Over the past decade, increasing attention has been focused on the principles of sustainable, high-performance green building design and construction as a solution to the well-documented, significant environmental effects of the conventional construction, operation, and maintenance of buildings. In response, the U.S. Green Building Council (USGBC) developed a volunteer green rating system called Leadership in Energy and Environmental Design (LEED) to assist the building design and construction industry in erecting high-performance, environmentally responsible buildings.

Although LEED and its principles have been broadly adopted by the design and construction industry, there are some chal- lenges within the healthcare sector. In the United States, few hospitals are registered for LEED certification and only one has received LEED certification: Boulder Community Foothills Hospital, in Boulder, Colorado. In addition, Providence Newberg Medical Center in Newberg, Oregon, will open its doors in spring 2006 as the first green hospital on the West Coast; it is expected that it will also receive LEED certification.

The healthcare sector's reluctance may be attributed to the general belief that current LEED concepts are incompatible with healthcare facility design and construction. However, recent research by the lead author has identified the challenges in current LEED design and construction practices in the healthcare sector, and this article provides our recommendations for an effective project planning approach for owners and project teams committed to developing high-performance, environmentally responsible healthcare facilities.

Speaking From Experience

In November 2004, the lead author conducted research at Texas A&M University to identify the issues associated with integrating the LEED rating system with the design and construction in the healthcare sector-and, most importantly, solutions to these challenges-based on interviews with owners, project managers, architects, and contractors involved with current LEED-registered healthcare projects in the United States.

Twenty LEED-registered healthcare projects were selected from the USGBC Web site. Ten are located on the East Coast, five on the West Coast, and five in the central United States. Information was solicited from the owners, project managers, architects, and general contractors of the chosen projects. Participants from 19 projects responded to the survey.

Out of those 19 projects, four projects are no longer pursuing LEED certification. The two most cited reasons given for this were the high initial capital cost and the inconsistency between healthcare regulations and LEED requirements. The first issue could be addressed by making a project decision based on the life-cycle cost and associated pay-off versus the up-front capital cost.

With respect to the second issue, it should be noted that the healthcare industry has developed its own guidelines to address the unique issues of sustainable design in healthcare: the Green Guide for Health Care. The healthcare field's first quantifiable sustainable- design guidelines for facility planning, design, construction, operations, and maintenance, the Green Guide borrows its credit categories and point system from LEED. The Green Guide is intended to help designers, owners, and operators voluntarily evaluate their progress toward high-performance healthcare facilities, and it is applicable to new facilities, additions, renovations, and major rehabilitation/adaptive reuse projects. During the pilot phase of the Green Guide system, team members for registered projects can participate in a Web-based discussion forum with other teams. The Guide will be revised by identifying and analyzing the green strategies of the current pilot projects.

In their responses to the author's survey, the owners and professionals involved with LEED-registered projects cited a number of issues and challenges associated with pursuing LEED certification. Many of them expressed concerns about the additional time required for planning, documenting, and certifying a green facility, including the “paper trail” and documentation required for LEED certification. They noted difficulties with procuring green materials in terms of cost and time, as well. The owners and project team members also stated that they had experienced difficulties overcoming ambiguity in defining a project's green objectives. There were additional challenges within the project teams themselves, such as lack of experience with the LEED point system and certification process, unclear scope of work, and communication issues among the various design, engineering, and construction disciplines.

Additionally, many of the owners surveyed expressed that they had been reluctant to register their projects for LEED certification. In many cases, this was because of the lack of historical data on green healthcare projects for forecasting cost and schedule decisions. And owners said they believed that it is difficult to integrate LEED objectives with existing healthcare regulations. Moreover, they were concerned that after they had invested the time, effort, and expense involved in seeking LEED certification, they might not receive final approval of their credits and certification by the USGBC.

Fundamentals of Success

Indeed, these are realistic challenges to implementing a LEED healthcare project, but they are not insurmountable. Based on our research, following are our recommendations to owners and project teams that have registered a LEED healthcare project and are working toward certification. We suggest that they need to understand and practice four fundamentals, as follows:

  1. Owner leadership. First and foremost, everyone involved in the project must recognize that LEED certification is an owner-driven process. Owner commitment and ongoing leadership are critical to a LEED project's success. However, integrating LEED and green objectives into a healthcare project is a relatively new process. In general, owners look for the potential of reducing the project cost and time, and they typically question the argument that high-performance building technologies will reduce operations costs over the life cycle of the building.

    Unfortunately, there are few data on LEED-certified buildings to prove this assertion. After all, the first LEED pilot projects were just certified in 2000. But there are energy-modeling tools available, such as eQUEST and DOE-2, that allow the project team to calculate and project life-cycle costs of a facility based on alternative mechanical system and energy designs. These interactive energy-modeling programs allow the user to enter the parameters of the project's mechanical system, light zones, building orientation, regional location, and other energy-related data. Then, based on these parameters, the programs calculate future operating costs and the potential savings over the period under study, which can range from 10 to 30 years. The results and the output of these modeling programs help the project team identify the most cost-effective, energy-efficient alternatives and help to convince owners of the value of a high- performance building. The outputs also serve as documentation for LEED credits.

    Owners also might be reluctant to integrate additional green objectives into the project when the project team has limited experience with LEED. In turn, involvement in an unfamiliar process can lead to added contingencies by architects and contractors, which could inflate the project cost for the owner. Therefore, it is essential for the project team to include at least one LEED-accredited professional who has experience working on healthcare projects.

  2. Early integration of LEED objectives. These must be adopted early in the project to ensure quality and manage costs. To be fair, a LEED-registered project requires a bit more careful planning and effort when compared with conventional projects. Owners and design teams must invest time and effort during the soft-cost phase of the project rather than making decisions during its later stages. Research conducted by the Construction Industry Institute (CII) in 19951 showed that all decisions made at the emergent stage of a project's life cycle have a greater influence on managing costs than decisions made at later stages of the project; specifically, the CII study showed that costs of well-planned projects are as much as 20% lower, on average, than the costs of poorly planned projects.

  3. Integrated design approach. Project teams enhance their opportunity for success in a LEED project by practicing an integrated design approach. The objective of implementing LEED is to create high-performance buildings. Therefore it is essential to involve all the potential team players early during project planning, both to ensure proper alignment of green objectives within the project team and to avoid communication gaps among the participants.

  4. Clearly defined roles and strategies. Owners and project teams need to define roles, responsibilities, and LEED strategies early in the project development phase. The current LEED rating system is divided into six categories: sustainable sites, water efficiency, energy and atmosphere, materials and resources, indoor environmental quality, and innovation credits and design/build process. Some credits are generally within the owner's control, including site selection, development density, brownfield development, and access to public transportation. Prerequisites requiring storage and collection of recyclable construction waste and implementation of an indoor air quality plan during construction and before occupancy are the responsibility of the general contractor. Credits for efficient use of daylight, outdoor views, increased ventilation, and specification of local/regional materials are in the design and engineering team's domain. Thus, achieving LEED credits is a team effort.

It is also worth noting that every LEED registrant has access to a variety of resources-including calculation tools and case studies-that may be useful to the team during the early planning stages of a project.

Key Strategies

The author's research with owners and project teams has identified a number of strategies that will help the team meet the challenges associated with the LEED certification process. To summarize:

  • Recognize that LEED is an owner-driven process. Identify the owner's level of commitment to LEED and the leadership required to meet green objectives;

  • Integrate LEED objectives and strategies into the project as early as possible;

  • Include at least one LEED-certified professional on the project team to guide the team through the process;

  • Develop a responsibility matrix of proposed LEED credits, including strategies and associated costs, to define roles and tasks within the team;

  • Identify costs early during the project to minimize financial variations at later stages;

  • Develop a well-defined scope of work to convey precise project objectives to the general contractor;

  • Involve a LEED-experienced general contractor early in the process to gain the benefits of credits under materials and resources, constructability studies, and alignment of subcontractors and suppliers with the LEED process (see below);

  • Provide flexible specifications that allow contractors to research alternative green materials (see below); and

  • Seek financial support from local or state government to minimize capital and commissioning costs (see below).

Finding a Green Contractor

There are several ways to find general contractors who understand sustainable design and construction practices. First, it is invaluable for owners to become involved in environmental organizations, where they will become more familiar with the issues and with LEED-experienced contractors. Second, owners can tap local USGBC chapters for information about contractors. Third, when reviewing contractors' responses to a project RFP, owners should evaluate each contractor's portfolio based on its experience with similar healthcare projects and the presence of LEED-accredited professionals on its staff. However, they should not eliminate a contractor solely on the basis of its experience with LEED healthcare projects, given the emergent nature of LEED in this industry.

Finally, owners and architects should assess the contractor based on its overall quality- improving efforts within the organization. For example, Skanska has a corporate commitment to abide by the International Standards of Environmental Quality ISO 14000 series. Additionally, Skanska's Healthcare Center of Excellence assists all its offices and clients with leading-edge concepts and best management practices to develop superior healthcare construction projects, including sustainable construction practices. Overall, owners should strive to build a proactive team, including LEED-proactive engineers, contractors, and vendors.

Flexible Specifications

Flexible specs help contractors research the costs and benefits of green alternatives. For example:

  • Write specifications for non- to low-toxic paints to allow flexibility for contractors to use natural paints, zero-VOC paints (0-5 g/l), or low-VOC paints (not more than 200 g/l);

  • Specify carpets with high natural content, such as jute, wool, cotton, corn, plant fiber (sisal), coir, conifer, and reed or those with high recycled content, such as reclaimed fiber or soda-bottle plastic (PET), along with nontoxic carpet adhesive and backings; and

  • Specify clay plasters made from 100% natural materials and drywall compound with low VOC content. These can be used as all-purpose joint cement and texture compounds.

Finding Grants

Many localities and states offer energy grants to fund capital costs of technologies associated with high-performance buildings. For example, Providence Health System received grants and tax credits to help fund green building initiatives incorporated into Providence Newberg Medical Center, which includes a 143,000-square-foot, state-of-the-art hospital; a 44,000-square-foot medical office building; and a healing and wellness garden. The system received a $200,000 grant from Energy Trust of Oregon, a $156,000 agreement with Pacific Gas & Electric to fund generator upgrades in return for distributed generation capacity, and a $15,000 grant for building commissioning from the Northwest Energy Efficiency Alliance, which will qualify the hospital for a $141,000 Business Energy Tax Credit through the Oregon Office of Energy. The health system anticipates that this financial support will enable it to achieve a 14-month return on investment in these initiatives.

The Time Has Come

Healthcare facility owners and project teams that are working through the process of LEED certification today are pioneers in the design and construction of green healthcare facilities. They are demonstrating that a commitment to “leadership in energy and environmental design” is compatible with healthcare design and construction, if the project team uses a strategic planning approach that, up front, incorporates the four fundamental practices described above: owner leadership, integration of LEED objectives into project planning, an integrated design approach, and clearly defined roles and responsibilities within the project team.

The healthcare design and construction industry can and should follow the lead of these LEED pioneers in developing high-performance, environmentally responsible healthcare facilities. It is an idea whose time has come for the industry, including the healthcare sector. HD

Priyanka Tyagi, MS, LEED AP, is an Architectural Specialist with Skanska USA Building, Inc., in Seattle. Tyagi, a member of the American Society for Healthcare Engineering (ASHE), earned her MS in Construction Management from Texas A&M University. This article is based on her master's thesis research.

Mark Howell is a Project Executive with Skanska USA Building, Inc. Howell earned his BS in Construction Management from Washington State University. He has 21 years' experience in construction with an emphasis on the healthcare market.


  1. Construction Industry Institute, Pre-Project Planning Research Team, coordinating author G. Edward Gibson, Jr. Pre-Project Planning Handbook, Special Publication 39-2. Edited by Rusty Haggard. April 1995.