1. law, govt and politics
2. legal issues
3. legislation
4. building laws

Purpose of presentation
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Provide information about the CON process and BAEFP Role
in Healthcare Projects.
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Introduction
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Background
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Overview of the CON Process
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Regulatory basis for Drawing Review (Part 710)
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General Guidance
Requirements for Application
Post Approval Requirements
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Applicable Codes and regulations
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Clarify the submission requirements for reviews.
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Overview
Schematic Design Submission
State Hospital Code Submission
Limited Reviews
Self Certification
Waivers
Introduction
BAEFP Role in Healthcare Design:
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To protect the health and safety of all
people that utilize healthcare
facilities in New York State and ensure
the physical plant standards are met
through quality assurance methods.
What we do.
Quality Assurance for the People of NYS
BAEFP Staffing are professionals:
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Licensed design professionals that include Architects and Engineers.
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Other professionals with many years of experience in healthcare.
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Experienced and knowledgeable in planning, design and construction
requirements in health care facilities.
Who we are
Quality Assurance for the People of NYS
BAEFP Healthcare Responsibilities:
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The bureau is responsible for oversight of all licensed facilities and services
for some of the following types of facilities:
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Hospitals
Primary Care Hospitals
Hospital Extension Clinics
Diagnostic and Treatment Centers
Residential Health Care Facilities
Long Term Care Facilities
Responsibilities
Quality Assurance for the People of NYS
BAEFP Role in Healthcare Design:
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Wide variety of responsibilities to ensure a safe environment in Health Care
Facilities within New York State.
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Objective is to develop an understanding of the following:
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Health care standards and needs.
Development of successful programs that are responsive to short and
long term goals.
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Code complainant facilities that are on time and within schedule.
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Yes, you can have projects that are on time, on schedule and within the
budget.
Roles
Quality Assurance for the People of NYS
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Pre-Planning/Pre-Submission Consultation
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Review Projects with potential programmatic issues:
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Life Safety
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FGI Functionality
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Unique Projects not addressed by FGI(i.e. Ebola Projects)
Technical Clarifications Provided to:
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Applicants
Architects/Engineers
Field Staff
Other State Agencies and Facilities
NYSDOH related and Nonrelated Bureaus
Regulatory
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Preparing and updating regulations to reflect healthcare current and
future needs
Preparing for Agendas and Recommendations for Public Meetings
Providing expertise to healthcare design committees
Working with local, state and federal governments:
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Committees
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Providing Education and or Training
Our Functions
Not Just Reviews
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Types of CON Review
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Certificate of Need (CON) Program
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A/E requirements for CON Application
Overview
The Certificate of Need Program
Article 28: Certificate of Need (CON) Program:
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Authorizes establishment, renovations, alterations and new construction:
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Hospitals
D & T Clinics
Nursing Homes
Home Care Agencies
Hospice (Considered Nursing Homes by CMS if patients are inpatients.)
Authorizes additions and acquisition of technology advance and or
specialty services
Types of Review
3 Major Types of CON Review
Three Types of CON Review (10 NYCRR 710.1)
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Limited Reviews:
Additions/Deletion of Healthcare Services
Relocation of extension clinics in the same service area
Part-Time Clinic Sites
Limited Architectural less than $6.0 Million
Reviews are STREAMLINED (Typically limited to the areas of work)
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Doesn’t negate LSC aspects per NFPA to include other portions of
the building.
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Administrative Reviews
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$6.0 Million to $15.0 Million
Full Review
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Article 28
Projects more than $15.0 million
New operators, facilities, new beds and advanced technological
services
Public Health & Health Planning Council
Certificate of Need (CON) Program
Review Units:
(In 2013, 22 different groups opined on projects.)
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Bureau of Health Facility Planning
Bureau of Financial Analysis (Finance)
Bureau of Architectural and Engineering Facilities Planning (BAER)
Division of Legal Affairs (DLA)
Office of Health Insurance Programs ( Medicaid)
Program Review
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Long Term Care
Hospitals & Clinics
OPWDD,OMH and OASAS
Review Units
Certificate of Need (CON) Program
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14 Day Letter Issued (RFI) More information needed to complete the review.
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Present Disapproval to PHHPC
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All Contingencies Satisfied Letter is issued
PHHPC Final Approval Letter issued. (Est. only)
Construction Completed (Construction only)
Final Project Implementation
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Administrative CON’s must be elevated for disapproval
Full Review CON’s
CON Approval is Finalized
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Approval
Disapproval
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Meet with applicant and resolve programmatic and life safety issues
Financing could be finalized
Construction could start
Project Opening
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Actions
Regional Office pre-Opening Survey
Authority to operate
Certificate of Need (CON) Program
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Early Starts.
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Case by Case Review
Contingencies need to be satisfied. Particularly the financial portion
Typically not allowed unless proper documentation and just cause.
Limited to specific areas of work.
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Site Work
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Demolition
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Fencing
Actions
Certificate of Need (CON) Program
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710.1(c)(5) Proposals eligible for limited review.
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Projects that meet the specific criteria, including but not limited to the following:
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Project costs totals do not exceed $6.00 million
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Capital projects that do not cross the threshold of Full and or Administrative reviews.
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Note 710.1(c)(5)(iii) The commissioner may, as an alternative to the submission of
architectural and engineering documentation referenced above, accept a written
certification by an architect or engineer licensed by the State of New York that such
project complies with Part 711 of this Title. The certification will be made available for
review at the next onsite survey conducted by the department in accordance with article
28 of the Public Health Law. The costs of any subsequent corrections necessary to achieve
compliance with the requirements of Part 711 of this Title, when the prior work was not
completed properly and was not accurately certified, shall not be considered allowable
costs for reimbursement under Part 86 of this Title. This subparagraph does not waive any
of the requirements of section 5-1.22 of this Title.
Limited Review
Certificate of Need (CON) Program
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Section 710.1 General provisions. (a) Medical facilities shall be planned to achieve
efficiency and economy of operation and care of high quality.
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710.1(c)(3) Proposals eligible for administrative review.
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Projects that meet the specific criteria, including but not limited to the following:
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Project costs totals do not exceed $15.00 million
Conversion of Bed Types
Additions to existing services.
Note 710.1(c)(3)(b) the commissioner may, as an alternative to the above, accept a
written certification by an architect or engineer licensed by the State of New York that
such project complies with Part 711 of this Title. The certification will be made available for
review at the next onsite survey conducted by the department in accordance with Article
28 of the Public Health Law. The costs of any subsequent corrections necessary to achieve
compliance with the requirements of Part 711 of this Title when the prior work was not
completed properly and was not accurately certified shall not be considered allowable
costs for reimbursement under Part 86 of this Title. This clause does not waive any of the
requirements of section 5-1.22 of this Title.
Administrative Review
Certificate of Need (CON) Program
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710.2(b) Those applicants that have indicated in their service and capital needs inventory
problems whose projected solutions exceed $15 million in total basic cost of construction should,
before filing a certificate of need application, have received a site visit report prepared by the
Department of Health and have completed the Capital Architectural and Program Alternatives
review process. As a result of this alternative review process, a preferred solution will be identified
by the department and, if agreed to by the applicant and incorporated into an application, will
expedite processing of the application to the commissioner and/or the Public Health Council for
action. In the event the applicant has not agreed to the department's designation of the
preferred solution, the applicant shall, when filing its application, indicate the preferred solution
as well as the solution it is seeking approval for.
(b) The application setting forth the scope and concept of the project shall include the following
if applicable:.
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710.2(2) a description of the site, including a topographic map, United States Geological Survey,
published by the United States Department of Interior Geological Survey, 7-1/2 minute series,
unless not published for such site, in which case 15-minute series shall be acceptable;
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710.2(4) an estimate of the total basic cost of construction predicated upon a construction start
date that coincides with the filing date of the application and a projection of such total basic
cost of construction together with a projection of the total project costs to the completion of the
proposed construction schedule;
Full Review
A/E Requirements for CON Application
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710.2(b) (8) a narrative description of the programmatic and/or architectural solution of each
functionally discrete component of the project, including the following when relevant to the
proposal: (i) justification of the need for the proposed change, and a determination of its relative
priority when compared with the applicant's other needed services and programs;
9) an architectural program for the project;
(10) architectural drawings, including if applicable:
(i)(a) schematic architectural and engineering design drawings, including site plan, room-byroom layouts of each floor in an appropriate scale, showing the relationship of the various
departments or services to each other. The major exit corridors, exit stair locations and
pedestrian and service circulation patterns shall be indicated along with existing buildings, if
additions or alterations are part of the project. In addition, applications shall include typical
sections and elevations, single-line diagrams of proposed building systems if applicable, or
outline descriptions of heating, ventilation and air conditioning, electrical power, lighting and
communications systems, plumbing, fire protection, materials handling and transportation
systems, dietary, water supply and sewage systems and preliminary layouts of mechanical
equipment rooms and riser diagrams and outline specifications; and
(b) a functional stack diagram which includes square footages, type of construction and
estimated cost of equipment for each functional area displayed and, where appropriate, the
relative cost of each area as well as the total construction cost for each discrete physical
structure involved and a set of single-line freehand sketches of each floor in an appropriate
scale, showing the relationship of the various departments or services to each other. The major
exit corridors, exit stair locations and pedestrian and service circulation patterns shall be
indicated, along with existing buildings if additions or alterations are part of the project;
Full Review
A/E Requirements for CON Application
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(ii) a list in outline form of functional project components, including the enumeration of primary
treatment spaces and the area to be included in each component;
(iii) a description of the functional and locational relationships among each related but discrete
component;
(iv) the current and proposed bed capacity of the facility by the type of bed, indicating the
total number of existing and proposed beds and nursing units and the type of room distribution
(e.g., single or multi-bed rooms), the number of each, and the patient or resident capacity of the
institution upon completion of construction;
(v) a description of proposed alterations or additions to existing structures;
(vi) a description of the energy sources, type and location of engineering systems which will be
used for heating, cooling, ventilation and electrical distribution;
(vii) a description of the proposed method of transport of clean and soiled materials and wastes;
(viii) a description of the intended dietary systems; and
(ix) a description of methods intended for water supply and sewage.
710.2(b)(10)
A/E Requirements for CON Application
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710.5 Amendments. (a) Subsequent to an approval or contingent approval of an application
under this Part, any change, as set forth in paragraphs (b)(1) through (7) of this section, shall
constitute an amendment to the application, and the applicant shall submit appropriate
documentation as may be required by the commissioner pursuant to this Part in support of such
amendment. The amended application shall be referred to the health systems agency having
jurisdiction and the State Hospital Review and Planning Council for their reevaluation and
recommendations. The approval of the commissioner shall be obtained for any such amended
application.
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Including but not limited to:
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Methods or terms of financing
Basic Cost of Construction
Beds or Services
The scope of the project is reduced but the budget has not change accordingly.
Project location and or site has changed.
710.5 Amendments
A/E Requirements for CON Application
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710.6 Determination by the commissioner. (a) After receipt of all the documentation and
recommendations required in sections 710.4 and 710.5 of this Part, and the satisfaction of all
applicable outstanding contingencies imposed on the approval relating to the project, the
commissioner shall make a determination. If the commissioner proposes to disapprove an
application or an amendment or issue a determination contrary to the recommendation of the
local health systems agency, the opportunity to request a hearing shall be afforded to the
applicant or the health systems agency, as appropriate, prior to a final decision. If the
application is approved, the applicant may proceed to apply for approval to start construction
of the project or specific project phases, if any, pursuant to section 710.7 of this Part.
(b) Any project cost incurred which exceeds a cost already approved under this Part shall not
be considered an allowable cost for reimbursement pursuant to any of the provisions of Part 86
of this Title unless, prior to incurring such cost or entering into a contract to incur such cost, the
applicant has requested, in a format prescribed by the department, and obtained, the written
approval of the commissioner for such increased cost.
710.6 Determination
by the Commissioner
A/E Requirements for CON Application
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Benefits for the Project
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Project Phases
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Project Control During the Phases
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DOH CON Project Processes
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Typical Management Plan A/E
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Purpose of BAEFP
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Shared Project Control
Overview
Management Plan of the Process
Benefits:
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Accountability
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DOH BAER
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Architects & Engineers
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Facilities
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Related Consultants
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End result is a project that:
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No surprises for the facility and A/E consultants
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Clear, Concise, Correct, Consistent from project to project
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Comprehensive to the prescriptive requirements and in compliance with
industry standards
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Shorter Review Times
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Less ping ponging of RFI’s
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Having the proper information from the beginning
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Level the playing field for all applicants and reviewers
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Proper planning is being provided.
Goals
Benefits for the Project
Process Flow Chart
Project Phases for Project Planning for CON
Related Projects
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Project Efficiency is improved
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Scope of Project is developed.
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Critical Tasks identified and
properly sequenced.
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Clear Milestones established.
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Complex or heavily involved
processes are carried out early in
the project that can impact the
budget, schedule and use.
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Roles of team members
established.
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Used internally and shared with all
project members.
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The client is involved throughout
the project.
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Expectations of the process and
complexity are developed with
the client.
Why A
Process Flow Chart
Site, Facility programs are analyzed in terms of sound
generation characteristics and isolation requirements.
Unalterable conditions that affect solution are identified.
User’s Needs
• Roles and Purposes of the Project Identified
• Activities to be accommodated.
• Space Program and Site Features required.
• Space Types or Site Features requiring
additional investigation.
• Identify flexibility of spaces or alternates if
allowed by the users.
• Programming Hierarchy and Priorities are
established.
• Send out Programming Questionnaire
Owner Approves Concepts and Programming
• Principal to review and sign off also.
• Owner confirms schedule.
• Determine any phase combinations of project
and identify termination dates.
• Identify appropriate project contingencies.
Project Control Identified in the Phases
NYSDOH Flow Chart
DOH CON Project Processes excluding
Modifications
Project Considerations
Client
Dependent
Architect
Control
Contractor
Dependent
Shared Control
Typical Management Plan A/E
Quality
Schedule
Cost
Construction
Administration
Construction
Documents
Individual control
Proposal
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Design
Development
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Primary Areas of Control
Shared/Bridging
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Involved
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Listening
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Disclosing
Schematic
Design
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Programming
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NYSDOH:
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Reviews
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Schematic Design
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Functionality
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Life Safety Issues Identified
SHC/DD
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Functionality
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Life Safety plans further advanced
Reviews are not for constructability
The purpose of the reviews are for occupant safety, using:
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Life Safety Codes (NFPA 101, 2000 Edition)
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FGI Guidelines (2010 Edition)
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Applicable References
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The design professional is ultimately responsible for complying with all the
referenced guides and standards and indicating the correct standards on
the life safety plans.
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DD submission is limited and final coordination has not occurred between all
trades.
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i.e. Sprinkler locations. Often sprinklers are performance specifications and are
design bid build.
Purpose of Reviews
Purpose of BAEFP
Applicant
Architect
Engineer
NYSDOH
Contractor
Shared Control
Shared Project Control
Quality
Schedule
Control Set by Others
Cost
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Construction
Administration
Shared Control
DD/SHC
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RFI’s Duration
Primary Areas of Control
Schematic
Design 30%
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100%
Documents
Project Considerations
NFPA, FGI,
ADDAG< NYS
Building Code
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Purpose of Compliance
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Code Compliance Responsibilities
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NYSHC NYCRR Title 10 Current Standards of
Construction
Section 711.2 Pertinent Technical Standards
Code Requirements for Projects in NYS and their
referenced standards
Permitting Agency Construction Document
Requirements in New York State
Permitting Agency Construction Specifications
Requirements
Handicap Accessibility Requirements
Overview
Code Compliance
SECTION 1.5 EQUIVALENCY
1.5.1* Nothing in this Code is intended to prevent the use of systems, methods, or devices of
equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety
over those prescribed by this Code. Technical documentation shall be submitted to the authority
having jurisdiction to demonstrate equivalency. The system, method, or device shall be
approved for the intended purpose by the authority having jurisdiction.
1.5.2* Equivalent Compliance. Alternative systems, methods, or devices approved as equivalent by
the authority having jurisdiction shall be recognized as being in compliance with this Code.
SECTION 4.1* GOALS
4.1.1* Fire and Similar Emergency. The goal of this Code is to provide an environment for the
occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) *Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development
4.1.2* Crowd Movement. An additional goal is to provide for reasonably safe emergency crowd
movement and, where required, reasonably safe nonemergency crowd movement.
NFPA 101 2000 edition
Purpose of Compliance
SECTION 4.2 OBJECTIVES
4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect
occupants who are not intimate with the initial fire development for the time needed to evacuate,
relocate, or defend in place.
4.2.2 Structural Integrity. Structural integrity shall be maintained for the time needed to evacuate,
relocate, or defend in place occupants who are not intimate with the initial fire development.
SECTION 4.4 LIFE SAFETY COMPLIANCE OPTIONS
4.4.1 Options. Life safety meeting the goals and objectives of Sections 4.1 and 4.2 shall be provided
in accordance with either of the following:
(1) The prescriptive-based provisions per 4.4.2
(2) The performance-based provisions per 4.4.3
4.5.2 Appropriateness of Safeguards. Every building or structure shall be provided with means of
egress and other safeguards of the kinds, numbers, locations, and capacities appropriate to the
individual building or structure, with due regard to the following:
(1) Character of the occupancy
(2) Capabilities of the occupants
(3) Number of persons exposed
(4) Fire protection available
(5) Height and type of construction of the building or structure
(6) Other factors necessary to provide occupants with a reasonable degree of safety
NFPA 101 2000 edition
Objectives of Code Compliance
4.6.2* Historic Buildings. The provisions of this Code shall be permitted to be modified by the authority
having jurisdiction for buildings or structures identified and classified as historic buildings or structures where
it is evident that a reasonable degree of safety is provided.
4.6.3* Modification of Requirements for Existing Buildings. Where it is evident that a reasonable degree of
safety is provided, the requirements for existing buildings shall be permitted to be modified if their
application would be impractical in the judgment of the authority having jurisdiction.
4.6.4 Time Allowed for Compliance. A limited but reasonable time, commensurate with the magnitude of
expenditure, disruption of services, and degree of hazard, shall be allowed for compliance with any part of
this Code for existing buildings.
4.6.5 Referenced Publications. Existing buildings or installations that do not comply with the provisions of the
referenced standards contained in this document (see Chapter 2) shall be permitted to be continued in
service, provided that the lack of conformity with these standards does not present a serious hazard to the
occupants as determined by the authority having jurisdiction.
NFPA 101 2000 edition
Authority Having Jurisdiction
4.6.6 Additions. Additions shall conform to the provisions for new construction.
4.6.7* Modernization or Renovation. Any alteration or any installation of new equipment shall meet,
as nearly as practicable, the requirements for new construction. Only the altered, renovated, or
modernized portion of an existing building, system, or individual component shall be required to
meet the provisions of this Code that are applicable to new construction. If the alteration,
renovation, or modernization adversely impacts required life safety features, additional upgrading
shall be required. Existing life safety features that do not meet the requirements for new buildings,
but that exceed the requirements for existing buildings, shall not be further diminished. In no case
shall the resulting life safety features be less than those required for existing buildings.
4.6.11* Changes of Occupancy. In any building or structure, whether or not a physical alteration is
needed, a change from one occupancy classification to another shall be permitted
only where such a structure, building, or portion thereof conforms with the requirements of this
Code that apply to new construction for the proposed new use or, where specifically permitted
elsewhere in the Code, existing construction features shall be permitted to be continued in use in
conversions.
2010 FGI Requirements
Modernization & Changes of Occupancy
1.1-5.1 Safe Environment
Every health care facility shall provide and maintain a safe environment for patients,
personnel, and the public.
1.1-5.2 Code Compliance
In the absence of state or local requirements, the project shall comply with approved
nationally recognized building codes except as modified in the latest edition of NFPA
101 and/or herein.
1.1-5.2.1 References made in these Guidelines to appropriate model codes and standards do
not, generally, duplicate wording of the referenced codes.
1.1-5.2.2 National Fire Protection Association (NFPA) standards are the basic standards of
reference, but other codes and/or standards may be included as part of these
Guidelines. See Section 1.1-5.5 (Referenced Codes and Standards).
1.1-5.2.3 Referenced code material is contained in the issue current at the time of this publication.
1.1-5.2.4 The latest revision of code material is usually a clarification of intent and/or general
improvement in safety concepts and may be used as an explanatory document for
earlier code editions.
1.1-5.2.5 Questions of applicability should be addressed as the need occurs. The actual version of
a code adopted by a jurisdiction may be different. Confirm the version adopted in a
specific location with the authority having jurisdiction.
NFPA 101 2000 edition
Modernization & Changes of Occupancy
1.1-5.3 Equivalency
1.1-5.3.1 Performance Standards
The minimum standards in these Guidelines have been established to obtain a desired
performance result.
1.1-5.3.2 Prescriptive Standards
Prescriptive limitations (such as exact minimum dimensions or quantities), when given, describe a
condition that is commonly recognized as a practical standard for normal operation. For example,
reference to a room or area by the patient, equipment, or staff activity that identifies its use avoids
the need for complex descriptions of procedures for appropriate functional programming.
1.1-5.3.3 Technical Standards
1.1-5.3.3.1 NFPA 101A is a technical standard for evaluating equivalency to certain requirements of
NFPA 101: Life Safety Code.
1.1-5.3.3.2 The Fire Safety Evaluation System (FSES) has become widely recognized as a method for
establishing a safety level equivalent to that of the Life Safety Code. It may be useful for evaluating
compliance with the Life Safety Code in renovations of existing facilities and in new facility designs.
For purposes of these Guidelines, use of the FSES is permitted, subject to AHJ approval, for new
construction and renovation projects. (The FSES is intended as an evaluation tool for fire safety only.)
1.1-5.3.4 Equivalency Concepts
While these Guidelines are adopted as a regulatory standard by many jurisdictions, it is the intent of
the document to permit and promote equivalency concepts.
FGI 2010
Modernization & Changes of Occupancy
1.1-5.3.4.1 When contemplating equivalency allowances, the authority having jurisdiction may use
a variety of expert sources to make equivalency findings and may document the
reasons for approval or denial of equivalency to the requester.
1.1-5.3.4.2 Alternate methods, procedures, design criteria, and functional variations from these
Guidelines, because of extraordinary circumstances, new programs, or unusual
conditions, may be approved by the authority having jurisdiction when the facility can
effectively demonstrate that the intent of the Guidelines is met and that the variation
does not reduce the safety or operational effectiveness of the facility below that
required by the exact language of the Guidelines.
1.1-5.3.4.3 In all cases where specific limits are described, equivalent solutions will be acceptable if
the authority having jurisdiction approves them as meeting the intent of these standards.
1.1-5.3.4.4 Nothing in this document shall be construed as restricting innovations that provide an
equivalent level of performance with these standards in a manner other than that which
is prescribed by this document, provided that no other safety element or system is
compromised in order to establish equivalency.
FGI 2010 Edition
Modernization & Changes of Occupancy

PART 711 GENERAL STANDARDS OF CONSTRUCTION

PART 712 STANDARDS OF CONSTRUCTION FOR GENERAL HOSPITAL FACILITIES

PART 713 STANDARDS OF CONSTRUCTION FOR NURSING HOME FACILITIES

PART 714 STANDARDS OF CONSTRUCTION FOR ADULT DAY HEALTH CARE PROGRAM FACILITIES

PART 715 STANDARDS OF CONSTRUCTION FOR FREESTANDING AMBULATORY CARE FACILITIES

PART 716 STANDARDS OF CONSTRUCTION FOR NEW REHABILITATION FACILITIES

PART 717 STANDARDS OF CONSTRUCTION FOR NEW HOSPICE FACILITIES AND UNITS
Public Health Law,
Section 2803
NYSHC NYCRR Title 10 Current Standards of
Construction

Section 711.1 Applicability. (a) This Part sets forth minimum construction and physical environment standards
applicable to all health facilities subject to Public Health Law Article 28, including but not limited to, general
hospitals, nursing homes and ambulatory care facilities.
(b) An applicant seeking approval to construct a new health facility or alter or renovate an existing health facility shall submit to the
department a completed application and functional program. The applicant shall ensure that all terms and acronyms are clearly
defined and consistently used in the application and functional program. The functional program, which is a detailed architectural
and design plan for the health facility, shall include a description of the following:
(1) the scope and purpose of the proposed construction project and other basic information relating to fulfillment of the applicant's
objectives;
(2) the services necessary for the complete operation of the health facility, the size and function of each space, any special design
features, the projected occupant load, and numbers and types of staff, patients, residents, visitors and vendors;
(3) the types and projected numbers of procedures to be performed in each treatment area and circulation patterns for staff,
patients or residents, and the public;
(4) the projected demand or utilization, staffing patterns, departmental relationships, space requirements, and circulation patterns
that are a function of infection control requirements and for clean and soiled materials;
(5) equipment requirements, including building service equipment and fixed and moveable equipment; and,
(6) potential future expansion that may be needed to accommodate increased demand.
(c) Once approved by the department, the functional program and the approved plans and specifications developed from it shall
be used in the development, design and construction of the project and serve as the basis for all subsequent construction
approvals regarding the specific project. The applicant or health facility operator shall retain and make available to the
department, upon the department's request, the functional program, all government approved plans and specifications
developed from it and any other design data to facilitate alterations, and program changes.
Public Health Law,
Section 2803
NYSHC NYCRR Title 10 Current Standards of
Construction

711.2 Pertinent technical standards. All
health facilities shall comply with the
pertinent provisions of the standards and codes referred to in this section
and with local laws relating to zoning, sanitation, fire safety and
construction, where such local laws represent standards in addition to
those required by this Part. Reference throughout this chapter to codes
and standards shall be those editions listed in this section. If a conflict
occurs between the following codes and standards or between them and
regulations elsewhere in this chapter, then compliance with the more
restrictive regulation is required. If federal regulatory requirements
conflict with the codes and standards referred to in this section, the
department may waive compliance with such standards and codes,
provided that a health facility fully complies with said federal regulatory
requirements.
711.2
Section 711.2 Pertinent Technical Standards
Life Safety
NYS Building Code
Accessibility
NYSDOH
NYS Building Code
Building Code of NYS
Existing Building Code of NYS
Fire Code NYS
Plumbing Code of NYS
Mechanical Code of NYS
Fuel Gas Code of NYS
Energy Conservation Code
of NYS
Property Maintenance Code
of NYS
2010 International
Code Council
ANSI-A117.1-2003
NFPA
NYSDOH does not establish the
code requirements for life safety
CMS does.
NYSDOH
ADAAG 28 CFR Part
35.151+ 2004
ADDAG=2010 ADA
Standards
Functionality &
Programmatic
Requirements
NYS Building Code
N/A
NYSDOH
Guidelines for Design
and Construction of
Health Care Facilities,
2010 edition.
NYSDOH has not adopted the 2014
Edition of the FGI Guidelines. It will
be reviewed and considered.
Working on it.
Please refer to Federal
Register/Vol. 68, No. 7 Friday
January 10,2003 Regulations.
Proposed, not yet adopted Vol.
79, Wednesday, No. 73 April 16,
2014 is under CMS consideration.
Code Requirements
Design to the most stringent requirement.
Code Compliance Responsibility
Life Safety
NYS Building Code
101-2006
13-2007
14-2007
30-2008
31-2006
70-2008
72-2007
80-2007
110-2005
111-2005
211-2006
252-2003
253-2000
257-2000
265-2007
286-2006
418-2001
701-2004
Life Safety Code
Installation of Sprinkler System
Installation of Standpipe and Hose System
Flammable and Combustible Liquids Code
Installation of Oil-burning Equipment
National Electric Code
National Fire Alarm Code
Fire Doors and Fire Windows
Emergency and Standby Power Systems
Stored Electrical Energy Emergency and Standby Power Systems
Chimneys, Fireplaces, Vents and Solid Fuel-burning Appliances
Standard Methods of Fire Tests of Door Assemblies
Test for Critical Radiant Flux of Floor Covering Systems Using a
Radiant Heat Energy Source
Standard for Fire Test for Window and Glass Block Assemblies
Method of Fire Tests for Evaluating Room Fire Growth Contribution
of
Textile Wall Coverings on Full Height Panels and Walls
Standard Method of Fire Test for Evaluating Contribution of Wall
and
Ceiling Interior Finish to Room Fire Growth
Standard for Heliports
Standard Methods of Fire Tests for Flame-propagation of
Textiles and Films
NYSDOH
101-2000
13-1999
14-2000
30-1996
31-1997
70-1999
72-1999
80-1999
110-1999
111-1996
211-2000
252-1999
253-2000
257-2000
265-1998
286-2000
Standard Method of Fire Test for Evaluating Contribution of Wall and
Ceiling Interior Finish to Room Fire Growth
418-1985
701-1999
Standard for Heliports
Standard Methods of Fire Tests for Flame-propagation of
Textiles and Films
Guide on Alternative Approaches to Life Safety
101A-1998
10-1998
Standard for Portable Fire Extinguishers
25-1998
Standard for the Inspection, Testing, and Maintenance of Water-Based
Fire Protection Systems
Standard on Fire Protection for laboratories Using Chemicals.
45-1996
54-1999
NFPA 54, National Fuel Gas Code, 1999 edition
58-1998
Liquefied Petroleum Gases Code
82-1999
Standard on Incinerators and Waste and Linen Handling Systems and
Equipment,
Standard for the Installation of Air Conditioning and Ventilating Systems,
90A-1999
90B-1999
Reference Standards
Life Safety Code
Installation of Sprinkler Systems
Installation of Standpipe and Hose System
Flammable and Combustible Liquids Code
Installation of Oil-burning Equipment
National Electric Code
National Fire Alarm Code
Fire Doors and Fire Windows
Emergency and Standby Power Systems
Stored Electrical Energy Emergency and Standby Power Systems
Chimneys, Fireplaces, Vents and Solid Fuel-burning Appliances
Standard Methods of Fire Tests of Door Assemblies
Test for Critical Radiant Flux of Floor Covering Systems Using a
Radiant Heat Energy Source
Standard for Fire Test for Window and Glass Block Assemblies
Method of Fire Tests for Evaluating Room Fire Growth Contribution of
Textile Wall Coverings on Full Height Panels and Walls
Standard for the Installation of Warm Air Heating and Air-Conditioning
Systems,
Code Compliance Responsibility
Life Safety
NYS Building Code
NYSDOH
91-1999
96-1998
99-1999
220-1999
221-1997
1996-241
Standard for Fire Walls and Fire Barrier Walls
Standard for Safeguarding Construction, Alteration, and Demolition
Operations.
251-1999
Standard Methods of Tests of Fire Endurance of Building Construction and
Materials,
255-2000
Standard Method of Test of Surface Burning Characteristics of Building
Materials,
Standard Methods of Fire Tests of Roof Coverings
Standard Methods of Tests and Classification System for Cigarette Ignition
Resistance of Components of Upholstered Furniture
Standard Method of Tests for Determining Resistance of Mock-Up
Upholstered Furniture Material Assemblies to Ignition by Smoldering
Cigarettes
Standard Methods of Fire Tests for Evaluating Room Fire Growth
Contribution of Textile Wall Coverings,
256-1998
260-1998
261-1998
265-1998
266-1998
267-1998
703-2000
Reference Standards
Standards for Exhaust Systems for Air Conveying of Vapors, Gases,
Mists and Noncombustible Particulate Solids,
Standard for Ventilation Control and Fire Protection of Commercial
Cooking Operations
Standard for Health Care Facilities
Standard on Types of Building Construction, 1999 edition.
Standard Method of Test for Fire Characteristics of Upholstered Furniture
Exposed to Flaming Ignition Source
Standard Method of Test for Fire Characteristics of Mattresses and Bedding
Assemblies Exposed to Flaming Ignition Source
Standard for Fire Retardant Impregnated Wood and Fire Retardant
Coatings for Building Materials
Code Compliance Responsibility
Handicap Accessibility Requirements NYSDOH
NYSDOH Requirements
Department of Justice
PART 711
GENERAL STANDARDS OF CONSTRUCTION
(Statutory authority: Public Health Law, Section 2803)
28 CFR
36.104
Definitions
28 CFR part 35.151+2004 ADAAG
= 2010 ADA Standards for Accessible Design
2004 ADAAG Means the requirements set forth in appendices B and
D to CFR 36 part 1191.
2010 Standards means the 2010 ADA Standards for
Accessible Design, which consists of the 2004 ADAAG and the
requirements contained in subpart D of this part.
The Department of Justice published its revised regulations for Titles II and III of
the Americans with Disabilities Act of 1990 “ADA” in the Federal Register on
September 15, 2010, which include the 2010 Standards for Accessible Design
“2010 Standards” or “Standards”. In the revised regulations, the Department
included detailed guidance with a section-by-section analysis of the revisions:
The following includes guidance from the revised regulations related to 28 CFR
35.151; 28 CFR part 26, subpart D; and the 2004 ADAAG. It addresses changes
to the Standards, the reasoning behind those changes, and responses to public
comments received on these topics.
711.2 Pertinent technical standards. All health facilities shall comply with the
pertinent provisions of the standards and codes referred to in this section and with
local laws relating to zoning, sanitation, fire safety and construction, where
such local laws represent standards in addition to those required by this Part.
Reference throughout this chapter to codes and standards shall be those editions
listed in this section. If a conflict occurs between the following codes and standards
or between them and regulations elsewhere in this chapter, then compliance with
the more restrictive
regulation is required. If federal regulatory requirements conflict with the codes and
standards referred to in this section, the department may waive compliance with
such standards and codes, provided that a health facility fully complies with said
federal regulatory requirements.
ADDAG
(c) Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA)
extends comprehensive civil rights protection to persons with disabilities. Health care
facilities must comply with the ADA and the regulations which implement it. Title 28 of the
Code of Federal regulations, Public Health Parts 35, Non-Discrimination on the
Basis of Disability in State and Local Government Services, and Part 36, NonDiscrimination on the Basis of Disability by Public Accommodations and in Commercial
Facilities, including Appendix A, "Standard for Accessible Design", 2004 edition. These
regulations are published by the Office of the Federal Register National Archives and
Records Administration. Copies may be obtained from the Superintendent of Documents,
United States Government
Printing Office, Washington D.C. 20402.
Handicap Accessibility Compliance
Handicap Accessibility Requirements NYSDOH
CFR Table of Contents
Title 28-Judicial Administration
Title 36-Parks, Forests, and Public Property
28 CFRJudicial
Administration
Chapter 1Departmen
t of Justice
Part 35-NonDiscrimination on the Basis of Disability in State and Local Government Services
Part 36NonDiscrimination
on the Basis of
Disability in by
Accommodations
and in Commercial
Facilities
36 CFR-Parks, Forests, and Public Property- Chapter XI-Architectural and Transportation barriers
Compliance Board
Part 1191-Americans with Disabilities Act (ADA) Accessibility Guidelines for Buildings and
Facilities; Architectural Barriers Act (ABA) Accessibility Guidelines Appendix D to Part 1191Technical
28 CFR Part 35-NonDiscrimination on the Basis of Disability in State and Local Government
28 CFR 35.149 Discrimination Prohibited
28 CFR 35.151.New Construction and Alterations
28 CFR 35.150-Existing Facilities
Subpart D-Program Accessibility
Appendix A to Part 35
28 CFR Part 36-NonDiscrimination on the
Basis of Disability in by Accommodations and
in Commercial Facilities
Subpart D-New Construction and Alterations
Appendix A to Part 36 Guidance on Revisions
to ADA regulation on Nondiscrimination on the
Basis of Disability by Public Accommodations
and Commercial Facilities
28 CFR Part 36, Appendix A to Part 36
28 CFR Part 36, Subpart D36.406-Standards
for New Construction
ADDAG
Handicap Accessibility Compliance
Submission Requirements for all Project Types
Agency
30%
60%
100%
Building
Permit
Local
Municipality
NYSDOH
DASNY
OGS
•
Not reviewed as part of the permitting process
•
Reviewed during the approval process
•
Submission for record keeping no review.
Comparisons
Permitting Agency Requirements
Submission Requirements for all Project Types
Agency
30%
60%
100%
Building
Permit
Local
Municipality
NYSDOH
DASNY
OGS
•
Not required as part of the permitting process
•
Reviewed during the approval process
•
Submission for record keeping no review.
Comparisons
Permitting Agency Specification
Requirements

Source of Waivers

Types of Waivers

Reasons for Waivers

Minimize the Amount of Waivers

Revised Waiver Form



Permitting Agency Construction Document
Requirements in New York State
Permitting Agency Construction Specifications
Requirements
Handicap Accessibility Requirements
Overview
Waivers
•
Request Source ( Point of Source):
•
Survey Waivers (Survey Waivers are used when a sanitarian finds
a structural or environmental deficiency during a survey, and
the facility requests a waiver.)
•
Regional Office Survey (Sanitarian)
•
Regional Office Endorsement (Principal Sanitarian &
Regional Office Director.)
•
Final Decision by BAEFP Bureau Director
Why Waivers?
Survey Waivers
•
Pre-Opening/Initial Waivers:
•
(Pre-Opening/Initial Waivers are used when a sanitarian finds a
structural or environmental deficiency during a pre-opening
survey, and the facility requests a waiver.)
•
Regional Office Survey (Sanitarian)
•
Regional Office Endorsement (Principal Sanitarian &
Regional Office Director.)
•
Final Decision by BAEFP Bureau Director
Why Waivers?
Pre-Opening/Intial Waivers
•
Plan Review Waivers:
•
(Plan Review Waivers are used when a BAEFP reviewer finds a
deficiency during a plan review, and the facility requests a
waiver.)
•
Waiver may be initiated by the Applicant after performing
due diligence.
•
Waiver initiated by BAEFP reviewer
•
Final Decision by BAEFP Bureau Director
Why Waivers?
Plan Review Waivers
•
Types:
•
•
•
•
•
•
Time Limited
Permanent
FES
Equivalency
Categorical
Actions of a Waiver:
•
•
•
Conditional
Time Frame
Other
Types of Waivers?
Types of Waivers
•
•
Poor Planning
•
Due diligence not performed early enough in the project
•
Design professional did not use the correct referenced
standards
•
OOPS
Hidden Conditions
•
Tight Urban Sites:
•
Lack of physical space
•
Shared sites with other entities
•
Conflict with other Life Safety Codes based on the municipal level
Reasons for Waivers
Reasons for Waivers
•
Proper Planning:
•
Due Diligence
•
•
•
Comprehensive Code Review
Existing Conditions Properly documented
Proper Site Selection
•
Does the facility have the capability to function as
planned.
•
Life Safety Constraints
Functionality Issues
•
Existing Conditions
•
•
Pre-consultation with BAEFP addressing the specific issues and
documented resolutions on file with BAEFP and the applicant
•
•
How to Avoid
Waivers?
E-mail
Meeting Minutes
Minimize the Amount of Waivers

Project Process Control Schedule Counter Measures

Project Process Quality Control

Project Process Control Benefits

Tools Used for Quality Control

On Going Quality Assurance

Process Flow Chart Diagram

Control Process
Overview
Project Process Control
Shorten reviews:
•
Shorten task contingencies.
•
Prescreening/triaging upon receipt
•
Administrative tasks delegated to admin assistant.
•
E-mails and telephone conversations at designated times (24 Hour
response)
•
Assign tasks to be run parallel with other tasks.
•
Limited and administrative reviews are being reviewed concurrently
as the other reviews. Dedicate reviewer is assigned
•
Waivers as part of the CON review stay with the reviewer CON
reviewer.
•
Eliminates redundancy on a review.
•
Reduces staff time by a minimum of 50%.
•
Consistency of review.
•
Shorten client reviews or eliminate a portion of the project deliverables.
•
Assign more staff or utilize outside resources.
Schedule Control
Project Process Control Schedule Counter
Measures
What is quality?
•
Quality is the ability to meet the following requirements:
o
Time- Delivery of services and properly allocated resources
o
On-Time-Services -Delivered when promised.
o
Completeness – Comprehensive services?
o
Consistent- Services be the same over and over?
o
Accurate- Errors that resulted in the unexpected?
o
Courtesy-Awareness, courtesy and respect?
o
Accessibility and Convenience - Usable and valuable?
o
Documented
o
Accountability
Quality is not an act, it is a habit.
Aristotle
Quality Control
Project Process Quality Control
•
Poor quality control can have major consequences and impact:
o
o
o
o
o
o
o
o
Budget
Schedule
Intended Use
Function
Durability and Service Life
Conformity to the project requirements
Serviceable and accessibility may be compromised
May not appear aesthetically pleasing.
Why Have Quality
Control?
Project Process Control Benefits
RISMI approach:
•
•
•
Review
•
Exam the current processes and associated tasks
Identify
•
Culminate the results from the review of the current processes to help identify
areas that require improvement:
•
White Boards (Snapshot of the current reviews , provides a status scoreboard.)
Standardize/Stabilize
•
Reviewing Submissions when received:
•
Does it meet the criteria for acceptance?
•
Go?
•
No go contact applicant ASAP, not when in the Q.
•
One point of contact when providing and disseminating information.
•
Design Guidelines for Review Submissions
•
Schematic Design
•
SHC/DD
•
Hospitals
•
Outpatient Facilities
•
Nursing Homes
Effective Quality
Control
Tools used for Quality Control
•
•
Measure
•
Project Status Data Base
•
Waiver Status Data Base
•
Audit Data Base
•
Quality of information received
•
Develop Mature Statistical Data
•
Confirm or deny patterns
Improve
•
Additional Training
•
Further standardization of work
•
Clearer instruction
•
Additional identifiable delivery milestones
•
Language of regulations and how we can provide clear intent.
Effective Quality
Control
Tools used for quality control
In an ongoing effort to improve quality, measure and
improve.
•
•
•
•
Continually monitor our performance and the applicant’s including
their consultants.
Note areas of concerns.
Share with the appropriate individuals.
Improve the processes and plan accordingly for the future.
Quality Maintenance is conducted to include all members to be an
important factor and be a continuous part of the problem solving effort.
•
•
•
•
Performance reviews.
Design reviews.
Post occupancy evaluations.
Client surveys.
Effective Quality
Control
On Going Quality Assurance
The end result is a project that:
•
•
•
•
•
•
•
Creates process control that aligns with NYSDOH Review Process
Functional
Durable and adaptable
Serviceable and accessible
Within Budget
On Schedule
Conforms to the project requirements
Effective Quality
Control
Tools used for quality control

Project Control that is the A/E Responsibility

Project Control for Improved Quality

NYSDOH BAEFP Tools

DSG Guidelines

Internal Checklists

Smart Boards (used for monitoring)
Responsibilities Of The
Project Managers
Proposed Management Plan
Architectural firms traditionally conduct quality control at
the end of the project by reviewing and commenting on
the construction documents.
•
•
Performed by an experienced architect at the completion of the
documents.
o
Involved with project.
o
Doesn’t have the time.
o
Generally Multi-tasking – Less Focused
Corrections come at a cost when it is too late.
o
Not enough time to complete the formal review .
o
Necessary corrections are not completed.
o
The set doesn’t get reviewed or coordinated properly.
Impact
•
Addendums
•
Changes orders during construction.
•
Budget could be affected
•
Creating delays with the construction schedule.
Ineffective Quality
Control
Project Control that is the A/E Responsibility
Current Processes
•
Reviews and identifies project:
o
Checklists
o
Deliverables
•
Applicants and their consultants comprehend the project requirements
and deliverables.
•
Early stages DD. Stop Designers from Designing
•
•
Peer reviews (drawings, specifications, cost opinions) for compliance.
o
End of each phase or when the deliverables are submitted.
o
During DD at the 90% milestone.
o
During the CD phase at the 50% milestone and at the 90%.
o
•
Minimizes the amount of design changes during CD phase.
Complicated projects or new building type projects require
additional time and earlier involvement in the DD phase.
The review process allows users to detect the differences between
compliance and deficiencies.
o
o
Effective Quality
Control
Provides enough time to complete the corrections.
Learn from it.
Project Control for Improved Quality
Progress made to date utilizing lean processes
•
•
•
What, How Come, Because
•
Process
•
Process Control
Current Conditions
•
Limited Reviews
•
Administrative Reviews
•
State Hospital Code Submissions
•
Waivers
Next round of improvements directed to:
•
Self-Certifications
•
Agenda projects
•
Modifications
•
Problematic Projects
Overview
Introduction
Why
•
After identifying there was no formal means of tracking the status of project
to be reviewed and or under review outside of NYSECON for admins or
Limited's.
•
NYSECON is limited in reporting all data. Enhancements are continually
worked on.
•
Notifications for SHC is developed further. Automated nudges for reviewers
along with applicant.
•
Central Area for everyone to see the workload.
•
What is outstanding in the hopper.
•
Current Conditions for projects.
•
Identify problem areas and or projects.
•
Used in huddles to nudge the reviewer.
•
Establishes or reestablishes priorities.
•
Helps manage the workload.
•
Anyone can answer the status of a project, whether it has been looked
at, waiting, etc. particularly the admin assistant.
Why
The main purpose for having whiteboards
Countermeasure Effects.
•
Individual reviewers are able to determine the status of a project at all times
now, including projects under review and assigned.
•
Not completed reviews though.
•
Means for others to view the status.
•
Less interruptions in the process.
•
Easier to manage workload.
•
Cohesiveness is developing.
•
Easier to prioritize projects. Better Planning.
•
Minimized the knee jerk reactions to shift in assignments to meet deadlines
etc.
•
Focused reviews
•
Used in huddles to nudge reviewers (and Applicant)
Favorable Results
Effective Countermeasures
DataBase Issues
•
Access was limited
•
Control of data was important
•
Who updates
•
How often
•
Would they update?
•
DataBase became very large
•
Hard to find data unless sorted
•
Original intent of database was to have smart data
•
Identify bottle necks
•
Identify hot or problem areas
•
Reviewer
•
Applicant
•
Facility
•
Design Professional
Not good for the
masses
Data Issues Related to Spreadsheets
Data Related to Process
•
What goes on the Whiteboard
•
Date
•
CON Number
•
Facility Name
•
Date Assigned from PMU
•
Bureau Director to Reviewer
•
Review Start Date (Eyes On)
•
RFI Dates
•
All projects assign to BAER are now on the white boards. Not just the
projects that have been started, nor for the week in question.
•
Once a project is completely reviewed and uploaded into NYSECON
then the project is removed from the board.
•
Parallel with the data in the spreadsheet. Admin. Assist is able to
update spreadsheets from whiteboard.
Current Condition
Information.
What is on the White Board
Project Status Spreadsheet
Project Information
Review Status
RFI Status
Final Approval Status
Comments:
Priority Date
Other Comments:
AER Review
Complete
Total Days Date
Assigned - Cont.
Sign-off
Cont. Signed-off
Final CDs Rec'd
Final Plan
Approval Sent
Resp Rec'd
Plan Review Sent
SHC Drawings
Rec'd
Contingent
Approval Given
RFI Review
Complete
Total Time Spent
Waiting for RFIs
RFI Rec'd
Time Spent
Waiting for RFIs
4-4-14
RFI #
DOH/
DASNY
RFI Issued
CON #
Agenc
y
Review Complete
SCM = SD, 30%
SHC = DD, 60%
CD = CDs, 100%
M = Modification
W = Waiver
AES = Self-Cert
Total Cost
Date Review
Started
Consultants
Date Assigned
Description
Review Type
Facility / Address
Reviewer
TAG #
Phase
Waiver Status Spreadsheet
Comments:
Distribution Date
A=Approved D=Disapproved
Date Returned
Date Sent
Follow Up
Date:
Type
P=Permanent
T=Time Limited
Status
A=Approved
D=Denied P=Pending
Sign-off
CMS (NFPA)
DHFP Director
BAEFP Director Review
RFI Review Complete
Response Received
Date Sent
RFAI
Draft Waiver Complete / or
Withdrawn
DOH Determination
Date Received / Assigned
Reviewer
Description &
Related Issues
Request Type:
Discipline/Trade
A=Architectural
E=Electrical
FP=Fire Protection
M=HVAC
P=Plumbing
C= Civil
Code Issue
(NFPA, FGI,
Program)
Survey Date
PR- Plan Review
PO/SU=Post Occ
SU/DNV=DNV
SU/TJC=TJC
SU/RO=Reg. Office
CON #
Waiver ID #
TAG #
Facility
Architect
Engineer
Started
Processing
Contact:
Facility / Address Description
Date Review
Project Information
SHC Status Spreadsheet
Facility
Description
t Status Sheet
CON Contact
Total
Projected
Cost
Cont.
SHC/DD
Approval Drawings
Date
Received
Slot #
Processing
Reviewer
CON #
Review Type
Tag #
Project Information
Approval
Status
Comments
Review Time:
SHC Drawings
Final Plan
Rec'd to Final
Date
Final Plan Review Total Time spent
Review Review Response
Waiting for
Final Plan Approval Date / Plan Approval 100 % DSG- 05
Started
Responses
Sent
SHC/DD Review Complete
Received
Received
Comments
NYSDOH Data Sets
Data Related to Process
•
BACKLOG Period
•
Date project is assigned from PMU to BAER
•
Date BAER director assigns to reviewer
•
Date Reviewer starts looking at submission. ( Eyes on date)
•
The Backlog period is important to track for BAER,
•
How long has the project sat on the rack before review.
•
When did it come?
•
Provides the ability to age the project.
•
May not be a reviewer’s issue, could be IT related.
•
Why it sat on the rack
•
Agenda
•
Forgot about it
•
Didn’t know that was my project
•
Been too busy with other things haven’t gotten around to it.
•
I dunno
•
Helps prioritize older projects that need memorialization.
What Data?
Data that is important on White Board
Better RFI Tracking
•
RFI Period
•
RFIs are requests for information that is usually provided by the design
professional and controlled most of the time by the applicant.(Many
facilities do not want us contacting their Architect.)
•
RFIs can hurt the review time if there are the following:
•
Multiple requests for information
•
Requests are not answered within 14 calendar days.
•
The reviewer fails to follow up on the status.
•
•
(Side note; as part of the lean process we currently have the
Admin Assistant providing the nudge to follow up on the status.)
•
There has been some early on discussions about making this an
automatic process.
RFIs are shared process time and not completely under BAER control.
Waiting Period
Waiting and why it hurts review times.
Time Frames
PMU
Assigns to
BAER
BAER
Director
Assigns to
Reviewer
RFI Date
Sent
Actual
Review
Time
Backlog
Period
•
Eyes on for
Reviewer
Waiting
Period
Beyond our Control (We can nudge though)
•
Under our Control
•
Partial Control
Process
RFI Date
Received
Process Control Time Frames
Individual Reviewer White Boards
•
The individual reviewers have their own boards and list the individual
projects assigned to them.
•
Flexibility to allow the individual to modify board according to their style.
•
It still needs to show the following:
•
CON Number
•
Status
•
Active
•
Waiting
•
Next in queue.
•
Use of Icons
Waiting Period
Individual White Boards
Smart Board= Status Metric Accounting & Reporting Tool
Current Conditions, revised layout 3 x times
Smart Board
Use of Icons to serve double duty:
Waiting
Active
Personalization(Reviewer
Identifier)
NYSDOH BAEFP Status
Regulatory Authority
•
The Commissioner can accept a written certification from a licensed architect or
engineer in lieu of a drawing review. Under Section 710.1, General Provisions, the
following language is listed as an option under the definitions of a full review, an
administrative review and a limited review.
•
The commissioner may, as an alternative to the submission of architectural
and engineering documentation referenced above, accept a written
certification by an architect or engineer licensed by the State of New York
that such project complies with Part 711 of this Title. The certification will be
made available for review at the next onsite survey conducted by the
department in accordance with article 28 of the Public Health Law. The
costs of any subsequent corrections necessary to achieve compliance with
the requirements of Part 711 of this Title, when the prior work was not
completed properly and was not accurately certified, shall not be
considered allowable costs for reimbursement under Part 86 of this Title. This
subparagraph does not waive any of the requirements of section 5-1.22 of
this Title.
Self-Certification
Self-Certification
Policy
•
The architectural self-certification process used for Limited Reviews includes all
administrative reviews and full reviews up to $15 million dollars in value.
•
The self-certification forms do not reduce or suspend the regulatory obligations of
the applicant. The facility is expected to meet all NYS codes and regulations, the
FMG 2010 Guidelines, the 2000 Life Safety Code, the NFPA codes and all other
codes listed in 711 (General Standards for Construction).
Self-Certification
Self-Certification and the Impact on BAER
Projects currently not allowed by Self-Certifications
•
•
•
•
•
•
•
•
•
Bulk Oxygen/Medical Storage
Surgical Renovations
New Ambulatory Surgical Centers
Gastrointestinal Endoscopy
Locked Units
Ventilator Units
Project Costs more than $15,000,000
Waiver Requests
The self-certification forms do not reduce or suspend the regulatory obligations of
the applicant. The facility is expected to meet all NYS codes and regulations, the
FMG 2010 Guidelines, the 2000 Life Safety Code, the NFPA codes and all other
codes listed in 711 (General Standards for Construction).
Self-Certification
Self-Certification Type Projects
Problematic Areas within Self-Certification
•
Each submission is unique and cannot be fashioned as a typical facility or design
due to there are hosts of influences that can affect how a building functions and
responds to those influences.
•
Typical problems with self-certification that spill over into AER:
•
Typically self-certification projects are very schematic or conceptual when
submitted and rarely are designed for compliance in a manner that is
acceptable.
•
Insufficient information is provided, at this stage. In order for this project to be
constructed, contract documents still need to be completed and submitted
to the local government for review and permitting. There is a very good
chance the plans will evolve and change from the original submission.
Self-Certification
Self-Certification and the Impact on BAER
Self-Certification Process Current Condition
•
Self-Certification typically has been an administrative function of processing and
with little to no oversight in regards to quality and substance of submission.
•
Typical problems with self-certification that spill over into AER:
•
No way to determine the quality of the submissions and how the outcome of
the project will be affected.
•
No accountability on several ends, including BAER, applicant and design
professional.
Self-Certification
Self-Certification and the Impact on BAER
Consequences of a Self-Certification that does not meet regulations
•
•
•
When issues occur at the pre-opening survey, requires addition resources to
research, review and provide a determination to what corrective action is
required.
•
Corrective actions may require the following:
•
Consideration of a waiver, whether it is time-limited or permanent.
•
Demolition and reconstruction of the area in question.
•
Additional Life-Safety Systems and equipment.
•
Additional off-setting Policy and procedures.
The significant difference though, between these two types of submission types it
costs more to make the corrections after construction has been performed versus
a change on a computer screen.
•
It could potentially delay the opening of the facility.
•
Additional costs maybe associated for redesign and build-out.
•
Lack of services to patientsLoss of revenue
•
Potential lawsuits for the A/E professional.
•
Put the occupants of the facility at risk.
•
Potential Audit of the project and related documents.
Self-Certification
Self-Certification and the Impact on BAER
Self-Certification Process Proposed Countermeasures
•
Review the regulations and determine how program can be strengthened by
clarifying regulations.
•
Develop policies and implement significant changes to what can be selfcertification and clearly define what is not eligible.
•
Involve the regional offices more.
•
Provide design guideline submission requirements as a minimum for self-certification
to include signed and seal checklist, authorized by both the by design professional
and applicant.
•
Expanding the internal control policy and standards.
•
Define scope and costs of self-certifications
•
Waivers associated with self-certification require review, establish criteria.
•
Develop audit program based on the three different facility types.
Self-Certification
Self-Certification and the Impact on BAER
Self-Certification Quick Facts
Costs Associated with Self-Certifications and Number of Self-Certifications
Projects under $100,000.00
Projects between $100,000.00 and $500,000.00
Projects between $500,000.00 and $1,000,000.00
Projects between $1,000,000.00 and $6,000,000.00
Projects between $6,000,000.00 and $15,000,000.00
Projects over $15,000,000.00
Total
Number
107
150
105
251
31
14
658
Issues Found During Survey- Self Certifications
Number
Surveys
Costs
Under $100,000.00
Between $100,000.00 and
$500,000.00
Between $500,000.00 and
$1,000,000.00
Between $1,000,000.00 and
$6,000,000.00
Between $6,000,000.00 and
$15,000,000.00
Self-Certification
28
Number
of
Surveys
w/issues
26
36
No. Issues NFPA
Cited
FGI
ADDAG
Other
129
39
32
4
55
26
164
44
44
3
69
31
11
128
83
13
3
24
75
19
368
131
72
17
167
4
4
35
27
4
0
0
Self-Certification and the Impact on BAER
Agenda Projects Current Condition
•
Agenda projects are associated with peak cycle times throughout the year.
During agenda periods agenda projects are a priority.
•
Scramble at the end of the cycle to review and develop reports.
•
Project review duration suffers.
•
Agenda Projects
Agenda or Contingent Projects and the Impact
on BAER
Agenda Projects Proposed/Revised Countermeasures
•
As soon a projects get assigned for contingent review.
•
Triaged by Bureau director and or Reviewer for compliance to the design
guideline submission requirements.
•
RFI goes out ASAP if missing information.
•
Projects for agenda are to be reviewed early on for resolution to ensure
placement on the agenda or receives a recommendation to be excluded
from the agenda. (Helps PMU develop reports earlier on to be used in the
Pre-PHHC planning meetings.
•
Standardization for reviews.
•
Provide whiteboard just for agendas/ separate from the other project types.
Agenda Projects
Agenda or Contingent Projects and the Impact
on BAER
Modification Process Current Condition
•
Modifications are a review process.
•
Not part of NYSECON
•
Not a formal submission to BAER?
•
Not tracked formally until recently.
•
No whiteboard for modifications.
•
Currently being reviewed for policy and procedure
•
Affects measurable time frames for other reviews. Not factored in, usually
becomes a priority if not reviewed in a timely manner.
•
This workload is not managed and no-one is accountable.
Modifications
Modifications and the Impact on BAER
Some of the tools used:
•
•
•
•
•
Effective Quality
Control
Design Guidelines
Code Review Checklist
Smart Boards
Peer review of documents
Training
•
Standardizing and sharing information can reduce errors.
NYSDOH Tools
DSG-01
Schematic Design Submission 30%
DSG-02
SHC/Hospital Design Development 60%
DSG-03
SHC/Out Patient Design Development 60%
3.9 Specific
Requirements
NYSDOH Internal Checklists