About the FGI Guidelines
The Guidelines for Design and Construction of Hospitals and Outpatient Facilities (the Guidelines) changes to keep pace with evolving health care needs and in response to requests for up-to-date guidance from health care providers, designers, and regulators. When possible, the Guidelines standards are performance-oriented for desired results. Prescriptive measurements, when given, have been carefully considered relative to generally recognized standards. For example, experience has shown that it would be extremely difficult to design a patient bedroom smaller than the size suggested and still have space for the normally expected functions and procedures.
The Revision Process
The Guidelines and the methodology for revising its content have been, and still are, evolving. When first published, the document comprised a set of regulations developed by a single department of the federal government as a condition for receiving a federal hospital construction grant under the Hill-Burton Act. Today, the Facility Guidelines Institute (FGI) develops the Guidelines using a consensus process similar to one approved by the American National Standards Institute (ANSI).
This process brings together the members of the Health Guidelines Revision Committee (HGRC), a balanced group of stakeholders in health care facility planning, design, construction, and operations and clinical services who volunteer their time to the development of the Guidelines. The committee considers proposals for change received from the public; achieves consensus on facility issues; and develops proposed revisions to the previous edition. The proposed revisions are then posted for public comment and revised by the HGRC, as needed, in response to those comments. The product of this revision process is compiled and published as a new edition of the Guidelines.
Basic Organization of the Guidelines
Main body. The main body of this document comprises four parts:
- Part 1 contains chapters that address considerations applicable to all hospitals and outpatient facilities, except as noted or modified in specific facility chapters in the remaining parts.
- Part 2 addresses facilities where inpatient care is provided, with chapters devoted to general hospitals, critical access hospitals, psychiatric hospitals, rehabilitation facilities, and children’s hospitals.
- Part 3 addresses facilities where outpatient care is provided.
- Part 4 contains the full text of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 170-2013: Ventilation of Health Care Facilities. This ANSI/ASHRAE/ ASHE standard—including all addenda issued by ASHRAE—has been incorporated directly into the Guidelines as minimum requirements for ventilation systems.
Appendix. An appendix is associated with most chapters in the main body of the text.
- An asterisk (*) preceding a section number indicates that explanatory or educational material can be found in an appendix item located at the bottom of the page.
- Appendix items are identified by the letter “A” preceding the paragraph number in the main text to which they relate.
Front and back matter. Informative introductory sections, including the table of contents, acknowledgments, a summary of major additions and revisions to the previous edition, and a glossary precede the main body of the document. A detailed index appears at the end of the book.
The glossary generally includes only terms that require a specific definition to clarify their use in the Guidelines. If a term is clearly defined in the Merriam-Webster Collegiate Dictionary as it is used in the Guidelines, a definition is not included in the glossary.
Uses of This Document
The Guidelines are made available for a wide variety of public and private uses. These include reference in laws, codes, rules, and regulations as well as use in private selfregulation and standardization of space and equipment requirements and the promotion of safe practices and methods in planning, design, and construction for various types of health care facilities.
Regulatory use. Use of the Guidelines or any portion thereof for regulatory purposes should be accomplished through adoption by reference. The term “adoption by reference” means citing title, edition, and publishing information only.
- Any deletions, additions, and changes desired by the adopting authority should be noted separately in the adopting instrument.
- To help FGI follow the uses made of this document, adopting authorities are requested to notify FGI at firstname.lastname@example.org when they adopt the Guidelines or use them in any other regulatory fashion.
Authorities adopting the Guidelines should encourage design innovation and grant exceptions where the intent of the standard is met. These standards assume that appropriate architectural and engineering practice and compliance with applicable codes will be observed as part of normal professional service.
It is recognized that many health care services may be provided in facilities not subject to licensure or regulation, and the Guidelines is intended to be suitable for use by all health care providers. It is further intended that when used as regulation, some latitude be granted in complying with the Guidelines requirements as long as the health and safety of the facility’s occupants are not compromised.
Code language in the Guidelines. For brevity and convenience, these standards are presented in “code language.” Use of words such as “shall” indicates mandatory language only where the text is applied by an adopting authority having jurisdiction (AHJ). However, when adopted by an AHJ, design and construction shall conform to the requirements of the Guidelines.
The word “Reserved” is used to help standardize numbering of the text and is not necessarily a placeholder for specific requirements.
Cross-references are sometimes used to include language from another chapter in the Guidelines in the chapter where the cross-reference appears. Such references include the section as identified by number and title and all its subsections, unless otherwise noted.
Use with other codes. The Guidelines addresses certain details of construction and engineering that are important for health care facility design and construction, but they are not intended to be all-inclusive, nor shall they be used to the exclusion of other guidance. When applicable, other details of construction and engineering that are part of good design practice and building regulation shall be consulted in addition to the Guidelines.
Local codes. For aspects of design and construction not included in the Guidelines, local governing building codes shall apply.
Model codes. Where there is no local governing building code, the prevailing model code used in the relevant geographic area is hereby specified for all requirements not otherwise specified in the Guidelines.
AHJ verification. Some projects may be subject to the regulations of several different jurisdictions, including local, state, and federal authorities. While coordination efforts have been made, the Guidelines may not always be consistent with all applicable codes, rules, and regulations. Therefore, it is essential that individual project requirements be verified as appropriate with all AHJs. Should requirements be conflicting or contradictory, the AHJ having primary responsibility for resolution should be consulted.
Interpretations of requirements. Users of the Guidelines can request interpretations of the language in the document. Interpretations, which are provided by members of the Health Guidelines Revision Committee, are intended to provide clarification; a summary of any background and previous discussion, if appropriate and available; and a rationale for the interpretation rendered.
It is understood that any such interpretation is advisory in nature, intended to assist the user and adopting AHJ to maximize the value of the Guidelines.
Requests for interpretation should be submitted through the FGI website; see www.fgiguidelines.org/interpretations.php for information.
While FGI administers the process and establishes rules to promote fairness in the development of consensus, it does not independently test, evaluate, or verify the accuracy of any information or the soundness of any judgments or advice contained in the Guidelines.
FGI endeavors to develop performance-oriented minimum requirements as suggested standards for American health care facility design, without prescribing design solutions. FGI disclaims liability for any personal injury or property or other damages of any nature whatsoever, whether special, indirect, consequential, or compensatory, directly or indirectly resulting from the publication, use of, or reliance on this document. FGI also makes no guaranty or warranty as to the accuracy or completeness of any information published herein.
In issuing and making this document available, FGI is not undertaking to render professional or other services for or on behalf of any person or entity. Nor is FGI undertaking to perform any duty owed by any person or entity to someone else.
Anyone using this document should rely on his or her own independent judgment or, as appropriate, seek the advice of a competent professional in determining the exercise of reasonable care in any given circumstance.
FGI does not have any power, nor do they undertake, to police or enforce compliance with the contents of this document. FGI does not list, certify, test, or inspect designs or construction for compliance with this document.
Any certification or other statement of compliance with the requirements of this document shall not be attributable to FGI and is solely the responsibility of the certifier or maker of the statement.
The content of this document, in both book and electronic form, is copyrighted by the Facility Guidelines Institute, Inc. By making this document available for use and adoption by public authorities and private users, FGI does not waive any rights in copyright to this document.
History of the Guidelines Document
The original General Standards appeared in the Federal Register on February 14, 1947, as part of the implementing regulations for the Hill-Burton program and were revised from time to time as needed.
In 1974 the document was retitled Minimum Requirements of Construction and Equipment for Hospital and Medical Facilities to emphasize that the requirements were generally minimum, rather than ideal standards. The 1974 edition was the first for which public input and comment were requested. Requirements relating to the preparation of plans, specifications, and estimates and to site survey and soil investigation, which had been a part of all previous editions, were removed. The Department of Health, Education, and Welfare’s (HEW) Office of Facilities Engineering published these requirements in a document titled Technical Manual on Facility Design and Construction.
In 1984 the Department of Health and Human Services (HHS) removed from regulation the requirements relating to minimum standards of construction, renovation, and equipment of hospitals and medical facilities, as cited in the Minimum Requirements, HEW Publication No. (HRA) 81-14500. Since the federal grant and loan programs had expired, there was no need for the federal government to retain the guidelines in regulation format. To reflect its non-regulatory status, the title was changed to Guidelines for Construction and Equipment of Hospital and Medical Facilities.
However, the document was, and still is, used by many state AHJs for licensure or registration. Further, HHS staff members use the Guidelines to assess Department of Housing and Urban Development applications for hospital mortgage insurance and Indian Health Service construction projects. For these reasons, regulatory language has been retained. The 1983–84 edition of the Guidelines was the last one revised and published by the federal government; at the same time, HHS published and distributed an addendum to the Guidelines titled Energy Considerations for Hospital Construction and Equipment.
At the conclusion of the revision cycle that resulted in the 1983-84 edition, HHS asked the American Institute of Architects Committee on Architecture for Health (AIA/CAH) to form an advisory group to work with, and be funded by, the Public Health Service for the next revision. When the revisions to the document were complete, the federal government declined to publish the document. The AIA/CAH asked several nonprofit agencies and professional associations to publish and distribute the Guidelines, and an agreement was finally reached with the AIA to publish the 1987 edition. At this point, revision of the Guidelines would have ceased, or the document would have ceased to exist, if J. Armand Burgun, Joseph G. Sprague, and Douglas S. Erickson had not taken it upon themselves to approach the Public Health Service and the Health Care Financing Administration and request a federal grant to fund a revision cycle. These same three people, working with the AIA/CAH, put together the first Steering Committee, which in turn set up the first Health Guidelines Revision Committee not under the aegis of the federal government. The members of this multidisciplinary group came from the federal and state governments and the private sector and offered expertise in design, operation, and construction of health care facilities. The 1992–93 edition of the Guidelines was published and distributed by the AIA. The Steering Committee from the 1992–93 cycle requested and received federal funding from HHS for another cycle. Substantial funding was also provided by the American Hospital Association and the AIA/CAH. The consensus process was enhanced and the input base broadened by asking the public to propose changes to the Guidelines and then to comment on the proposed changes accepted by the HGRC. Approximately 2,000 proposals and comments were received and processed. Three HGRC meetings were held to discuss the merits of all proposals and comments. More than 65 experts attended these sessions and reached a consensus on the content of the 1996–97 edition of the Guidelines. To better reflect its content, the title of the document was changed to Guidelines for Design and Construction of Hospital and Health Care Facilities. It was during this revision cycle that the AIA Committee on Architecture for Health became the AIA Academy of Architecture for Health (AIA/AAH).
In an effort to create a more formal process and to keep the document current, the Facility Guidelines Institute was founded as an independent, not-for-profit 501 (c)(3) corporation in 1998. The main objectives of FGI are (1) to see that the Guidelines is reviewed and revised on a regular cycle with a consensus process carried out by a multidisciplinary group of experts from the federal, state, and private sectors, (2) to stimulate research in support of evidence-based guidelines, and (3) to reinvest all of the net revenue derived from FGI’s share from the sale of Guidelines documents in research and development for improved future editions of the Guidelines.
FGI is primarily interested in consensus methodology and in overseeing the Guidelines revision process. Specifically, FGI wants to make sure the Health Guidelines Revision Committee
- is properly funded,
- has a balance of stakeholder representation from individuals with expertise or jurisdiction,
- uses the consensus process,
- requests public input in the form of proposals for change and comments on proposed changes,
reviews and revises the Guidelines on a timely basis to maintain a balance between minimum standards and the state of the art in health care design and construction, and
- operates under a formal set of bylaws governing its purpose, scope, membership, and goals that include standing rules governing voting procedures, recognized duties and responsibilities for committee members, and established rules regarding appointments, terms, and officers.
FGI monitors public requests for interpretation of the Guidelines text. Goals are to make sure requests are answered in a timely manner, interpretations are rendered by the individuals best equipped to reflect the intent of the committee when the document was written, and interpretations are made available to the public.
The 2001 edition of the Guidelines resulted from the first revision cycle to be completed under the aegis and direction of FGI. It received major funding from HHS/ Health Care Financing Administration and the AIA/ AAH. The American Society for Healthcare Engineering (ASHE), the National Institutes of Health (NIH), and the AIA provided staff and technical support. The membership for this revision cycle included an increased number of state AHJs, consistent with the increasing number of states utilizing all or portions of the Guidelines as state regulation by adoption. The work of the HGRC was greatly enhanced by the attendance and participation of these AHJs.
The 2001 Guidelineswere the result of many hours spent at three meetings, each attended by 82 to 86 members of the 97-member HGRC. Committee members spent countless hours in subcommittees and focused task groups reviewing the proposals for change and comments on them. The text for the 2001 edition of the Guidelines formally adopted at the final HGRC meeting in Denver was sent to the HGRC members for letter ballot. A major change in format was adopted for this edition, placing appendix material at the foot of the relevant pages in the main text. A glossary of terms and a form to request an interpretation were added to the book.
The 2006 edition of the Guidelines also received major funding from HHS/Centers for Medicare and Medicaid Services, ASHE, and NIH, and the AIA again provided staff and technical support. This edition was also the result of many hours of formal and informal meetings on the part of more than 107 HGRC members.
The 2006 HGRC took on the challenge of two goals stated in the preface of the 2001 edition: to prepare more committee-generated changes to reflect the collective knowledge and experience of the members and to improve the format, readability, and indexing or searchability of the document to make it a more useful, userfriendly tool. The HGRC developed a number of work groups and added time to the revision cycle to draft proposals for new language. The committee also approved a complete reorganization to make the Guidelines more accessible to users. This time-intensive effort resulted in a book presented in four parts: one with information applicable to all health care facility types, one on hospitals, one on ambulatory care facilities, and one for other health care facilities.
The 2010 edition of the Guidelines also received funding from HHS/Centers for Medicare and Medicaid Services, and ASHE provided staff and technical support. This edition was also the result of many hours of formal and informal meetings on the part of more than 116 HGRC members. More than 25 focus groups were formed in Baltimore to review specific sections of the 2006 document or to work on developing new sections for the 2010 edition. Two specialty subcommittees were formed to take on major projects on acoustic design and patient handling and movement. Expertise on these specialty subcommittees was bolstered with contributions from outside technical and subject experts.
The 2010 HGRC took on numerous challenges to modernize the document and meet the needs of the enforcing, design, and owner communities. Major new sections on acoustics, patient handling and movement, bariatric accommodations, cancer treatment/infusion therapy services, freestanding cancer treatment facilities, and telecommunications areas in hospitals were added by the committee, along with new material on wayfinding, patient safety assessments, and outpatient rehabilitation facilities. To make the usability of the Guidelines more consistent with other national standards, a further reorganization of the document was undertaken for the 2010 edition.
One monumental change in the 2010 edition was the incorporation of the 2008 edition of ANSI/ASHRAE/ ASHE Standard 170: Ventilation of Health Care Facilities in the Guidelines. During the 2010 revision cycle, the HGRC voted to abandon the Guidelines ventilation table and partner with the American Society of Heating, Refrigerating and Air-Conditioning Engineers by adopting ASHRAE 170 along with all subsequently issued addenda as part of the Guidelines document.
In 1999 ASHRAE identified the need for an ANSIapproved standard on the ventilation of health care facilities. The rationale was twofold—first, to keep its newly introduced HVAC health care design manual from becoming the de facto ASHRAE standard, and second, to generate a broader public review of new research and findings in the ventilation of health care facilities. In an effort to avoid having two standards addressing identical design issues, with real potential for significant conflict, the FGI Board of Directors approached ASHRAE in 2007 with a proposal to include Standard 170 as part of the Guidelines. Both organizations saw this as a great opportunity and worked closely to make it a reality. As a result, for the first time, Standard 170 was presented in its entirety in the Guidelines, making it the primary document on health care ventilation systems.
With any merger, the gain does not come without some interim adjustments. The 2010 edition retained all Guidelines ventilation content not covered by Standard 170. Further, Standard 170 has what ASHRAE terms “continuous maintenance” project status. The maintenance committee, comprising a mixture of HGRC and ASHRAE members to give it a broad expertise in health care environments, took on the task of keeping 170 current with practice in the field, meeting periodically to develop proposed changes rather than waiting for the end of the three-year revision cycle to issue a new document. The official addenda prepared by the committee are published free of charge on the ASHRAE and FGI websites. It is the hope of the Standard 170 committee that state agencies will adopt these addenda as they are issued, as they represent state-of-the-art thinking in the industry.
As were the previous editions of the Guidelines, the 2014 edition was developed and written during a three-year period by more than 125 dedicated health care experts serving on the HGRC. The revision process emulated other consensus processes in which the public has an opportunity to propose changes to the existing document, the committee responds to these proposals and issues a draft, and the public responds to the work of the committee by submitting comments. Focus groups and specialty subgroups focused on specific topics, reviewing existing text and writing proposals and comments to update it, writing new material, and reviewing proposals and comments from the public. The list of subcommittees in the acknowledgments section outlines the areas of the 2014 edition these groups worked on.
Other subcommittees undertook several tasks to refine the content of the 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities. A task group led by Scott Miller and Rebecca Lewis of the AIA Academy of Architecture for Health reviewed the document for consistency. Kurt Rockstroh, Tom Jung, and Chad Beebe planned a review of the references to the functional program, and Jon Cechvala led a task group to look at minimum area vs. clearance requirements. Skip Gregory led an effort to standardize the language used to describe location of spaces (see the glossary), Paul Shackelford led a group in considering the nursery bassinet complement, and Ramona Conner led a group in revising the sterile processing requirements for surgery facilities. Standing Committees of the Facility Guidelines Institute coordinated the correlation effort at the HGRC meetings (led by Gregg Moon); considered the cost of proposed changes to the Guidelines (chaired by Tom Gormley and Pamela Ward-O’Malley), and revised the glossary (led by Maria Allo). All these efforts improved the clarity and usability of the document.
As in past editions, significant changes are marked throughout the 2014 Guidelines for Hospitals and Outpatient Facilities with a vertical rule beside the text. The glossary of terms defined as they are used in the Guidelines has been updated to reflect how these terms are used in this edition.
In addition to the customary revisions, for 2014 the Facility Guidelines Institute’s Board of Directors implemented a longstanding goal initiated by founding member Martin Cohen, FAIA, FACHA, to separate the hospital and ambulatory requirements from nursing home and other residential and long-term care requirements. Jane Rohde, AIA, AIA, FIIDA, ACHA, AAHID, LEED AP, of JSR Associates was appointed to chair this monumental undertaking, and a specialty subgroup made up of industry leaders, including representatives of residential care and health organizations and the Rothschild Foundation, was carefully chosen. The result is a new standard, published separately, that supports contemporary concepts in health, care, and support services for the elderly and others who require long-term services.