Ventilation Management Plan (VMP)

Key Takeaways:

• The Conflict: New facilities built to FGI 2018/ASHRAE 170-2017 are often cited by Joint Commission for not meeting the older FGI 2008/ASHRAE 170-2008 standards enforced by CMS/NFPA 99-2012. Ambulatory Surgery (ASC’s) or hospital facilities built to chapter 20 of the Life Safety Code must follow the 2008 ASHRAE 170.
• The Solution: For hospital projects, consider the development of a Ventilation Management Plan (VMP) once the facility is operational.
• The Strategy: Refer to standard PE. 01.01.01 EP 1 note 2, that allows facilities to utilize the most current edition of the FGI or, that which is adopted by the State regulations.
• Expert Insight: ASHRAE Guideline 43 provides the operational framework to support this approach.

The Ventilation Management Challenge: Modern Buildings, Legacy Standards

It is a common and frustrating scenario for healthcare facilities management. You have just completed a state-of-the-art tower, fully compliant with your state’s latest mandates (likely FGI 2018). Yet, during your survey, the Joint Commission cites you for failure to adhere to FGI 2008 and its associated ASHRAE temperature and humidity guidelines.

Why is This Happening?

The disconnect stems from the regulatory lag. CMS (and by extension, the Joint Commission for deemed status surveys) has adopted the 2012 edition of NFPA 99. The NFPA 99-2012 edition specifically references the ASHRAE 170-2008 edition.

Meanwhile, your state Authority Having Jurisdiction (AHJ) has likely adopted a much newer code (like FGI 2018/ASHRAE 170-2017) which may offer different, often more flexible, ranges for temperature and humidity, critical for areas like Sterile Processing Departments (SPD) where staff wearing PPE need cooler temperatures for comfort and safety. Utilize the FGI reference map Adoption Map – Facility Guidelines Institute for specific information on State adoption.

The Solution: The Ventilation Management Plan (VMP)

Once a facility is operational, you are no longer strictly bound to the construction code for daily management if you have a robust operational plan. This is where ASHRAE Guideline 43 comes in, a standard our team is actively involved with. It provides the framework for managing ventilation systems in operating facilities.

How to Respond to a Joint Commission Citation for Not Adhering to FGI 2008

While there are no guarantees, our contacts and client experiences indicate that JC reviewers have accepted the following logic. You should respond with these three key points:

• Current JC Standards – State clearly that the organization is following PE. 01.01.01 EP1, following State guidelines as permitted. 
• State AHJ Approval – Provide evidence that your state Authority Having Jurisdiction (AHJ) has adopted this newer version of the code for construction, and you are compliant with the state mandate.
• Operational Transition – Explain that while CMS adopts NFPA 99-2012 (referencing ASHRAE 170-2008), this reference is primary for new construction at that time. Once operational, facilities can adapt ventilation management following a developed Ventilation Management Plan (VMP).

In fact, several of our clients have successfully used this approach. The VMP demonstrates to the surveyor that you are not “ignoring” the rule, but managing it through a recognized, safe, and documented operational framework.

Need Help Developing Your Ventilation Management Plan?

Patton Healthcare Consulting experts are part of the committees writing these standards. We can help you build a compliant Ventilation Management Plan tailored to your facility. Contact us to learn more.