Healthcare Development Magazine by Employer healthcare Congress

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TABLE OF CONTENTS JANUARY 2011 | I SSUE 10

FEATURES 5 LOCATION, LOCATION:

HOLISTIC SUSTAINABLE DESIGN FOR THE HEALTHCARE BUILDING SECTOR BEGINS WITH THE SITE by Amy Douma

STUDY ~ SAVE MONEY, GO 10 CASE GREEN by Heather Cummings

14 AYURVEDA ~ AS IT IS TODAY By T. Agarwal

EDITORIAL Editor-in-Chief

Renée-Marie Stephano

Assistant Editor

Sarah Hunt

ADVERTISING SALES Info@HealthcareDevelopmentMagazine.com

PRODUCTION Graphic Designer

Tercy U. Toussaint

For any questions regarding advertising, permissions/ reprints, or other general inquiries, please contact: Info@HealthcareDevelopmentMagazine.com

18 TAKE ALL THREE! 22 SUSTAINABLE COMMERCIAL ZERO By James Tupen

WASTE SYSTEM by Justin Silverthorn

26 CASE STUDY~ PARRISH MEDICAL CENTER

31 CONTROLLING MICROBIAL GROWTH by Kevin Krenzke

by Rick Smith

TO A HEALTHY 34 ASPIRING ENVIRONMENT FOR EVERYONE by Peter Doo

ANGELES MEDICAL CENTER 39 LOS CAFETERIA GETS REJUVENATED By Jim Webb

43 SO YOU WANT TO BE A NURSE by Sharon Zelinka

DEVELOPMENT AND 43 HOSPITAL PROFESSIONAL HEALTH PERFORMANCE by Tatiana Jaconelli

Copyright © 2011 Healthcare Development Magazine. All rights reserved. Healthcare Development Magazine is published monthly. Material in this publication may not be reproduced in any way without express permission from Healthcare Development Magazine. Requests for permission may be directed to info@HealthcareDevelopmentMagazine.com. Healthcare Development Magazine is in no way responsible for the content of our advertisers or authors.

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Letter From the Editor

2011 A New Year of Healthcare Expansion And Sustainability 2010 was a very tough year for healthcare development and sustainability. With the global economic recession being felt around the world, there are many healthcare projects that have been put on hold because of a lack of financing and an inability to obtain investment in the project. Literally, thousands of healthcare projects around the world have been delayed. We hope to see 2011 be a year of stabilization, as financing and investment increase for healthcare and all these healthcare projects on hold, get a green light to break ground and start construction. As one of the only organizations working on a global basis in education of green healthcare and hospital development it is exciting to see how each country moving forward is developing its own green initiatives and hospital projects. We are currently working with healthcare providers and governments in over 90 countries. We had over 85 countries attend our Sustainable Healthcare and Hospital Development Conference in Los Angeles this past year. We are excited to be a resource for so many governments and hospitals looking for solutions on building new healthcare projects and making their projects “Green.” We hope to continue to be a valuable resource, and help connect and network players from both sides of the table. This year we are expanding our efforts with launching a social network for sustainable healthcare and hospital development, as well as several other initiatives in this space to help the industry grow and bring industry participants together.

Renée-Marie Stephano, Esquire Editor-in-chief Healthcare Development Magazine Renee@HealthcareDevelopmentMagazine.com

Location, Location: Holistic Sustainable Design for the Healthcare Building Sector Begins with the Site by Amy Douma

The healthcare industry may not have initially been on the “cutting edge” of sustainable design. Considering medical facilities must adhere to complicated procedures to ensure proper waste disposal and other health and safety protocol and are intensive consumers of energy (twice that of commercial buildings in the U.S.), the healthcare industry has taken longer than some other building sectors to institute green or sustainable-design strategies. Recently, however, the healthcare sector has made clear connections between the built environment and health, and thus tremendous strides in the design of more sustainable facilities. In 2002, the American Society of Healthcare Engineering (ASHE) set out sustainable-design initiatives for this building sector, focusing on ensuring health at three different levels: the health of staff, patients and visitors who occupy

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a building; the health of the community at large of which the facility is a part; and the health of a world in which the facility needs to conserve natural resources. The Green Guide for Healthcare (which released a new version in July 2010) has further defined sustainable strategies for this building sector. As the U.S. Green Building Council’s LEED for Healthcare is still in the public-review stage, LEED for New Construction has remained a guide for green building until LEED for Healthcare is officially online. As a result of these initiatives and guidelines, healthcare administrators and facility managers are increasingly recognizing the value of sustainable design to staff, patients and visitors, as well as the facility’s “bottom line.” In addition, they’re adopting a holistic approach to the design of new and the renovation of existing healthcare facilities with an emphasis on

Location, Location: Holistic Sustainable Design for the Healthcare Building Sector Begins with the Site

preservation and prevention. Many green design initiatives address the reduction of energy and water consumption through high-efficiency mechanical and low-flow plumbing systems. Others designate sustainable materials for interiors and exteriors that will support and enhance occupant and community health. Sustainable design strategies also focus on bringing outdoor natural amenities (such as flower gardens, water features, walking paths, and native landscaping) inside to staff, visitors, and patients via windows that also draw sunlight to interior spaces. However, for a healthcare facility to be designed and constructed in a truly holistic manner, architects, builders, and facility managers must also address site or location, which can determine decisions on cost-effective sustainable strategies in a variety of ways. Understanding the specific challenges and opportunities for sustainability that exist at either end of the site spectrum (rural versus urban sites), can save considerable time and expense in deciding on a holistic approach to designing sustainability.

designed to forge strong connections with the larger community. When administrators relocated Jefferson County Health Center to a rural site in southeast Iowa, they collaborated with their architects to incorporate such initiatives into the site planning. The new 120,000-square-foot hospital with attached clinic occupies a 35-acre site near a highway exit for accessibility to the community. The facility also shares an entry drive with a nearby historical amenity: Three restored barns that provide a variety of cultural and recreational activities to the community. The barns are connected to regional biking and walking trails that link with new trails on the health center site. The health center’s trails wind around an inexpensive and picturesque retention pond, which serves as a community amenity while helping to minimize soil erosion and contamination. Rain gardens near the health center also help control rain runoff. On sites where land is available, retention ponds and rain gardens are ideal solutions to storm water management. The design of Jefferson County Health Rural Settings: Challenges and Center also maximizes space on its rural site with Opportunities a high ratio of open area compared to the facility’s developed footprint. The facility’s compact design Healthcare facilities located in rural or features “arms” that extend toward a native-prairie greater-suburban areas must often contend with landscape planted with vegetation that provides such un-sustainable realities as contributing to wildlife habitat and promotes biodiversity. “sprawl.” The availability and lower cost of land In addition, hardy low-maintenance, native in these areas encourages horizontal development, vegetation eliminates the need for an irrigation which can result in a less energy-efficient footprint system. than that of urban facilities. On the other hand, The building’s extensions also embrace rural sites are more likely than urban locations to courtyards with healing gardens and rain gardens, have the land necessary for such green initiatives which are easily viewed from inside the facility as storm water retention ponds or geothermal through large picture windows. Such strong energy fields. Facilities on rural sites can also be connections between interior spaces and exterior

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landscaping provide healing views that enhance patient health and support staff well-being. The gardens were designed as places of relaxation and contemplation for staff, patients, and visitors, whether enjoyed from inside the building or from a sitting area outdoors. Lower land costs and space availability in rural areas provide great opportunities for using native plantings, restoring natural habitats for wildlife, and providing relatively simple and inexpensive storm water control systems. Land availability in rural locations can also provide the area required for such green technologies as a geothermal energy field. In Winnebago, Minnesota, the new Adolescent Treatment Center operated by the United Hospital District features geothermal underneath its site. Geothermal uses a simple piping system underground, at a depth where the earth’s temperature remains steady, to heat and cool the building. At 17,000 square feet, the geothermal well field is nearly the same size as the facility itself. Due in part to this sustainable technology, the treatment center enjoys energy performance approximately 30 percent better than that required by code.

Urban Sites: Challenges and Advantages Many would argue that urban sites are inherently more sustainable than rural settings. Urban locations, for new or renovated healthcare facilities, usually have been previously disturbed or developed, as opposed to “greenfield” sites which are more common in rural areas. In larger metropolitan areas, the site can maximize infrastructure that already exists for the facility, including utilities, public transportation and recycling systems. For example, many cities

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now have recycling infrastructure that provides opportunities for re-purposing construction waste, sorting trash, and diverting materials from landfills without requiring special procedures. The need for extensive surface-parking areas may also be less on urban sites. Compared to rural medical centers, city healthcare facilities often require fewer parking stalls per square foot of building due to their proximity to bus lines, light-rail routes or other public transportation. To reduce a facility’s footprint on the site, parking is often contained in multi-story garages or placed underground. Both parking scenarios minimize the extent of on-grade parking surfaces, and thus reduce the heat-island effect (the heat captured and retained by buildings, concrete, and asphalt). For example, Hennepin County Medical Center’s (HCMC’s) Whittier Clinic, a 60,000-square-foot outpatient facility in Minneapolis, was designed with almost half of its available parking underground to conserve site space and minimize its visual impact. But this strategy also fulfilled a community-based requirement unique to the location. The site’s design needed to be sensitive to special zoning requirements along a primary pedestrian street next to the location. In accommodating the zoning requirements, the architects also included a new bus stop (as the site is near public transportation), racks for bicycle parking, and seating next to planted areas. The development of HCMC’s Whittier Clinic addressed community needs in other ways. Because the clinic was developed on an abandoned industrial site which had been contaminated through prior uses, considerable effort and funds were dedicated to remediating the “brownfield” site. To complete the site’s transformation from urban blight

to community amenity, small parks and gardens, planted with low-maintenance native plants and hardy non-native species, were incorporated into the site design. As a result of these sustainable strategies, the development is helping to revitalize an urban area that had recently suffered from neglect. Once considered an oddity in an otherwise pedestrianoriented district dense with mixed retail and housing, the site is now home to a thriving medical clinic used by a multicultural neighborhood that was actively involved in the facilityâ&#x20AC;&#x2122;s planning process. In addition to providing natural amenities to the neighborhood in the form of plantings, parks, gardens, and restful sitting areas, the medical center includes meeting rooms for neighborhood groups with windows that reinforce the projectâ&#x20AC;&#x2122;s connection to the community at large. In such ways, HCMCâ&#x20AC;&#x2122;s Whittier Clinic demonstrates how a sustainable urban healthcare development can engage and invigorate a metropolitan community and act as a catalyst for future growth.

Holistic Healthcare Design: Sustainability Begins with Site As healthcare facilities reinvent themselves as more holistic centers for healing and well-being, the incorporation of sustainable construction methods, materials, and technologies can demonstrate a strong commitment to highquality patient care, as well as a dedication to preserving and enhancing the health of its surrounding neighborhood and the global community. Healthcare facilities can also contribute significantly to the social and economic well-being of their communities. This aspect

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of sustainability is arguably as important as highefficiency heating and cooling systems, low-e glazing and less water-consumptive plumbing. And it begins with the site itself. For a medical center to be sustainably designed and constructed in a holistic manner, location must be addressed. Increasingly, architects, builders, and facility managers involved in the healthcare building sector are working to better comprehend the advantages and disadvantages, challenges and opportunities offered by specific sites, from the rural to the urban. Sustainable-design strategies that include initiatives unique to the projectâ&#x20AC;&#x2122;s site also can enhance facility operations and the bottom line. Today, by understanding cost-effective strategies specific to each unique site, healthcare administrators and managers are developing facilities that sustain the health and well-being of clients and staff, as well as the world in which they live.

About the Author

Amy Douma is an Associate Vice President in the Minneapolis office of HGA Architects and Engineers. HGA is an integrated architecture, engineering, and planning firm that helps prepare its clients for the future. With offices in Minneapolis and Rochester, Minnesota; Milwaukee, Wisconsin; and Los Angeles, San Francisco and Sacramento, California, the nationally recognized firm has developed expertise in the healthcare, corporate, arts, community, higher education, and science/technology industries since 1953. HGAâ&#x20AC;&#x2122;s culture for interdisciplinary collaboration, knowledge sharing and design investigation enables its clients to achieve success with responsive, innovative and sustainable design. Visit www.HGA.com.

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Case Study ~ Save Money, Go Green

Case Study ~ Save Money, Go Green by Heather Cummings

With healthcare costs on the rise, hospital sustainability is more important than ever. While the term “sustainability” can be interpreted in many ways, we define it as anything of, relating to, or being a method of harvesting/using a resource so that the reserve is not depleted or permanently damaged. Green medical centers across the nation have realized that it makes good financial sense to protect our environment and health through sustainability initiatives. Tom Petersen, P.E. has more than 30 years of experience in environmental health and safety consulting and engineering. He is also the president of Environmental and Engineering Solutions, Inc. (EES), a consulting firm which helps organizations to achieve their sustainability goals, while complying with federal, state, and local environmental health and safety regulations. According to Petersen, there are a few steps hospitals can take to help preserve the environment while saving themselves big bucks.

Keep it Simple The first step in any sustainability effort is to keep it simple. Start small and build from success. Hospitals must identify the initiatives that are easy to implement, cost little or nothing, and have substantial payback before tackling the more complicated issues. A Philadelphia hospital did just that and had enormous success.

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The EPA and the AHA (American Hospital Association) had set a goal for all hospital medical devices to be mercury-free by 2005. This was an objective that the Philadelphia hospital had already accomplished, and rather than brushing it off, their “green team” used that benchmark as the first success story in their sustainability program. By pinpointing an existing success, the green team was able to increase confidence in the sustainability program and foster support for future endeavors.

Build From Success Now that the green team had a stepping stone, they needed to find another simple, but effective, sustainability strategy. They were learning to consistently seek new sources of information on sustainability. This Philadelphia hospital found their next initiative through a Sustainable Healthcare Conference in 2004. The green team had learned about Di(2-ethylhexyl) phthalate (DEHP) (a vinyl plasticizer that was used to manufacture many IV bags and IV tubes). DEHP is a toxin known to cause reproductive changes in the organs of developing animals. After further research, it was determined that these animal studies were relevant to humans and that current exposure levels to critically ill infants, healthy infants and toddlers, and pregnant or lactating women were of specific concern. Once equipped with this information, The Patient Safety Committee at the Philadelphia hospital agreed to phase out DEHP. They

satisfaction. The new Hospira, VisIV containers were DEHP-free, latex-free, PVC-free, had specific design features to enhance patient and caregiver safety, as well as a longer shelf life than the previous DEHP product. Additionally, the Hospira product eliminated the protective cover wrap, which reduced waste by approximately ten tons per year and increased the ease of use for the pharmacist and caregiver.

Limit Unnecessary Waste/Expenses

began with the neonatal intensive care unit (NICU), Pediatrics, Labor & Delivery and Maternity Units, where the potential risk to low weight developing infants and fetuses was believed greatest. After the successful phase out in select departments, the green team, in conjunction with The Patient Safety Committee, agreed to a complete phase out of DEHP at the hospital. The decision to switch to Hospira’s new DEHP-free, VisIV containers paid off through increases in waste reduction, patient safety, and staff

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While eliminating ten tons of waste per year was a huge success, all waste generated in patient rooms and restrooms was currently being treated as infectious waste, which costs $455 more per ton to process than municipal waste. Thus, a ten ton reduction simply wasn’t enough. With the cooperation of Epidemiology, Administration, Environmental Services and Nursing, the green team set a goal to reduce red bag waste (RBW) to less than 25 percent of the total waste stream. The hospital purchased new step-on lidded red bag waste containers for all medical/surgical patients’ rooms, the Emergency Trauma Center (ETC), and the Labor and Delivery Floors. This allowed the staff to safely “source-separate” waste at the patient’s bedside. The hospital staff was trained to dispose of items soiled with blood as RBW, and labels were placed on top of the lidded containers informing staff of what constituted infectious waste. With the cooperation of staff and administration the hospital reached its goal to reduce RBW to less than 25 percent, and in time they even exceeded the goal.

Case Study ~ Save Money, Go Green

Environmentally Preferable Purchasing

Purchasing Department and employees were encouraged by hospital administration to purchase the safest, least toxic, and most environmentally friendly products and services available. The hospital convened local manufacturers, suppliers, group purchasing organizations, and Philadelphia-area hospital executives to leverage their influence and buying power. With the other organizations’ cooperation the green team was able to create a policy to reduce the consumption of resources, reuse materials, recycle or re-sell materials, and explore the use of alternative materials. Current suppliers were expected to comply with the policy or risk losing business. The result was incredible. The hospital’s office supply partner now offers more than 3,000 environmentally friendly office products: facility supplies, recycled paper, rechargeable batteries, refillable ink cartridges, remanufactured toner cartridges, and Green Seal cleaning supplies. Most corrugated shipping boxes were made from 35 to 100 percent recycled products, and other vendors deliver their products in reusable totes. One of the most significant moneysaving initiatives for healthcare purchasing is the safe reprocessing (cleaning, testing/verifying, sterilizing, and packaging) and remanufacturing (disassembling, repairing) of “single-use” medical devices. After thorough scrutiny by the Infection Control Committee, the hospital now saves approximately $500,000 per year by safely reprocessing and reusing “single use” devices. Often the devices are reprocessed and reused many Through the previous sustainability times versus discarding the devices after a single initiatives one can see the importance product use. There is more than $1,000,000 in potential selection and packaging can have on waste. As cost savings yet to be realized, and reprocessing a result, the green team focused its next efforts saves approximately 7,000 pounds per year in on environmentally preferable purchasing. The waste.

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Conserve Energy The next objective for the green team was to conserve energy use throughout the hospital. They focused on everything from top to bottom. The hospital replaced more than 3,000 bedside incandescent lamps with LED lamps, which reduced electrical usage substantially; occupancy sensors were installed in conference rooms; exit signs were replaced with LED lamps; and four-foot fluorescent tubes were changed from T12 to T8, saving additional energy. The hospital was awarded a $3 million matching grant from the Pennsylvania Department of Environmental Protection for a natural gas powered electrical cogeneration plant, which is currently under construction, and will drastically reduce expenses and the hospital’s carbon footprint. While this Philadelphia hospital took on some larger projects, the important thing to remember is where they started. The green team’s sustainability efforts started small and grew. By making environmentally conscious decisions, such as installing bike racks, offering public transportation discounts to employees, using integrated pest control, or creating a Blue Wrap (a polypropylene #5 plastic) recycling program, other hospitals can grow their sustainability programs while reducing their costs.

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About the Author

Ms. Cummings is an alumnus of the Pennsylvania State University. She graduated with a bachelor’s degree in advertising/public relations and minors in psychology and environmental education. During her undergraduate career she interned at Dick Jones Communications, Inc., a higher education public relations firm, and created a public relations campaign for Cooperative Extension, an educational Pennsylvania non-profit. Prior to working at EES Ms. Cummings served as the marketing consultant for a small business in the Bucks County area. She specializes in higher education public relations, social media, and environmental education. At EES Ms. Cummings executes all in-house marketing tactics including, writing and editing blog entries; preparing proposals for potential projects; writing, targeting and pitching company articles; updating social media outlets; and attending networking events. Contact Heather at Heather@eesolutions.net.

By T. Agarwal

Ayurveda As It Is Today www.HealthcareDevelopmentMagazine.com

Ayurveda, originated in India, is a holistic healthcare approach that primarily uses medicinal herbs for preparation of medicines and various other therapeutic applications. The age old system of medicine is sustainable by its very definition as it uses parts of plants for its medicinal properties instead of chemicals as used in modern medicinal system. Ayurveda is believed to be originated in the Vedic era in Indian subcontinent. At its peak, this system of medicine was spread across South and South East Asia including India, Sri Lanka, Nepal, Pakistan, Myanmar, Thailand, and Indonesia. Also, the treatises on Ayurveda (Charak Samhita and Sushruta Samhita) were translated to Arabic language. Though, its practice went to a backseat with the increased influence of modern medicinal system especially during the last century, it has seen re-emergence in the recent past. This revival has brought the age old healthcare practice as a strong alternate to modern healthcare system and emerged as a key contributor for India to gain traction as a medical tourism destination.

Current Status According to recent estimates the market size for Ayurveda healthcare in India is about USD 1.4 billion. This includes exports of herbal raw material and medicines worth more than USD 700 million per year. Further, the Ayurveda healthcare market in India is expected to grow at about 20 percent per year during the next five years. Industry players believe that the herbal healthcare would integrate with mainstream healthcare in the near future.

“…there is a possibility of pharmaceutical players like Ranbaxy and Cadilla enter the herbal healthcare market…” -President and CEO, Himalaya Drug Company, a major player in Herbal Healthcare,

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Growth Drivers Further, the key drivers for the growth of Ayurveda healthcare include favorable government policies in India, focusing on development and growth of traditional healthcare, consumer awareness of the potential of Ayurveda healthcare system, and increasing preference for a sustainable herbs-based therapy over chemical-based therapy. Another reason for revival of age old Ayurveda healthcare is emergence of IT, ITES industry in India. The workforce in such industries is highly susceptible to lifestyle diseases such as back pain, mayopathy, hypertension, depression, insomnia, spondylitis, paralysis etc. Ayurveda healthcare system proves very effective in cure of such diseases permanently in contrast to modern healthcare systems that, in general, provides temporary relief in such diseases. The revival of Ayurveda is spearheaded in South Indian states especially Kerala, which has become a brand in medical tourism for Ayurveda treatment.

The Kerala Story The state in South India, Kerala, has a very highly developed eco-system for Ayurveda healthcare practice. Currently, Ayurveda healthcare industry in Kerala alone accounts for about USD 120 million. This is a result of the timely initiatives of the state government and the private sector. Various cities of the state have emerged as hub for Ayurveda hospitals, training centers, and Ayurvedic drug manufacturing plants. Such cities include Kottakal, Calicut, Thrissur, and Koratty. Kottakal is known for its Ayurvedic institute, Arya Vaidya Sala – one of the pioneers in resurgence of Ayurveda healthcare practice. There are a large number of big and small herbal drug manufacturers in Kerala. Many of the big manufacturers adhere to Good Manufacturing Practices (GMP) guidelines at their plant.

Take All Three!

Some of the Ayurveda centers of repute in Kerala include: • • • • • •

Arya Vaidya Sala – runs hospital in Kottakkal Ayur Xaqti – runs hospital, training centre, and manufacturing plants in Calicut Vaidyaratnam Oushadasala – makes and markets herbal drugs. Also owns 1500 retails stores. Confederation for Ayurvedic Renaissance Keralam Pvt. Ltd (CARe-Keralam) - a group of 15 Ayurveda firms Kerala Ayurveda – runs hospitals in Mumbai, Delhi, Gurgaon and Noida The Kandamkulathy Ayursoukhyam - an Ayurvedic resort at Thrissur

Way Forward There has been a recent trend of healthcare practitioners from other countries such as Japan and South Korea visit Kerala to attend trainings in Ayurveda healthcare practices. Such practitioners set up their hospitals in their home countries after completion of their training. Also, many entrepreneurial Indians have set-up their Ayurvedic hospitals in various countries such as the US, the UK, Canada, and Sweden etc. The trend is expected to continue in the near future and it is estimated that the global Ayurveda healthcare industry would be about USD 5,000 billion in 2050.

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About the Author

T. Agarwal is the Sales Director of iQuest Solution. iQuest Solution is a fast growing research and analytics firm based in India. The company provides custom research based knowledge services including business research, market research, and investment research. Tel - +91 – 124 – 425 3488/ +91 – 124 – 429 4239 Email – tagarwal@ iquestsolution.com Website – www.iquestsolution.com

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Take All Three!

Take All Three! By James Tupen

How do you choose between environmentally friendly construction, economically friendly construction, and a building that functions well for the current and future occupants? What if you can have all three? Is it really possible to build an environmentally friendly building while improving the functionality for tenants and do it all on par with traditional construction costs? I have long been a firm believer that the world at large will become environmentally friendly on a very consistent and predictable basis when we succeed in making the environmentally friendly choice the economically friendly choice. Repeatedly, Iâ&#x20AC;&#x2122;ve heard from designers, engineers, contractors, subcontractors, and product manufactures that it is impossible to be economically and environmentally friendly. After pursuing an opportunity since 2000, the perfect opportunity to prove an environmentally friendly and occupant friendly medical office building could be delivered under the constraint

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of traditional construction costs came to fruition in late 2007. In 2000, I put together a plan to develop a medical office building on the campus of the St. Anthony North Hospital in Westminster, Colorado. I located the building in the most logical area of the campus which was in a north parking lot adjacent to the hospitalâ&#x20AC;&#x2122;s ER, ORâ&#x20AC;&#x2122;s, and labor and delivery rooms. At the time there was really no thought to environmentally friendly positioning or solar loads. There was an administration change at the hospital and the development came to a stop. A few years later, a new developer executed a ground lease with the hospital, located the building in roughly the same place and proceeded to complete design work. The leasing effort did not produce the needed results and the traditionally designed building was not constructed. In 2007, after winning a new request for proposal from the hospital, I was now locked into the location on the campus, but given

the opportunity to design and build a new building. How often does a perfect case study with similar buildings on the same hospital campus with two complete sets of plans, one traditional and one environmentally friendly, present itself? The project that was never built was a 3-story traditionally constructed steel frame building with 50 percent brick and 50 percent stucco project with punched windows. The building used a traditional over-head HVAC system with three rooftop units with DX cooling and gas heat connecting to VAV boxes throughout the building. Floor heights were between 14’4” and 15’4” depending on the floor to ensure sufficient height to provide an acoustical ceiling with a 9’ height. Given the soil conditions, the building needed to be constructed on caissons. The hospital provided me with 12-month-old price from a reputable general contractor right at $110 per square foot for the core and shell construction. This pricing

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was determined in 2006, so we were heading into a market timing in which construction costs were still rising. With a very solid baseline for traditional construction costs established, it was time to throw out the traditional plans and start from scratch with a creative design team using and integrated design approach that include weekly meetings of the entire design, development and construction team. The location on campus, shape, and size of the building was dictated by the hospital. The exterior coloring and brick material was provided by the remainder of the campus as well. We still had many opportunities to do something different. We started by implementing a low-pressure under floor air delivery system using radiant heat and cooling at the perimeter provided three key advantages: (1) increase flexibility in zoning and tenant comfort, (2) vastly improved energy efficiency and (3) lower floor to floor heights

Take All Three!

of 13’4” still allowing for 9 -10’ acoustical ceiling heights. Pricing and comparing the under floor air system to a traditional overhead system requires considering many factors, not just HVAC components. Overall, because we are delivering air from below, instead of above, cooling is more efficient. Overhead systems start by blowing cold air from the ceiling through the hottest air in the space hard enough to mix the air completely in the room and achieving our desired temperature. As such, all the air in the space is conditioned, even the air that is well above the people in the room near the ceiling. To accomplish this, overhead systems generally deliver supply air at 55 degrees. This supply air is delivered using fans capable of producing 2-3 pounds of pressure in the ducts. By comparison, the under floor air is delivered at 65 degrees that rises naturally as it warms. As such, the floor plenum is pressurized with only a halfpound of pressure. Providing warmer air at a lower pressure combined with low-E glass gave us the ability to eliminate one roof top unit as compared to the traditional overhead design. Overhead space usually contains duct work, fire sprinklers, plumbing, light fixtures, and wiring. By eliminating duct work from above and providing some room under the floor for some services, everything can compress and create more usable space. We were able to reduce the floor to floor height to 13’4” and still provide a 9-10’ acoustical ceiling. With the reduction in floor to floor heights because of the raise floor eliminated three feet of exterior skin system and structure from the entire building. Similarly, the raised floor provides a plenum for air delivery and there is no duct work required. So we were able to eliminate the cost for ductwork.

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More efficient glazing and the radiant perimeter system helped reduce the load required of the RTU’s and allowed us to eliminate one RTU completely with a minor upsizing of the remaining two RTU’s. The radiant perimeter system is comprised of two water loops, one hot and one cold. The hot water loop ties into base board radiators and is just a traditional radiant heat system. The heat from the radiators rises across the perimeter walls and helps prevent exterior cold loads from entering the building. In the ceiling is a similar concept, but using chilled water. As the solar load on the building’s skin system creates a heat load on the perimeter, the heat rises into a plenum that contains the chilled beam – basically a radiator with cold water circulating through. The chilled beam then drops the cold air in front of the perimeter skin system shielding the remaining space from the exterior heat load. Combining the reductions in cost – less building skin, no duct work and one less RTU with the added costs of a raise floor and the perimeter radiant heating and cooling system the net cost of

The final cost of the core and shell of the LEED Gold certified 60,000 square foot building including construction management fees was $106 per square foot. Because there were no VAV boxes or duct work to procure as part of tenant improvements, the tenant spaces were constructed below the market average for medical tenant improvements as well. With a little extra effort to map a new course instead of just doing things the way we always have, it is truly possible to â&#x20AC;&#x153;take all threeâ&#x20AC;? and construct environmentally friendly, economical buildings that work very well for the occupants.

the under floor air delivery system was less than the traditionally constructed system. The under floor system also calculated to be approximately 40 percent more energy efficient which translates into lower operating expenses. The efficiency comes largely from the supply air being 10 degrees warmer and using radiant heat and cooling at the perimeter to handle the skin loads. In the first year of operation, the building uses significantly less electricity and gas than the traditionally constructed building, adjacent to the campus. Adjusting for differences in square footage and occupancy between the two buildings, the under floor air delivery system averages $0.45 per square foot less in utilities. Other cost effective and environmentally friendly choices included recycling to help offset the cost of construction waste removal, white TPO membrane roof, which is the same price as black but reflects heat instead of absorbing it, solar ban 60 glazing was an inexpensive upgrade given that solar ban 80 had just come out and the improved glazing over traditional helped lower our overall load calculation for the HVAC equipment and careful attention to material selection throughout the project.

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About the Author

James C. Turpen is the Chief Executive Officer of Centum Health Properties. He is responsible for business development, acquisitions/dispositions, ground up development, and leasing. James has over 15 years experience in the field of healthcare real estate. His experience includes leasing over one million square feet of healthcare space, managing several million square feet of medical office space, ground up development, management of physician tenant improvements, acquisition, and brokerage of over $100 million of healthcare real estate, coordination of the facility side of JACHO review and more. James was employed at Aardex LLC during the construction of the above case study. Centum Health Properties offers a full range of acquisition, development, leasing and operation services in the healthcare real estate market focused primarily in the central and western states.

Sustainable Commercial Zero Waste System Zero waste concepts have become more common now, than ever. Zero waste commercial kitchenâ&#x20AC;&#x2122;s challenge our everyday thought of what sustainability is and how we achieve it. Standard many years ago were typical garbage disposers and pulping systems. These systems, which assist with large volume operations, have never addressed the waste streams final destination in a sustainable manner. Embracing zero waste concepts takes a great amount of planning. The initial costs are relatively considerable, but the savings on the investment pay off in a few years. Unlike the traditional systems in place today, the zero waste concept uses grey-water directly from the dish machine (conveyor or flight type) to fill the waste slurry system (open system or close coupled). This in turn will prime and fill the pulping system, which will save approximately 40-60 gallons of fresh potable water each time for the initial fill. Throughout the hours of operation, the grey-water pumps will automatically feed the

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system to maintain the correct water levels. Once the system has reached the proper water level, the system is ready to start. Benefits when using grey-water are that the water already having latent detergents will have a â&#x20AC;&#x153;cleansingâ&#x20AC;? effect on the entire system, additionally keeping odors and disease to a minimum. In most cases, the leftover food products are brought to a drop off point where the scraping begins. Plates, service trays, and residual kitchen cooking waste are deposited into a trough where a six inch deep flume of grey-water carries away the waste to the pulper and extractor. Food scraps, trimmings, and peelings are beneficial and add to the overall end result of organic composting. Additionally, in some instances, operators choose to use disposable corn based portion control products, which are more commonplace now, than ever. These products can also be collected and macerated to achieve a full organic waste stream as well. Users of this system experience the benefits of volume reduction and material handling, as well as

freedom from the tedious task of sorting their waste for disposal. Once the waste products are pulped, they are then introduced to two variants for composting, dehydration, or vermiculture organic decomposition. These end results can be achieved by either mechanical means or vermicast bedding solutions. The final products are small particles that can be used as a soil amendment for vegetative gardens or soil conditioning. In one case study, a school implemented this system for 1150 students on campus and has saved approximately 32,000.00 gallons of fresh potable water each year, by recovering the waste water of the dishwasher. Additionally, the chemical used in the dishwasher is bio-degradable and consequently has very low surfactant content. This assist’s with attaining a very high rate of processing at the waste water treatment facility, hence making the impact of the environment less damaging. The reduction of waste products was approximately 90 percent in comparison to standard refuse hauling. Reducing waste volume’s also reduces labor costs, by decreasing the time and effort needed for trash removal. It also reduces costs associated

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with waste transportation, disposal, and pest control. Zero waste systems are very effective in reducing costs and simplifying the waste disposal process in schools, hospitals, prisons, cruise ships, casinos, or any other institutional foodservice facility where the volume of or handling of foodservice waste presents a costly or logistically difficult situation.

Key features at a glance: • Water savings of 20,000*-50,000* gallons of water savings(*dependant of system requirements). • 144,000.00** pounds of waste are diverted from the local landfill(**based on 400# daily processing system). •

Less harmful protein laden substances returning to the municipal waste stream.

• Waste volume reductions using a Zero Waste system can be as high as 90 percent. •

Reduced waste hauling with system ROI at approximately 2-4 years.

Take All Three!

About the ASF Advanced Foodservice Solutions (“AFS”)’s commitment is to provide business and design consulting services to augment each client’s opportunity for success understanding the inherent uniqueness of every client and project as the basis for fresh, innovative, and creative design solutions yet meeting financial and budgetary goals. AFS is proud to state as an independent consulting company and this ensures that all work is done with the best interest of our clients in mind. AFS mission is to conduct the activities of the company using the highest ethical standards of the profession; strive to develop a long-term relationship with our clients by respecting their needs and implementing effective

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solutions to strengthen this partnership; contributing to the community and maintain an atmosphere that encourages learning, exploring, and the true enjoyment of the foodservice design business. We recognize that in a globally competitive market, you need every edge you can get. You must plan carefully and respond quickly in a rapid changing environment. Whether your facility is in the preliminary design stages or fully operational, AFS Design Team’s goal is to act as a true partner to each client and deliver creative, aesthetic, and practical solutions that meet the specific requirements of the project at hand. By involving the AFS Design Team at the earliest stage of a project, you are assured that the project flow from idea to implementation is consistent. Our years of experience, educational background and internal resources have made the AFS Design Team, the quality leader in situation assessment and solution development with highest level of ethics and respect for our clients.

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Case Study

Parrish Medical Center Building Green Design into Healthcare Systems

Advanced medical technologies and best-in-class care partners are integral to any healthcare facility’s success; however, it takes more than technology and staff to ensure the highest level of care for patients. To achieve and maintain optimum environments for care, healthcare facilities must engage in innovative and fiscally responsible facility management. Building efficiency plans should support patient comfort and workplace productivity, while also factoring in sustainability measures.

Healing through Innovation Building for sustainability is a natural extension of a patient-centered healing experience. Recognizing that the physical environment can play a significant role in patient care, while supporting reduced operational costs and carbon emissions, the Parrish Medical Center (PMC) in Titusville, Florida, chose to implement green design and energy efficient upgrades to construct its new facility, Parrish Healthcare Center at Port St. John. Completed in 2009, the outpatient healthcare campus was designed to meet the needs of the growing Port St. John community,

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located 20 miles south of the main PMC hospital. Approximately 60 healthcare professionals and support staff work at the 72,500 square-foot facility, which houses diagnostic imaging, physical therapy and rehabilitation, a sleep-disorder lab and physicians’ offices. The facility is a model for energy efficient infrastructure and is the first Leadership in Energy and Environmental Design (LEED®) silver certified healthcare outpatient building in the state of Florida. The certification from the U.S. Green Building Council recognizes high performance facilities that support sustainable planning, design, and construction, as well as a quality environment for occupants. To receive LEED silver certification, PMC

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Case Study: Parrish Medical Center

had to meet criteria in six categories, including: sustainable site development, water conservation, energy and atmosphere, material and resources, indoor environment quality, and innovative design. How did PMC combine excellence in health and medicine with building management to attain LEED certification? Hospital leadership turned to Johnson Controls to serve as project partner and LEED consultant. The collaboration provided LEED-accredited professionals from process through completion to achieve a holistically designed and energy efficient facility based on patient-centered outcomes.

The Silver Lining of LEED Certification The first step toward achieving LEED silver certification is to conduct an energy audit. The audit analyzes the hospital’s current energy usage, identifying wasteful processes and activities, provides solutions where improvements can be made. As part of the audit, key internal and external stakeholders were interviewed to explore cost effective, integrated systems, infrastructure and technologies. The forum for defining and communicating PMC’s vision enabled upfront planning, which helped align the hospital’s design and budget goals with the LEED certification system. The energy audit also included the evaluation of credits for cost, payback timeframe and savings in energy and operational costs. A model of the new healthcare campus’ energy consumption enabled the project to be tied to an energy savings performance contract. A performance contract allows PMC to reduce its utility costs and carbon footprint, while using cost savings generated through reducing energy to repay the project capital investment over the term of the contract.

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The Makings of an Energy Efficient Haven The Parrish Healthcare Center at Port St. John project included six key components that helped the facility to become LEED certified and achieved the goal of creating an energy efficient environment for employees and patients. Sustainable site development set the stage for facility construction. PMC provides incentives for energy efficient behaviors, such as preferred parking for alternative fuel vehicles and carpoolers. Reflective roofing material reduces heat gain, enabling heating, ventilating and air conditioning (HVAC) equipment to run more efficiently. Storm water is managed and

treated for landscape maintenance, and light pollution is minimized through onsite light retention efforts. Water conservation measures contribute to overall facility sustainability and support PMCâ&#x20AC;&#x2122;s environmental stewardship. The installation of lowflow plumbing fixtures, dual flush toilets and waterless urinals reduce water usage by up to 50 percent. Holding ponds trap water for use in irrigation throughout the healthcare campus and the use of native vegetation requires 50 percent less water, further extending water loss reductions. A Metasys building management system integrates building controls, including lighting, HVAC and security systems across the campus to ensure streamlined and efficient facility management. High-efficiency lighting incorporates occupancy and daylighting sensors to reduce light pollution and conserve energy. YORK HVAC equipment uses environmentally friendly refrigerants to reduce environmental impact. Engaging PMC staff to help plan and

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implement recycling programs and procedures encourages employee participation in sustainability efforts. Policies and processes implemented diverted 50 percent of construction waste from landfills. Ten percent of construction materials contain recycled content, and 60 percent of manufactured materials were obtained within 500 miles of the construction site, cutting down on high costs and carbon emissions associated with transportation and delivery. Indoor environment quality is a high priority for all healthcare facilities. PMC ensured that from its groundbreaking on, patients have a care-conscious setting during their time at the facility. Indoor air quality was a key element evaluated with a no smoking policy established, and low volatile organic compound (VOC) adhesives, sealants, paints, carpeting and composite woods used. The Metasys building management system monitors for the ongoing efficiency of HVAC equipment and carbon dioxide levels. Innovation and design were criteria as

Case Study: Parrish Medical Center

part of the LEED certification. PMC provided a communications program for its staff, including sustainability and energy education to help employees and patients learn the benefits of an environmentally responsible facility. Educational kiosks throughout the medical center inform patients and visitors of the new building’s energy efficient features. A high-performance green housekeeping program was implemented to keep facilities safe and clean while reducing the use of harsh chemicals and cleaning products. This program is especially important because medical facilities are often 24hour operations. Constant sterilization, cleaning, and maintenance must be conducted to keep the facility safe and secure for all occupants. Additionally, the facility includes nature trails and a wildlife preserve land allocation to provide a healthy and healing environment for patients, and a habitat for the endangered Scrub-Jay.

includes a state-of-the-art security system. The facility is also equipped to withstand natural disasters such as hurricanes. • Wayfinding – Visible graphics and signage denote the different areas of the building, ensuring that it is easily navigable for patients, staff, and visitors. • Cultural responsiveness – Colors, fabric textures, and artwork specific to the region are incorporated in the facility’s interior design. These features enable patients to heal their bodies, minds, and spirits while at the facility.

A New Opportunity for Healthcare Facilities

Achieving its goal of implementing sustainability measures without compromising overall patient comfort and care, Parrish Medical Creating a Sanctuary for Patients Center will serve as a model for healthcare facilities. Pursuing LEED certification aligns with healthcare The Parrish Healthcare Center’s design facilities’ patient-centered outcomes. It is also a is intended to create a peaceful environment for fiscally responsible choice, providing opportunities patients. The design incorporates seven elements of for savings in operational and energy costs. a healing environment: • Nature – The area’s existing ecology was integrated into the facility’s design. Plants and a fountain are included in the atrium, bringing the outdoors inside. • Color and healthy lighting – Soothing colors create a therapeutic environment, while sophisticated lighting is easily customizable to meet the needs of a wide range of patients. • Healthy building – Interior building materials use recycled content and emit low VOCs. • Physical security – Patients, visitors, and staff can rest assured knowing that the facility

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About the Author

Rick Smith, Director of Healthcare Sales, is responsible for the healthcare vertical market strategy and offerings. He has 22 years of energyrelated sales and management experience that covers a variety of vertical markets. Smith has been with Johnson Controls for six years.

Controlling Microbial Growth by Kevin Krenzke

This article compares three established technologies used for over 20 years in the healthcare environment, to control microbial growth. These preservatives are used to protect the treated articles and include metal-based, triclosan-based and silanebased technologies. All three technologies are used with a standard cleaning protocol. Metal-based technologies, in its simplest form, use a coating system formed by binding ions (ex: silver) to a fine ceramic powder. Trade examples of this technology include Alphasan, Fossshield and X-Static. This technology is found as a treatment of HVAC, floors, walls, lockers, safety cabinets, bedpans, soap dispensers, and medical devices. For metal-based technologies to work, they must leach. This mode of action releases ionic free radicals that react with cell DNA and disrupts critical life processes in the cell. Since this mode of action leaches, adaptive zones have been created which can cause resistant species. We found metal-based technologies are harvested through mining and therefore can be costly to manufacture. Unlike silver-based, triclosan-based technologies are created by adding, blending, melting, molding, or extruding a biocide into the final article. Trade examples

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of embedding or surface applying trioclosanbased technologies include Amicor, Microban and UltraFresh. You can find this treatment is used on bed frames, handrails, door handles, and linens. Triclosan-based technologies also leach for their mode of action. This mode of action releases toxic polychlorinated biphenlys (PCB) for cellular absorption, which can cause lethal mutations in cells. Recent laboratory studies have shown that Triclosan does alter hormone levels in test animals. In July, the EPA announced that the result of these recent studies does merit further review and the EPA would begin a safety review of this technology. Silane-based technologies permanently bond to any surface that contains oxygen, nitrogen, or carbon with Silicon as the bonding agent. This application is a surface application that does not affect the original physical properties of the treated article. It is odorless and colorless technology that attracts microorganisms with its ionic charge and

Controlling Microbial Growth

Originally developed by Dow Corning Corporation, the material preservative technology is EPA registered with 30 years of safe and effective use, controls microbial growth without the use of heavy metals, silver or poisons, is effective against a wide range of microorganisms, including bacteria and fungi (mold and mildew) and is laboratory proven not to promote an environment for adaptive organisms.

About the Author

physically destabilizes cell membrane on contact through a physical control and not a chemical control. This technology is found on hospital garments, wound dressings, stents, catheters, bandages, stocks, building materials and now casework. Although all three technologies would help protect our casework, in July 2010, Case Systems made the decision to offer our casework treated with, ÆGIS Microbe Shield® technology, a silane-based technology. With a permanent bond to the surface material, ÆGIS Microbe Shield® technology does not off gas, leach or migrate into the environment.

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Kevin Krenzke is the Regional Sales Manager for Case Systems, a manufacturer of quality, adaptable, and aesthetically pleasing Divisions 12 (Manufactured Casework), 11 (Plastic Laminate Casework) and 6 (Architectural Millwork) products. For three years, Kevin has assisted Case Systems in actively researching these technologies to determine which technology adds an extra layer of protection for storage and work surface solutions from bacteria and other microbes that can cause staining, deterioration and odors for healthcare, education and laboratory settings. Contact Kevin Krenke at 989-496-0451 or via email at kevin.krenzke@casesystems.com.

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ASPIRING to a Healthy Environment for Everyone by Peter Doo

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Two local healthcare organizations dedicated to serving a vast constituency in the Baltimore area, including indigent and low income communities, have achieved high levels of LEED certification in 2010. Doo Consulting LLC acted as the LEED consultant to Baltimore Medical System and Maryland Health Care for the Homeless as each owner pursued their project goals. The Baltimore Medical System (BMS) is a federally qualified health center, with long standing service to the East Baltimore community. BMS has been awarded a LEED‐CI (commercial interiors) Platinum rating, the highest in the LEED rating system. In March 2010, its new facility opened with the capacity to serve 22,000 people annually, with nearly 100,000 visits. In recognition of the fact that health disparities often have their root causes in environmental factors, the project sought to create a platform for educating its low income community about healthy living. The design incorporates natural light in all work spaces, enhanced ventilation, and uses all non‐toxic materials in the paint, furnishings, and finishes. Energy conservation is expected to exceed 50 percent and water conservation 40 percent. The project includes a healing garden and storm water retention area. Both of these features were paid for by grants. Though not directly related to the Commercial Interior, these aspects of the project contribute to the overall sustainability of the building and were potential LEED Innovation credits. As it turned out, this project was so rich in Innovation Credit opportunities, that the project was unable to take advantage of all of them. The center strives to help the patients and visitors understand the connections between their environments, such as their home and office, and their health. There are education rooms for classes, displays about health and the environment, and tours.

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Not far away, HealthCare for the Homeless (HCH) is achieving a LEED Gold‐NC (new construction) certification. HCH provides health related services, education, and advocacy to reduce the incidence and burdens of homelessness. After a project start that did not originally include the pursuit of a formalized green building protocol, HCH took the opportunity to re‐evaluate the design of their new building due to a change in the site boundary. In the period since the project began, the conversations about green building had intensified, lending support to the new perspective. In reconsidering the project, HCH determined that they would provide the healthiest environment possible for this at-risk population, consistent with their mission to provide high quality medical programs and their budget. The project includes several innovations, including a Green Roof that filters storm water and an ultra violent germicidal irradiation (UVGI) system to reduce the incidence of airborne infection. The decision to go from a “brown” building to a “green” building transformed the project team and the entire HCH organization from its constituents to its boardroom. The approach to these projects is informative to institutions that may want to consider a LEED certification for their new facility. The most frequently asked questions for projects such as these are “What did it cost?” and “How did you do it?” One can assume, and rightly, that these two not for profit institutions, serving disenfranchised communities, would not have easy access to funds. Therefore, any spending on facility design and construction would have to be carefully planned and monitored. Both facilities used a construction management process to plan and build their projects. Both projects chose to hire Doo Consulting LLC as the sustainability consultant to collaborate with the project team to determine the most appropriate and

Aspiring To a Healthy Environment For Everyone

cost effective sustainable building strategies. Doo Consulting also managed the LEED process and documentation. Ultimately, both projects were built within their budgets and achieved levels of LEED beyond the project’s initial expectations or requirements.

BMS When the project began, Baltimore Medical System was trying to get the developer to agree to certify the new medical office building at the Silver level under the LEED for New Construction rating system. The project team for design and construction of the building and its interiors would be the same. BMS, who would be a tenant in the new building and occupy at least 50 percent of the space, would commit to the cost of building all of their space consistent with the LEED requirements to achieve a Silver rating; however, because of the unknown cost of building to a LEED Silver level, the developer, though supportive, was only prepared to commit to achieving a Certified level of LEED. In order to break the deadlock, Doo Consulting advised that the project pursue separate certifications, a Core & Shell Certification for the developer and a Commercial Interior certification for Baltimore Medical System. Though achieving two certifications, instead of one, increased the consulting and certification costs, it had significant benefits to the project team. First, was to be able to separate the costs and strategies that each project would pursue for their certifications. For the developer, this meant that he did not have to worry about the impact of his building’s certification on the tenant. The design and construction of the core and shell would meet the requirements of his financial platform without

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pressure to satisfy the desires of a key tenant. For BMS, the benefit was the ability to segregate its project costs and to pursue funding and grants to support its goals with absolute clarity that any such funding was going to BMS alone and not being diluted in the overall project construction. Once this concept was accepted, BMS began a capital campaign to support, not a Silver certification, but a Platinum one! The strategies pursued by the project team were coordinated to maximize funding opportunities as well as both projects’ sustainability goals. Examples are the “healing garden” and the rain gardens which are actually a part of the project site improvements and as much a benefit for the developer and community

as they are for BMS. Such elements of shared benefit, gave the developer the achievement of a LEED Core & Shell certification at the Gold level, two levels above his initial commitment! Grants were obtained to pay for several green features that would not have been included in the project had they not been funded. Their aspiration to provide a LEED Platinum facility for the population they serve resonated with funders and other contributors to their capital campaign. Overall, costs for BMS may have been one to two percent above more conventional construction. The developer readily acknowledges that some of energy and water efficient strategies are already a part of his other non-certified projects. In this case, they were all integrated into a single project. Several features were only done because of the funding they received. The benefits include significant operating savings for the life of the project while promoting a healthier environment for clients and staff.

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HCH HealthCare for the Homeless struggled internally with its decision to pursue a LEED certification. The board of directors was unconvinced of the benefit to the institution and had serious concerns about the costs of going green; however, the project site was provided by the city of Baltimore and the Baltimore City Council had recently passed a green building law that would soon require new buildings in the city to achieve a LEED Silver certification. While HCH would slip in before the regulation took effect, their Chief Operating Officer decided that committing to achieve a LEED Silver certification would be politically astute as well as providing a real benefit to the staff and clients of the project. The project had a strict budget but because of the ownerâ&#x20AC;&#x2122;s commitment and the engagement of the entire project team early in the process, this project achieved a LEED Gold certification within its budget.

Aspiring To a Healthy Environment For Everyone

There were two programmatic goals in pursuing a LEED Certification. First, HCH wanted to provide a healthy environment for its clients and staff. Second, HCH wanted to reduce ongoing operating costs. With these goals in mind, the project team evaluated various green strategies, assessed costs and benefits, and lastly, checked them against the LEED metrics. Many strategies presented little or no additional cost, though, not all approaches were obvious. One of the less obvious cost neutral strategies pursued for this project was the storm water quality management. Located in floodplain, on a previously developed site in the city, HCH was unable to install a SWM vault to manage its run‐off according to code. Typically, a building owner would pay a fee-inlieu to cover the cost of a storm water management improvement elsewhere in the city, but with the commitment to sustainability and the project site within eight blocks of the Inner Harbor, neither the owner or the consultant were willing to relocate management responsibility. Although it was not an allowable practice at the time of construction, the consultant convinced the city and state officials to allow the design and construction of a green roof to manage the storm water run-off as a pilot project. In a win‐win‐win solution, HCH met its regulatory requirement on site for the same cost as the fee‐ in‐lieu, storm water was managed on site and not mitigated to a location farther from the harbor, and the city and state had a pilot project to examine and evaluate for future application and broader acceptance. A few credits were obtained for strategies that HCH already intended to include in the project. One such was an innovation credit for the installation of in‐duct, ultra‐violet germicidal irradiation (UVGI) devices to clean the air within the building. Many acute respiratory illnesses are present among the

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clients because of the nature of the population served. In their previous facility, transmission of these illnesses to other clients and the staff was a particular problem. UVGI devices were installed at the new facility earning a LEED Innovation Credit while not being considered an added cost. Energy and water efficiency points were achieved while designing a system to reduce ongoing operating costs. These goals were a part of the building program and not considered “extra” features provided for the sake of achieving a LEED rating. There were green features that HCH did not include because they did not provide a reasonable cost benefit. An interior “green wall” that would contribute to improving air and acoustical quality was one example. As a result of the project team’s considered approach, this LEED Gold project was delivered for the original non-green building budget. These projects support the contention that aspirational green projects can be achieved with little or no increased project cost. The key to such success is an early commitment to the project’s goals, engagement of the project team, and a dedicated project owner.

About the Author

Peter Doo, AIA, President of DooConsulting, LLC is a sustainability consultant with over 30 years of experience in building design and construction. Peter is a LEED AP and founder of the USGBC Maryland Chapter. Lorraine Doo, MPH, LEED AP, has expertise in public health and the impact of the environment on healthcare. Doo Consulting provides services to guide, coordinate, and administrate the LEED certification process for all LEED rating systems. For more information, visit the website at www.dooconsulting.net

LOS ANGELES MEDICAL CENTER CAFETERIA GETS

REJUVENATED

By Jim Webb

Kaiser Permanente’s Los Angeles Medical Center campus, which spans five city blocks along Sunset Boulevard in Hollywood, recently underwent a dramatic facelift, with the hospital’s buildings gaining a unified appearance and the food servery in the main section of the hospital getting a dramatic recasting in a more prominent location.

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The Rejuvenate Café, completed in October 2009, was designed to accommodate contemporary service models, customer needs, and alignment with the longrunning Thrive campaign, which promotes health and wellness, sustainability and freshness, while providing a vision to the hospital staff and outside customer base which exemplifies great food and great environmental

LOS ANGELES MEDICAL CENTER CAFETERIA GETS REJUVENATED

design. At approximately 1,800-square-feet, including a featured stretch of terrace along Sunset Boulevard and adjacent to the main hospital, the 400-seat café offers a dramatic first impression, which is a big change from the old usage of this space pre-renovation: a medical records storage area. Webb Design, in collaboration with Taylor Architects, created a food service facility, and interior design plans and specifications for the development of this project. Initially, the project began with a programming phase, which incorporated the needs of the hospital operationally and programmatically, while conforming to project budget allocations, construction deliverables and sustainability requirements. It was important for the team to convey a design concept which delivered accurate representations of space and equipment allocation, interior design motifs, and operational requirements. Project phasing and construction scheduling were a main focal point, as was plan approval protocol. Webb Design interviewed project stakeholders and presented concepts developed by the efforts of the team. Costel Coca, a project designer with Webb Design, was instrumental in developing the new servery. He said the facility is transforming healthcare retail food service to an exciting, hospitality-driven environment that consistently earns outstanding feedback and grades from customers. “The modern exhibition food theater, which we have created in the new Café Rejuvenate, enables people to not only order customized and freshlyprepared cuisine instead of having to just order food from a counter, but in most cases to also see their food being prepared,” said Coca. “The mainstream example of convenient food service has thus reached a new level, and it also serves as the design foundation for Kaiser’s “Thrive” service model.”

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SERVERY HIGHLIGHTS: INVITING, FLEXIBLE AND HEALTHY In addition to the main servery, Webb Design studied adjacent spaces for the purpose of providing a thorough study of all areas and establishing responsible design criteria for future design and construction development. The hospital has more than 5,000 employees, 700 doctors, and thousands of patients. The primary goal for the Rejuvenate Café was to create a space that effectively serves any and all of these people. As a high-traffic location, the Café also needed to present an inviting-yet-open feeling while being easy to clean. Slip-resistant floors make the area safe and an open space design allows for easy reaching and cleaning of equipment, according to Margaret Aslanian, department administrator of food and nutrition services at Kaiser Permanente’s Los Angeles Medical Center. The design also offers versatility, allowing flexible change in food service programming as menu trends evolve. This was important, as the Thrive brand also invites community participation through professional cooking demonstrations and menu displays. Knowing the site would emphasize fresh food choices and a steady flow of traffic, Aslanian said it was important that work flow was addressed in the servery design, through features like making sure work stations had the necessary food preparation equipment in close proximity, that floor space would accommodate rolling push carts and multiple workers, and that there was enough counter space, dry and cold storage, for daily food preparation demands. Among the sustainability concerns for the café was a desire to purchase items from local vendors, in order to lessen energy consumption and emissions, plus an ability to recycle plastics, paper, and even cooking oil, according to Aslanian. Webb Design supported and promoted steps to ensure these sustainable practices by identifying local suppliers and assisting the team with project approvals through the construction process.

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LOS ANGELES MEDICAL CENTER CAFETERIA GETS REJUVENATED

In support of Kaiser Permanente’s sustainability the new servery has received from hospital visitors. philosophy, Webb Design also implemented many energy, labor and ergonomic strategies, giving the “This new space is very inviting, it works well with the hospital financial returns to last for a life time. upgraded design and flow of the hospital campus, and has become the popular meeting spot at the hospital,” Among the green improvements: said Aslanian. “The Rejuvenate Café has really • The dishwasher is Energy Star rated, which will become an important part of the hospital campus and yield a significant energy savings through less water our community.” usage than the previous ware washing equipment. • The exhaust system leverages technology that About the Author reduces exhaust air requirements by 30 percent versus As a 31-year industry veteran, Jim Webb has long conventional hoods. enjoyed the opportunity to share his unique take on • The kitchen now has high-efficiency fryers the commercial foodservice market as a frequent with self cleaning burners to reduce fuel consumption featured speaker at industry events. He is founder by 37 percent. and principal of Webb Design, a food service design • The sink features low-flow pre-rinse spray and consulting firm based in Tustin, CA. For more valves, with 0.64 gpm versus previously-mandated than 21 years, his firm has provided front and back 1.6 gpm, to reduce water consumption by 40 percent. of the house design to the foodservice industry while winning multiple design industry awards, including While the hospital is thrilled that food sales business at four National Design Awards and an International the hospital increased by nearly 40 percent, it is even Interior Design Association award in 2009. more pleased with the finished result and the response

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SO YOU WANT

TO BE A NURSE by Sharon Zelinka

It’s a great day when the message comes back, “You passed the board exam!” It’s even greater if it says your score is 99 percent and you are the highest in the state. You may cheer, jump up and down, cry for joy or sigh with relief, but dear nurse, this like being born; it is just the beginning of a journey filled with unique experiences. Finishing the courses and passing the exam may make

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you a nurse, but it does not make you an excellent nurse. Here I want to illustrate those special ingredients that take you on your journey from a nurse to an “excellent nurse”. Stop a minute, take my hand and let’s walk the road that will be the one you must travel to become an excellent nurse. There will be ten ingredients.

SO YOU WANT TO BE A NURSE

Nursing is one of the largest professions on earth, highly respected by most, and touches the lives of all. Whether you are being born or near death, the nurse is often the “one” you want near to help. We will consider in these series of articles some of the necessary ingredients to becoming an “excellent” nurse. As in all professions there are great, good, fair, poor, and unsatisfactory nurses. After 50 years in this profession, permit me to share a few critical ingredients found in an excellent nurse.

COMPASSION It was a beautiful afternoon, following four hours of college classes, when I arrived home, put my books on the table, dressed quickly in the white starched uniform, clipped the cap with the black stripe on it, (of which I was very proud!!!) and headed to the hospital. My area was in the labor section and I loved coaching the new moms and helping to relieve the pain whenever I could. Placing that precious bundle in the arms of a new mom was a joy beyond description. Today there was a handsome young couple, so excited about the baby that would soon be theirs to hold. Since they were the only ones there that evening, I worked with “breathing” and “relaxing” between contractions to ease the pain. I chatted with both parents about their hopes and dreams of the future with their new baby. (We didn’t know the sex ahead of time in those days!) They had just recently finished college. The baby’s room was decorated and Grandma and Grandpa were in the waiting room. Joy and anticipation filled the air. Then she was born, little Lisa, the diagnosis “Downs Syndrome” was made, and shock and

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disappointment replaced anticipation and joy. At this time it is not skill, speed, knowledge or management duties that are important, but compassion. Now is the time for compassion. Years have flown by and this afternoon I dressed in colored scrubs, no cap with the revered black stripe, but my heart of compassion still firmly in place. I was on “admissions” this evening and as usual had 50 questions for the elderly couple who had just entered the room. He sat in a wheelchair waiting to be admitted to a Long Term Care facility, never to return home again. They had lived together 60 years and rarely had been apart one night in that entire time. Together they had four children whom they loved dearly. Together they had watched first teeth appear, first steps taken, first day at school, graduations, college, marriages, grandchildren, and great grandchildren arrive. Days filled with homework, fishing trips, camping, basketball games, birthday parties, Christmas programs, piano lessons, broken bones, and butterfly kisses. Bedtime prayers, tucking each one in

every night and letting them know Jesus loved them. I helped him prepare for bed, asking the usual questions, took his vital signs (blood pressure, pulse, and respirations) and tucked him into bed. I was then able to turn to his wife and put my arm on her trembling shoulder saying “Can I pray with you?” Tears fell down her cheeks, her head rested on my shoulder and I did the most important thing I had done all day! Truly, “Compassion” is an essential ingredient necessary to an excellent nurse. You can be a nurse without it, but surely not an excellent nurse.

TEAMWORK Nursing is a profession dependent on teamwork. From the person who cleans the bathrooms, to workers who fix the meals, control the air conditioning or answer the phone—all are members of a single team with the singular goal of providing excellent care to patients. As with a chain, any broken link causes the care to be less than excellent. Since the nurse leads the team, it is often your people skills that make this team a smooth working machine. Like oil in the motor of your car, respect and recognition of the contributions and value provided by the “less recognized members of the team” can be read in your words, your attitude, and your body language. Your lack of respect, unkind words, and attitudes can also have a negative impact that “drain the oil” from the engine and make it impossible to reach a high level of performance. Imagine your home. Think of the power that ten minutes of preparation can make in the morning. You start the coffee and set the table. Gather breakfast foods before you wake the family. Think of the tone of voice you would prefer to wake up to. Better than the alternative: rushing, grouchy, half

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awake, unprepared, and unsettled. In the same way, ten minutes before your shift with your team can change your entire day. Have assignments in place with reminders of special needs, making sure rounds are made, etc., letting workers know what you expect (i.e. lights answered within a specific time frame, accountability when leaving the floor for any reason). Remember your tone of voice—the same tone you want them to use when talking to you! Smile; be positive—even on the busiest day! When rearing a family, you discover some children need little motivation to do their work and some must have every job spelled out and be checked on to see if it is done. Even so, your team will have all different types of people, so you will need to have duties clearly written out, and some will require follow up. Learn to accept the different personality types and work with them. See that the goals are accomplished in a pleasant fashion. Be flexible. If there are multiple ways to reach a goal, allow the worker to select which method they prefer. Achieving your goals is the key. Be more than a team leader. Be an excellent team leader who respects every member of the team. Smile, your attitude is contagious!

INTEGRITY Nursing, a profession esteemed so highly, puts everyone who chooses this in a position that demands integrity. You can be a nurse without integrity, but you cannot be an excellent nurse without this valuable ingredient. Every single day you will be challenged with choices that demand integrity, from washing your hands to giving the correct medication. As you handle narcotics, you will always face the challenge of trying them or selling them. Many nurses have

SO YOU WANT TO BE A NURSE

failed the test of integrity with this challenge and have lost it all. This valuable ingredient must reach every part of your day to day dealing with doctor’s orders, using sterile technique when needed, being fair to fellow employees and punching the time clock. Working closely and with situations that call for strong emotions such as catastrophe, injury, disease, and death can put us in situations that call for all we have to not get inappropriately involved with coworkers and patients. Be careful, dear nurse, your home, your family, and your life are in the balance. You can be a nurse without integrity, but you cannot be an excellent nurse without it. Winston Churchill, the great British statesman once said “If a person has integrity, nothing else matters, if a person does not have integrity, nothing else matters.”

ATTITUDE Have you had a day when morale was great, people worked together, smiles were frequent, everyone did their job to the best of their ability, and patients had excellent care? If these days are rare where you work, there is a reason: Attitude Have you had a day when tempers flared, everyone felt overworked and underpaid, no teamwork was evident and “that’s not my job or that’s not my patient” was the phrase of the hour, the reason is the same: Attitude Your attitude makes a difference and your attitude is contagious. This is true in the home and in the workplace, in the shopping mall or on the highway. All of us have the ability to control our attitude. Attitudes are not like the flu or chicken pox which just takes hold of us. We must determine what kind of attitude we will have and make that

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decision for the sake of family, our coworkers and patients, our fellow shopper, and the other people on the highway. We must work on our attitude. Before you argue that you cannot help or change your attitude, imagine how your behavior changes when someone in authority walks through the door. If you can change your behavior to impress that person, you have the power to change it. Being thankful is a first step. Realize that many people are without work, and others are too ill to work or have had no opportunity to obtain skills to hold a job. There is a world full of people who would love to be able to do what you are doing today. Examine your heart; are you more skilled at complaining or encouraging? The answer to this question will tell you much about your attitude. Are the people on your team happy and eager to work together or griping and complaining? Check your attitude as the leader, your preparation, your compassion, and your integrity. Make your team the best ever. You can be a nurse without a good attitude, but you cannot be an excellent nurse without it!

About the Author

This article is first in a series of articles called, So You Want to be a Nurse. We hope you enjoy these uplifting articles by Sharon Zelinko, RN, Inventor of Gripsors stainless steel gripping bandage scissors. These scissors assist nurses in performing routine medical by gripping IV lines and many other connections. Check her website www.gripsors. com. Gripsors were invented for nurses.

Hospital Development and Professional Health Performance by Tatiana Jaconelli

A Brief History The industry of medical equipment was founded with the goal of developing efficient products to human health, but with the increasing expansion of this market, it is observed that the prospect is also changing, and currently there is also concern about environmental responsibility. According to the Prospective Study Medical Equipment, Hospital and Dental (ABDI, 2009), this segment is one of the most promising areas for the next 15 years.

The Development in Brazil The World Health Organization released its first survey on the medical technology industry notes that Brazil is the worldâ&#x20AC;&#x2122;s second largest producer of

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medical technology among emerging markets, second only to China. (SINDHOSP, 2009) According to the Brazilian Association of Importers of Equipment, Products and Supplies Medical and Hospital (Abimed), from January to May 2010, the sectorâ&#x20AC;&#x2122;s industrial production of materials and equipment used in medical diagnosis and grew 11 percent over the same period in 2009. (Portal Fator Brasil, 09/2010) The study also shows positive data in the creation of new jobs. In the first half of 2010, the industrial and commercial activities in the sector of materials and equipment used in medical diagnosis and were generated 4560 new jobs over the stock in December 2009, according to data from the Ministry of Labour. There were 659 new jobs occupied in June. (Portal Fator Brazil, 09/2010)

Hospital Development and Professional Health Performance

In the last decade, the number of companies operating in the chain rose 42 percent to 463 companies, of which over 90 percent operate with 100 percent national capital and generate 31,300 direct jobs and 72,000 indirect jobs. Medical Industry reported revenue of $4 billion in 2008, a growth of almost 5 percent over 2007. Exports accounted for 7 percent of revenues. (SINDHOSP, 2009)

Performance of Professional Health The development of the physician-hospital directly modify the organization, functioning, and procedures of hospitals and other institutions. Health suffers direct impact of technological advances in various segments. Today, a hospital must have on its staff several professionals, such as electronic engineer, and electronics technician, as well as in the medical device industry, where we see the need for these professionals. This exchange of experience allow developing products more secure and responsive to real needs of the patient or user. As resources can mention the research and development (R&D) became crucial in a market of global competition as well as knowledge of health professionals. Note that this is a branch on the rise for these professionals, as with the integration of development professionals and the public health benefits with a better quality end product targeted to your needs. The industry needs to continue working together with customers to understand what the market needs. According to the study by the Regional Council of Medicine of São Paulo in 2007, revealing several features that involve the doctors in the state of Sao Paulo, note that the workplace as companies, which operate 14 percent of

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professionals, concentrated physicians higher salaries and are more frequent among men (16 percent versus 9 percent of women). To apply their knowledge in the medical device industry, the health professional develops skills similar to those it already uses in the healthcare environment (i.e. in the direct care to patients, such as integration with a multidisciplinary team, and others, such as monitoring the development of products, research through clinical trials and the customer relationship, where we highlight the efficiency of service and technical assistance). Conclusion The market for medical equipment is heated and health professionals have a big challenge ahead, apply their knowledge in developing new technologies, and thus meet the needs of patients who use it.

About the Author

Tatiana is a Product Specialist at Magnamed Tecnologia Médica in São Paulo, Brazil. She develops in comercial area as direct relationship with physicians, customers, sales teams, marketing and support areas. She graduated in Physiotherapist from UNISA, post graduation at Respiratory Therapy from InCor and Exercise Physiology at São Paulo Federal University. Tatiana´s experience included six years as respiratory therapy in ICU at Albert Einstein Hospital and Oswaldo Cruz Hospital. View Tatiana’s profile on Linkedin at http://br.linkedin.com/in/tatiananegrini or contact Tatiana at tatijaconelli@terra.com.br. If you would like to learn more about the company that Tatiana works go www.magnamed.com