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Commissioning to the Rescue! - Avoiding risk during construction & renovation

In every healthcare facility, patient safety and well-being are of utmost importance. A remodeling project in the building has the strong potential to put patients at greater than usual risk.

Hospitals are under ever-increasing scrutiny concerning the risks they are exposed to during construction and renovation. At the same time, budgets are tight, schedules are shorter than ever, and skilled labor is hard to find, which makes mitigating these risks even more difficult. Despite these constraints, critical system failure is unacceptable at any time during construction or renovation in a modern health care center.

What are the causes of these risks?

These risks arise in part due to the intricate interaction between systems that often do not get tested due to the high level of complexity and little knowledge of how to optimize the interaction between these systems. The traditional construction process has not delegated responsibility to coordinate between these systems to any one party in the past. This leads to honest mistakes on the contractors’ part who believe they had completed everything required under their contract for this project. This lack of coordination ultimately leads to Owners being surprised by their expensive systems not performing as designed.

Though sub-optimal building performance is a major headache and expense in all large buildings that have not been properly commissioned, it presents a greater risk in the healthcare setting due to the presence of patients.

Below are some of the issues that we have seen in hospitals undergoing renovation/construction and how a good commissioning team can help to address them. Without a commissioning authority in place during the entire construction project, these issues have a much greater likelihood of arising and putting patients at risk. While these lists are not all-inclusive regarding the items addressed by a good commissioning team, they do represent some of the more pressing issues in today’s healthcare environment.

Elevator issues

  • Elevators – Are appropriate elevators on emergency power?

  • Elevators – How do all involved systems integrate with security and other services for the functionality of lockdown, fire mode, and code call procedures?

  • Elevator recall – Do elevators respond appropriately if smoke detectors are triggered nearby or in the elevator shaft? Do shunt/trip breakers work correctly if fire suppression systems are triggered?

  • How a good commissioning team addresses these issues:

The key to solving these issues is the testing that a commissioning agent uses to verify equipment performance on a basis.We have found that elevator vendors are quite good at providing a way to interface their equipment with fire alarm and electrical systems, but they do not perform any testing to ensure that the systems work as intended.

Emergency Power issues

  • Generators – Have generators been tested at full load, on-site, and under actual conditions for extended periods? Without this testing looking specifically at machine cooling, room ventilation, and fire protection performance, problems are likely at the time emergency power is actually needed.

  • Transfer switches - Do they operate properly when needed?

  • Emergency lighting – Are lighting levels necessary for emergency egress maintained during a power failure?

  • AHUs – Are appropriate units on emergency power?

  • Cooling & Heating – Are systems required to support critical AHUs on emergency power?

  • Med vacuum and air compressors - These are both critical systems that always need to be available. Are they on the emergency power system?

  • HVAC control system – Are controls for critical systems that use emergency power also on emergency power?

  • Fire alarm system - Are all necessary components of the system on emergency power?

  • How a good commissioning team addresses these issues:

A careful review of building construction documents and equipment submittals during the commissioning process can identify and prevent most of these issues from becoming a problem during the operation of a facility. The emergency power system in a medical facility is one of the most critical services provided and must always perform without failure if patient safety is to be ensured.

Fire and life safety issues

  • Has testing been done after all systems are completely integrated to ensure the building as a whole is fully operational?

  • Alarms and enunciators – Are all devices mapped appropriately to indicate the correct device that is in alarm during an event?

  • Smoke control – Are pressure relationships maintained properly during a fire alarm?

  • AHU shutdown – Are AHUs controlled properly during a fire alarm?

  • How a good commissioning team addresses these issues:

Once again, the key to ensuring the correct operation of the fire and life safety equipment is the system-wide testing utilized during the commissioning process. Smoke control can be a difficult thing to accomplish since it can involve many different AHU systems which interact with each other. Without proper testing, it is impossible to ensure that the system will perform as intended.

Nurse call

  • Operation of emergency and code calls of nurse call system and the subsequent sequence of notification, escalation and response procedures: are all of these in place and working correctly?

  • Are patient rooms properly mapped in the system to accurately reflect which room is in alarm?

  • Are pull stations located where they are required?

  • How a good commissioning team addresses these issues:

Many times, issues with the nurse call system are found during the pre-functional testing of these systems. All the questions above are addressed during the commissioning processes (if you have a good technical commissioning team – some ‘commissioning’ firms do not test on site and/or confirm corrections made by contractors.)

Operator Training

  • Very often, there is not enough time and effort placed on the training of operational phase staff to learn and understand the system and its responses. Has this been considered? Is there a plan in place?

  • Operators are commonly not given a chance to drive the system before the facility becoming operationally “live.” This presents additional risk to patients. Has this been considered? Is there a plan in place to address this issue?

  • Operator skill and confidence correlates well with their trust in the system when a genuine multi-failure scenario is presented. For new staff or unskilled operators encountering a multi-failure scenario, often panic can set in, resulting in systems being reverted to ‘manual mode,’ rendering all sophisticated automation redundant and compounding the probability of human error. Has this been considered?

  • Overall: is the plan in place for operator training adequate? If not, how will that be addressed?

  • How a good commissioning team addresses these issues:

Owner training and the assembly of an Operation and Maintenance (O&M) manual are integral parts of the commissioning process. Valuable information is often lost in an un-commissioned building when the construction team fails to hand over equipment owner’s manuals or provide any type of operator training. Commissioning works to ensure that these obligations (which are very often required as part of the project) are met. A well trained and support operating team is much more able to meet the requirements of the highly regulated healthcare environment they must work in!

Positive and negative room pressure relationships

  • Air pressure relationships are critical to reducing hospital acquired infections. Have the following especially critical areas been fully analyzed from the design phase through to the occupancy phase to ensure they will operate as intended? Have these spaces been tested by a 3rd party to ensure that at the time of occupancy they ARE indeed operating as intended?

  • Positive and negative isolation rooms

  • Operating rooms

  • Sterile Processing

  • Pharmacy compounding rooms

  • How a good commissioning team addresses these issues:

Room pressure relationship testing is very similar to the smoke control mentioned earlier. Many different sources can affect the delicate balance between these rooms. Some of these include:

  • Plugged AHU filters

  • Improper air balances

  • Blocked return air registers (usually by well-meaning staff members)

  • High outside wind conditions

  • Extremely hot or cold weather conditions

  • Merely opening a door in the facility

Without proper testing and constant monitoring, it is impossible to ensure that these systems will perform as intended.


  • Has functional testing been done on wandering patient and mother/baby protection systems to confirm inter-operability of security, nurse call, and location accuracy of asset tracking?

  • Has the function of fixed and mobile duress systems and the subsequent sequence of notification, escalation, and response procedures been tested?

  • How a good commissioning team addresses these issues:

The overall performance of a security system is often overlooked after installation is complete. The vendor may do a thorough job of installing and testing their system but rarely are the interactions with other systems confirmed. Functions critical to the operation of these systems include:

  • Do exit and elevator doors actually lock to protect a wandering patient from possible injury?

  • Do exit path doors lock appropriately to prevent an infant abduction?

  • Are both security and nursing personnel alerted when either of the above events occur?

  • Do the fixed and mobile duress systems function properly and meet the needs of the staff using them?

  • Some mobile duress systems only cover a limited area in the facility and will not function outside of that area. Are the staff trained to know where these limits lie?

Functional testing of these systems during commissioning can ensure that all these crucial systems perform properly.

Construction Risk Control

Construction projects pose a higher risk to healthcare facilities than any other facility types due to the around-the-clock operation of healthcare facilities.

Evacuation of the areas under construction may be impossible which means that extraordinary efforts must be made to protect the health and safety of patients, visitors and staff. A good commissioning team will address all the following issues to help mitigate risk.

  • ICRA - Infection Control Risk Assessment

  • Dust control is the biggest issue for infection control during construction. Careful planning and review of the proposed methods for dust control are critical. Commissioning can help with this process by ensuring that contractors fully understand all of the details that go into making a dust-proof environment.

  • PCRA - Pre-Construction Risk Assessment

  • The pre-construction risk assessment includes addressing issues such as:

  • HVAC shutdown

  • Utility shutdowns like hot/cold water, sewer systems, steam, medical gas, etc.

  • Noise issues

  • Vibration issues

  • Odors such as paint, welding, etc.

  • Environmental hazards such as asbestos, lead, mold, or other chemicals in the area

  • Security issues such as locking down the work site and any after-hours work that may be required

  • ILSM – Interim Life Safety Measures

  • The interim life safety measures review includes addressing issues such as:

  • Exits being compromised during construction

  • Fire or smoke barriers breached

  • Fire or smoke dampers being removed/replaced

  • Fire alarm and detection systems being impaired

  • “Hot” work such as welding or brazing

In addition to the standard benefits of commissioning a facility, a good commissioning team will help to mitigate the risks during construction and remodeling in the healthcare setting.

Also, because of the importance of risk management in the healthcare setting, these facilities are excellent candidates for recommissioning or continuous commissioning.

In addition to the safety (link to previous post here!) benefits to commissioning your healthcare facility, there are a number of code requirements that the healthcare industry specifically needs to be aware of.

Watch for my next post on those code requirements. Like and subscribe!

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