After years of consideration, the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission have adopted the 2012 edition of NFPA 101Life Safety Code, effective July 5, 2016. Overall, this is good news, since the 2012 edition reduces conflicts with other current building codes, such as the International Building Code (IBC). In its rule, the organizations adopt most of the 2012 NFPA: Health Care Facilities Code, sections with a few notable exceptions. One important exception that significantly affects healthcare designers is where patient room windows are required.

The requirement states that buildings must have an outside window or outside door in every sleeping room, and for any building constructed 60 days past the publication date, the sill height must not exceed 36 inches above the floor. Exceptions include newborn nurseries and rooms intended for occupancy for less than 24 hours. Special nursing care areas must have windows with sills not exceeding 60 inches above the floor. Windows into atrium spaces are allowable.

Once again, we have the conundrum of a patient (usually outpatient status) staying in a room for 23 hours—which would require an overnight stay, essentially making it “a sleeping room.” In 2014, CMS floated its first proposal of this exception that was far clearer, but the language did not survive in the final rule:

“Newborn nurseries and rooms intended for occupancy for less than 24 hours, such as those housing obstetrical labor beds, and recovery beds would be exempt from the window sill height requirement. The 2000 edition of the Life Safety Code allowed for observation beds in the emergency department to be exempt from the 36-inch window sill requirement. However, we do not propose to incorporate an exemption for observation beds, because they are frequently occupied for greater than 24 hours. Therefore, observation beds would be required to meet the 36- inch window sill requirement. Window sills in special nursing care areas, such as those housing an intensive care unit, critical care unit, hemodialysis, and neonatal patients, would not exceed 60 inches.”

So the questions are raised: How will this requirement be enforced? And how will this affect the design of short-stay units? Many observation, clinical decision, or universal care units are in design or under construction that are imbedded within the hospital, without windows, to allow for close proximity to adjacent feeder departments such as emergency, surgery, and special procedures. My previous blog, “Designing to Incorporate the Short-Stay Patient,” reviewed the competing interests of location for operational efficiency versus patients’ access to natural light and views. There is no shortage of compelling research on how natural light affects outcomes in hospitals, including reducing length of stay, improving sleep, easing pain, and improving the work environment. Enforcing a sill height at 36 inches means that outward views are also important. Yet it’s costly to increase building perimeter or provide atriums to allow for natural light into short-stay patient rooms, especially in this environment of decreased reimbursement for outpatient hospital stays.

There may be a middle ground. As I previously proposed, patients staying 12 hours or fewer, or those patients not staying overnight, don’t necessarily need a window. Sleeping rooms for less than 24-hour stays could have borrowed lights or simulated windows that represent day/night lighting conditions. Allowing immediate proximity to windows in a suite or an adjacent corridor could provide relief as patients begin to ambulate. For instance, the new universal care unit at Advocate Good Shepherd Hospital in Barrington, Ill., utilizes large skylights to infuse natural light in the patient room corridors. For me, waking up in the morning without any orientation to natural light and views to the outdoors is most disheartening, and certainly not conducive to healing.

It’s important that the Joint Commission and CMS clarify how they’ll be interpreting the latest federal rule so there is clear guidance on design parameters. As healthcare designers we should seek innovative, cost-effective solutions that create the best family and patient experience, regardless of code mandates.