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.


    Quick Links:

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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 [email protected]. 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.)

          RE ASHRAE STANDARD 188

          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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              WasteCare Calculator – Help Revolutionize Medical Waste Management


              Help revolutionize medical waste management decision making. You’re invited to test WasteCare—Mazzetti’s (BETA) Waste Footprint Calculator—our waste stream environmental impact calculator.

              You can access the CALCULATOR HERE: http://wastecare.mazzetti.com/.

              We are developing this free tool to help hospitals and healthcare organizations choose the most environmentally friendly ways to conduct all business—ideally, environmentally and economically friendly. This calculator will help hospitals to do this for the first time ever. As part of our Benefit Corporation status, we are providing this tool to help make the world a better place and to provide you with the information you need to implement your own facility solutions.

              Your feedback towards improving this tool, is very much appreciated. FEEDBACK PORTAL is here: http://wastecare.mazzetti.com/#/feedback


              By providing a few pieces of information, the tool allows you to calculate the environmental footprint of your full waste stream.  It also allows you to easily compare one scenario to another so you can see how changes you make might impact the environmental footprint.

              e.g. Do I cause more CO2 emissions by landfilling my msw at the local dump or driving it across state to the incinerator?  How can I maximize landfill diversions while keeping CO2 emissions below a certain threshold?

              Using the Calculator

              To get started, simply go the calculator and sign up for a user account. The calculator starts with a base case consisting of four waste streams, but you can easily add or delete waste streams and add comparison cases. Indicate the weight of the waste stream in tons per day, the electricity region in which the waste will be treated, the type of fuel, and approximate distance to the treatment facility/landfill. The calculator will provide data on resultant air emissions, water use, and energy use.

              Providing Feedback

              In some senses, the calculator is assembling data on environmental impact in a way that is easily accessible. This means that the calculator can only be as good as the underlying data and assumptions.  Part of the purpose of the calculator is to invite discussion, debate, and improvement of underlying data and sources. You can click on links to find the equations, factors used, and data sources for all calculations being performed behind the scenes. You can provide comments directly here. If you believe you have a better source of data or have comments on the factors or equations used, please provide that information. Our intent is to create “open” conversation, so that, we are both creating a tool that is of use in considering the environmental impact of waste stream disposal choices and inviting a conversation about the underlying data we use to make those decisions.

              Next Steps

              Jump in and try it out! If you run into any difficulties, please report on the feedback form. (Comments will be reviewed daily.)

              Thank you for your shared interest and contribution towards creating a valuable tool for the industry and our environment.


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                Six Changes on the Horizon for California Health Facilities Code


                NOTE: This content is primarily intended for AEC professionals doing business in California in Healthcare.

                For the past couple of months, I have served the State of California on the State Health Facilities Code Advisory Committee and the State Plumbing, Electrical, Mechanical, and Energy Advisory Committee. (That probably sounds a lot grander than it really is). Basically, we were a multi-disciplinary team of volunteers who spent several days reviewing proposed state building code changes and providing feedback. I have been privileged through the years to work on codes and standards in so many capacities–it is always a different and interesting process.

                In this particular case, we reviewed, among others, the following (which will become the new California law in due course):

                1. OSHPD is adopting the requirement for a Patient-Safety Risk Assessment.

                California continues to be unable to muster the political will to adopt the FGI Guidelines. So, every cycle, staff have to cobble together pieces and parts of the Guidelines and try to weave them into the current state regulations. (I fantasize working with state legislators and others to get our beautiful state to adopt the Guidelines; I never seem to get there.) The Patient Safety Risk Assessment is an extremely important part of a structured process to manage risks for the benefit of the patients, providers, and progeny (I couldn’t think of another ‘p’ word for visitors).

                1. OSHPD has made a substantial expansion of the regulations regarding mental health treatment.

                I think this is interesting, and it makes me think about adding one regulation and taking away two. This mental health population has been tragically under-served in our country, such that mental health issues have become a serious factor in declining public health. These new regulations help inform the industry  what is needed for effective treatment in a wide range of clinical settings. One of my co-committee volunteers (with a hospital chain) thanked OSHPD for helping to develop these regulations, as his organization had needed that kind of guidance.

                1. OSHPD has created other requirements for technology spaces in Healthcare.

                Again, I’ve assisted many owners, post-occupancy, tackling insufficient space for their burgeoning equipment appetite. The OSHPD regulations are not excessive. They will ensure that these control cabinets stay out of the soiled utility room. (I can still remember, as a young engineer, designing a nurse call control cabinet into a soiled utility room, because I didn’t know I needed to plan the space earlier.)

                1. OSHPD has provided the option for an outpatient observation unit.

                This should help some payors to save some money and keep the people out of the hospital.

                1. OSHPD has adopted language covering energy storage systems.

                This is critically important, as we are starting to design significant energy storage systems for a number of progressive clients as parts of microgrids. This clarity is needed.

                1. OSHPD has adopted the national standards in adopting new humidity provisions. California and OSHPD were actually the inspirations for these changes. A number of years ago, I sat on the Hospital Building Safety Board with a number of really good people. We had a committee that looked into the issue of humidity – it was well-known that few humidifiers in California hospitals were ever turned on, and we concluded that there was, in fact, no evidence that humidity levels made any difference (times were simpler then). I drafted a letter to ASHE, ASHRAE, FGI, and others, asking them to consider this issue. As a result of California’s committee work, the national organizations changed their standards, and now, California is finally able to adopt these national standards.

                There were many more, but the volume makes it only interesting, probably, to a code-junkie who fantasizes about the FGI, so I will end the list there.

                But, I do want to add one more observation.

                I recently came across what looks to be an interesting book– American Amnesia. Its thesis is that America’s economy, and all successful modern economies, are blends of the innovation and dynamically efficient resource allocation, together with governments’ investments in common goods such as infrastructure, education, and public health. The book remembers the idealism of people who want to return to a democracy of decency, where people with disagreements can focus on the power of shared solutions rather than bludgeoning each other in search of selfish success. I remember this book because just this morning, I was in a meeting with some people at the ASHE PDC conference, and we were bemoaning the current President’s interest in eliminating the ENERGY STAR Program. “The only governmental program that helps people make or save money.” Wow.

                What I have observed, in my work with OSHPD over the years, is a narrative remarkably closer to the one in American Amnesia, distant from the divisive government-bashing dystopian vision of our current leaders. In OSHPD, in its volunteer citizen committees, I have spent years watching people trying to listen to each other, to hear each other, to understand each other. I have watched people from all perspectives work towards common solutions. I have watched people who give generously of their own time (in full disclosure, the state does pay a stipend of $100 a day – before taxes – so for those who claim the benefit, not entirely volunteer) to help the state agency do its job better. I think, in truth, we are not so divided after all–in truth, that is the kind of world we want to live in and the one we must work together to create.

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                  ASHRAE Standard 170 – Healthcare Ventilation UPDATES


                  The ASHRAE 170 Committee—focused on ventilation standards in healthcare– met at the annual ASHRAE winter conference.

                  Several significant changes are coming that will impact engineers, architects, and owners if implemented. The following are the highlights of this committee’s work:

                  ·       Addendum M – Allowing Adiabatic humidifiers has been approved and published. Adiabatic humidifiers are much more energy efficient.

                  ·        Addendums N – Adding new chapters to separate outpatient requirements (new Chapter 8) and Residential requirements (new Chapter 9) is going out for public comment. (The current chapters 8 and 9 will become 10 and 11.) This is to accomplish two things: (1) 2018 FGI Guidelines will have three separate book – Hospitals, Outpatient and Residential – and these will align with those, and (2) Reviewing and eliminating “overkill” guidelines for Outpatient and some Residential facilities.

                  ·    We are providing an interpretation regarding Central Sterile Decontamination rooms. The current temperature requirement is 60 – 73 degrees. Maintaining 60 degrees can be very costly, but some AHJ’s (Authority Having Jurisdictions) and engineers have been interpreting the requirement as being that the system MUST be designed to maintain 60 degrees. The interpretation will allow the Owner to determine where “within” the range they want the temperature to be maintained.

                  ·      Addendum O: Allowing facilities an “alternative means” of compliance to meet the Guideline based on a risk assessment. Numerous comments were provided, so the committee will review and make modifications to the document. After which, the addendum will have a 2nd public review. I predict this will likely move forward.

                  For further info, please feel free to contact me directly:  [email protected].

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                    Healthcare Ventilation Standards: Why More Research is Needed


                    Remember that time when you experienced an unpleasant staleness in a building, any building? Perhaps you felt light-headed, maybe even disoriented?

                    Though invisible, good ventilation is critical in all types of buildings. It provides adequate 02 for respiration and removes contaminants (i.e. air pollutants) and C02 from the air – two things that are not only important for your health but vital for your life! And, though poor ventilation is difficult to visually detect, its presence (or lack thereof) is felt.

                    Now consider a critical building such as a hospital. Not only is the comfort of patients and staff of concern, but the prevention of airborne infection and the assurance of a safe environment for everyone is imperative. After all, this is a place of healing.

                    Ventilation for non-healthcare, commercial buildings is governed by ASHRAE Standard 62.1 Significant research supports why specific ventilation rates exist. (Again, the primary role of ventilation here is to provide adequate O2 for respiration and to remove air pollutants and contaminants.)

                    Ventilation standards for healthcare facilities, including hospitals, is established by ASHRAE Standard 170 in most states. Unlike 62.1, we lack sufficient evidence for aspects of the standards. The “evidence” dates back to the 1850’s with Florence Nightingale, prescribing two air changes per hour (for certain spaces). We still reference this (in part) today.

                    WHY the slow progress towards change?

                    The healthcare industry is cautious about change, which is understandable. There is an underlying fear of putting patients at greater risk or opening doors to potential litigation. These are sound fears. However, with the surging importance of sustainability and impacts of climate change, motivations are being forced to change.

                    Mazzetti has been highly visible, on this invisible issue… Ten years ago, we formed the Healthcare Ventilation Research Collaborative to evaluate alternative ventilation strategies for healthcare facilities. The research proved displacement ventilation greatly reduced energy consumption, improved the removal of airborne particular matter, and had an increase in ventilation effectiveness, thereby improving patient comfort.

                    As a result, the approach to ventilation was amended in ASHRAE 170 and adopted subsequently into code in most states. It was this research initiative that enabled displacement ventilation to become a viable option that was ultimately selected  for Lucile Packard Children’s Hospital Stanford project (to be completed later this year).

                    Late last year, we spearheaded a proposed addendum to ASHRAE 170 that was developed by an international collaborative of epidemiologists, infection preventionists, micro-biologists, and designers. The addendum acknowledges that no single set of regulations could adequately cover all possible scenarios, but that allowing some flexibility to apply local knowledge and assess local threats would produce better outcomes.

                    Read more about this “one-size-doesn’t-fit-all” proposed addendum.

                    Our hypothesis, though controversial for some, is that we frequently over-ventilate spaces. We don’t truly understand ‘why’ the standards prescribe a certain number of air changes. As a result, hospital owners (likely) are wasting energy dollars without improving indoor air quality.

                    What if, we could actually observe the relationship of indoor air quality and energy per varying air changes? For owners, there’s potential to save upfront costs (less ventilation needed, less HVAC equipment needed) and operating costs (less energy spend), while maintaining the health and safety of all occupants.

                    We have this opportunity—an opportunity to readdress ventilation in healthcare, so that we can improve indoor air quality, while eliminating wasted energy. We are participating on a research team, funded by the California Energy Commission (CEC), to generate much-needed evidence for ventilation codes in healthcare.

                    To receive updates on this effort, subscribe here.

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                        Fuel Cells for Healthcare Emergency Power


                        In 2011, Mazzetti-Perkins+Will was one of two winners of the Kaiser Permanente “Small Hospital, Big Idea” Competition (SHBI, for short). One of Kaiser’s goals going into the project was a “near-zero impact on the environment.”

                        A key element of our design was the combination of energy systems, focused around a set of fuel cells using waste gas from a landfill. The idea behind the design was to eliminate the diesel generators that are currently used for emergency power, and to use instead the unique modular design of fuel cells so that they could power both normal and emergency operations. In addition to using a renewable fuel, as defined by the state of California, emissions from fuel cells are considerably less than emissions from even the best diesel generators. The problem was, codes in effect at the time, and, arguably today, don’t seem to allow this design.

                        One of the things our SHBI entry included was a regulatory strategy. Much of what was in that design could not be built under then-current regulations. A key element of that strategy was to do the work to change the codes to make this design real.

                        Kaiser never proceeded with the promised design and construction of this hospital, but we have continued to patiently pursue the modernizing of relevant healthcare codes so as to allow the healthcare industry access to this important technology.

                        And now, all of a sudden, with all of the attention turning to micro-grids, our idea is suddenly starting to get attention.

                        We are hearing from a number of our clients and others that they are interested in pursuing the use of fuel cells as emergency sources, and that they are being prevented by the regulatory community.

                        So, if a healthcare facility wanted to substitute fuel cells for diesel generators, is there a regulatory path NOW to make it happen?

                        It is important to know that fuel cells are constructed differently and operate differently from diesel generators. So, such a replacement is not a simple one for one change. Fuel cells, first, can’t start up and assume loads as fast as diesel generators can. So, a design with fuel cells would mean they would need to be operating in both normal and emergency states. Many fuel cells generate both heat and electricity. For these units, in an emergency, there would need to be ways to use both. Most fuel cells currently run only on natural gas, and so, on-site fuel storage will be an issue for disaster resilience.

                        In 2015, NFPA 99 addressed all of these concerns, and was the first national model code to embrace the use of fuel cells as an emergency source for healthcare facilities:

                        “ Fuel Cell Systems. Fuel cell systems shall be permitted to serve as the alternate source for all or part of an essential electrical system, provided the following conditions apply:

               Installation shall comply with NFPA 853, Standard for Installation of Stationary Fuel Cell Power Systems.

               N+1 units shall be provided where N units have sufficient capacity to supply the demand load of the portion of the system served.

              * System shall be able to assume loads within 10 seconds of loss of normal power source.

               System shall have a continuing source of fuel supply, together with sufficient on-site fuel storage for the essential system type.

               A connection shall be provided for a portable diesel generator to supply life safety and critical portions of the distribution system (if present).”

                        These requirements are considerably more stringent than similar requirements in other NFPA documents but are reasonable safeguards for deploying this technology.

                        NFPA intends for 99 to be the document that calls out performance needed for all systems for healthcare. The National Electrical Code, NFPA 70, then, is intended to follow 99, and to detail the technical requirements for achieving these performance needs.

                        NFPA 70, referring back to NFPA 99, requires that emergency loads in a health facility have a normal and an alternate source of power, where the alternate source of power is:

                        “(1)    Generator(s) driven by some form of prime mover(s) and located on the premises

                        (2)    Another generating unit(s) where the normal source consists of a generating unit(s) located on the premises

                        (3)    An external utility service when the normal source consists of a generating unit(s) located on the premises

                        (4)    A battery system located on the premises.”

                        Then, Articles 700 and 701 go on to detail some of the more specific requirements for these generators.

                        Article 700 in the NEC covers “Emergency Systems.” This article (700.12(E)) allows the use of Fuel Cells for these systems so long as it is not “a single fuel cell system.” So, the redundancy requirements of NFPA 99 are met. Further, Article 701, “Legally Required Standby Systems” covers other emergency loads, and it, too, allows the use of fuel cells (701.12(F)) under the same conditions.

                        The other relevant NFPA regulation is NFPA 110. This document is a standard for Emergency Power systems. It is widely recognized as a standard but not codified in many jurisdictions. Nonetheless, it requires energy converters to be “rotating equipment […] consist[ing] of a generator driven by one of the following prime mover types: (1) Otto cycle (spark ignited) (2) Diesel cycle (3) Gas turbine cycle.” To date, 110 has not kept up with NFPA 99, 70 and emerging practice in explicitly allowing fuel cells. However, 110 does provide ( that “other types of prime movers and their associated equipment meeting the applicable performance requirements of this standard shall be permitted, if acceptable to the authority having jurisdiction.” That is, locations following NFPA 70 and 99 will comply even with the current versions of NFPA 110. We have recently submitted proposals to the 110 committee to bring that standard into agreement with 99 and 70, but this action is pending.

                        When Kaiser started its SHBI competition, it intended to change the way hospitals were conceived, planned, and developed. In at least this one aspect, we are on a path to helping make that vision real.

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                          10 Predictions for the Future of Healthcare


                          In 2013 and 2014, The Facility Guidelines Institute (FGI) led a series of workshops to try to discern ways that healthcare would evolve and the likely impact on the built environment. (Disclosure: I am on the board of directors, chairing research and development.) That work is well-documented on their website (www.fgiguidelines.org). It used scenario planning to examine 16 fundamental forces, and how they would come together (like the fingers on a ouija board) to point to the right answer.


                          Thinking deeply about these trends, and their possible expression, the FGI concluded that the future (with respect to the FGI) was going to look something like this:

                          Future Since that experience, I have been thinking deeply about this–about how the FGI needs to be pursuing its follow-on research to help and how to find ways to help healthcare organizations to respond.

                          As an engineer, with an engineering company, I have little ability to influence national reimbursement policy, or patient engagement (other, perhaps, than my own, and that of people close to me). But, there are two things that engineers do well, that I am increasingly focused on.

                          First, engineers are good at designing effective PROCESS. This process engineering has moved into healthcare. We now have quality programs, LEAN programs, and process improvement programs. Improvements from these processes tend to be incremental but dramatically effective over time. One of the things that emerged from the FGI work was that, as much as we need effectively designed buildings, maybe more importantly, is effectively designed HEALTHCARE. And the kinds of changes and kinds of designs needed may be more dramatic than those we have normally seen in the strict process improvement world.

                          I was at an ACHE conference a few months ago, talking with healthcare CEOs. At the time, the FGI was considering creating an Advisory committee of healthcare CEOs to help us keep a constant view of the future, so that we could continually reinvent ourselves and continually stay ahead of the industry. One of the CEOs told me, “You don’t want us; hospital CEOs are the most conservative, risk-averse people there are. If you want to know about the future of healthcare, go talk to tech entrepreneurs.” Indeed.

                          And that is the second most important reality for healthcare–technology. It will be the lever that frees process and experience designers to really create innovative designs for a new healthcare. Technology by itself can never solve a problem; only technology stitched together with carefully designed systemic human responses, can technology make a difference.

                          So, coupling industrial, process engineering, and design with technology is the direction I am trying to steer. Over the years, Mazzetti has been sending our people for training in LEAN and process improvement. Like Jonas Salk, who vaccinated himself and his family against polio to show that it worked, we have been doing the hard work of learning to use these tools on our own operations. Now, as we combine forces with GBA, the icon of healthcare technology, we aim to fill this need, and to work with clients to help them find ever better ways of delivering health to the populations they serve.

                          For, the people they are serving, are us.



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