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The Lean Approach to Health Care Building Codes and Standards

Douglas S. Erickson, FASHE, CHFM, HFDP, CHC

Many manufacturing, construction, health care, and other businesses look to lean process improvement to create more value for customers with fewer resources. One aspect of the health care industry that could use a dose of lean thinking is the building and fire codes and standards used to regulate health care facilities. After decades during which more and more requirements were heaped onto obsolete codes, the International Code Council and the American Society for Healthcare Engineering (ASHE) of the American Hospital Association are partnering to revise the I-Codes with the goal of reducing to zero the waste caused by code application and enforcement.

A popular misconception is that lean processes are suited only for manufacturing. Not true. Lean can be applied to every business and every process. Lean is not a tactic or a cost reduction program but a way of thinking. The core idea is to maximize customer value while minimizing waste.Additional lean concepts include eliminating waste along entire value streams instead of at isolated points, and creating processes that require less human effort, less space, less capital, and less time than traditional ways of doing things.

Health care reform, developments in medical technology, and advances in medicine are changing the U.S. health care system, and building and fire codes must keep up with these dramatic changes to support patient care. The overall safety of patients and health care workers is a primary responsibility of all health care organizations and will not be compromised. However, ASHE has quantified the waste from overregulation and misapplication of building and fire codes at a staggering $5-6 billion a year. Most of this waste is caused by the difficulty of complying with the sometimes-conflicting requirements of multiple building codes and standards written by multiple code organizations. This is a trend that cannot be sustained by a system that is daily challenged to reduce costs and provide more with fewer resources.

"The fire codes and fire code inspections have worked to reduce fires, save lives, and minimize property damage. Fire code development is possibly approaching a crossroads. Will it continue to be a tool to save lives, reduce fires, and minimize property damage or will it transition into a process that favors profits, turf, and market share over protecting society as a whole from the ravages of fire? Will it continue to be a valuable resource for a community wishing to positively influence fire and life safety or will it become a book of confusing and incongruent regulations that cost billions of dollars and provide minimal benefit?"

Jon Nisja, Fire Marshals Association of Minnesota, in Fire Code Enforcement: What's "Right" and What's "Wrong"?

These code differences arise not only from the actual language in the documents, but also from the two schools of thought from which they are developed: The ICC uses a consensus process heavily influenced by code-enforcing authorities, while NFPA uses a consensus process that includes a broader range of experts but is heavily influenced by manufacturing, vendors, and special interest groups. As well, the actions of authorities having jurisdiction (AHJs) at all levels of government not only differ because they are enforcing different codes, but because they interpret the language in the same codes differently. Health care organizations are left to absorb the risks, financial and otherwise, that arise from these conflicts, sometimes tearing out completed work approved by one AHJ to satisfy the requirements of another.

The mission of the ICC Ad Hoc Committee on Healthcare is simple: Its goal is to take a fresh look at how current codes and standards support modern health care practices and to recommend appropriate updates through the ICC code development process.

The challenge for all interested individuals, organizations, coalitions, industry and professional associations, and enforcers is to put aside concepts developed decades ago, before health care became the first industry to mandate fully sprinklered new construction and major renovation projects. As one of the most stable industries in the United States today, health care has become an easy target for manufacturers, vendors, service providers, and special interest groups who use the standards process to maximize profit and market share. This activity can no longer be tolerated if health care organizations are to provide cost-effective, quality patient services. Health care has reached a crossroads, and continuing to spend precious resources on outdated and convoluted building/fire codes and standards is not part of the prescription for recovery.

In the future, codes and standards must be developed and updated using lean principles to permit the health care industry to focus on current facility issues and to respond to changing customer desires with variety, high quality, low cost, and fast throughput times. In particular, the latest National Fire Incident Reporting System (NFIRS)1 statistics show that between 2004 and 2006 medical care facilities (hospitals, clinics, infirmaries, and other facilities that provide care to the sick and injured) were responsible for approximately five (one patient per year) civilian fire deaths. In comparison, the latest statistics reported by the Centers for Disease Control & Prevention (CDC) estimate the annual number of health care-associated infections (HAIs) at 1,737,125 with a direct cost ranging from $35.7 billion to $45 billion. During the same period, the CDC estimates that more than 494,935 patients died (98,987 patients per year) due to HAIs.2

Many of us know a family member, friend, or acquaintance who has gotten an infection from a hospital stay, but how many of us know someone who has been injured or died in a health care fire? The statistics show it's time for change. We must come together to write understandable, cost-effective, and research-based standards that will support quality health care into 2020 and beyond.

1 Jennifer D. Flynn, "Structure Fires in Medical, Mental Health, and Substance Abuse Facilities," NFPA, February 2009.
2 R. Monina Klevens et al., "Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002," Public Health Reports 122 (March-April 2007).