If at first you don’t succeed, try, try again. That’s one of the lessons gleaned from projects that healthcare organizations launched over the past decade to achieve some major sustainable design goals.

Some had their eyes on never-before-seen levels of energy efficiency, while others introduced unfamiliar systems as part of a new facility design. In several cases, these projects didn’t hit their anticipated marks when they first opened their doors. But through a commitment to both sustainability and the bottom line, as well as to positively impact their communities, the providers continued to adjust, tweak, and redesign, helping to raise the bar and set an example for all.

Regarded as one of the industry’s green leaders, Gundersen Health System began testing the limits on attainable energy targets in healthcare (or how much energy a building uses for a given size) when it recently built its 427,000-square-foot Legacy Building in La Crosse, Wis. “Our goal was to achieve 115 kBtu per square foot per year,” says Alan Eber, manager of engineering and energy at Gundersen Health System. “The average for hospitals in our region is about 250 kBtu so it was well below half of what the average hospital uses.”

To figure out how to deliver that efficiency, Gundersen and its project team put together a list of methods to reduce energy inside the building, from added insulation to a geothermal heat pump. “There were a number of different criteria that we used to rank those choices starting with payback,” he says. “The second one was how far of a step is it toward achieving our goal. Then we looked at things like additional maintenance and will it allow us to expand and grow, or are we pigeon-holing ourselves by doing this?”

The hospital opened in 2014 and was achieving 129 kBtu per square foot after its first year of operation, Eber says—not quite where it wants to be, so it’s continuing to adjust its systems and revisit energy use throughout the building in an ongoing effort to bring that number down. One of the biggest design lessons on the project was the potential to reduce energy use with the geothermal heat pump, Eber says. The system takes excess heat in the hospital and puts it back into the system so burning fossil fuels isn’t required to heat the hospital, resulting in “a huge energy savings,” he says. “Every hospital has the opportunity and it takes some effort and a little bit of TLC to get it working correctly, but once it does, there’s almost no better way to save energy than there.”

Other organizations, such as Ascension Health (St. Louis), took advantage of downtime during the Great Recession to look for inventive ways to save money through new building and operating standards. In 2010, the organization announced that all new hospitals would be designed to achieve an Energy Star rating of 75 or better. Its Clay County Hospital in Middleburg, Fla., one of the system’s first to use the new design standards, exceeded that goal, earning an Energy Star score of 97 through a combination of technologies such as energy recovery air handling units and a variable air volume turndown in non-critical spaces to minimize fan, cooling, and reheat energy.

Gerry Kaiser, senior director in the facilities resource group at Ascension, says the organization uses a lifecycle approach to justify what might be a “slight upfront premium” to put in the kind of systems and equipment that it does. “Once the hospital is open, it’s very difficult to get money spent on upgrading equipment, whether it’s five or 20 years old,” he says. “We try to design our hospitals to last and to perform knowing that no one wants to spend money on the unglamorous things in the future.”

Reflecting on Palomar Medical Center (PMC) in Escondido, Calif., which set out to become “the hospital of the future” when design work started on the project in 2002, Thomas Chessum, a principal at CO Architects (Los Angeles), says it’s easy to see how far the industry has come. He says PMC took advantage of the technology of the time, such as passive shading systems, heat-load reduction, and daylighting, to reduce its energy consumption, since LED lighting was still cost-prohibitive and active building programs like chilled beam systems weren’t yet mainstream. “Now we’re getting to the point where you don’t have to ask the trade contractor if they’ve done [chilled beams as a mechanical system] before,” he says. “They’ve either done it or they’ve dying to do it because they see where it’s going.”

Below, Healthcare Design looks back on these on these industry-leading projects to dig more into what they did, how those design initiatives have worked, and the lessons they can impart to the industry at large.


Project: Gundersen Health System, The Legacy Building, La Crosse, Wis.

Opened: January 2014

Summary: Design for the Legacy Building began in 2007 as part of an overall campus renewal project, which included building upon Gundersen’s longstanding commitment to sustainable design. A year into the design phase, CEO Jeff Thompson declared a goal for the entire healthcare system to be net zero by the end of 2014. On Oct. 14, 2014, the health system achieved its first day of energy independence and since then has recorded multiple days where it has made more clean energy than it has used. The Legacy Building, designed by AECOM (Los Angeles), plays a key role in achieving that goal with aggressive energy performance goals, a new geothermal heat system, and building-wide design features that had to have a payback of five to 10 years before they were even considered. “Our goal is not to force our patients to pick up the tab for us spending money not smartly,” says Alan Eber, manager of engineering and energy at Gundersen Health System. “Everything we do has to have a payback. We’re not going to go spend money just to be green; we want to spend money that will ultimately pay for itself in the future.”

What stood out: To help meet the system’s net-zero energy goal, Eber says the project set an energy target of 100 kBtu per square foot for the 427,000-square-foot hospital. “The architects came back and said, ‘We don’t think we can do that,’ so we agreed to 115,” Eber says. Still, that number was well below the average 250 kBtu per square foot that most hospitals in the region were hitting and thus demanded a “leave no stone unturned” approach to finding the latest and most efficient energy systems and features to put in place. In the end, the building featured walls with 25 percent more insulation than a standard building, thermally efficient windows, high-efficiency chillers and chilled water pumps, a daylight harvesting system, and—the granddaddy of them all—a $4 million geothermal heat system. “There’s no question that’s the biggest energy savings we have on the building,” Eber says.

Lessons learned: The building came out consuming 136 kBtu per square foot, and today it’s hitting 129 kBtu. Eber attributes the need for more fan power and outdoor air than was originally expected as part of the reason why Gundersen hasn’t hit its target yet. “There were some code issues that happened during the construction of the building and we needed to bring in some more outdoor air in some areas,” he says. “In Wisconsin, that takes a lot of energy to bring in minus-20-degree air and heat it up to 70 degrees.” In addition, shortly afte
r opening, the design team realized the building was over-lit in some areas, prompting them to use light meters to determine where fixtures could be removed. “We probably removed the amount of light we had in our staffing areas by a third,” he says. There were lessons on the geothermal system, as well, which took about nine months to achieve efficiency. Since then, Eber says it’s been running smoothly and the investment is on track to achieve total payback in just over seven years.

Today, Gundersen continues to tweak and adjust the building systems and is focusing on reducing energy use in unoccupied areas in the evenings and on weekends to get it closer to its energy target. It’s also considering replacing its T5 fluorescent lighting system with LEDs by first testing the lamps in its mechanical and staff rooms. Ideally, Eber says he’d like to see the Legacy Building cut 5 kBtus per year off its energy consumption. “Striving to achieve 115 kBtu per square foot for our new hospital is a big step toward reaching [energy] independence for consecutive months and ultimately years,” he says.

Photo credit: AECOM


Project: St. Vincent’s Healthcare, Clay County Hospital, Middleburg, Fla.

Opened: October 2013

Summary: In 2010, Ascension Health released a set of system-wide performance standards regarding architecture and engineering, with one of the goals stating that all new hospitals would be designed to achieve an Energy Star score of 75 or better. The 155,000-square-foot, three-story Clay County Hospital was one of the first out of the gate to test how those performance measures would mesh with existing design methods, such as the requirement that all patient rooms be supplied with 100 percent outside air. “That presents a special challenge,” says Gerry Kaiser, senior director in the facilities resource group at Ascension. However, when it was all said and done, Clay County far exceeded its goal, achieving an Energy Star Score of 97 that puts it in the top 3 percent for energy efficiency among similar buildings in the same environment.

What stood out: Working with architecture firm HKS (Dallas), MEP firm TLC Engineering for Architecture (Orlando, Fla.), and general contractor Brasfield & Gorrie (Jacksonville, Fla.), the project team considered several options to achieve the operator’s 100 percent outside air requirement before choosing a system that uses an energy recovery wheel in the air handling units to serve the patient floors. “It recovers both the latent and the sensible heat that you would otherwise lose just by exhausting the air stream to the outside,” says Ben Roseborough, a principal and senior mechanical engineer, Jacksonville division, for TLC Engineering. “It recovers it and preconditions the outside air to minimize the load of heating and cooling.” Another measure contributing to its energy goal is a variable air volume turndown applied to non-critical spaces to minimize fan energy (by minimizing airflow), cooling energy (by minimizing the amount of unneeded cooling of airflow), and reheat energy (by minimizing the heating needed to offset the unneeded cooling). “While this is a common strategy in non-healthcare applications, it’s a relatively recent application in Florida hospital design,” he says. Clay Hospital also incorporated an automated setback schedule in the ORs (with a nurse override) that dials down the number of air changes in the room from 20 to six per hour when the rooms go from occupied to unoccupied mode.

Lessons learned: When the building first came online it wasn’t on track to achieve its desired Energy Star goal, so the team set up weekly meetings and worked with commissioning firm TME (Little Rock, Ark.) to identify where it could dial down energy consumption. “The entire team kept moving and pushing forward to reduce energy usage and ended up doing better than our minimum,” Roseborough says. Part of the problem related to the fact that the building automation system wasn’t fully programmed before the opening, Kaiser says, meaning that general tuning of the systems had to take place during the first few months of operation. One of the biggest lessons on the project was trying to get the staff not to readjust the preset systems once they were set, which can put the overall system out of balance and eat up energy. “What happens is that someone calls and says they’re cold, so they raise the temperatures and then forget to change it back,” Kaiser says. To stay on top of potential issues, energy reports are emailed to certain staff members on a daily basis. “If we have an uptick in the energy consumption, we might get on the phone and say, ‘What did you do?’” Kaiser says.

Photo credit: Ben Tanner Photography


Project: Palomar Health, Palomar Medical Center (PMC), Escondido, Calif.

Opened: August 2012

Summary: Ten years in the making, the nearly $1 billion Palomar Medical Center was designed to be the “hospital of the future” at a time when industry best practices such as building information modeling (BIM), integrated project delivery (IPD), and sustainable design were just starting to take off. In fact, PMC served as a pilot project for the Green Guide for Healthcare and had two main directives: Create an environment that promotes health and healing and reduce the impact on the natural environment in construction and operations. Thomas Chessum, principal at CO Architects (Los Angeles), says those goals were achieved largely through a strategy of reduction and the avoidance of energy consumption through such features as shading, heat-load reduction, and daylighting. “All of those things that were done at Palomar were the right technology for the day,” he says.

What stood out: One of the most striking—and visible—green design features is a 1.5-acre green roof over the diagnostics and therapeutics wing. The undulating roof was designed to allow for 30-foot-high ceiling spaces in the unit to house the HVAC, IT wiring, and plumbing, which otherwise would be placed in vertical columns, making future renovations difficult and costly. With few green roof examples in healthcare to follow at the time, Chessum says the design team and owner took a trip to the California Academy of Sciences in San Francisco to gather ideas on planted rooftops. The final design features native plantings and drought-tolerant succulents that were expected to reduce solar radiation by almost 30 percent and contribute about $1 million to $1.5 million in energy savings. (For more on green roofs in healthcare, see “View from the Top” on page TK.) To take advantage of the hospital’s arid valley setting and drive down energy costs, the building is oriented to minimize east/west exposures. The façade features a perforated metal screen on the south side to provide shade to patient rooms, while horizontal louvers on the building protect from the sun’s angle in the summer. Chessum says PMC also made a large investment in a central plant that houses waste-heat recovery equipment for chillers and boilers to save energy at the point of creation. “Other than reducing heat loads through shading and things like that, the biggest payback in terms of energy use was in that central plant and using high-end premium equipment,” he says.

Lessons learned: Aside from a small ant infestation on
the green roof, Chessum says the space has been relatively maintenance-free and is providing the pleasant view and heat reduction qualities that the project sought. On the façade, the team did a lot of modeling to know what shading would be effective in minimizing glare and heat gain inside the patient rooms, so that patients and staff could enjoy access to natural light and views to the outdoors to the fullest. “One of the goals is that the window blinds don’t get closed and I would say that’s been pretty successful,” he says. “I don’t see many shades down.” Reflecting back on the project, Chessum says he thinks PMC was five years ahead of its time. “Compared to what we’re doing today, I look at it and say ‘Wow, if we had these things that we have the ability to do today, what more could it have been?’” For example, things like LED lighting and automated lighting controls weren’t advanced enough or were still too cost prohibitive to fully implement. The important thing to note, he says, is that the project team got the fundamentals of the building right, so that going forward, as building systems continue to improve and hit the market, the owner can introduce them into PMC to further improve its performance. “Fundamentally, they have what they need from the building itself, such as proper orientation, the views, daylighting, and the shading,” he says. “The building has given them all of that, and now we can just continue to layer onto it.”

Photo credit: Tom Bonner

Anne DiNardo is senior editor of Healthcare Design. She can be reached at anne.dinardo@emeraldexpo.com.