Go for the Silver or go for the Gold? That's a question being posed today by a number of hospitals across the country as they prepare to build new or replacement facilities.

The flurry of publicity following the June 2006 opening of Providence Newberg Medical Center in Oregon, the nation's first hospital to attain a LEED Gold certification, is continuing to draw attention to green design from the healthcare sector.

Taking the green path is, in many aspects, synonymous with creating a healing environment through provision of healthy indoor air quality, access to nature, and improved energy performance. The LEED Green Building Rating System awards points based on a facility's adherence to guidelines in five categories: sustainable sites, water efficiency, energy and atmosphere, materials and resources, and indoor environmental quality. The four levels of certification-Certified, Silver, Gold, and Platinum-are awarded based on the number of points accrued.

Starting down the green path

One facility making the commitment to go green for its new replacement is Rockingham Memorial Hospital (RMH) in the pastoral, gently rolling hills of Harrisonburg, Virginia. Early in the conceptual stage, the hospital's Board of Directors made the decision to build its new hospital and health campus as environmentally friendly and sustainable as possible. It is, in fact, RMH's intent to become the first LEED-certified hospital in Virginia.

In late 2004, RMH's Board approved construction of a 600,000-square-foot greenfield hospital to replace the existing, almost century-old, 270-bed facility sitting on its original 15-acre landlocked site in the heart of the city of Harrisonburg.

When the doors of the new facility open in mid-2010, RMH officials hope to be able to say that a LEED certification was achieved through negligible additional costs to the $198 million construction budget approved by the Board for the project. In other words, they anticipate the long-term benefits and pay-back to be such that they outweigh any upfront costs necessary for “going green.” The myriad benefits anticipated for the community include good indoor air quality for patients, visitors, and staff; improved employee satisfaction; improved energy and water utilization efficiency; wetland preservation; land preservation; and thoughtful waste management.

Taking the first step

After the decision was made to build a new facility, the first step was to select a location. Although hospital officials sought another city location, the economically booming area offered no ideal site within the city limits. When the search turned to the wide-open (but quickly vanishing) spaces of surrounding Rockingham County, ideas began to form regarding the potential look, feel, and focus of the new facility.

“When we decided to move to the county, everywhere we looked to build was in a rural, pastoral setting,” explains Dennis Coffman, director of Facilities Planning and Development at RMH. “We didn't want to put a big, ugly concrete monster in the middle of this beautiful environment.”

The site selected was a 234-acre farm bounded by rural neighborhoods and located about two miles away from the current facility. From the beginning, Coffman says, new facility planners focused on the commitment to be a good neighbor to the farmers and other county residents who would live near the new facility. But “how do you do that when you are going to drop a 600,000-square-foot building in the middle of a farm?” he asks.

Among the first tasks in planning the new facility was development of a vision and a set of design principles for what hospital officials began to call a new “hospital and health campus.” The vision was this: “Our campus will be a beautiful park-like setting, in harmony with the surrounding area, with facilities designed to bring the best of 21st century health, wellness, and medical care to our community.”

Design principles addressed the need for accommodating technological advancement, quality clinical care, patient safety, and efficient operation, along with the desire for a healing environment-inside the facility and out-for patients, family, visitors, and staff. Hospital officials examined issues such as parking, light-pollution control, and land conservation. They discussed having a facility that would take advantage of natural light not only to enhance healing, but to conserve energy. They considered the use of building materials that would emit little or no environmentally unfriendly gases. In essence, said Coffman, new facility planners focused on green building from the very beginning of the project.

“That's different from what you usually see,” he explains. “The way it usually happens, someone plans and designs a building, then they decide to build green. The additional costs they incur come from changing after the design has been completed. For us, green has been a part of the planning and design process from day one.”

Building an environmentally sustainable facility is simply “the right thing to do” for the community, says Coffman. An avid outdoorsman and lifelong Rockingham County resident, he wants his children and grandchildren to be able to enjoy the nature of the rural environment as he has. Similarly, hospital officials want the community to be able to enjoy the new hospital and the surrounding health campus as a “destination” for health and wellness, replete with walking trails, playing fields, and healing gardens, but also with built-in sustainability that is not so visible to the naked eye.

“It's right for our neighbors, our patients and customers, and our business,” Coffman says. “As we've planned the new hospital, we believe we have made good operational decisions based on LEED and what makes good business sense for us.”

Getting down to the details of green

Some “green” aspects of the project that garner LEED points, such as a highly sophisticated HVAC system, are inherent in a healthcare facility, says Duke Rose, who serves as project manager with Bovis Lend Lease Construction. “Many hospitals in their normal design are green because so many features are already a part of a hospital environment,” Rose explains. “Hospitals normally have more air turnover than you would see in offices or schools, due to infection control.”

Other much more visible health-related aspects that also score LEED points, such as bicycle racks and low-VOC paints, will appear when the facility nears completion. As part of “going green,” RMH will encourage employees to use alternate transportation and will install showers for employees who want to ride bikes and run on-site.

“There are a lot of good intuitive design considerations we've followed that lead us to a good building,” says principal-in-charge Harold D. Petty, AIA, medical design director with Earl Swensson Associates, Nashville, Tennessee. “These considerations don't necessarily cost more money, but are just good design.”

However, the biggest cost saver of all is early planning, he says. “Trying to start with the LEED philosophy in the beginning is much more effective than doing it after the fact,” Petty says. “The very siting of the building and even the grading were done to meet LEED criteria.”

As an example, RMH recycled on-site concrete barn and farmhouse foundations by crushing them into gravel to be used during construction. Rose and Cody Albergotti, a LEED Accredited Professional with Bovis Lend Lease, trained subcontractors to sort up to nine types of recyclable materials on-site. “We're recycling metal, drywall, glass, paper, cardboard, plastic, brick and rubble, concrete, and masonry,” Albergotti says. “In a project that wouldn't be requiring this, we would throw it all into one big dumpster.”

RMH is also responsible for documenting subcontractors' compliance with LEED emissions standards for building materials.

“We're making sure that most products used in the building-sealants, paints, carpets, flooring-have the right chemical makeup and are not emitting pollutants,” Albergotti says. Fortunately, there's little added cost to materials that are free of Volatile Organic Compounds (VOCs), he says. “Materials are more readily available these days that meet the criteria.”

Finding subcontractors suited to build a hospital in the Shenandoah Valley has been a challenge due to its distance from major metropolises, Rose notes. But, he adds, as a general rule, finding subcontractors who can effectively build green is not as difficult. “We just don't have large enough outfits that could bond the job here. But if you have background in doing hospital work, you're capable of doing green work,” he says.

Says Dennis Coffman, Rockingham's director of facilities planning and development, “We have relied upon Bovis Lend Lease to pull on past relationships with contract partners. Some have been contacted and asked if they have an interest as independent contractors in coming to work on our project. In some cases, we have dropped the bonding requirement as a strategy. This has been considered on an individual basis, and it has allowed us to drop the price of the job in those areas. Also, we have broken up parts of the job into smaller components to get more small contractors involved. Examples of this are mechanical/plumbing and electrical, in which we have two contractors for each discipline dividing the work. Generally speaking, we would have liked to see more bidders on the job to create more competition and keep the bids lower.”

Paul McCown of consulting firm SSRCx, Inc., in Nashville, Tennessee, serves as LEED project facilitator for RMH, providing direction to the design team. He explains that many aspects that will bring RMH's new facility up to green standards may not be visible to the public eye. For example, any facility seeking LEED certification must meet or exceed the requirements of the latest version of ASHRAE 90.1, an energy guideline, he says.

“ASHRAE 90.1 establishes energy-use thresholds for HVAC equipment, lighting, and domestic hot water heating, as well as building envelope requirements based on the climate zone in which the facility will be built,” he explains. “We expect to achieve credits for energy efficiency in various ways, the most compelling of which is utilizing methane gas from a nearby landfill [in Rockingham County] for some of the building's heating requirements.” FreemanWhite is partnering with County officials in developing a capturing system.

One of the biggest design obstacles was siting the building to avoid wholesale excavations and instead working with natural contours of the land. Part of this involves capturing rainwater runoff in a containment pond flowing into a lake and filtering it before it reaches the ecosystem.

Collecting data after the new RMH facility is operational is crucial to ensuring other healthcare institutions seeking LEED certification will benefit from RMH's learning process. Meanwhile, Petty says, “This is a stepping stone for our firm to other potential LEED-certified projects. We do a postanalysis on our projects to determine what works and what doesn't. Part of this project will involve looking at sustainability and patient safety one year after operations and identify lessons learned.”

But can you stay on budget?

Because LEED certification is based on a point system, it's possible for a healthcare facility to incorporate many sustainable components, yet still not achieve certification at one of the four levels. As cost estimates came in for the project, Coffman acknowledges some costs were slightly above the allotted budget. “In some cases, these companies just don't know what to estimate because they've never built green before,” he says. “So I think we felt that impact. Using good communication and effective negotiations, we've been able to reduce the uncertainties and firm up those quotes. Over the past few months, due to the high inflation of construction costs, we have undergone an intense value engineering analysis that, in fact, eliminated some green building efforts but validated others.”

Says Paul McCown, PE, CEM, LEED AP, CxA, manager of the Sustainable Solutions Group of SSRCx, LLC, “The higher-than-expected project costs are related to the overall project scope more than to any green or sustainable design features. Our research for this project shows that the base design of the hospital-that is, the way RMH planned to design the hospital-aligns well with the LEED rating system. We decided to pursue LEED certification after evaluating the base design. We realized that by paying attention to details-materials, air handling unit arrangements and placements, building insulating values and light levels-we could tweak the base design and pursue LEED certification.

“Regarding ROI, we have performed a few studies on independent systems and have accepted some system changes that make economic sense, and have rejected others. Specifically, the project team studied the use of methane gas from a nearby landfill and determined that we had to allocate funds to do this or we would be missing a big opportunity for long-term energy savings. Also, we are using an exhaust gas economizer on our boilers. We evaluated capturing condensate from all the air handlers for use in replacing the need for potable water in the cooling towers and using a heat recovery device on the dining room air handling unit, but these didn't show substantial energy savings over first-cost investment, so they are not in the project. Regarding an ‘ultimate ROI,’ an energy model of the entire building is being completed to show the overall energy savings of the combined systems.”

McCown adds that any cost increases associated with building “green” likely will decrease over time, as more data accrues and energy-saving technology becomes time-tested. “As more buildings go for LEED certification at the upper levels of Gold and Platinum, the technology utilized to accomplish this high level of green design will become more proven and more predictable regarding lifecycle use and cost savings,” he says. “It is one of our goals as a LEED facilitator to support contractors in data collection and evaluating other construction processes such as waste management, so that they do not bear the burden of collecting, organizing, and reporting the data necessary for LEED compliance.”

Coffman emphasizes that, whether or not RMH achieves Silver LEED certification, it will build an environmentally friendly and sustainable facility that will honor the values, culture, and heritage of the community it has served for nearly a century.

“And, at the end of the day, our intention has been to have built a hospital that will contribute not only to a healthier community, but to a healthier environment.” HD

Holly Martin is in public relations for Rockingham Memorial Hospital.

For further information, contact Dennis Coffman, director, RMH Facility Planning and Development, at 540.433.4394 or dcoffman@rhcc.com.

Healthcare Design 2009 May;9(5):68-74