Think about this: If you were asked to identify the one building type that needed the highest-quality indoor air, the lowest levels of toxic off-gassing, the greatest access to daylighting and outdoor views for occupants, the most efficient energy and water usage—in other words, the greenest building—what would you think of first?
Hospitals, right? Sure you would. Hospitals should be leading the way in providing patients, their families, doctors, nurses, technicians, and office staff the ultimate sustainable experience. Sick people should have the greenest buildings of all.
Sadly, healthcare institutions have been infamously laggard in rallying to the green building cause. Of 2,758 projects registered with the U.S. Green Building Council's Leadership in Energy and Environmental Design new construction program (LEED-NC), only 73—a measly 2.6%—are in healthcare, and not all of these are big, acute-care hospitals. Compare that to 1,130 multiuse projects (41%), 569 office buildings (21%), 183 university structures (7%), and 148 K-12 schools (5%) in LEED-NC, and the disparity is readily apparent.
The reasons—or excuses—are all familiar: Hospitals are already heavily regulated. Hospitals are extremely complex structures. Hospitals have tricky adjacencies. Hospital boards and CEOs are risk averse. Hospitals suck up enormous amounts of air and water—they're energy hogs, so they can't possibly be made green.
It's also true that LEED Version 2.2 is not hospital-friendly. LEED is fine for office buildings and schools, but until the LEED Application Guide for Healthcare is out (hopefully sometime this year), hospital officials will continue to view LEED as peripheral to their central mission.
Then there's the Green Guide for Health Care (www.gghc.org ). This well-conceived set of guidelines goes far beyond LEED in rating hospital projects. GGHC requires integrated design, something LEED only hints at. It covers both construction and operations, and it offers specific health policy reasons for each of its credits. Unlike LEED, however, it is self-compliant: Building Teams rate their own performance, which to some is a shortcoming. Currently, 79 projects are participating in the GGHC pilot program.
Despite these obstacles, some brave souls are trying to build hospitals that meet LEED or GGHC standards. BD&C talked to Building Teams from six such efforts, to see what advice they have to offer AEC Building Teams about how to apply sustainability to their own healthcare projects.
The hospitals and systems: Dell Children's Medical Center, Austin, Texas; St. Mary's/Duluth (Minn.) Clinic (SMDC); Children's Hospital of Pittsburgh; Metro Health, Grand Rapids, Mich.; New York-Presbyterian Healthcare System, based in Manhattan; and Kaiser Permanente, based in Oakland, Calif.
Please note that some of the following recommendations could apply to any project, but they all have special relevance in healthcare projects, due to the cost and complexity of hospital design and construction.
"Your relationship with the owner is key," says Beth McGregor, an associate architect and LEED Accredited Professional with Pittsburgh's Astorino, the design firm for that city's new Children's Hospital. Upon completion, the project will seek LEED certification for its 265-bed, 900,000-sf clinical services hospital and LEED Silver for its 260,000-sf research building.
Having a viable relationship with the owner is true in any project, but it's especially relevant if you're involved in a LEED or GGHC hospital project. "There are basic things where you can get certification, but there are some things that require you to push a little with the client," says McGregor. That's why you need buy-in on high.
It's easier, of course, if those in the C suite have already bought in to sustainability. At Metro Health in Grand Rapids, the decision to adopt LEED traces back four years, when the board adopted green principles related to patient care. "That commitment started at the CEO and CFO level," says Jarrad Pitts, project manager for the new Metro Health hospital in Grand Rapids, Mich.
Robert Robbins, AIA, senior designer at HKS Inc., Dallas, says he was inspired by the enthusiasm his client, St. Mary's/Duluth Clinic, brought to the project. "They talked about their responsibility to their patients and staff, and the long-term benefits of sustainability," he says. "They didn't have to be sold on it."
In most cases, however, it won't be that easy. With all the pressures on hospital executives, the CEO may have "limited stamina" to deal with a green agenda, says James Moler, national manager for engineering systems in Turner Construction's healthcare unit, based in Nashville. That's when you need help from elsewhere.
Even if you have the CEO or the hospital board on your side, you also need someone inside to do the day-to-day slogging. In the case of New York-Presbyterian Healthcare System, that's Jennifer Kearney, the system's energy programs manager, who has led the LEED-Existing Buildings and GGHC Operations pilot at the system's Weill Cornell Medical Center and the LEED-NC and GGHC Construction pilot for a new heart hospital at Columbia Presbyterian.
"It really helps to have someone like a Jennifer Kearney whose role is to unite all the interests and disciplines around the idea of best practices and green approaches," says Kurmit Rockwell, a certified energy manager with ConEd Solutions, Arlington, Va., and a consultant to New York-Presbyterian. The hospital system was named Energy Star Partner of the Year for excellence in energy management in 2005.
Don't start off pitching the project on the basis of energy savings or environmental benefits alone. "The green folks are talking about saving the planet, but the healthcare executives' job is to provide a service that helps sick people get well. They're not on the same page," says Moler. His advice: "Talk about the green agenda being a health agenda."
In fact, you might even avoid the phrase "green building," says Ron Kirk, project manager on the SMDC hospital in Duluth, Minn. "It didn't mean much to us," he says. "Our goal was to create a healthy building."
"We're doing LEED as a complement to doing healthcare, not as a statement of being environmental," says Metro Health's Pitts. "We'll do everything we can, but not if it means sacrificing direct patient care."
"Get your team together as early as you can, and evaluate which things make sense as early as possible," says Pitts. If you're going for LEED certification, it's crucial to "educate the team early on the intent of LEED," he says.
Michael Horman, associate professor of architectural engineering at Pennsylvania State University, says that getting the contractor and systems engineers engaged early also is crucial in hospital projects, especially complicated ones involving LEED or the Green Guide. "They bring competencies in terms of constructability and providing accurate costs of systems," says Horman. "If you've got a contractor who understands the green process, they can help in materials selection and recycling."
That has been the case for St. Mary's/Duluth Clinic, where Harvey Anderson, VP of facilities, says M.A. Mortenson, the contractor on the 225,000-sf expansion, "took responsibility that all requirements for LEED were in their contract, and managed all the sub and materials vendors."
Don't forget your suppliers and subcontractors. Alan Harbert, construction manager with Austin's White Construction Co., the CM firm for Dell Children's, says that, by getting all the subcontractors trained in the construction waste component right from the start, the project has exceeded its 75% recycling goal. He also pushed his concrete contractors early to get as much fly ash content in the concrete as possible; as a result, they're over 30% fly ash content.
It's crucial to cram everybody in a room for two or three days at the beginning and hash out the basic program. For Dell Children's, architectural firm Karlsberger, of Columbus, Ohio, brought in several outside sustainability consultants to facilitate the discussion: Greg Franta, FAIA, now with the Rocky Mountain Institute/ENSAR; Gail Vittori of the Center for Maximum Potential Building Systems and the driving force behind the Green Guide and the LEED Application Guide for Healthcare; and Keen Engineering, North Vancouver, B.C., whose president, Kevin Hydes, chairs the U.S. Green Building Council.
Turner Construction's Moler says a visioning session can help "build a framework and a common vocabulary." "We put LEED and GGHC up side by side, and we ask which credits can be earned without breaking the bank. At the end of that session, we see how to incorporate them in the project, or we see if additional work needs to be done."
"See what you're already doing that's green, and get a baseline as to where you would fall in LEED or GGHC and where you could be with a little effort," says Kurmit Rockwell of ConEd Solutions.
Turner's Moler says that many hospital projects could easily get 22 LEED points with no additional cost, "so you're only a few points from certification." A well-conceived GGHC project may have many points in the bank even before you get too far into design.
Kaiser Permanente SVP John Kouletsis uses a kind of triage approach: first, eliminate any ideas that make no business sense; second, set aside ideas that need further analysis. What's left are the things that you must do.
What's "reasonable" is relative, but you should have a good idea what the CEO and hospital board expect in terms of payback periods on first costs.
For Dell Children's, the team set a goal of a seven-year return. "That supports the hospital's business model," says White Construction's Tom Howard.
Kaiser's Kouletsis says he has to demonstrate a payback of 3–5 years to his management, "unless it's something that's overwhelmingly of interest to the community," such as getting rid of fluorescent lights that contain mercury. "We always ask: What is the value to our patients, our members, and the corporation? Because if there's no margin, there's no mission."
For the Dell Children's project, the Building Team established basic principles, says White Construction's Howard. "We said, Let's not do anything dumb. Let's not spend $100,000 to get a LEED point with no payback," he recalls.
Harvey Anderson, VP of Facilities for SMDC, in Duluth, says they quickly dismissed cost outliers like photovoltaics. "Our budget couldn't handle it," he says. "Based on our climate, we couldn't get some of the points no matter how much money you threw at them."
At Kaiser Permanente, Kouletsis is willing to experiment a bit in new technology. He's had success partnering with manufacturers to develop new environmentally preferable products, such as new rubbing flooring (the nora brand from Freudenberg Building Systems) and nonvinyl-backed carpet (the Ethos brand from Tandus Group).
He recently tested formaldehyde-free rice board and wheat board at Kaiser's manufacturing facility in Vernon, La. "We discovered it's not yet cost-effective," he says. "We liked the material, but we were not willing to pay the extra price."
He's also testing insulation made from—are you ready for this?—recycled blue jeans. The cotton material costs no more than foam insulation, has a higher R-value, is more resistant to mold and mildew, and is safer to work with, he says. The only drawback: It takes longer to install than foam insulation.
Use all the arguments for sustainability that you can muster, says Turner's Jim Moler: the potential for better staff recruitment and retention ("Some of these hospitals are getting applications from all over the country"), greater control over the spread of infection, better patient outcomes, and improved public perception of the hospital.
But be prepared for skepticism from hospital boards and managers if you push "evidence-based design" (EBD) too far. Kaiser Permanente's Kouletsis urges caution in pushing the benefits of evidence-based design, which sees good design itself as improving patient outcomes. "At Kaiser, we're not a slavish follower of evidence-based design and green building," says Kouletsis.
For the LEED-EB effort at its Weill Cornell Medical Center and future reconstruction at Columbia Presbyterian, New York-Presbyterian's Jennifer Kearney projects "an enormous payoff" in energy reduction from retro-commissioning in four major buildings, totaling three million sf. The program will extend over the next 3–5 years.
"There are buildings that are more than 100 years old," she says. "This will provide us with a roadmap to savings. In New York City, where energy costs are the highest, anything we do will have incredible paybacks."
Kearney is also about to implement an environmental management system, to ensure 100% compliance with EPA regulations and to track waste reduction. "An EMS gives you measurable and verifiable results," says Kearney.
They're the hospital's primary patient base, so keep their needs in mind.
New York-Presbyterian has replaced fuel-oil burners with natural gas systems, even though gas is more expensive, says Con Ed Solutions' Kurmit Rockwell. "Everything we do has to have an immediate impact on the patients and workers, and then to the health of the surrounding community," he says.
At Kaiser's Modesto hospital, the facilities director has set aside a small plot of unused land for community residents to have a "Victory Garden" to grow vegetables in.
"Take advantage of what's out there," says Turner Construction's Moler. One example: Oregon distributes funds from a tax on utility bills for energy conservation projects. Minnesota Power gave St. Mary's/Duluth Clinic rebates for reducing peak load by replacing old mechanical systems with more energy-efficient units.
Dell Children's Medical Center was able to get Austin Energy to build at 2.5 MW natural gas-fired turbine generator with absorption chillers, heat-recovery equipment to produce steam, and backup equipment.
By not having to build its own central plant, parent Seton Healthcare Network will save $6.8 million, the bulk of which is being reinvested in other energy-conservation measures and LEED initiatives, says Robert Moroz, AIA, former VP of facilities.
The freebies don't even have to be fully "green" to benefit the project. The city of Duluth created a tax-increment finance zone and is subsidizing the construction of an 800-car parking garage and skyway system for St. Mary's/Duluth Clinic—amenities that don't come out of the project budget, and therefore make green initiatives more feasible.
The goal is not "greenness" for its own sake. It's improved patient care. The challenge to Building Teams, says Penn State's Michael Horman, is "to bridge the physics of buildings with the physiology of healthcare. Until that happens, we're probably going to keep fumbling around with greening in healthcare."
Remember, too, that going "green" is not enough of a differentiating factor by itself, warns Kaiser Permanente's Kouletsis. Just as Kaiser aspires to be seen as a fully integrated healthcare system, "the same concept has to apply to the design" of hospitals themselves. "If it's an integrated package, then it's good," he says. "It can't be greenwash."
Kouletsis urges hospital systems of all sizes to keep trying to do the right thing for the environment, as long as it makes sense within their business plans. "You don't have to be a $30 billion corporation like Kaiser to do these things," he says. "It's not related to size. It's related to commitment and vision."
GGHC Green Guide Pilot
(as of January 2006)
|The self-certifying Green Guide pilot has healthcare projects in Canada, China, Malaysia, and Poland. Work is under way to merge it with the LEED Application Guide for Healthcare.
|Million sf total||22|
|By facility type|
|Medical office building||11|
|By construction type|