Abington Memorial Hospital Abington, PA. Green Healthcare Facilities

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1 Green Healthcare Facilities

2 Research Green Healthcare Facilities The Healthcare Industry The healthcare industry has been one of the most prominent markets today with over 120,000 buildings in the United States. Healthcare facilities average between 70 and 75 million square feet of construction every year with over $20 billion in healthcare construction costs. The design of a healthcare facility is influenced by the many services offered in a hospital, from the productivity hospital staff to patient care. Due to these features, hospitals are one of the most complex building types. There are several functions of a hospital that need to be incorporated into its design: Bed related inpatient functions Out patient related functions Diagnostic and treatment functions Administrative functions Service functions (e.g. food, supply) Research and teaching functions Source: WBDG Hospital In addition to the necessary hospital services, there are several other aspects that must be considered during the design phase of a hospital. Ninety nine percent of inpatient healthcare facilities are owner occupied. A designer must maximize the available space, resources, and access to the building. Future options must also be considered, as many healthcare facilities perform renovation in order to accommodate changes in technology and patient flow. As with any building type, the owner wants the most for their money. The design of the building must be optimized in terms of layout, performance, and image. Human scale, physician/staff accessibility, and patient safety also need to be incorporated into the design. These factors can intertwine and conflict with each other, often causing one or more of them to be sacrificed. Another important aspect of the design is that it must facilitate its occupants. There must be adequate methods of communication and information transfer within the hospital. One of the most important requirements of a designer is 40 of 97

3 to humanize the facility in terms of the patient s experience, finances, physical needs, and emotional needs. In addition to the design factors that must be incorporated into a healthcare facility, the structure needs to meet building codes and industry regulations. Successfully incorporating these factors into the design of a hospital can be an extremely difficult, and expensive, task. Once constructed, the hospital still has many requirements, from an operational standpoint and as a functional healthcare institution: Increase general and technical performance Increase flexibility and ease of operation Reduce redundancies and energy demand Reduce waste and obsolescence Recruit and retain top level staff (physician to service personnel) Reduce administrative/ regulatory pressure Meet and exceed consumer demand Attract new patients Stay current (economic, social, cultural, political, technological) Fulfill purpose and mission Source: Guenther 5 Architects, Picture Perfect: The Healthcare Model, Greenbuild 2003 The healthcare industry is different from other industries, given the level of complexity in its construction and the various functions it must incorporate. The healthcare industry employs over 6.2 million workers, which is a total of 6% of the workforce. Inpatient healthcare facilities occupy far more square feet than any other building type, as seen in the figure to the right. Figure 11: Square Feet per Building Due to the nature of the healthcare industry, hospitals are highly inefficient in terms of resources. The healthcare industry creates 5 million tons of solid waste annually. Healthcare facilities are the fourth highest consumer of energy for all building types with 515 trillion BTU s per year, 11% of all commercial consumption. The amount of energy consumed in a single inpatient healthcare facility is 4.5 million kwh, 22 times the average for commercial buildings. The average energy use per square foot for all healthcare buildings is still two and a half times that of an average commercial building. This is partly due to the fact that a hospital must be operational 24 hours a day, seven days a wee and require full emergency back up systems. 41 of 97

4 Figure 12 shows the various methods of energy consumption in healthcare facilities. The majority of energy is consumed by site electricity and natural gas. The healthcare industry, inpatient facilities in particular, are significant consumers of electricity and natural gas. Figure 13 shows the use of electricity and natural gas in healthcare facilities versus an average commercial building. Figure 12: Energy Consumption in Health Care Buildings by Energy Source Energy Consumption per Building in Healthcare Facilities Inpatient Health Healthcare (all) Avg. Commerical Natural Gas (thousands cubic feet) Electricity (thousands kwh) Source: Energy Information Administration, 1999 Commercial Buildings Energy Consumption Survey Figure 13: Energy Consumption in Health Care Buildings by Energy Source The healthcare industry is a large consumer of energy and a significant producer of waste. Financially, there is a need for improvement. While a majority of energy and waste is unavoidable, there are ways to design for a more efficient facility. A life cycle analysis can be an effective way to reduce nonessential costs to the hospital owner. Efficient design is critical to the building s overall cost and performance. The average age of a healthcare facility is 23.5 years, compared to a commercial building s 30.5 years. A study by the National Bureau of Standards concludes that the cost of a typical building s design and construction accounts for only 2% of a building s life cycle cost over a 30 year period. The salaries of the hospital employees account for 92% of the building s cost, which is thirteen times the cost of the facility s construction, furnishing, maintenance, and interest. Even a 42 of 97

5 marginal improvement in the design can yield significant benefits to the owner in terms of a life cycle cost. Consumer demand is based on cost, accessibility, quality of service, and quality of medical care, which all come at a high cost to the hospital owner. Figure 14, below, shows the healthcare construction spending versus the number of hospital inpatient days. In the past several years, more money has been spent on construction in the healthcare industry, while fewer patients are being treated. Healthcare facility spending is becoming ineffective in terms of patient care and shows room for improvement. Source: (1) Forecast of Total Health Facility Spending by U. S. Dept. of Commerce, (2) Forecast of Hospital Inpatient Days by Moser Associates, Figure 14: Forecast of Hospital Inpatients vs. Health Facility Spending 43 of 97

6 Green Building Design The buildings that we live in, work from, and enjoy during our leisure activities represent the largest contributions to anthropogenic environmental impacts and resource depletion and threaten our environmental, economic and social sustainability either directly or indirectly. U.S. Green Building Council One of the most important issues to building owners is quality. The level of quality can be measured in many ways: initial cost, level of design, operation, maintenance, and overall functionality. As the market is constantly evolving, building owners are also becoming smarter. Sustainability is becoming more and more prevalent in the construction industry today. A sustainable building can be described as having a minimal effect on the environment; in terms of the construction materials, construction methods, energy use, and operating and maintenance methods. Issues such as life cycle analysis, recycling, energy efficiency, and waste reduction are proving to be a viable part of the building industry. The U.S. Green Building Council is an organization that promotes healthy, productive, and environmentallyfriendly buildings. The USGBC has developed the LEED (Leadership in Energy and Environmental Design) Green Building Rating System. It is a nationwide standard developed to promote sustainable buildings. There are six categories in which sustainability is measured: sustainable sites, water efficiency, energy & atmosphere, materials & resources, indoor environmental quality, and innovation & design processes. There are a total of 69 points that can be achieved, with various levels of achievement: platinum, gold, silver, and certified. (See Appendix I) According to the USGBC, there are many steps that can be taken to attain a sustainable building, such as construction material recycling, storm water management, alternative transportation, and water efficient fixtures. Energy efficiency can be achieved by having renewable energy sources, building systems commissioning, chlorofluorocarbon reduction, and a minimum energy performance, which is designated by ASHRAE. 44 of 97

7 Sustainable buildings provide significant benefits, for both the owner and the occupants. A more efficient building yield financial savings for the owner and a healthier environment can lead to higher productivity and well being. Below is a list of ways a building can benefit from sustainable construction. Reduce operating costs Reduce risk and potential environmental liability Meet potential future regulatory requirements Improve market performance Enhance recruiting and retention of staff Enhance public image and community relations Demonstrate corporate responsibility Reduce health burdens associated with environmental factors Source: Guenther 5 Architects, Picture Perfect: The Healthcare Model, Greenbuild For most owners, the primary objective to almost any building facility is to make a profit. As previously mentioned, a life cycle analysis can be extremely beneficial to an owner in regards to the long term cost of a building. A life cycle analysis forces the owner to use materials which will last longer, are more durable, and require less maintenance. The possible economic benefits of sustainable construction include an increase in property rental value income and initial sales price. Costs for financing, operating, and maintaining the facility can also be reduced. A more sustainable building is likely to result in more long term savings, as seen in the figure below. The level of savings is dependent on the sustainable characteristics of the building. Source: The City and County of San Francisco, Dept. of the Environment, April Figure 15: Net Present Value Cost of Building Ownership 45 of 97

8 The attainment of a sustainable building does not come without a cost premium. It is estimated that owners can expect a 5% premium to attain Green building functions. Costs for the building construction, design, and development are likely to increase because Green building design is not a standard in the industry. In addition, less experienced designers are likely to have a higher fee. However, there is great potential for a sustainable project to generate substantial cost savings to the owner. Along with long term life cycle cost savings, the government offers tax credits for Green construction, through the Green Building Tax Credit Program. The tax credits are awarded differently for each state. New York, Maryland and Massachusetts are the only states which have enacted the policy. Each state must develop its own version of the LEED rating system, as the LEED guidelines were not developed as a national standard. Therefore, the tax credit policy differs in each state. For example, Maryland offers up to 8% of the building s construction cost and must be at least 20,000 square feet with a LEED rating of silver or higher. New York is offering a total of $25 million in tax credit over a period of 4 years. An apartment building and an office building in New York City received a $5 million and a $6.6 million tax credit, respectively. Benefits of Green Healthcare Facilities The healthcare industry has the greatest potential to benefit from Green building practices. The purpose of a hospital is to administer patient care in a healthy, efficient manner with minimal cost. One of the primary benefits of a sustainable building is that it is a healthier environment for the occupants. What better facility to have a healthy environment than a hospital? Of the many benefits of a sustainable building, there are two in particular which directly apply to the functions of healthcare facilities: improved productivity and an enhanced well being of the occupants. There are several ways in which sustainable buildings can have an effect on its occupants, both patients and staff. One effect is the improvement of physician productivity. This could potentially result in the treatment of more patients, more effective procedures, and higher quality treatment. The American Institute or Architect s Academy of Architecture and Health reports that natural lighting, outdoor 46 of 97

9 landscaping, rooftop gardens, solariums, and small atria have positive impacts on the patients, as well as the staff. Sustainable buildings have been shown to increase productivity in several building types. Reports show that sustainable buildings affect occupant s product defect rate, product quality, and absenteeism. Below is a list of projects which have benefited from Green building construction: Renovations New Buildings Reno, NV Post Office Lockheed Building 157 Cost: $300,000 Cost: $2 million Energy Savings/yr: $22,400 Energy Savings/yr: $500,000 Productivity: 6% increase in processing rate Productivity: 15% rise in production One year payback Boeing West Bend Mutual Insurance Energy Savings/yr: 90% lighting improvement Energy Savings/yr: 40% electricity Productivity: 20% improvement in defect rate Productivity: 16% rise in claims processed Hyde Tools Wal mart Cost: $98,000 Productivity: Increased sales in daylit Energy Savings/yr: $48,000 portion of the store Productivity: Improved product quality $25,000/yr Pennsylvania Power & Light ING Bank Cost: $8,362 Cost: $700,000 Energy Savings/yr: $2,035 Energy Savings/yr: $2.6 million Productivity: Increased drafting rate 13.2% Productivity: Absenteeism down 15% Absenteeism down 25% Source: Greening the Building and the Bottom Line: Increasing Productivity through Energy Efficient Design, RMI Studies have also been performed on students in classrooms in California. Students were analyzed in classrooms with varying levels of natural sunlight. Results show that students scored 20% 26% higher in classrooms with the most amount of natural sunlight. A school in North Carolina found that students exposed to full spectrum light are absent 3 4 days less than students in artificially lit classrooms. The U.S. Green Building Council plans to create national LEED certification guidelines for schools in the near future. There are over 40 million inpatient surgeries and 32 million outpatient surgeries performed in the United States every year. The healthcare industry employs millions of people for tasks ranging from highly specialized surgeons to support staff. Given the various functions of a hospital, there are many potential ways to 47 of 97

10 improve productivity. The U.S. Green Building Council suggests that a 6 16% increase in the building s productivity can be achieved from sustainable construction. Even a slight improvement in productivity could result in more efficient patient care. Most importantly, a hospital is a place where injured or unhealthy people go to be treated. A hospital should nurture the recovery of its patient in every way possible. Green construction would be beneficial to a hospital because it enhances the well being of its occupants, in this case, the patients. Sustainable buildings have been proven to have a significant effect on the health of its occupants. Research shows that a higher quality hospital space can lead to a shorter length of stay for the patient. Dr. Roger Ulrich, an environmental psychologist at Texas A&M University, has performed a study on a group of patients in a hospital in Pennsylvania. Specific patient rooms were used in the study: those that had a natural scenic view and those that faced an adjacent brick wall. The postoperative recovery time of the patients in each of the rooms was compared. The results showed that patients in the room with a natural view had a shorter length of stay, fewer medical complications, and required less pain medication. This study shows that Green building conditions, such as natural sunlight, have a positive impact on the health and recovery of the patients in a hospital. According to the U.S. Environmental Protection Agency, poor indoor air quality is one of the top five environmental risks to public health. Americans spend about 90% of their time indoors. Respiratory illnesses cause over 176 million days of lost work, with annual health care costs of around $30 billion. One of the six requirements for achieving LEED certification is healthy indoor environmental quality (IEQ). Having a clean, efficient mechanical system is an extremely important attribution to a hospital, since there are patients with suppressed immune systems. The characteristics of a building, including indoor environmental quality, affect the seriousness of health problems, such as common colds, influenza, allergies, asthma, and sick building syndrome. These health problems are influenced by the mechanical system s ventilation, amount of outside air, microbiological pollution, and air temperature. A healthy IEQ contributes to the overall well being of its occupants, including reduced absenteeism, increased staff retention, recruitment, and increased productivity. It is crucial to have a healthy building, especially in the case of a hospital. A healthy indoor environmental quality would greatly benefit a hospital, for both its staff and its patients. 48 of 97

11 : Sustainability The is not a sustainable building according to the standards set forth by the USGBC. However, the hospital is interested in the benefits of Green buildings and believes that it is a beneficial quality of a building, especially a hospital. The owners of the hospital participate in sustainable practices when it is practical. Recycled materials are used for select interior finishes, such as carpeting. Light sensors are located in rooms which do not have to be operational for long periods of time. The hospital actively opts for environmentally friendly practices as long as it is cost effective. The hospital owners believe in the benefits of a sustainable environment. had 31,004 inpatient admissions in The hospital takes the opinions of its patients very seriously. The hospital administers a satisfaction survey to each of its patients after their stay in the hospital. Several of the questions in the survey relate to Green building practices, such as a clean environment and design of the patient rooms. The survey asks the patient to rate the pleasantness of room décor, room cleanliness, and room temperature. The full survey is available in Appendix J. Greening of Healthcare Facilities Survey Results In order to obtain additional information about sustainable healthcare facilities, a survey was sent out to industry professionals who have had experience in this area. Recipients of this survey included contractors, engineers, building owners, architects, and sustainable building consultants. The survey contained questions pertaining to the building s level of sustainability, sustainable design factors, and the effect of sustainable design on physician productivity and patient well being. The survey is available in Appendix K. The survey yielded only five responses; only four of which could be used in its entirety. The results below show the distribution of answers to the question asking the participant to rank the benefits of Green buildings according to their importance in the design of a hospital/healthcare facility. 49 of 97

12 Least Important Most Important Life Cycle Cost Savings 25% 25% 50% Lower Operating Costs 25% 25% 50% Higher Physician 100% Productivity Higher Staff Productivity 100% Enhanced Well-being of 25% 75% Occupants Enhanced Patient Care 25% 25% 50% Increased Property Value 50% 25% 25% Financial Incentives 25% 50% 25% Environmentally Friendly 25% 25% 25% 25% Marketing Device 25% 25% 50% Table 2: Greening of Healthcare Facilities Survey Results The results from this distribution show a high regard for the well being of the patients and the increased physician/staff productivity. The following question asked the participant to identify how the benefits of a Green healthcare facility would affect physician/staff productivity. The participants expressed belief that performance can be affected by the enhanced well being of the personnel and marketing used to attract outside physicians. In every survey response, the participant stated that a more pleasant working atmosphere will positively affect the productivity of the working occupants. Likewise, a more pleasant atmosphere was also believed to positively affect patient recovery. The improved health of the patients and reduced recovery times were also believed to affect patient recovery. The participants of the survey were asked to rate the appropriateness of having a hospital be Green. All of the responses were of the highest level. An architect responded to this question with a quote: As design professionals, we should carefully examine those products we routinely specify in the creation of healing environments for our healthcare clients. 50 of 97

13 ASHE Green Guidelines for Healthcare Construction There are over 450 buildings registered with U.S. Green Building Council s LEED sustainable rating system and only 7 of them are hospitals. The LEED rating system was primarily developed for typical office buildings, which are usually operational for less than 10 hours a day and have no outstanding requirements. Hospitals must be fully operational for 24 hours a day, 7 days a week. Consequently, this will result in a higher energy use than a typical office building. Hospitals also must have full back up emergency power systems. These systems can be very expensive and must be operational at all times. Hospitals use extensive amounts of water, due to the activities that take place in the hospital, such as cleaning, food preparation, laundry, and surgical procedures. Hospitals also have thorough infection controls requirements and building codes which they must meet. These requirements are far more intensive than a typical office building. The government s policy on tax credit for sustainable construction is an effective incentive. However, hospitals and social service groups which provide medical care are non profit organization. This means that they are already taxexempt. The tax credit incentive does not encourage sustainable hospital construction. The LEED rating system is highly effective for generic building construction, such as office buildings. However, it is not highly applicable to healthcare facilities. The Center for Maximum Potential Building Systems, along with the American Society for Healthcare Engineering (ASHE) is developing Green Guidelines for Healthcare Construction (GGHC). It is a self certifying tool that can be used to achieve Green building practices in healthcare facilities. The GGHC closely follows the LEED rating system, but focuses on issues specific to healthcare facilities. There are a total of 106 achievable points, as opposed to the 69 in the LEED rating system. The Green Guidelines for Healthcare Construction statement was first published by ASHE in January Development of the guidelines began in February 2003 and a draft version was posted in December 2003 for public comment. February 29, 2004 was the close of the public comment period and the pilot version of the Green Guidelines for Healthcare Construction will be released in the spring of of 97

14 Green Healthcare Facilities Conclusion The design and construction of healthcare facilities must incorporate various aspects of the building s use. The quality of the design drastically affects the employees, patients, and the building s efficiency. There are many ways in which these design factors influence critical aspects of the hospital. Two of the important qualities of a healthcare facility are physician/staff productivity and the well being of its patients. One way in which these qualities can be affected is through sustainable design. Sustainable buildings have been shown to increase the productivity of its occupants and promote the occupant s well being through healthy and environmentally friendly design. Green building construction has benefits which are highly applicable to healthcare facilities. 52 of 97