ISHE 2017 Summer Newsletter!

Dear ISHE Member,

Welcome to the ISHE Member Newsletter, Summer Edition. If you are not currently an ISHE member, we hope that you will join our award winning organization. Please feel free to share this newsletter with interested parties. Click here for the Spring newsletter!

ASHE Insider

Click here for the latest edition of the ASHE Insider!

ISHE 2017 Spring Newsletter!

Dear ISHE Member,

Welcome to the ISHE Member Newsletter, Spring Edition. If you are not currently an ISHE member, we hope that you will join our award winning organization. Please feel free to share this newsletter with interested parties. Click here for the Spring newsletter!

ASHE and Healthcare Infrastructure Research program looking to highlight innovation

ASHE is working with the Healthcare Infrastructure Research program in Washington, D.C., to identify and highlight innovations in our field. ASHE members and others can submit innovative work from their hospitals or companies for consideration in this project. A team of top health care representatives from various organizations–including Cleveland Clinic, Kaiser Permanente, Catholic Health Initiatives, HCA, VA, Defense Health Agency, and National Institutes of Health–will be reviewing submissions. The team will highlight innovations that have advanced the effectiveness of American health care facilities and will outline actionable strategies for future innovation. Submit your innovative work today using a quick online form, which can also be used to indicate interest in underwriting or sponsoring this project.
Continue to this online form

ISHE 2017 Winter Newsletter!

Dear ISHE Member,

Welcome to the ISHE Member Newsletter, Winter Edition. If you are not currently an ISHE member, we hope that you will join our award winning organization. Please feel free to share this newsletter with interested parties. Click here for the Winter newsletter!

Give your input on a potential change to ASHRAE 170

ASHRAE recently published an addendum to ASHRAE 170: Ventilation of Health Care Facilities to clarify requirements for steam humidifiers and adiabatic atomizing humidifiers. A PDF of the published addendum can be downloaded here. Also, ASHRAE is seeking comments on another proposed addendum to ASHRAE 170. Proposed addendum o would allow health care providers that have the expertise to analyze, implement, and document their specific ventilation requirements to use a risk-based approach to establish alternate ventilation rates. The proposed change is out for First Advisory Public Review Draft until January 15. ASHE encourages members to review this proposal and submit advisory comments before the January 15 deadline.

2017 Sponsorship Opportunities Now Available!

If you would you like to take advantage of ISHE's 2017 sponsorship opportunities please click here!
Various sponsorship levels have been established for partners of all sizes. Please click here to evaluate which level of sponsorship is best for your organization. 
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What the Trump presidency will mean for health care

The American Hospital Association is inviting ASHE members to watch a recording of a Town Hall discussion on the election results and what they mean for health care facilities. The Town Hall addresses policy versus politics, the future of the Affordable Care Act, key players in the new administration, and big issues still at stake in Washington.
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USP 800 brings new regulations to hospital pharmacies

New rules for handling hazardous drugs are more comprehensive and stringent

November 2, 2016

William N. Bernstein, LEED AP, AIA

A pharmacy cleanroom at Santa Barbara (Calif.) Cottage Hospital, designed by Bernstein & Associates, Architects.

The U.S. Pharmacopeial Convention (USP) has introduced an important new chapter on compounding standards in the 2016 compounding compendium called USP 800, Hazardous Drugs (HDs) — Handling in Healthcare Settings.

Many people in the health care environment are already familiar with USP 797, Pharmaceutical Compounding — Sterile Preparations. USP 800 is not as widely known, but that is about to change. First published in February, USP 800 will become officially enforceable on July 1, 2018.

As the title indicates, USP 800 addresses the handling of HDs in a hazardous setting. This topic had been addressed in a substantial manner in USP 797; however, in the creation of USP 800, USP has created a separate guideline to address just HDs (and is currently revising and reissuing USP 797 accordingly).

The USP 800 guidelines on handling HDs are now more comprehensive and stringent than they were in USP 797.

Click here to read more.....

ISHE 2016 Fall Newsletter!

Dear ISHE Member,

Welcome to the ISHE Member Newsletter, Fall Edition. If you are not currently an ISHE member, we hope that you will join our award winning organization. Please feel free to share this newsletter with interested parties. Click here for the Fall newsletter!

CMS Call on Emergency Preparedness Rule!

The Emergency Preparedness Requirements Call on 10-5-2016 is now available online!

Description: The Emergency Preparedness Requirements final rule established national requirements for Medicare and Medicaid providers. During this call, CMS discusses the new requirements and revisions in the final rule, as well as how to plan for both natural and man-made disasters, while coordinating with other emergency preparedness systems. A question and answer session follows the presentation. 


  • Provisions of the final rule
  • Enforcement process
  • Overview of available technical assistance 

Target Audience: The final rule applies to 17 categories of providers and suppliers:

  • Hospitals
  • Critical Access Hospitals
  • Long-Term Care Facilities, Skilled Nursing Facilities, and Nursing Facilities
  • Religious Nonmedical Health Care Institutions
  • Ambulatory Surgical Centers
  • Hospices
  • Psychiatric Residential Treatment Facilities
  • Programs of All-Inclusive Care for the Elderly
  • Transplant Centers
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities
  • Home Health Agencies
  • Comprehensive Outpatient Rehabilitation Facilities
  • Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
  • Community Mental Health Centers
  • Organ Procurement Organizations
  • Rural Health Clinics and Federally Qualified Health Centers
  • End-Stage Renal Disease Facilities

Call Materials:

Slide Presentation [PDF, 925KB]  

Audio Recording [ZIP, 19MB]  

Written Transcript [PDF, 350KB]

Registration: To register for an MLN Connects Call, please visit the MLN Connects Event Registration website.

2018 FGI Drafts Available

Dear ISHE members, below is the press release announcing the 2018 revision cycle public comment period. Please share with others who may be interested!

Access Drafts and Comment Systems

Public Invited to Review and Comment on Draft 2018 FGI Guidelines Documents

The Facility Guidelines Institute (FGI) invites users of the FGI Guidelines to comment on its draft 2018 documents, posted for public review beginning September 29, 2016. Input from the field is critical to revising the Guidelines documents, which provide fundamental standards for design and construction of hospitals, outpatient facilities, and residential health, care, and support facilities.
The multidisciplinary, 100-member Health Guidelines Revision Committee (HGRC), the body responsible for the content of the Guidelines, revises and updates the text every four years to keep pace with changes in the health care and residential care fields and to clarify the requirements to make compliance easier. “Although we are only in the middle of revising the FGI Guidelines documents, HGRC members have been putting forth a yeoman’s effort to verify the need for existing requirements and validate newly proposed language,” said Douglas Erickson, FASHE, CHFM, CHC, HFDP, chair of the 2018 HGRC. “Now we need users of the Guidelines to review the draft documents and provide comments, supportive or constructive, for consideration by the HGRC during the final stages of developing the 2018 documents.”
The 2018 Guidelines revision cycle will yield three Guidelines documents—for hospitals, for outpatient facilities, and for residential health, care, and support facilities. Therefore, three drafts have been created as well as an electronic comment system for each book. To learn more about the comment period, to access the draft, and to link to the three comment systems, please visit the FGI website.
The public comment period will close on December 12, 2016. Comments may be made only on proposed changes to the text (deletions, revisions, or new material) in the 2014 FGI Guidelines for Design and Construction of Hospital and Outpatient Facilities and Guidelines for Design and Construction of Residential Health, Care, and Support Facilities. Following are some of the changes proposed for the 2018 FGI Guidelines documents:
Hospitals and Outpatient Facilities

  • New guidance on design of telemedicine spaces
  • New design requirements for accommodations for care of patients of size
  • Clarification of procedure room and operating room requirements: procedure types, facility types, hybrid ORs
  • New classification structure based on procedures performed and patient acuity for determining imaging room requirements
  • New flexibility in pre- and post-procedure patient care area design requirements
  • Two options for sterile processing area design: two required rooms (decontamination and clean) with an exception for a single room for small tabletop sterilizers
  • New design requirements for a sexual assault forensic examination room
  • Revised mobile/transportable medical unit chapter
  • Updated acoustics requirements
  • Expanded sustainability requirements re: waste minimization, potable water, and energy efficiency
  • Revised guidance for emergency preparedness and management (formerly provisions for disasters)

Residential Health, Care, and Support Facilities

  • Updated acoustics and lighting requirements
  • Updated minimum requirements for grab bar configurations to align with the latest research
  • New chapter on settings for individuals with intellectual and/or developmental disabilities
  • New chapter on long-term residential substance abuse treatment facilities
  • New telemedicine section to address the increasing provision of telemedicine services in residential facilities
  • Language shift from “bariatric resident” to “person of size” since people who need accommodations include those who are not necessarily obese or receiving treatment for obesity, such as very tall people

Commenters are asked to provide their take on the costs and benefits of any changes to the draft text they submit, using an optional cost/benefit comment box and a required cost/benefit matrix provided in the comment systems. The FGI Cost/Benefit Committee will review all comments and make recommendations to the HGRC.

ASHE is conducting a survey of health care facilities to collect operational characteristics and 2015 energy and water consumption data. The survey will quantify trends in energy and water use in health care facilities. Additionally, the data will be anonymously shared with EPA with the goals of:

  • Updating the ENERGY STAR 1-100 score models for both General Medical & Surgical Hospitals and Medical Office Buildings
  • Expanding to new ENERGY STAR 1-100 score models for other health care space types
  • Evaluating the potential to develop a 1-100 score for water efficiency

All health care organizations are encouraged to participate. The deadline to complete your submission is October 14, 2016. A webinar and Q&A session will be held on September 14, 2016 at noon Central Time.

                                  Click here to access the Survey!                             Click here to Register for the September 14th Webinar!

The success of ASHE's effort will largely depend on the response rate, so please set aside time to complete this important survey. To help encourage participation, ASHE will randomly select one survey participant from each ASHE region to win a $250 Amazon gift card.

If you currently use Portfolio Manager, you will be able to share your Portfolio Manager data with ASHE, which allows you to skip sections of the survey. You will still need to provide additional operational characteristics about your facility.

Questions? Please contact

CMS issues correction to new fire safety requirements

The Centers for Medicare & Medicaid Services in June published a correction to its recently updated fire safety standards for hospitals. The May final rule adopted the National Fire Protection Association’s 2012 Life Safety Code (with minor amendments) and most chapters of its 2012 Health Care Facilities Code for hospitals and certain other facilities that participate in the Medicare and Medicaid programs. The correction states that hospital outpatient surgical departments must meet Life Safety Code provisions applicable to ambulatory health care occupancies, “regardless of the number of patients served.” The standards for ambulatory health care occupancies normally apply to facilities that provide services simultaneously to four or more patients.

Joint Commission stops considering Plans for Improvement

The Centers for Medicare & Medicaid Services (CMS) has asked the Joint Commission to make several changes to its Statement of Conditions process and the Joint Commission will no longer consider hospital Plans for Improvement (PFIs) starting Aug. 1, the American Society for Healthcare Engineering (ASHE) told its members in an Advocacy Alert email blast this month. The major changes, which were announced at ASHE’s annual meeting in Denver by George Mills, FASHE, CEM, CHFM, CHSP, director of engineering with the Joint Commission's Department of Engineering, call for all life safety deficiencies to be corrected within 60 days, although a time-limited waiver process will be available through CMS regional offices. Mills said the PFI process still can be used as an internal management process.

ASHE video explains CMS changes to health care field

Changes to the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation requirements have brought up many questions from health care facility managers. Tim Adams, FASHE, CHFM, CHC, American Society for Healthcare Engineering’s (ASHE) director of member professional development, answers many questions in a new video addressing the CMS changes.

The 42-minute video can be accessed by non-ASHE members, and the organization encourages viewers to share the resource with health care executives within their facilities. CMS will begin surveying hospitals according to the new requirements in November.

Mark P. Grimes has Retired

After 10 years as AHJ, today is my last day as the Idaho Facility Fire Safety and Construction Supervisor.   I wish you all success and satisfaction in your careers and personal lives.  My career has been extremely satisfying and I have been honored to have worked with you, but now it is time to focus on family and friends in this new chapter.  Nathan Elkins will be the new Health Care Licensing AHJ in Idaho, he will do a fine job in helping you to build and maintain a safe environment in Idaho facilities.

As always, feel free to contact me if you need something, I am retiring, but will always want to help if I can.

Mark P. Grimes

ISHE 2016 Summer Newsletter!

Dear ISHE Member,

Welcome to the ISHE Member Newsletter, Summer Edition. If you are not currently an ISHE member, we hope that you will join our award winning organization. Please feel free to share this newsletter with interested parties. Click here for the Summer newsletter!

ISHE has earned the Platinum Level of Affiliation with ASHE for 2015!

The Platinum Level is the highest Level of Affiliation that can be attained by an ASHE Chapter. This accomplishment reflects our membership's dedication to Education, Leadership, Communication, and Advocacy for the Healthcare Engineering profession.

ASHE chapters participating in the Levels of Affiliation Awards Program submit documentation demonstrating that they have met several criteria based on affiliation objectives ASHE would like to achieve to make its chapters stronger and more viable, which in turn benefits the fields of healthcare engineering and facilities management.

Way to go ISHE!

Joint Commission deletes some program requirements

The Joint Commission recently approved deletion of 131 requirements from its hospital accreditation program that it states are no longer necessary because they have become a routine part of operations and clinical practice. For instance, Element of Performance Standard EC.02.03.01 states that hospitals must take measures to minimize fire risk if patients are permitted to smoke. The Joint Commission states that it is being deleted because it is duplicative of another Element of Performance Standard. The changes will go into effect July 1.

Adoption of the 2012 edition of the Life Safety Code

After several long years the wait is now over!  Starting July 5th, CMS will be using the 2012 edition of the code.  The best news is that with you and your chapters support, CMS heard our concerns with their proposed rule. I would say that the final rule looks pretty good considering where it started. The changes that CMS made wouldn’t have happened without the comments submitted by your members.

Some notes of the new rule include:

-          Hospital providers can use the appropriate occupancy types for the situation per the Life Safety Code

-          CMS didn’t go with the 4 hour fire suppression out of service rule

-          The window sill requirements will only apply to NEW construction

-          Smoke evacuation will not be required in operating rooms

-          Roller latches will be permitted in some situations

Additionally, the adoption of the 2012 edition virtually eliminates the need for all of the categorical waivers and I believe we can now use maintenance free batteries on our Gensets (perhaps a small issue but that one sure feels good to have behind us)

In preparation for the adoption we have provided, and will continue to develop several resources. Please take a few moments to review the content provided on our Life Safety Code adoption website. We have several articles that will detail each of the requirements, the final CMS rule, a webinar series, on demand webinar recordings and previous conference sessions that will help you comply with the new regulations. Bookmark this page as it will be continuously update over the next several months.

I know everyone has a lot of questions, so we are collecting questions about the adoption and I encourage you to share this link with your members: SUBMIT A QUESTION ABOUT THE NEW REGULATIONS  We will be answering the questions we can and creating a Frequently Asked Questions section on the website.