Preparing for a new ventilation management regime
Preparing for a new ventilation management regime
This article was first published in Health Estate Journal, February 2021
Preparing for a new ventilation management regime
Andrew Steel, Managing Director, Airmec Essential Services
The introduction of a revised version of HTM03-01 Specialised Ventilation for Healthcare Premises, will no doubt be followed by a lot of commentary on the technical detail of amendments and improvements in design specifications, inspection processes, air change rates etc. All these requirements will be documented in the standard itself when it is published and hospital estates managers will in any case need to go through them in detail in order to match them to specific premises. None of the detailed proposals we have seen as we go to press seem to be contentious: they have real potential to plug gaps and can reduce risks.
There is, however, likely to be an elephant or two in the room for some trust managers. We imply no malpractice or complacency, but pragmatism often means that current practice focuses on ultra clean ventilation and other critical systems but can exclude significant proportions of the ventilation infrastructure. The proposed updates appear to bring all ventilation under the HTM-03 umbrella. Meeting all the requirements of the revised standard will call for capital expenditure on new equipment, significant refurbishment and, often, periods of shutdown while works are undertaken. Without a considerable new branch of the magic money tree, can the revisions have teeth? As we see it, the agility and professionalism of healthcare estates managers and engineers has been well proven by the Covid-19 challenges, so there is no doubt that the will to accommodate change exists. In this particular area, they may be helped by changes in the oversight of ventilation management. There are specific recommendations on membership of Ventilation Safety Groups (VSGs), building on the experience and success of Water Safety Groups. This approach will perhaps empower Estates and Facilities Managers and streamline the changes implicit in managing the new requirements.
In the following paragraphs we will focus on what appears to be the overarching challenge in the guidance and its implications: the increased emphasis on the safety of all ventilation equipment and infrastructure, not just that servicing critical areas.
At Airmec, it has always been our belief that the entirety of the ventilation infrastructure in healthcare premises presents a potential risk to staff and or patients if systems are not regularly inspected and maintained; and that all of its condition and efficacy should be duly checked and audited. Furthermore, we believe that most estates management teams agree with us and given budget and resources, would all be doing just that. Covid-19 has surely put ventilation centre stage to remind us of this responsibility. Remember, too, that ventilation systems also include water drip trays and vital fire dampers, which brings other HTM guidance and mandatory requirements into the ventilation arena: Safe water in healthcare premises (HTM 04-01) and Managing Healthcare Fire Safety (HTM 05-01).
Most trusts have heating and ventilating groups that already approximate to the Ventilation Safety Group (VSG) structure outlined in the draft of the revised standard, and the change will not be a great leap for them. It will, however, bring more people to the table and we welcome the greater emphasis on and wider membership of VSGs. The new versions of the heating and ventilating groups will typically include infection prevention and control representatives, finance managers, clinicians and co-opted external practical expertise. From our experience of working as co-opted members of Water Safety Groups, it’s an approach that can only help to increase the efficiency and safety of ventilation systems, and help estates managers at the sharp end of maintenance to make their case for change and investment where necessary.
The legacy
To remind ourselves where we are let us go back to 2007 when the current standard was published, referring as it does to new installations and major refurbishments. At the time, little consideration was given to how the installed system could be economically operated and maintained during its working life.
HTM-03 is, of course, split into two parts - Part A: Design and Validation and Part B: Operational Management and Performance Verification. With the benefit of hindsight, tempered over nearly a decade and a half of exceptional budget pressures, we can see that it is Part B of the HTM-03 that is the immediate challenge. What should all along have been routine maintenance for Trusts, has all too often turned into a maintenance backlog with no matching budget for remediation. Bringing even more plant into the equation – older and ‘non-critical’ - will only compound the problem.
Older systems designed and operated under the HTM 2025 were implicitly not covered by the 2007 version of HTM03-01, unless subject to major renovation work. The title of the standard Specialised Ventilation for Healthcare Premises has perhaps been taken literally. Have some Trusts confused ‘specialised’ with ‘critical’? The draft HTM03-01 revision, however, states clearly that the guidance contained in Part B applies to all ventilation systems installed in healthcare premises irrespective of the age of the installation. Backroom systems and tucked-away basement plant rooms in older buildings in the estate will all be covered.
We can find no really clear definition of what is meant by ‘specialised’ or ‘critical’. The HTM-03 has always listed the departments that will usually have specialised ventilation requirements (operating and laser surgery suites, intensive treatment and isolations units, imaging, X-ray and scanning units; path labs etc.) without expressly omitting other areas.
The temptation may well have been to focus limited resources on these named critical areas and ‘front of house’, when surely all ventilation systems in premises delivering healthcare services has always presented the need to provide a good standard of ventilation for patients and staff? The new wording seems to leave no room for doubt that everything is to be included in the ventilation maintenance and management strategy. It calls for an inventory of all ventilation systems installed and in use or capable of being used, including those at community and mental health facilities. The new guidance provides a powerful argument for increased maintenance budgets.
Get the measure of the job
The foundation of planning is of course the system information – the up to date asset register and inspection records. The Ventilation Safety Group simply cannot operate effectively without a recent asset register, inspection report and risk assessment, not least because it is required to produce a ventilation policy document on behalf of the healthcare provider. While in its simplest form this document can be a straightforward statement that the provider or trust will follow the guidance provided in HTM03-01: Part B, it may, according to the HTM “also specify any departures from that guidance in terms of local additionalrequirements or derogations.” That calls for a detailed understanding of the assets.
The systems the guidance expects you to have cover are:
- local exhaust ventilation systems (LEVs)
- critical healthcare ventilation systems (CHVs)
- general ventilation systems (GVS)
- general extract systems (GES
- smoke and heat exhaust ventilation systems (SHEVs)
That looks like a full house to us and, indeed, there are many provider trusts with ventilation policies that do already apply HTM-03 principles to all parts of buildings within or attached to areas that can be accessed by patients. Doing so is not a big leap in compliance on inspection: ventilation ducts house fire dampers which should be inspected and tested anyway. As indicated earlier air handling units have drip trays, pumps and drains that present risks of water-borne pathogens and are (or should be) already subject to Legionella prevention measures (HTM-04 and ACOP-L8 best practice).
Lest we fall into the trap of just describing ways to write policies and tick compliance boxes, we should be mindful that all is not necessarily well in the real world – this is not a desk exercise. In the course of our inspection work we have seen simply unacceptable levels of corrosion, rooftop systems sitting in puddles of stagnant water, the bio-risk of fungal growth and fire risk of dust accumulation in ducts, water collected in corroded air handling unit drip trays, and fire dampers that are simply not fit for purpose. It may be worth noting here that, among all the other regulations and standards it mentions, the HTM-03 expects that principles of ACOP-L8 to be adhered to and, in our experience, the mention of that usually gets the attention of the budget controllers.
Our point, however, is not to create tension between estates and finance managers, but to stress that the risks that the revised guidance addresses are often real and present dangers. The solutions, however, are rarely easy, or the procedures would already be in place. Ideas like fitting sinks and drainage in plant rooms so drip trays can be cleaned easily could mean big capital expenditure – not least because these rooms often have solid concrete ground-floor or basement floors. Having means of visible inspection in all plant and ducts is a laudable goal, but they should have been designed in when the plant was installed. Adding them now carries a price ticket. Even where such portholes do already exist, we often find that internal lamps have failed and neither the budget nor the clinical downtime needed to replace them are readily available. Lack of easy access for inspection may mean more clinical downtime has to be factored in at inspection time. The recommendation to have clinicians serving on the VSG will certainly help with planning and to make a case for prioritising changes that can minimise clinical downtime.
Having a current asset register, inspection report and risk assessment is the foundation of good, efficient and economical management. With the new guidance imminent, this may mean revisiting what might be a comprehensive register of perceived high-risk areas but is not complete register of all systems.
Management approach
It is Ventilation Safety Groups (VSGs) that will oversee, ensure and enable day-to-day delivery on the recommendations of Part B. While they do also oversee the design and modification of systems, the main thrust of their work will be in maintaining the standards of existing systems.
The revised standard refers specifically and at length to VSGs and their composition. We anticipate Trusts will be looking at who else can add value to the management of ventilation plant at their next scheduled policy review, if not sooner, and will agree that the broader church from which members are drawn will be an advantage.
Ventilation Safety Groups (VSGs) will ‘typically’ comprise:
- Duty holder – typically the Trust chief executive.
- Designated person – this is the person who will make Trust senior management at board level aware of any major risks presented by the hospital ventilation systems.
- Authorising Engineer – an independent person who provides advice, audits the system and reviews documentation.
- Authorised Person (AP) – on site staff trained specifically to have the technical knowledge needed for the practical implementation of the engineering policy and procedures.
- Competent Person (CP) – these are people trained and delegated to carry out routine maintenance and testing work.
- Infection Prevention and Control (IPC) representative – this is a new departure for VSGs and probably a welcome one. Who can argue against IPC recommendations?
- User – this will be a representative of the clinicians managing the departments where the equipment is installed. The User(s) will give voice to the logistical issues accompanying maintenance and inspection work.
- Contractors – specialists who have close contact with and knowledge of your infrastructure.
Enrolling trusted contractors makes sense to us: they can help you turn guidance into a costed, audited inspection and testing regime and to prioritise and plan maintenance. Of course, we would say that as just such a third-party adviser and service provider (contractor) to many different types of trust and buildings. Having experience of both air and water services, we’d be confident that this alignment of the approach to these two essential services is a logical move that will bear fruit. What alignment does not mean is that the two can be combined – while the Duty Holder and Designated Person could be the same for both, authorised engineers and competent persons have different skill sets for air and water hygiene. However, it’s worth exploring the scope for efficiency and cost savings if the same contractors work across the board for you.
You may not always like what consultants and contractors have to say. After all, we are the people who produce the Red-Amber-Green reports that inevitably mean more work and more expenditure, but we have insights into where there may be efficiencies, such as dovetailing cleaning and inspection with fire damper testing.
With a revamped and, it is to be hoped, enthused regime embracing the entirety of your ventilation infrastructure, your own authorised and competent persons should be enabled to broaden their skill sets. Now might be a good time to review the training and support you give them. For instance, is the AP role really one of pure management, as current training courses would seem to suggest? Or should those people be equipped with practical knowledge and experience of the jobs they ask CP’s and contractors to do? That would put them in a better position to challenge contractors’ costs and timescales and to allocate procedures to the most cost-effective people.
Should the competency of CPs extend beyond the intricacies of, say, air change rates in ultra clean ventilation (UCV) areas and include the everyday practicalities of changing fan belts and filters in the general ventilation systems? After all, most estates will have more routine ventilation infrastructure than ultra clean. It’s business for us but, for from your point of view does it make sense to hire contractors and paying their skilled technician rates for such basic tasks? There may be different ways to divide the labour.
Lastly, we’d suggest that estates management and maintenance teams become involved in capital project work. We still see new installations that lack the inspection hatches we think are needed and/or site them in the wrong places to facilitate long-term maintenance. Insist on having your say and ideally reserve the right not to sign the job off. Treating Parts A and B as part of the whole should generate synergy.
Based on what see in the field, we do see the revisions of HTM-03 as positive changes. They build on what works and they amend where real-world experience has shown potential shortfalls. The policy and management changes that you will be enacting to accommodate the new guidance are an opportunity and, if nothing else, we urge you to unlock the potential of your own people.