- Life Safety Code (NFPA 101)
- The NFPA standard that protects building occupants from fire and smoke through egress, fire-rated construction, and occupancy rules; adopted by CMS.
- NFPA 99
- The Health Care Facilities Code — risk-based requirements for medical gas/vacuum, electrical safety, and gas equipment in healthcare occupancies.
- NFPA 70 (NEC)
- The National Electrical Code — the standard for electrical installation, including the essential electrical system and isolated power.
- NFPA 110
- Standard for Emergency and Standby Power Systems — governs testing and maintenance of the generator-based emergency power supply system (EPSS).
- NFPA 72
- National Fire Alarm and Signaling Code — installation, testing, and maintenance of fire alarm, detection, and notification systems.
- NFPA 25
- Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems — sprinklers, standpipes, and fire pumps.
- NFPA 241
- Standard for Safeguarding Construction, Alteration, and Demolition Operations — fire safety during construction in an occupied facility.
- CMS Conditions of Participation
- Federal requirements a hospital must meet to bill Medicare/Medicaid; the Physical Environment CoP adopts NFPA 101 and NFPA 99 by reference.
- Deemed status
- When CMS recognizes an accreditor (e.g., The Joint Commission) as proof a facility meets the Conditions of Participation.
- Statement of Conditions (SOC)
- The proactive document a hospital uses to manage and track Life Safety Code deficiencies and their correction plans; a key survey artifact.
- Interim Life Safety Measures (ILSM)
- Temporary, compensating actions (fire watch, signage, training) that keep occupants safe when a life-safety feature is impaired or during construction.
- Authority Having Jurisdiction (AHJ)
- The organization, office, or individual responsible for enforcing a code or standard or approving equipment, materials, an installation, or a procedure.
- CMS-enforced edition of NFPA 101
- CMS currently enforces the 2012 edition of the Life Safety Code (and NFPA 99) for healthcare occupancies.
- Means of egress
- A continuous, unobstructed path of travel from any point in a building to a public way; a core requirement of NFPA 101.
- Defend-in-place
- The hospital fire strategy of protecting occupants by moving them horizontally through smoke barriers rather than fully evacuating the building.
- Smoke compartment (new hospital)
- Under the 2012 Life Safety Code, a smoke compartment in a new hospital may not exceed 22,500 square feet.
- Fire watch trigger (fire alarm out)
- Per NFPA 101 (2012), a fire watch or evacuation is required when a fire alarm system is out of service more than 4 hours in a 24-hour period.
- Fire watch trigger (sprinkler out)
- Per NFPA 101 (2012), a fire watch or evacuation is required when an automatic sprinkler system is out of service more than 10 hours in a 24-hour period.
- OSHA Hazard Communication Standard
- Requires identifying hazardous chemicals, labeling, an SDS for each, and worker training; underpins safe chemical handling in a hospital.
- Safety Data Sheet (SDS)
- A standardized document detailing a chemical's hazards, handling, and protective measures; must be readily accessible to staff every shift.
- OSHA Bloodborne Pathogens Standard
- Requires an exposure control plan, engineering controls, PPE, and training to protect workers from blood-borne infectious materials.
- RCRA pharmaceutical waste (Subpart P)
- EPA rules governing how healthcare facilities accumulate, label, and dispose of hazardous pharmaceutical waste.
- Regulated medical waste
- Sharps and infectious waste that must be segregated, contained, and treated separately from general trash under state rules.
- ADA minimum doorway clear width
- 32 inches of clear width is the minimum for doorways accessible to wheelchair users under the ADA.
- Safe Medical Devices Act
- Requires healthcare facilities to report adverse events (deaths/serious injuries) related to medical device use to the FDA and/or manufacturer.
- NFPA 99 risk categories
- A risk-based approach (Category 1–4) where requirements scale with the harm a system failure would cause to patients and staff.
- CMS time-limited waiver
- When a hospital cannot immediately correct a Life Safety Code deficiency, CMS may grant a time-limited waiver if patient safety is not jeopardized.
- Bill of quantities
- A construction document specifying the quantity, quality, and description of materials and work needed for a project.
- Stakeholder analysis
- Identifying all parties affected by a project and their level of influence so the team can plan communication and manage expectations.
- Risk register
- A living document that logs identified project risks, their likelihood and impact, owners, and planned responses.
- Critical path method (CPM)
- A scheduling technique that finds the longest sequence of dependent tasks, setting the shortest possible project duration; delays here delay the project.
- Float (slack)
- The amount of time a non-critical task can slip without delaying project completion; critical-path tasks have zero float.
- Gantt chart
- A visual bar-chart schedule showing project tasks against a timeline, with start/finish dates and overlaps.
- Earned Value Management (EVM)
- A technique that integrates scope, schedule, and cost to measure project performance and progress against the plan.
- RACI chart
- A responsibility matrix clarifying who is Responsible, Accountable, Consulted, and Informed for each project task.
- Scope creep
- Uncontrolled expansion of project scope without adjustments to time, cost, or resources — a leading cause of overrun.
- Change control board
- The group that reviews and approves or rejects proposed changes to a project's scope, schedule, or budget.
- Design-bid-build
- A traditional delivery method where design is fully completed, then the project is bid and built by a separate contractor.
- Design-build
- A delivery method placing design and construction under a single contract, allowing overlap and earlier cost certainty.
- CM-at-risk
- A delivery method where a construction manager commits to a guaranteed maximum price and manages the build, joining during design.
- Infection Control Risk Assessment (ICRA)
- A multidisciplinary process matching the type of construction activity to nearby patient risk to set required containment precautions (Class I–IV).
- ICRA precaution classes
- Class I–IV containment levels that escalate with patient vulnerability and the dust/disruption of the construction activity.
- Pre-Construction Risk Assessment (PCRA)
- A Joint Commission-required assessment of air quality, infection control, utility needs, noise, vibration, and other hazards before construction.
- FGI Guidelines
- The Facility Guidelines Institute's Guidelines for Design and Construction — the primary U.S. reference most states adopt for healthcare facility design.
- Commissioning (Cx)
- The process of verifying that building systems are installed and perform per the design intent and Owner's Project Requirements.
- Owner's Project Requirements (OPR)
- The document recording the owner's functional needs and expectations that drives the design and commissioning of a facility project.
- Pre-functional checklist (PFC)
- A commissioning document verifying equipment is properly installed and ready before functional performance testing begins.
- Construction-phase ILSM rounds
- Routine rounds checking barrier integrity, signage, and fire-safety measures to keep an occupied facility safe during construction.
- ASHE ICRA 2.0
- An updated ICRA process combining the type of construction activity (dust generated) with the risk group of affected patients to set precautions.
- Fishbone (Ishikawa) diagram
- A cause-and-effect quality tool used to identify the root causes of a problem in a project or process.
- Preventive maintenance (PM)
- Scheduled, time- or usage-based servicing performed to prevent failure; the compliance baseline, documented in the CMMS.
- Predictive maintenance (PdM)
- Condition-based maintenance using monitoring (vibration analysis, thermography, oil analysis) to act only when a fault is developing.
- Reliability-centered maintenance (RCM)
- A strategy that assigns the best maintenance approach to each asset based on its function and the consequence of its failure.
- Run-to-failure (reactive)
- Repairing equipment only after it breaks; acceptable only for non-critical, easily replaced assets.
- CMMS
- Computerized maintenance management system — software that schedules, tracks, and documents work orders, PM, assets, and inventory.
- Infrared thermography
- A predictive technique using thermal imaging to find hot spots in electrical and mechanical systems that signal impending failure.
- Vibration analysis
- A predictive technique that detects bearing wear, misalignment, and imbalance in rotating equipment before failure.
- Building Automation System (BAS)
- A centralized control system that monitors and automates HVAC, lighting, and utilities, reducing manual intervention.
- Variable Frequency Drive (VFD)
- A motor controller that varies fan/pump speed to match load, sharply reducing the electrical consumption of HVAC motors.
- Negative pressure (AII room)
- An airborne-infection-isolation room kept negative to adjacent spaces so airborne pathogens (e.g., TB) stay contained.
- Positive pressure (PE/OR)
- A protective-environment room or operating room kept positive to adjacent spaces so contaminated air does not flow in.
- ASHRAE Standard 170
- The standard for ventilation of healthcare facilities — sets air changes per hour, pressure relationships, temperature, humidity, and filtration by space.
- Operating room air changes
- Per ASHRAE 170, a new operating room requires a minimum of 20 total air changes per hour.
- AII room air changes
- Per ASHRAE 170, an airborne-infection-isolation room requires a minimum of 12 air changes per hour, negative to surrounding spaces.
- MERV rating
- Minimum Efficiency Reporting Value — rates an air filter's efficiency; higher-acuity hospital spaces require higher-MERV final filters.
- HEPA filtration
- High-efficiency particulate air filtration (≥99.97% of 0.3-micron particles) used in protective-environment rooms and other critical spaces.
- Water management program
- A documented plan (per ASHRAE 188 / CMS) to control Legionella by mapping the water system, setting control limits, and monitoring temperature/treatment.
- ASHRAE 188
- The standard for Legionellosis risk management for building water systems; the basis for a hospital's water management program.
- Backflow prevention device
- A plumbing device that prevents reverse flow and contamination of the clean potable water supply.
- Essential electrical system branches
- Under NFPA 99/110, the three branches are life safety, critical, and equipment; life safety and critical restore power within 10 seconds.
- Automatic transfer switch (ATS)
- A device that automatically transfers a hospital's load from utility power to the emergency generator within 10 seconds of an outage.
- Generator weekly inspection
- Under NFPA 110, the emergency generator set is inspected weekly to verify readiness.
- Generator monthly load test
- Under NFPA 110, the generator is exercised under load monthly for at least 30 minutes at a minimum of 30% of nameplate kW.
- Generator triennial load test
- Per NFPA 110, an extended (3-hour) load test is required every 36 months to confirm the EPSS can carry the load over time.
- Medical gas zone valve box
- A valve box located outside a patient-care area used to shut off oxygen or other medical gas to a single zone during an emergency.
- Medical gas area alarms
- Per NFPA 99, area alarm panels monitor medical gas pressure for anesthetizing locations and Category 1 patient-care areas.
- Surge protection device (SPD)
- A device that protects hospital electrical equipment from damaging voltage spikes and transients.
- Arc flash study interval
- Arc flash labels/study should be reviewed at least every 5 years or whenever a major electrical system modification occurs.
- Domestic hot water temperature
- The recirculation loop is kept at or above ~124°F as part of Legionella control in the water management program.
- Load bank testing
- Applying an artificial load to a generator to verify it can handle its designed load and to prevent wet stacking.
- Fire damper testing interval
- Fire and smoke dampers in hospitals may be tested every 6 years (versus every 4 years in non-hospital occupancies).
- UV-C disinfection
- Ultraviolet germicidal irradiation used to reduce airborne and surface pathogens, supplementing infection-control measures.
- Net present value (NPV)
- Discounts all future cash flows to today's dollars at the cost of capital; a positive NPV adds value — the preferred capital metric.
- Internal rate of return (IRR)
- The discount rate that makes a project's NPV zero — its effective yield; accept when it exceeds the hurdle rate.
- Payback period
- The time needed to recover the initial investment; simple but ignores the time value of money and cash flows after payback.
- Return on investment (ROI)
- Net benefit divided by cost, expressed as a percentage; a quick comparison metric with no time dimension.
- Life-cycle cost analysis (LCCA)
- Total cost of owning an asset over its life — purchase plus energy, maintenance, downtime, and disposal; guides repair-vs-replace.
- Total cost of ownership (TCO)
- The full cost of an asset including purchase price and all ongoing operating costs like service contracts and energy.
- Capital budget
- The plan for long-lived assets and projects above the capitalization threshold; these are depreciated, not expensed.
- Operating budget
- The plan for recurring day-to-day expenses — labor, utilities, supplies, and service contracts.
- Capitalization threshold
- A dollar policy (e.g., $5,000) above which a purchase is capitalized and depreciated; below it, the item is expensed.
- Depreciation
- Allocating an asset's cost over its useful life to reflect loss of value; not a cash outflow since the cash was spent at purchase.
- Straight-line depreciation
- Spreading an asset's depreciable cost evenly across its useful life (e.g., a $500,000 boiler over 20 years = $25,000/year).
- Double-declining-balance depreciation
- An accelerated method recording larger depreciation expense in an asset's early years.
- Budget variance analysis
- Comparing actual spending to the budget to explain and act on differences (e.g., utility spend over forecast).
- Quick ratio
- A liquidity measure (current assets minus inventory, divided by current liabilities) indicating ability to meet short-term obligations.
- Scenario analysis
- Evaluating the financial impact of varying operating assumptions to test a project's sensitivity and risk.
- Cash flow analysis
- Monitoring cash inflows and outflows to assess a facility's or project's liquidity and financial health.
- Lease vs. buy analysis
- Comparing the total financial impact of leasing versus purchasing equipment, considering cost of capital, tax, and useful life.
- Environment of Care (EC)
- The Joint Commission framework for managing the physical hospital safely across safety, security, hazmat, fire/life safety, medical equipment, and utilities.
- Six EC management plans
- Safety; Security; Hazardous Materials & Waste; Fire/Life Safety; Medical Equipment; and Utility Systems — each needs a plan and annual evaluation.
- EC annual evaluation
- A yearly review of each management plan's scope, objectives, performance, and effectiveness — a required deliverable for surveyors.
- Emergency Operations Plan (EOP)
- The document defining a facility's all-hazards response and recovery; updated at least annually to reflect changes.
- Hazard Vulnerability Analysis (HVA)
- A tool that identifies potential emergencies and ranks them by probability and severity to prioritize preparedness; reviewed at least annually.
- Four phases of emergency management
- Mitigation, preparedness, response, and recovery — the all-hazards cycle a hospital's program must address.
- After-action report (AAR)
- A post-exercise or post-incident review documenting gaps and improvements; drives updates to the HVA and EOP.
- Safety committee
- The interdisciplinary group that receives environmental risk reports, reviews EC plan evaluations, and recommends corrective actions.
- Environmental rounds
- Regular tours of the facility to identify safety hazards and compliance issues, with findings reported to the safety committee.
- Transformational leadership
- A leadership approach that inspires and motivates a diverse team toward a shared vision — effective for managing facility staff.
- Strategic facility plan
- A long-range plan aligning the facility's space, infrastructure, and capital investment with the organization's mission and regulatory needs.
- Integrated facility management
- Coordinating facility functions and data on one platform to improve interdisciplinary communication and decision-making.
- Performance metrics (facilities)
- Measurable indicators tracked over time and reported to leadership — e.g., percentage of PM work orders completed on time.
- Policy and procedure
- A document providing consistent, repeatable guidance for responding to a situation (e.g., a utility failure), ensuring a uniform response.
- 2026 Joint Commission consolidation
- For the 2026 cycle, TJC consolidated the physical-environment standards into two chapters: Physical Environment and Emergency Management.
- Ligature risk assessment
- An evaluation of the physical environment (in behavioral health) to identify and remove features a patient could use for self-harm.
- Data analytics in facilities
- Using operational data to improve decision-making — energy optimization, predictive maintenance, and resource planning.
- Vendor contract negotiation
- Prioritizing total value and long-term partnership incentives — not just lowest price — when contracting facility services and supplies.
