HTM 03‑01 Annual Verification: The Numbers to Hit and the Evidence to Show

Annual ventilation system performance verification failures cancel lists and erode confidence. This guide aims to set out in simple terms the thresholds to meet, the evidence to present, and who signs what under HTM 03‑01 and devolved nation guidance such as SHTM03/01.

Ventilation performance verification is conducted to provide the healthcare provider with assurance that the system installed is operating in a satisfactory manner and does not present a hazard to patients and staff. Poorly maintained or sub-optimal performance can lead to increased health risks that are widely recognised. The Health and Safety at work Act etc 1974 places the following duties on employers/organisations:

2 (2) a. The provision and maintenance of plant and systems of work that are, so far as is reasonably practicable, safe and without risks to health.

2 (2) e. The provision and maintenance of a working environment for his employees that is, so far as is reasonably practicable, safe, without risks to health, and adequate as regards facilities and arrangements for their welfare at work.

All critical healthcare ventilation systems as designated by your healthcare providers ventilation safety group must be subjected to performance verification at least annually. Some complex and high-risk areas will require more frequent verification as determined necessary by risk management.

It is vitally important to ensure the safety of patients and staff during the shutdown and testing of ventilation systems. Your site Authorised Person (Ventilation) should co-ordinate with the user departments and agree the shutdown in writing through an “authorisation for disconnection” or “permit to work” procedure. Your healthcare providers ventilation safety group should provide guidance on permit to work procedures to be followed.

Lastly, the annual verification should be aligned with other annual maintenance activities such as fire damper testing, cleaning of wetted components and filter changes (if required) etc. Whilst conducted in the same shutdown, the performance testing should be conducted prior to the maintenance works to give a true indication of performance at the end of a maintenance cycle. Conducting maintenance first then achieving a close “pass” will not ensure suitable performance to the next verification.

Ventilation performance measurement can be complex and involves the use of calibrated equipment and mathematical formulas to determine results. Historic use of grille correction factors can also add layers of further complexity that should be understood to provide accurate data. It is vital that internal staff or contractors are suitably qualified and experienced in this type of work and have deep understanding of the required standards to meet.

Your site based Authorised Person (Ventilation) should conduct and record a competency assessment of the proposed verification engineer before works are commenced. It is the responsibility of the verification engineer to prove competence to the Authorised Person (Ventilation) by way of skills, knowledge, attitude, training, and experience. Safety documentation such as “authorisation for disconnection” or “permit to work” may only be issued to a demonstrably competent person.