Green Bill of Health

Hospitals are complicated environments for green-design practitioners. Their scale, the critical nature of their mission and their often-stretched budgets can make sustainability—however it’s defined—a tough sell, without clear evidence of a quick return on investment. This may be changing, if slowly, as ties become clearer, connecting at least some areas of sustainability to better patient outcomes.

A difficult definition

As interest in broad environmental initiatives has grown, “sustainability” has become more difficult to define. It might be more accurate to say the difficulty lies in choosing which definition to use as a guidepost. For healthcare executives, there’s also a growing number of organizations, each with its own standards and certification programs, dedicated to environmentally friendly medical-­facility design, which can make choosing a definition even more challenging. As a result, building-team leaders say they sometimes encounter clients with a confusing array of priorities.

“Sustainability is very important to owners today. The emphasis on which aspects of sustainability, their motivations and experience level with sustainability continues to vary greatly, however,” said Troy Hoggard, architect and vice president with the Chicago office of Cannon Design and a member of the firm’s healthcare practice. “For example, we have clients who think sustainability means energy reductions, as these can have a very short payback. At the other end of the spectrum are clients who lead the industry by joining the Practice Greenhealth Healthier Hospitals Initiative.”

Practice Greenhealth is one of the recently founded organizations and rating systems focused on improving sustainability in healthcare design. These new programs are in part a response to the 2011 release of the U.S. Green Building Council’s new Leadership for Energy and Environmental Design (LEED) healthcare standard, LEED HC. Previously, hospitals had fallen under LEED NC (new construction) guidelines. Hoggard said the document hasn’t been universally accepted.

“The advent of LEED HC has somewhat polarized the owners because it is significantly more difficult to achieve Gold under LEED HC than [with] the older standards,” he said. “So LEED is becoming more of an elite goal for some clients and less important for others who were not as motivated.”

Some designers aren’t convinced any single standard or certification program can address the multitude of issues covered by the term “sustainable” for facilities as complex as a modern hospital. For example, Colin Rohlfing, vice president and sustainable development director in the Chicago office of architecture/­engineering firm HDR Inc., suggested building-team members cast a wide net when seeking input on ways to make hospitals healthier for both patients and the environment.

“Sustainable design philosophy and design approach should not focus solely on checklists and one rating system,” he said. “Design teams should seek to blend the best of multiple rating systems for inspiration.”

However, Rohlfing is a fan of the WELL Building Standard, which he said targets design decisions focused on the health and well-being of building occupants. 

“Office buildings, hotels and residential facilities may use it the most, but it will change the face of the healthcare industry,” he said.

When the healthcare marketplace is in flux, patients also are helping to drive change, said Robert Meurer, a member of GE Healthcare’s global design team. 

“Healthcare facility owners are often looking for ways to distinguish themselves to patients as the healthcare model reflects a growing influence of consumerism,” he said, noting that some facilities are installing healing gardens and adding locally sourced, organic food to their menus. “Through LEED and other quantifiable practices, healthcare providers can now draw the connection between environmental and human health.”

Regardless of definition or certification, reducing energy use tops the list of sustainability goals for most hospitals because these facilities are such large energy consumers. To begin with, systems are in use around the clock. They also face requirements for high air-exchange rates to help prevent the spread of infection, use enormous amounts of domestic hot water for sterilization purposes, and run energy-­intensive imaging equipment that is difficult to power down when not in use.

Perhaps because the problem seems too large, few facilities have targeted efficiency improvements as standalone projects. A 2013 survey conducted by the American Society for Healthcare Engineering and Health Facilities Management magazine found that only 45 percent of responding hospitals had conducted energy audits that year, and only 39 percent set and monitored an energy budget.

However, when planning new facilities, healthcare executives are putting more thought into boosting efficiency. In large part, these budget-conscious managers are motivated by an understanding that gained efficiencies will provide savings throughout the entire life of what could be a 50-year building.

“Because healthcare has large overhead and small margins, the impact of lowering energy bills can be dramatic,” Hoggard said. “The U.S. Department of Energy has calculated that every dollar of energy saved is equivalent to $20 in revenue for the average U.S. hospital. Every client is asking for efficiency. The issue is how much can they afford and at what payback period.”

Benefits of scale

Determining which efficiency upgrades make the most sense depends on the overall project scale, Hoggard said. For smaller department-level renovations, lighting and controls are often the best investments. In addition, Rohlfing said upgrading to higher-­efficiency medical equipment now is becoming an option.

“The EPA is developing a new product specification for medical imaging equipment,” he said, adding that the LEED healthcare standard also is promoting such advances. “LEED for Healthcare pilot credits are focusing on sterilization equipment and point-of-use electric steam generators that are in the lowest 25 percent of energy consumers in their category. This includes requirements for idling and standby mode, as well.”

Larger, campus-wide construction or renovation can incorporate central-plant improvements, such as high-efficiency chillers and other equipment that can create significant operational savings. With their combined need for heat and electricity, hospitals also can offer great opportunities for cogeneration.

“Energy is a market that has timing like any commodity exchange,” Hoggard said. “If you can build some flexibility on when you buy or sell energy into the grid by producing some power on-site, those are large savings per unit of production. Because hospitals are required to have redundant energy sources, the economic case for cogeneration can be compelling.”

Designing for those redundant energy sources—generally diesel or natural gas backup generators—lately has become more complicated, Rohlfing said. The Environmental Protection Agency (EPA) has issued regulations on the emissions of stationary engine equipment that all owners must follow.

“EPA Tier 4F regulations for these types of generators are now in effect. They can remain fossil-fuel-based, but their emissions requirements are much more stringent,” he said, adding that this has some facilities looking beyond traditional diesel and natural gas. “Bio-based solutions for rural healthcare facilities have become more prevalent.”

Considering a hospital building could have a lifespan of 50 years or more, sustainability for these facilities also means building flexibility into design plans to make future renovation easier. Hoggard calls it “the most requested sustainable goal.” Technologies, medical treatment protocols and even payment structures are constantly evolving, and all of them can affect building design. His firm is working on two complete hospital-replacement projects, and he said the related planning efforts are the most complex he’s ever seen.

“Our planning has to demonstrate multiple growth scenarios with minimal cost and disruptions to future operations,” he said, noting the priority placed on the issue by top-level hospital executives. “This is an area where a sustainable outcome is so wired into the thinking of the C-suite that they don’t usually consider it green. It’s just survival in the market.”

GE Healthcare’s Meurer sees this kind of long-term thinking regarding hospital-systems operation as critical to organizational success. But he said this planning needs to be based on a foundational understanding of a facility’s mission that remains constant, even as ideas of best practices continue to evolve.

“Hospitals will likely remain the core of centralized healthcare for some time,” he said. “Healthcare facility owners, regardless of what sustainability means to them, must remember the ‘why’ behind their operations—bringing effective, quality healthcare to patients.”

About the Author

Chuck Ross

Freelance Writer

Chuck Ross has covered building and energy technologies and electric-utility business issues for a range of industry publications and websites for more than 25 years. Contact him at

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