Green building without sustainable operations is like peanut butter without jelly. It’s like starting a race but not finishing. It kills me when I hear of “green buildings” that use mercury-containing products, clean with bleach throughout the site, or have not signed onto the Healthy Food Pledge.

The Lucile Packard Children’s Hospital expansion project represents an example of a facility that gets it.

I had a virtual sit-down with Robin Guenther, AIA, of Perkins+Will and Krisanne Hanson, sustainability director for the hospital, to explore the integration of green building with sustainable operations for a true healing environment and the future of healthcare.

Perkins+Will is leading the design of the new 521,000-square-foot, LEED-registered addition to the existing Lucile Packard Children’s Hospital on the Stanford University Medical Center campus in Palo Alto, California.

The addition will include 150 new private acute and critical care patient beds, and extensive new surgical and diagnostic services. There also will be a below-grade patient parking structure, as well as three new inviting multiuse outdoor garden spaces to link the addition to the existing hospital, which is already known for its multiple landscaped courtyard spaces.

Perkins+Will is responsible for the architectural and interior design for the new addition, expanding upon the master plan developed by KPF, and is working closely with HGA, the architect of record, and medical planners.

Perkins+Will is developing the approach toward the overall patient and family experience throughout the new building, as well as ensuring that the design incorporates many environmentally responsible and energy-efficient design solutions to help Packard Children’s achieve a LEED rating.

Packard Children’s dedicated to extending its sustainability commitment to sustainable operations, as evidenced by its use of the Green Guide for Health Care as well as its Practice Greenhealth Environmental Excellence Awards.

Janet Brown: Krisanne, tell me about your role as director of sustainability and about your involvement with this expansion.

Krisanne Hanson: I started at Stanford University Medical Center seven years ago as the director of housekeeping, patient transport, and grounds, and transitioned to my new role as sustainability director in 2010. I remember meeting Robin Guenther in the early stages of the Lucile Packard Children’s Hospital expansion design process.

It was through Robin’s meeting discussions and coming to understand her expertise that I convinced our leadership to register and participate in the Green Guide for Health Care (GGHC) pilot program (of which Robin was a co-coordinator) for sustainable operations at both Stanford Hospital and Packard Children’s. We used the GGHC operations section to develop teams for each of the Green Guide sections, and also used the Practice Greenhealth awards application to document and compile our results.

I felt this would be a thorough assessment of our baseline sustainable operations and also provide a framework for us to gain familiarity with working in a LEED facility.

Brown: Robin, tell me a bit about the Packard Children’s expansion.

Robin Guenther: The Lucile Packard Children’s Hospital was opened as a pediatric convalescent facility in 1991, designed by Derek Parker and his team at Anshen + Allen. It has multiple levels, 26 terraces derived from multiple setbacks with a central garden as a focal point. The design effectively brings nature into the space.

When I first saw it, I understood why Derek Parker is one of the best healthcare architects of all time. At the same time, Packard Children’s has evolved into a major 21st century academic medical center, but the building now lacks support space and teaching space, and all the beds are semiprivate.

As it has grown, it has progressively constructed standalone diagnostics; at the start, it relied on the adjacent Stanford Hospital for imaging and surgery.

The addition by Perkins+Will is a 521,000-square-foot addition onto the 250,000-square-foot existing hospital. The entire center of gravity for Packard Children’s is moving to the addition—it’s getting a new entrance and a new public circulation sequence. In addition to pediatrics, Packard Children’s has a large expectant mothers and newborns program, so the existing main entrance will be repurposed into a distinct entrance for women and NICU.

Brown: What was the vision of the expansion?

Guenther: The goal was to recreate that feeling of nature infused into the building with a focus on efficiency and flexibility for the needs of the future. The existing facility no longer represents what Packard Children’s Hospital is. The expansion supports the facility’s growth and meets the needs of its growing staff and patient population.

Brown: What comes to mind when you think about a healthy environment and the Packard Children’s expansion? What was critical in your mind when taking on this challenge at Perkins+Will?

Guenther: The team wanted to retain the sense of intimacy and connection to nature. The critical sustainability attributes are based upon the location—in this case, Northern California. We couldn’t take on this expansion without taking on water conservation. Water is such an issue, particularly in California, where there is virtually no rainfall for 6-8 months of the year.

We designed a 220,000-gallon cistern system that collects rainwater and condensate from air-handling units. The collected water will be used to irrigate all landscaping, including a 50,000-square-foot rooftop garden. In order to recreate nature outside the rooms (a key feature of the original building design), we included planter boxes outside every patient room window. But even drought-tolerant plants need water, so the irrigation system waters the planters.

There is also a Discovery Garden, which is an internal garden for patients and families. The cafeteria has outdoor seating on the edge of it; a chapel is in the far corner, separated by an arbor and family labyrinth. The main garden has 50,000 square feet of walking paths and hidden art for children to find and explore.

The gardens and landscape design are a big part of Packard Children’s, and the water collection will save about 900,000 gallons of water per year. This effort only gave us one point with LEED, which speaks to the need for goal-setting and meeting the needs of the community, and not just looking for LEED points.

Brown: What steps were taken to protect the existing habitat?

Guenther: The existing 9-acre site had only 50,000 square feet of building area but was literally covered with surface parking. At the completion of this addition, the 521,000-square-foot building (with no surface parking) will have added 4.5 acres of habitat. This illustrates the impact surface parking has on a site and how moving parking underground increases green space, even with a building literally 10 times the area.

There is remote parking for staff and bio-fuel shuttles from the lots or from public transportation to reduce single-vehicle car use. The dedicated staff entry and staff garden feature bike racks to support the staff who commute by bicycle.

Brown: Krisanne, tell me about the commitment to habit
at and landscaping at Packard Children’s.

Hanson: When I first began gathering our baseline data on this topic, I was educated on the history of landscape for Packard Children’s by Brad Sorensen, our grounds supervisor, who is a degreed horticulturist. He shared that in the design and permitting phase of the original Packard Children’s, there was a drought cycle under way and xeriscaping was required.

Additionally, because this is a children’s hospital, no pesticides can be used on the landscape, and the flora and fauna plans have lists of approved plants to ensure potential toxins to children and adolescents are avoided. Tree habitat is an important aspect of the Stanford campus, as well as the City of Palo Alto (known as the City of Tall Trees).

For hospital construction, all trees were inventoried and those that had to be removed have been stored offsite and will be replanted prior to opening. Trees that cannot withstand this process are being harvested and will return to the new facility as furniture and accent pieces.

Brown: What’s the “look” of the facility?

Guenther: The building is themed around the California ecosystems—rocky shore, the redwood forest, foothills, Central Valley, high desert floor, and a mountain floor. Our art consultant and signage consultant have designed art and graphics programs that support the theme. Each floor has a color, a flower, and a tree that are native to each of those regions.

Every nursing unit has a theme animal—the design team worked with a Stanford University ecologist to ensure that the selected animals were authentic to each eco-region. The art integrates into the building, adding both an aesthetic and a wayfinding value.

The lobby floor is polished concrete (to avoid the Bisphenol A found in epoxy terrazzo), and the rocky shore and redwood forest are represented by colorful mosaic inserts set into the floor.

Brown: What is Packard Children’s doing to avoid toxic chemicals in building materials, furniture, and finishes?”

Guenther: Proposition 65 is California’s requirement to warn occupants of potentially toxic materials in indoor environments. The goal was to avoid all Proposition 65 chemicals—but we couldn’t completely accomplish that. Lead for radiation shielding, for example, is an unavoidable material in healthcare construction today. There is no good substitute for it in the marketplace.

Perkins+Will minimizes chemicals of concern using our Precautionary List and the Pharos Tool to avoid formaldehyde, chlorinated plastics, perfluorinated compounds, and brominated fire retardants, where possible.

Brown: Is there an easy win in building materials?

Guenther: Millwork and casework include formaldehyde-free substrates and Forest Stewardship Council-certified wood. Some of the displaced redwood trees were harvested onsite and will be used for the entrance canopy, trellis in the dining area, and some site furniture.

The flooring choice at the moment is rubber and a non-PVC plank that looks like wood. The healthcare team compared linoleum and rubber, and went for rubber because they felt it is quieter and more comfortable underfoot. They already use it now; as they have been renovating nursing units, they have transitioned from vinyl to rubber.

Brown: Krisanne, what does this choice—PVC to rubber—mean operationally for floor maintenance?

Hanson: The move to no-wax flooring made it possible to maintain the floors without impacting patients and staff. In order to provide the traditional method of scrub, top coat, and burnish to a high shine, we need access to the floors at a time with no individuals in the space—this is very challenging in the healthcare environment.

We have been implementing green cleaning practices for almost a decade, with microfiber mops in 2004 and HEPA filtration vacuum systems, and moving to Green Seal-certified chemicals in 2007. Also, our environmental services management partner brings research and pilot testing of cutting-edge equipment. For example, we use … an auto scrubber that uses no chemicals to clean. The technology electrically converts water into a powerful cleaning agent without the need to add chemicals.

At Stanford Hospital, where we still maintain finished floors, we use … a deep scrubber that acts with agitation versus the heavy stripping chemicals. The environmental services team came out very well in their GGHC operations section, with seven of the eight credits earned. We are now working on integrated pest management, reduction of odor control devices, and our off-site cleaning contractors.

Brown: Robin, I keep hearing about hospitals going for LEED versus those that are using LEED but not paying for certification. Help me understand the value of LEED. Does it work to use LEED but not officially register the expansion?

Guenther: There is a long distance between the top end of the construction process—the experts: designer, owner, large construction manager—and the person on site with the hammer and the nail. They are two completely different worlds. People who say they’re going to self-certify and use the Green Guide, or use best practices, need to understand that the goal of third-party certification is market transformation. It requires someone with real determination on the construction site to say “no” to the wrong materials or processes.

It is very common for the distributor to not have the product that was specified. When the truck pulls up with a different product and it’s unloaded, someone has to be there to notice. It might create a delay, lead to questions about whether it really matters, etc. I believe that 90% of the time, in a self-certification process, a team will make a decision to install the material that shows up in the truck—even if it’s not the correct choice.

LEED certification ensures that the superintendent and design team are on point to control material delivery and installation. On LEED projects, the detailed documentation requires showing the material that is there and a need to demonstrate the material that was used. So LEED provides the structure, the control, and ensures that the supervision is there to make sure that intent is followed up with action.

This ensures the shared goal of getting the right product that actually is prioritized over the time and money issue. It transforms markets because it forces the distributor to go back and get what was specified—the distributor starts carrying the product with no added formaldehyde, for example. You need a goal that transcends the here and now for everybody.

While a number of low-emitting, healthier materials are more common now, the focus moves to the next era of technology—LEED pushes owners and their teams to innovate further, often to less common material options.

Brown: Krisanne, talk to me a bit more about how Stanford University Medical Center manages sustainable operations on a day-to-day basis.

Hanson: We realized that many of the environmental or sustainable attributes in healthcare must be addressed within the area of support services. Energy management, water conservation, green cleaning, sustainable foods, waste management, and better buying—all of these things fall under support services and general services. Our senior leadership has always been very supportive of sustainability.

By structuring activities around the Green Guide operations section, departments took a leadership role on assessing and committing to environmental improvement. We had already addressed mercury elimination and achieved the Practice Greenhealth Making Medicine Mercury Free Award in 2003. We took on integrated opera
tions, facilities management, food services, waste management, chemical management, environmentally preferable purchasing, and environmental services.

The Guide gave us the road map we needed to set goals and measure progress. The Guide also aligned very nicely with the Practice Greenhealth awards program, making it easier to document our progress and gain recognition for our efforts. Each of the Guide sections had a separate team, but they all reported to the vice president of general services, Wes Palmquist, who both pushes and supports us on our sustainability initiatives.

Results were connected with performance so staff was fully engaged and onboard. It also helped when we understood this tool would someday become LEED-HC-EB. As the sustainability director, I provide the technical assistance, education, and resource support to the departments and report on our results. In addition to the support services teams driving change, we have departmental-based champions throughout the facilities.

Brown: We all know that energy systems and conservation efforts are at the top of the list for healthcare.

Guenther: Packard Children’s gets its thermal energy from Stanford’s combined heat and power plant. They purchase power from their local utility—today, 40% of that is generated with renewable, and it’s improving over time. Packard Children’s will be using displacement ventilation to reduce energy demand in the inpatient units.

This system requires integrated design between the façade and mechanical systems to reduce solar exposure—in this case, Mazzetti, Nash, Lipsey, Burch did the system design and energy modeling. A system of fixed exterior louvers and vertical fins, integrated with planters, provide the solar shading that enables displacement ventilation.

Another innovation is that for central IT, the data center is on the roof, so that keeps it cool and allows for natural ventilation. It’s accessible off of the elevator to the roof.

Brown: Any last thoughts on sustainability?

Hanson: I would only add that it is support from our leaders that allows us to take bold action, and I would highlight that this commitment comes directly from the top. Christopher Dawes, our president and CEO of Packard Children’s Hospital, has shared, “As a children’s hospital, we have the responsibility to model the healthiest environment possible for our patients, their families, and the community. We take that responsibility seriously, and we intend to lead the entire industry in making children’s hospitals healthier places to be.

Guenther: Packard’s modeled energy performance suggests a 38% reduction in energy use intensity and overall water reduction approaching 45%. These performance improvements are only possible with owners who have a deep commitment to occupant and community health—owners who understand that built environment decisions have consequences that are within our control. Through Packard Children’s leadership, it is a building that will walk the talk around high-performance healing environments.

For more information on Lucile Packard Children’s Hospital, please visit Janet Brown, EDAC, can be reached at