Hospital Submittal Review: FGI, ASHRAE 170 & NFPA 99

On a hospital project, a GC checks each submittal against the project spec and against the codes that spec invokes: the FGI Guidelines for Design and Construction of Hospitals, ASHRAE 170 for ventilation, and NFPA 99 for medical gas and electrical systems.

That's the core difference with construction in healthcare facilities. After the design team signs off, a state health department may inspect the installed work against those same codes. A submittal can match every line of the spec and still miss a requirement the spec only names by reference, and that gap is why healthcare construction submittals come back so often.

What are the FGI Guidelines for design and construction of hospitals?

The FGI Guidelines set the minimum requirements for designing and building hospitals, outpatient facilities, and residential health, care, and support facilities. The Facility Guidelines Institute, an independent not-for-profit, develops them through a consensus-based process and helps fund research on healthcare settings. Most hospitals in the U.S. have been designed against some edition of the guidelines for decades.

For a general contractor, the edition matters most, because the guidelines only become enforceable when a state adopts them. As of August 31, 2026, 42 states had adopted some edition of the FGI documents, so the version behind your project may be several years old. The 2026 edition also changed the name and split the content in two:

• The FGI Codes for Planning and Design, which hold the minimum requirements.

• The FGI Handbooks, which add commentary.

You'll see both the old and new names on construction projects for a while.

Why are healthcare construction submittals harder to review?

Hospital submittals are harder to review because codes stack onto the spec for every package, and more reviewers see the work after the design team does.

Codes stacked on the spec in healthcare facilities

On a typical office job, the spec is the finish line. In healthcare facilities, the spec often points somewhere else. A Division 23 section might say "maintain pressure relationships per ASHRAE 170" or "comply with NFPA 99" without listing a single value. The reviewer then has to open the code, find the right table for that room type, and check the submittal against it.

Dense MEP packages for operating rooms and patient rooms

An AHU serving operating rooms carries a long list of technical characteristics: filter ratings, humidity range, airflow, coil coatings, controls. One unit can carry dozens of checkable items, and its submittal often runs to dozens of pages. Then come the medical gas zone valves, alarm panels, essential electrical system gear, and patient room headwalls, and most packages on the job get just as long.

State and AHJ review adds another approval layer

On a hospital job, a missed characteristic turns into a patient safety problem. Infection preventionists often weigh in on materials and sequencing, and the state health department or local AHJ inspects work against the adopted code. A product the design team approves can still fail that inspection after it's installed.

When asked how vague references to standards like NFPA 99 or ASHRAE 170 affect a PE’s submittal review and which requirements teams most often overlook, Tom Port, the co-founder of BuildSync, says:

When a hospital specification simply references NFPA 99 or ASHRAE 170 without providing specific values, it puts a significant burden on the reviewing engineer. They have to identify the applicable requirements and manually verify that the proposed equipment meets them.

We often see critical details like air change rates, pressure relationships, filtration requirements, and electrical system characteristics overlooked because those values aren't explicitly stated in the project specifications. The biggest risk isn't necessarily identifying something that's wrong; it's failing to identify something that hasn't been checked at all.

What do GCs check against ASHRAE 170 for airborne infection isolation rooms and operating rooms?

GCs check ASHRAE 170 submittals for the ventilation requirements of each space type, and FGI has folded the standard into its guidelines for several editions. The current version is ANSI/ASHRAE/ASHE Standard 170-2025. The submittal checks cover:

• Pressure relationships, with negative pressure for airborne infection isolation rooms so contaminated air stays in the room and positive pressure for operating rooms and protective environment rooms.

• Total and outdoor air change rates for each space the unit serves.

• Final filter ratings, plus HEPA filters wherever a space serves immunocompromised patients.

• Temperature, humidity, and exhaust requirements by room type.

The room-by-room detail is in the [ASHRAE 170 submittal review checklist].

What do GCs check against NFPA 99?

GCs check NFPA 99 submittals against each system's risk category, which reflects what happens to patients and staff if that system fails. The submittal checks cover:

• Medical gas and vacuum outlets, zone valves, alarms, and piping materials. Medical gas often sits inside the plumbing systems scope, so confirm which sub's package carries it.

• Essential electrical system equipment, branch by branch.

• Receptacle and grounding requirements in patient care spaces.

Federal and local enforcement don't always use the same edition, and the [NFPA 99 submittal requirements guide] covers each edition's requirements.

How does an infection control risk assessment change renovation and new construction submittals?

An ICRA adds temporary-protection submittals to renovation work, and FGI's space requirements add healthcare-specific checks to finishes on both renovation and new construction.

ICRA submittals in existing spaces

Renovation in existing spaces leans hardest on the infection control risk assessment (ICRA), which many jurisdictions require through their adoption of the FGI Guidelines. In FGI's terms, the ICRA is one part of the owner's broader safety risk assessment (SRA). The ICRA produces submittals a ground-up new construction job may never see:

• Temporary barriers, plus ceiling and door protection.

• Negative air machines with HEPA filters.

• Procedures for keeping dust out of occupied patient care areas.

FGI finish requirements in patient rooms and ancillary services

FGI's space requirements reach finish submittals as well, from patient rooms to ancillary services such as imaging and lab spaces. Cleanable surfaces and handwashing station components carry healthcare-specific requirements but look like ordinary architectural products, which makes them easy to miss.

Where do hospital submittal reviews break down on construction projects?

Hospital submittal reviews break down where a code requirement never made it into the spec as a value someone can check.

Two habits close most of these gaps:

• If you can't confirm a value from the submittal or the construction documents, turn it into an RFI before it turns into a rejection.

• If the schedule and spec disagree, flag both and note which one is more stringent. Most contracts default to the stricter requirement, but get the design team to confirm it in writing.

Got a hospital submittal you'd like a second set of eyes on? Try BuildSync free on your most complex healthcare package.

How to review hospital submittals in six steps

1. Confirm the adopted FGI edition, the NFPA 99 edition, and the AHJ before the first package arrives.

2. Pull every code reference out of the relevant spec sections and list the values each one requires for your room types.

3. Break each submittal into individual products, then break each product into technical characteristics.

4. Check every characteristic against the design and construction documents, and verify it against the source page.

5. Send open items to the sub, or write an RFI when the documents are silent or contradict each other.

6. Return an issue report and a marked-up submittal so the sub knows what to fix.

These steps follow the same construction submittal review process used on any commercial job, with code checks added at steps 2 and 4.

When manual review can't keep pace on healthcare construction

Skepticism about software checking hospital submittals is reasonable. A miss can show up in an operating room, so you should watch a tool work on your own submittals before you trust it.

How BuildSync handles code references in hospital submittals

BuildSync performs deep technical analysis. It splits each submittal into products and checks every technical characteristic against your plans and specs, with a link to the source page in both documents so your team can trust but verify.

On hospital work, the Unknown list matters most: it holds the code questions to settle before submission. The output is an Excel issue report plus a marked-up copy of the original submittal, ready to send. 

For teams on Procore, zero friction integration means BuildSync runs inside the existing submittal workflow without changing how project management handles ball in court. Your team still makes the call.

Results from a healthcare general contractor

Monteith Construction, a GC focused on healthcare, uses BuildSync on work like the UNC 7th Floor Renovation, a fast-schedule job with complex MEP submittals. In the hospital renovation submittal review case study, PM Daniel Recktenwald says, "I spend 70% less time reviewing submittals." On one grilles and diffusers package, the review caught fins facing the wrong direction. BuildSync's research puts the cost of each rejected submittal at about $805, and catches like that one add up across multiple projects.

When asked about the most common Unknown BuildSync flags on healthcare projects and why an Unknown can be more useful to a GC than a Fail, Tom Port, the co-founder of BuildSync, says:

One of the most common Unknowns we see is when a submittal doesn't provide enough information to confirm compliance with the design requirements. A Fail tells you something is wrong, but an Unknown highlights something that hasn't been verified. On healthcare projects, where the consequences of missing a requirement can be significant, that distinction is critical.

Getting your next hospital project right the first time

Hospital submittal review gets easier once you treat the spec as a translation of the codes, from the FGI Guidelines for Design and Construction of Hospitals down to NFPA 99, and look for the places where that translation is thin. Settle the editions early and turn every code reference into a checkable value, and fewer packages come back on your next project.

See BuildSync on your next hospital project. Book a demo.