When Arthur Mombourquette decided to construct Brigham and Women’s Hospital’s new comprehensive cardiovascular care facility according to green design principles, people were skeptical. “Every architect and engineer I spoke with said, ‘You can’t do this,’” said Mombourquette, Vice President of Support Services at the Brigham. The year was 2002. The skeptics thought that green materials were unaffordable, green design was overly complicated, and the resulting building wouldn’t be energy-efficient enough to make the arduous process worthwhile.

They weren’t alone. Even as recently as 2007, nearly half (47%) of respondents to a survey by the trade publication Building Design + Construction said they expected to pay a 3-15% premium for green building design. Only 8% thought that the cost differential between green and non-green design would be negligible.

As it turns out, the 8% were right. Industry research has shown that with an experienced team, a green hospital project can be built at or near the cost of a conventional project. Furthermore, green design is vital to the health of patients and the planet.

For years hospitals have been unwitting contributors to pollution and sickness by exposing patients, staff, and the community to noxious chemicals now associated with a wide range of adverse health effects. Many floors, carpets, paints, cleaning supplies, building materials, and furnishings release volatile organic compounds (VOCs) into the air, which is further polluted by poor ventilation and inefficient energy consumption. It is now thought that these factors lead to longer patient recovery times and more staff sick days, besides contributing to global warming.

Mombourquette was adamant that the Carl J. and Ruth Shapiro Cardiovascular Center would be different. Sustainability, he says, “isn’t just about saving energy. It’s about creating a healthy environment.” That is, a place that promotes healing, reduces stress, improves patient and employee safety, and is sensitive to the community it’s built in, while reducing the carbon footprint.

If every health care facility were to embrace green building design, the effects would be felt around the globe, according to Bill Ravanesi. Ravenesi directs the Boston office of Healthcare Without Harm, a global coalition of almost 500 organizations working to protect health by reducing pollution and promoting high performance healing environments in the health care sector. The health care sector comprises about a seventh of the U.S. economy and is the nation’s second largest consumer of energy per square foot. Annually the sector constructs 100 million square feet of medical building space and spends $5.3 billion on energy. “That makes it imperative that health care become a better steward, not only of health but of the environment and the planet,” says Ravanesi. “Of all the industry sectors, it is the only one that has taken an oath: first do no harm. It is in its mission to do the right thing.”
 

The business case for green design
Today, the case for green design in health care facilities is no longer just tied to energy savings. According to the Institute for Innovation in Large Organizations (ILO), a membership organization of upper-level executives in multi-billion-dollar organizations, the rationale for building green today accounts for financial gains, improved patient outcomes, better staff health, reduced turnover, and community benefit through a reduced environmental impact.

That was certainly the case for Brigham and Women’s Hospital. When it came to constructing the 440,000 square foot, 10-story Carl J. and Ruth Shapiro Cardiovascular Center, “we pursued green design holistically,” says Mombourquette. “We installed state-of-the art ventilation and cooling systems and energy-efficient lighting, but we also thought about the people who would work in the building, the patients who would stay there, and the residents of the neighborhood surrounding it.”

Some 70 percent of interior spaces receive natural light during the day—“not the first thing that comes to mind when you think of sustainability,” Mombourquette says. Other green features include low-energy fixtures, an Energy Star-compliant roofing system, high-efficiency air handlers and conveyance systems that improve air flow, low-flow plumbing fixtures, water-efficient landscaping, a wastewater recycling system, and environmentally friendly and recyclable carpets and floor coverings. Non-toxic recycled rubber floors require no waxing or stripping with toxic chemicals and are softer underfoot, potentially reducing slips, falls, and stress fractures. In addition, during construction, contractors recycled more than 90 percent of construction waste and used recyclable building materials

Today, the Shapiro Center, an advanced tertiary care facility, is a LEED Silver building, a designation granted by the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) program. The Shapiro Center is the first health care center in New England and one of only four in the country to be awarded this status.

A growing body of research suggests that green health care facilities such as the Shapiro Center improve patient outcomes and reduce health risks to staff. Examples cited by the ILO include a case study ⁽¹⁾ at the Mackenzie Health Sciences Centre in Canada, which found that depressed patients in sunny rooms recovered faster than those in darker rooms; a study of 17 hospitals in Canada ⁽²⁾ showing decreased tuberculin conversion (a positive tuberculin test result) among employees working in patient rooms with better ventilation; and a study at Bronson Methodist Hospital in Michigan ⁽³⁾ showing that applying green design principles such as improved ventilation, private rooms, music, light, and nature in its redevelopment project led to reduced nosocomial infections and lower nurse turnover rates.

Additional benefits to green hospital construction, reported in a study by Robin Guenther, Principal at Perkins + Will in New York and author of Sustainable Healthcare Architecture, included a “consistent, positive correlation between green building, staff recruitment, retention, and performance.”

While Mombourquette says it’s still too early to tell whether the Shapiro Center will demonstrate these benefits, one thing is for certain: it shattered the assumption that green design costs a lot more than non-green design. In fact, constructing according to LEED Silver standards added less than one percent to the overall project cost, while reducing energy costs per square foot. And this is a 24x7 facility with 16 operating rooms and 134 intensive care beds.

It helped that elements like sunlight, sophisticated air handling systems, and green cleaning products were part of the original design, Mombourquette says. Still, the expense turned out to be a far cry from earlier estimates. Other LEED-certified hospitals are finding the same thing, says Guenther, who interviewed the heads of 15 LEED-certified health care projects. A third required no additional capital for LEED certification and the vast majority paid less than a two percent premium

A green era
Much has changed since 2002. Today, the health care sector has completed or begun numerous green projects, many of which follow LEED specifications or standards developed by the Green Guide for Healthcare. In fact, there’s enough experience in the field now that LEED is developing a new certification level for the industry: LEED-HC.

Yale-New Haven Hospital is undertaking a $750 million project to build three new facilities. One, the 14-story Smilow Cancer Hospital, will house over 4,000 square feet of elevated green space, a healing garden, and energy-conservation measures such as a high-efficiency HVAC system and a sloped ceiling with special insulated glass panels with fixed louvers that reduce the need for artificial lighting by optically controlling light and heat transmission from daylight while directing it deeper into the rooms. These measures are expected to result in energy costs for a 511,000 square-foot building that are roughly equal those of much smaller (350,000 square feet) facilities, according to C. Bradford Bevers, Director for Facilities Design and Construction. He says designing green is “good for the operation of the building, good for the environment, good for patients and employees, and is also the way to be a good neighbor.

In addition to the Shapiro Center, a number of green hospital initiatives are underway in the Harvard medical community. The Spaulding Rehabilitation Hospital is getting redesigned to meet LEED Silver standards. The Massachusetts General Hospital (MGH) is developing a Building for the Third Century (B3C), scheduled to open in 2011. Designed to meet LEED Gold standards, the 530,000-square-foot clinical facility will have several healing gardens and a green roof, and will be built using recycled wood and renewable and locally acquired materials, while recycling 90 percent of demolition materials. Beth Israel Deaconess Medical Center (BIDMC) has been performing energy projects with earnest over the past four years. In that time, it has found that payback is possible for initiatives ranging from installing high-efficiency heating and cooling systems to implementing recycling programs to using green cleaning products. For example, BIDMC has seen a 48 percent return on lighting upgrades, a six-month return on motors and variable frequency drives, a 130 percent return on vending misers (which turn off unused vending machines), and a 70 percent return on water conservation efforts. Rebates from utility companies and government programs boosted these returns substantially, says Utility Manager Mark Lukitsch. Such incentives are now nearly ubiquitous.

Partners HealthCare, the Boston-based health care system that includes the Brigham and Women’s Hospital and MGH, is investigating a distributed energy policy for all of its hospitals in an effort to move away from centralized power plants and fossil fuel-generated power. MGH, for example, is investigating cogeneration (production of electricity from steam, heat, or other forms of energy produced as a by-product of another process), Spaulding will use fuel cell cogeneration technology, and Martha’s Vineyard Hospital is exploring windmills and solar power.
 

The future
These projects and others have not only helped create a more sophisticated case for green hospital construction, but have lowered the cost of materials and supplies. In 2007, Partners HealthCare and seven other major health systems banded together with Health Care Without Harm, Practice Greenhealth, and the Center for Health Design to create the Global Health and Safety Initiative. The group has already used its members’ purchasing clout to generate eco-friendly building materials, processes, and products that cost roughly the same as their toxic counterparts. Today, they are working on getting food suppliers to sell healthier (i.e., hormone- and antibiotic-free) meat and dairy products and trans fat-free baked goods for their patients and staff. Next up: finding a low-cost, earth-friendly alternative to Styrofoam for their cafeterias. These efforts help hospitals make a substantial case for themselves as responsible corporate citizens.

Although hospitals have fewer dollars to spend on new construction these days, the lessons learned on LEED and Green Guide for Healthcare projects are being applied to renovation projects and throughout hospital operations. We have reached the point of no return, say health care facilities directors. Hubert Murray, Manager of Sustainable Initiatives at Partners, says that in the future, “Sustainability will no longer be a discipline. It will be just the way we do business.”

Robin Guenther agrees. “It’s no longer acceptable to not build the most energy-efficient and environmentally progressive building you can,” she says. “It’s the new baseline of health care construction.”
 

PHMI and international perspectives
Eco-consciousness is an international issue, but challenges and design considerations are different for hospitals outside the U.S., says Lorain Matthews, AIA, LEED AP, a Director at Partners Harvard Medical International who is involved in facility and infrastructure development projects. While U.S. hospitals are primarily investigating ways to lower energy costs, hospitals in emerging countries are working to raise the quality of health care, which necessitates using more energy and resources.

Matthews explains that even though many of these organizations are focused on health care improvement, “clients from all over the world raise the issue of sustainability. They are driven by the high cost of energy and a desire to set a good example for their country and their region.”

One approach, which PHMI is employing in an academic medical campus development in Pakistan, is to create a “sustainable master plan” that incorporates both traditional and modern design principles from the beginning. “Bringing in sustainable principles early allows these ideas to become part of the ethos of the team,” says Matthews.

Sustainability measures for the master plan—which includes a 350-bed hospital, medical, nursing, and allied health colleges, residences, and support services—focus on three areas: strategic site planning, integrated landscape design, and resource-sensitive energy models. For example:

• Planning: Although the site has 500 acres, the campus buildings will be contained in a compact, walkable campus of only 100 acres. This approach minimizes the impact on the environment and reduces transportation needs.
• Landscape: Much of the remaining 400 acres will be restored as a beautiful river valley. These principles will carry into the planning of the hospital by marrying the courtyard vernacular style of the region with best practice hospital planning. The aspiration is to create a forward-looking health care model that combines the best of both worlds by bringing the light, air and landscape into the structures while meeting the infection control standards of a high-quality patient care environment.
• Energy: The campus will rely on tri-generation, which combines hot water, chilled water, and power generation to create an integrated and productive energy model. It may also use renewable energy strategies, such as solar, wind, and geothermal power.

“We’re intrigued by traditional models for built form in the countries in which we work, and look for ways to merge them with sophisticated hospital systems to create something that is a more integrated and sustainable hospital design for each unique location,” says Matthews. “To me this is a powerful way to learn from the past to create a more sustainable future.”

--Written by Natalie Engler for Partners Harvard Medical International

For more information:

Healthcare Without Harm:
noharm.org

Green Guide for Healthcare:
ghc.org

U.S. Green Building Council:
usgbc.org.LEED

Practice Greenhealth:
practicegreenhealth.org

The Center for Health Design:
healthdesign.org

Global Health and Safety Initiative:
lobalhealthsafety.org

Physicians for Social Responsibility:
psr.org

CleanMed:
cleanmed.org