Today, the building industry is challenged to address the same critical issues that lie in the years ahead. Global warming, rapidly diminishing supplies of oil and natural gas, unbridled air pollution, and government instability resulting from the above, are all critical concerns that face us in the 21st century. Many building sectors are already in the midst of a shift toward a sustainable philosophy.

For almost a decade, we have seen reports about high-performance schools that enhance learning, sustainable office buildings that improve worker productivity, green retail spaces that experience increased sales, and energy-efficient residential units that sell faster than the competition. These headlining projects all have a common thread – extraordinary design and a conscientious attempt to minimize the use of natural resources. While the Toyota Prius opened up a mass market for environmentally friendly cars, these exceptional projects are paving the way for future advancements in building design.

On the converse, relatively few healthcare facilities have made similar headlines. However, the proven benefits in other sectors have many healthcare institutions embracing the sustainable design ideology. Motivated by a concern for public health, a desire to reduce operating expenses, and a sense of social accountability, healthcare providers are now asking the same questions as those of Chairman Toyoda.

The Environmental Challenge

Yogi Berra once said, "prediction is very hard, especially when it’s about the future." Yogisms aside, there is surmounting evidence that uncharted levels of global warming and climate change are imminent, due predominately to our built environment’s consumption of carbon-based fuels. Statistical evidence indicates that the building industry is the largest contributor to greenhouse gasses – even greater than the transportation or manufacturing industries.

After brainstorming the key concepts and characteristics that would become the overarching principles for 21st century cars, Toyota designers and engineers reduced their list down to two – natural resources and the environment.

Last December, in a similar move to reverse the environmental impact of the built environment, the American Institute of Architects (AIA) released a policy statement adopting aggressive targets in the fossil fuel consumption of buildings. The resolution, known as the Architecture 2030 Challenge, is a global campaign initiated by New Mexico architect Edward Mazria, AIA. Aimed at reversing the continued escalation of carbon dioxide and other greenhouse gasses into the atmosphere, the 2030 challenge asks the global architecture and building community to target the following:

• All new buildings and developments should be designed to use 50 percent of their current fossil fuel energy consumption – half the national average for that building type as benchmarked by the U.S. Department of Energy
• At a minimum, an equal amount of existing building area is to be renovated annually to use 50 percent of the amount of fossil fuel energy it is currently consuming
• The fossil fuel reduction standard for all new buildings be increased to 60 percent in 2010, to 70 percent in 2015, to 80 percent in 2020, to 90 percent in 2025, and, finally, to 100 percent in 2030

While the amount of energy consumed in other building sectors has been steadily decreasing, healthcare facility use has been on the rise, according to the Energy Information Agency. Considering that healthcare facilities consume over twice the amount of energy of other building types and emit commensurate amounts of carbon dioxide, it is time to aggressively consider a new design process.

Tools for the Task

Until recently, it has been difficult to perceive what it means to integrate environmentally responsible design into the framework of institutional facilities. Industry accepted tools and guidelines were not available. Once they did emerge, they were not readily accepted. This, in part, is because medical facilities are already one of the most heavily regulated building types and are plagued with constantly evolving policies and regulations. However, there is a number of sustainable design tools now available specifically targeted at assisting designers, owners, contractors, and operators in adopting environmentally preferable strategies. These tools also begin to establish the baseline for defining 21st Century healthcare facilities.

In 2001, the U.S. Green Building Council launched the LEED® Green Building Rating System. It was quickly adopted by many commercial and governmental projects, but was initially considered incongruent, or unsuitable, for healthcare facilities. Nevertheless, a handful of committed designers and owners have since demonstrated that LEED® can indeed be as effective a tool for healthcare projects as it is for commercial projects. LEED®, an acronym for Leadership in Energy and Environmental Design, is the building industry’s most recognized consensus-based rating system that offers a respected third-party certification of a project’s environmental achievements.

Thousands of projects are registered and awaiting future certification. Of the more than 600 projects that received certification as of August 2006, only seven are healthcare projects. Five of the seven projects received their certification in 2006, including Lacks Cancer Center at Saint Mary's Health Care in Grand Rapids, Michigan and Isaac Ray Treatment Center in Logansport, Indiana. These come well after the Boulder Community Foothills Hospital that was certified in late 2003. Many other large-scale projects are expected to receive certification in the near future including the Center for Health & Healing at the Oregon Health & Science University in Portland, Oregon and St. Mary’s Duluth Clinic in Duluth, Minnesota. The Center for Health & Healing is reported to be 61% more energy efficient than code requires – an astounding accomplishment.

The anticipated LEED® Application Guide for Healthcare Projects, currently in development, should make implementing the LEED® rating system even more effective for healthcare projects. The first version for public review and comment is expected to be released mid-2007.

Another valuable tool is the Green Guide for Health Care™ (GGHC). The GGHC is the first quantifiable sustainable design toolkit specifically tailored for the healthcare sector. It is a voluntary educational guide designed to inspire health-based design principles and to encourage self-certification of high-performance healing environments. According to the GGHC website, more than 100 health care systems – representing 27 million square feet in new construction – are using the GGHC to build and operate hospitals that are healthier for people and for the environment.

The GGHC is unique in that it identifies specific health concerns for each of its 42 different credits requirements, which integrate solutions or improvements to these health concerns. Another unique aspect of the GGHC is its operational and maintenance protocols. Centered on environmental health, these protocols offer recommended practices imperative to maintaining the health and environmental profile of the facility operations. Such protocols are critical components of a healthcare system and are most successful when considered during the programming and design phases.

The popularity of both of these relatively new tools is encouraging and already proving to be highly influential in transforming the design, construction, operations, and maintenance of healthcare facilities. There are many synergies between the two products, and healthcare systems are encouraged to use both – gaining the third-party certification offered by LEED® and the health benefits afforded by the GGHC.

Healthier Healing Environments

In this century, we have only begun to understand the qualitative and quantitative health benefits that can be realized when sustainable strategies are implemented in healthcare projects. Historically, the programmatic needs of healthcare facilities drive large, dense floor plates which make daylighting an incredible challenge. Nevertheless, superior healing environments result when innovative designers overcome these obstacles and successfully integrate natural daylighting into their projects. Day-lighted environments speed the healing process and pacify the anxiety and stress of patients, caregivers, and families. Numerous surveys document that patients with views to nature had measurably accelerated post surgical recovery times, required fewer medications, and experienced less depression.

Material selection is also a factor in improving the healing environment. By selecting benign building materials that are free of toxins, healthcare institutions can improve indoor air quality and protect the health of patients and staff. Current transformations in the building materials market are allowing designers to develop cancer treatment centers free of carcinogens; pediatrician clinics free of airborne chemicals that trigger asthma; and landscapes maintained without toxic herbicides, pesticides or chemical fertilizers.

All building materials that have the propensity to negatively impact human health will likely be phased out in the century ahead and replaced with healthier alternatives. Currently, there are several under scrutiny. Polyvinyl chloride (PVC) is a concern due to the dioxins that are generated during the manufacturing process. PBTs, persistent bio-accumulative toxins, are chemicals of particular health concern because they do not readily break down in the environment and have a wide range of negative impact on human health, including links to cancer. Formaldehyde, a compound common in many wood-based products such as particle board and plywood, is also a probable human carcinogen. Mercury, a potent neurotoxin, is commonly found in thermostats, switches, and certain lamps.

Fortunately, due to the green building industry’s ability to transform the industry, there are a growing number of safe alternatives to these products that are equal or superior in performance. This is acutely important in areas housing patients with impaired immune, respiratory, and neurological systems.

Better Economics

Toyota’s number one business principle is to "Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals." Sustainable design strives to apply this same philosophy. For instance, high-efficiency lighting, daylight harvesting, high performance building envelopes, green power, and cogeneration are benign alternatives to the more polluting technologies associated with cheaper, first cost solutions. The same strategies result in facilities that use fewer natural resources over their lifetime, allowing a healthier relationship between operational costs and revenue.

Several commissioned studies on the costs of LEED® certified projects in general conclude that the cost premium for a silver-certified project is, on the high end, about two percent for build-to-suit projects. Assuming a cost of $400 per square foot for an average healthcare facility, this would equate to a cost premium of approximately $8 per square foot. Considering the potential for energy cost savings, staff retention, better recruitment, increased productivity, and a healthier indoor environment, this seems like a small price to pay for a 50-plus year facility. While some of the benefits cannot be measured on a traditional balance sheet, there is a strong case for improved economic success.

Sustained Success

The phrase "first, do no harm" has for many years been a hallowed pledge for physicians – one that recognizes that human acts with good intentions may have unwanted consequences. It is one of the principle precepts all medical students are taught in medical school. Sustainable development teams can apply the same basic premise to the facilities on which they work. This entails design, procurement, construction, and operational methodologies that look beyond the cheapest first cost solutions to a more holistic approach that targets the institution’s long term economic goals without compromising the health of the community it serves.

A complete, integrated approach to high-performance healing environments will complement most healthcare organization’s values and business objectives. Perhaps the single most significant factor in determining the feasibility of incorporating sustainable strategies into 21st century healthcare projects will be the core business values of the healthcare system and their design teams. Like Toyota, those that do will position themselves for greater market share and sustained success.