The question “How green can healthcare be?” nags at healthcare providers and their building teams these days. As an industry, we're merely treading water in the rising tide of sustainable design. Every day, new developments raise the bar for environmentally intelligent design across the spectrum. That's a good thing, except when our clients are overtaken by high seas—or left floundering on the shore like beached whales.

The latest challenge shaping sustainable thinking arises from the American Institute of Architects' (AIA) new position on Architecture, energy, and climate change. Rather than let building designs remain addicted to oil, last December the AIA adopted a tough stance to promote sustainable design and resource conservation: The policy calls for “a minimum reduction of 50 percent of the current consumption level of fossil fuels used to construct and operate buildings by the year 2010.”

This laudable and achiev- able goal builds on the work of Santa Fe–based architect Edward Mazria. He calculates that between now and 2030, 75% of the overall building stock will have been newly built or renovated. By stepping up the efficiency of operations—to a 60% reduction by 2015, then to 70% by 2020, and so on—we will make the built environment of the United States a positive contributor to global climate stability.

No wonder the AIA dove in. This outcome instantly appeals not only for environmental reasons, but also for obvious economic and even geopolitical benefits. Except for the most ardent promoters of fossil fuels, no one stands to lose. Or do we?

Healthcare owners and designers will find it especially difficult to navigate these uncharted waters. In terms of total energy used, health-related facilities bear among the highest burdens across all commercial building types (only foodservice structures and convenience stores burn more).

The numbers are striking. According to the Department of Energy's Energy Information Administration (EIA), office buildings use on average about 90 kBtu—the equivalent of 26 kilowatt-hours—per square foot every year. Healthcare buildings? Multiply that by two or three times. Consider these examples, also from the EIA's 2003 Commercial Building Energy Consumption Survey (figure):

  • Outpatient healthcare: 83 kBtu per square foot per year

  • Skilled nursing: 127 kBtu per square foot per year

  • Inpatient healthcare: 229 kBtu per square foot per year

That's not a misprint: 229 kBtu, the equivalent of about 67 kWh per square foot of enclosed inpatient space annually!

But wait. There's more.

While energy use is decreasing for most building types surveyed, it is increasing in healthcare. An EIA analysis in 2004 showed that total U.S. office energy use had declined by 11% from 1989 to 1999, while healthcare's share had grown by 15%.
Figure. annual energy usage intensity of commercial buildings by category. courtesy of the energy information agency's commercial building energy consumption survey.

Sink or Swim

For those healthcare professionals and designers who want to do their share for the environment and global climate, the EIA data are certainly disconcerting. It seems we're not treading water but, instead, contributing more significantly to global carbon imbalance as each day passes. Yet, there are many reasons for optimism.

First, leadership on healthcare design has arrived. The first LEED-rated hospital opened just three years ago, Colorado's Boulder Community Foothills Hospital. Powerful initiatives have been launched recently, too, like Hospitals for a Healthy Environment and the Green Guide for Health Care. These tools enjoy broad support among a wide coalition of building owners, designers, and health professionals. And the U.S. Green Building Council's LEED “Application Guide” for new healthcare construction is in development.

Even more telling, the perfect storm made landfall in the Pacific Northwest this summer: The Center for Health & Healing at Oregon Health & Science University, the world's first LEED Platinum healthcare building. This reasonably priced facility consumes an estimated 125 kBtu per square foot per year in building energy—a 61% reduction over its baseline load estimate. (That's no misprint, either.)

Second, we should take heart in the surprisingly short history of sustainable design. While its underpinnings can be traced back to Rachel Carson's 1962 Silent Spring or the 1973 oil embargo, contemporary green practices and tools are brand new. It was only in 1993 that U.S. Green Building Council formed; two years later, fewer than 100 people attended its annual meeting to hear the idea of a green building rating system (eventually LEED) discussed publicly for the first time. LEED was only launched in 1998, with the first Platinum rating awarded in 2000 to SmithGroup's Chesapeake Bay Foundation Headquarters.

So while the momentum seems irreversible today, in historical terms we've only just begun. And in the health services sector, it's déjà vu: We're reliving the same challenges faced by green design proponents in the early days.

Healthcare architects still report back from the trenches that sustainability is a hard sell. Hospital and clinic operators still ask for cost-benefit analyses to prove the value of green choices. “None of our clients are looking for this,” say designers. “We're not sure how to do it, and isn't life already complicated enough?”

A Call to Arms

We can't get off that easy—not today. By going Platinum, the Center for Health & Healing drove an important stake in the ground. Yes, it can be done. Slowly but surely, best practices are being recognized by healthcare clients everywhere. We no longer need a cost-benefit analysis for a low-flow toilet, and we don't struggle to find a low-VOC paint.

This is a call to arms: Sustainable designers and their clients need to show the industry we know what we're doing, so we can garner an ever-greater portion of healthcare building dollars. An aggressive look at our mounting energy use is just the start. There are many more steps to take:

1. Show stakeholders that green is mainstream. In commercial construction, the green leaders are now big-name organizations, not niche players. It's a top agenda item among perhaps 75% of educational clients. The era of the boutique specialty firm as the green designer of choice has peaked, too: Large Architecture and engineering firms serve the lion's share of the sustainable design market.

2. Focus on “future-proofing” healthcare ops. Care delivery and facility operations are expensive already. With energy costs escalating as fast as environment-of-care standards, sustainable design becomes a risk-management strategy. For our insurance-oriented industry, it seems wise to invest in future-proofing against rising operational costs.

3. Commit to tracking energy use. To future-proof, we have to benchmark. But a review of recent literature suggests that healthcare organizations rarely publish data on building energy use. Knowing actual and estimated energy use levels for sustainable buildings is critical, in part because once you start measuring something, it takes on greater significance. (Perhaps Healthcare Design will commit to publishing estimated annual kBtus on its featured projects?)

4. Build on healthcare's moral imperative. Professionals in the health fields are on a mission: To make a difference in people's lives. And they care more about the big picture—like climate change—and what they can do to make the world better. So, philosophically, sustainability advocates and health advocates are aligned.

There's an old axiom: “It exists, therefore it is possible.” From that perspective, the Platinum certification for the Center for Health & Healing is terrific news. Mazria's “2030 challenge” exists, and economic and moral imperatives make it possible. Using new green technologies and best-in-class design, we can align healthcare design activities with our personal beliefs. We can stop believing that this only happens elsewhere in the profession.

Healthcare building teams have worked hard, but we have farther to go. As Deming said, “A big ship traveling at top speed takes both time and distance to change course.” But the challenge is there—let's focus on it. HD

Russell Perry, AIA, LEED AP, is a Principal at the Washington, D.C., office of SmithGroup, a leading healthcare design and planning firm. Serving as the national leader of the firm's growing sustainable design initiatives, Perry joined SmithGroup in 2005 after 11 years at William McDonough + Partners, where he was a founding partner. His sustainable design experience has resulted in significant projects around the world.