green@work : Magazine : Back Issues : Sep/Oct 2005 : Cover Story

Cover Story

The Dollars & Sense of Greening Healthcare

More and more, the healthcare industry is moving toward building green, seeking to increase the health and workplace benefits that ecologically based design and construction bring.

by Diane Greer

Multi-storied atriums stream daylight into lobbies. Large single rooms look onto rooftop gardens. Thirty-seven-inch plasma TVs deliver Internet access along with films and interactive games. Furniture and finishes utilize non-toxic, low-VOC (volatile organic compounds) and recycled materials. A 150-seat organic restaurant prepares meals for in-room delivery.

This isn’t a cutting-edge resort—it’s the soon-to-open Sarkis Gabrellian Women’s and Children’s Pavilion at Hackensack University Medical Center (HUMC) in Hackensack, N.J. HUMC, the fourth-largest hospital in the nation, is in the vanguard of healthcare’s green building movement, which seeks to make ecologically based decisions regarding resource consumption, materials utilization, waste management and indoor air quality (IAQ) the norm for healthcare facilities, extending the medical community’s credo of “do no harm” to it buildings and operations.

“ A few pioneering institutions have made the investment in green building,” says Jim Moler from the healthcare group of Turner Construction, one of the nation’s premier builders of healthcare facilities. “They have demonstrated that there are health benefits, recruitment and retention benefits, and public relations benefits. This has gotten the attention of the industry, and there are not many healthcare executives who are simply rejecting it out of hand.”

The timing could not be better for greening healthcare. The booming hospital construction market offers significant opportunities to green the nation’s stock of medical facilities. FMI Corp., a consulting firm specializing in the construction industry, estimates investment in new and renovated facilities will reach $31.8 billion in 2005, and top $35 billion by 2008. Old and obsolete infrastructure, growing demand from an aging population of baby boomers, demographic shifts and the rapid advancement of new technologies are some of the factors driving the boom.

“ This is the strongest healthcare construction market I have ever seen in my life,” says Robert Levine, vice president at Turner Construction’s healthcare group, “and I have been in the business for 40 years.”

Why Green Hospitals?
A business case for building green hospitals is emerging from the experiences of industry leaders and ongoing research. Preliminary results indicate investments in healthier and greener healthcare facilities will pay off directly and indirectly by lowering operating costs, improving patient outcomes and retaining staff. In short, designing, constructing and operating green hospitals is not only good for the environment, but also for patients and the industry’s bottom line.

The business case for greening healthcare starts with lower costs. With hospitals using voracious quantities of energy and water, early adopters have found curtailing usage in these areas offers the greatest costs savings. Hospitals are the second-largest consumers of energy next to food-service facilities, and are estimated to waste as much as 30 percent of the energy they use. In an industry with tight margins and high-energy utilization, even a small percentage reduction in energy consumption can translate into big savings.

At the Patrick H. Dollard Discovery Health Center in Harris, N.Y., green design cut energy costs an estimated 27 percent below those of a conventional building, according to Robin Guenther, principal at Guenther 5 Architects, the firm who handled the project. The Center, only the second healthcare facility to receive Leadership in Energy and Environmental Design (LEED) accreditation, provides treatment and diagnostic services for individuals with severe disabilities.

Renewable energy, in the form of 40 400-foot-deep geothermal wells, provides the heating and cooling at the Center. Guenther designed an innovative system utilizing geothermal energy in conjunction with radiant slab heating/cooling. Other features include a high-efficiency building envelope exceeding New York state’s energy efficiency code by 50 percent, window glazing, solar shading devices, a reflective roof and energy-efficient lighting.

Boulder Community Foothills Hospital (BCFH) in Boulder, Colo., opted for a centralized utility plant designed to be both energy-efficient and flexible to accommodate expansion plans. BCFH, the first hospital in the country to achieve LEED accreditation, houses maternity and pediatric services. Installation of the freestanding plant reserved space for extra chillers and boilers. Piping was also sized to accommodate growth.

At BCFH, a flexible control system allows heating and cooling to be controlled on a room-by-room basis and also monitors IAQ. “We heard loud and clear that people wanted to be able to control their room’s atmosphere, so we allowed people to open their windows,” says Kai Abelkis, environmental coordinator for BCFH. The system’s sensors know when a window is open, and shuts down the system to save energy.

Other measures include energy-efficient lighting, occupancy sensors, building-shading devices, and high-efficiency chillers, motors and fans. Energy savings for the new facility were calculated to be more than 27 percent with an estimated payback of 12 years, according to Krisit Ennis, sustainable design director at Boulder Associates, one of the project’s designers. Abelkis adds that the payback period has dropped to eight years as the result of rising energy costs.

Hospitals use vast amounts of potable and processed water. Thirty percent of water in a hospital comes out of fixtures, while the remaining 70 percent is processed water, used in lab equipment, sterilizers and laundry operations. Recently, hospitals have started focusing on saving water to improve the bottom line.

“ Water innovations today have a lot to do with how the medical equipment is being cooled,” says Walt Vernon, principal at Mazzetti and Associates. “In the old days they used to take water and run it though the equipment to cool it, and then dump it down the drain. Today we are recirculating more.”

Xeriscaping—landscaping using indigenous, drought-resistant plants—reduces water used for irrigation at BCFH by 54 percent. Although slightly more expensive to install than traditional landscaping, xeriscaping produces a quick payback by reducing water utilization and maintenance. The facility has also deployed waterless urinals in all the public restrooms.

The Discovery Health Center captures rainwater from rooftops for use in landscaping and in the fire protection system; the system is designed to capture 395,000 gallons of water a year. Water-saving devices are also installed throughout the facility.

Green construction practices offer another means of lowering costs. One example can be seen in the recycling of construction debris. “In many areas of the country, it actually saves the project money to segregate and recycle construction waste rather than send it to a landfill,” Moler says. Ennis has seen similar savings in her projects in Colorado and California.

Building commissioning, required for LEED certification, also produces savings. Commissioning calls for the testing and adjustment of mechanical, electrical, HVAC and control systems prior to occupancy to ensure efficient operation. Recently, Vernon took part in a survey of 10 campuses of large healthcare systems. The survey found many of the facilities were utilizing energy inefficiently. “Part of the problem was poor commissioning,” Vernon says.

An Environment of Healing
Greening healthcare doesn’t just lower costs—it promises to contribute to how well a patient heals. “The way we design and build hospitals can actually get you out of the hospital quicker,” Levine points out. “That’s dramatic.”

Green building shares numerous design strategies with a new field called “Evidenced Based Design” (EBD). EBD is based on the notion that the way hospitals are designed and built can actually impact patient outcomes. Incorporating natural light, outdoor views, healing gardens, and positive distractions such as artwork, music, aquariums and water elements are just a few of the means of reducing patient stress, improving staff working conditions, and providing patients and their families with a sense of control.

Roger Ulrich at Texas A&M University started the movement in the 1980s. Ulrich was interested in whether viewing natural settings could reduce patient stress and produce measurable gains in patient outcomes. He analyzed the records of two groups of patients at a single hospital who underwent identical gall bladder surgery. The only difference between the two groups was that one had a view of a small copse of trees, while the other looked onto a brick wall.

Ulrich discovered the group with a nature view recovered faster (7.96 days vs. 8.7 days), required fewer painkillers and had fewer nurses’ observations of crying or agitation. Since Ulrich’s landmark study, a growing body of evidence supports the concept of design having a positive effect on clinical outcomes in addition to improving hospital safety and staff satisfaction.

Elements of EBD are incorporated into the new Women’s and Children’s Pavilion at HUMC. The design includes green rooftops, viewable from patient rooms and corridors. A two-story atrium with skylights brings light into the nursery, family lounge and pediatric patient corridor. Large private rooms provide privacy for patients and a sleeping alcove for a family member. Positive distractions are provided in the form of televisions with Internet access offering educational material, games and other entertainment.

“ We are trying to incorporate views of nature and things that make patients feel better,” says Suzen Heeley, director of design and construction at HUMC. “We are creating more of a hospitality-style environment, and really thinking about the patient and their family’s experience when they are here.”

Heeley believes their consumer-driven focus will provide a competitive advantage. “We are looking at the baby boomer market,” says Heeley. “This is a very demanding market and a competitive healthcare environment. We are looking at what can we do to go beyond what other facilities are doing.”

Improving Indoor Air Quality
Good IAQ is one of the key ingredients in green hospitals, and essential in controlling the spread of infectious disease, reducing indoor pollutants and eliminating chemical exposures. The elderly, cancer patients, asthmatics, children and people with depressed immune symptoms are particularly susceptible to IAQ issues.

Chemical hazards such as VOCs, carcinogens, mutagens and endocrine
disrupters are found in a wide range of building products, furniture and equipment used in healthcare facilities. These hazards negatively impact IAQ.

“ Hospitals are supposed to be healing environments, but have the potential for making people sicker,” says Deidre Imus, founder of the Deidre Imus Environmental Center for Pediatric Oncology. “It just makes sense to build hospitals totally green and environmentally friendly. That means using the least level of toxicity in everything that you do.” She is quick to point out that green alternatives must also work as well as and be cost-competitive with the products they replace.

HUMC is working hard to only use green building materials, furniture and finishes in their new facility. “The Deidre Imus Environmental Center has been instrumental in pushing us to try to eliminate any toxins or potential toxins from the environment, in addition to meeting our LEED requirements,” Heeley says.

Casework and millwork at the Women’s and Children’s Pavillion are made of wheat board to eliminate formaldehyde, and rubber flooring replaces vinyl to eliminate polyvinyl chloride (PVC). Wall-protection systems for hand and bumper guards are also PVC-free. All sealants, adhesives and finishes employ products with the lowest-VOC content available.

Both BCFH and the Discovery Health Center rate IAQ extremely important, and aggressively pursued green building products, furniture, finishes and medical supplies. “This is a maternity and pediatric care center, and ergo needs to be sensitive to environmental issues,” Abelkis says. “We know the challenges the environment is posing on mothers—mercury, dioxin, the list goes on and on. We cannot build a facility that has a negative effect on these women.”

Caring for Staff
Patients aren’t the only ones who benefit from greening healthcare. Amenities such as access to views and daylighting are gaining recognition as important factors in staff performance and retention. With hospitals facing increasing problems hiring and retaining nurses and other skilled workers, this is a significant issue.

“ Amenities for staff in design is just starting to be talked about,” says Kim Shinn, director of sustainable design at TLC Engineering. “There is starting to be a lot of evidence that staff who do not have regular access to daylight and views tend to make more errors than staff who are more humanely housed.”

At BCFH, designers provided daylight and views to clinical labs located in the basement. “We put in deep area window wells that are pretty wide and they are landscaped,” Ennis says. “They look out into a landscaped area instead of being enclosed in the basement.” Break spaces for staff were designed to be bright with nice views. The cafeteria spills out into a courtyard facing the Rocky Mountains.

In his book Futurescan 2002: A Forecast of Healthcare Trends 2002-2006, Russell Coile points to research linking a healthcare organization’s values with its effectiveness in attracting and retaining staff. “At Boulder Community Hospital, the board of directors believes there is a direct link between the quality of the environment and the quality of health for our community,” Abelkis says. He says the decision to build a LEED facility reflected those values to the community and the staff. “Everyone who works here is very proud of the fact that this hospital recognizes the importance of building a green facility,” Abelkis says. “I get folks all the time saying they are proud that this is a value of this hospital.”

Staff and construction workers also benefit from steps to improve IAQ and employ green materials. Green building specifications aim to minimize the use of nonrenewable resources, opting instead for products made from recycled materials or rapidly renewing resources like cork and bamboo. While searching for a green replacement for fiberglass insulation, Imus found cotton insulation made from recycled denim jeans. “At first the installers were not very happy about the cotton insulation because it is not as easy to work with as the traditional fiberglass,” Heeley says. “But at the end of the project they said they actually felt better because they did not have the itch they had working with fiberglass.”

Greening hospitals extends beyond construction to include maintenance practices. Daily operations such as cleaning affect worker health and safety in addition to impacting IAQ. Imus has been working with HUMC and 20 other hospitals to green their cleaning products. She stresses that green cleaning not only improves IAQ, but also benefits hospital workers by reducing accidents and sick days resulting from exposure to caustic cleaners, solvents and other hazardous materials. As an added benefit, replacement of traditional cleaning products with green products has resulted in savings ranging from three to 75 percent in facilities taking part in Imus’ “Greening the Cleaning” program.

Slow Adoption
Despite compelling arguments, the healthcare industry has been slow to embrace green design and building practices. Currently, only two healthcare facilities, BCFH and the Discovery Health Center, have achieved LEED accreditation. Thirty-two other projects are in the pipeline.

One reason for the slow adoption is that LEED was originally designed for commercial buildings. “LEED certification did not take into consideration the uniqueness of building a hospital,” says Abelkis. The regulatory environment has also contributed to the slow pace.
“ Healthcare is a highly regulated industry,” Vernon points out. “The regulations create little flexibility in healthcare buildings. To pursue many green strategies, you need some flexibility.”

Another hurdle has been the perception of higher initial costs associated with green building. “Often clients are under the impression that it just costs more,” Ennis says. “And with healthcare clients, if they have more money, they want to buy a piece of medical equipment.”

Ennis notes that sometimes she can work around higher initial-cost concerns by talking about payback. But the payback benefits from green building, such as energy savings, accrue to the operating budget. “Unfortunately, the budget for construction projects is not tied to the budget for operating the buildings” Ennis explains. “So if you are trying to shift money from operations to construction, it is very difficult.”

Driving the Market Toward Sustainability
Several factors are converging to encourage the building of green healthcare facilities. First, more products meeting green design criteria are now available. Manufacturers are making progress eliminating VOCs, formaldehyde and other toxic substances from products. At the same time, the price and quality of sustainable products are becoming competitive with conventional products.

Kaiser Permanente, the nation’s largest nonprofit healthcare system, has used its considerable buying power to move the market toward more sustainable products. The organization has adopted the “Precautionary Principle,” which advocates erring on the side of caution when there is credible evidence that materials might result in environmental harm and replacing them with safer alternatives.

Kaiser’s influence on the market is best illustrated by a story. One of Kasier’s carpet suppliers didn’t take seriously a mandate in 2002 to deliver a carpet without PVCs or risk losing Kaiser’s business. In 2004, a competitor, Tandus Group Inc., produced a carpet to meet Kaiser’s specifications and won the 10-year contract to supply PVC-free carpets to 20 new hospitals. Other large hospital-purchasing organizations, such as Consorta Inc. and Premier Inc., are following Kaiser’s lead, pledging to purchase environmentally responsible hospital equipment and supplies.

Another promising development is the Green Guide to Healthcare (GGHC), a new toolkit and best-practices guide for building and operating green healthcare facilities. “GGHC is a self-certification metric tool, modeled on LEED but specifically tailored to healthcare,” says Guenther from Guenther 5 Architects.

GGHC modifies and supplements LEED to reflect characteristics specific to hospitals such as high energy and water utilization. Facilities earn credits by focusing on such things as the elimination of toxic substances, asthma triggers and phthalates. The guide also emphasizes the strong connection between human health, environmental health and the built environment. For example, GGHC includes strategies for implementing design elements that foster a healing environment, like gardens.

HUMC is seeking LEED accreditation and also piloting GGHC, along with 58 other healthcare facilities. “GGHC has done a good job explaining to people what the health issue is behind the credits,” says Ennis, “so healthcare clients can make the connection of why they should care about it.”

The objections and hurdles to sustainable hospital design and construction are gradually being stripped away. Healthcare organizations, designers and builders are gaining experience with each new building. Sustainable product markets are maturing. The industry is learning to expand its traditional focus beyond price, performance and availability to include environmental and human health considerations. And, most importantly, everyone is discovering that greening healthcare is not only good for the environment, but also good for patients, staff and the bottom line.