Is it an Operating Room or is it an Imaging Center? It Depends….

Written by Dale Anderson, AIA, NCARB, LEED AP BD+C, CSBA, EDAC, MBA, GGP, ACHA

More and more Hospitals are recognizing the value of imaging-based surgeries when it comes to their patient care. Trying to determine whether this space is an operating room or a fancy imaging center starts to become a challenge for both Owners and Architects. Confusing the decision also depends on whether the facility is using the FGI Guidelines and which version is currently active in their State.


42 states have adopted some edition of the Guidelines (this includes Wisconsin, which has adopted only the HVAC requirements).

6 states (Colorado, Idaho, Kansas, Maine, Mississippi, New York) that adopt the Guidelines permit use of a more recent edition than that adopted in some instances.

3 states do not adopt but allow use of the Guidelines as an alternate path to compliance in some instances.

5 states do not use the Guidelines in any official capacity, although most of these appear to use the documents for reference.

(Facility Guidelines Institute, Adoption of the FGI Guidelines, January 15, 2021).

Washington State happens to fall into the second category above – while currently the 2014 edition of the Guidelines is still formally the active document, the Department of Health (DoH) both allows and recommends the 2018 edition be used for healthcare projects in development. According to DoH, the 2018 would have been adopted by this time if the COVID situation had not interrupted the normal path of code implementation.

Between the 2014 and 2018 editions the definitions and requirements of Imaging Centers has changed substantially due to the desired medical practices of imagery-guided surgeries. Owner and Architects not involved in this market sector can be hit with big surprises if they haven’t committed the time to research the differences and understand the impact to design requirements and construction cost budgets. Even the imaging equipment vendors are somewhat behind in understanding the differences between the two FGI editions and what it means with their conceptual equipment layouts.

Once contracted by Owners to provide design assistance to participate in these tenant improvements (typically they are Hospital-based and not separate, stand-alone facilities), Architects need to start having the difficult conversations with the medical providers to understand their usage intentions. Here in Washington State using the 2018 FGI Guidelines has made great strides in defining the requirements of an imagery-guided practice. Most of the definition differences relate to sedation of the patient and the type of surgeries intended for the space. The Owner could very easily end up with an Imaging Center that is required to be designed as a full-blown Operating Room. So let’s look at the three conditions that will determine this decision.

According to the 2018 FGI Guidelines, all Imaging Centers are now designated into three specific types of activities. From Table 2.2-2:

Class I Imaging Room – Diagnostic radiography, fluoroscopy, mammography, computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and other imaging modalities

Class 2 Imaging Room – Diagnostic and therapeutic procedures such as coronary, neurological, or peripheral angiography; Electrophysiology procedures

Class 3 Imaging Room – Invasive procedures; Any Class 2 procedure during which the patient will require physiological monitoring and is anticipated to require active life support

Depending on where your project lands in the above classification also presents specific requirements for the design of the space. This will include attention to details of spatial programming, equipment placement and access, and architectural, mechanical, and electrical detailing. Each of the varying classifications has differing requirements that need to be accommodated, translating into design and construction cost impacts to your project.

A word to the wise – get to know the differences, review the 2018 FGI Guidelines (consider them as a given already now instead of waiting for formal adoption), and open a good dialogue with your Owner regarding the impact to their projects. Take a look at the sample Floor Plan in this article to see what some of the FGI impacts can be to an imaging center. No Owner wants major project surprises down the road after budgets, schedules and design planning has already been completed and commitments made to medical providers.