Health Facility Commissioning

What is health facility commissioning?

The ASHE Health Facility Commissioning Guidelines (HFCx Guidelines) defines “commissioning” as a process intended to assure that all building systems in a facility, including sustainable building technologies, are installed and perform in accordance with the design intent, that the design intent is consistent with the owner’s project requirements, and that operations and maintenance staff are adequately prepared to operate and maintain the completed facility. The LEED-New Construction (NC) Reference Guide states that “a commissioned building provides optimized energy efficiency, indoor air quality and occupant comfort” and goes on to say that “conventional commissioning has limited the focus to HVAC systems but that coordinating other building sustainable design systems in the commissioning process results in higher performance, sustainable buildings.”

Despite advocacy for commissioning, the process is not always followed and many buildings designed for high performance fail to achieve high-performance results.

Register for ASHE's health facility commissioning course to gain respected industry knowledge. For the list of upcoming sessions, course descriptions, pricing, and registration, visit the ASHE website for more information.

The American Society for Healthcare Engineering (ASHE) is convinced that commissioning is critical to the success of every health care facility project and thus developed the Health Facility Commissioning Guidelines to help health care organizations achieve the facilities they want. Similarly, the Sustainability Roadmap is focused on tools that can be used to improve the cost-effectiveness, quality, satisfaction, and environmental performance of health care facilities. Commissioning is fundamentally in alignment with these objectives. To that end, the Roadmap’s performance improvement measures (PIMs), where appropriate, link to specific and targeted commissioning and retrocommissioning topic areas found in the ASHE Health Facility Commissioning Guidelines.

Understand the Meaning of “Green Buildings,” LEED® Certification, and Commissioning

Due to a number of factors – including the current health care business environment, diminishing fossil fuel supplies, escalating and volatile energy costs, global warming concerns, and a fragile electricity transmission grid – a growing percentage of the population now supports sustainable design and construction initiatives, which focus on stewardship of natural and fiscal resources. Many in the health care industry believe that a societal “tipping point” has been reached regarding the importance of green initiatives, and health care facilities often elect to employ sustainable design and construction practices on their projects.

A widely recognized indication of sustainable design and construction practices is LEED certification. LEED is an acronym for Leadership in Energy and Environmental Design, a sustainability rating system for buildings developed and promoted by the U.S. Green Building Council (USGBC). In recognition of the environmental benefits of commissioning, a minimum level of commissioning activity – referred to as “fundamental commissioning’ of building energy systems – is a prerequisite for LEED certification.

It should be noted that a LEED® rating by itself does not ensure superior energy efficiency. A 2008 USGBC study of 121 new buildings certified through 2006, reported in The New York Times on August 31, 2009, found that 53 percent of LEED-rated buildings would not qualify for the EPA Energy Star label and, perhaps even more alarmingly, 15 percent scored below 30 in the Energy Star program, indicating they are less efficient than 70 percent of comparable buildings. These statistics demonstrate that LEED certification and its fundamental commissioning prerequisite are not sufficient to ensure delivery of a high-performance building. Additional steps, including measurement and verification of actual building performance and ongoing commissioning, are required.

Understanding the commissioning and retrocommissioning processes described in the ASHE Health Facility Commissioning Guidelines and Health Facility Commissioning Handbook can help you improve the performance of your facility’s next construction project. In addition, these commissioning principles can be applied to facility operations as well. Using the PIMs to help implement specific actions can help an organization apply commissioning ideas to maximize performance of building operations.

It is time to make commissioning a standard part of every health care facility project, regardless of size or cost. The ASHE health facility commissioning process can help you optimize delivery of your next construction or renovation project and can improve your operations.

For more information on commissioning, read the description of the process below. Also, visit the Roadmap page on Building Design and Construction under the Topics tab.

Developing a Commissioning Business Plan

In developing commissioning goals, it is sometimes helpful to consider goals the C-suite would want to address, such as patient safety, increased market share, space use, return on investment, safe staffing levels, reduced infection rates, and patient and visitor satisfaction.
A commissioning business plan should cover the following:

  1. Executive summary and table of contents
  2. Current plan
  3. SWOT analysis
  4. Goals
  5. Business strategies
  6. New service programs
  7. Financial projections
  8. Quality control

Sample Business Strategy
Grow a sustainable culture and workforce that supports commissioning through daily work regimens and continuous, batch, and job order processes.

  • Objective #1: Institute standardized task training to assure optimal equipment performance as documented in the computerized maintenance management system (CMMS).
  • Objective #2: Develop key quality indicators that reflect desired outcomes as established in the basis of design (BOD) and assure that system reliability meets expectations.
  • Objective#3: Develop an incentive-based award system to assure that ongoing compliance with the BOD exceeds expectations.

Systems to Consider for Commissioning
Below is an index of the major categories of systems to be commissioned. For more details, view the more detailed sub-category list on the Roadmap.

  1. Building envelope
  2. Life safety systems
  3. HVAC systems
  4. Controls
  5. Plumbing systems
  6. Medical gas systems
  7. Electrical systems
  8. Fire alarm systems
  9. Information technology
  10. Fire protection system
  11. Interior lighting
  12. Exterior lighting
  13. Refrigeration
  14. Vertical transport
  15. Material handling

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Selecting a Health Facility Commissioning Authority

The health facility commissioning authority (HFCxA) should be selected and engaged at the very outset of a project. Early engagement of the agent facilitates timely HFCx design reviews and allows opportunities for input as the design evolves, well before extensive effort is expended on one specific design.

Commissioning is a professional service that should be delivered by a firm with training and expertise in providing commissioning services. The selection of a HFCxA should be based on qualifications that include key personnel, references, and experience. The necessary skill sets are defined in the owner’s commissioning project requirements. You should note that commissioning project requirements are separate from requirements regarding professional engineering services, and that contracting for those services is left to the discretion of the owner. A suggested process for selecting a HFCxA includes the following steps:

  1. Establish an experienced selection committee.
  2. Provide a common basis for HFCxA selection (e.g., a request for qualifications)
  3. Short-list qualified HFCxAs.
  4. Interview qualified HFCxA candidates.
  5. Make the selection.
  6. Negotiate the HFCxA fee and contract.

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Design Phase Commissioning

The selected HFCxA should organize and attend a pre-design conference at the beginning of the design phase of a project. Persons attending the conference should include, at minimum, the representatives of the owner (including user-group representatives), the architect, the engineer, and the contractor team (if engaged at this stage of the process). For the conference to be productive, the representatives must have the authority to make decisions on behalf of the organizations (including the owner) they represent.

The commissioning process for the project is established at the predesign conference, including specific roles and responsibilities for each individual and firm involved. The HFCxA should prepare an agenda for the meeting and forward it to all parties well in advance of the conference.

Commissioning Objectives

  • Set project energy efficiency goals.
  • Facilitate development of the owner’s project requirements (OPR).
  • Facilitate development of the basis of design (BOD) for systems to be commissioned.
  • Review the OPR and BOD.
  • Review the schematic design documents.
  • Develop the commissioning plan.
  • Prepare the commissioning specifications.
  • Review the design development documents.
  • Review the HVAC control system sequences of operations.
  • Review the emergency generator load priorities and sequence of operations.
  • Review construction documents.
  • Update the commissioning plan and commissioning specifications.
  • Facilitate development of the utility management plan.
  • Attend the pre-bidding conference.

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Construction Phase Commissioning

After the bidding and pricing of a construction project is complete, but before construction begins, the HFCxA should organize a commissioning conference. The HFCxA, owner, contractor, subcontractors, and design team meet to review the commissioning plan and commissioning specifications to make certain all parties fully understand the process and their assigned roles and responsibilities. In particular, the process for submittal review and approval established in the project manual and the commissioning specifications should be reviewed.

Commissioning Objectives

  • Develop and maintain the issues log.
  • Review submittal data and shop drawings.
  • Review operations and maintenance (O&M) manuals.
  • Conduct commissioning meetings.
  • Attend selected project meetings.
  • Lead O&M staff construction site tours.
  • Complete pre-functional checklists and inspections.
  • Review HVAC control system programming.
  • Review emergency power system programming.
  • Witness equipment and systems startup.
  • Review TAB (testing and balancing) report.
  • Witness functional performance tests.
  • Facilitate pressure testing.

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Transition to Operational Sustainability

Many health care facilities have significantly reduced their maintenance staffing levels and budgets in recent years. In fact, staffing levels for skilled crafts and trades (e.g., electricians, plumbers, HVAC technicians, and controls instrument technicians) are shockingly low. As a result, health care facility managers can no longer solely rely on qualified staff to maintain complex equipment and systems. Rather, they must depend to some extent on technology to detect inefficiencies and provide guidance for optimizing operations.

Commissioning Objectives

  • Develop O&M dashboards.
  • Facilitate maintenance staffing training.
  • Facilitate implementation of HVAC control system trends.
  • Prepare the commissioning report and systems manual.
  • Facilitate development of the maintenance budget.
  • Facilitate fire and smoke damper inspections and testing.
  • Facilitate completion of the statement of conditions (SOC).
  • Facilitate development and implementation of the building maintenance program (BMP).

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Postoccupancy and Warranty Phase

After a construction project has been completed and the space is occupied, and once the building systems have been subjected to actual load conditions, facility managers look at data trends for information that indicates ways system operations can be optimized for both building comfort and energy management. By integrating trend data into the O&M dashboards, vital real-time feedback can be obtained. The HFCxA can assist the staff in interpreting the trend data and making adjustments to optimize performance.

Commissioning Objectives

  • Review trend data.
  • Measure and verify actual energy performance.
  • Conduct postoccupancy owner training.
  • Conduct postoccupancy performance tests.
  • Participate in the end-of-warranty review.
  • Benchmark energy performance.

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Retrocommissioing is a systematic process that identifies low-cost operational and maintenance improvements in an existing building that has not previously been commissioned. As in the commissioning process for new construction, a HFCxA should lead the effort. The HFCxA should work in conjunction with O&M personnel to identify energy-consuming systems and develop items of work that will optimize building performance. They may also discuss ways to continue the commissioning process on an ongoing basis by using a tool such as Continuous Commission®. Chapter 6 of the Health Facility Commissioning Guidelines has a full description of retrocommissioning, and the Health Facility Commissioning Handbook provides in-depth information on the subject.

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Sample Tools

For more information about health facility commissioning, see the ASHE commissioning publications: Health Facility Commissioning Guidelines and the supporting document Health Facility Commissioning Handbook.

Table of contents for both books:
Part 1: An Introduction to Health Facility Commissioning
Part 2: The Health Facility Commissioning Process

Chapter 1: Predesign Phase
Chapter 2: Design Phase
Chapter 3: Construction Phase
Chapter 4: Transition to Operational Sustainability
Chapter 5: Post-occupancy and Warranty Phase
Chapter 6: Retrocommissioning


Sample tools from the HFCx Guidelines:

  • Sample Commissioning Request for Proposals
  • Sample Commissioning Contract
  • Sample Owner’s Project Requirements for Health Care Facilities
  • Sample Basis of Design Document

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Contact us to write a case study on your commissioning success or failure. What do you think about the connection between commissioning and sustainability?

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