Who is best to carry out ventilation verification?

At Healthcare Estates 2024, ventilation verification professionals, Dr Louise Webb, AE (Ventilation) of DRLC, and Gareth Twynam, managing director at AirisQ, discussed the challenges of ensuring that the air-handling plant supplying clean air to operating theatres and other critical areas is adequately monitored and managed. Here they explore the issues that annual ventilation plant checks – known as ventilation verifications – bring up, comparing and contrasting how the roles of professional ventilation verifier and Authorising Engineer (Ventilation) are positioned to ensure indoor air in healthcare premises is of the highest quality.

HTM 03-01: Specialised ventilation for healthcare premises. Part B: The management, operation, maintenance and routine testing of existing healthcare ventilation systems, recommends that air-handling units and theatre suites are checked annually using a standard checklist. The checklist for the ventilation plant is found in Appendix 1, and is titled Annual inspection of critical ventilation systems — AHU and plantroom equipment. The other area that the guidance directs attention to is found in Appendix 2 — Operating suite annual verification. This is concerned with an annual check of the fabric of the operating theatre itself, and associated rooms such as the anaesthetic room and dirty utility.

HTM 03-01 does not specify who should carry out the annual verification of critical ventilation. It would be possible, as asserted in the HEJ article, ‘A look at bringing verification in house’, (HEJ — October 2024, pages 113 to 116), to carry out the Annual Verifications using staff from the Estates Department. Dr Scott Brown’s article cites the Competent Person as the most suitable member of the Estates team to carry out this work.

This article explores the situation where these annual checks are undertaken by an ‘in-house’ CP(V), or a third party, and how the verification reports are used by the Authorising Engineer (Ventilation).

In-house or independent: which offers the best value for money?

One issue for the NHS is that it has to find funding to use independent verifiers, and it could be argued that using in-house verification is better value for money for the cash-strapped service. As a service-provider to the NHS, AirisQ aims to consistently improve its product to ensure that customers are getting the best value for money, and the most out of the service the company offers.

Ensuring best value is one of key requirements that the business has to meet from both clients and potential clients. Gareth Twynam explains: “When responding to a tender, I am at pains to find out what this actually means to each NHS Trust, and how AirisQ can implement measures that will improve the Trust’s ability to read reports, digest the data, and create a format that is useful for its staff to make improvements over the course of the year.”

A specialist in the field

The fact that AirisQ is a specialist in this field means that it can harness innovation and technology to aid clients’ processes, giving, say, an NHS Trust Estates & Facilities Department more time to concentrate on development, and thus improve value for money. The AE (Ventilation) gets involved with verifications in a number of ways, and in their role such individuals read many verification reports to enable them to assess the standard of the critical air-handling units in the Trust.

Some clients allow Authorising Engineers to access these reports directly from the verifiers, either via email or via online portals. Online portals are a very efficient way of getting these reports, as Authorising Engineers can see this data almost in real time. This may mean cost and time savings for the NHS, as the AE (Ventilation) then does not need to request the reports every year from the Estates Department.

Authorising Engineers also benefit from using reports from a small pool of verifiers, as they can get attuned to the report style and layout, which again means cost saving for the NHS.

The quality of the annual verification process is essential to enable the NHS estate to keep its mechanical ventilation systems working efficiently and effectively. Many Trusts are struggling with recruitment of technical staff to carry out planned preventative maintenance (PPM). If the in-house CP(V) were diverted from their PPM tasks to start carrying out ventilation verifications, there would be a knock-on effect on the amount of PPMs that could be completed. This could have a deleterious effect on the overall quality of operation of the air-handling units, as regular tasks would be neglected in favour of carrying out verifications.

AirisQ has responded to many commercial tenders from the NHS for ventilation verification, and all its NHS clients have specified that staff carrying out verifications should be at least AP(V) qualified. This contrasts with the belief that CP(V) staff are suitable to carry out ventilation verifications. In addition to taking air flow measurements, further work is required using engineering mathematics to calculate air change rates.

Quality of service’s many elements

In any system, the quality of the service provided is a combination of initial education, experience, and Continuing Professional Development. Verification companies are specialists in their field, and it has taken AirisQ over 15 years of improvement and innovation to develop its reports to where they are today. As Gareth Twynam says: “There is more that goes into these compliance reports than the two technical appendices in HTM 03-01: Part B containing templates for air flow measurements.”

If Competent Persons — Ventilation (CP(V)) are asked to carry out the annual ventilation verifications they are effectively being asked to ‘mark their own homework’, and give themselves a ‘to do’ list to rectify the issues they have found. Although there is no requirement in HTM 03-01 for independent verification of critical air-handling units, having an independent verification report gives the Board a level of confidence that what is being reported is accurate. Gareth sums this up: “I feel that if they’re scoring their own maintenance, it’s a lawsuit waiting to happen. As an independent service-provider with no links to construction or maintenance, we can objectively assess and verify a system, and create a list of actions that help to raise the level of compliance. In my opinion, there may be resistance to doing this internally, as this would effectively be creating work, and therefore cost, for the department.”

The organisational issues involved in asking employees to carry out compliance checks for their managers are many and varied. Let’s look at the situation where the Competent Person carries out the checks. By NHS standards this role is typically a grade 5. The Authorised Person (Ventilation) is usually a grade 6 or 7, and would be the Line manager for the CP(V). This would potentially present a problem. The CP(V) verifier could be unearthing issues with the critical ventilation that could involve significant amounts of capital spend. They might also discover areas of poor maintenance. Both of these scenarios could present stressful issues for the CP(V), in that they could be unsure how their feedback would be received.

In contrast, when an independent company undertakes these checks, it can deliver the reports safe in the knowledge that its staff will be at arm’s length from any spending decisions based on their findings. Gareth Twynam describes his experience as an independent ventilation verifier: “Can you imagine a situation where a band 5 has to communicate to the director of Estates that the operating theatre has failed its checks and it cannot be put back into use? The pressure they could be put under to ensure that the theatre ‘passes’ would be very unfair.

“This,” he continues, “is the beauty of using an independent provider of verification. We’re so used to talking to, and dealing with, a whole variety of different people, levels, and roles — including AEs, that our staff develop that ability to assess a system pretty quickly after verifying, and then communicate that to everyone with potential solutions. We operate at a distance from the local politics, which can often cloud judgement.”

It could be argued that the in-house verifiers should be supported by the Ventilation Safety Group (VSG). Let’s consider that idea in detail. The membership of the VSG, as described in HTM 03-01, includes the director of Estates, Consultant Microbiologist, the head of Estates, the Infection Control lead, and the AE (Ventilation). This group of people meets to discuss the strategy of the organisation, capital projects, exception reports on problems with ventilation, and the risk register. On balance it would not be appropriate for this group to get bogged down with the minutiae of how to verify an air-handling unit.

Is in-house verification more flexible than using outsourced providers?

The ability to carry out checks on ventilation which supplies critical areas of the healthcare estate requires flexibility from the service-provider, particularly in the Operating Theatre Department. Here, it is often the case that theatres can only be accessed during the weekend or in the evening. This could require in-house staff to work a 6 or 7-day week on overtime rates to carry out these checks.

A private company whose job role is to carry out ventilation verifications sets its standards by being able to meet clients’ expectations. In an Estates Department, where staff are expected to fulfil many different roles and tasks, as well as dealing with emergencies, they would not be able to solely focus on verifications, as well as PPMs, and maintain that level of flexibility.

Gareth explains: “There have been many cases where emergencies have arisen, and we make it happen to get there within 24 hours. We understand the fast-moving nature of the NHS, and the clinical need to get these critical areas verified and back into action.”

The role of the AE (Ventilation) is multifaceted. Such individuals are independent consultants, and need to be able to keep up to date with all aspects of the relevant topic. To do this they are typically members of professional organisations, attend conferences, and maintain good professional networks — including with ventilation verification companies.

The ability to talk to verifiers about how they are implementing aspects of the HTM 03-01 guidance as they go about their business is a very important part of the AE (Ventilation) role. Louise Webb explains: “Our AEs will critically assess the reports that verifiers produce, and give feedback to the verification company as necessary. If each Trust created their own verification reports, this quality improvement feedback loop would be enormously complex.”

In addition, when new facilities are built, it is essential that Validation Reports — a type of testing which proves the performance of the air-handling unit, are delivered as part of the commissioning. The AE (Ventilation) ensures that this task is carried out by an independent company. This is in line with HTM 03-01 guidance.

Specialist equipment for the right airflows

“The airflows in a UCV theatre require specialist equipment, which would be unlikely to be part of an Estates Departments toolkit,” Louise Webb continues. “So, in these cases the Trust may have to purchase this equipment and then pay to get training in how to use it. Alternatively, the Trust could bring in independent experts, and thus the AE (V) would be presented with three different reports for the same estate. This would also mean that the reports would probably be produced at different times, meaning it would be very difficult to take a time-stamped view of the state of the ventilation provision.”

Independent verifiers, by and large, produce reports in the space of a few weeks. This means that the overall view is a snapshot in time, which is useful for forward planning.

The area of ventilation that would not be able to be verified in-house is Local Exhaust Ventilation (LEV), which must be tested by a competent person (P601 Certified) every 14 months to ensure that the system is tested throughout the changing seasons. The AE (Ventilation) is also involved in checking the accuracy and regularity of these reports to ensure that all LEV systems are being used safely.

In summary, to quote Scott Adams, creator of the Dilbert cartoon, “Normal people… believe that ‘if it ain’t broke, don’t fix it’. Engineers believe that ‘if it ain’t broke, it doesn’t have enough features yet’. In this case the authors believe that the methodology of using external verifiers of healthcare ventilation systems is the most appropriate way of ensuring compliance.