Construction and Renovation Safety in VUMC Healthcare Facilities

According to the Architectural and Engineering Guidelines for Submission, Approval and Inspection of Occupancies Licensed by the Tennessee Department of Health,"Patient safety during construction/renovation of a facility is of highest priority, and is the responsibility of the facility."  The Joint Commission (Accreditation Requirements EC.02.06.05) also requires hospitals to manage the "environment during demolition, renovation, or new construction to reduce risk to those in the organization."

In order to manage these hazards at Vanderbilt, Environmental Health and Safety (OCRS), Facilities ManagementInfection Prevention, and the Office of Planning, Design & Construction have developed a construction safety and oversight program.

The primary protocols associated with this program are outlined in the following VUMC Policies:

The purpose of the program is to provide a comprehensive plan to assess air quality control, infection control hazards, implications, and interventions when new construction and/or renovation in the patient care setting is anticipated. These policies apply to all VUMC healthcare facilities: on-campus and off-site.

All new construction or renovation projects in patient care areas are to be evaluated prior to work and reviewed during construction to promote patient safety and cleanliness. This consultative review is performed by the applicable VUMC construction manager, Infection Prevention and OCRS. During the initial consultation review, a Construction Matrix is completed, outlining the scope of work and the level of protection/dust control required for the project. Construction activity in any healthcare area is performed by methods that minimize dust generation.

Weekly jobsite inspections are performed by representatives of OCRS, Infection Prevention, Facilities Management, and Office of Planning, Design & Construction.

The Department or Unit Manager working in areas where there is construction or renovation activities is responsible for:

  • Providing a safe environment for the patient and staff.
  • Working with Facilities Management, Office of Planning, Design & Construction, and the contractors to isolate construction activities from patient care activities.
  • Reporting any problems to Facilities Management or Office of Planning, Design & Construction.


Send a message to if you have questions about construction safety or to request an infection control permit.


VUMC Documents Used in the Healthcare Construction Safety Program