In many respects, sustainable design and the creation of healthy healing environments should not be seen as a new phenomenon. Its origins date back more than a millennium and can be found in the imperative set forth in the Hippocratic oath calling on physicians to “first, do no harm.” Creating environments that promote healing complements the development and practice of treatments that heal. Yet hospitals historically have not been among the healthiest environments.

Why is it so difficult to design and operate hospitals sustainably? In part it has to do with the complexity and high cost of designing and building healthcare facilities today. Regardless of its size or location, with cost per square foot as a driver space is at a premium, whether designing an urban academic medical center or a suburban community hospital. As changes in treatment and industry standards drive equipment needs and room size and layout, facilities are remodeled or torn down and rebuilt. Significant up-front costs that can be recouped over the life of a project must prove themselves financially viable in shorter periods of time. Energy and air handling demands are high, to support complex (and potentially toxic) technologies.

What happened to the Hippocratic oath in all of this? How can a hospital introduce sustainable design and operations, “doing no harm” in ways that meet U.S. Green Building Council standards while boosting patient satisfaction?

Low albedo roofing, drought-tolerant and native planted green roof gardens, were identified to obtain LEED v2.1 Reduction in Heat Islands credit at Concord Hospital in Concord, New Hampshire

A project and its champion

The Concord Hospital expansion project was designed to create a new patient wing that would be acuity-adaptable, with a new Emergency Department, new entrance for inpatients and visitors (East Wing), and a surgical wing to accommodate new, larger operating rooms, and a more efficient central sterile supply (North Wing).

For any healthcare project to be successful there must be a project champion whose commitment to the larger institutional vision frames the design and implementation process. At Concord Hospital, located in Concord, New Hampshire, that champion was the hospital's former Vice-President for Facilities, Raymond Gerbi. With a long-standing interest in evidence-based design, Ray approached the expansion project from the outset as Concord Hospital's powerful and passionate advocate for the creation of a truly healthy environment and the metrics to support it.

A culture of collaboration was established from the outset of the project between Concord Hospital and the three major firms on the project team. A partnership agreement establishing shared project principles and processes for problems resolution was drawn up and signed by all parties. Project principles included:

  • Meet financial goals

  • Be environmentally responsible

  • Provide a user-friendly, forward-looking healing environment and a series of commitments by each team member to processes for problem resolution, such as:

  • Make all decisions within the context of the project vision

  • Establish a method of delivery and communication that is an open, honest, direct, respectful, timely, accurate, and comprehensive dialogue that takes into consideration the ‘big picture' goal vs. personal goals

  • Develop and adhere to realistic timeframe for responses and actions

This played a central role in keeping the design and construction project, and the target of LEED certification, clearly on track.

Sunken gardens buffer patient rooms from the road while introducing nature and daylight into the space

Making a commitment

Receiving LEED v2.1 certification for Concord Hospital's East and North Wing expansion was the culmination of a process that began with a conscious cultural shift for this community hospital in New Hampshire and a commitment to creating a holistically healthy environment. Key to their approach on matters both large and small was ensuring buy-in and investment in changes by hospital staff.

In 2009 Concord received the Partner for Change Award for the fourth consecutive year. The award, presented by Practice Greenhealth (formed by the merger of Hospitals for a Healthy Environment and the Green Guide for Health Care), recognized the hospital for its efforts in creating healthy environments. Specifically called out were significant increases in hospital-wide recycling, the implementation of initiatives to eliminate hazardous materials, the introduction of energy-efficient heating and electrical equipment, and the use of Green Seal-certified cleaning products.

Prior to the start of the expansion project, Concord Hospital's senior leadership implemented a program to establish healthy practices in the facility. This included the replacement of vinyl flooring in patient rooms, winning staff support by testing flooring materials on-site to get staff feedback and ensuring that hospital operations remained uninterrupted by replacing the floors on a rolling basis. Recognizing the potentially adverse impact on revenues, the hospital expanded the definition of a healthy environment to include the menu in the cafeteria, with the elimination of certain menu items, including fried foods. Contrary to expectations, revenues increased following the change.

A challenging site, a sustainable design

In creating a LEED-certified hospital that would increase patient satisfaction particular attention was given to the use of daylight and the natural environment. The site posed the challenge, turned into opportunity by the design. The only available site for Concord Hospital's expansion was a challenging one: a narrow parcel of land with a two-elevation grade change that required a design that would not bury a substantial part of the proposed building so as to deprive it of access to natural light.

Through the introduction of a series of gardens on the steeply graded site, the design allows for maximum use of the site, bringing nature and daylight deep into clinical spaces while garnering a LEED credit for reduction in heat island. At-grade and rooftop gardens create privacy and access to light while a series of sunken gardens act as a buffer between the roadway and patient rooms. Sunken gardens that were created around the addition that houses the new ICU, provide the unit with daylight and views.

Patient and staff satisfaction

Since the expansion's completion, Concord Hospital's Press-Ganey scores for patient satisfaction have increased significantly, according to Domenic Ciavarro, Ray Gerbi's successor as Concord's Vice-President for Facilities. The hospital's score now stands at a remarkable 99th percentile relative to all inpatient facilities, compared to the 92nd percentile in fiscal year 2006, prior to relocating to the new East Wing. A formal Post-Occupancy Evaluation (POE) of the facility is now underway.

Shortly after the expansion project was completed, Ray Gerbi sent me the following note: “One of our senior surgeons, who spends a substantial amount of time in the ICU, made it a point to stop me today and tell me what a difference the new unit had made for patients and staff. He was used to coming onto the old unit and finding patients and staff stressed and patient care challenging at times because of the environment. Now he says he goes on to the unit with confidence that the care our sickest patients are receiving is being provided in a much more positive and uplifting environment and that the staff is much more positive about their work. He attributes this significant improvement in care and functionality to the design of the unit.”

Game point for Hippocrates.


Meeting the requirements set forth for LEED certification is just the tip of the ice
berg in creating truly healthy environments for the practice of healthcare. Taking a longer view and a more holistic approach is also the only truly practical and financially viable option.

As real estate continues to be more valuable and healthcare institutions continue to grow and evolve, the continued investigation of innovative and sustainable design and construction methods becomes all the more important. In this way, we can increase building's density while at the same time enhancing its quality and sustainability. Doing so successfully will be one of the greatest imperatives facing healthcare institutions as they look toward the future. HD

Angela E. Watson, AIA, LEED AP, is a Principal at the Boston architecture firm of Shepley Bulfinch Richardson & Abbott, where she is a leader in the firm's healthcare practice. She is a co-author of “Patient and Staff Environments: The Impact of Daylight and Windows on ICU Patients and Staff,” a published study of Concord Hospital. Healthcare Design 2010 January;10(1):16-20