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Environment of Care Considerations


Female healthcare professionals in masks.

By Jim Kendig, field director 

Editor’s Note: Some of this content was initially presented in a white paper authored by Joint Commission Resources and Deloitte. COVID-19: A Resource for Recovery

Even as the COVID-19 vaccine rolls out, intensive care units (ICUs) in this country are increasingly taxed and some in small communities are becoming overwhelmed.   

It’s more important than ever to continue innovating on how to optimize our environment of care. Below, I’ve outlined a few considerations: 

Increase Resources & Building Infrastructure  
Negative pressure rooms, also called isolation rooms, are a type of hospital room that keeps patients with infectious illnesses, or patients who are susceptible to infections from others, away from other patients, visitors and health care staff. 

They are called negative pressure rooms because the air pressure inside the room is lower than the air pressure outside the room. This means that when the door is opened, potentially contaminated air or other dangerous particles from inside the room does not flow outside into non-contaminated areas. 

Instead, non-contaminated filtered air flows into the negative pressure room. Contaminated air is sucked out of the room with exhaust systems, which are built with filters that clean the air before it is pumped outside of and away from the health care facility. 

Air exchange rates, or “air changes per hour,” simply refer to the number of times that air gets replaced in each room every hour. The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) provides guidelines for air changes per hour, and they vary depending on the room: 

  • bedrooms should have 5-6 changes 
  • kitchens 7–8 changes
  • laundry rooms 8–9 changes 

Heating, ventilation and air conditioning (HVAC) contractors use these “changes per hour” recommended ranges to calculate the amount of airflow that's needed in different rooms to ensure adequate house-wide air exchange. Each room's volume (height × width × length) is multiplied by the recommended number of hourly changes, then divided by 60. 

Expanding capacity for airborne isolation and negative pressure areas have been a major challenge to health care organizations that did not have an advanced understanding of their capabilities through a heating, ventilation and air (HVA), and those who had not faced other infectious disease outbreaks or epidemics in recent years. The level of challenge is dependent upon the age of the HVAC system. The following recommendations may be helpful for organizations struggling with infrastructure issues. 

Evaluate air circulation exchange rates and the effectiveness of air filters throughout the facility continually. Be sure to consider the year installed, max operational efficiency and status as new construction or renovation is planned. 

Maintain an adequate supply of medical gasses. During the COVID-19 response, this has proven just as challenging as managing supplies of personal protective equipment (PPE) and critical medications in some cases. 

Maintain Equipment Needs & Loaner Inventory 
Regional, state and federal stockpiles are invaluable tools in knowing about available resources. Optimize this by knowing what supplies you are receiving and what ancillary supplies need to accompany equipment for proper use (e.g., a ventilator with connective tubing). 

Remember that inspection, testing and maintenance requirements may involve the use of a waiver. Many organizations used a waiver temporarily at the onset of the pandemic to limit bringing service personnel into the building. If your organization is using a waiver, please be able to discuss: 

  • why the waiver is being used 
  • why the organization cannot comply with the existing regulation during the declared public health emergency (PHE) 

Develop a system for extending the life of critical supplies to ensure availability to those most likely to benefit when supplies are critically low. Designate staff to manage suppliers and to streamline control and accountability over delivery deadlines. 

Safety & Security Controls 
Even in a pandemic, we cannot forget about diversion or overutilization. Drug utilization still must be based on organizational guidelines.  

Security teams need to be sufficiently staffed to restrict facility access. Additional screening needs to occur at entry points. It’s important to account for additional security when planning staffing.  

We know there are so many moving parts to consider as this pandemic ebbs and flows. Remember, we’re here to help in any way possible. Please feel free to reach out to your account executive at any time. 

Jim Kendig is the field director for the Life Safety Code Surveyors/Engineers at The Joint Commission. In this role, he oversees half (approximately 40) of the surveyor cadre who specialize in surveying The Joint Commission’s life safety, environment of care, and emergency management standards. Previously, Mr. Kendig also served as a Joint Commission Life Safety Code Surveyor. Prior to joining The Joint Commission, he was a vice president and safety officer for a four-hospital system in Florida on the “Space Coast.”