Comments on Revisions to Utility Systems (EC7)
Note: ASHE comments are highlighted in yellow.
General Comment
The chapter numbering should stay the same as it is now to provide continuity with existing plans. Leave Utility Systems as EC 7.
Current Standard: EC.7.10 Current EP: 9
The organization establishes risk criteria* for identifying, evaluating, and creating an inventory of operating components of systems before the equipment is used. These criteria address the following:
- Life support
- Infection control
- Support of the environment
- Equipment support
- Communication
*Note: The organization may choose not to use risk criteria to limit the types of utility systems to be included in the utility management plan, but rather include all utility systems.
Revised Standard: EC.6.01.0 Revised EP: 2
The [organization] maintains a comprehensive inventory of all operating components of utility systems; or maintains an inventory of selected operating components of utility systems (including all life support systems) based on risks for infection control, occupant needs, and systems critical to patient care.
What are the “risks of infection control”? Perhaps this should read…”based on the risks of infection”.
What is the definition of “critical”? Wouldn’t “including life support” be part of critical?
Consider revising as follows: “The [organization] maintains a comprehensive inventory of all operating components of utility systems; or maintains an inventory of selected operating components of utility systems based on preventing the spread of infection, occupant needs, and systems critical to patient care.”
Current Standard: EC.7.10 Current EP: 10
The organization develops appropriate strategies for all utility systems equipment on the inventory for ensuring effective, safe, and reliable operation of all equipment in the inventory.**
Note: organizations may use different strategies as appropriate. For example, strategies such as predictive maintenance, interval-based inspections, corrective maintenance, or metered maintenance may be selected to ensure reliable performance.
Revised Standard: EC.6.01.0 Revised EP: 3
The [organization] identifies inspection and maintenance activities for all operating components of utility systems in the management plan.
Note: [Organizations] may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability-centered maintenance, interval-based inspections, corrective maintenance, or metered maintenance may be selected to ensure dependable performance.
Modify as follows: "For example, activities including but not limited to predictive maintenance..."
Current Standard: EC.7.10 Current EP: 11
The organization defines intervals for inspecting, testing, and maintaining appropriate utility systems equipment on the inventory (that is, those pieces of equipment on the inventory benefiting from scheduled activities to minimize the clinical and physical risks) that are based upon criteria such as manufacturers’ recommendations, risk levels, and current organization experience.
Revised Standard: EC.6.01.0 Revised EP: 4
The [organization] defines in writing the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on manufacturers' recommendations, risk levels and [organization] experience.
What does in writing mean? Is this an additional requirement? Revise as follows:
“The [organization] defines the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as manufacturers' recommendations, risk levels and/or [organization] experience.”
Current Standard: EC.7.10 Current EP: 12
The organization identifies and implements emergency procedures for responding to utility system disruptions or failures that address the following:
- What to do if utility systems malfunction
- Identification of an alternative source of organization-defined essential Utilities
- Shutting off the malfunctioning systems and notifying staff in affected areas
- How and when to perform emergency clinical interventions when utility systems fail
- Obtaining repair services
Revised Standard: EC.6.01.0 Revised EP: 9
The [organization] has procedures for responding to utility system disruptions.
AND
Revised Standard: EC.6.01.0 Revised EP: 10
The [organization]'s written procedures address shutting off the malfunctioning systems and notifying staff in affected areas.
AND
Revised Standard: EC.6.01.0 Revised EP: 11
The [organization]'s written procedures address how and when to perform emergency clinical interventions when utility systems are disrupted.
AND
Revised Standard: EC.6.01.0 Revised EP: 12
The [organization]'s written procedures address how to obtain emergency repair services.
AND
Revised Standard: EC.6.01.0 Revised EP: 13
The [organization] implements its procedures for responding to utility system disruptions.
The current EP does not state “written” but each of the proposed changes do (with the exception of EP 9 & 13) so at minimum this is inconsistently written – and at maximum this dramatically increases the documentation that is required for compliance.
EP 9 and 13 should be combined. “The [organization] has procedures for responding to utility system disruptions and implements them as needed.”
Current Standard: EC.7.10 Current EP: 13
The organization maps the distribution of utility systems.
Revised Standard: EC.6.01.0 Revised EP: 7
The [organization] maps the distribution of utility systems throughout the building.
This actually makes it worse as we are going from mapping the system distribution to only limiting it to the building – this excludes campus based utilities.
Current Standard: EC.7.10 Current EP: 14
The organization labels controls for a partial or complete emergency shutdown.
Revised Standard: EC.6.01.0 Revised EP: 8
The [organization] labels utility system controls in order to prepare for a partial or complete emergency shutdown.
This is poorly written – “in order to prepare” – what does that statement do to improve this?
Consider revising as follows:
“The organization labels utility system components to facilitate a partial or complete emergency shutdown.”
Current Standard: EC.7.10 Current EP: 16
The organization designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed,* to control air-borne contaminants (such as biological agents, gases, fumes, and dust).
*Areas specially designed Include spaces such as operating rooms, special procedure rooms, delivery rooms for patients diagnosed or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), patients in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms.
Revised Standard: EC.6.01.0 Revised EP: 6
In areas specially designed to control air-borne contaminants (such as biological agents, gases, fumes, and dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.
Note: Specially designed areas for control of air-borne contaminants include spaces such as operating rooms, special procedure rooms, delivery rooms for [patients] diagnosed or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), [patients] in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms. Footnote: for further information, see NFPA 90A.
This is a very broad statement. For instance, what gases are of concern?
The reference to NFPA 90A is inconsistent with this EP. The EP appears to be dealing with providing a proper patient care environment. One of the primary reasons for pressure relationships, air exchange rates and filtration is to minimize the spread of infection. NFPA 90A deals with limiting the spread of smoke, not the spread of infection.
The 2006 Edition of the Guidelines for the Design and Construction of Healthcare Facilities would be a much better reference. Note that the guidelines for air exchange rates and pressure relationships have changed over the years, so specific HVAC parameters may depend on when the building was constructed.
Current Standard: EC.7.20 Current EP: 5
The organization provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal electricity is interrupted: Blood, bone, and tissue storage units
Revised Standard: EC.6.02.0 Revised EP: 5
The [organization] provides emergency power for: equipment that could cause [patient] harm when it fails including life support systems; blood, bone, and tissue storage; air compressors; and vacuum systems.
Should be Medical Air Compressors. Not all air compressors are required or need to be on emergency power.
Vacuum systems should be “Medical and Surgical Vacuum Systems, consistent with NFPA 99
Current Standard: EC.7.20 Current EP: 7
The organization provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal electricity is interrupted: Emergency/urgent care areas
Revised Standard: EC.6.02.0 Revised EP: 6
The [organization] provides emergency power for: areas in which loss of power could result in [patient] harm including operating rooms, recovery rooms, obstetrical delivery rooms, nurseries, and urgent care areas.
The language should match that of NFPA 99, chapter 3, 1999 Edition or whichever Edition would be appropriate.
Current Standard: EC.7.30 Current EP: 2
The organization maintains documentation of performance and safety testing of each critical component identified in the plan before initial use.
Revised Standard: EC.6.03.0 Revised EP: 1
The [organization] conducts and documents performance and safety testing of utility systems components on the inventory before initial use.
What is safety testing of utility system components? Performance testing includes that the system operates safely. Consider revising the EP as follows:
“The [organization] conducts and documents performance testing of utility systems components on the inventory before initial use.”
Current Standard: EC.7.30 Current EP: 3
The organization maintains documentation of maintenance of critical components of life support utility systems/equipment consistent with maintenance strategies identified in the utility management plan (see standard EC.7.10).
Revised Standard: EC.6.03.0 Revised EP: 3
The [organization] documents the inspection, testing, and maintenance of: components of life support utility systems.
Add the following: ...utility systems consistent with maintenance strategies identified in the utility management plan.
Current Standard: EC.7.30 Current EP: 4
The organization maintains documentation of maintenance of critical components of infection control utility systems/equipment for high-risk patients consistent with maintenance strategies identified in the utility management plan (see standard EC.7.10).
Revised Standard: EC.6.03.0 Revised EP: 4
The [organization] documents the inspection, testing, and maintenance of: components of infection control utility systems.
Add the following: ...utility systems consistent with maintenance strategies identified in the utility management plan.
Current Standard: EC.7.30 Current EP: 5
The organization maintains documentation of maintenance of critical components of non-life support utility systems/equipment on the inventory consistent with maintenance strategies identified in the utility management plan (see standard EC.7.10).
Revised Standard: EC.6.03.0 Revised EP: 5
The [organization] documents the inspection, testing, and maintenance of: components of non-life support utility systems.
Modify to read; "The [organization] documents the maintenance of: components of non-life support utility systems on the inventory consistent with maintenance strategies identified in the utility management plan."
Current Standard: EC.7.40 Current EP: 1
The organization tests each generator 12 times a year with testing intervals not less than 20
days and not more than 40 days apart. These tests shall be conducted for at least 30 continuous minutes under a dynamic load that is at least 30% of the nameplate rating of the generator. Note:
Organizations may choose to test to less than 30% of the emergency generator’s nameplate. However, these organizations shall (in addition to performing a test for 30 continuous minutes under operating temperature at the intervals described above) revise their existing documented management plan to conform to NFPA 110 (2005 edition) testing and maintenance activities. These activities shall include inspection procedures for assessing the prime movers’ exhaust gas temperature against the minimum temperature recommended by the manufacturer. If diesel-powered generators do not meet the minimum exhaust gas temperatures as determined during these tests, they shall be exercised for 30 continuous minutes at the intervals described above with available Emergency Power Supply Systems (epss) load, and exercised annually with supplemental loads of25% of name plate rating for 30 minutes, followed by50% of name plate rating for 30 minutes, followed by75% of name plate rating for 60 minutes for a total of two continuous hours.
Revised Standard: EC.6.04.0 Revised EP: 4
Twelve times a year, the [organization] tests each emergency generator for at least 30 continuous minutes at intervals not less than 20 days and not more than 40 days apart.
Revise as follows: "The [organization] tests each emergency generator (those generators required to provide power to a load specified in NFPA 99) twelve times a year for at least 30 continuous minutes at intervals not less than 20 days and not more than 40 days apart.
Revised Standard: EC.6.04.0 Revised EP: 5
The [organization] tests each emergency generator with a dynamic load that is at least 30% of the nameplate rating of the generator; or meets the manufacturer’s recommended prime movers’ exhaust gas temperature; or tests every 12 months with supplemental (dynamic or static) loads of: 25% of nameplate rating for 30 minutes, followed by 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 2 continuous hours.
Which test is this referring to? It is not specified in the EP.
Current Standard: EC.7.40 Current EP: 2
The organization tests all automatic transfer switches 12 times a year with testing intervals
not less than 20 days and not more than 40 days apart.
Revised Standard: EC.6.04.0 Revised EP: 6
Twelve times a year, the [organization] tests all automatic transfer switches at intervals not less than 20 days and not more than 40 days apart.
Revise as follows: The [organization] tests all automatic transfer switches serving loads required by NFPA 99 to be on emergency power twelve times a year, at intervals not less than 20 days and not more than 40 days apart.
Current Standard: EC.7.40 Current EP: 3
The organization tests all battery-powered lights required for egress. Testing includes (a) a
functional test at 30-day intervals for a minimum of 30 seconds; and (b) an annual test for duration of 1.5 hours.
Revised Standard: EC.6.04.0 Revised EP: 1
At 30 day intervals, the [organization] performs a functional test for a minimum of 30 seconds of all battery powered lights required for egress.
Revised Standard: EC.6.04.0 Revised EP: 2
Every 12 months, the [organization] performs a functional test for a duration of 1.5 hours of all battery powered lights required for egress; or the [organization] replaces all batteries every 12 months and performs a random testing of 10% of all batteries.
Is there a code or standard that is the source of the option to replace the batteries every twelve months? What is the procedure for performing the battery test required for the 10%. A voltage test would not indicate the condition of the battery, although one could argue that it is a test?
Current Standard: EC.7.40 Current EP: 5
Facilities that have a generator providing emergency power for the services listed in Elements of
Performance 5 through 17 of Standard EC.7.20: The organization tests each emergency
generator at least once every 36 months for a minimum of four continuous hours. This test shall be conducted under a load (dynamic or static) that is at least 30% of the nameplate rating of the generator.*
** Note 1: To be in initial compliance with this Element of Performance, organizations
must have performed this test by July 1, 2007. Organizations that have successfully operated their generator(s) since July 1, 2004, according to the test criteria described above, will be considered to be in initial compliance with this Element of Performance and are required to retest before the three year anniversary date of such occurrence.
Note 2: Organizations that cannot achieve a minimum load of 30% of the emergency generator’s nameplate rating, must assess the prime movers’ exhaust gas temperature and meet the minimum temperature recommended by the manufacturer.*This test may satisfy one of the tests required by Element of Performance 1. **After the test, the fuel supply should be replenished. Any problems identified during the test shall be resolved promptly. For additional guidance, see NFPA 110 (2005 edition) Standard for Emergency & Standby Power Systems.
Revised Standard: EC.6.04.0 Revised EP: 7
[Organization]s with a generator providing emergency power for the services listed in Standard EC.7.20 EPs 6 and 7 test each emergency generator at least once every 36 months for a minimum of 4 continuous hours.
Footnote: For additional guidance, see NFPA 110, 2005 edition, "Standard for Emergency & Standby Power Systems."
If the EP references NFPA 110 for additional guidance, then why not follow NFPA 110 for the 3 year test?