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Healthcare facilities are some of the most complex and heavily regulated of any building type. The broad span of spaces inside these buildings encompasses everything from patient rooms to emergency facilities, laboratories to cafeterias to offices, and more.
Perpetual advances to technology paired with a growing list of codes and compliance regulations generate a constant need for existing facility renovations and new facility construction.
With the vast majority of hospitals funding renovations and expansions (74%), most facilities continue to operate through the duration of the construction process. Patients, staff, and visitors are often in close proximity to active construction where, “the risk for contamination with health care construction is present and, therefore, it is essential that construction personnel be well-trained to identify and mitigate the risk,” say researchers from the recent study, “Renovation in hospitals: Training construction crews to work in health care facilities,” published by the American Journal of Infection Control, which surveyed a total of 129 respondents working in various roles at the top 15 U.S. healthcare contractor firms.
The question is, how do we educate healthcare construction workers on how to work around everyday activities, mitigate any unexpected construction emergencies, while safely and effectively getting their work done?
While the CDC requires healthcare facilities to perform an Infection Control Risk Assessment (ICRA) before any renovation, construction, or repair project, they are not required to execute the recommendations that result from the assessment. Furthermore, the construction workers themselves are not required to participate in or implement said training.
ASHE also offers a Health Care Physical Environment Worker certification, recommending that each general contractor/project lead hold a Certified Healthcare Construction (CHC) certification and that at least one CHC should be part of every healthcare construction project. However, just like ICRA this certification is recommended, not required.
While most construction companies do choose to participate in specialized ICRA or ASHE training courses, these courses are often geared towards project managers and the knowledge gleaned fails to land on those that need it most: the workers and subcontractors on site. As a result, they often do not have an understanding of the importance of infection control during a project.
One proposed solution is through legislation, making ICRA certification mandatory for all construction personnel who work on healthcare construction sites. In New Jersey, Joseph Demark, Jr., the President and Business Manager of the Green Advantage Pre-construction Risk Assessment/Infection Control Risk Assessment (PCRA/ICRA) Certificate Program is doing just that, working to see that ICRA certification is required legislatively for all healthcare facility construction workers in NJ.
However, many construction companies are opposed to this solution. As aforementioned, healthcare facilities are required to perform an ICRA assessment, but not required to implement the recommendations. And many in fact, do not.
The reason is twofold. First, there is no standardized method of how to implement the results of an ICRA plan and no consequences if it isn’t implemented. “Hypothetically, let’s say you did receive an ICRA plan document from the Owner with the RFP or even during Pre-Con. Aside from confirming the project title, relative work area and some broad dust control requirements; what did that document do for you?” asks Claire Foster of AMI Environmental. “One of the biggest issues with the broad concept measures ‘identified’ in an ICRA plan, is the absence of a clearly identified path to compliance for the workers in the field. This oftentimes leads to a lot of subjective evaluation that ultimately drives the tradesmen to throw up their hands and view ICRA concepts as an impediment to scope execution.”
What Claire is expressing is not a one-off situation. It is a common theme construction companies encounter when bidding a healthcare construction project. If a construction company approaches a facility, asks them what their ICRA plan requires of their workers during construction and the facility personnel don’t know, it makes it very difficult for the construction company to know what to include in a bid. Once hired, the construction company can only implement the procedures that have been budgeted for, and without guidance from the facilities ICRA team, are left to use their best guess in terms of everything else.
It appears that the issue is not the lack of education on the side of the construction companies, but the lack of clarity on whose responsibility it is to spearhead the implementation of the ICRA recommendations.
Starc Systems, a temporary containment solutions company states, “Infection control should be a primary concern for contractors, project managers, architects, and facility and construction management teams in the developmental and planning stages of an ICRA construction project. An ICRA strategy should be agreed upon by all parties. The ICRA team works together to study risk factors, potential hazards to patients, people, and medical equipment, and ways to minimize the risk of HAIs related to the ICRA construction.
Even if the importance of ICRA is understood by both healthcare facilities and construction companies alike, and the issue of responsibility is solved there is still the question of financial responsibility.
Smaller healthcare facilities such as post-acute care, rehabilitation, clinics, and skilled nursing facilities fall victim to lax implementation of ICRA protocols the most, as they tend to have the smallest construction budgets. Since following ICRA recommended construction procedures come as an added cost, (the ICRA Instructor Guide states, “The Infection Control Risk Assessment may require you to spend more time putting up barriers to isolate your work area than it takes to actually perform the work,”) many facilities choose to have very lax protocols or opt-out of the recommendations entirely.
If the healthcare facility operators don’t budget for proper ICRA protocols such as the installation of anterooms and HEPA-filtered air filtration units, or aren’t willing to pay for the increased labor costs associated with the recommended safety precautions such as increased construction area cleaning and specific protocols for debris removal, then we as general contractors will be unable to execute the requirements for construction procedures. As a result, those of us who require our employees to uphold the protocols will lose the bids. The other GC’s who decide to disregard ICRA recommendations to come in at a lower price will be the ones getting the work and the patients will suffer the consequences,” says Erik Good, Senior Project Manager at Global Construction.
If making the courses themselves mandatory is not the answer, perhaps passing legislation that makes the implementation of the ICRA recommendations required could solve the problem?
“The importance of compliance is protecting lives,” notes Jonathan Flannery, FASHE, Senior Associate Director of Advocacy for ASHE. “Keeping patient and staff safety foremost in mind, we don’t want to do things just to save money. But we want to do things in a way that uses resources wisely.”
With the problems that can be addressed by ICRA training and credentialing only getting worse, an even greater emphasis needs to be placed on the importance of ICRA training, credentialing, and plan implementation. As we emerge into a post-COVID-19 world, industry leaders in both healthcare and construction must make their voices heard in an effort to find a solution that is feasible and beneficial to the facility operators, the construction companies, and most importantly, the patients.
Bill Bryant, Senior Project Manager, Global Construction, started his career as a commercial electrical apprentice. After three years of attending trade school, and working on various commercial projects, he was given an opportunity to become a superintendent for a large production builder. Over the past 20 years, Bill has built hundreds of structures along the front range including a 300-unit apartment complex in Lakewood and The Home Depot in Boulder. He has spent the last 12 years specifically working in the multi-family industry repositioning numerous properties, value add and CapEx projects across the country. The Colorado native graduated from Golden High School and attended IECRM.
