Healthcare Embraces Sustainability

There are many arguments for healthcare facilities to pursue green standards.

The importance of indoor air quality for human wellness was one of the reasons WakeMed pursued LEED for Healthcare on its North Hospital project in Raleigh, NC. EwingCole worked with WakeMed to select building materials, furniture, and furnishings that met low-VOC emission standards and were free of hazardous compounds. Photo: Brian Strickland, courtesy EwingCole

“Hospitals have incredible potential to contribute to a more integrated definition of ‘green,’ one that certainly touches the basic building-driven metrics,” according to Randy Guillot, FAIA, LEED AP, firmwide health and wellness practice area leader, design director, Gensler, Chicago.

“For example,” Guillot said, “hospitals utilize 50% more energy than a typical office building per square foot, and a recent report from the U.S. Department of Energy shows that the average hospital spends 15% of its revenues on energy. Therefore, the typical measures of sustainability related to energy, etc. are particularly relevant. But in addition, wellness principles around the sustainability of human health, happiness, and engagement are particularly important in these kinds of critical environments considering not just the sustainability of the building but of the people that occupy it. Climate change is also a health issue; impacts to communities and resources are real.

“With the rapid consolidation of hospitals and healthcare systems, combining multiple projects and taking advantage of a range of sustainability opportunities, hospitals and healthcare systems can have significant impact over single-building projects. Energy delivery, supply chain, and other operational economies of scale, as well as good design, can have a ripple effect throughout the communities where these hospitals are based. This also includes how sustainability can extend the life of the health campus,” Guillot continued.

In addition, “many cities and towns throughout the country are rife with shuttered or under-utilized healthcare facilities. These facilities vary in size, shape, design, context, and age, and have come to symbolize the state of the healthcare real-estate market. Together these are the hospitals left behind, and it’s a phenomenon that only promises to grow. Inventive reuse of these facilities can extend the useful life of buildings around the healthcare system’s mission and help to create more livable communities,” he added.

“The health of the natural environment is the foundation for community, financial, and individual wellness,” commented Maria Papiez, AIA, EwingCole, Philadelphia. “Since many of us spend 90% of our time indoors, the built environment is often a bridge between people and nature. That bridge is extra important in healthcare settings, as research has shown positive impacts on healing time and patient satisfaction when we have connections to nature. The healthcare typology exemplifies the importance of a dual focus on sustainability—protecting nature that our health depends on and designing environments that promote wellness. Our opportunity as designers is to understand that the built environment plays a vital role in health and healing, and to design spaces that support the care provided by medical staff,” she said.

“One of our long-term healthcare clients, Geisinger Health System, Danville, PA, has a deep understanding of this relationship,” Papiez noted. “While undertaking a recent large-scale central energy plant upgrade, Geisinger not only made decisions based on significantly improved efficiency and cost savings, but also described the concomitant improvement to population health outcomes, such as asthma attacks, work-loss days, and direct medical costs, as well.”

The Memorial Sloan Kettering Cancer Center in West Harrison, NY, the third major project EwingCole has completed for MSK, began with a 1950s office building and transformed it into a sophisticated, serene environment for the care of cancer patients. Connecting with the landscape was particularly important. Photo: Courtesy EwingCole

Financial pressure

Going green may not be the first thing that comes to hospital administrators’ minds. Most rank financial pressure as their top concern, so linking sustainability to financial performance is critical, Guillot thinks. “If you can show a significant annual energy savings by acting sustainably, it becomes a business imperative,” he said. “In addition, it doesn’t take a big leap to link sustainability and green building to health, at the very least our shared interest in the health of the planet, but it is often not one of the driving principles for the work—it should be. There are many examples of successful healthcare environments where a person’s health and responsible use of resources has produced transformative results.”

Citing the Sustainability Roadmap for Hospitals (2010), Guillot noted that CEOs who pursue sustainable building strategies do so for these reasons:

• improving brand image and reputation
• saving money
• increasing employee satisfaction and retention
• managing risk and regulatory compliance
• improving facility operations and pursuing performance excellence
• demonstrating corporate social responsibility.

Another factor that makes hospitals and related facilities good candidates for green and sustainable measures is that healthcare buildings are often located on large campuses with interconnected energy systems, Papiez observed. “Even small improvements in efficiency of these systems can have large impacts across an entire campus, reducing environmental burden and operating costs. With 8% of all carbon emissions in the U.S. coming from healthcare buildings (roughly 6,000 nationwide), improvements are critical,” she said.

The waiting areas and public spaces at the Memorial Sloan Kettering Cancer Center are all defined by how they interact with the surrounding nature. “The building is surrounded by a series of landscapes, including structured upper and lower gardens and a wetland meadow for viewing and visiting. Photo: Courtesy EwingCole

Infrastructure improvements

Infrastructure improvements are part of nearly every one of EwingCole’s healthcare projects, regardless of scale. Two have recently made major upgrades to their energy and HVAC infrastructure with affiliated, significant improvements to efficiency and cost, Papiez related.

“EwingCole has worked with Geisinger Health System since the 1960s. With a deep understanding of the organization and its building portfolio, we recently participated in the design of the integrated steam, cogeneration, and chiller plants currently in operation at the 2.2 million-sq.-ft. campus of the Geisinger Medical Center in Danville, Pennsylvania,” she said.

“A detailed evaluation of system options was undertaken, reviewing numerous aspects of efficiency, reliability, maintenance, environmental cost, and human-health cost. A centralized strategy was selected for this large campus in which a portion of the electricity and heating/cooling come from cogeneration and a portion come from a more traditional combination of utility electricity with boiler generation of heat and chiller generation of cooling,” she explained.

“Cogeneration, or combined heat and power, provides a total energy solution by recovering and utilizing the waste heat generated during the production of electricity to produce steam for heating and cooling with significant improvements to efficiency. A newly constructed chiller plant and expanded boiler plant bring these services into a central location on campus. To further improve efficiency of operation and reduce cost, a 1 million gal., 8,000-ton-hour thermal storage tank allows the cooling load to be shifted to off-peak hours. In total, this combination of equipment and strategies resulted in $2.2 million in annual utility cost savings and dramatically decreased pollutants released into the atmosphere, resulting in improved health outcomes for the surrounding population, Papiez said.

“At WakeMed North Hospital, EwingCole was commissioned to convert a 110,000-sq.-ft. outpatient clinic in Raleigh, NC, into a 61-bed, 242,000-sq.-ft. community hospital. This WakeMed campus began development in the late 1990s with an outpatient healthplex and, over time, added a stand-alone emergency department, a medical-office building, and a parking garage. With conversion to a full hospital, mechanical systems delivery was collected into one new central energy plant that houses the hospital’s generators, chillers, and boilers in one location. The central plant was approved as part of the project to ensure more efficient and comprehensive maintenance of this equipment in contrast to the challenges of a large inventory of point-of-use equipment. Technologies such as geothermal, fuel cells, and photovoltaics were evaluated for this project, but did not pass evaluation against the owner’s ROI criteria. However, a central energy location and higher-efficiency equipment still contributed to an energy savings of nearly 25% annually,” Papiez related.

Guillot agreed that infrastructure improvements play a huge role in the upgrading of health-campus performance. “Most of our hospital building stock in this country is old, with systems and infrastructure to match. Significant reduction in energy use and operational budgets can happen when central-plant equipment can be replaced on schedule with highly energy-efficient components. Balancing life-cycle costs with equipment costs can yield paybacks of less than eight years, and the annual savings from these kinds of moves and others, like envelope upgrades, can yield major operational savings. After smart improvements are made to the existing infrastructure, some healthcare systems, like California-based Kaiser Permanente, are opting to buy clean energy. As tax incentives disappear for solar and other renewables, the investment in this becomes more challenging for some healthcare systems,” he said.

There are healthcare systems such as Gundersen Lutheran in Lacrosse, WI, that continue to lead in the area of health systems using renewable energy, Guillot said. Some years ago, the healthcare system set a goal of achieving energy independence by 2014. By 2009 it had already made progress toward that goal, saving over $1 million in energy costs alone,” he noted.

“Equipment is a huge energy user in hospitals,” Guillot added, “and thinking of equipment in the same way as infrastructure can yield surprising effectiveness. Hospitals are now major consumers of computer technology, so even rethinking how to supply and operate computers can yield energy and environmental savings throughout a large system, according to Kaiser Permanente’s Electronic Products Environmental Assessment Tool (EPEAT).”

At WakeMed North Hospital, EwingCole was commissioned to convert a 110,000-sq.-ft. outpatient clinic in Raleigh, NC, into a 61-bed, 242,000-sq.-ft. community hospital. With conversion to a full hospital, mechanical systems delivery was collected into one new central energy plant that houses the hospital’s generators, chillers, and hot-water boilers in one location. Photo: Brian Strickland, courtesy EwingCole

Beyond saving energy

Saving energy might be a prime motivator, but there is solid foundation of research relating characteristics of green healthcare facilities to patient health outcomes.

“EwingCole’s embedded research team works with our healthcare studio on a regular basis to support and guide design decisions and evaluate facility performance by a variety of metrics once buildings are complete and in use. We regularly consider research on this topic in two primary areas,” Papiez said.

“First, the positive impacts of nature on wellness and healing are well documented. Physiological markers such as heart rate, stress reduction, and attention restoration are several of the ways in which health impacts, based on the incorporation of nature into healthcare facilities, are evaluated,” she said. “While an understanding of the therapeutic benefits of nature is not new, Roger Ulrich’s 1984 study, published in Science, is often cited as among early research on this topic. It showed that recovery times were faster and pain medication use was lower in surgery patients that had a window view to a wooded area versus a brick wall. Subsequent studies have built and expanded upon his research to review a variety of settings and include benefits to healthcare staff, as well as patients. Two recent EwingCole projects have centered on the incorporation of nature for healing and wellness.”

Papiez cited the Memorial Sloan Kettering Cancer Center in West Harrison, NY, as an example. It is the third major project EwingCole has completed for MSK. “The project began with a 1950s office building and transformed it into a sophisticated, serene environment for the care of cancer patients. Connecting with the landscape was incredibly important on this project. The waiting areas and public spaces are all defined by how they interact with the surrounding nature,” she explained. “The building is surrounded by a series of landscapes, including structured upper and lower gardens and a wetland meadow for viewing and visiting. A variety of indoor rooms within the center’s 300-foot-long lobby are defined by skylights and low-hanging chandeliers and ceiling elements to allow patients, family, and caregivers to engage the gardens while waiting. Several small outdoor courtyards are contained within the building footprint to provide access to natural views and daylight from interior portions of the cancer center as well. The building design and material palette are minimal to support views to the natural environment outside.”

One of the most direct outcomes from effective daylighting is shorter patient stays, but extending that concept to the clinician workplace, such as this meeting space in the Shirley Ryan Ability Lab, Chicago, is expected to have comparable results on effectiveness and overall engagement of the healthcare teams. Photo: Tom Harris, courtesy Gensler/HDR

Biophilic design aids healing

In addition, biophilic design principles, based on the notion of healing within a natural environment, drove the design of the new Abington Health Center Asplundh Cancer Pavilion in Willow Grove, PA, Papiez continued. “Biophilia is the innate human connection to and love of nature, and biophilic design provides a framework for incorporating elements and characteristics of nature into the spaces we inhabit.

For the Asplundh Cancer Pavilion, the vision was to reconnect the building inhabitants to an ecologically restored and vibrant landscape. Views to an adjacent creek were one of the primary drivers for early building massing, while a winter garden with views to the rain garden contains the main lobby and was placed directly adjacent to the main building entry. The building program was organized around providing views to the outdoor landscape, and natural materials such as wood and stone are used to bring colors, and textures into the building itself. The winter garden lobby is filled with daylight, contains several distinct planted areas, and showcases a vertical pier clad in birch bark.”

Another area of research is examining the links between indoor air quality and a variety of health and performance markers, such as cognitive function, Papiez said. “Over the past few years, the Harvard School of Public Health, Boston, has shown significant improvements to cognitive performance through improvements to indoor air quality, including increased ventilation rates, decreased carbon dioxide levels, and decreased VOC levels (Environmental Health Perspectives, 2015). While this research has focused on non-healthcare environments, the impact on human ability to cognate and make important decisions could likely translate to other building typologies.

“The importance of indoor air quality for human wellness was one of the reasons WakeMed pursued LEED for Healthcare on its North Hospital project in Raleigh, NC. EwingCole worked with WakeMed to select building materials, furniture, and furnishings that met low-VOC emission standards and were free of hazardous compounds. While most LEED programs offer guidance on VOC emissions, LEED for Healthcare takes a more holistic look at the indoor environment. The newest versions of LEED, LEED v4, have built on this approach for all programs,” Papiez said.

“One of the most direct outcomes from effective daylighting is shorter patient stays, as proven by studies for some time now,” Guillot added. “Daylighting saves on energy when coupled with effective shading strategies. I would suggest that looking at the clinician workplace in both the inpatient and outpatient setting will have comparable results on effectiveness and overall engagement of the healthcare teams. This is the next frontier in my mind. Hospitals will typically push staff areas to the center of floor plates—farthest from natural light. Locating these functions closer to windows and access to daylighting is part of an overall sustainable/wellness strategy for all, not just patients.

“The conversation in hospitals has typically been how to reduce steps for caregivers. It is important to provide effective care at the right time and to lean out waste, but what if we also could build an environment that promotes healthy activity and mobility into the lives of every employee, patient, and family member to promote healthy behaviors?” Guillot asked.

The concept behind the Shirley Ryan Ability Lab, Chicago, is known as translational medicine, which centers on physicians, therapists, and research scientists working with patients in an open setting called an ability lab. Photo: Dave Burk, courtesy Gensler/HDR

Other resources

Energy isn’t the only resource to consider when making a hospital or any other building green and sustainable. “Hospitals are huge consumers of one of our most precious resources: water. Large U.S. hospitals averaged about 43 million gallons and $200,000 [annually] per building, according to the U.S. Energy Information Administration,” Guillot observed.

“Water conservation can help health systems save dollars invisibly, but also become visible amenities on campus through landscape design. This decreases the strain on water supplies and reduces the needs to treat and release the water. Clinically, infection control can be improved through the use of water conserving, such as low-splash hand-washing stations,” he said.

Further, green-roof strategies can routinely reduce runoff by 50%. These roofs can soften the hard-edged, glare-producing of visible roofscapes of healthcare campuses and contribute to the overall sense of wellbeing,” Guillot commented.

As much progress as has been made toward greener, more sustainable and environmentally friendly healthcare facilities, much opportunity still exists for improvement in that area.

“In our experience, only a few healthcare systems are regularly pushing the boundary on system-wide sustainability topics like incorporation of renewable energy sources and material selection for environmental and human health. As these strategies undergo further testing and application, the economic pressures, risk adversity, and regulatory requirements that hamper the progress of large healthcare systems will likely diminish,” Papiez said.

“Rethinking a healthcare system’s standard presents an opportunity to use materials from sustainable sources, including looking at supply chains,” Guillot said.

“Ideas like regenerative design or salutogenic design—design that focuses on human health and wellbeing—should be at the core of the design process,” he added. “Spaces that encourage physical activity and build mobility through access to public transportation or walking paths are all things that contribute to a sustainable and regenerative environment.”

Standards and Certifications

Additionally, there is a growing body of standards to guide hospital administrators and design professionals. “A commitment to sustainability should begin with holistic sustainability standards but also require measurement of performance over time after project completion,” Papiez commented. “LEED and other sustainability metrics can be successfully coupled with these broader strategies as one aspect of an overall approach,” she said.

“While the foundation for sustainability is independent of project type, the methodology to accomplish certain goals and the thresholds for achievement of those goals do depend on factors particular to each building typology, especially healthcare. Specifically, healthcare buildings require more energy than many other building types based on HVAC system requirements such as air changes, 24/7 occupancy, energy-intensive procedures and equipment, and particular lighting needs. Additionally, healthcare facilities provide care for patients in a vulnerable state of wellbeing, and special consideration for quality of the indoor environment can support their healing,” Papiez said.

For WakeMed North Hospital, EwingCole used LEED for Healthcare as the sustainability metric, Papiez related. “LEED for Healthcare further promotes healthy buildings and healing environments by encouraging patient-centric strategies like places of respite while maintaining the foundational credits in energy and water efficiency. It also focuses more specifically on the quality of the indoor environment, from the selection of material contents to eliminate toxins and contaminants, to improved acoustics, and the incorporation of daylight and views. The project is tracking for Gold Certification later this year,” she said.

“Green Guide for Healthcare and LEED BD+C for Healthcare are two excellent resources for learning more about green design in healthcare,” Guillot added. “In the past, certification for healthcare was one of the few areas that had a special designation. As the LEED system has become more specialized and fine-tuned around building types, healthcare is now one of the many specialized rating systems offered,” he said.

There is little doubt that healthcare facilities have become greener and more sustainable in recent years. That trend will likely continue—equally to the benefit of patient well being, the healthcare system’s bottom line, and the environment.

Click here for the September 2017 edition of Ken’s View.


— Green Guide for Healthcare

Climate Action: A Playbook for Hospitals

— Practice Greenhealth

— Gunderson Health System Envision

— Sustainability Roadmap for Hospitals

— Kaiser Permanente Electronic Products Environmental Assessment Tool (EPEAT)

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