In healthcare facilities, ventilation and air quality are a critical component to outcomes, moving from simple comfort to patient safety, such as controlling infections or protecting the vulnerable.

While hospitals have historically been designed and built for HVAC systems to follow standards around the ventilation of health care facilities, they were left without a standard guide for day-to-day operations and maintenance. How a facility is built and how it is maintained can be two different pieces cut from the same cloth. 

ANSI/ASHRAE/ASHE Standard 170 dictates how a building must be designed and constructed, stopping at how to run HVAC systems dynamically or manage environmental changes. ASHRAE/ASHE Guideline 43 provides an operational framework to run HVAC systems safely and intentionally, replacing ad-hoc operational choices with a defensible, standardized program.

Guideline 43 was adopted in June 2025 and advocates the development of a Ventilation Management Program (VMP) as the deliverable. 

“Standard 170 is the design standard: That’s how I built my building. There’s nothing in Standard 170 that tells me how to operate it day-to-day,” explained Dino Coliano, consultant for Setra and founder of AVANZARE Services. “My Ventilation Management Program provides the standardized, risk-assessed rulebook to operate safely while maintaining clinical compliance.”

To date, a small number of health and hospital systems have been involved with creating or adopting Guideline 43. Now is the time for healthcare facilities to learn from these first movers how they can adopt the guide for themselves.

How to Create a VMP in Your Organization

“A few health systems that were early adopters of Guideline 43 and the VMP concept were involved in writing the guideline, and implemented at their own hospitals as test cases,” Coliano said.

He hears a lot of managers of other facilities note they have heard about the guideline, but are unsure how it supports their role. It provides a framework for the facilities to create ground rules and understand where to start, explained Coliano, a designated Senior ASHE member.

“Having a more formal VMP, as outlined in Guideline 43, ensures we have multi-disciplinary input in how we operate and maintain our spaces, equipment, and HVAC systems,” he encouraged.

Coliano recommends creating a VMP by following the framework in Appendix F of Guideline 43, which includes a process for creation. This would be created as a multidisciplinary team, consisting of organizational departments that span facilities, infection control, nursing, and executive leadership.

The nine-step process for creating a VMP includes:

1. Forming a committee
2. Determining the code reference
3. Developing a source of truth
4. Weighing risk and performance metrics
5. Creating a response plan
6. Providing education
7. Developing the policy
8. Gaining approval
9. Maintaining the plan

As a consultant and active member of ASHE, Coliano has noticed four successful elements that early adopters have when successfully bringing a Ventilation Management Program to fruition:

• A change agent: An internal leader pushed ventilation management onto the executive agenda.
• Cross-functional teamwork: Facilities teams brought together Infection Prevention, Nursing, Clinical Leadership, and Executive Management to review and approve operational parameters.
• Written documentation: They standardized policies, procedures, and pre-written responses to save time when issues arise.
• Future vision: They recognized that VMP mandates would eventually be recognized and incorporated into standards.

“Having documented, pre-written excursion responses and getting buy-in from all parties saves time and ensures the environment of care has a positive impact,” Coliano explained. “Educate to the plan, operate and maintain to the plan, and monitor to the plan.”

Why Now is the Time to Adopt Guideline 43

The VMP concept is rapidly transitioning from a nice-to-have guideline into something that every organization should have. Coliano calls on associations and organizations to lead training for authorities having jurisdiction so inspectors recognize and understand Guideline 43 and programs in the field.

With the 2025 update to Standard 170, which can incorporate revisions and addenda between full updates, and the 2027 NFPA 99, which covers health care facilities, recognizes HVAC VMPs in Chapter 9.

“Until Guideline 43 was published in June 2025, no two space ventilation programs that I have seen nationally were the same, as there was no ‘playbook’ or ‘template’ to follow. Every hospital and health system created and managed their space ventilation program differently,” Coliano explained.

Now with a VMP in place, if a surveyor with the Joint Commission or another authority questions an operational setting, the facility manager can present documented policies backed by consensus rather than a single maintenance department choice. 

“Having documented, pre-written excursion responses and getting buy-in from all parties saves time and ensures the environment of care has a positive impact,” Coliano explains. “Educate to the plan, operate and maintain to the plan, and monitor to the plan.”