Despite the correlation between health care’s fundamental principles and the tenets of green design, most health care organizations haven’t been aggressive in moving toward green buildings. They have been reluctant because of some unique challenges posed by incorporating green design principles into health care facilities. But a growing body of experience shows that those obstacles can be overcome by a mix of commitment, teamwork, pragmatism and financial savvy.
The timing is right for the health care industry to apply green principles. Health care construction is at a high level as the industry responds to changing demographics, medical needs and technology. This boom in construction represents an opportunity to create a generation of buildings with significantly smaller environmental footprints.
Although the term “green design” is widely used, it may be useful for health care facility executives to think of “greener” design. After all, is there any absolutely “green” building — except perhaps for one that is never built? “Greener” is useful for another reason. It recognizes that green design is not a one-size-fits-all solution. It is sometimes said that green design is simply good design. But if an organization is struggling to make payroll, is it good design to spend more of its limited capital in pursuit of green goals? Good green design has to support the goals of the organization.
The goals of the organization should be the starting point for any discussion of green strategies. The facility executive should be clear about why the organization is interested in building and operating a greener facility. There are three basic reasons for a facility executive to incorporate a green element into the design and operation of a health care building:
Despite the benefits of green design, health care organizations face obstacles that other types of building owners don’t.
First cost is a barrier for pursuing green design in many kinds of facilities. However, health care facilities present a special challenge because of their thin margins and high first costs even without green measures. Hospitals in California can now cost $1,000 per square foot, and many health care organizations — pressed by insurers, doctors and regulations — simply cannot afford to invest additional capital in green design measures.
Another major obstacle to bringing greener building solutions into the health care environment is the mass of regulations that govern health care facilities. Because of the role they play in society, health care institutions are heavily regulated by both building codes and operational codes. Each regulation creates a barrier to trying new design strategies, including green strategies.
A third challenge is overcoming the lack of familiarity with green design measures and technologies. Health care organizations are conservative — with good reason. As a result, they tend to be reluctant to embrace new approaches until the new approaches have been pioneered and proven elsewhere. This attitude is especially prevalent in the infection control staff at many institutions. That’s easy to understand, given the serious risk of hospital-acquired infections.
Despite those obstacles, a growing number of health care organizations are adopting green design principles. A good deal of information is available about particular ways health care institutions have implemented greener design and operations elements. The Green Guide for Health Care and its technical briefs give many good examples of particular things that facilities have successfully implemented. (See “Moving Forward with Green Design”) Valuable information is also available from such groups as the U.S. Green Building Council, the American Society for Health Care Engineering, and Hospitals for a Healthy Environment, which is also known as H2E. But limitations on resources and other factors can make it difficult for a health care facility to take some of the measures mentioned in those resources.
Nevertheless, there are ways for health care organizations to overcome some of the obstacles to green design. Consider the following eight prescriptions for dealing with challenges.
Because the concerns of infection control specialists, often embodied in regulations, are so serious, they offer special challenges for implementing various kinds of strategies. However, they offer as many opportunities. Many strategies involving the use of greener materials inside the building will not only make the building more environmentally responsible, but will also provide a healthier environment for the patients, staff and visitors. Other concerns can only be overcome by careful study of proposed measures and even scientifically conducted studies. A recent study on ventilation strategies by Kaiser Permanente involved infection control specialists in the effort to determine the effects of various proposed alternatives.
Involving infection control professionals is extremely important in building a case for the safety of the proposed measures. Once the infection control staff has agreed that a particular green design element is safe, there is still the issue of regulations, which may block the use of green measures. For example, codes currently prohibit the use of displacement ventilation in hospitals, which could save energy. A research project is currently underway to examine the effect of displacement ventilation used with reduced air change rates on ventilation effectiveness, thermal comfort and infection control.
Regulators often have pathways for alternate means of complying with their regulations, but these are likely to offer additional hurdles to implementing newer, greener designs in health care buildings.
Despite these challenges, the health care industry offers many opportunities for implementing green building strategies. Health care organizations are steeped in an ethic of caring — caring for their patients, for their communities and for the greater good. Health care organizations can work towards all of these goals by pursuing green design. Overcoming the challenges to green design will require applying to buildings the same single-minded dedication that health care practitioners bring to their art.
While it may be challenging to get all the parties in one place, the most sensible way to implement green strategies in a new facility is to use an integrated design approach.
The advantages are numerous. First, by gathering all the stakeholders in one location and hammering out a vision, expectations — and the cost — can be clearly understood by all parties involved.
“Everybody has to buy into this,” says Joe Kuspan, architectural designer with Karlsberger Associates. “You are only as strong as your weakest link.”
Two prerequisites in the Green Guide for Health Care call for integrated design. One reason is an attempt to reduce cost and complexity by focusing on green up front, says Adele Houghton, project manager, Green Guide for Health Care. “The later you start, the more of a cost premium there is,” Houghton says.
Holding one charette — as short, intense design meetings are often called— isn’t enough. Stakeholders need to meet throughout the process, says Alan Scott, principal with consulting firm Green Building Services. “Bringing them in and updating them on new opportunities and challenges and getting their feedback can be a very valuable experience,” he says.
On one project, the team decided to shift from using a photovoltaic array to improving indoor environmental quality because the urban site had a number of logistical challenges regarding PV use. Had the team not been meeting regularly, the decision may have been made to simply drop the PV array without switching focus to indoor environmental quality.
— Brandon Lorenz, senior editor
Further advances in technology may pave the way for more efficiency gains without penalizing indoor air quality. Displacement ventilation, where air is discharged at floor level and vented through the ceiling, is one possibility.
Introducing the air at ground level reduces the amount of fan energy needed to move the air and eliminates the penalty that comes with cool air picking up the heat load from lighting systems and transferring it into a room. Improved circulation means fewer air changes are required. And cooling air in a displacement ventilation system also doesn’t need to be as cold and increases free cooling days, says Robin Guenther, principal for Guenther 5 Architects.
Such systems are already in use in Scandinavia, Guenther says. They haven’t yet found widespread use in acute care facilities in the United States because some infection control staff fear that air rising from the floor would pick up dirt and other contamination. Research is currently underway to examine the impact of displacement ventilation on comfort, ventilation and infection control.
Dell Children’s Medical Center in Austin, Texas, uses raised floor cooling in its office space, while some clinics have adopted displacement ventilation. In the case of one facility in New York, displacement ventilation and a radiant heating system combine to achieve significant savings, says Guenther.
Despite numerous challenges, facility executives have plenty of motivation to consider energy efficiency on their next health care project. Health care ranks second only to the food service industry in intensity of energy usage, according to the Department of Energy. And energy costs are soaring.
“It will not work for hospitals to take a position that they have to use that energy to save lives,” says Robin Guenther, principal for Guenther 5 Architects in New York. “Collectively in this industry we have to be smarter than that. We have to find a way to do both things.”
Given the rise in energy prices, CFOs are likely to be more receptive to projects such as upgrading old chillers or adding variable frequency drives, Guenther says.
“Within the next 12 months there is absolutely going to be far more discussion about climate change impacts from the use of fossil fuels and more pressure on the health care industry to do something about it,” she says.
Walter Vernon is a principal with Mazzetti & Associates, a mechanical, electrical, plumbing and telecommunications consulting and engineering design firm headquartered in San Francisco. Vernon is an electrical engineer with more than 20 years of experience in the design and construction of health care facilities. He is co-coordinator of the Green Guide for Health Care and a member of Kaiser Permanente’s Environmental Stewardship Council.