The Pre-Construction Risk

Assessment
It Is The Right Thing to Do…

Gehring Health Facility Resources

Our Premise……
The incomplete or ineffective
implementation of the PCRA can increase
the construction costs to the hospital and
put patients, staff members and visitors
at risk. It is much better to plan for any
eventuality and manage the process from
beginning to end.

Gehring Health Facility Resources

How Can We Get This
Important Tool Right?
Leo Gehring, CHFM, CHC, FASHE
Principal, GHFR
501-944-4422
leogehring@aol.com

Gehring Health Facility Resources

 Does
What We
Do
Matter to
Our
Patients?

5
What Our Customers Are Reading?

6
The Most Important Elements
Plan
People
Rules
Communication
Performance
You
 It Is All About Process
Check Lists

Procedures

Policies

Standards

Contract Language
Leadership

Money
Do You Feel Lucky?
Let’s Review the Basics……

Gehring Health Facility Resources

Major Referenced Codes
 NFPA 10 – Standard for Portable Fire Extinguishers
 NFPA 19 – Specifications for Motor Fire Apparatus
 NFPA 70 – National Electrical Code
 NFPA 72 – National Fire Alarm Code
 NFPA 80 – Standard for Fire Doors
 NFPA 99 – Health Care Facilities - 1999 Edition
 NFPA 101 – The Life Safety Code - 2000 Edition
 NFPA 110 – Standard for Emergency & Standby Power
 NFPA 241 - Standard for Safeguarding Construction,
Alteration, and Demolition Activities
First Things First – Let’s Talk Risk Management

TJC Risk Assessment Process

1. Identify the issue.
2. Develop arguments that support the proposed process or issue.
3. Develop arguments that oppose the proposed process or issue.
4. Evaluate both arguments.
5. Reach a conclusion.
6. Document the process.
7. Monitor and reassess the conclusion
 TJC Risk Icon
Proximity to patient
Probability of harm
Severity of harm
Number of patients at risk
The Hospital Manages it Environment during Demolition,
Renovations , or New Construction to Reduce Risk… –
EC.02.06.05
When Planning…..
• State Rules and Regulations
• Guidelines for Design and Construction (2010 Edition)
• Other Reputable Standards and Guidelines When the Above Do Not
Meet “Specific Design Needs”
Preconstruction Risk Assessment (PRCA)
• Air quality
• Infection Control
• Utility Requirements
• Noise
• Vibration
• Other Hazards

Takes Action to Minimize Risks – Direct Impact

The Hospital Establishes and Maintains a Safe and Functional
Environment – EC.02.06.01
• The Features of the Environment of Care Include:
• Quality of Artificial and Natural Light
• Privacy
• Size and Configuration of Space
• Security for Patients and Their Belongings
• Ventilation, Temperature Control and Humidity
• Clear Access to Internal and External Doors
• Space to Allow Staff to Work Efficiently
• Clean and Free of Offensive Odors

• Emergency Access to Locked and Occupied Spaces – Direct

Impact
• Furnishings and Equipment Safe and in Good Repair
• EP13 – The organization maintains ventilation, temperature and humidity levels
suitable for the care, treatment and services provided.
Ventilation System is Able to Provide Appropriate
Pressure Relationships, Air-Exchange Rates and
Filtration Efficiencies EC.02.05.01 EP 6

• In areas designed to control airborne contaminants the

ventilation systems provides appropriate pressure
relationships, air exchange relationships and filter
efficiencies…….
• Negative or positive pressures in relationship to adjacent
areas
• Reference 2010 Guidelines
• The correct number of air changes per hour
• Correct filtration
• Direct Impact
2010 Guidelines for Design and Construction of
Health Care Facilities
• 1.2-2.1-2 Functional Program Requirement
• The Health Care Provider Shall Supply a Functional Program
for Each Facility Project
• The Functional Program for the Facility Shall Describe the
Following:
• Required Services
• Environment of Care Components
• Delivery of Care Model
• Facility and Service Users (People)
• System Design
• Layout and Operational Planning
• Physical Environment
Renovations, Alterations and Modernizations
LSC 18.1.1.4.5

• A major rehabilitation shall involve the

modification of more than 50 percent, or
more than 420 m2 (4500 ft2), of the area
of the smoke compartment
• A minor rehabilitation shall involve the
modification of not more than 50 percent,
and not more than 420 m2 (4500 ft2), of
the area of the smoke compartment
 Means and Methods Issue
A term used in construction to describe the day-to-day
activities a contractor employs to complete
construction. In some cases, these activities may
require incidental design or engineering elements; the
rigging of scaffolding for a particular purpose or minor
modifications of plans to solve on-the-spot
construction difficulties (e.g., moving a door a few
inches to avoid interference with another door) are
just a couple of examples of such "means and
methods." Means and methods of construction are
ordinarily understood to be covered under general
liability policies, rather than professional liability
policies.
Why is the Design Community Reluctant to
Specify Means and Methods?
• Some Say It About Insurance
• Does This Stance Really Absolve Them Of Responsibility? -
Nope

• Remember The Golden Rule – He Who Has the Gold

Makes The Rules
• Why Shouldn’t We Specify, Engineer and Draw the Mitigation
Requirements?
• Shouldn’t We Specify, Engineer and Draw the Mitigation
Requirements?
Preconstruction Risk Assessment Requirement
When Planning for demolition, construction or
renovation the hospital conducts a preconstruction
risk assessment (EC.02.06.05)
• Does it really happen during planning?
• When does it usually happen, if at all?
• Why?
• Does the ICRA take the place of the PCRA?
• This Is The Subject Of Our Conversation….
PRCA Process Sample

• PCRA.doc
Pre Construction Risk Assessment
“During The Planning Phase Of A Project”
• Why Is This So Important?
• Why Is There Always Time To Do It Over - But Never Time to Do It Right In
The First Place?
• When Should The Assessment Be Conducted?
• How Can It Save Us Time and Money?
 Step By Step Process
What is Your Policy?
•Air Quality
•Infection Control
•Utility Requirements
•Noise and Vibration
•Other Requirements
How to Develop an Effective
Preconstruction Risk Assessment Policy

• Use the TJC Standard as a Guide

• Use the Guidelines for Design and
Construction of Healthcare Facilities as a
Guide
• Consider adopting the “Guidelines” as your
policy
 Air Quality Requirements
• How Do We Provide The Appropriate Air Quality
During The Project?
• Temperature
• Humidity
• Pressure Relationships
• Cleanliness
• Protection Of Systems
• Comfort
 Infection Control
• Infection Control Risk Assessment (ICRA)
• Infection Control Mitigation Requirements (ICMR)
• Multidisciplinary team
• Barriers
• Pressurization
• Housekeeping
• Debris Removal
ICRA Elements
• Classification of Work
• Patient Risk Group
• Required Procedures
• Oversight and Documentation
 ICRA Matrix
PATIENT
TYPE A TYPE B TYPE C TYPE D
Risk Group

LOW
I II II III / IV
Risk Group
MEDIUM
I II III IV
Risk Group
HIGH
I II III / IV IV
Risk Group

HIGHEST
II III / IV III / IV IV
Risk Group

2002 Update
It Is All About Barriers!
Can We Do Better?
Can We Add Value?
Required Procedures CLASS IV
• Isolate the Site for barrier construction
• Complete all critical barriers before
construction begins.
• Maintain negative air pressure within
work site utilizing HEPA equipped air
filtration units.
• Construct anteroom?
 Utility Requirements
 The hospital designs and installs utility systems that
meet patient care and operational needs. EC.02.05.01
 The hospital inspects tests and maintains utility
systems. EC.02.05.01
 These standards are not suspended during
construction projects
 Shutdowns
 Connection to existing systems
 Protection of systems
 Keeping accurate records
Life Safety Code Foundations
• Prevention
• Point of Origin
• Detection
• Compartmentalization
• Suppression
• Egress
• Everything Starts with Design and Construction –
Source Documents
The Hospital Designs and Manages the Physical
Environment to Comply with the Life Safety Code -
LS.01.01.01
• Electronic Statement of Conditions – Direct Impact
• Plan for Improvement Time Frames – Situational
Decision Rule
• PFI’s That Have Been Accepted by TJC
• Automatic 6 Month Extension
• 45 Day Rule

• Fire Control Agency Reports

Life Safety Process
• When a Hospital Finds that it is out of
Compliance with Standards LS.02.02.20 –
LS.04.02.50 they either resolve the issues
immediately or manage it through one of the
following options:
• A Process that Corrects the Deficiency
within 45 days
• A PFI thru the SOC Process
• A LSC Equivalency Approved by TJC
The Hospital Protects Occupants During Periods When the
Life Safety Code is Not Met or During Periods of
Construction - LS.01.02.01

• Fire Department Notification & Fire Watch –

Direct Impact
• Alternate Exits – Direct Impact
• ILSM – Situational Decision Rule
• ILSM Measures – (3) Are Direct Impact
• Training to Compensate – Direct Impact
 ILSM Mitigation Measures
• Ensuring exits provide free and unobstructed egress. Personnel
shall receive training if alternative exits must be designated.
• Ensuring
free and unobstructed access to emergency
departments/services and for emergency forces.
• Ensuringfire alarm, detection, and suppression systems are not
impaired. A temporary, but equivalent, system shall be provided
when any fire system is impaired. Temporary systems must be
inspected and tested monthly.
• Ensuring temporary construction partitions are smoke tight and
built of noncombustible materials.
• Providing
additional fire-fighting equipment and use training for
personnel.
ILSM Mitigation Measures
• Prohibiting smoking in or adjacent to all construction areas.
• Developing and enforcing storage, housekeeping, and debris-removal
policies and procedures that reduce the flammable and combustible fire
load to the lowest level necessary for daily operations.
• Conducting a minimum of two fire drills per shift per quarter.
• Increasing hazard surveillance of buildings, grounds, and equipment with
special attention to excavations, construction areas, construction storage,
and field offices.
• Training personnel when structural or compartmentation features of fire
safety are compromised.
• Conducting organization wide safety education programs to ensure
awareness of any LSC deficiencies, construction hazards, and these ILSMs.
Noise and Vibration
• Must predict and have a proactive plan for
construction events that will cause disruption
to sensitive areas:
• Hammer drilling
• Sheet and pile driving
• Demolition
• Heavy equipment
• Normal noise
• Normal vibration
Other Hazards
• Hardest to predict
• Past events?
• Murphy’s law
• Flood
• Earthquake
• Tornado
• Lightning strike
• Are we prepared?
• Are you sure?
Emergency Management
• Applies to hospitals, critical access hospitals, long term care
• Emphasis on “scalable approach” to help manage response
to combination of escalating events
• Define capabilities to self-sustain for 96 hours
• What can we really do and for how long?
• Can construction activities cause an emergency situation?
• Effective 1 January 2014 Enhanced Oversight and
designation of responsible individual
The Hospital Has an Emergency Operations Plan
EM.02.01.01
• Emergency Operations Plan (EOP)
• The Hospitals Leaders Participate in Planning
• The Plan is Written
• The Hospital establishes response efforts
when organization cannot be supported by
community for at least 96 hours in six critical
areas
• What do you do when it all falls apart?
The Hospital has an Emergency Operations
Plan - EM.02.01.01

• In preparation for any occurrence plan for managing

six critical areas of emergency response:
• Communications
• Resources and assets
• Safety and security
• Staff responsibilities
• Utilities management
• Patient clinical and support activities
In Summary……
The incomplete or ineffective
implementation of the PCRA can increase
the construction costs to the hospital and
put patients, staff members and visitors
at risk. It is much better to plan for any
eventuality and manage the process from
beginning to end.
How Lucky Are You?
Thank You!