Some of the most spectacular hospitals ever conceived were built more than 80 years ago for treating tuberculosis. From the great TB hospitals of Europe, such as Alvar Aalto's Paimio Sanatorium in Finland, to the modest “cure cottages” of the Adirondacks, the Architecture was the cure. Founded on the TB treatment at the time—fresh air, rest, and peace of mind—these facilities faced their patient rooms toward the sun and enabled caregivers to pull patient beds through glass partitions onto open-air sunporches. Despite this seemingly simplistic treatment, a significant number of patients improved. Architects later began to replace the dark, suffocating Victorian edifices of all types with new light and airy buildings for healing. But now, as the result of heavy regulations, medical technologies, and high-tech treatments, hospitals don't look like this anymore. When we walk into most medical facilities these days, it's hard to imagine a history of hospital design in such harmony with nature.

Change is on the horizon. In 1998, the EPA and the American Hospital Association (AHA) formed Hospitals for a Healthy Environment to reduce waste and toxicity. The Green Healthcare Construction Guidance Statement of January 2002 issued by the American Society for Healthcare Engineering (a division of AHA) calls for healthcare design and construction to protect occupants, local and global communities, and natural resources. The U.S. Green Building Council will soon pilot the much-awaited LEED ® Application Guide for Healthcare Facilities. In October 2004, the invaluable Green Guide for Health Care self-certifying rating system became available to designers and facility managers.1 Most important, successful sustainable healthcare projects have been built using this rating system.

By the same token, certain hospital areas simply don't lend themselves to the principles of sustainable design—some treatment and diagnostic/treatment spaces can't and will never have natural light or ventilation. For these reasons, hospital designers—in hopes of applying any sustainability at all—must apply green design with a practical bent to pursue sustainable design strategies that bring identifiable benefits to their clients. This raises the green design dialogue onto the solid foundations of mission and financial justification, and challenges the entire design team to aspire to a higher level of design. This perspective is illustrated by this sampling of some successful pragmatic strategies, many of which were offered by distinguished design colleagues (see acknowledgments at the end of this article).

Site: Sustainable site design protects local ecosystems, minimizes site disruption and destruction, and lessens the impact on the surrounding community. Select a site that is compatible with use patterns and then work with the site, not against it. Significant regrading by large earthmovers pollutes the air, promotes erosion, and destroys local ecosystems.

If local zoning calls for more parking than required, examine all the options, build what is needed, add permeable paving for spillover, and leave the rest green and undisturbed. Add planted green fingers and buffers as hints of nature for occupants moving to and from their cars. Save existing mature trees (or plant new buffers) to shade the buildings and block winds for enhanced energy efficiency.

Defining and limiting construction access and staging on the building site prevents irreparable damage to green space and existing ecosystems.

Building: The sustainable building is compact, is sited to maximize light and views, is built with high-quality materials, and has lower operating costs that exceed expectations. When siting the building, proper positioning is key to the design of any sustainable building. Seeking eastern and northern exposures improves daylight and views, and reduces HVAC loads and overall energy consumption. (South- and west-facing windows have a significant impact on a building's overall load.)

Invest in long-lasting, high-quality regional materials for the exterior building components, with overhangs to protect the materials and keep the building cool. Install only high-quality windows that exceed ASHRAE 90.1, using known brands to insulate the interior from the elements and cut sunlight.

Because dark roofs have a tremendous impact on the local microclimate and increase cooling HVAC loads, remember that selecting the right roof can significantly reduce operating costs.

Minimize the building footprint. Building vertically or adding additional floors to an existing building conserves the site, requires minimal demolition, and extends existing cores. When adding horizontally, attach at major circulation paths and locate new spaces close to existing parking services.

Materials: Sustainable interior finish selections improve patient outcomes and staff productivity, conserve resources, and reduce long-term costs. Interior material selection is paramount to good sustainable design. Fortunately, the building industry has embraced green design and offers extensive choices at competitive prices. Cut back on wallcoverings or wall protection as much as possible in healthcare projects. At one facility we know of, extensive wall protection is no longer a construction standard in some areas, but rather is added after the fact as wear and tear dictate.

When painting, keep your overall finish palette neutral with accents of bold paint color only in the areas frequently affected by wear and tear. Accent colors in your upholsteries and art can, in long-lasting natural materials, limit wasteful remodeling and keep long-term costs down.

Consider specifying as much hard flooring—cork, rubber, linoleum—as possible. High-quality, low-maintenance floors cleaned with green cleaners last longer, look fresher, and are easier on the feet.

When carpet is appropriate, look for a new standard that provides the industry with a comprehensive evaluation of the total environmental impact (Environmentally Preferable Product [EPP] certification) awarded by independent third-party certification organizations such as Scientific Certification Systems. This certification is based on better product performance; lower total environmental impact; higher use of green energy; documentation of significant efforts to protect the health, safety, and environment in manufacturing; and sensitivity to end-of-life responsibility. Antron® nylon was the first carpet fiber to achieve EPP certification by an independent third party, with more than 230 carpet styles manufactured by Interface, Inc., C&A Floorcoverings, Bentley Prince Street, Lees, and Milliken & Company.

Consider modular systems for fit-out. Modular furniture, casework, and even partitions are easy to assemble, disassemble, and move as needs change. Buy them once, but reuse them many times in many different ways and create no waste.

When custom casework is required, specify well-performing water-based finishes and formaldehyde-free, agro-based core materials such as wheatboard. Since hospitals have miles of mineral fiber ceiling tiles, use the largest tile you can (to reduce the number of grid elements), specify high-quality and easy-to-maintain tiles with a high recycled content, and recycle your old tiles. (For example, the Armstrong Ceiling Recycling Program will pick up and recycle any brand at no charge.)

Indoor Environmental Quality: Sustainable material selection, thermal comfort, and natural light improve patient outcomes and staff productivity. Bring natural light deep into the building by incorporating atriums, courtyards, and skylights. Views to nature are powerful medicine, and less problematic than indoor plants that require maintenance that can pollute the indoor environment.

High indoor air quality is completely within reach. Specify finishes with low VOCs that require minimal maintenance.

Use as many monitored HVAC zones as possible with additional monitoring (CO2 sensors, air-flow sensors, and outdoor air dampers). Also consider a 100% outdoor-air heat recovery system to fight infection and eliminate that classic “hospital smell.”

Energy: Sustainable energy strategies cut energy costs and reduce fossil fuel consumption and emissions. The extensively zoned HVAC zoning that improves indoor air quality also allows for load profiling and greater energy efficiency. Only those zones in need of conditioning expend energy, while others remain idle. Also consider variable-frequency drives on HVAC motors with more than 5 horsepower for even greater efficiency.

When pursuing sustainable energy practices, lighting is critical, as “lighting makes up a large portion of a…building's energy budget.”2 Make use of energy-efficient T8 and T5 fluorescents with good color rendering throughout your facility—even for decorative lighting. Task lighting and natural light reduce the need for ambient light. In addition, occupancy sensors installed where possible prevent one of the biggest energy drains of all: lighting empty rooms.

Most sustainable projects utilize centralized HVAC systems, hot water reheat, and electronic DDC controls. Also consider low-temperature chilled water and supply air, which allow for size reductions in equipment and ductwork.

Water: Sustainable water strategies promote aquifer recharge and lower building operation and consumer costs for supply and treatment. To cut down on high water consumption in hospitals, install motion sensors in all public restrooms where water use is least controlled. Specify low-flow faucets in all other spaces where appropriate. If the owner wants irrigation, reduce water use by planting indigenous plants and installing a high-efficiency irrigation system that delivers water as needed.

Waste & Recycling: Sustainable waste management saves money, slows resource depletion, and diverts valuable resources from landfills. Since most hospitals undergo ongoing renovations and repairs, site planning and designs should include staging areas for construction waste recycling and storage space for salvaged items such as doors and plumbing fixtures. If hospitals aren't designed with space for reusable building elements, facilities have to trash them. Maintaining good staff access to and communication with the loading docks can be helpful for a smooth-running recycling program.

Finally, when renovating existing facilities or building new ones, require the contractor to recycle construction and demolition (C&D) waste. Once ignored, C&D recycling is becoming a well-established practice. In September 2004, Turner Construction Company, the largest commercial builder in the United States, announced its commitment to C&D recycling on all future projects—not just LEED. Job-site sorting reduces trips to landfills, keeps the building site clean, and generates salvage income to offset the nominal labor costs involved.


Healthcare facilities that pursue sustainable building practices and operations work with the healing process, not against it. Once again, like the early TB hospitals, Architecture is playing a key role in medicine. When LEED registration and Green Guide for Health Care self-certification prove to be hard pills to swallow, careful prioritizing of solid sustainable practices is still a step in the right direction. Careful incorporation of green design and operations where possible is an ounce of much-needed prevention and sets a foundation for increased awareness and steady improvement. It also reaps lower operating costs, increased productivity, and improved patient outcomes. HD


  1. Healthcare—The lost sheep of sustainable design. Progress Report on Sustainability. Building Design & Construction, November 2004, p. 40.
  2. LEED-NC Version 2.1 Reference Guide, p. 137.



The author thanks the following distinguished colleagues and industry leaders for the ideas contributed to this article: Lynn Garske, environmental stewardship project manager, Kaiser Permanente, California; Tom Van Landingham, associate, Christner, Inc.; Laurel Harrington, ASLA, landscape architect, Christner, Inc.; Robert Ducker, AIA, LEED® AP, principal, Christner, Inc.; Hunter Beckham, ASLA, landscape architect, Christner, Inc.; Mark Matteson, PE, Heideman | Associates, St. Louis; Carl Moore, Modern Roof Consulting, St. Louis; Joe Bauer, AIA, LEED® AP, associate, Christner, Inc.; Grace Crews Corbin, AIA, IIDA, LEED® AP, associate, Christner, Inc.; Lucy Williams, LEED® AP, Christner, Inc.; Jim Ryan, president, Architectural Woodwork Corporation, St. Louis; Terry Bader, executive director of construction/facilities management, St. John's Mercy Medical Center, St. Louis; Ed Barr, manager of support services, Thomas Jefferson University Hospital, Philadelphia; Joe Howard, director of facilities management, Boulder Community Foothills Hospital, Boulder, Colorado.