Imagine a cancer center constructed without materials that contain known human carcinogens, or a hospital that serves organic food and meat without added antibiotics.

These are among the more than 160 strategies that define a new age of “high-performance healing environments,” according to the Green Guide for Health CareVersion 2.0, released in November 2004 (see for the full guide).

Drawing on sources such as the Green Healthcare Construction Guidance Statement from the American Society for Healthcare Engineering (ASHE), the U.S. Green Building Council's LEED® (Leadership in Energy & Environmental Design) Green Building Rating System, Green Building Council Australia's Green Star rating system, the U.S. Environmental Protection Agency's ENERGY STAR® rating system, The Center for Health Design's research, and the International Organization for Standardization (ISO) 14001 Environmental Performance System, the Green Guide for Health Care has defined a comprehensive, voluntary self-certification system for the design, construction, and operation of high-performance healthcare buildings.

As the first quantifiable sustainable-design tool kit for hospitals, the Green Guide provides the framework, so to speak, for the healthcare industry to fulfill its promise to “first do no harm.” In today's world, this admonition poses a greater challenge—and more significant opportunity—for the healthcare industry than ever before.

The challenge was laid out at the 2004 CleanMed Conference by Kathy Gerwig, former national director of environmental programs at Kaiser Permanente, the nation's largest nonprofit health plan. “In the United States, we are experiencing alarming increases in chronic diseases. Cancer, asthma, birth defects, developmental disabilities, autism, endometriosis, and infertility are becoming increasingly common. Mounting evidence links the incidence and severity of these diseases to environmental toxicants,” Gerwig said.

The situation creates a paradox for the healthcare industry. Gerwig added, “In the course of providing healthcare to individuals, healthcare institutions use chemicals and materials that are hazardous to human health.”

The evidence has convinced Kaiser Permanente and other healthcare institutions to adopt a precautionary approach by eliminating or reducing hazards wherever possible and choosing safer alternatives. For example, hospitals across the United States are working to reduce harm by replacing mercury thermometers with non-mercury devices.

In the process of building new facilities, hospitals have an opportunity to apply the precautionary approach on a grand scale—choosing safer materials that are not associated with chronic health issues, for instance, and incorporating design elements that have the potential to aid the healing process.

Currently, the healthcare sector is experiencing an unprecedented building boom. According to a survey conducted by Hospitals and Health Networks magazine in 2004 (“A Good Old-Fashioned Building Boom” by Dave Carpenter, March 2004, pp. 34-42), 60% of hospitals and 68% of health systems need to replace aging facilities.

At the same time, the green-building movement is burgeoning in the United States. “Sustainable development is the most vibrant and powerful force to impact the building design and construction field in more than a decade,” wrote the editors of Building Design & Construction in an October 2003 progress report on sustainability. A recent update includes survey results showing that interest in the field has risen markedly in just the past year.

Until now, the healthcare industry has been characterized as slow to respond to the rapidly emerging green-building trend. Perceived obstacles include complexity of the building type, constrained capital spending, and regulatory-compliance requirements. Available green-building tools, such as LEED, have targeted the commercial building market, which is markedly different from the 24/7, energy-intensive healthcare sector.

The Green Guide for Health Care is the first green-building best-practices guide created as a custom fit for the healthcare sector. It is structured as a point-based rating system, with 96 construction credits in categories that mirror those of the LEED system—Site, Energy, Water, Materials, and Environmental Quality—and 72 operations credits. The system is organized for self-certification, with suggested documentation to ensure compliance with credit requirements. There are no minimum point thresholds at this time; part of the goal of the Green Guide Pilot process (more on the Pilot below, under “Development of the Green Guide for Health Care”) is to track industry progress.

A unique feature of the Green Guide is that it explicitly addresses the health issues associated with every credit, from site selection to building materials. For instance, credits are offered for the elimination of persistent bioaccumulative toxic chemicals (PBTs), such as mercury and dioxin, from building materials. Other credits reward energy performance within the rigorous regulatory structure of healthcare facility operations.

The Green Guide also emphasizes sustainable design elements that foster a healing environment. The Center for Health Design and Dr. Leonard Berry and colleagues, in their article “The Business Case for Better Buildings” (Frontiers in Health Services Management 2004;21[1]:3-24) define a healing environment as a better building with the following primary goals: reducing stress, improving safety, and contributing to ecologic health.

“We knew it was impossible to develop a guide for high-performance healing environments that didn't give full value to the tremendous work being done on the factors that reduce stress and improve safety and performance in hospitals,” says Gail Vittori, co-coordinator of the Green Guide and codirector of the Austin, Texas–based Center for Maximum Potential Building Systems. Greg Roberts, AIA, ACHA, a principal with WHR Architects in Houston, concurs: “We knew going into this process that hospitals need to grasp the links between buildings and health; likewise, it was understood that hospitals needed different strategies than LEED presently offers.”

As a result, the Green Guide includes strategies related to creating places of respite (healing gardens, for example) and to improving the acoustic environment, and it has substantially increased the focus on access to natural light and views.

Development of the Green Guide for Health Care

The compelling idea that the healthcare industry has an important role to fulfill in advocating for “health-based” sustainable building strategies caught the attention of ASHE as far back as 2001, when that organization assembled the Green Building Task Force that developed the initial ASHE Green Healthcare Construction Guidance Statement.

The ASHE statement articulated the overall goals of protecting health at all levels: the building occupants, the community, and the global ecosystem. “The construction and use of buildings in all sectors consumes 3 billion tons of raw materials annually (40% of raw stone, gravel, sand, and steel; 25% of virgin wood; 40% of energy resources; 75% of PVC [polyvinyl chloride]; and 17% of freshwater flows) and generates significant waste (24 to 40% of municipal solid waste from construction and demolition alone), 50% of CFCs [chlorofluorocarbons], about 30% of U.S. CO2 production, and substantial toxic emissions,” says the ASHE statement.

The statement continues: “Given this, the opportunities are significant to improve environmental quality through green planning, design, construction, and operations and maintenance practices.”

Kim Shinn, PE, a member of the ASHE Task Force and a Green Guide Steering Committee member, says, “ASHE charged us with the task of creating a set of guiding principles that could become the standards for selecting quality, high-performance projects. We focused on defining strategies that impact health and respond to the unique profile of hospitals. For example, healthcare is unique among commercial building types, in that process water applications account for 70% of water use, so conservation efforts should focus on those applications.”

The Green Guide built upon this earlier ASHE document and underwent an intensive two-year, multi-stakeholder development and review process, convened by Vittori with funding from the Merck Family Fund. Vittori's goal was to create a voluntary, metric self-certification tool specific to the regulatory and performance challenges of healthcare.

In November 2003, an initial draft (Version 1.0) of the Green Guide for Health Care was made available on the Web. More than 1,200 people downloaded Version 1.0, and more than 1,000 comments were logged. “Immediately, we noticed a tremendous response to the new credits being introduced that were specific to the industry,” says Tom Lent, Healthy Building Network and Green Guide co-coordinator. “The ‘places of respite’ credit, for example, elicited extensive feedback. People grasped the importance of the operations piece and encouraged its further development and expansion. As a result of the comment-period input, Version 2.0 is stronger and more comprehensive than the initial draft,” he explains.

In November 2004, Version 2.0 Pilot was released under the sponsorship of the New York State Energy and Research Development Authority, Merck Family Fund, and Hospitals for Healthy Environment (H2E), a joint project of the American Hospital Association, the American Nurses Association, Health Care Without Harm, and the U.S. Environmental Protection Agency. The 280-page document is available for downloading at A print version is under development and is expected to be released this spring.

In addition to launching the document, the Green Guide Web site is sponsoring registration and tracking a wide range of Pilot projects through 2005 to test the viability of the range of sustainability strategies in Version 2.0. The Pilot participants are eligible to participate in a Web-based forum to exchange project information and experience. In the first month following the launch, approximately 2,000 registrants downloaded the Pilot document, and more than 400 design teams expressed interest in participating in the Pilot.

What's on the horizon?

Who is building “green hospitals” and why? “Without exception, the early adopters of sustainable hospital building are organizations seeking to define ‘healing environments,’ which realize that sustainable building practices are inseparable from healing environment goals,” says Walt Vernon, PE, principal of Mazzetti Associates, San Francisco.

Early adopters include Kaiser Permanente, which is building 19 hospitals and dozens of medical office buildings—some 30 million square feet of construction—over the next ten years. “The leveraging power is enormous,” says Gerwig, who was recently promoted to vice-president of Workplace Safety at Kaiser Permanente.

“We've been pioneers of sorts in testing emissions of building materials like vinyl-free resilient flooring, because the marketplace is not moving at our pace,” Gerwig adds. Kaiser Permanente was able to get its carpet manufacturer to produce a new vinyl-free carpeting product specifically geared to healthcare environments.

The market-leveraging opportunity of the healthcare sector was mentioned recently by Boston Mayor Thomas M. Menino, the keynote speaker at the first-ever Design for Health Summit for Massachusetts Healthcare Decision Makers. The event drew together leaders from the state's top healthcare facilities for two days to discuss trends and opportunities in green building.

“A strong city is a healthy city, and green buildings promote health,” Menino said. “As leaders in the healthcare industry, you have the purchasing power to change the supply and demand of green materials.” HD