Is Your HVAC System Ready for Your Next Joint Commission Survey?

The Joint Commission is increasingly placing emphasis that hospital facilities meet the requirements of The Joint Commission Standard EC.02.05.01, specifically the control of airborne contaminants through proper air pressurization of critical spaces. The Joint Commission reports that 47% of all hospitals in 2013 and 53% of all hospitals in 2014 have received non-compliance scores for EC.02.05.01 based on failure to maintain proper space pressurization.

Standard EC.02.05.01 requires spaces such as operating rooms, special procedure rooms, pharmacies, sterile supply rooms, protective environment rooms and airborne infection isolation rooms to maintain proper air pressurization at all times. At a minimum, each facility shall test and verify proper air pressurization annually. Unfortunately many air pressurization tests fail during Joint Commission surveys. To ensure proper air pressurization in these areas, annual testing may not be adequate for some facilities.

Some remedies to assist in maintaining proper airflow pressurization are as follows:

  • Increase system testing to quarterly intervals.
  • When deficiencies are found, employ retro-commissioning procedures to re-establish and maintain air pressure relationships.
  • Install visual indicators (ball-in-tube monitors) to assist staff in identifying when systems are not maintaining proper air pressurization.
  • Install digital airflow differential pressure monitors connected to the facilities Building Automation System to provide continuous monitoring of space differential pressures and to alarm the facility’s maintenance staff immediately when differential air pressure is not maintained.

Providing these safeguards will not only ensure your HVAC system is better prepared for you next Joint Commission survey, it will ensure your facility has the ability to control airborne contaminants and create a safe environment for patients, visitors and staff. If you need assistance in understanding more about controlling air pressurization in your facility or have questions for your next project, please do not hesitate to contact Michael Jacobs, PE, LEED AP at 717-845-7654 or maj@ba-inc.com.

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