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health care workers walking

Best Practices: Discussing ASHE ICRA 2.0 TM in Healthcare

March 1, 2023

The use of infection control risk assessments (ICRAs) during hospital design and construction projects has been evolving over the past several decades. As investors or owners in healthcare real estate, you need to take special precautions to maintain a safe environment and protect both patient and site workers’ health during capital improvement projects or other construction. This applies to both healthcare workers and construction workers. For the healthcare workers, in addition to noise, common concerns include the risk of vapor and dust migration in and around construction sites. For work crews involved in capital improvement projects and/or other construction, there are often high-risk individuals in proximity of the work area. Also, there are often few to no ‘after-hours’, so capital improvement projects are regularly conducted alongside healthcare operations. There are important guidelines outlined and best practices established for healthcare real estate investors and owners during capital improvements, renovations, and/or other construction projects. When originally issued, the ICRA process was meant to ensure that patients, staff, capital improvement workers, and visitors are properly protected from infectious diseases while they work on providing an improved healing environment. ICRA has been expanded to include guidelines for design and construction of hospital and healthcare facilities.

The origin of the ICRA Process

The first formal guidance suggesting that a risk assessment be performed for susceptible patients, with consultation from an infection control professional (i.e., an ICRA aka Infection Control Risk Assessment), was introduced in the 1996-97 edition of the Guidelines for Design and Construction of Hospital and Healthcare Facilities. These Guidelines were published by the American Institute of Architects (AIA), which is known today as the Facility Guideline Institute (FGI). The FGI Guidelines are the most widely recognized standard for planning, designing and construction of hospital, outpatient, and residential health care facilities. The guidelines are adopted by states for regulatory purposes and other reference in laws, codes, rules, regulations, and the promotion of safe practices and methods in planning, design, and construction for various types of health care facilities. 

The Environment of Care Joint Commission Standard EC.02.06.05 (2) requires, “When planning for demolition, construction, renovation, or general maintenance, the hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services“. The Joint Commission Standards FAQs, “What is the requirement for an organization to have a pre-construction risk assessment?”, states the following, “The Joint Commission does not prescribe a particular risk assessment and implementation process. Recommendations can be found in the 2018 FGI Guidelines for Design and Construction of Hospitals and the Centers for Disease Control and Prevention (CDC).” 

In July 2020, The American Society for Health Care Engineering (ASHE), put together a multidisciplinary team to improve the existing ICRA process guide to better serve healthcare organizations; ASHE ICRA 2.0™ was released in 2022, which included an improved tool kit and an e-learning course. The goal of ASHE ICRA 2.0™ was to reduce ambiguity and provide a better understanding of the ICRA process, more descriptive language and definitions of work activities, work areas, and controls.  

What are the steps in the ICRA process?

The ICRA process includes five distinct steps: Define the activity, Identify Patient Risk, Define Class of Precautions, Assess Surrounding Area, and Establish a Mitigation Plan. These steps are crucial because a project team often faces certain challenges during the initial stages of completing an ICRA, most notably acquiring accurate information.  

Step 1: Define the activity

Defining the activity helps reduce infection risks by eliminating incidental work, defining the entrance to and egress from the work area, worker garments and clothing cleanliness, work materials and equipment movement in the environment, etc. The ASHE ICRA 2.0™ Table 1 – Activity Type lays out the various types of work so the user can establish which category (type) the project falls into. One of the benefits of ASHE ICRA 2.0™ was expanding upon and clarifying the activity types to reduce ambiguity.  

Step 2: Identify Patient Risk

Infectious contaminants may be released into the environment through water leaks (stagnation), dust, and dirt. Temperature and humidity play a critical role for not just healing but controlling proliferation of microbial organisms. The ASHE ICRA 2.0™ Table 2 – Patient Risk Group helps the user determine the risk group designation from lowest to highest. In summation, low risk defines non-patient care areas, but considers staff and visitors; medium risk defines patient care support areas; high risk identifies patient care areas; highest risk identifies procedural, invasive, sterile support and highly compromised patient care areas.  One of the biggest changes in ASHE ICRA 2.0™ – Table 2 included moving all patient care areas to the high-risk category and any invasive patient care to the highest-risk category. 

Step 3: Define Class of Precautions

A variety of controls may be introduced during a project to make the work areas/procedures safer for patients, staff, and other occupants. Examples include anterooms, rerouted traffic flow and egress, air filtration, trash and debris containment, etc. The precautions to be utilized depend on the results of Steps 1 and 2. After identifying the Activity Type and Patient Risk Group, ASHE ICRA 2.0™ provides five classes of Precautions in Table 3. ASHE ICRA 2.0™ expanded to add a fifth class of precautions to make a greater distinction between the classes. Equally as important is that Class II is intended for routine maintenance (such as patching walls, etc.) and to have a pre-established ICRA for those tasks. Several other key changes occurred within ASHE ICRA 2.0™, including how specific environmental conditions such as sewage, mold, and/or asbestos require a more stringent class of precautions (IV for low and medium risk groups, V for high and highest risk groups).  

Step 4: Assess Surrounding Area

Adjacent locations above, below, and to the sides of the work area can easily be impacted by the construction activities. The relationship between spaces is often more complex than it appears. The HVAC system, pressurization, and mechanical shafts are a few examples. Data, water, and medical gas systems may also be affected by work in an adjacent location; excessive noise, vibration, dust, etc., may be generated. Table 4 includes assessment criteria for assessing adjacent areas and ASHE ICRA 2.0™ includes more detailed criteria for this process.  

Step 5: Establish a Mitigation Plan

For each of the five classes of precautions determined in in Step 3, corresponding mitigation activities are provided in Table 5.  The mitigation activities are performed before and during work activity. ASHE ICRA 2.0™ provides better guidance of expectations for controls as well as greater clarification. ASHE notes that each mitigation class includes the minimum suggested requirements.  The local ICRA team can decide to add additional strategies to their plan as not all projects are similar, and some require additional mitigation activities.  

Close Out

Perhaps the most challenging aspect of the project as it pertains to infection control and prevention is the close out of the project. As the project nears completion, the ICRA team should reevaluate the status of the project and risks to the patients, including possible mitigation methods. For example, are the original environmental conditions in the work area restored after project completion (pressure, air changes per hour, temperature, and humidity, etc.) The ASHE ICRA 2.0™ Table 6 provides mitigation activities to be performed upon completion of the work activity. Verification and validation are critical at this point in the ICRA process.  

What are the benefits of ASHE ICRA 2.0™?

Many of the ASHE ICRA 2.0™ steps will benefit from the input of a multidisciplinary team that includes members such as infection prevention, facilities, medical staff, contractors, and other stakeholders. Each one of these members may be able to identify a risk or mitigation strategy that others are not as readily aware of, both before and during activities.  

The ASHE ICRA 2.0™ approval process should allow all impacted by the ASHE ICRA 2.0™ implementation to understand what should be expected by those involved in the project activities. Communication with the team is an ongoing process where the ICRA (and PCRA) are continually reviewed and updated throughout the life of the project.  Frequent inspection, testing, and monitoring are vital for tracking the progress of the project and for identifying if potential risks arise during the project. 

The development of risk assessments for infection control during health care facility design, construction and operations continues to evolve.  Compliance with the ASHE ICRA 2.0™ process supports the Joint Commission’s initiative, “Leading the Way to Zero”, considering patient safety is the number one goal.  

Learn more about how VERTEX assists healthcare leaders manage risks and establish best practices to maintain a safe environment and protect patient health. Our experienced team of healthcare professionals is here to advise and guide you through the process.  To learn more please contact either our Technical Director of Healthcare Services Archie M. Barrett, Jr., CIEC, CMC ( or Senior Industrial Hygienist Karl Stefan, CIEC ( 

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