What is value to a healthcare institution? Value is providing quality healthcare services to your patients at a competitive, fair price. It is respecting your employees and providing them with a safe and healthy workplace. Value is serving your community without being a burden on its resources. These values represent the “triple bottom line,” where equal value is placed on economic prosperity, social responsibility, and environmental stewardship.

Unfortunately, the economic bottom line has too often defined our values. If paying the lowest price is all the industry demands, then the industry will continue to experience rising nosocomial infections, unhealthy indoor environments, increased employee absenteeism, and loss of talented personnel, while becoming ever more susceptible to regulatory sanctions, liability claims, and increasing energy and utility costs. In short, all three of these values are interrelated and must be accounted for to achieve a sustainable healthcare system in the 21st century.

The healthcare industry stands at a defining point for facility design in this new century. Over the past few years, tremendous strides have been achieved in the way medicine is practiced, with the fast-paced shift to the “digital” hospital, the advancing technology of diagnostic and treatment equipment, and “smart” medicines. These have had a tremendous impact on how healthcare is delivered, while at the same time placing new demands on the facilities in which medicine is delivered. Aging infrastructures in existing facilities that are incapable of accepting these new technologies and lack the flexibility to adapt to them are just two of the major motivations behind one of the biggest healthcare building booms in history.

Several recent surveys predict that hospitals are planning to meet these demands by increasing capital spending by an average of 14% annually over the next five years.1, 2 What an opportunity this gives the industry to break from the design/construction mind-set of the past and lead the nation toward a more energy-efficient, flexible, and healthy building environment! The time is ripe for value-added, high-performance, sustainable design and construction. However, even with these high-tech medical practices, the healthcare industry still suffers from profound technologic inconsistencies.

Using some of the most advanced technologies ever developed, the United States leads the world in medical breakthroughs. But at the same time, we design and construct our healthcare facilities using materials, systems, and techniques that have outlived their effectiveness in meeting the demanding challenges of today's healthcare environment.

Businesses in other sectors have embraced sustainable design principles to cut costs by reducing energy consumption and improving productivity. It's time for the healthcare industry to realize the full potential of sustainable design to improve the quality of our nation's health facility infrastructure.

The common fear of many embarking on a capital project, when faced with the question of whether to pursue sustainable or high-performance design, is the notion that it will increase costs. While there are as yet insufficient numbers of green healthcare facilities from which to gather historic cost data, early indicators from the few completed projects to date don't support that fear.

Kaiser Permanente, the largest nonprofit healthcare organization in the United States, has been a leader since 1963 in moving the healthcare industry toward a long-term vision of environmental stewardship.3 Driven by California's seismic safety codes to upgrade or replace its 29 medical centers and 423 medical offices, Kaiser Permanente has used this opportunity to incorporate sustainable design practices in its building projects through use of its Eco-Toolkit, a design and construction resource guide used by Kaiser's project teams (a copy can be downloaded at http://www.healthybuilding.net/healthcare/Eco_ToolKit_2.0_copyrighted.pdf. Kaiser's experience, in one of the nation's most expensive construction markets, has demonstrated that green buildings and other sustainably directed initiatives don't cost more, but they do add business value to operations and social value to the organization's mission.

The first recipient of the Vista Sustainable Building Award, sponsored by the American Society of Healthcare Engineers in conjunction with the AIA Academy of Architecture for Health, has demonstrated that sustainable design and energy efficiency do not have to cost more. The Patrick H. Dollard Discovery Health Center in upstate New York was the first healthcare project registered with LEED™ (see “Building Green in the Countryside,” p. 52 in this issue). Designed by Guenther 5 Architects, the on-site ambulatory clinic, administered by the Center for Discovery, a not-for-profit healthcare agency, provides services for children and adults with severe and multiple disabilities. Currently seeking LEED certification, the Center for Discovery employs many green building strategies, from use of nontoxic materials to water efficiency. The project underwent rigorous financial reviews by the New York State Department of Health to ensure that the green building features did not impact the construction costs, since construction costs play a large part in determining reimbursement rates within the state. The Department of Health did not want to establish a precedent of allowing cost premiums for green building features. But the real value that resulted was the 25% less energy use by the Center than by comparable facilities—an “operational savings of approximately $18,000 to $20,000 per year at current energy costs.”4

Another first for healthcare facilities is the Boulder Community Foothills Hospital, in Boulder, Colorado,5 which achieved the first LEED Silver rating in 2003 for an acute care hospital. The design integrates the use of local, renewable, recycled, low-emitting, and resource-efficient materials (materials that were not as readily available then as they are today). Irrigation usage was cut in half in a state where water conservation is a demanding issue, and energy utilization was reduced by 27%. These strategies were just a few of those used throughout the facility to add value to the hospital's mission and demonstrate commitment to the community.5

During the past ten years, a number of green buildings in other building-type categories that rate performance and measure costs have been developed. Several studies have been published supporting the notion that sustainable design does not have to cost more. Moreover, these reports document the real benefits in productivity, energy efficiency, and health, and the true value in attracting high-quality employees while controlling operational and maintenance costs.

In its cost-benefit analysis for California's Sustainable Building Task Force, Capitol E, a national clean-technology deployment and strategy firm, has conclusively demonstrated that sustainable building is a cost-effective investment.6 In a study of 33 green buildings around the country, Capitol E found that “the total financial benefits of green buildings are over ten times their average initial investment required to design and construct a green building.” Although the average cost premium for green buildings is slightly less than 2%, reports are demonstrating that this premium tends to decline as experience in green building design/construction grows.7

Costing Green: A Comprehensive Cost Database and Budgeting Methodology, a study of 61 projects seeking LEED certification, concludes: “Many projects can achieve sustainable design within their initial budget, or with very small supplemental funding. This suggests that owners are finding ways to incorporate the elements important to the goals and values of the project, regardless of budget, by making choices and value decisions.”8

To aid in making those value decisions, tools are being developed to guide the healthcare industry. The soon-to-be-released version 2.0 pilot Green Guide for Health Care (http://www.gghc.org) will offer healthcare project teams a self-certifying design guide for incorporating high-performance, healthy practices into their projects. The U.S. Green Building Council (http://www.usgbc.org) has also initiated the development of the LEED Application Guide for Healthcare Facilities for those healthcare projects desiring achievement of LEED certification and the associated branding recognition.

Despite fears about increased costs, more than 29 healthcare projects across the country and Canada are working toward adding value to their projects and have registered them for LEED certification. Others using the public comment version of the Green Guide for Health Care are already putting into practice many of those recommendations.

The U.S. healthcare industry has met many challenges and made tremendous advances in facility design during the past few years, transforming hospitals from the institutional “pea green” look of the postwar years to the bright and colorful “hospitality” feel of today. Can the industry transform itself once more and provide holistic health facilities through values founded on the “triple bottom line”? HD

Greg L. Roberts AIA, ACHA, CCS, LEED™ AP, is a Principal and Senior Specification Writer with Watkins Hamilton Ross Architects, a firm specializing in healthcare architecture in Houston and Dallas. He serves on the Steering Committee of the Green Guide for Health Care and the Core Committee of the LEED Application Guide for Healthcare Facilities, two national initiatives focused on green healthcare facilities. He also serves on the National Environmental Task Team of the Construction Specifications Institute. He lectures on sustainability and has published articles in a number of national magazines.

  1. Financing the future. Healthcare Financial Management Association (HFMA), March 2004.
  2. Building the future. Turner Construction Company, 2003.
  3. Bonda PS.Putting the “healthy” back into healthcare. Green@Work, Jan/Feb 2004.
  4. Solomon NB.Environmentally-friendly building strategies. Architectural Record, August 2004, p. 179.
  5. Healthcare's LEED leader. HEALTHCARE DESIGN, May 2004, pp. 70-75.
  6. Kats G ,et al. The costs and financial benefits of green buildings, October 2003 (for full text, see http://www.cap-e.com.
  7. Kats GH.Green building costs and financial benefits, 2003 (for full report see http://www.usgbc.org/Docs/News/News477.pdf.
  8. Matthiessen LF, Morris P.Costing green: A comprehensive cost database and budgeting methodology, 2004 (for full report see http://www.dladamson.com/publications.html.