In today’s cloudy economy, one area that is flourishing is healthcare, especially as it relates to cleaning maintenance and restoration. Building occupants face threats from numerous biological contaminants that occur in indoor environments and can be spread through the ventilating air, while building owners and developers face liability due to exposure risks from these indoor environmental toxins.

These contaminants have the ability to navigate into and spread around buildings through various paths, depending on the contaminant. Many spread via the ventilation system, while others are surface bound and can spread through cross contamination such as hands, equipment, and furniture. New and emerging bacteria such as Community Acquired-MRSA (Methicillin-Resistant Staph Aureus) may enter the building along with individuals carrying these organisms on clothing, hair, skin and nares (nasal passageways).

One area of risk that is often overlooked but that is critical for healthy indoor environments is that of the service providers and restoration contractors. Typically, contractors on a jobsite travel from one area to another throughout the day. Whatever bacteria, toxins or germs are in one location now have the opportunity to travel to other areas, making cross contamination a real and true possibility.

The service provider, often unknowingly, becomes a vector or vehicle for the contaminant.

Contractor Risks in Healthcare Facilities

Infections acquired within a hospital environment are known as nosocomial infections. Construction workers and contractors in hospitals and outpatient facilities are believed to cause anywhere from 5,000 to 7,000 nosocomial deaths annually. These deaths are directly related to a lack of compliance protocol and training in infection control during the construction/cleaning process.

It is crucial that hospitals and medical facilities manage risk and liability by hiring restoration companies that can prove due diligence for infection control protocol and education, and that can follow the Best Practice Standards embedded in the facility’s safety program. This adds a layer of protection not only for the hospital and the patients, but for contractors on the job as well.

These standards are mandated by the Joint Commission, the accrediting organization for hospitals, and call for criteria that address the exposure risk to infectious diseases during real work time. The CDC recommends and the American Institute of Architects strongly enforces the standards, known as ICRA-infection control risk assessment.

What is an ICRA?

An ICRA is a multidisciplinary, organizational, documented approach that after considering the facility’s patient population and program:
  • Focuses on reduction of risk from infection
  • Is phased for facility planning, design, construction, renovation, facility maintenance
  • Coordinates knowledge about infection, infectious agents, and care environment, permitting the organization to plan for potential impact
  The Centers for Medicare/Medicated Services and the Joint Commission require all healthcare projects which receive Medicare/Medicaid funding to implement an ICRA. The ICRA maps out which areas under construction have the least to the most at-risk patients; the construction work being completed; and the precautions for protection. 

The ICRA Matrix

One of the ways to understand the ICRA is the ICRA matrix. It is a systematic approach which facilitates communication between the workers, clinicians, engineers and architects. It features the class of infection control precautions from I to IV, the construction project type from A to D, and the patient risk group from low to highest.

The following table is a typical format for a construction project.

ICRA complements OSHA guidelines and/or state occupational safety mandates for workers. Some of the most critical internal risk factors for projects include:
  • Dust containment, proper removal and moisture control
  • Education and correct training of workers and staff
  • Site preparation
  • Monitoring and tracking for adherence to infection control as mandated by the JC
  • HVAC system maintenance; water system
  • Daily clean-up and removal of debris


Remediation and restoration contractors need to take extra care in upfront planning responses for healthcare facility projects, as typical emergency calls from hospitals are without much notice. Designing a response plan and protocol with guidance from an expert will minimize risk during real work time. Once on site, the plan can always be revised.

At a minimum, design and implement a specific healthcare safety policy to which all team members adhere on each project, and defines in detail the following:
  • Clear responsibilities for the project scope
  • Central coordination of all team members and subs
  • Consistent review process
  • Competencies/Skills
  • Metrics and follow-up
  • Training and Education
  Demonstrate your understanding of ICRA and how important it is to the facility in which you are working, and your client will never go elsewhere.