Something in the shade of clear may be in order—that is, healthcare facilities that are carbon neutral, water balance, and zero-waste, or that even give back resources to the environment. The challenge calls for buildings that breath, and dedicated teams that dream beyond green, say Perkins+Will architects Michelle Halle Stern, AIA, PE, LEED AP (below), and Robin Guenther, FAIA, LEED AP (left), in this part two interview with John Oberlin, HEALTHCARE DESIGN online editor. (Find part one in the August 2008 HEALTHCARE DESIGN Clean Design & Operations supplement.)

John Oberlin: Is there much value in new healthcare construction using recycled or reclaimed material?

Robin Guenther, FAIA, LEED AP: Well certainly there’s an increasing amount of product in the market that utilizes recycled content. Some materials have been used for recycled content before green design was on anyone’s radar. For example, structural steel has been recycled content for decades. I think that initially there was the perception that material offerings that use recycled content were of lower quality than materials made from virgin material stock. But that’s largely been debunked in the product offerings, and there’s an increasing number of high-performance products that utilize high levels of recycled content.

Michelle Halle Stern, AIA, PE, LEED AP: I haven’t had much experience with salvaged or reused materials. Have you, Robin?

Guenther: No. There are certainly green renovation projects in which they’re able to salvage certain products out of the job and reuse them, such as door bucks, doors, or some interior fit-out materials. But in terms of really constructing new healthcare facilities with materials salvaged from other buildings? There’s much less of that. I don’t think people have been able to hit the LEED point thresholds on that easily. But that’s across the board, not unique to healthcare.

Part of it may just be the supply change. It’s about how you locate materials that are salvaged, how you access them, and who you buy them from. There have not been, in the broader commercial marketplace, good systems for that except with office furniture or certain other material loops. But with the growing use of the Internet, I’m sure in the next five years you’re going to see many more businesses that broker used materials in a much bigger way.

Oberlin: I’ve read that architects and specifiers can help push the manufactures in that direction by constantly requesting recycled or reclaimed materials.

Halle Stern: It’s been really interesting to see the change in terms of manufacturer’s savvy and education. Ten years ago you would ask a company or rep, “What do you have in a green product, where do your materials come from?” and you would get blank stares. And now every time a rep comes into your office, sustainability is a piece of their presentation.

Oberlin: The public comment period for the Green Guide for Health Care (GGHC) operations section has just ended (June 20). Can you talk about some of the new features? I see strategies are now grouped by facility departments and there’s alignment with LEED for Existing Buildings.

Guenther: The GGHC Operations has always been organized by department. But this version of the Operations Section really benefited from having individual work groups comprised of a lot of facility people from around the country who do this work in hospitals. They were able to focus more specifically on particular operational areas of healthcare and really round out a lot of the strategies that impact a hospital’s environmental footprint. And so there is an expanded set of credits. For example, the earlier version of the Green Guide Operations Section had four credits related to food. Now there’s seven or eight. There’s more on waste. There’s a general deepening of the tools and resources that are available to people, and it’s more comprehensive than the first version.

Oberlin: The updated guide emphasizes integrated operations and education. How critical is that for a healthcare organization to have this cross-departmental group facilitating environmental programs and getting involved with the new construction and renovation processes?

Guenther: In researching my book [Sustainable Healthcare Architecture] we realized that a lot of hospitals that embark on sustainable construction only do it once they’ve got their operational house in order and really begun working on pollution prevention initiatives with realized success. It was astounding to us that there was such a direct crossover in the pioneers and the innovators in sustainable building with people who have been pioneers and innovators in operations. The emergence of Practice Greenhealth as a joint effort between Hospitals for a Healthy Environment and the Green Guide is just starting and it will enrich this intersection of design and operation, as well as move the market forward.

A common methodology for hospitals has been to work on pollution prevention initiatives in order to get reasonable cost savings associated with pollution prevention—primarily from reducing their regulated medical waste. So their waste costs go down, and they invest some of that savings in hiring a green building program manager. Once they get a manager that can run a “green team,” which is a cross-discipline team centered around hospital operations, they find operational changes to implement that deliver monetary savings and benefit. There’s an increasing number of hospitals that have that in place.

Halle Stern: And I found out in a project that I’m working on, that the fact that they’re going for LEED certification has really infused some new energy into the safety and environmental service folks who are already doing some of these programs. But now they are expanding their programs and really getting at waste reduction, moving to green cleaning, and finding that it all relates to new construction, and that they have a real story they can tell the public.

Oberlin: Are these environmental services groups getting involved with the planning and design process?

Halle Stern: Yes, when there is a project. And it’s happening concurrently. For example on a current project, we get together monthly with the hospital’s green and design teams to talk about the LEED process. And they’re integrally involved in that. It’s interesting to see the back and forth, especially on issues like recycling where they want to do a recycling program but they’re not really sure to what extent. But then we bring up specific LEED requirements, and that drives them to expand their program.

Oberlin: The GGHC update also includes an emphasis on ongoing education for staff, patients, visitors, and the general public on the connection between a green facility and human health. What role does the education of the stakeholders play in the process of designing and operating a facility?

Guenther: The education of the stakeholders around hospital operations is pivotal in achieving higher-performing green buildings and operations. Many of the green operation initiatives are about occupant behavior, and they call on people to interact with the building and its operations fundamentally differently. If you don’t couple the strategies with ongoing staff education, it all falls apart and people revert to the old pattern of behavior. Whether you are talking about recycling or maintaining flooring, it’s really been shown across the green building world that occupant education delivers a lot of savings and pays for itself.

And certainly healthcare—it is 16% of the United States’ gross domestic product—can exert upstream influence on its suppliers to deliver more environmental product and downstream influence over patients and staff that enter it. This is a pivotal equation in realizing a greener future for all of us. When patients enter hospitals, they are at an educable moment about health. And likewise, hospital staff are always engaged, in a sense, in their own health in caregiving to others. So hospitals can be models for healthier living.

Oberlin: The AIA recently released a report analyzing three rating systems—Green Globes, SBTool 07, and LEED for New Construction—as compared to their 2030 carbon neutrality goals. Specifically in healthcare design, how do you see these three rating systems comparing?

Halle Stern: I think they are all going toward goals that are similar. One of the issues people have with Green Globes is a lack of transparency and an impression that there are some ulterior motives with industry being involved. But it is used pretty widely in Canada. I’m of the feeling that at least you’re doing something—it is a step in the right direction.

Guenther: My sense about all of these rating systems as we move into healthcare is that they focus on different aspects of the built environment. In healthcare, what we need to do is match what healthcare organizations value to rating systems that deliver on those values. For example, increasingly, we’re seeing people concerned about mitigating climate change impacts—whether because hospitals are in communities that have adopted the 2030 challenge or the Mayors’ Task Force on Sustainability—so hospitals are coming forward and wanting to work on climate change impacts.

They might also have an enlightened CFO who’s worried about carbon pricing and taxation and trying to be proactive and reduce the carbon footprint. If you want to focus on reducing the carbon footprint, those tools will not be the same in terms of their strategies to get there. One of the exercises we do with clients is to ask, “What is your objective in this and what do you value?” Hospitals will also value being recognized in their community for their sustainable initiatives. And clearly the system that the public understands is LEED; it is the market-excepted green building tool.

One of the issues that drove us to do the Green Guide for Health Care was our notion that healthcare is not going to take this seriously unless there’s a pretty explicit health basis in a rating system, so that people can connect the dots between green building strategies and health. So when we created the Green Guide that is what we focused on. And that’s been quite useful in getting the healthcare industry comfortable with and interested in a lot of what these strategies bring. It connects the strategies to mission. In an increasingly complex world of competing and sometimes contradictory green building tools, sorting that out for owners will increasingly be part of the job we need to do as architects.

Oberlin: Have you noticed that it’s the architects or the health system bringing the Green Guide to the table?

Guenther: Both. For example, Catholic Healthcare West wants to use it on all their work. It doesn’t matter what architect Catholic Healthcare West hires, they put the Green Guide in front of them. Kaiser Permanente does the same thing. So in some instances it can be driven by the health system. In others, we might present it—particularly if clients aren’t familiar with LEED, or don’t understand why they should use it. I find it’s often easier to bring them in with the Green Guide first because of its explicit health connection, and then say, “Oh by the way, all these credits are in LEED, as well.”

Halle Stern: We’re seeing people start with the Green Guide and then try and obtain the third party certification; so they ultimately go for LEED certification.

Oberlin: San Francisco is in the midst of deciding to impose stringent green building codes, and Boston has already done so. Are many major cities going in this direction?

Halle Stern: There are countless municipalities and states that are adopting LEED in some form; maybe not to the extent of Boston, where any building over 50,000 square feet has to meet certification. But even in Chicago, all new, public buildings must be at least LEED Silver, and there is now a green permit process encouraging the private sector to build green by offering expedited permits. We’re seeing that in other municipalities as well. Oregon and several other regions also have some tax credits. There’s money out there for pursuing green.

Oberlin: Does this affect healthcare construction differently; is there an opinion on this?

Guenther: In a number of municipalities and in most states that have adapted a requirement for LEED compliance, the healthcare industry has often been exempted from that largely on the basis that there was not a LEED specifically tailored for healthcare. One of the likely outcomes of the release of LEED for Healthcare is that the sector will no longer be exempted from having to meet LEED requirements.

Also, in the world of community hospitals, which are among the largest employers in the community, there are hospital executives and board members who are in other industries that are proceeding with LEED certification. When you see the number of innovators in community hospitals that were among the earliest LEED certified healthcare buildings, you realize that peer pressure in executive circles and in marketplaces really moves a lot of this forward. And so while these hospitals weren’t required to do it, as community leaders they were compelled to.

Michelle Halle Stern is the National Market Sector Research Manager for Perkins+Will's Healthcare Sustainability practice.

Robin Guenther is a Perkins+Will architect, serving on the boards of the Center for Health Design, the AIA Guidelines for Construction of Hospitals and Health Care Facilities, and the Advisory Council on Sustainability for the NYC Department of Buildings. She is also on the steering committee for the Green Guide for Health Care and the LEED for Healthcare Core Committee.