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Surmounting the frustrations of building codes.

More and more, admistrators of facilities that serve older people are challenging the appropriateness of the rules and regulations under which they must operate. The reasons are obvious: Residents are older, more frail, more confused and more difficult to manage. Recruiting and retaining high quality staff has become increasingly difficult and more costly. Reimbursements are based on government's ability to pay for needed services and have little or no relationship to quality of care or the needs of residents. Finally, regulations based on archaic assumptions, lack of research and Obsolete technologies have been used to establish the maximum level of care, rather than the minimum level.

As examples of the recently more aggressive attitude toward outdated regulations:

In Michigan, the maximum are allowed per bed has been increased. This followed an effort by providers to demonstrate that the previous regulations, which limited, for example, wheelchair access about the rooms, forced residents to become more dependent on the nursing staff to move about. The regulations had not only created dependency, but increased the costs of nursing care.

In other similar developments:

* New York has recently initiated a demonstration program creating an incentive for providers to find new and innovative ways to provide higher quality, cost-effective nursing care.

* Maryland is presently reviewing its nursing home regulations in an attempt to make them more appropriate and performance-based.

* The American Association of Homes for the Aging has established the AAHA Clearinghouse on Aging and Environmental Design Codes (see box). The Clearinghouse is made up of an expanding national network of providers, designers, regulators and researcher. They are collaborating on creating an information resource on issues of aging, environmental design and codes that will be made available to those individuals or sponsors that are interested in finding relief from burdensome building regulations.

As examples of such regulations that are being challenged or that demand rethinking based on research and new technology:

Even though the mandated distance between nursing station and the resident rooms is too far for effective staffing, there is a reluctance in many states to allow sub-staff stations that allow the caregivers to be located closer to the residents they serve.

The ratio of beds per bathing unit is often inappropriate, when you consider the efficiency of new bathing systems and availability of staff to bathe more than several residents at the same time. As a result, many more bathing units are built than can be staffed or are necessary. These extra units end up becoming very expensive storage areas.

One state says nursing beds must be parallel to the windows while another state requires beds to be perpendicular to the windows. Neither makes any sense, but they are requirements, nevertheless.

* Most accessibility codes that dictate environments for older people were not designed to address the needs of the frail elderly and, in many cases, are inappropriate and create barriers for these residents.

It would be easy to list many more instances of regulation that make little sense or that obstruct effective design and operational solutions. For now, though, it is more constructive too suggest appropriate ways to facilitate change or, at least, work within the system as it exists.

The best strategy for dealing with review agencies is to make them a part of the design team at the earliest possible stage of development. Reviewing authorities are more likely to approve a projector a concept that they are familiar with, that evolved with their help, and where they understand what you are trying to do and why it is important. The following ten strategies can be used as a checklist when establishing your approach to requesting regulators to grant a variance or to waive a requirement.

1. Know the Regulations - It is important for you and your architect to know the requirements of the regulations. Sometimes they will allow you to do what you want to do within the rules. For example, one provider wanted an activity room to be easily accessible to residents by eliminating the doors to the corridor. This was accomplished without code change by configuring the corridor space outside the activity space so that it was not part of the egress system. Therefore, no walls or doors were required to separate the activity room from the actual corridor.

2. Understand the Review Process - Know when and to whom to talk, and follow established channels. The person you circumvent could be the one you need to approve your project later. By knowing the review process, you can allow, adequate time for preparation. 3. Start with a One-On-One Meeting - Get to know who you are dealing with, and build a relationship that can help you now and in the future. Do not treat regulators as adversaries. Try to build a team relationship. 4. Do No Overload with information on First Meeting - Spend more time asking questions about the issues. Find out the regulator's agenda. Several short meetings can be more effective than one marathon meeting. The intervals between meetings provide time to build on previous successes or to modify your strategy if necessary. Look for areas of agreement and then build on them. 5. Take Time to Educate - But Do Not Lecture - Help them understand the results you are trying to achieve and why. Many regulators know what the rules say, but may lack insight into why it exists or how it came into existence. A little research on your part can help give them insight that might prove helpful to you. 6. Do Not Take Fully Developed Plans - Plans that are final or appear too developed do not leave room for adjustments without great expense. Early concept sketches allow for much more flexibility and innovative thinking. 7. Make It Easy For Regulators To Give Favorable Rulings - Find comparable situations in other states showing that what you want to accomplish has been successful elsewhere. Conduct surveys to obtain data to support your request. Use data from Post-Occupancy Evaluations. 8. Show How You Can Meet The Regulations But Not The Need - Use diagrams and videos to show the problems residents and staff experience in real-life situations. Invite regulators to inspect full-size mock-ups of proposed ideas. 9. Show the Benefits of the Proposed Approach - Show how money will be saved in first costs as well as long-term costs. Show how care will be improved - far example, a design allowing staff more time for care giving rather than task performing. 10. Be Sure to Budget for Consultant's Services - Code variances can be obtained with as little as one meeting and at a cost of $1,000, or they may be as complex as changing a law at a cost of $100,000 or more. The changes in the New York regulations mentioned earlier were initiated by one provider at a cost to that provider of more than $150,000. Be sure your expectations are realistic. Establish a budget, then make a go/no-go decision when you reach predetermined mileposts.

We have found that most regulators appreciate being asked for input. Getting them to helps suggest ways to solve the problem makes them a part of the solution, and that is to your benefit.

For major issues, form advocacy groups. Use state or national associations to help promote and lobby for changes to regulations that will allow you to provide higher quality of care, more cost-effective care or both. By the same token, if you have had a particular problem with a code issue, or a success with a code waiver, I would suggest you share it with the AAHA Clearinghouse so others can benefit from your experience (see box).

It is not easy to "buck" the system, but by tolerating inappropriate and obsolete regulations, we are penalizing our nursing home residents. Indeed, one of the best reasons for advocating change is that the change will benefit the older people you serve. For many of them, your team is one of the few advocates they have.

In summary, if you are planning to develop a truly innovative facility, be prepared to have to challenge the codes. They were not written to encourage innovation. Obtain the services of consultants who have successfully guided clients through similar circumstances and be prepared to pay for their services. Be sure to allow adequate time to effect the changes that innovation will probably require; otherwise, artificial deadlines may force you to settle for less than an optimum design.

The challenge of changing the system can seem overwhelming, but the benefits can be enormous. It will be one of the inevitable costs of facility renovation and innovation, at least until the regulations are "brought up to speed."
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Title Annotation:how to overcome undue expense caused by building laws
Author:Crawford, Ronald O.
Publication:Nursing Homes
Date:May 1, 1992
Previous Article:'Mr. Nice' and 'Mr. Tough'.
Next Article:Contruction in a quiet zone.

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