As recently as 10 years ago, the idea that natural light, views of nature and clean, fresh air in health care facilities could actually speed patients’ recoveries would have been viewed by many as new-age nonsense. While few would have argued that those elements would do harm, the focus was on technology, value engineering and fast-track construction, not amenities many perceived as bells and whistles.
Similar doubts and conflicting priorities slowed the adoption of green building in the health care industry. There was the perception that green design would cost more, take longer and result in a lower quality building.
But that was before research by academics and non-profit organizations began to produce evidence that natural light, views of nature and clean air improve patient outcomes and increase staff productivity. Meanwhile, as interest in green building began to explode, facility executives learned how to make the business case for green and project teams learned how to design green health care facilities at a cost comparable to traditional construction. It wasn’t long before owners, designers, and facility executives realized how complementary evidence-based design and green building really are.
The result: A rapidly growing repertoire of health care facilities all over the country that are light, airy, patient- and staff-focused, and environmentally responsible. And the timing couldn’t be better. As the population ages, health care needs are increasing and more space is necessary. According to FMI, a firm that provides management consulting and investment banking to the construction industry, health care construction will grow to $45.4 billion by 2009, up from $34 billion in 2005.
One example of an organization that has embraced both the health care construction boom and the convergence of evidence-based design with sustainability is Kaiser Permanente. The nation’s largest health maintenance organization (HMO) is in the midst of a 10-year, $24 billion master plan for new hospital construction, and is carefully considering how those hospitals can be both green and healthy.
“The most interesting part about our environmental strategy is that we realized early on that, if we just do environmental building, but don’t focus on patient health and safety, it’s a non-starter,” says Christine Malcolm, senior vice president, hospital strategies and national facilities for Kaiser Permanente. “Focusing on patient health and safety strengthens the business case for environmental strategies.”
But it’s not just the health care giants that understand the convergence. New health care facilities like the Providence Newberg Medical Center in Newberg, Ore., the Medical Center of the Rockies in Loveland, Colo., and the Dell Children’s Medical Center of Central Texas in Austin, are all striking examples of successful projects that took the convergence of evidence-based design and green construction to the nth degree. Though built to accommodate many different needs, they share many characteristics that reflect emerging trends in health care construction all over the country.
It makes sense that natural light and views of nature improve mood and reduce stress, but only in the last several years has evidence emerged about how they can benefit patients and staff at health care facilities. A study titled “The Impact of Light on Outcomes in Healthcare Settings” by The Center for Health Design in 2006 concluded that “adequate and appropriate exposure to light is critical for health and well-being of patients as well as staff in health care settings. Natural light should be incorporated into lighting design in health care settings, not only because it is beneficial to patients and staff, but also because it is light delivered at no cost and in a form that most people prefer.”
The study synthesizes data from dozens of peer-reviewed studies and reports how natural light improves the mood of depressed patients, decreases staff errors, reduces the amount of pain medications spinal surgery patients need, and brings about a variety of other positive effects.
“A bright room positively influences outcomes,” says James Moler, manager of engineering systems at Turner Healthcare. “Daylighting has both energy and evidence-based design value.”
How does daylighting influence energy? Simple. The more natural light a building brings in, the less electric light is needed, resulting in a more energy efficient building. In addition, fewer heat-generating artificial lights may mean HVAC systems don’t need to work as hard during the summer months to condition lighting-heated air.
Designing health care facilities with lots of light, then, seems natural, though not easy for health care facilities with large floorplates. However, at the nearly 500,000-square-foot, $200 million Dell Children’s Medical Center, designed to be the first ever LEED Platinum-certified health care facility, about 64 percent of all space has access to natural light.
“We made sure there was daylight wherever it could be,” says Joe Kuspan, senior vice president and director of design for Karlsberger, the lead architect for Dell. “The really neat thing is that there are no offices or patient rooms without daylight.”
Daylight was also identified as a goal early on for the Providence Newberg Medical Center, the first LEED-Gold-certified health care facility. The project team led an eco-charrette at which the community could provide input about the design and features of the new facility. Nine guiding principles were developed, including making the facility “welcoming, and not intimidating” and “environmentally responsible and sustainably designed.” Maximizing natural light was one way the project team addressed these issues.
“In northwest Oregon, sunlight is at a premium,” says Richard Beam, director of energy management systems for Providence Health and Services. “But we still thought the more daylight we could bring in, the more welcoming the facility would be.” Through modeling, the design team oriented the building on its site to achieve optimum exposure to daylight.
The way a building is oriented on its site also influences another feature of evidence-based design. Back in 1984, a study that ultimately launched the field of evidence-based design showed that patients with views of nature went home three-quarters of a day earlier, had $500 lower cost-per-case, used fewer heavy medications, had fewer minor complications, and exhibited better emotional well-being than patients with a view of a brick wall. Many follow-up studies have also supported the benefits of views of nature.
The Providence Newberg Medical Center is one example of a health care facility designed with patient views in mind. Newberg is located in the heart of Oregon wine country, and the building was sited so that patients and visitors have sweeping views of the countryside from the public areas and patient rooms. The idea is to provide a calming feeling and help patients and their families relax, says Beam.
Designers of the Medical Center of the Rockies, a 600,000-square-foot facility pursuing LEED Gold certification, oriented the building to face southwest, giving patients a stunning view of Longs Peak and the foothills of the Rocky Mountains. In addition, says Bob Gance, director of facilities, a carefully developed landscaping plan conserves water and gives patients and visitors calming views through the building’s wide expanses of glass and extra-wide patient-room windows. “The whole idea is that the landscaping will be returned to a natural wild life area,” says Gance. “Patients will be able to look out their windows and see foxes running and jumping.”
But no matter how stunning the scenery around a facility, there are always areas that won’t have access to it. Kuspan and his colleagues solved this problem at Dell Children’s Medical Center by embedding a series of six courtyards throughout the facility.
The courtyards provide patients and staff with relaxing views almost anywhere in the facility, and they make it convenient to take patients outside from almost any location in the building. And there’s an additional benefit: The courtyards make it easier to bring in fresh air. “We draw intake air from the courtyards,” says Kuspan. “It’s good, clean air — no exhaust from cars or other bad air from the street.”
Bringing in non-contaminated air is certainly important, but a more pressing concern is making sure that air doesn’t become contaminated after it’s already in the building. Ensuring good indoor environmental quality as a measure to reduce nosocomial, or hospital-acquired, infections is a crucial goal in buildings designed to facilitate health. It is also another example of the intersection of green building and evidenced-based design. Both The Green Guide for Health Care and LEED have sections devoted to indoor environmental quality, including guidance on everything from products with low-VOC emissions to higher ventilation rates.
According to The Center for Health Design, nosocomial infections account for 88,000 deaths per year and cost $4.5 billion in care. And several studies link poor ventilation, or poorly maintained ventilation systems, to higher incidences of nosocomial infection rates.
One such study by The Center for Health Design concluded that “the importance of good air quality in controlling and preventing airborne infections in health care facilities cannot be overemphasized. Providing clean filtered air and effectively controlling indoor air pollution through ventilation are two key aspects of maintaining good air quality.”
With this in mind, design teams for new health care facilities are using a variety of strategies that combine use of high-efficiency particulate air (HEPA) filters with high ventilation rates. There are several codes and standards — ASHRAE 62.1-2004 and AIA’s design guides are probably the most oft-consulted — that specify ventilation rates and provide benchmarks for indoor air quality. The Center for Health Design cites a study indicating that peak efficiency for removing particles in the air space occurs between 12 and 15 air changes per hour.
But some hospitals have stepped up their ventilation rates to well beyond code — 100 percent outside air, to be exact. For example, all new Kaiser Permanente facilities will have 100 percent outside air, says Malcolm. The Providence Newberg Medical Center took the same approach.
“This significantly lessens the possibility that someone would be harmed by airborne pathogens and contract a communicable disease,” says Beam.
Not all design teams are willing to take the energy-intensive step of using a 100 percent fresh air ventilation system. But Beam says there are ways to mitigate the energy penalty — rooftop heat recovery systems, for one. Another possibility is using a finely tuned building automation system to closely monitor air changes and ventilation rates, as is the case at the Medical Center of the Rockies.
“We try to optimize outside air,” says Gance. “We run everything with the BAS, including stepping down our VAV boxes when they’re not needed and throttling down our HVAC system, too. We ask our BAS to do a lot more computing than normal.”
The goal is to find a balance between the higher-than-average energy requirements of health care facilities and the evidence-based design strategies that improve patient health. That balance isn’t always easy. Energy, for instance, is one area where sustainability and evidence-based design may be at odds. Lately, this conflict has manifested itself in another trend as well: the extra energy required in a facility with all single-patient rooms.
Evidence-based design research has illustrated that single-bed rooms are a critical factor in reducing nosocomial infection rates, along with outside air and HEPA filters. “The single-patient room isn’t necessarily a sustainable strategy,” says Todd Tierney, a principal with Anshen + Allen, an architectural firm that has concentrated on the convergence of evidence-based design and green. “But it is an evidence-based design strategy. It’s the best for the caregiver, patient health and privacy.”
The single-patient-room philosophy conflicts with green because current design practices mean that more space is required for fewer total patients than double- or group-occupancy models of care. This means the overall footprint and energy use of a facility may be greater. But given privacy and other issues, most experts agree that single-bed patient rooms are the way most health care facilities of the future will be built.
Even with the high energy requirements, it’s clear that many design teams are still making indoor environmental quality and the health of the patient and staff the top priority.
The good news is that air changes and filtering aren’t the only ways to think about indoor environmental quality. Closely inspecting procurement strategies for materials used in health care facilities has become a staple of many health care organizations’ environmental plans. For instance, Kaiser Permanente has partnered with an organization called Health Care Without Harm to help train its staff how to buy materials that don’t contain harmful chemicals such as lead, mercury and dioxins, or other criteria that have landed a material on the blacklist — PVC, for example. The HMO has also eliminated the use of latex gloves and vinyl IV bags, and worked with carpet manufacturers to eliminate PVC from carpet backing while still meeting the organization’s performance criteria.
“We have a list of chemicals we can’t have in our buildings,” says Thomas Cooper, Kaiser Permanente’s principal for environmental design and research. “A lot of our environmental purchasing policy is based on our own standards.”
Both LEED and The Green Guide for Health Care provide guidance on low-emitting materials as well, and many project teams see the selection of low-emitting building materials as good ways to be environmentally responsible and focus on the health of patients and the productivity of staff.
And that’s the whole point. Ultimately, the intersection of green and evidence-based design is a facility in which patients have the most stress-free and healthy environment in which to heal and staff can do their jobs most effectively and without fear of getting sick themselves. Health care facilities now aren’t just designed so that they “do no harm.” They are becoming active parts of the healing process — both for the patient and the environment.
The current boom in health care construction presents a golden opportunity to transition from the old notion of building to a new philosophy that combines evidence-based design and green strategies. A study titled “The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity” by researchers including Robert Ulrich, an architecture professor at Texas A&M University and one of the world’s foremost experts on evidence-based design, provides some guidance.
The landmark study compiled data from more than 600 other evidence-based design related studies. It concludes that “evidence-based design is not about hospitals that are simply nicer or fancier than traditional hospitals. Rather, the focus of evidence-based design is to create hospitals that actually help patients recover and be safer, and help staff do their jobs better.”
But the meat of the study is a list of actions health care facility executives and design teams should take when building new health care facilities. Items include:
— Greg Zimmerman