About the FGI Guidelines
In 2014, for the first time, the Facility Guidelines Institute published two Guidelines for Design and Construction (Guidelines) standards, separating the requirements for hospitals and outpatient facilities from those for long-term residential care—nursing homes and hospice facilities, assisted living facilities and independent living settings, and non-residential support facilities (adult day care facilities, wellness centers, and outpatient rehabilitation centers). The new Guidelines for Design and Construction of Residential Health, Care, and Support Facilities will be updated in future editions to keep pace with evolving care models, facility types, and requests for up-to-date guidance from 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 and research. For example, the resident safety risk assessment concept was developed by a collaborative team, including the Center for Health Design and members of the Health Guidelines Revision Committee (HGRC) and the HGRC Specialty Subgroup on Residential Facilities, using an evidence-based approach to this key planning and programming component.
A specialty subgroup of more than 40 volunteer industry experts came together as part of the 2014 Guidelines revision cycle to update, improve, and create the new design Guidelines for residential care communities. The ultimate goal was to provide the framework for physical environments that support positive resident and staff outcomes and respond to the national movement to integrate person-centered practice and the built environment. The evolution of communities focused on the person-centered values of choice, dignity, respect, self-determination, and purposeful living has begun to transform services for seniors and others who need long-term care in the United States. This change in approach has significant implications for the design and construction of the residential communities where those services are delivered.
A person-centered culture requires the creation of built environments for both long- and short-term living, including community-based settings that allow both residents and their caregivers to express choice and practice self-determination in meaningful ways at every level of daily life. Often, an unintended barrier to creating positive person-centered care models in long-term care settings is outdated and obsolete regulations and licensing. This is one of the reasons for developing the new Guidelines for Design and Construction of Residential Health, Care, and Support Facilities, which provides minimum design requirements and additional recommendations for design of these facilities. The goal is to provide a set of guidelines that will streamline the design portion of the licensing process for long-term care settings, help authorities having jurisdiction evaluate design documentation, provide consistency between states, and improve resident care environments and outcomes around the country.
Basic Organization of the Guidelines
Main body. The main body of this document comprises six parts:
- Part 1 contains chapters that address considerations applicable to all residential health, care, and support facilities, except as noted or modified in specific facility chapters in the remaining parts.
- Part 2 provides common elements applicable to most of the facility types in the book. This material applies when referenced from the common element and facility chapters in Parts 3 through 5.
- Part 3 provides requirements for residential health facilities: nursing homes and hospice facilities.
- Part 4 provides requirements for residential care and support facilities: assisted living facilities and independent living settings.
- Part 5 provides requirements for non-residential support facilities: adult day care and adult day health care facilities, wellness centers, and outpatient rehabilitation therapy facilities.
- Part 6 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 for nursing homes, hospice facilities, and some aspects of assisted living facilities as indicated in the Guidelines. Additional references to other ASHRAE standards are provided in the Guidelines for assisted living facilities, independent living settings, and non-residential support facilities.
Appendix. An appendix is associated with 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.
Cross-references. Cross-references are used throughout the Guidelines to include language from another chapter in the text where the cross-reference is located. These references comprise the section number with the section name in parentheses. For example: See Section 2.2-3.1.4 (Resident and Participant Kitchen).
Front and back matter. Informative introductory sections, including the table of contents, acknowledgments, 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 self-regulation and standardization of space and equipment requirements and the promotion of safe practices and methods in planning, design, and construction for various types of residential health, care, and support 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 residential health, care, and support services may be provided in facilities not subject to licensure or regulation, and the Guidelines is intended to be suitable for use by all care and service 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. Use with other codes. The Guidelines addresses certain details of construction and engineering that are important for residential health, care, and support facility design and construction, but they are not intended to be all-inclusive, nor shall they be used to the exclusion of other guidance or codes.
- Local codes. For aspects of design and construction not included in the Guidelines, local governing building and licensing 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 for compliance 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 designer, care or service provider, 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.
The Revision Process
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 facility planning, design, construction, and operations and in provision of care and clinical services who volunteer their time to the development of the Guidelines. For development of specialized material, the HGRC members work with specially convened specialty subgroups of relevant industry experts. For development of the new Guidelines for Residential Health, Care, and Support Facilities, HGRC members with expertise in residential health, care, and support facilities worked with members of the Specialty Subgroup on Residential Facilities, composed of volunteer experts in gerontology, research, provision of care, lighting, and acoustics and representatives of industry organizations (see the acknowledgments section for details). The HGRC and subgroups consider proposals for change received from the public; achieve consensus on facility issues; and develop proposed revisions to the previous edition of the Guidelines. 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. The next revision cycle will begin in 2015 to prepare updates for the 2018 edition.
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 guidance for American residential health, care, and support 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.
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 2001 Guidelines was the result of many hours spent at three meetings, each attended by 82 to 86 members of the 97-member HGRC. The text for the 2001 edition of the Guidelines was adopted at the final HGRC meeting in Denver. 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 received major funding from HHS/Centers for Medicare & Medicaid Services, ASHE, and NIH, and the AIA again provided staff and technical support. This edition was 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, user-friendly 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 received funding from HHS/Centers for Medicare & Medicaid Services, and ASHE provided staff and technical support. This edition was also the result of many service hours from 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. Three specialty subcommittees were formed to take on major projects on acoustic design, patient handling and movement, and surfaces and furnishings. Expertise on these specialty subcommittees was bolstered with contributions from outside technical and subject experts.
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.
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 is in the acknowledgments section.
In addition to the revisions for the Guidelines for Design and Construction of Hospitals and Outpatient Facilities, 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 outpatient requirements from nursing home and other residential and long-term care requirements. Jane Rohde, AIA, FIIDA, ACHA, AAHID, LEED AP, of JSR Associates, Inc. was appointed to chair this monumental undertaking, and a specialty subgroup of industry leaders, including members of the Health Guidelines Revision Committee and representatives of residential health, care, and support organizations, was pulled together. A partnership with the Hulda B. & Maurice L. Rothschild Foundation was established to share funding and resources for interim meetings of the Specialty Subgroup for Residential Facilities to complete the work on writing the new Guidelines. Thomas Jung, retired AHJ from New York, and David Green, representing SAGE and retired executive director of Evergreen, a Wisconsin-based community, as associate chairs shared in the leadership of the proposal, comment, and voting process of the HGRC. The result is a new set of guidelines, published separately, that supports contemporary concepts in health, care, and support services for the elderly and others who require long-term health, care, and support services.