One year into its life as a functioning, self-certifying rating system, the Green Guide for Health Care has attracted more than 75 projects to its Pilot program, representing more than 20 million square feet. Green Guide Pilot projects are located in 23 states across the United States, as well as five other countries. They include acute care hospitals, specialty hospitals, medical office buildings, and retirement communities.

With such a large pool of participants, the time has come to evaluate how accurately the Green Guide Steering Committee estimated the resonance that green building would have in the healthcare sector. When the Steering Committee began work on the Green Guide, using the U.S. Green Building Council's Leadership in Energy and Environmental Design rating system for New Construction (LEED-NC) as the main framework document, only a handful of healthcare projects had registered with LEED. It was not clear whether this was the case because green building was irrelevant to hospitals or because LEED-NC, written for commercial office construction, was not equipped to negotiate the increased complexity, level of regulatory oversight, and energy intensity required to produce functioning acute care hospitals.

The Green Guide was developed for the healthcare sector by adapting some LEED-NC credits and adding new, health-based credits to recognize current trends in healthcare, such as evidence-based design, healing environments, and infection control. More importantly, the committee reframed the document's sustainability goals to emphasize each credit's connection with human health. Every credit intent is qualified with a “Health Issues” paragraph unique to the Green Guide. The Green Guide also combines Construction and Operations into a single document. Green Guide Pilot projects are not required to use both sides of the document concurrently, but the large majority of them have found that they achieve better overall results when operations concerns are incorporated into design and construction.

What are some of the lessons learned from the Green Guide's first year?

1. The Green Guide works well for healthcare projects. Pilot projects have found that the Green Guide provides an overarching framework for coordinating compliance with regulations in a way that reduces the hospital's overall environmental footprint. Many credits in the Green Guide complement each other in ways that are reinforced by the Integrated Design Prerequisites. For example, Clark/Kjos Architects has focused the design of the Wellspring Medical Center in Woodburn, Oregon, on carving interior gardens and an atrium out of an existing big-box retail structure. The resulting design strives to improve indoor environmental quality, daylighting, and views while taking advantage of the clinical benefits associated with places of respite and a direct connection to the outdoors.

2. Healthcare project teams support a voluntary and self- certifying program. The flexibility represented by a voluntary, self-certifying system has convinced a wide variety of hospitals, architecture firms, engineering firms, and construction companies to use the Green Guide as an educational tool for green building. Green Guide Pilots commit to completing the prerequisites and as many credits as possible. Absent achievement thresholds, many Pilot participants are using the Guide as a marker for continuous improvement, freeing projects to take risks on new procedures without the fear of public failure.

Thus, Palomar Pomerado Health's replacement hospital in San Diego is pursuing a variety of strategies to conserve water. Process water (water used in building equipment) often accounts for up to two-thirds of a hospital's total water consumption. The Green Guide encourages research into process water conservation by offering a process water credit in addition to the domestic water reduction credits available through LEED-NC. Palomar Pomerado has taken up the water efficiency credits in the Green Guide as a challenge and begun researching a wide range of possibilities in both domestic (water fixtures) and process water. The project incorporated a “wish list” of water efficiency strategies early in schematic design that ranged from more conventional solutions, such as dual-flush toilets, to more aggressive technologies, such as eliminating chemicals in condenser water. By focusing on water conservation early in the design process, the project team has the opportunity to maximize the integration of building form and mechanical/water systems design.

Five Most Selected Construction Green Guide Credits (Taken from the “Y” and “?” columns of project checklists)

EQ c-4

Low-Emitting Materials (53 Pilots)

EQ c-3

Construction IAQ Management (51 Pilots)

SS c-4

Alternative Transporation: Bikes and Public Transportation (48 Pilots)

MR c-2

Construction Practices (48 Pilots)

Five Most Selected Operations Green Guide Credits (Taken from the “Y” and “?” columns of project checklists)

IO c-1

Building Operations & Maintenance (39 Pilots)

IO c-2

IAQ Management (39 Pilots)

EE c-3

Energy Efficient Equipment (38) Pilots)

EE c-4

Refrigerant Selection (38 Pilots)

TO c-1.1

Alternative Transportation: Public Transit (36 Pilots)

3. The Green Guide needs to more specifically address additions and renovations. The Pilot process has revealed a key underlying similarity between the Green Guide and LEED-NC: Neither system is well suited to building additions and minor renovations. In fact, the pool of Pilot projects reflects the Green Guide's emphasis on freestanding, new construction. As of October 2005, 60% of Green Guide projects by square footage were new construction, while only 35% were additions, renovations, or a combination of these. (The remaining 5% were operations projects, meaning they were not under any type of construction and used only the Operations section of the Green Guide.) The reality in the healthcare marketplace is the inverse. The Green Guide Steering Committee is currently responding to this gap by reviewing the Version 2.1 credits for applicability to renovations and additions.

4. Incorporate the Green Guide early in the planning and budgeting phases of a project. The Oregon Health & Science University (OHSU) replacement acute care hospital in Portland did not begin incorporating strategies from LEED or the Green Guide until the project was already under construction. At that point, it was already too late to incorporate many credits from either rating system. Nevertheless, Perkins+Will and Mazzetti & Associates, the architecture and engineering firms on the project, managed to incorporate a few key conservation strategies, such as low-energy fans, night setback controls for the air-conditioning system, and induction lamps in the parking areas. However, they ran out of time on several key strategies for energy and water conservation, such as working with the equipment manufacturer to develop a strategy for conserving sterilizer wastewater. OHSU has learned from this experience and has integrated green strategies into the planning and design of a subsequent mixed-use healthcare project that is striving for a LEED-NC Platinum certification.

5. Green Guide credits are transforming the marketplace. Several Green Guide credits were designed to serve as catalysts for market transformation. For example, the credit that encourages use of ENERGY STAR medical equipment was developed in collaboration with the U.S. Environmental Protection Agency's ENERGY STAR program to spur demand for such energy-efficient equipment. It is estimated that up to 40% of a facility's energy can be consumed by plug loads (i.e., from equipment that plugs into the wall). Although ENERGY STAR has not yet launched its program for medical equipment, fully two-thirds of Green Guide Pilot projects are pursuing or attempting to pursue the route prescribed for achieving this credit. This indicates a strong interest from the healthcare sector in medical equipment that both performs well and uses minimal energy.

6. Pilot projects are pursuing both LEED-defined strategies and unique Green Guide strategies. The most pursued “new” credits establish direct connections between human health and the environment: for example, the Places of Respite credit (which rewards devoting program space for people to connect with the outdoors), the expanded Construction Practices credit (which limits on-site noise and air pollution), the expanded Low-Emitting Materials credit (which includes limits for flooring and insulation), and the Energy-Efficient Equipment credit (described above).

7. The emphasis on the connections between health and sustainability in the Green Guide engages healthcare professionals. Kaiser Permanente, the largest nonprofit healthcare system in the country, has made an organization-wide decision to register construction projects with the Green Guide and not with LEED on grounds that the Green Guide emphasizes the connection between human health and sustainability. The health-based credits that resonate with Kaiser include credits that limit exposure to certain classes of chemicals, limit construction noise and air pollution, and reduce the hospital's impact on the surrounding community. Kaiser has registered six Pilots with the Green Guide and is in the process of incorporating the Guide into its internal green construction guidelines.

The Green Guide Steering Committee is moving quickly to respond to the lessons learned from the Pilot's first year of operation. The Guide was updated three times in 2005. Version 2.2, due to be released this year, will continue this process of dynamic development in response to Pilot suggestions. The Green Guide will also release a collection of technical briefs in 2006 that add depth to the technical background in credits unique to the Guide. All healthcare projects are encouraged to join the Green Guide Pilot, a free process, and to engage in the document's continued development as the industry's premier best practices document for high-performance healing environments. HD

Adele Houghton, AIA, LEED AP, is Pilot Project Coordinator, Green Guide for Health Care

Scott Slotterback is Program Lead, Project Development, Support and Review, Kaiser Permanente National Facilities Service

Walt Vernon, PE, is Principal, Mazzetti & Associates. Slotterback and Vernon are Steering Committee members of the Green Guide for Health Care.