Just when it was warming up to the color green, the healthcare building field turns to look up the steep hill to The 2030 Challenge and it realizes that "green" may not be good enough. Something in the shade of clear may be in order—that is, healthcare facilities that are carbon-neutral, water-balanced, and zero-waste, or that even give back resources to the environment. The challenge calls for buildings that breathe and dedicated teams that dream beyond green, say Perkins+Will architects Michelle Halle Stern, AIA, PE, LEED AP, and Robin Guenther, FAIA, LEED AP, in an interview with HEALTHCARE DESIGN Online Editor John Oberlin.

John Oberlin: Is there a difference between the terms "green" and "sustainable"?

MichelleHalle Stern, AIA, PE, LEED AP: They certainly do get used interchangeably, and I don't know that people think of them differently, although I think of them differently. With "sustainability" you have the definition that you are going to meet your needs without compromising the needs of future generations, whereas "green" could be just materials and more of the strategies rather than the big-picture concepts. But they are definitely used interchangeably.

RobinGuenther, FAIA, LEED AP: I think there are so many ideas that we call "green" or "sustainable" that people don't necessarily see how they create sustainability in the true definition of meeting your needs without compromising the needs of future generations. I think there is a level of skepticism associated with the term "sustainable design" that allowed "green design" as a more user-friendly term.

Oberlin: Are you coming across any apprehensiveness on the part of administrators or designers in implementing sustainable design in healthcare facilities?

Halle Stern: In concept most of them are on board with it and think it's great. Usually the first question is: "Is it going to cost me more money?"

Guenther: There has been an enormous change in the marketplace in the last 24 months. I don't think it was necessarily on the radar screen of administrators two years ago. But it is certainly now in the C suite of hospitals, at the board level, and it is now coming through at the facility management level of hospitals. I think the perceived obstacles, besides Michelle's point about first cost, have really been lack of knowledge, both internal lack of knowledge and lack of knowledge among the design professionals who are being hired. With the designers, it's not so much a lack of formal training. You may have LEED-accredited professionals on the team, but it is really a lack of experience executing a new project. And then the third one has been a lack of understanding about how to integrate it into the design process effectively.

Oberlin: How do you as a designer or architect approach any apprehensiveness and convey the message of sustainability?

Guenther: Anymore, it's not so much that we have to convince them that it's the right thing to do; we have to show them how to get it done. It's really talking to owners and going in with a clear set of processes, objectives, tools, and resources. Two years ago you might've had to really sit with people and list the 65 reasons why they have to care about sustainability, but I'm seeing that that's no longer the issue for most of them. And actually I think it is true for those people for whom that's an issue; they're simply not ready. That has been another interesting issue in the marketplace: There's been a kind of mismatch between owners' readiness and architects' zeal, and that's starting to settle down now.
Robin guenther, faia, leed ap

Robin Guenther, FAIA, LEED AP

Michelle halle stern, aia, pe, leed ap

Michelle Halle Stern, AIA, PE, LEED AP

Halle Stern: We're also seeing a lot of competition between institutions, where they say, "Oh, this hospital down the street is building green, so we had better do it, too."

Oberlin: Robin, your new book Sustainable Healthcare Architecture points to green building approaches that surpass conventional green building ideas. Can you explain conventional green design compared with what is explained in your book, and the future of how we are going to look at green design?

Guenther: In the green building marketplace, there's been a recognition that LEED Platinum, which is the highest standard defined by the U.S. Green Building Council, still doesn't get us where we need to be as a culture and as a building industry in terms of meeting the core requirements and the core objectives of The 2030 challenge, meaning producing carbon-neutral buildings that are zero-waste and water-balanced. LEED has been about reducing the environmental demands that the buildings place on resources, but not eliminating them. And so the Cascadia Region Green Building Council (http://www.cascadiagbc.org) has authored the Living Building Challenge, which goes beyond LEED. Living Buildings essentially are carbon-neutral, zero-net energy, water-balanced, zero-waste, and in essence make no demands on ecosystems [at large] and the ecosystems they sit within. This is the gold set we need to get to.

Oberlin: Is the Living Building Challenge also a rating system?

Guenther: Yes, with 16 prerequisites and no credits, because the point is there is no incremental "getting there." If you want incremental, you use LEED. But if you want to achieve a Living Building, this is what you need to do. There are a number of buildings under construction now in the process of being certified as a Living Building. But it is the next frontier. And in the book, we thought about what it means to deliver carbon-neutral, zero-waste, toxic-free, water-balanced healthcare buildings and what that would look like.

Interestingly, at the AIA convention we did a workshop on living buildings with about 65 architects from around the country, a few healthcare people, to get people to begin to envision that. Amazingly, one of the key elements that everyone reported out from their exercises was less focus on the core Architecture of the building and more on how these buildings impact the communities they sit in and how they form connections to broader community environmental goals. One of the primary differences of Living Buildings is that you have to move even further out beyond the building than LEED does and connect it to the community. It pulls that whole dialogue in healthcare into a much broader dialogue about the future of the delivery and what the built environment in healthcare will become in a generation. I think that makes it quite exciting, because it allows that dialogue to take place within the context of much broader industry issues than simply sustainability and green building, such as core issues around how services will be delivered and what services might move to homes.

Oberlin: In the permaculture movement—the idea of developing human settlements that mimic the structure and interrelationship found in natural ecologies—there is a strong connection between system stability and system component diversity. Is there more we can learn from natural systems structure while designing the built environment?

Halle Stern: When you get into that Living Building Challenge concept that's where a lot of this plays in. For example, does the building breathe? What happens in terms of passive survivability? We have this whole field of biomimicry in which we look at how organisms do things and mimic them in more of a technological methodology. When you think about it, natural systems have evolved over millions of years, and they must have done something right that we can learn from. It is kind of arrogant to believe that we've got all the answers.

Guenther: If nature teaches us one thing, it's about resilience, and I think that increasingly we are realizing that we've created a medical infrastructure that doesn't demonstrate resilience. It certainly is safe and it has layers of prescribed back-up systems in the event of emergencies, but in times of climate stress and episodes of grid breakdown it has not proven to be overly resilient. I think the dialogue is really just beginning about how we can learn from the resilience of nature in making a medical infrastructure that is inherently more resilient.

Oberlin: The USGBC is now in the process of responding to the first round of LEED for Healthcare public comments. Robin, you're on the core committee; can you let us in on any interesting features?

Guenther: Well the LEED for Healthcare tool used the Green Guide as its foundation document, and actually received more public comments than any other LEED tool has in the past. I think part of that is because it drew on all the people who had been using the Green Guide for the last two years, and they have a lot to say about its credits moving over to LEED for Healthcare. Some of the key differences between LEED NC and LEED for Healthcare that come from the Green Guide are the inclusion credits around places of respite, the idea of environments reducing occupants stress as being a key component of greening healthcare facilities, and an increased emphasis on daylight. Another key difference is the credits around medical equipment efficiency, which continues to be geared to transforming the market in major medical equipment. LEED for Healthcare has also introduced credits aimed at the acoustic environment, which actually started in LEED for Schools.

Oberlin: What do you expect for the future of sustainable healthcare design?

Guenther: I think there is going to be a huge uptick in LEED registration in healthcare projects as LEED for Healthcare comes online. I also think new greener materials will be introduced into the marketplace to satisfy projects looking for LEED points and sustainable building, and that those products are going to have other performance benefits above and beyond their sustainability. It's ultimately going to save hospitals money and have either improved performance or other benefits. Because what we are seeing in product introduction is that very few products are being introduced purely because they're sustainable. Manufactures are building in other performance attributes. Those performance attributes are really going to be taking hold and delivering value.

I also think we will continue to see unstable resource prices—particularly energy prices. Hospitals that are doing aggressive energy conservation measures are going to see the difference in their bottom line and will be economically outperforming their competitors that have not taken this into account. The average LEED healthcare project is saving on average about 20% energy reduction. LEED for Schools' average is closer to 35%. Those percentages are really going to start stacking up as oil prices increase.

Halle Stern: At the more philosophical end of it, we will see more hospitals coming to the realization that there is a connection between environmental health and patient health. Hospitals will be finding that their mission and values align with sustainability.

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.