime, I thought I would share a couple of interesting changes.

1.  The NEC is going through what they call a “transition” from the old paradigm of referring to healthcare buildings as buildings, towards the NFPA 99 paradigm of thinking about healthcare spaces. That is, in NFPA 99, two cycles ago, we recognized that the lines between kinds of healthcare facilities are getting blurry. Indeed, one thing we talked about many times in those days was “the Cath lab in a shopping center.” The idea was, healthcare is increasingly leaving what we think of as a hospital and migrating into more and more OTHER kinds of buildings. And, in the end, we don’t care if the Cath Lab is in the hospital or in the shopping mall, we want to be sure the staff and patients are supported and protected. So, NFPA 99 sets up the requirements for healthcare spaces, not healthcare buildings. So, the Cath Lab in the shopping center will have the same outlets, grounding, emergency power, etc as the cath lab in the hospital. The challenge is, the NEC still thinks about buildings and the kinds of things that belong in buildings. This transition began with the current (2017) version of the NEC and will continue into the next (2020) version. We worked hard to try to craft language in the NEC to bridge this divide, and I hope we got it right.

2.  Two cycles ago (I think), in NFPA 99, we added the provision that healthcare facilities can use fuel cells as their alternate power sources for their essential electrical systems. This was a pretty big change, but one that is sorely needed. In California, for example, we have very stringent air quality restrictions, and our tried and true solution – diesel generators – are quite problematic from this perspective. Fuel cells generally produce much lower emissions of all pollutants, and are, therefore, preferable from a health perspective (and, after all, isn’t that what ‘HEALTH’ care buildings are about??) There is a large and growing fleet of buildings, including high-reliability facilities such as data centers, that have moved to the use of fuel cells in lieu of diesel generators. So, we know they work. I will write another time about the nuances of this issue, but the point of this particular discussion is that, when the NEC imported the Fuel Cell language from NFPA 99 in the current version, it added the requirement for listing. This is a big problem, as neither UL (who sits on CMP 15 with me) nor any other listing agency has any protocol for listing a fuel cell as an emergency source. So, this cycle, we modified the language to remove the requirement for listing and allow field testing of a fuel cell installation in order to ensure proper operation. This change should allow the use of fuel cells in healthcare facilities in most parts of the US, when enacted. I am working with at least one client to implement a demonstration project using this technology in parallel to their existing diesels. I would LOVE to work with additional clients in other locations – let me know if you are interested.

3.  Several years ago we performed a research project funded by the California Energy Commission to measure the actual load on branch circuits in medical office buildings. What we found was that our calculations, done in conformance with NEC requirements, significantly overstate the actual demand on most circuits. At a circuit level, this is not so troubling, as we know that someone COULD plug a lot of stuff into one circuit. But, aggregated over an entire department, or floor, or building, these over-sizing factors result in transformers, feeders, switchgear, generators, relative to the actual loads these components will experience during operation. Over the past six months, a collaborative of electrical engineers and hospitals have worked together, with funding from ASHE, to extend this analysis to hospitals. Some of the data is shown in the graph above. This graph shows the connected (red) loads; the NEC calculated load (yellow); the actual load (measured over two weeks – orange); and loads calculated using one of three potential new formulas for sizing these components. In summary, I presented this data to three panels of the NEC: the demand factor committee, the Research Advisory Committee, and the CMP 15 (on which I sit). At this point, “the powers that be” are intrigued, but (understandably) cautious. We created a task force that will work, over the course of 2018, to advance this research and come to consensus on the right way to move forward with appropriate code changes. I will write more on this topic another day, but for now, I am hoping that other engineers and other hospitals will help us. Please let me know!

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Pushing for More Sustainable Outcomes–Join us.


We’ve listened to you, our clients, as we’ve collaborated on projects. Reading between the lines, we hear your need (and the Healthcare industry’s need) to push for more sustainable outcomes. Complacency is, literally, a non-sustainable reality.

Towards the “push”, earlier this year we rolled out our BETA WasteCare Calculator  to help inform more sustainable medical waste management decisions. This is an “open” calculator that allows users to input information about their waste stream to calculate out puts and air emissions. The calculator shows all the factors and equations used to calculate and encourages discussion about these factors and equations. Help revolutionize medical waste management decision making.


And now, we have “pushed” to help inform the reality of energy consumption of medical equipment. Historically, healthcare energy efficiency efforts have been focused on lighting and building systems, ignoring medical equipment (primarily) because it seems intractable. Manufacturers have been minimally expected to design more energy efficient devices. The EPA considered but abandoned an effort to extend its popular ENERGY STAR rating to medical equipment.

healthcare energy mgmt

We know you are increasingly pressured to reduce your carbon footprint and increase sustainability efforts. You’ve asked us for this direction; we’ve heeded the call. We are working with our partners and clients to collect and analyze actual energy usage to provide insights to inform design and influence policy. Access the site here to participate and discover more.


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Bringing Together the “Right” People to Shape the Future of Emergency Care


Durell-ColemanWe caught up with Durell Coleman (left). Durell is the Founder and CEO of of DC Design (a social impact design firm) and the facilitator for the upcoming clinicians + designers  *workshop –“Reimagining the ED”. (More details on the workshop here.) He shares his excitement for this 1st workshop…

A big part of what’s important for solving any problem is ensuring the right people are in the room when it’s being discussed. The “Reimagining the ED” workshop at the Healthcare Facilities Symposium is an opportunity to bring together the right people. Physicians, nurses, patient representatives, and architects will have the opportunity to learn from each other and collaboratively redesign the way we address key issues in the ED.

How do we ensure access to the right supplies, at the right time, given the layout of the department?

How do we accommodate the diverse needs of behavioral health patients, geriatric patients, and the rest of the public in a way that renders the best care and experience to all parties involved?

These are the questions clinicians are excited to explore (and hopefully answer!) with architects, during the workshop. Interdisciplinary teams will put forth new design recommendations that will culminate in an FGI-created white paper (with the potential to influence the FGI guidelines). The recommendations from this workshop will play a key role in shaping the future of emergency medicine in the US and around the world for years to come. 

If you are already registered for the Healthcare Facilities Symposium and Expo and would like to add the FGI/ACEP Workshop to your registration please complete this form and email it to jenabeth@jdevents.com. Otherwise, you can REGISTER HERE.

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Uniting Clinicians and Designers to Push Beyond Fundamental Requirements


As you may have heard, the FGI is evolving its work.

Historically, we (as I’m an FGI Board member) have focused on developing the best set of evidence-advised, forward-looking set of Fundamental Requirements possible. We have found, though, that what many people want is not just what is Fundamental, but what is BETTER, or Beyond Fundamental. 

Moreover, our Fundamentals involve a fixed cycle with a determined timeline. That timeline makes it difficult, sometimes, to more fluidly deal with new ideas that don’t fit into that timeline. And, we are represented, on the committee, by only one or two clinical professionals from each clinical pathway.

We are determined to do better.

Towards this, we are launching a program to bring together clinicians from around the country, to work with teams of designers to identify opportunities for improved outcomes at the nexus of health delivery, patient experience, and infrastructure. The first event, September 18, will focus on the Emergency Department–“Reimagining the ED” Design Workshop.

In each workshop, teams of clinicians and designers will, in a structured way, define clinical processes and identify points where infrastructure (at the scale of device, room, department, or department in relation to the whole) can be removed or changed to allow better outcomes. Each workshop will focus on a different, specific clinical pathway, so no two will ever be the same. 

Our kick-off workshop will be held in conjunction with the Healthcare Symposium on September 18 in Austin Texas. We will be focused on the Emergency Department, in all its incarnations. We have already scheduled 25 clinicians from around the country, as well as members of the FGI/HGRC to participate. 

Those of you who participate will: 

  • Have the opportunity to work with and learn from clinicians from across the country and emergency departments of all varieties.
  • Have the opportunity to work with and learn from the best and brightest design professionals from around the country – a rare opportunity to collaborate rather than compete.
  • Get your name listed as an author for the White Paper that FGI will publish with the outcomes. 
  • Be able to shape the future of healthcare through the FGI and its work.

We are very excited about this new pathway, and we hope you will join us. Together, we will make healthcare great again!

Keep in mind, space is limited to the first 100 designers. Click here to register and reserve your spot. 

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Water Management: Why Identifying Potential Risks Supersedes Testing



With everything we touch, our philosophy is to minimize all waste, which includes material waste, excess/unnecessary time and money expenditures, medical waste, etc. (Interested in revolutionizing medical waste management, check out our BETA WasteCare Calculator.)

We believe in doing what is most efficient and effective and nothing more (minimal waste). Effective water sustainability and infection prevention are both attainable. For purposes of this article, we’ll focus on the water infection prevention piece, while addressing what you need to know regarding the CMS memo and offer the least-burdensome suggestions for compliance.

By now you’ve likely seen the recent memo from the Department of Health and Human Service CMS re Legionella Risk. (For those of you who are familiar, feel free to skip over the next section.)

Snapshot of the CMS Memo Read entirety here.

 “Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations.”

Essentially, the CMS is requiring Medicare-certified healthcare facilities to implement water management policies and procedures to reduce the potential risk of Legionella (and other waterborne pathogens). The water management program should consider the ASHRAE 188 Standard and the CDC Toolkit.

AND, healthcare facilities that are unable to demonstrate measures to minimize the risk of LD are at risk of citation for non-compliance with the CMS Conditions of Participation.

This is really not new! Rather, CMS has added ASHRAE-188 to their list of “Examples of organizations that promulgate nationally recognized infection and communicable disease control guidelines, and/or recommendations” and clarified survey procedures.


Don’t sell yourself short! You likely have many, if not all, of the component already in place. The following are the seven things you need to know about the new CMS requirement:

1. Establish a DESIGNATED TEAM
2. If not in existence, develop water flow diagram for building(s)
3. Identify “at risk” areas/systems/equipment and populations
4. Develop and implement risk mitigation strategies
5. Monitor, review and document results
6. Appropriately respond to outlier conditions
7. Review Program periodically

(If you read CMS §482.42 Condition of Participation: Infection Control , you will find each of the items above except TEAM. All they have done on the ‘TEAM’ front was to specifically include others outside of Infection Control.)


The 188 process is not a testing process; it is a risk management process. (Several of my colleagues and I have been actively involved in providing Healthcare facilities better information re Legionella and how to manage it, along with other water pathogens. You can discover more in the ASHE Water Management Monograph, that we co-authored, here.

Standard 188 does ask each facility to assess its risk based on a number of factors and to effectively manage that risk. Testing water for Legionella is one way to manage but so is adequately maintaining your water systems and equipment…. so is testing for residual levels of chlorine… so is IP surveillance.

According to Steve Cutter, Director of Dartmouth-Hitchcock Engineering Services, “The decision to conduct legionella testing is to be made by the organization based on a risk assessment… There are documented cases of Legionellosis where Legionella is not found in the potable water supply, as well as cases where Legionella was detected in the water, but no disease. Until limits are established, finding a single CFU in a test result can expose the organization to significant costs.”


Our IP Consultant Enid Eck preaches, “Prevention is key”. This is applicable for any risk management plan, including water. The key is to understand your patient population, your water quality, your water systems and equipment, and to scrupulously maintain the latter.


Later this month, we are hosting two live events to further address your questions on this topic.


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Lucile Packard’s Children’s Hospital: Where Innovation is Reality


On Monday, I had a kind of bittersweet experience, as I was able to join Perkins + Will (P+W) Healthcare designers from around the country to tour the new Lucile Packard Children’s Hospital Stanford (Packard Children’s ). (We were design partners, along with HGA, for over a decade on this project.)

The sweet part was being able to spend time with so many wonderfully creative people, touring this most amazing, innovative project, and the pride I felt in what our people had collectively created.

The bittersweet part was that this is probably one of the last engineering design projects in which I can claim to have had an active role. As Mazzetti has grown and my focus forced to change, I am still able to help on projects here and there but not in the same leadership type of role I previously took. With Packard Children’s, I was privileged to work alongside a great team of architects, as well as the great people of Mazzetti. And my gosh, it shows!

Packard Children’s Hospital, in Palo Alto California, will be one of the most sustainable large hospitals in the country. It will be the first US hospital to use Displacement Ventilation in all patient areas, reducing first costs and energy consumption/costs. Accomplishing this feat required intricate coordination between the architectural team, the engineering team, and the energy modeling team.

It required carefully designed exterior shading systems integrated with sensors in the building, working with the building automation system (see below).

shading Indeed, the energy design of this building was so critical, that in early stages of the project, we worked with the EIR team to craft a Carbon Emissions forecast and a set of sustainability strategies from water to effluent to energy that are remarkable in their aspiration. Many of these ideas originated from the Kaiser SHBI competition, we won with P+W.

But, as proud as I am of the exceptional engineering that went into this building, I was blown away by the care, and the thought, and the genius, really, of the whole team, led by my friend Robin Guenther (at P+W). I started working with Robin on the Green Guide for Healthcare (GGHC), when I was a young engineer, eagerly trying to help Kaiser with its national energy needs. Robin and I spent years working with so many great people on the GGHC. So, to now be able to bring that spirit of voluntarily innovating to eliminate waste in the form of wasted energy, water, materials, and health on this beautiful building was the opportunity of a lifetime.

The teamwork to craft this place of healing was truly inspiring and a monument to all the many people we have worked with along the way to make it a reality.

(Scheduled Open Date: December 2017)

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