THE BLUE TAPE SOLUTIONThere is a piece of blue tape on the floor about six feet from the admissions counter with a sign that asks people to stay behind the line, for the privacy of people at the counter. Aside from that, there isn’t anything I could see that might help someone feel more comfortable talking about personal health issues while a throng of people stand within earshot just a few feet away.
Speech privacy in healthcare facilities is an issue that has long frustrated designers and facility owners. How much privacy? Where is it needed? How is it measured? The frustration began in 1996 when Congress began to define healthcare speech privacy by enacting the Health Insurance Portability and Accountability Act (HIPAA). In 2000 the Department of Health and Human Services attempted to further clarify HIPAA speech privacy requirements in Section 164.502 of the Federal Register’s final ruling on Standards for Privacy of Individually Identifiable Health Information, which states:
“Protected Health Information includes individually identifiable information in any form, including information that is transmitted ORALLY, or in written or electronic form. This Privacy Ruling requires that covered health care entities make reasonable efforts to limit the use or disclosure of protected health information to the minimum necessary.”
Unfortunately, this is as concise as it gets. HIPAA establishes broad requirements for speech privacy and HHS goes a little further in helping to clarify them, but ultimately, HIPAA relies on the industry to establish anything more specific, or measurable. The definition of “oral privacy” is accepted among industry professionals and found in consensus-based standards as being achieved when the measured Articulation Index (AI) is less than 0.20. According to Jodi Jacobs of Lencore Acoustics Corp., the Office for Civil Rights (OCR), the enforcement arm of HIPAA, has accepted this as a measurement of compliance with the law.
OCR gets involved with a healthcare facility when a complaint is filed. They investigate and make rulings based on their discoveries. Penalties for non-compliance can include hefty fines (up to $250,000) and imprisonment! In an article titled “Oral Privacy and HIPAA-We Really Need to Talk,” Jacobs writes that meeting HIPAA oral privacy standards “… can be as simple as implementing a common-sense approach to speech privacy. In fact, you may be able to meet the new privacy standards by applying a two-part solution that is straightforward and time-tested.” She goes on to say that a combination of a high quality ceiling tile and sound masking installed in the area between the ceiling tile and the deck has been used successfully to satisfy HIPAA requirements in several cases.
ACOUSTICS, HEALTHCARE AND LEEDIn November 2007 the U.S. Green Building Council (USGBC) released the LEED for Healthcare Rating System for public comment. One round of public comment has been completed.
Included in the rating system is a proposed Indoor Environmental Quality Credit 2: Acoustic Environment: Exterior Noise, Acoustical Finishes & Room Noise Levels. The intent of the credit is to “Provide building occupants with an indoor healing environment free of disruptive levels of sound.”
The credit makes reference to HIPAA, but there is no requirement to comply with it. Instead, the credit requires compliance with four sections of a 2006 AIA/AHA document titled “Draft Interim Sound and Vibration Design Guidelines for Hospital and Healthcare Facilities,” hereafter referred to as simply the “Guidelines.” The Guidelines go far and above anything currently found in HIPAA and offers explicit prescriptive and performance-based recommendations in achieving optimal acoustical performance in healthcare facilities.
There are two “options” teams can pursue under this proposed credit; Option 1 addresses speech privacy and room noise levels, while Option 2 deals with acoustical finishes and exterior noise. Meeting the requirements for a single option earns a single point, two points are available for meeting the requirements of both.
Teams that elect to pursue speech privacy requirements of the proposed credit will need to design the facility to meet criteria for enclosed rooms, open plan spaces, and sound isolation between rooms in accordance with the Guidelines tables 4-3, 4-4, and 4-1 respectively.
Tables 4-3 and 4-4 establish minimum acceptable values measured in terms of Articulation Index, Privacy Index, Speech Transmission Index, and Speech Intelligibility Index. The requirements are different depending on the speech privacy goal type: normal, confidential, or secure.
Table 4-1 establishes requirements for STC ratings of partitions between various types of room adjacencies; patient room to patient room, exam room to public space, toilet room to public space, etc. The STC values range from a low of 35 to a high of 60, depending on adjacency.
Room Noise Levels
The credit establishes a straightforward requirement for room mechanical system noise levels in accordance with Table 3-1, Recommended Criteria for Noise in Interior Spaces. The table lists several room types with a corresponding range of acceptable mechanical system noise levels.
In satisfying requirements of this part of the credit, design teams are required to select room finish materials with sound absorption coefficients that result in whole room sound absorption values established in Table 2.3-1. Spaces are listed by type with recommended room sound absorption coefficients ranging from 0.15 to 0.25. A mathematical calculation is provided that can be used to determine a room’s sound absorption using material sound absorption coefficients and the surface area of walls, ceiling and floor. An example is provided illustrating a 10 by 10 by 10-foot painted concrete room with a sound absorption coefficient of 0.01 and changing the ceiling from concrete to an acoustical ceiling panel system with a sound absorption coefficient of 0.90, resulting in a room sound absorption coefficient of 0.16.
The fourth and final part of the credit addresses unwanted exterior-to-interior noise transmission and requires that the building envelope (including closed windows) be designed to specific STC ratings depending on exposure category and percentage of window area. The closer the building is to noise sources such as highways, airports, and railways the higher the STC requirement for the exterior walls. The same is true for the higher the window area as a percentage of total wall area. STC values for exterior walls range from a low of 35 to a high of 50.
Each of the four parts of the proposed credit--Speech Privacy, Room Noise Levels, Acoustical Finishes, and Exterior Noise--requires commissioning to verify that the required design criteria has been met. Without the commissioning, the points cannot be acquired. The testing criteria required is based on ANSI and ASTM standards, all of which are well understood, and used frequently by acoustical consultants.
Bill Stewart, President of SSA Acoustics, a Seattle-based acoustical consulting firm, likes what he sees in the proposed LEED for Healthcare Acoustics credit, but wonders how realistic it really is. Using a hypothetical 50-room healthcare facility as an example, he walked through each of the four parts of the proposed credit and calculated the necessary staff and hours required to conduct the required testing at commissioning. His rough calculation was a staggering $25,000 minimum. That’s assuming all goes well; everything passes the first time, the contractor is completely cooperative and ready for the testing, the weather is favorable, etc. “The way to improvement is not to set such a high standard. It simply is not going to happen. This is something that, in a meeting with clients and designers, will be value-engineered right out of the project,” says Stewart.
Setting the Bar Too High?
One of the USGBC’s goals is to “Encourage and accelerate global adoption of green building practices through LEED standards, tools and performance criteria.” While HIPAA requirements for speech privacy in healthcare settings are vague and largely unenforceable, the new proposed LEED for Healthcare credit is something that appears to be achievable only for the wealthiest of facility owners. According to Stewart, the criteria are correct, the goals laudable. The credit as written is an all-or-nothing prospect; all criteria must be met for all rooms and all of it commissioned.
Is there nothing in between? Encouraging and accelerating adoption of green building practices necessitates a certain amount of crawling before breaking into a full-out sprint. If there is no incentive for the majority of users to pursue the credit, it actually becomes a disincentive and counts against a project due to the impossibility of acquiring the points, hardly a hallmark of encouragement and acceleration.
Because LEED for Healthcare has not yet been balloted by the membership, there may still be time to get it right. According to the USGBC Web site, a second public comment period will follow the first. There is opportunity yet to provide comments that will encourage the USGBC to consider easing some of the requirements of the credit to allow more facilities to pursue it. Some of my offerings would be:
• How about credit for addressing only critical areas such as reception, waiting, and other public spaces?
• Instead of commissioning as a requirement in achieving these points, why not move it into an additional commissioning credit and provide additional points for it there? This would be consistent with the way commissioning is currently addressed in LEED rating systems.
• For field testing, allow a slightly lower value than lab tested STC ratings, as the current International Building Code does for dwellings.
• How about half-point increments to allow teams to tackle smaller portions of the credit?
If the credit is balloted by the membership as is, I expect that the tape on the floor telling me where to stand will be there for a very long time.