The new 2006 edition of the Guidelines for Design and Construction of Health Care Facilities, commonly referred to as the “AIA Guidelines,” offers health care providers, federal agencies, local and state regulatory agencies, architects and engineers a glimpse into the next four years of health care design.

The Facility Guidelines Institute (FGI), formed in 1998 by the executive committee of the Health Guidelines Revision Committee (HGRC), provides a revision committee for guidelines and procedures updates every four years.  Architects, engineers, clinicians as well as state and federal officials are part of the guidelines revision committee. 

The guidelines are supported by the Department of Health & Human Services’ Centers for Medicare & Medicaid Services and the National Institutes of Health, The American Society for Healthcare Engineering of the American Hospital Association and American Institute of Architects/Academy of Architecture for Health. Together, these organizations created the 2006 edition of the guidelines.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), many federal agencies and authorities in more than 40 states use the guidelines as a code or a reference standard when reviewing, approving and financing plans or developing their own requirements for construction of hospitals and other health care facilities. 

User friendly format

For the industry, the 2006 edition offers notable features that make it easier to use than previous editions. For the first time, for instance, the book is offered in two formats—a bound, three-hole-punched hard copy or a searchable CD version.

Inside the book, users will find even more changes. The guidelines have been significantly reorganized in response to a study by the Clemson University School of Architecture in Clemson, S.C., commissioned by the FGI. 

The most visible changes are those designed to help navigate the guidelines. Previously, the contents included a list of facility types in the order the topics were added to the book. This year, however, the book is divided into four parts, including: Part 1, general considerations providing information applicable to all facility types; Part 2, hospitals; Part 3, ambulatory care facilities; and Part 4, other health care facilities—including nursing, hospice, assisted living and adult day care facilities.

“We worked closely with the AIA Healthcare Guidelines Revision Committee task force to review the document,” says David Allison, AIA, ACHA, co-investigator at Clemson University School of Architecture. “Now, the text has been broken into shorter paragraphs with more subheads to make it easier to reference requirements—and [the subjects have been] placed in basically the same order in every chapter.” 

The reorganization is accompanied by a new numbering system that reflects the division of the content into parts. The first part of each paragraph reference is the chapter number, which appears at the top of the page. This is followed by a hyphen and the paragraph number. For example, the reference to typical patient rooms in a hospital medical-surgical unit is 2.1 through 3.1.1. 

For users accustomed to the organization and numbering of past editions, a relocation matrix is included at the back of the book to ease the transition.

General info

As in previous books, the 2006 edition begins with information and requirements applicable to all health care facility types. Now constituting Part 1, it also features added language on patient safety issues, added language in support of sustainable design, clarity of wayfinding and a focus on patient privacy/confidentiality and safety and security. While these subjects were in the previous edition, each topic is greatly expanded.

Chapter 1.1 provides the user with a general overview of the book, serving as a guide for interpretation and application. Chapter 1.2 contains an expanded discussion of the environment of care components of the functional program and issues of sustainable design.

Because the JCAHO has established more detail in its environment of care standards, JCAHO representatives were given opportunities to participate in the guidelines discussion. Each operation has a functional program that describes how the space should function with patients, staff and medical equipment. However, the guidelines address only the built environment portion—not the operational issues.

Chapter 1.5 is dedicated to the contents of former Chapters 5 and 6, which cover planning, design, construction and post-construction considerations. It includes a revised section on the infection control risk assessment (ICRA) process with information about the preparation of infection control risk mitigation recommendations.

The new guidelines also clarify the responsibilities and roles of the parties in ICRA, including those of the owner, infection control specialist, architects and contractor, with regard to infection control implementation. The guidelines committee also addressed infection control challenges in the built environment by focusing on issues such as the placement of hand-washing stations, overall ventilation and the single-bed patient room.

New in Part 1 is Chapter 1.6, which introduces the concept of common facility requirements that apply to all health care buildings. Topics covered in this section include building automation systems, MEP systems and other common and guideline requirements in the health care built environment.

Guidelines for hospitals

Part 2 of the new guidelines covers general hospitals, psychiatric hospitals and rehabilitation facilities from the 2001 edition of the guidelines, along with a completely new chapter on small inpatient primary care hospitals.

The guidelines are designed to work in tandem with rural health care providers to allow an effective and efficient design. Thus, the guidelines committee understood that special considerations exist when designing rural hospitals—including a lesser number of staff, reduced flexibility in terms of operations and a limited amount of resources. The new chapter on small hospitals was added to address facilities that are more commonly constructed in rural areas or underserved communities.

Also in Part 2, the single-bed modification for general medical-surgical units is a major addition to the guidelines for patient advocates, infection control professionals and clinical staff.

The guidelines committee recognized that there was limited evidence and data available to make good, solid minimum guidelines for patient room bed requirements. The FGI funded research prior to proposing a minimum standard of single-bed patient rooms. After extensive research of existing findings in addition to studies performed in several hospital locations, the committee felt that the new data provided a better basis for evidence-based changes. In creating the guidelines, the committee looked at issues such as patient safety, infection control, privacy, patient falls, therapeutic impact and operating costs.

The final proposed language reads, “In new construction, the maximum number of beds per room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement. Approval of a two-bed arrangement shall be obtained from the licensing authority.”

Examples of conditions that would give rise to multibed rooms might include limited staff or other resources not available to rural health care providers. Urban health care providers, with limited footprint and space, might also be exempt due to the slightly greater square footage needed to accommodate single-room layouts.

Moreover, when therapeutic value is at stake, single patient rooms might not be the best case option. Multiple bed layouts, for rehabilitative or recovery-based healing, promote progressive healing for like-afflicted patients. For example, orthopedic or geriatric patients can be inspired by a roommate’s steady recovery, while undergoing a similar procedure.

Additional language states, “Where renovation work is undertaken and the present capacity is more than one patient, maximum room capacity shall be no more than the present capacity, with a maximum of four patients.”

Ambulatory care facilities

Formerly Chapter 9 of the 2001 edition, the outpatient facilities focus has been divided into 11 chapters for the 2006 edition. The change was made because ambulatory care is becoming one of the largest components of capital expenditure in today’s health care market. This spike has led to increased outpatient-related facilities, from freestanding urgent care to ambulatory surgery centers.

To accommodate these new facility types, the guidelines have been expanded to cover additional elements prevalent to the built environment in a broader application. Chapter 3.1 offers guidelines for outpatient facilities in general, while sections on specific facility types that previously appeared in Chapter 9 are located in individual chapters. In addition, the former Chapter 12 on mobile, transportable and relocatable units is now located in Part 3.

Content changes include moving the freestanding emergency service section to the general hospital chapter. However, a new classification, “freestanding urgent care facilities,” appears for the first time in Part 3. Urgent care facilities are defined as facilities providing basic care for nonemergency conditions on a less than 24-hour-per-day schedule.

Throughout the document, the committee was determined to keep the level of guidance consistent regardless of whether the facility was designed in an inpatient or outpatient setting. Because emergency care can be a part of both facilities, the committee decided to place the section with outpatient care to maintain a balance.

Similarly, Part 3 features greatly expanded and improved guidelines requiring outpatient surgery facilities to provide the same environmental design functions, controls and finish materials as those found in the surgery departments of inpatient facilities.

Likewise, the book also outlines a new chapter created for office surgical facilities. These new guidelines promote positive outcomes when surgical procedures are rendered in an office surgical facility environment.

Other facility types

Nursing facilities, hospice facilities, assisted living facilities and adult day care facilities are covered in Part 4 of the guidelines. While Chapter 4.1 on nursing facilities (formerly Chapter 8) was not extensively revised, requirements for the remaining facility types were nonexistent in previous guidelines.

Because of their increasing importance, hospices, assisted living facilities and adult day care facilities had placeholders in the previous edition of the guidelines. The committee was unable to go beyond this point largely because the stakeholders in each of these particular niche facilities had previously been unable to agree on regulatory guidelines. However, after much discussion and debate, standards and guidelines were set for the 2006 edition.

The book outlines hospice facility requirements in Chapter 4.2, recognizing programmatic similarities between nursing and hospice facilities. The assisted living facility requirements in Chapter 4.3 resulted from an intense collaborative effort between the HGRC members, including several state authorities and representatives from a number of national associations representing both the assisted living industry and consumers.

Chapter 4.4 is directed toward “significant” programs, which are those regulated by the state. Thus, this part of the guidelines would apply to a state-licensed health care facility. Housing projects, which are not licensed by the state, would not be considered.

Finally, though not part of the four formal sections of the guidelines, another notable change to the 2006 edition is the expanded glossary. Definitions of commonly used terms that appear throughout the guidelines have been added to facilitate understanding, clarify issues and help maintain consistency.

Specific definitions and terms were also expanded to address and clarify words and phrases that were confused in previous editions. For example, the question of what constitutes a monolithic ceiling was discussed and a new definition was developed.

In fact, all of the changes were made to promote consistency over the depth of detail and breadth of coverage in each facility component type. While debate and discussion occurred in the context of each of the facility types, the guidelines ultimately respond to the individual needs of the occupant.

Keeping up to date

These changes were made to help keep the guidelines up to date with the constantly changing world of health care.

Once again, these guidelines offer those responsible for health care design and construction a detailed and up-to-date document that promotes quality care for patients, families, staff and the community. 

Need to get a copy?

The Guidelines for Design and Construction of Health Care Facilities is sold for $140 plus shipping. The price includes the bound, three-hole-punched hard copy and the searchable CD version. 

Copies can be purchased through the American Society for Healthcare Engineering (ASHE) by going to www.ashe.org/ashe/products/pubs/importantresources.html. ASHE members receive a discount. (American Institute of Architects (AIA) members get a discount when buying through AIA.)

Have guidelines questions?

The Facility Guidelines Institute acts as the day-to-day contact with the public to monitor requests for interpretations, making sure the requests are answered in a timely manner, interpretations are rendered by those best equipped to reflect the intent of the committee when the document was written and that the interpretations are made public.