Healthcare Development Magazine | March 2011 by MT Association

MARCH 2011

HEALTHDEVELOPMENT CARE M A G A Z IN E YOUR GUIDE TO SUSTAINABLE HEALTHCARE & DESIGN

This Isn’t Your Father’s Healthcare World PG 7

Pros and Cons of Vegetated Roofing for Hospitals PG 10

Department Of Defense Brings Their Sustainable Design Commitment To Healthcare Facilities PG 14

March 2011 // Issue 11

FEATURES 7

This Isn’t Your Father’s Healthcare World By Dale A. Anderson

21 The Community Hospital At Ft. Belvoir Set To Be A Shining Star Of Sustainability By Jennifer R. DuBose and Joshua Crews

Pros and Cons of Vegetated Roofing for Hospitals By Elizabeth Hart

Department Of Defense Brings Their Sustainable Design Commitment To Healthcare Facilities By Jennifer R. DuBose and Joshua Crews

32 New Rady Children’s Hospital Acute Care Pavilion Becomes

First Critical Care Hospital in California to Blend Both Mandates By Bonnie Kutch

38 Sharp Healthcare Leads the Way in Energy and Resource Management By Julie Brown

Greening Healthcare, a New Opportunity for Engaging Employees By Tom Badrick

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Utilizing 46 Veterans Hospitals ® Green Globes for Continual Improvement

By Jane M. Rohde and Sharene Rekow

50 Changing and Helping Healthcare in Haiti

By Steven Steinberg, AIA, Principal of Healthcare at RATCLIFF

24 Creating a Healing

Environment for Healthcare’s Sensitive Populations By Rachel Belew and Paul Bates

28 Relieving Patient and Caregiver Anxiety through Sustainable Healthcare Design By Gary Jereczek and Lynn Drover, CID, IIDA

Letter From the Editor

Global Opportunities in Green Healthcare & Sustainable Healthcare By Renée-Marie Stephano The United States has been a leader in Sustainable Healthcare and Green Healthcare. Many existing hospitals have implemented green healthcare practices and upgraded their infrastructure. It is almost a given fact that any new major healthcare or hospital project in the US will be “green” and focus on a sustainable healthcare approach. While the US is one of the largest green markets, one of the most overlooked markets for green healthcare is the international marketplace. There is a healthcare building boom occurring all over the world, and the investment in healthcare internationally is significantly greater than in the United States. The international “green healthcare” building boom is occurring as governments invest in healthcare, but also there is growth in many developing countries of the middle and upper class, and these people are demanding the highest quality healthcare. Developers can’t even keep up with the demand for new healthcare services globally. One of the problems is many of the governments and developers building hospitals don’t have access to the same green healthcare services and experts as in the United States. Many of the leading companies don’t offer the same services internationally or are not marketing and servicing these international markets. Sustainable Healthcare needs to catch up to the growth of the global market, and global players need to be educated on the most cutting edge options when designing and building healthcare facilities.

HEALTHDEVELOPMENT CARE MA G A Z I N E YOUR GUIDE TO SUSTAINABLE HEALTHCARE & DESIGN

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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. Healthcare Development Magazine is in no way responsible for the content of our advertisers or authors.

This Isn’t Your Father’s Healthcare World

This Isn’t Your Father’s Healthcare World By Dale A. Anderson Building designers are faced with a multitude of design trends and functions that change very rapidly – this is especially true in the world of healthcare facilities. Architects are already charged with protecting the “health, safety, and welfare” of the occupants of the buildings they design. Healthcare Architects have an added responsibility to provide facilities that actually improve the well-being of the building occupants. The buildings must not only protect – they must assist with healing and betterment of their patient world.

ealthcare facilities have trends that also may be observed in other facilities, including sustainability, evidence-based design, and lean construction. The question is how these are applied and combined – which may be unique to the healthcare world.

Sustainability This topic has been thoroughly reviewed in thousands of discussions and articles across the media over the past 10+ years that it has truly been in the limelight. The concepts range from optimal site utilization, through energy efficiencies, material resource management, to operational issues and facility maintenance – many of these seemingly very obvious. That hasn’t made it any easier for the healthcare world to adopt the concepts and strategies that are available. Recent studies have identified hospitals as the second most energy-intensive sector in the U.S., behind only the fast food industry. Statistics show hospitals spend nearly $8.5 billion per year on energy, consume twice the energy per square foot compared to traditional office space, and produce more than 30 pounds of CO2 per square foot1. The good news is that hospital managers are starting to realize that they can reverse this trend. Over the past year many articles in healthcare journals have highlighted case studies of organizations that have made the swing to sustainability once they understand the benefits of the business case it offers. Partnering with the U.S. Dept. of Energy’s “EnergySmart Hospitals” initiative has created an opportunity for the increased use of energy efficient technologies across the 8,000

hospitals in the U.S. Efficiency levels targeted include 20% improvements for existing facilities and 30% improvements for new construction2. Much of this success can be attributed to the use of newer, more energy efficient HVAC systems and controls, plus implementation of commissioning services to finely tune the operation of these systems. Increased costs to implement these systems typically have a payback of five to eight years, depending on utility incentives and projected increased annual energy costs. Other concepts being adopted include increased use of daylighting, which has multiple benefits, and healthier construction materials for occupied spaces. Most organizations are now realizing to achieve the highest levels of results with these strategies requires hiring Sustainability or Resource Conservation Managers for their campuses. Another process to minimize the pain of adoption is through Energy Service Contracts (ESCO) with organizations that help analyze existing building conditions, look for opportunities for improved system efficiencies, and, in most cases, provide the funding for the building modifications required (revenue is generated through operational savings). For the truly committed organization, there is always the option of third party certification by either the Green Guide for Health Care for upcoming LEED for Healthcare (release planned for later this year)….

Evidence-Based Design Having somewhat paralleled the development of sustainability in the built environment, the practices of this trend are regularly explored in various healthcare HealthcareDevelopmentMagazine.com

The difficulty in applying this type of process relates to two main hurdles – time and money. To conduct the type of research and set up test theories for a new facility design can force the project to take substantially longer to design and build, and require additional capital funds to make happen. In today’s economy time nearly always equals cost and any delay has a compounded cost increase, let alone from the additional efforts to go through these steps. Again, for the truly committed project team, guidelines are available and case studies illustrate how to follow just such a process.

Lean Construction journals as well. These are concepts that promote facility design based on actual research and evidence of betterment to patients, staff and visitors. This trend has its own set of major challenges applied to healthcare design, although they are not the only challenges existing. The basic philosophy is that EvidenceBased Design can influence these challenges by paying attention to medical error impacts, functions of caregivers and other staff members, physical facility designs related to equipment and functional processes, and maximizing design response to the natural environment3. The application process starts with a thorough understanding of the needs of a facility and its function. Research is conducted to find documented evidence of similar situations and the responses that were presented, plus results achieved. Once analyzed the operations and design team is able to identify those key components that made the responses both a success and a failure. Adopting the positive results, looking for similarities, and developing improvements allows the new facility design to take shape with the hopes of their own successes. The final step is documenting the results of the new facility once in operation and testing the theories that were used. This is done so others may learn from the results achieved, successful or not, and provide for the next betterment thought process. From steps such as using single patient rooms, better sanitization of staff, medical record computers at the bedside, and standardization of room design for flexibility, healthcare facilities are improving the wellbeing of the patient. These types of features are also resulting in nurse providers who actually have more time to care for their patients – the main reason they got into healthcare to begin with. 8

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This trend is probably the newest kid on the block, at least compared to the others, as it has now been applied to the design and construction industry. Most folks in the design and construction world will have heard something about lean, but they may not realize where it came from, what it’s all about, and how the applications go far beyond the built environment. Generally speaking, the Toyota Production System is credited with the development of lean methods after World War II. The system was actually a new form of assembly line streamlining for fabrication and assembly of their automobiles. The term “lean” came from the pursuit of perfection by Toyota engineers they defined perfection as the elimination of waste4. The goal of Toyota’s production plant was to deliver a car meeting the customer’s exact specifications through mass production, while eliminating any remaining parts inventory. Parts would be delivered exactly when required to match the progress of the assembly line effort (i.e. a just-in-time delivery process). As the concept continued to evolve and was adopted into the construction industry it took on a slightly different focus – an integrated approach to decisionmaking early in the overall development process and full sequencing of design and construction activities to match the project schedule need for results (still a just-in-time response). Lean construction can be considered as a different delivery method for buildings by four distinct differences from conventional delivery: decentralized decision-making, controlled processes, management for throughput and not speed, and improvements to reliability. As with both sustainability and evidence-based design the comment might be heard that this process is simply “common sense”. If that were the case for all of these, they would have been applied across the board many years ago –

yet, all of these still have their adoption challenges. What most designers, including healthcare, may not realize, is that lean has taken the medical world by storm in another direction as well – through the dayto-day operations of newer healthcare facilities and the resulting changes in facility design. Lean healthcare is developing in response to the critical conditions being found in many patient facilities. Hospital organizations are struggling with cost increases, poor quality of patient care, staff shortages, and general employee unrest. The combination of these results would indicate problems are deeper than possibly realized by management. Lean healthcare studies are finding ways to improve patient delivery through a detailed review of what current conditions are and how they might be modified. One example of such studies is called a “spaghetti diagram” that maps the walking paths of nurses as they provide their daily routine of patient care. Not surprising, the studies found nurses walking many miles during the day, most of which had little to do directly with patient care. By looking at alternative layouts to the floor plan shorter routes can be identified and more time dedicated to being in the patient rooms themselves. This same process has been applied to nearly every aspect of hospital operations and patient delivery. Results are beginning to be published in healthcare journals noting improvements to operations and reductions in patient errors. Examples of improvements noted include better access to supplies and linens for patient rooms, elimination of surfaces promoting infections, just-in-time distribution of medications and supplies to patient floors, decentralized nurse stations, common acuity patient rooms, and other changes5. There is little doubt that the concepts are working and proving themselves when applied – it simply remains to be seen how quickly the concepts will be adopted throughout the system (sound familiar to the challenges of other trends?).

happens that a major side effect (what’s a healthcare condition without side effects?) of these trends are a better environment for the building occupants, especially the patient world. What hospitals have found, amazingly, is that patients who recover quicker are healthier, and allow for a larger patient load to be accommodated – this all translates into more revenue, and, again, the justification based on the business case.

1 “Healthcare: A Business and Ethical Case for Sustainability”, BetterBricks, an initiative of the Northwest Energy Efficiency Alliance (NEEA), 2010 2 ”Targeting 100!”, University of Washington’s Integrated Design Lab and BetterBricks, 2010 3 ”An Introduction to Evidence-Based Design”, The Center for Health Design, 2008 4 ”What is Lean Construction”, Lean Construction Institute, 1999 5 Healthcare Design Magazine 08.10, Vendome Group LLC

ABOUT THE AUTHOR

Dale Anderson has been providing programming and design

Summary

of healthcare facilities to clients throughout his 30+ year career. With a specialty background experience in outpatient and inpatient services, he has participated in a wide variety of clinical facilities, imaging centers, ambulatory surgical centers, women’s health centers, dental facilities, and hospital facilities. His experience ranges from the smallest of tenant improvement projects to large, full-service medical office buildings, and to full-scale hospital buildings.

While the above trends clearly have their own benefits in various ways, what is it about them that make implementing all of them desirable? In the end it’s all about the business case for adopting these trends. Let’s face it, healthcare organizations have to be in business and make money or they have to close their doors. Several of the trends and approaches certainly provide the justification for the facility results in a financial manner. It also just

Of special interest, Dale combines the latest philosophies of “evidence-based design” (using patient-based results evaluations) and “sustainability” (environmentally-friendly architecture). He received EDAC (Evidence-Based Design Accreditation and Certification) in 2009 as one of the first professionals in the State of Washington. He was the third professional in the State of Washington to receive the LEED (Leadership in Energy and Environmental Design) Accreditation and is also a Certified Sustainable Building Advisor. Mr. Anderson has worked on projects consisting of “green” design elements for more than 20 years. As a BCRA Principal he provides a hands-on approach to leadership of his projects along with team members that are experienced in all technical aspects of healthcare design and documentation.

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Pros and Cons of Vegetated Roofing for Hospitals

Some of the benefits of vegetated roofing include: • Energy conservation • Storm water management • Extended life of the roof membrane • Mitigation of the Urban Heat Island effect • Much-needed habitat for native plants

Pros and Cons of Vegetated Roofing for Hospitals By Elizabeth Hart

Therapeutic gardens have been in use for thousands of years to help restore the health of those suffering from various ailments. Yet, in modern hospitals these gardens have all but been replaced by sterile, built environments.

oday, healthcare facilities struggle with competitive pressures, a staggering expense of operations, and pressure to be more sustainable. Many hospitals are turning to a more holistic approach of facility management to help alleviate economic and environmental pressures. These new and retrofitted buildings are increasingly incorporating rooftop gardens into their facilities. Benefits of a Rooftop Garden Rooftop gardens, more commonly known as “green” or vegetated roofs, can provide compounding economic and environmental benefits to the buildings they adorn, and to the surrounding community. As new green building trends emerge, the benefits of covering low-sloped roofs with vegetation are becoming widely known and practiced. Hospitals can reap even greater rewards with green roofs, through lowered stress levels of patients, 10

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visitors, and hospital staff that have visual access to vegetation. One of the most widely recognized benefits of adding a vegetated roof or wall is that it can significantly reduce the energy expenditure of the building. One way they achieve this is by serving as added rooftop insulation, limiting the thermal transfer through the roof and keeping the indoor temperatures more stable. Roof membranes are hot. When sunlight hits a roof, it turns from light energy into heat energy. For example, on a 90 degree day a dark or gray roof membrane is generally between 160 – 180 degrees Fahrenheit. Even white reflective membranes are still really hot – 108 – 121 on a 90 degree day. The heat can soak down into the building from the roof and reflect inside through the windows. Rooftop HVAC systems take in the air at those high temperatures and then have to cool it down to a comfortable level for the interior.

But when sunlight hits a plant, instead of turning to heat, it is converted into plant food – that’s what photosynthesis is all about. Vegetation doesn’t get hot from sunlight the way that impermeable surfaces can. On a vegetated roof, the temperatures are often lower than the ambient temperatures, reported at closer to 77 degrees on a 90 degree day. That’s a significant reduction on the load for the rooftop HVAC system, which may then be downsized. Another cooling effect of vegetation is that after soaking up the water they drink, plants release it back into the air – a process called evapotranspiration. This not only cools the building, but also helps to mitigate the Urban Heat Island effect of the surrounding community. The Urban Heat Island effect is the reason why urban areas are much hotter than surrounding suburban and rural areas. Impermeable dark surfaces, especially low-sloped roof membranes, are the major contributors to this effect. Old Roof Maintenance and Removal Roof maintenance and replacement is costly and time consuming for any building, but hospitals are especially affected. Their re-roofing projects come with the economic burdens of not only the cost of the roof, but also the disruption to the facility’s operations. Roofing is noisy, it’s smelly, and it often occurs in view of patient windows, creating privacy concerns. Constantly patching a leaky roof brings added problems with water entry into the building – which can lead to mold, pests, air leakage, and a negative image of the hospital by patients and visitors who witness the leaks.

From an environmental standpoint, when the old roof membrane is removed, it is sent to a landfill where it is not likely to decompose for a long, long time. After all, it is a waterproof membrane – and likely the size of the footprint of the building. Then there are the environmental consequences of manufacturing and shipping the new roof membrane. As much as the roofing industry is working on more environmentally friendly membranes, the options available right now for reliable waterproofing generally consist of asphalt, bitumen and PVC - not very friendly materials. The most economically – and environmentally – sustainable roofing practice of all is to keep the existing roof membrane protected, watertight, and on the roof for as long as possible. Exposure to sunlight, weather, foot traffic, and the daily cycles of thermal expansion and contraction accelerate deterioration of roofing materials. Plants, growth media, and all the layers of green roof components isolate the membrane and keep it preserved. By protecting it from the elements, green roofs can extend the life of the roof membrane by double or more. This isn’t a guess, it’s the industry standard. When the roof does have to be replaced, the plants and growth media can either be reused or composted, and the other green roof components can be recycled. They aren’t Just Practical They are Pretty But the greatest human aspect of green roofs is that they are beautiful! They can be designed to look like a grassy groundcover, a flowering meadow, or a full service park with benches, sidewalks and trees. This is especially important for the many hospitals that are multi-level buildings, with inevitable window views of unsightly roofing membranes, mechanical equipment and parking lots. Views of the built environment (human-made, rectilinear forms) are known to cause heightened stress, but views of nature have the opposite effect. Looking at nature and greenery elicits relaxation, not just for patients, but also for visitors and hospital staff. Studies show that patients with visual access to nature have lower blood pressure, fewer postoperative complications, and use fewer doses of

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strong narcotic pain drugs. They receive more positive written comments from staff, and they have a greater overall satisfaction with the healthcare provider and quality of care, as compared to patients who can only see the built environment. These studies imply that views of nature may enhance clinical outcomes and reduce hospital stays, thereby increasing economic benefits to the facility by reducing the cost of care. With the high rates of turnover of hospital staff, a more beautiful, less stressful environment may help draw and retain employees and physicians. It can also reduce stress levels for visitors, who might spread the word about their positive experience at the facility. The layers of plants, growth media, and membrane protection can provide sound insulation to the building interior from helicopters, traffic, and construction noises, further reducing stress in patients and healthcare providers. And there’s more! Vegetated roofs provide countless benefits to the surrounding environment. Plants improve air quality and sequester carbon dioxide. They can reduce the water load for on-site and municipal storm water runoff systems by absorbing rain, and they improve the quality of rooftop runoff that does reach watersheds. They can provide a much-needed habitat for native plants and pollinators, all while reducing the overall cost of operating the facility and creating positive market identity. In many municipalities, including New York City, Chicago and Los Angeles, rooftops are being used to grow vegetables and herbs – eliminating the fuel used for transport, extra packaging, and the use of chemical preservatives, because the food is harvested from overhead as needed. It’s easier to monitor organic food production on-site rather than relying on costly organic certifications from faraway farmlands. One municipal building in Portland, Oregon is using its rooftop garden to supplement over-extended food banks, contributing the veggie portion of hundreds of meals each season to local homeless shelters. So what’s the downside? What about the cost? The extra weight? Pollen? Maintenance? And, the dreaded Leak…

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Let’s start with leaks. Every hospital Facility Manager’s nightmare is trying to chase down a leak. It can be an endless process of flood testing, thermal scanning, patches and repairs, and ultimately leads to re-roofing. But, there is a very cost-effective way to eliminate this whole process, through the use of electronic leak detection systems. They are installed on bare roof membranes or underneath vegetated roof systems. At any time during the lifecycle of the roof, if there is a leak or just a concern of a leak, the detection system can be used to locate even a pinhole break in the roof membrane, and show its location on the roof within a square foot. The vegetated roof components can then be cut away just from that area, the repair made, and the components replaced. There are several leak detection system options on the market which are very simple, inexpensive, long-lasting and highly effective. And what about the cost - well, green roofs are expensive. They are generally at least three times as costly to install as a traditional roof, and even more so if they are made accessible to visitors. The costs can be offset or recovered over the lifecycle of the building through energy savings, extending life of the membrane, positive market identity and marketing, and through the benefits to patients and staff who view them on health care facilities. However, while the life cycle cost savings may pencil out, some facilities just don’t have the capital for the upfront costs adding a green roof. Green roofs are heavy. Even the lightest green roofs generally weigh much more than traditional membranes. Many facilities already have the structural weight capacity built in, but a structural engineer report is the first step in determining the viability of a green roof on an existing facility. If the structure cannot support the weight, it is usually not cost-effective to build in extra structural support. These buildings may not be good candidates for green roofs. As far as pollen and other allergens, green roof plant selections should be species that do not create an abundance of pollen. Any pollen aggravation is much more likely to come from the surrounding areas than from vegetated roof plants, if system is designed accordingly.

Green roofs do require maintenance. It can be as infrequent as twice-annually for established lowprofile systems, and more regularly for those that resemble park-like settings. Each roof is different, and the designer or manufacturer should provide an operations and maintenance plan to the facility. There are landscape services, experienced with rooftop garden maintenance, which can be utilized if the facility prefers not to maintain their green roof themselves. The most important concept to consider when looking at vegetated roofing options is that each building, and in fact each roof section, may call for different green roof configurations. There is no one-size-fits-all solution, and most industry professionals will emphasize the importance of using a green roof specialist to help identify the unique conditions of each roof section and assist in the coordination of appropriate plants, soils, components and maintenance. Every building has a roof; the vast majority of which are empty, hot and wasted real estate, contributing to the energy spend in the building, to the Urban Heat Island effect, and to storm water runoff concerns. Every roof can either continue to contribute to so many of our economic and environmental concerns, or they can be adjusted to begin reversing the damage. While vegetated roofs do not make sense for all buildings, for those they adorn the benefits to the facility operations, the building occupants, and the surrounding city are instantly evident and deeply inspiring for the people who are fortunate enough to view them.

ABOUT THE AUTHOR

Elizabeth Hart CDT GRP, received her B.S. in Sustainable Development and Biology, with a concentration in phyto-remediation (the use of green plants to clean toxic waste sites). She is practiced in various methods of sustainable agriculture, especially urban agriculture, to create infrastructure for cities to being to support themselves. Elizabeth is a founding member of Portland, Oregon’s GRiT (Green Roof info Think-tank), devoted to re-vegetating urban areas and reaping all the benefits to the environment, economy and society that come with it. She is currently the Sustainable Technologies Specialist for the western division of an international roofing manufacturer, and is experienced in all phases of vegetated roofing – from the conceptual design, specification and procurement, through installation, maintenance and repair. She works with architects, landscape designers, contractors and building owners to be sure each unique vegetated roofing system will function as intended. Her green roof projects include hospital and medical office buildings, K-12 and higher education facilities, municipal, private and residential buildings and each one makes a difference to the building occupants, community and greater environment! Elizabeth can be reached at ehart@tremcoinc.com

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Department Of Defense Brings Their Sustainable Design Commitment To Healthcare Facilities

The U.S. Department of Defense (DoD) is an established leader in promoting sustainability in the built environment. Government agencies have promoted green building practices for many years. Since 2000, when the U.S. Green Building Council (USGBC) published the first edition of Leadership in Energy and Environmental Design (LEED) for new construction, 28% of the more than 35,000 total building projects participating in the LEED certification and rating process are federal, state, and local government owned or occupied. The federal government is the largest single owner of LEED certified buildings. Even among federal agencies the Department of Defense stands out as a leader; as of January 2010, 189 federal projects had received certification, and 49 of those projects, roughly 25%, were for the Department of Defense (DoD), more than any other federal government agency (National Renewable Laboratory for the U.S. Department of Energy Federal Energy Management Program, 2010). Currently, the number of registered and certified federal projects has dramatically increased to 369 and another 3,665 federal projects are pursuing certification (U.S. Green Building Council, 2011). More than LEED

Department Of Defense Brings Their Sustainable Design Commitment To Healthcare Facilities By Jennifer R. DuBose and Joshua Crews

xecutive Order 13423, Strengthening Federal Environmental, Energy, and Transportation Management, signed in 2007, requires Federal agencies have “a plan to implement sustainable design, construction, and operation and maintenance” (U.S. Department of Energy & Federal Energy Management Program, 2010). The Executive Order also established an Interagency Sustainability Working Group that developed High Performance and Sustainable Building (HPSB) Guiding Principles that apply to all new federal construction with the goal of reducing energy consumption and environmental impact of all federal buildings, including healthcare facilities. The Guiding Principles apply sustainable building design, construction, and maintenance to the existing federal building stock, new construction, and major renovations through five principles. The five principles include employ integrated design principles, optimize energy performance, protect and conserve water, enhance indoor environmental quality, and reduce environmental impact of materials. Implementation of these principles should help the federal government meet their goals of improving water conservation and energy efficiency, reducing ownership costs, promoting sustainable environmental stewardship, and providing healthy, safe, and productive built environments. In addition to LEED and the HPSB Guiding Principles, the DoD must construct facilities to comply with many other federal ordinances, mandates and policies including Executive Order 13423, Executive Order 13514, Federal Leadership in Environmental, Energy, and Economic Performance, EPAct 2005, EISA 2007. However, overlap occurs between the federal policies, ordinances, and mandates that promote sustainability and the potential LEED credits to be achieved.

Although each of the Services within the DoD has its own requirement that facilities be built to LEED Silver standards, simply achieving LEED Silver does not guarantee compliance with all required sustainability regulations. Conversely, complying with all the federal sustainability regulations may or may not result in a LEED Silver certification. The combination of federal mandates, executive orders, and policies as well the Services’ LEED requirements ensure the highest level of sustainability. The multiple sources of regulation prove to be even more challenging for the Military Health System (MHS), the agency within the DoD responsible for providing healthcare to military personnel. The synergies between delivering care and environmental sustainability has allowed the MHS to become a leader in the design and construction of sustainable, world class healthcare facilities such as the Community Hospital at Ft. Belvoir and the Replacement Hospital at Ft. Riley.

Sustainable Healthcare Guidance Until recently the Green Guide for Health Care (GGHC) was the only green building standard that primarily focused on the specific and unique components of design, construction, operations and maintenance of healthcare facilities. Released in 2003, the GGHC intends to provide “healthcare specific and health focused tools, technical guidance, and educational resources to a learning community” for the creation and implementation of “high performance healing environments” (Green Guide for Health Care, 2010). The GGHC utilizes the language and structure found in LEED credits for New Construction and Existing Buildings (U.S. Green Building Council, 2011). As of February 2011, more than 280 projects were registered with the self-certifying, voluntary program however; none of these were federal healthcare projects. HealthcareDevelopmentMagazine.com

The USGBC released a standard specifically for healthcare, LEED 2009 for Healthcare, in late 2010 (U.S. Green Building Council, 2010). This standard was built with the help of many of the same people that developed GGHC and based on the pilot program experiences of the GGHC. The newly released standard includes various modifications to the LEED 2009 standard related to prerequisites and credit opportunities to make it more applicable to healthcare settings. Additional emphasis is placed on integrative project planning and a design process that engages a multitude of disciplines in keeping human health as a ‘fundamental evaluative criterion for building design, construction and operational strategies.’ (ID Prereq 1 from LEED 2009 for Healthcare 2010).

World Class Beyond federal mandates that require DoD projects to meet sustainability standards, the MHS is tasked with building ‘world class’ facilities that support the best possible care for our services men and women. In 2008 the Assistant Secretary of Defense tasked a subcommittee of the Defense Health Board with reviewing the health facility projects underway in the National Capital Region to evaluate whether or not these projects would help the DoD achieve their goals of providing world class care. Part of the report that this group released included a thoughtful and thorough definition of world class for a healthcare facility. In addition to many other criteria specific to design and operations of a healthcare facility, The Defense Health Board report, “Achieving World Class,” states that for a medical facility to be considered World Class it must “demonstrate environmental responsibility and sustainability in the facility design, construction and operation by, but not limited to: having achieved LEED certification [and] embracing the recommendations contained in the latest edition of the Green Guide for Health Care (GGHC)(Green Guide for Health Care, 2010). Military Health System projects that have gone out for bid since this report was released have added world-class criteria to their requests for proposals, in addition to sustainability as a core principle, raising the bar even higher.

Increased Scrutiny on Building Impacts Signed by President Obama in October 2009, Executive Order 13514 on Federal Leadership in Environmental, Energy and Economic Performance required all Federal agencies to produce sustainability plans that would set concrete targets for energy, waste and water conservation. 16

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The DoD’s first Strategic Sustainability Performance Plan was released on September 8, 2010 and included measurable targets for the reduction of fossil fuels, solid waste, and greenhouse gas emissions associated with facilities in addition to operations. Performance toward these targets will have to be reported on a semi-annual basis by all DoD departments, agencies and field activities (Department of Defense, 2010). Achieving these aggressive goals will require a commitment to sustainable design, construction and operation of all military facilities. While healthcare facilities are not singled out, they are covered by these commitments and will be an important part of the DoD achieving their goals. This report solidifies and makes clear the commitment to sustainability that was already apparent within the DoD, accelerating the actions that they were likely to take. Combined with the emphasis on worldclass facilities it is clear that the MHS is motivated and committed to creating exemplary sustainable healthcare facilities.

While the DoD is a leader in creating sustainable buildings it is faced with a number of challenges. Sustainability is but one goal that the DoD must balance against specific issues in MHS projects: meeting anti-terrorism and force protection requirements; covering the potential of additional upfront costs for sustainable design features; and awareness of the multitude of federal sustainability requirements.

Even with the advancements of the LEED certification program, healthcare projects have generally been slower than other market sectors to adopt sustainable building practices. Industry professionals have traditionally placed primary focus on the safety and well being of patients and felt that attention to environmental issues would compromise their efforts. Others have resisted applying green building strategies to healthcare because the existing guidance and tools are not tailored to unique characteristics of healthcare facilities. Additional explanations for the slower pace of sustainability in healthcare include too many regulatory requirements and a risk adverse culture as well as additional cost. However, keeping patients safe and doing no harm is consistent with sustainability. MHS hospitals have shown a commitment to sustainability and have provided performance standards for other facilities in the industry to model. The following table shows the remarkable achievements are anticipated in two MHS projects currently being constructed.

For example, anti-terrorism standards require building separation as well as separate constructs for power and fuel supply, but LEED encourages dense development for sustainable sites and minimal building footprint to prevent habitat disturbance. Furthermore, industry professionals are still learning the process and implementation of sustainable design. Healthcare design professionals must balance the intricacies of designing a healing environment that embraces evidence-based design principles and maximizes environmental conservation and preservation.

The Department of Defense has been a leader in promoting sustainability in its facilities and is poised to make an even bigger impact with commitments to increasing the energy efficiency of its building portfolio and shifting more of its energy consumption to renewable sources. With the large number of healthcare facilities being planned and built in the next few years, the Military Health System (MHS) has an opportunity to deliver high performance sustainable buildings that support world-class care. We should look to the hospitals that they are building now was models for sustainable hospital design.

Architects and engineers are not always aware of the specific requirements found within the various federal mandates due to the large amount of guidance coming from different sources, In spite of the challenges and complexity facing the design and construction of sustainable healthcare facilities, the MHS is in the process of constructing the following hospitals targeting high levels of LEED certification.

References •

Department of Defense. (2010). Strategic Sustainability Performance Plan. Retrieved Feb, 2010, from http://www.acq.osd.mil/ie/download/green_energy/dod_sustainability/DoD%20SSPP-PUBLIC-26Aug10.pdf

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Green Guide for Health Care. (2010). Who We Are. Retrieved June 29, 2010, from http://www.gghc.org/about.whoweare.overview.php

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National Renewable Laboratory for the U.S. Department of Energy Federal Energy Management Program. (2010). Federal Buildings Awarded LEED Certification. Retrieved February 15, 2011, from http://www1.eere.energy.gov/femp/pdfs/fed_leed_bldgs_sum_102009.pdf

•

U.S. Department of Energy, & Federal Energy Management Program. (2010). Guidance for Sustainable Design. Retrieved Feb. 15, 2011, from http://www1.eere.energy.gov/femp/program/sustainable_guidance.html

•

U.S. Green Building Council. (2010). LEED 2009 for Healthcare New Construction and Major Renovation. (Draft Checklist for 3rd public comment).

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U.S. Green Building Council. (2011). Government Resources. Retrieved February 16, 2011, from http://www.usgbc.org/DisplayPage.aspx?CMSPageID=1779

ABOUT THE AUTHOR

Jennifer DuBose is a Research Associate with

the College of Architecture at the Georgia Institute of Technology where she is responsible for project development and management. Ms. DuBose is a LEED accredited professional with a background in sustainable facilities and organizational sustainability. She has worked with government and private sector clients to help them develop policies and strategies for greening their facilities and operations. Ms. DuBose has a master’s degree in public policy from Georgia Tech with a focus on sustainable development. After completing her undergraduate degree in Philosophy at Oglethorpe University she served as a Peace Corps Volunteer in the Democratic Republic of Congo. She may be reached at jennifer.dubose@coa.gatech.edu

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ABOUT THE AUTHOR

Joshua Crews is a Graduate Research Assistant at the Georgia Institute of Technology in Atlanta, Georgia. Josh graduated from the University of Florida in 2007 with a Bachelor of Design in Architecture and pursued his career in healthcare design with Gresham, Smith and Partners until beginning his graduate studies at Georgia Tech. He is currently conducting research on sustainability in the Military Health System, flexibility in healthcare architecture, and the utilization of Active Design Guidelines in multi-family affordable housing projects. Josh is part of the Healthy Environments Research Group within the Health Systems Institute and is pursuing the Master of Architecture professional degree in the College of Architecture. You can contact Josh at crewsj@gatech.edu

The Community Hospital At Ft. Belvoir Set To Be A Shining Star Of Sustainability The Military Health System (MHS) within the Department of Defense is producing large scale hospitals that serve as industry precedents for sustainability. Even with a host of requirements, regulations, and challenges, the MHS is excelling in the production of highly sustainable facilities such as the Community Hospital at Ft. Belvoir. Ft. Belvoir, Virginia, just south of Washington D.C., will be home to a new hospital serving active and retired military and their families from all three Services in the National Capitol Area. The U.S. Army Corps of Engineers, Norfolk District is managing the construction of the more than $800 million state-of-the-art medical treatment facilities (U.S. Army Corps of Engineers, 2009). The facility is on schedule to open later in 2011 and is on an accelerated timeline as part of the 2005 Base Realignment and Closure directive (Medical Construction & Design, 2011).

ustainability has been incorporated into the design and construction of the Community Hospital at Ft. Belvoir. The new complex will include 55 primary and specialty outpatient clinics, as well as extensive ambulatory surgery and ancillary capabilities. There will be 120 inpatient singlebed rooms, with the exception of semi-private in the behavioral health unit. This state-of-the-art medical facility will also include 2 parking decks, a standalone central utility plant, and helipad, situated on more than 45 acres, (HDR/Dewberry, December 19, 2008). The entire facility utilizes energy-saving technologies, a landscape design with native and adaptive plantings, and water-saving design elements to decrease its impact on the environment. A rainwater collection system has been designed to significantly reduce potable water use while simultaneously increasing awareness and promoting sustainability. As a Military Health System project, federal government mandates provide unique opportunities and barriers in the design and construction process. The Community Hospital at Ft. Belvoir is registered with the Green Building Certification Institute and is actively pursuing LEED® Silver certification (DiPenti, 2010).

The Community Hospital at Ft. Belvoir

By Jennifer R. DuBose and Joshua Crews

LEED Initiatives • Expected energy savings: 27.6% below ASHRAE standards • 62% of the 45 acre site restored with native vegetation • Rain water collection system (roof swoops, below grade cistern, visible drainage system) • Green roofs and courtyard gardens • Low-E and Low VOC materials, products, and furniture throughout • LEED and EBD integration

Locating the hospital structure along the natural high point in the site topography allows continued protection for the wetlands located to the northeast and southwest of the project. A mature oak forest, preserved by a steep natural swale on the western side of the hospital, will accommodate pedestrian traffic and a walking trail. Irrigation needs will be minimal because 62% of the site area is being restored with mid-Atlantic/ Coastal Plains native and adaptive vegetation. Interior connections to the landscape are being provided by intermittent courtyards that break up the building structure and bring daylight in to the interior. Green roofs and “curbless” planted areas in the parking zones are designed to capture, treat, and filter storm water runoff. Additionally, reduction of the heat island effect and storm water runoff is achieved with permeable paving in the parking spaces and an “open pavement approach” in the service access areas (HDR/Dewberry, December 19, 2008).

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have been specifically designed to provide patients and staff respite areas and reduce stress. Carbon dioxide monitors will be used to adjust ventilation to “sustain occupant comfort and well-being” (HDR/Dewberry, October 14, 2008). Individual spaces and group areas contain both lighting and thermal controls to promote occupant comfort and improve staff productivity. Lowemitting materials and furniture are specified for the project to protect indoor air quality and reduce building occupants’ exposure to harmful chemicals. A “Green Cleaning” policy will also provide a positive effect on indoor air quality with a reduction in the use of harmful chemicals as well as reduce patients’ stress with the use of low decibel rated vacuums.

Site plan

(HDR/Dewberry, June 10, 2008)

The water collection system for the Community Hospital at Ft. Belvoir is designed to collect rainwater that falls on the buildings and store it for later reuse in landscape irrigation. Collecting and reusing rain water for landscape irrigation will drastically decrease the amount of potable water used in the facility and reduce the quantity and rate of storm water runoff. The curved roofs of outpatient clinics will help direct rainwater into vertical pipes that will run through the waiting rooms. Condensation from the HVAC system is funneled to underground cisterns with a capacity to hold 160,000 gallons for future irrigation use. The courtyards, enclosed on 3 sides by glazed curtain walls, expose the building occupants to seasonal changes and the variable conditions of “wet” and “dry” that occur throughout the year in the Virginia climate (HDR/Dewberry, August 2008). The project team creatively used the synergies between sustainable design and the Military Health System’s evidence-based design (EBD) principles to meet both LEED requirements and the EBD requirements throughout the design, construction, and operations phases of the project. Green roofs that provide occupants with a connection to nature help to minimize the impact of storm water as well as providing enhanced insulation. Ultraviolet (UVC) technology will be used to prevent surface organisms and other bacteria or mold from growing inside the HVAC system also reducing energy loads by preventing the air handling units from straining to compensate for restricted air flow. Gardens 22

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Because Ft. Belvoir’s Community Hospital is a federal facility, unique government conditions have steered the implementation of sustainability and LEED certification. In the case of Ft. Belvoir, government regulations played a positive role in the implementation of sustainable features. The U.S. Department of Energy’s Federal Energy Management Program (FEMP) issued the Energy Policy Act of 2005 (EPACT 2005) that requires a new federal facilities be designed 30% below the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) standards when life cycle cost effective. Early models render the Community Hospital at Ft. Belvoir 27.6% below ASHRAE energy consumption standards due to the energy-saving lighting design, rainscreen system, high efficiency variable speed chillers and multi-stack heat recovery chiller system. The rainscreen system applied to the exterior of the facility will reduce energy consumption by increasing the insulation value of the façade and minimizing thermal bridging from the outside to the interior. Though the rainscreen creates additional up front construction costs, the long term energy savings along with the EPAct ‘05 energy reduction requirement prevented it from being value engineered out of the project.

Annual Value of Benefits (HDR/Dewberry, May 2010)

43%

The Community Hospital at Ft. Belvoir is an example of what is possible when a project team sets their sights high and works hard to stay true to the project mission. This new hospital will provide a superior environment for caring for our nation’s warriors while also raising the bar for sustainable construction and operation. References •

DiPenti, M. (2010). Conference Call on June 14. Health Systems

•

HDR Arcitecture Inc. (2009). Ft. Belvoir Sustainable Features

• • • •

Air Pollutant Savings $558,039

•

Energy Bill Savings

•

$474,470

37%

In order to show compliance with federal mandates and quantify qualitative sustainable initiatives, HDR has evolved the Sustainability Return on Investment (SROI) tool (HDR Arcitecture Inc., 2009). The SROI utilizes a traditional life-cycle cost analysis, but additionally monetizes external costs and impacts such as greenhouse gases, criteria air contaminant as well as water, waste, and noise (Manning, Larocque, & Berger, 2010). Additionally, the SROI can be utilized to overcome initial investment and financial barriers in the implementation of sustainable design features. By accounting for non-cash variables such as reduced air contaminant emissions, conservation of fresh water, as well as improved health, productivity, resiliency,

GHG Savings $163,461

•

$8,088

HDR/Dewberry. (August 2008). Community Hospital at Ft. Belvoir

•

ABOUT THE AUTHOR

Jennifer DuBose is a Research Associate with

Sustainable Design and Construction. Monthly Report.

HDR/Dewberry. (December 19, 2008). Community Hospital at Ft. Belvoir Sustainable Design and Construction. Monthly Report.

HDR/Dewberry. (June 10, 2008). Community Hospital at Ft. Belvoir Sustainable Design and Construction. Monthly Report.

HDR/Dewberry. (May 2010). Community Hospital at Ft Belvoir Sustainable Design and Construction. quarterly report(2).

HDR/Dewberry. (October 14, 2008). Community Hospital at Ft. Belvoir Sustainable Design and Construction. Monthly Report.

Manning, R., Larocque, S., & Berger, L. (2010). Defining Benefits

of Green with Sustainable Return on Investment. The USGBC 2010 Federal Summit Education Session Presentations 100 series.

Medical Construction & Design. (2011). Fort Belvoir Community

Hospital Tracking Well for Spring 2011 Opening. Retrieved article/117-news/345-fort-belvoir-community-hospital-tracking-

$80,039 Economic Value of Water

Brochure.

Feb, 2011, from http://www.mcdmag.com/component/content/

Water Bill Savings

13%

Institute, College of Architecture, Georgia Institute of Technology.

and safety of the building occupants, the SROI can provide potential investors with a “comprehensive costbenefit analysis over a project’s entire life-cycle.” The SROI can also facilitate decision making by providing the true value of an alternative, the viability of that alternative, and the probability of a positive payoff for the alternative (Manning, et al., 2010). The end result of an SROI renders sustainable features to be more cost effective than if a traditional life-cycle cost analysis is used. Cost effectiveness is particularly important because federal mandates such as EPACT 05 and the High Performance and Sustainable Building Guiding Principles require projects incorporate sustainable features “when cost effective.”

well-for-spring-2011-opening.html

U.S. Army Corps of Engineers. (2009). New Fort Belvoir (Va.)

Community Hospital Project. Retrieved July 13, 2010, from http:// www.nao.usace.army.mil/projects/military%20projects/fort%20 belvoir/homepage.asp

ABOUT THE AUTHOR

Joshua Crews is a Graduate Research Assistant at

the Georgia Institute of Technology in Atlanta, Georgia. Josh graduated from the University of Florida in 2007 with a Bachelor of Design in Architecture and pursued his career in healthcare design with Gresham, Smith and Partners until beginning his graduate studies at Georgia Tech. He is currently conducting research on sustainability in the Military Health System, flexibility in healthcare architecture, and the utilization of Active Design Guidelines in multi-family affordable housing projects. Josh is part of the Healthy Environments Research Group within the Health Systems Institute and is pursuing the Master of Architecture professional degree in the College of Architecture. You can contact Josh at crewsj@gatech.edu HealthcareDevelopmentMagazine.com

f course, it’s important to remember that hospitals, nursing homes, rehabilitation facilities, physicians’ offices, and clinics have unique indoor environmental needs:

• They house a large number of people who

have heightened susceptibility to infections, respiratory distress, and other problems associated with air contaminants.

• Their high occupant density results in

an increased concentration of biological contaminants, such as viruses and bacteria.

• Their high occupant density results in close proximity between at-risk patients and infectious individuals.

In an effort to address the unique needs of healthcare facilities, sustainable design, construction, and maintenance practices that are specific to healing environments have been developed and implemented across the North America. In fact, green building in the healthcare sector has experienced remarkable growth in recent years, due largely to the influence of green building rating systems, such as LEED for Healthcare, and guidance from sustainable building programs, like the Center for Maximum Building Potential’s Green Guide for Healthcare.

The Gray Area of Green Healthcare Design

Creating a Healing Environment

for Healthcare’s Sensitive Populations Written By Rachel Belew and Paul Bates

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Primum non nocere. First, do no harm.

These three famous words from the Hippocratic Oath are among the most powerful tenets of modern medicine. They define not only the doctor’s responsibility to his or her patient—but also the role and responsibility of the environment in which the patient heals. A healing environment whose integrated design, construction, and fit-out are grounded in techniques to optimize human health will help nurture patients on the road to recovery.

Yet, while green attributes like energy efficiency, water conservation, and waste reduction are important for outdoor environmental protection, a common pitfall of sustainable building construction is the unintended oversight of indoor air quality (IAQ). Research shows that poor indoor air quality is a significant risk factor for acute and chronic health effects, including asthma, upper respiratory complications, headache, nausea, irritation of the mucous membranes, flu-like symptoms, and even rare forms of cancer. Unfortunately, one of the greatest misconceptions in the marketplace today is that “green” equals “healthy.” In fact, products, materials, and techniques used to design, construct, and maintain high-performance; energy-efficient buildings can sometimes conflict with efforts to optimize indoor air quality, leading to “green” buildings that suffer from indoor air pollution. HealthcareDevelopmentMagazine.com

Airtight insulation techniques used to maximize energy efficiency, for example, can have the unintended corollary of reducing outdoor air exchange, which enables the build-up of airborne pollutants, including biological contaminants and hazardous chemicals. Recycled content materials, while stewards of waste reduction, can sometimes introduce toxins into the indoor environment by way of off-gassing—especially if the materials’ original use was never intended for the indoors (e.g., automotive tires recycled into flooring). And low-VOC paints, almost universally considered “green” alternatives to standard paints, can still off-gas potentially harmful chemicals indoors. Why? Because they are not assessed for their impact on indoor environments; rather, they’ve been evaluated based on their ability to react with sunlight and cause groundlevel ozone—an outdoor environmental issue.

So, you see, going “green” isn’t so black and white. What You Can’t See May Hurt You Indoor air is an intriguing, complex environment that contains a myriad of visible and invisible contaminants; in fact, it is often two to five times more polluted than outdoor air. Among the contaminants most commonly found in healthcare settings are particulates, or particles that suspend in the air (e.g., dust; mold spores; pollen; dander; asbestos fibers) and VOCs, or volatile organic compounds, which originate from interior products and turn to gas at room temperature (e.g., formaldehyde; acetaldehyde; benzene; toluene). While large particles get caught in the nose and throat and are cleared from the respiratory tract by coughing or swallowing, VOCs hundreds of which can be present in the indoor air at any given time are easily inhaled and tend to metabolize quickly into the bloodstream. VOCs originate from the products and materials used to build, fit-out, furnish, and maintain indoor spaces. The all-too-common “new construction” smell is generated, in large part, by VOCs that off-gas from products like flooring, cabinetry, adhesives, sealants, electronics, furniture, and cleaning products. Exposure to VOCs is known to cause eye, nose, and throat irritation; cough; headache; general flu-like symptoms; skin irritation; 26

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high concentrations of cleaning chemicals can have a detrimental effect on indoor air quality even if all other sources of VOCs are well-controlled.

children including disruptions to the endocrine system (hormones), gene activation, and brain development.

The Elderly, The Sick, and IAQ

and even cancer. Some VOCs produce offensive odors. Others have the potential to chemically react with other compounds in the air, giving rise to additional VOCs that may also be a threat. As a result, even though the concentration of individual VOCs may be below odor thresholds or known toxicity levels, their presence in complex mixtures may pose unexpected health risks. Children, the elderly, and people with chronic illnesses or suppressed immune systems are especially vulnerable to the negative health impacts of VOC exposure. As these sensitive populations are likely to spend considerable time in a healthcare setting, special consideration must be given to the design, construction, and maintenance of their indoor environments.

Children and IAQ Children’s heightened VOC exposure risk is rooted in their physiology. Their immune, respiratory, and neurological systems are still developing; they breathe in a greater volume of air than adults do with respect to their body size; and their heart rate is faster, allowing their bodies to metabolize more chemicals more rapidly. This is what’s known as a greater body burden: pound for pound, children’s bodies simply absorb more chemicals than adults’ bodies do. Childhood exposure to VOCs is also linked to asthma the third-ranking cause of hospitalization in children, according to the Asthma and Allergy Foundation of America. In fact, a 2004 study out of Australia found that children exposed to high levels of VOCs were four times more likely to develop asthma than adults. What’s more, a growing body of science suggests that exposure even to low concentrations of VOCs can have negative effects on fetuses, newborns, and

Similarly, the elderly and the sick are at an increased risk for adverse health effects from exposure to indoor air pollutants. According to the Merck Manual of Geriatrics, as people age, their arsenal of germ-fighting white blood cells shrinks, delaying and weakening their bodies’ response to certain antigens, or toxins. The same holds true for the sick or fatigued, whose immune systems can be compromised due to external stressors. Consequently, when elderly or ill individuals encounter a new antigen, their bodies are less able to recognize and defend against it. Studies show that exposure to indoor air pollution later in life can also increase the risk of developing respiratory complications including asthma, chronic obstructive pulmonary disease (COPD), bronchitis, and emphysema as well as neurologic and cognitive problems, such as motor dysfunction and loss of visual acuity. Controlling and Managing Airborne Chemical Exposure One of the simplest and most cost-effective ways to ensure optimal indoor air quality in a healthcare environment is to practice source control. Just as the name suggests, source control is the act of controlling the various sources of pollutants in an interior space. In other words, it’s the strategic selection and use of products, materials, and techniques that proactively limit number of contaminants that can enter a building, thereby minimizing the risk of compromised indoor air quality. To minimize exposure to VOCs, a healthcare facility’s owners, managers, and designers should specify as many low-emitting products and materials as possible. This is because dodging the sources of airborne chemicals helps ensure a healthier interior space from the onset. Sources of VOCs include everything from work stations, case goods, and office seating to mattresses, wall covering, flooring, and cleaning products. In fact, the specification and use of lowemitting cleaning products is particularly important, as

It is also critical to ensure that the building’s heating, ventilating, and air conditioning (HVAC) system is in proper working order. Mechanical ventilation systems help usher in fresh outdoor air, which helps dilute indoor air contaminants, and high efficiency air filters help block out particulates. Diligent plumbing upkeep and regular maintenance can help prevent mold and moisture problems in the facility, as well.

Healthier Hospitals, Healthier Patients It all boils down to this: the healthier the healthcare environment is the healthier its patients and staff will be. By thoughtfully considering a building’s potential impact on occupant health, and by planning for, designing, and constructing the building to proactively address that impact, building professionals can do their part to fulfill the Hippocratic Oath and truly practice what healthcare professionals preach: first, do no harm.

ABOUT THE AUTHOR Rachel Belew

is the Public Relations and Communications Manager for the GREENGUARD Environmental Institute. She helps raise awareness about indoor air quality, the GREENGUARD Environmental Institute, and the GREENGUARD Certification Program℠. Rachel holds a M.S. in Journalism from Columbia University. Her articles on sustainability and green building have appeared in numerous interior design and architectural trade publications. Rachel is a LEED Green Associate. She can be reached at rbelew@greenguard.org.

ABOUT THE AUTHOR Paul Bates

is the Market Outreach Manager for the GREENGUARD Environmental Institute. He’s responsible for creating and delivering Continuing Education Units (CEUs) to architecture and design professionals; industry and trade organizations; and the general public. Paul also trains manufacturers of GREENGUARD Certified products to help them to deliver their own CEUs. Paul is a LEED Accredited Professional.

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Relieving Patient and Caregiver Anxiety through Sustainable Healthcare Design By Gary Jereczek and Lynn Drover, CID, IIDA

Two patient and caregiver populations are more likely than others to feel the negative impact of anxiety: cancer patients and the parents of infants in Neonatal Intensive Care Units. The architectural design of treatment spaces for these fragile patients can have a big impact on their emotional well being. When special attention is paid to sustainable design elements, patients and their caregivers can experience soothing, healing environments that reduce stress and anxiety. Background

he diagnosis of cancer has a profound impact on a patient’s emotional health and a ripple effect on their loved ones. “Most patients, families, and caregivers face some degree of depression, anxiety, and fear when cancer becomes part of their lives,” according to the American Cancer Society. “Fear of treatment, doctor visits, and tests may also cause apprehension (the feeling that something bad is going to happen).” Additionally, Stanford University has focused on alleviating acute stress disorder and post traumatic stress disorder for the parents of preemies. “Research has indicated that having an infant in the Neonatal Intensive Care Unit (NICU) is highly stressful for parents and multiple studies have demonstrated that parents can develop significant psychological reactions to this experience.” Left untreated, these disorders, can lead to problems with the parent-infant relationship, and in turn, negatively impact the infant and the family as a whole.”

Serene Setting Calms Cancer Patients The majority of radiation treatment facilities are located in the cold, dim basements of local hospitals, their treatment vaults sequestered below layers of concrete. In contrast, daylight, natural wood finishes, and landscaping form the centerpiece of Kaiser Permanente’s Cancer Treatment Center in South San Francisco. Despite surrounding urban density, the standalone structure was carefully placed on its triangular site to provide optimum access to natural light. Dr. Joseph I. Song, M.D., the site’s medical director, sought to make this a flagship cancer treatment center for Kaiser Permanente in California. He worked side-by-side with the design team to incorporate many sustainable design elements. The building is arranged as a series of small spaces that appear expansive. The prominent entry courtyard is visible to all: patients

and caregivers have outdoor access from the waiting room, while the glass-walled conference room and staff break room are strategically placed alongside the courtyard. A key sustainable design element in this structure is daylighting. Linear skylights and expansive windows in all exam rooms and offices flood the structure with natural sunlight. The skylights intentionally direct patients through the high-traffic center corridor of the building. The staff treasures this light-filled space. As sunlight reflects off the wood finishes, a quality of warmth and a sense of security permeate the building. This serene quality helps patients, caregivers and staff to manage the symptomatic emotional trauma of cancer treatment.

“There is phenomenal natural light throughout the center and it is very calming for patients and staff” said Marcy Kaufman, M.S., R. N., Kaiser Permanente’s radiation oncology administrator.

“We treat 75 patients a day, but it doesn’t feel like it. Everyone is friendly and very positive in this setting.” The cancer center was designed to LEED® Silver equivalency. Wood panels, certified by the Forest Stewardship Council, bring a feeling of warmth to the interior finishes. Selected for their low-VOC content, carpet tiles incorporate a leaf pattern to guide patient way finding to treatment spaces. Walls in critical locations are free of miscellaneous devices and are rich in botanical-themed artwork. Even the nature-based names of the treatment vaults (Big Sur, Yosemite, Tahoe, and Sequoia) divert a patient’s attention from the high-tech radiology procedures they will undergo.

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Addressing Environmental Concerns in the NICU Setting The healthcare industry now recognizes the positive role played by the natural world in a healing environment. A new Neonatal Intensive Care Unit is under construction at the Tom and Billie Long Patient Care Tower at John Muir Medical Center-Walnut Creek. Numerous sustainable design elements were incorporated to ease the anxiety of infants and their parents. Natural light inside each private patient room is controlled with PVC-free sunshades and blackout shades. These adjustable shades protect sensitive pre-term babies’ eyes from sunlight, while allowing older babies the opportunity to grow accustomed to daylight as they prepare to leave the hospital. Windows with scenic views to the outside and clerestory windows bring natural light into interior spaces, while rooftop gardens provide parents, visitors, and staff with easy access to nature. While challenging, it is possible to produce an environment virtually free of volatile organic compounds (VOCs), mercury, and other persistent bioaccumulative toxins (PBTs), all of which affect the indoor air quality for patients, family, and staff. To help assure this, the design team worked closely with Valerie Briscoe, RN, MSN, CNS, NNP, the clinical nurse specialist and sustainability champion for the new 35-bed NICU, to create an environment that is as toxin free as possible. Through our teamwork, we identified some of the hiding places where PBTs, VOCs, and other harmful chemicals can be found, including: • Flooring • Paint

• Ceiling Finishes

• Medical Devices

• Electronic Equipment • Bedding

• Millwork

• Wall Finishes • Furniture

• Cleaning Agents

• Window Coverings • Tubing

Each patient room is equipped with a rolling chair/ recliner made of upholstery that avoids phthalates, dioxins, and per-flouro-chemicals to facilitate “kangaroo care,” skin-to-skin bonding between the parent and baby. Resilient flooring made of renewable resources provides a hygienic surface. Finally, a nature-based palette of finishes reflects the hospital’s setting at the base of a nearby mountain range and is composed of high performance/low-VOC materials serving to mitigate patient and parental anxiety.

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Anxiety-Relieving Benefits from Sustainable Healthcare Design Healthcare clients may not be aware of the wide range of sustainable finishes available in today’s marketplace. Architects and designers can advance the cause of environmentally-conscious purchasing decisions by presenting sustainable materials and educating clients on both their aesthetic and green attributes. Given the option, we have found many clients willing and eager to incorporate sustainability throughout their new medical structures. Our most successful sustainable healthcare projects occur when we work with an internal champion, such as Dr. Song with Kaiser Permanente or Ms. Briscoe at John Muir Health. We encourage you to begin each new design by identifying and teaming with a sustainable design advocate from the client’s team. Together, you can make a significant impact on the environmental and emotional health of patients, visitors, and staff. The environmental design elements with the greatest impact include: • Views or access to nature

• Access to daylight, 24-hour diurnal light cycle • Materials and finishes that don’t “off gas” (e.g., PVC-free shades) or require strong off-gassing maintenance chemicals

• Passive diversions, such as nature-based artwork

Winston Churchill once said, “We shape our buildings, thereafter they shape us.” Patients and caregivers who experience the benefits of sustainably-designed healthcare settings absorb the tranquility around them. Additionally, staff stress is reduced in these settings, resulting in fewer medical errors. Healing environments can shape their inhabitants by diminishing patient and caregiver anxiety.

“We shape our buildings, thereafter they shape us.” Winston Churchill

ABOUT THE AUTHOR Lynn Drover, IIDA, AAHID, CID, LEED®AP, ID+C is

an Interior Designer-Interiors Specialist for Ratcliff’s Healthcare Practice Area. She is currently leading the interior design of the new Tom and Billie Long Patient Care Tower at John Muir Medical Center-Walnut Creek. Ms. Drover earned her B.A., Interior Design, from San Francisco State University and a Certificate in Healthcare Design from Canada College.

ABOUT THE AUTHOR Gary Jerecezk,

AIA, is a Senior Associate-Senior Project Manager for Ratcliff’s Healthcare Practice Area. He led the design of the Kaiser South San Francisco Cancer Treatment Center. Mr. Jereczek earned his M. Architecture and B. A. Architecture from the University of California, Berkeley.

Ratcliff’s primary practice areas of healthcare, academic, and civic architecture present limitless opportunities for sustainable architecture. The firm strives to design sensitive healing environments that are attentive to patient comfort and well being. To contact Mr. Jereczek or Ms. Drover, visit www.ratcliffarch.com.

References i. http://www.cancer.org/Treatment/TreatmentsandSideEffects/EmotionalSideEffects/ AnxietyFearandDepression/anxiety-fear-and-depression-anxiety-and-fear, September 8, 2010 ii. http://clinicaltrials.gov/ct2/show/NCT00186472, September 8, 2010

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New Rady Childrenâ&#x20AC;&#x2122;s Hospital Acute Care Pavilion Becomes First Critical Care Hospital in California to Blend Both Mandates By Bonnie Kutch San Diego County parents with children who require critical care now have available to them a pediatric hospital facility unlike any other in the country â&#x20AC;&#x201C; a whimsical, healing oasis that harmonizes earthquake safety with sustainable design.

uilt by McCarthy Building Companies, Inc., and designed by Stantec, the new $260 million Rady Children’s Hospital Acute Care Pavilion is the first acute care facility in California to meet the rigorous standards for quality and safety mandated by the Office of Statewide Health Planning and Development (OSHPD), while also exceeding the level of occupant health and environmental sustainability needed to earn it LEED Certified status.

and lowered into its respective hole. All holes were then filled with grout to secure the anchors and allowed to cure. An initial pull test was conducted on the anchor rod. Then a sleeve was placed over the exposed rod, and the foundation section was formed and poured with concrete. Once the foundation section was cured, the anchor rod was prepped and finally tested, and an anchor plate and a hex nut were then tightened down on the foundation section and torqued to specifications.

Construction of the 279,000-square-foot, five-story facility was completed in late June 2010, 15 days ahead of schedule, and the hospital was equipped, furnished and ready to receive patients by mid October. The U.S. Green Building Council (USGBC) awarded official LEED certification of the building in February of this year.

Making sure the building was well connected to the bedrock below the structure was important, since the bedrock gives the building the most secure possible connection to the earth. This keeps the building tied together and anchored to solid ground. The entire foundation system, structural steel bracing system, and the interior sheer walls are designed to allow the building to resist the forces generated in an earthquake, while allowing the structure to move as necessary.

California’s Seismic Requirements

Rod Tie-Down Operation

OSHPD oversight of California hospitals was born of the 1971 Sylmar earthquake, which caused several hospitals to collapse, endangering the lives of hundreds of patients and hampering the hospitals’ ability to provide emergency care to the injured. In 1973 the state of California passed the Alfred E. Alquist Hospital Seismic Safety Act and, ever since, all hospital construction has been governed by this legislation. The standards not only help enforce patient safety during the earthquake, but also ensure that facilities can continue to function and care for the injured following earthquakes.

To seismically secure the new Acute Care Pavilion, McCarthy chose a Micro-Pile application of a “Dywidag” tie-down anchor rod system. Considered a novel approach in the healthcare design world, a tie-down prevents the building foundations from uplift during an earthquake. The Uniform Building Code requires that the foundation of structures be designed to resist the upward force of a seismic event.

As a result, OSHPD is responsible for overseeing all aspects of construction for general acute care and psychiatric hospitals, as well as multi-story skilled nursing homes and intermediate care facilities in California. Construction oversight of OSHPD facilities adds a heightened level of complexity to already complicated healthcare construction projects in California, based on the state’s strict criteria for project inspections as well as reviews and approvals of any and all changes of construction materials or methods. For the Acute Care Pavilion, Rady Children’s Hospital employed an onsite inspector-of-record and three field inspectors who were bound to the letter of the law. McCarthy had the integral role of working through all construction issues, developing proactive solutions, documenting every discussion and construction activity, and gaining the confidence of OSHPD inspectors, who visited the site three times a week. Not a single detail of the project could afford to be overlooked, down to the torque of each bolt. 34

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It is not unusual for structural foundations to be supplemented with caissons or driven piles, should the soil conditions dictate the need to literally “float” the building with the assistance of these foundation elements and secure the foundation to the bedrock layer below. This insures the solid embedment of the foundation supports and makes sure that any building settling will be minimal and uniform. For the Acute Care Pavilion, the problem was not how to “float” the building foundation, but how to hold it down. To complicate the problem, the need to add tie-down anchors was determined late in the preconstruction process, requiring the structural engineer to either redesign the entire foundation, or come up with an acceptable hold-down alternative. The project team analyzed the problem and selected the “tie-down” technology as the most effective solution for keeping the project on schedule. The installation of the tie-downs required McCarthy’s team to drill individual 60’ deep holes that were only 8” in diameter for each tie down rod. Each rod, made of 2-1/2-inch diameter solid steel, was hoisted by a crane

There are 144 of these anchor rod tie-downs installed in the foundation of the Rady Children’s Hospital Acute Care Pavilion to meet the unique seismic hold down requirements of the building’s five-story structure. This innovative solution not only kept the project on schedule, but also provided the necessary seismic uplift restraint required for the building.

Mission: Green Rady Children’s Hospital is the only dedicated pediatric medical center in the San Diego region whose demand for services had outgrown its existing facilities. The new 279,000-square foot Acute Care Pavilion was built on a tight, 148,650-square-foot site at the southeast end of the hospital campus, adjacent to the existing Rose Pavilion. Second- and third-floor bridges and a groundfloor walkway connect the existing facility to the new four-story building. The Acute Care Pavilion houses a much-needed surgical center, 84 medical-surgical beds, a neo-natal

intensive care center, and a cancer center. It also provides 16 operating rooms with associated support departments, a 28-bed hematology and oncology unit, a 10-bed bone marrow transplant intensive care unit, a 32-bed neo-natal intensive care unit, and 84 acuity adaptable medical surgery beds. The facility’s exterior features a glass-fiber reinforced, precast concrete exterior; integral-colored plaster; storefront and curtain wall glass systems with colored accents; and metal panels, railings and canopies. For many years, Rady Children’s Hospital has been committed to green practices throughout its operations, so when it came time to expand, it set on a mission to become the largest children’s hospital in the state with a world-class LEED Certified facility. Marrying a world where patients and operations are paramount with that of an eco-friendly environment would challenge the project team, but also represent a significant construction milestone.

A Knowledgeable Approach To properly address the LEED aspects of the project and carry through the facility’s sustainable design in a thoughtful, practical manner, McCarthy employed a dedicated LEED professional and, during the course of the project, 10 of the construction team’s members became LEED APs. Construction execution required rigorous tracking and monitoring to ensure compliance with the credits. Where there was so much as a shadow of doubt, the project team took extra precautions at every turn. More than anything, success of the project required trust on the part of the owner that the project team members would work cohesively with OSHPD, the USGBC and one another, always with the hospital’s and patients’ best interest in mind. Tim Jacoby, vice president of facilities for Rady Children’s Hospital, led the triumphant collaboration.

garden off the main entry, intended for parents and siblings, sets the stage for the whimsical themes experienced throughout the facility.

Working in accordance with LEED 2.1, the project team achieved 31 points, well exceeding the 26 points needed for LEED certification. Since beginning the application process for this project, the USGBC has rolled out the LEED 3.0 for Healthcare Green Building Rating System, which has made it more enticing for hospitals to seek certification since the requirements are more specific and applicable to healthcare facility issues.

Whimsical Healing Gardens The project team earned an “Innovation in Design” credit for the introduction of a series of healing gardens that utilize sustainable design principles and embrace the hospital’s healing arts program, which was originally developed in 1993 in conjunction with the Rose Pavilion construction. The program seeks to enrich the experience of patients, families and staff via works of visual and performing arts, and through healing gardens that draw on artists’ talents to transform normally lackluster courtyards into whimsical, outdoor retreats. In synchronicity with the hospital’s healing arts program, the new Rady Children’s Hospital Acute Care Pavilion provides an environment focused on the needs and imaginations of children – one that is also intended to help relieve the stress of families with sick or injured children. Central to the theme of the building is the “River of Life”, manifested through an immense, four-story mineral panel that incorporates a kinetic lighting system, which radiates a rainbow of vibrant colors through the front entry curtain wall. A mosaic tile version of the “River of Life” flows from the mineral lobby wall, through the lobby, and out to the first-floor courtyard. Called “Carley’s Magical Gardens”, these landscaped courtyard areas were designed through the collaboration of local artists T.J. Dixon, Kim Emerson, Albert De Matteis, and James Nelson. The first floor 36

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Located on the second floor off the hematology and oncology unit, the primary healing garden features a giant tiled bird with a place for patients to deposit their wishes, which staff later collect to better understand the children’s wants and needs. A life-size bronze figure of a young girl sitting at an eight-foot-long table is the centerpiece of the secondfloor healing garden, and provides a place for organized activities and family gatherings. Other whimsical objects include a mosaic tile and concrete tree playhouse, privacy bench, performance stage, and interactive garden screens and gates. A divided basketball playing area accommodates both regular and immune-deficient patients.

Nearly 80 percent of construction waste materials at the job site was recycled. A thorough flush-out of the building was performed upon construction completion and again immediately before receiving patients. The project team went above and beyond the LEED requirements by declaring the entire hospital campus a “no smoking” zone.

Inspiration from Rady Staff Working next door to the existing Rady Children’s Hospital and observing everyday trauma there greatly affected the minds and hearts of McCarthy’s construction team members, who were inspired by the passion and commitment of the Rady Children’s Hospital staff. After all, this was no ordinary construction project, but rather a life-saving mission on behalf of parents and their critically sick or injured children.

On the third floor is another landscaped bamboo garden with a rubber-surfaced playing area for patients and a retreat area for staff. A vast ground-floor outdoor terrace, strictly for staff use, features large Jacaranda trees, light posts and bike racks.

Greater Green Means The Rady Children’s Hospital Acute Care Pavilion’s energy efficiency level is 23 percent better than ASHRAE 90.1, utilizing the LEED Energy Cost Budget methodology. This was achieved by incorporating the following sustainable design features: ää Occupancy sensors in operating rooms to reduce the ventilation rate by 60% when unoccupied, yielding a 45% annual energy savings; ää Variable frequency drives on air handling unit motors to adjust the fan speed due to filter loading; ää Carbon dioxide monitoring for high occupancy areas to reduce ventilation rates, based on the number of occupants; ää supply air temperature reset strategy, which saves energy by adjusting air temperatures based on load; ää A 24,000-square-foot cogeneration plant that provides free heating and high temperature water, and contains two 700-ton natural gas-fired absorption chillers; and ää variable frequency drives on cooling tower fans and hot water pumps. The project also utilizes recycled and locally obtained steel, concrete and other building materials; low VOC-emitting paints, glues, carpet, and wood; water-efficient landscaping; abundant daylighting; and a dedicated bicycle storage area. A reflective concrete “cool roof” system helps minimize heat gain and control rainwater run-off, while painted steel screens conceal rooftop mechanical systems.

ABOUT THE AUTHOR Bonnie Kutch, principal of Kutch & Company,

is the San Diego media representative for McCarthy Building Companies, Inc. McCarthy is the nation’s 10th largest domestic general contractor (Engineering News-Record, May 2010) and has been ranked among the top five healthcare builders in the nation and among California’s top five green contractors (California Construction, May 2010). In Southern California, the firm has completed over $2.4 billion in healthcare work for the region’s most elite healthcare institutions. In addition to San Diego, McCarthy has offices in Newport Beach, Sacramento and San Francisco, Calif.; Phoenix; Las Vegas; Dallas; Houston; St. Louis and Atlanta. McCarthy is 100 percent employee owned. More information about the company is available online at www. mccarthy.com. Ms. Kutch can be contacted at bkutch@kutchco.com.

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Sharp Healthcare Leads the Way in Energy and Resource Management By Julie Brown As the primary healthcare provider in San Diego County, Sharp Healthcare is not only setting the standard for healthcare in the region but also energy and resource management.

harp HealthCare is a not-for-profit integrated regional health care delivery system based in San Diego, California. Sharp’s facilities include four acute-care hospitals, three specialty hospitals, and numerous medical offices and support services buildings.

The Green Initiative

each of their hospitals, health plan and medical groups. These “Green Team” members ensured that their efforts and findings would be communicated throughout the rest of the Sharp community Reporting to the Green Team is the Natural Resource Subcommittee, comprised of the engineering managers from each of their entities, facilities development, and business development.

In January 2009, Sharp’s executive management team launched a system wide Green Initiative to proactively manage the energy and resource performance of the system’s facilities infrastructure. According to Vice President, Business Development Donna Serpico-Thompson, the Green Initiative “affirms Sharp’s commitment to the environment, and therefore the health of the communities we serve.” Her first step was to gather representatives from

To aid the Green Team in meeting its energy goals, Sharp also participated in San Diego Gas & Electric’s (SDG&E®) Healthcare Energy Efficiency Program (HEEP), a program administered by SDG&E through a contract awarded to Willdan Energy Solutions (aka Intergy Corporation). The HEEP program offers a full range of energy efficiency services to assist customers with identification of and financing for energy conservation measures.

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Phases i and ii of the Energy Assesment for Cost Saving Initiative Starting in May, 2009, and through the following month, HEEP assisted Sharp with energy assessment activities at its hospitals and medical clinics. The HEEP program staff conducted energy assessments which included a review of ENERGY STAR® ratings and a Phase I energy audit to identify cost-effective energy conservation measures.

Improvements in Energy Performance Using ENERGY STAR’s benchmarking tool, Portfolio Manager, Sharp monitored the ENERGY STAR ratings of its facilities as changes were implemented. Results showed improved ES ratings, earning Chula Vista an ENERGY STAR® label. In addition, results for Sharp Grossmont and Sharp Memorial Hospitals identified them as eligible for the ASHE and ENERGY STAR Energy Efficiency Challenge (E2C) award for facilities that show an increase in energy performance of 10% or more annually. Sharp Grossmont and Sharp Memorial both exceeded this with a 20% improvement in their energy performance.

The Phase I energy audit identified a total of 73 energy conservation measures (ECMs) across three hospitals and two ECMs for the medical clinics. From these, 25 ECMs were identified Facility for a Phase II analysis. This more comprehensive analysis generated detailed information on energy Sharp Chula Vista cost savings, project installation Medical Center costs, financial incentives available through SDG&E’s HEEP, and simple payback on the potential ECMs. Sharp Grossmont This provided the Natural Resource Hospital and Sharp Sub-Committee with the necessary Memorial Hospital financial analysis for decisions about capital requests for ECMs. Results of the Phase II analysis revealed five projects with a simple payback of five years or less. Eight offered longer payback periods but provide promising returns in the long term. The conservation measures not only include retrofitting lighting and other infrastructure updates but also took into consideration energy use by vending machines, computers and servers. Taking advantage of system level conservation measures also uncovered energy savings in technology. For example, features already found in workstations running Windows and Mac operating systems will also cut the amount of energy used by each PC in half. Configuring workstations to use Computer Power Management Features to place monitors and computers into low-power sleep mode saves energy, money and helps protect the environment. Deploying this feature can result in savings of $25-$75 per workstation. One project in particular stands out. The recommendation to retrofit lighting in its Chula Vista facility stands to reap $151,000 in savings annually. This represents a seven-month return on investment.

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Award

Eligibility

ENERGY STAR Building Label

Awarded to buildings with an energy score of 75 or higher in Portfolio Manager.

ASHE and ENERGY STAR Energy Efficiency Challenge (E2C)

Awarded to buildings demonstrating energy performance improvements of 10 percent or more annually.

Since undertaking its Sustainability Initiative, Sharp has earned recognition for improving the energy performance of two of its hospitals.

According to Serpico-Thompson, every month Sharp tracks the ENERGY STAR ratings of each hospital and Sharp owned buildings are included in the ES database. This “helps us keep on track and monitor utilization every month. All of ourwhospitals have seen improvement over the last year.”

ENERGY STAR Ratings Before and After Comparison The table below shows the change in ENERGY STAR rating of four of Sharp’s hospitals during the course of the Sustainability Initiative.

Hospital

August 2009

September 2010

Chula Vista

Coronado

Grossmont

Memorial

The bottom line: the resulting recommendations stand to save the hospital system approximately $1 million by 2012. This is in stark contrast to the $2 million in additional energy costs Sharp would have incurred had it not chosen to take these steps. “Due to multiple energy initiatives being implemented at the same time, it is difficult to track each project’s actual impact to energy savings and thus its individual return on investment. Each project implemented was expected to save in kilowatt hours and dollars, thus providing a resulting increase in ES scores,”SerpicoThompson commented. “Sharp has realized the improvement in ES scores over the last year. This means that each project is positively affecting Sharp’s long-term impact on the environment and reducing energy costs.”

ENERGY STAR’s Portfolio Manager provides an energy performance rating on a scale of 1-100 for hospitals and MOB’s. A score of 50 is average.

About the Company Willdan Energy Solutions provides overall project management for SDG&E’s Healthcare Energy Efficiency Program (HEEP). Julie Brown, project manager with the Putnam Price Group, is a member of the HEEP team and authored this article. The Healthcare Energy Efficiency Program (HEEP) is funded by California utility customers and administered by San Diego Gas & Electric Company, Southern California Edison and Pacific Gas & Electric under the auspices of the California Public Utilities Commission, through a contract awarded to Willdan Energy Solutions (aka Intergy Corporation). California customers who choose to participate in this program are not obligated to purchase any additional services offered by the contractor. For more information on the program please contact Alex Araiza at Willdan Energy Solutions via email at aaraiza@willdan.com.

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ealthcare can be a challenging field if you have responsibility for finding and retaining staff. What is the answer to this growing crisis? There are no magic wands, but organizations that recognize opportunity and adapt will find themselves in a better position to succeed in the future. One such opportunity is the increased interest in being green. Going green is not just good for the planet but good for business and in more ways than one. By nature healthcare professionals tend to care about the planet. An unhealthy environment makes for an unhealthy population. Many companies are finding that beyond this, employees are very interested in knowing what their own employer is doing and that’s an opportunity to engage them as employees in doing more things as an organization and to make them proud to be a part of the team.

Recruit and Retain

Greening Healthcare,

a New Opportunity for Engaging Employees By Tom Badrick We have all heard about the challenges facing the healthcare world going forward. Labor shortages for doctors, nurses and ancillary professions make for a difficult task ensuring your facility has the right staffing to ensure your patients get the best care. Competition from competing healthcare organizations in shared geographic regions makes retention even more challenging. On top of that, turnover rate is significant as people leave the profession and the education and credentialing systems are insufficient to provide sufficient new professionals. Employee turnover in the healthcare sector is extremely high; so high in fact that in some US states it is more than double the national average of 15.6% per year. This issue is being mirrored worldwide. In some developing countries, they experience a brain drain. In 2006, it reported that 57 countries, most in Africa and Asia, face a severe health workforce crisis. It estimated that at least 2.4 million doctors and nurses and 1.9 health administrators are needed to fill the gap.

Employee retention and recruitment may seem like the same concept, but each require a very different approach to be successful. With recruiting, the approach is one of educating potential employees about your organization and the benefits of working there. Often this is focused on salary and benefits, with other factors such as working conditions, location, scheduling. However in the last decade, an organization’s green performance has started to become more important and is a contributing factor in attracting new top talent. Employee retention is appreciably different, with the focus being on keeping those employees already on staff satisfied. This is often measured with employee satisfaction surveys. Employee attrition is unavoidable to some degree with retirements and life changes but to retain top talent, it is useful to develop a strategy. Whether it is retention or recruiting, greening your organization can be an asset that shouldn’t be overlooked.

Greening Healthcare a Human Resources Function? With the new emphasis on greening of healthcare, much attention is directed towards tools such as LEED and other technical areas. An often overlooked component of the Greening of Healthcare is the human factor. We put our focus on the science, measurement tools such as LEED that tell us how we

are doing and when we have arrived at the goal. But greening healthcare is an extension of healthcare itself, the intersection of science and humanity. Just as you cannot successfully treat a patient without considering the patient as a person, you cannot “green” healthcare successfully without including people in the equation. So what does including people into the greening of healthcare equation mean? It means engaging employees in every process. It means considering the impact of greening efforts upon and for the patients. It means thinking of the “greenness” of your organization as an asset when trying to recruit or retain top talent.

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Green Myths Let’s start by dispelling a few myths. The first myth is that employees might be slow to support the effort. Most employees are interested in what their employer is doing to support being green. Beyond that, they want to know how they can be involved. Don’t overlook this opportunity. The second myth is that it’s not something physicians care about. So much emphasis is placed on professional titles that often misperceptions can occur. One example is “doctors don’t care about recycling.” Where this type of societal stratification might be relevant in some situations, it’s not the case with being green. Whether a physician, nurse or housekeeper, when we all go home at the end of the day we care about the planet the same way. So with those myths brushed aside, let’s look at one way to use being green as an asset when trying to recruit and retain employees.

Weaving Green into the Organizational Fabric

Engaging employees is often a goal for both management and human resources and one creative way to increase employee involvement/engagement is through the creation of green teams. Green teams are similar to many other committees or teams within healthcare only a green team focuses on ways to improve the way in which the organization performs on green issues. Some teams focus on a limited number of issues like starting or increasing recycling while others take on more complex challenges like energy management programs

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As any manager knows, employee turnover is both expensive and disruptive. One recent survey found that the average cost to replace a departing employee is 30 percent of that employee's salary. According to the Human Resource Management Association, 20.4 percent of health care employees one in five quit their jobs every year. The number easily exceeds the 12 to 15 percent turnover rate experienced in most other industries. Recruiting and retaining employees, especially critical need employees can be enhanced by engaging employees through green efforts, especially the creation and support of a green team. A green team implemented effectively can help any organization by building camaraderie, enhancing cross-functional communication and helping save money not only on retention costs but most green projects also save the organization money.

Often in healthcare people are appointed to teams but in this case it’s useful to look at seeking volunteers who have a passion for the topic. There are many benefits of doing this including cross pollination of idea’s between departments and creating an environment for employees who have not had the opportunity to participate in team projects. This provides a new avenue for the organization to identify potential future leaders. Once the team is in place there are some key steps to follow. The first step is to make sure the team understands its role and charter. The second step is to make sure the team has all the tools it needs to succeed. This would include education about what green means. From there developing goals and a timeline will help ensure the team accomplishes its purpose. This is important not just to satisfy the objectives of management, but also as a way to create a satisfying experience for the team members.

Green Teams

Green Teams, a Solution

There are a few key steps to starting a green team. The critical initial step is to make sure management is willing to support having a green team. To achieve management support it helps to address a few key issues in your proposal. First you should define the purpose of the team including defining the scope of what the team will do. You should also have some idea what the benefits of such a team provide to the organization. Second, you should decide who should be involved. Although it is critical to ensure the involvement of key areas such as Supply Chain and Engineering, how you go about doing that should remain flexible.

One of the benefits of the green team model is the change it can bring to the organizational culture. There are many projects and tasks a team can tackle, but how the team takes on those projects is also important. If you can identify ways to make accomplishing the goals fun, such as contests between departments, social activities and offering incentives for successes, then you won’t just be accomplishing the goals, you will make being green second nature and build camaraderie amongst employees. This not only supports better employee involvement, but better patient care because it’s well documented that employees who like where they work provide better patient care.

Additionally management should support the efforts of the green team, not just by allowing them to form, but by making sure that the team is communicating to employees what they are doing. This can be in a newsletter, making time for a brief green team report at management meetings and departmental meetings and supporting team communication effort such as promoting Earth Day activities. It is important not to overlook the value of the green team activities on external communication as well. Possible starter projects for green teams:

• Start a recycling program or enhance an existing program.

• Help manage utility costs by participating in • • • •

energy auditing and promoting energy awareness campaigns Help start farmers markets or farm stands on campus to promote local farming Help organize car pooling and other green transportation projects Help in efforts to reduce paper use Participate in Earth Day and other community activities

ABOUT THE AUTHOR Tom Badrick, is President of Badrick Consulting

specializing in healthcare sustainability program design and implementation. Tom is a leader and recognized speaker in the healthcare sustainability field. Tom successfully crafted and directed the nationally recognized and award winning sustainability program for a large health system in Portland, Oregon and has guided and assisted many other organizations with creating and expanding successful programs as well as partnering with suppliers. Tom has a background in Environmental, Health and Safety in biotech, chemical manufacturing and the electronics industries. Badrick Consulting offers a wide range of services from program creation/ development to partnering in management of specific components of a sustainability program ranging from waste management to climate change initiatives. The Badrick Consulting web page can be found at www.badricksustainability.com and Tom can be reached via email at tbadrick@aol.com.

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Veterans Hospitals Utilizing

Green Globes

for Continual Improvement By Jane M. Rohde and Sharene Rekow

As an investment into continual sustainability in VA hospitals, 21 facilities utilized the Green Globes® Continual Improvement of Existing Building (CIEB) on-line survey for evaluation of current operations. The Green Globes CIEB program helps establish performance baselines, best practices and certification for operations and maintenance of a building in the environmental assessment areas of energy, water, resource management and emissions and pollutant controls. The fully interactive, web-enabled tool allows facility personnel to measure, document, and improve the sustainability of a building over time. Each hospital upon completion of the survey proceeded to being third party assessed for certification. Jane Rohde, a third party assessor reviewed documentation and completed site visits for all 21 hospitals. All of the hospitals were awarded between two to four Green Globes (4 Globes being the highest available certification).

eneral recommendations and best practices that came out of the different assessments that would be applicable to both private and public hospitals include the following:

• Evaluate spaces that were designed originally for

one use and are now being utilized for something else as related to energy use. For example, one VA facility used to include a surgical suite within an ambulatory care setting, but was taken out of service. When space was needed for education and training, the surgical suite was utilized; however the entire unit was being heated and cooled as though surgery was still being completed. This created a large surge of unnecessary energy use, as there was other classroom and office space available that could be usable for education and training.

• All VA hospitals have an Energy Manager and

a Green Environmental Management Systems Coordinator (GEMS Coordinator). As a result of having these two positions that usually have a dual role of every day operations, industrial hygiene, and/or facility responsibilities, there is a dedicated focus on sustainable practices that improvement outcomes, as well as creating financial savings. For example, one Energy Manager, once on board realized that all of the steam traps had not be reviewed since the facility had opened. Once repairs and/or replacements to the traps were completed, energy use decreased enough that other planned projects were no longer required.

facility, in-house activity staff had programs for staff wellness that continued to recognize healthy eating and exercise program. A marketing plan for communicating sustainable initiatives to staff, patients, residents, and family resulted in a creation of a toolkit that included reusable water bottles, recycling information, and ways to save money within individual households.

• Working with local agencies, community planning

departments, and department of recreations and parks to create connections to walkways and bike paths from the hospital to the community atlarge.

• Evaluate all recyclables at point of service.

Having recycling containers and a stream that requires the waste is the first step; but education and training as well as having containers at the point of use of products promote a successful process. Some hospitals have completed audits and include the utilization of recycles sharps containers, collection of recyclables within dietary settings (commercial kitchen), and effective composting programs.

• Utilizing staff’s creativity for ideas and continual

improvement is key to creating an integrated team approach to sustainability. In one hospital, the plant and facility team, who were always seeking ways to improve energy use, had even harnessed the energy created from all of the elevators when traveling downward. In another

San Diego Recycling Program was extensive; even including the recycling of Styrofoam peanuts by UPS

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• Many of the hospitals are embracing culture

change initiatives that support patient-centered and resident-centered care models. In one facility, a Planetree director position has been created to promote person-centered care models. There were also Eden Alternative™ and small house concepts being utilized for the Community Living Centers (CLCs), which are long term care settings within VA Hospitals. Additional information on culture change includes the following resources:

• Planetree:

www.planetree.org

• Pioneer Network:

www.pioneernetwork.net

• Culture Change Now:

www.culturechangenow.com

• The Eden Alternative®: http://www.edenalt.org

• National Alliance of Small Houses: •

www.smallhousealliance.org The Green House® Project: http://www.thegreenhouseproject.org

• Access to successful outdoor activity areas and places for respite was predominantly driven by nursing management staff. Specifically in the CLCs easy access and areas located for ease of staff monitoring of outdoor space were the most utilized by residents and patients.

Asheville VA CLC Garden: individualized tomatoes with residents’ names on their tomato supporting resident-centered/patient-centered care models.

• Utilization of microfiber cleaning processes; which

not only reduce the utilization of chemicals and water, but more importantly improves infection control. Both using of mop heads and cleaning cloths is recommended. The microfiber system allows smaller and lighter housekeeping carts to be utilized. This assists with reducing potential staff injuries as well as having the added benefit of protecting wall surfaces. The older stainless steel carts that are still used in some facilities are not only heavier, but also do higher levels of damage when coming into contact with corners and wall surfaces. Within housekeeping closets utilizing premeasured systems for chemicals also assists with indoor air quality by controlling the old premise; “if a little bit of cleaning chemical is good, then a lot of cleaning chemical is better.”

• Completion of staff and patient surveys is important

for continual improvement. However, once these types of surveys are completed, they need to reach those that can impact positive change. By utilizing an integrated team approach to sustainability, implementation of recommendations is more apt to occur on a regular basis.

From the successful piloting of the Green Globes® CIEB assessments, the Veterans Administration has awarded the Green Building Initiative® (GBI) to provide an on-line, sustainability self-evaluation tool for an additional 173 hospital facilities. This new tool will be for healthcare; specifically hospitals that include in-patient or long term care beds. Both energy and water consumption calculations shall be based upon the number of beds within a hospital facility. The CIEB – Healthcare – Hospitals self-assessment tool has been developed based upon the recommendations and outcomes from the 21 VA third party assessments; utilizing recommendations from VA staff as well as information gleaned from the recommendation reports completed for each pilot hospital. The 173 buildings to be assessed encompass some of the largest and most complex commercial buildings in the United States. This project represents the first steps in what could be a broader sustainability assessment/ certification initiative spanning entire campuses. Green Globes is highly compatible with the elements of the High Performance and Sustainable Buildings Guidance utilized by the Federal Government and is an important tool to help federal agencies evaluate compliance with the Executive Order.

Until now, it has been difficult to have a continual improvement tool that allows facility departments to evaluate systems on a regular basis utilizing in-house knowledge. The new CIEB – Healthcare – Hospitals tool provides a fresh approach to sustainability that is based in the development of practical and efficient operations. For more information on the Green Globes® evaluation tools and Green Building Initiative, see www.thegbi.org.

ABOUT THE AUTHOR

Jane Rohde, AIA, FIIDA, ACHA, AAHID, LEED AP is the principal and founder of JSR Associates, Inc., a senior living and healthcare consulting firm providing the following services; client focus groups for creative program and care model development, innovative funding strategies, and design and project management services based on evidence based research, sustainable design principles, and resident focused/patient centered programming. Jane sits on the Environmental Standards Council; part of The Center for Health Design. Jane is the former Vice President of the Board of Regents for the American Academy of Healthcare Interior Designers (AAHID) and sits on the Health Guidelines Revision Committee (HGRC) for the 2010 and 2014 Cycles of the Guidelines for Design and Construction of Health Care Facilities. Jane services on the committee for the development of ASHRAE 189.2 Design, Construction & Operation of Sustainable High-Performance Health Care Facilities. Jane speaks nationally and internationally on senior living, aging, healthcare, evidence based design and sustainability.

ABOUT THE AUTHOR

Sharebe Rekow, CAE, is the VP of Marketing/

Sales/Membership at the Green Building Initiative. Prior to joining the GBI, Sharene held several director and top management positions at national and local nonprofits which include the Better Business Bureau, the Rotary Club of Downtown Portland and Associated General Contractors of America. As well, she has been the channel director to the nonprofit marketplace in a software-as-a-service company.Sharene specializes in coalition building between the GBI and national, industry- related leaders and nonprofits. As VP of marketing/membership for the Green Building Initiative, Sharene is responsible for external activities that educate and inform potential members, partners and the public about ways to interact significantly in the green building movement. Her role includes the branding and recognition of the GBI as a green building leader through the development of partnerships, web seminar training, trade shows and public recognition. She may be reached at Sharene@thegbi.org.

She may be reached at Jane@jsrassociates.net.

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Changing and Helping Healthcare in Haiti

By Steven Steinberg, AIA, Principal of Healthcare at RATCLIFF

When Dr. Olajire Idowu, a pediatric surgeon at Childrenâ&#x20AC;&#x2122;s Hospital of Oakland, California, sought help for a mission to provide sorely needed medical care in Haiti, he turned to his friend Christopher P. Ratcliff.

A Challenging and Rewarding Adventure The challenges will include adjusting standards (architectural and engineering) to the realities of the region while bringing value to a hospital campus lacking basic necessities and infrastructure. Being accustomed to designing to the exacting standards of Western codes and requirements; learning to work with local building officials and building materials will also serve as a learning experience for the healthcare group.

Sustainability is very much a part of the program. The firm’s director of sustainability will be working to ensure that the efforts are healing not only to the people of Haiti but to the environment.

r. Idowu had seen Ratcliff’s youngest daughter through a medical crisis several years earlier, and the experience had forged a bond between the doctor and the Ratcliff family and inspired the young woman to pursue a career in medicine.

people. It was built in the 1930s by the U.S. Marines during one of the American occupations of Haiti and is currently run by the Haitian Ministry of Health in partnership with Partners in Health and Project Medishare. It provides a variety of services including surgeries, deliveries, dental, HIV and tuberculosis care.1

She organized her high school classmates to put on a fundraiser for Dr. Idowu’s philanthropic organization, Medical Care for Children of All Races Everywhere (Medical C.A.R.E.), which embarks on missions to provide proper training, tools, and techniques to local doctors and nurses in developing countries.

St. Therese has a crumbling infrastructure and technology that is well behind what is considered standard in developed nations. Patients are admitted to shared, open air wards. There are no private rooms save a few isolation rooms for TB-infected patients. There are no CAT scans, no EKGs, no ventilators. The current “Emergency Room” is literally a room that is too small and ill-equipped to care for patients in an efficient manner.2

A Quest to Improve Conditions at St.Therese Hospital The healthcare group will travel to Hinche (pronounced “Ench” in Kreyol), Haiti, where we will lay the groundwork to construct a new emergency department (ED) and intensive care unit (ICU) at St. Therese Hospital. St. Therese is the main hospital for Hinche and much of the surrounding area, serving an estimated 220,000 52

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The mission will be both rewarding and challenging. Haiti is the poorest nation in the Western Hemisphere; healthcare services are scant and resemble less than combat medical services. The country is still reeling from the devastating earthquake that struck Port Au Prince in 2010.

Joining with Medical C.A.R.E. on this project is Dr. Rick Spurlock of Emergency Physicians International (EPI), a nonprofit organization that seeks to improve medical care in developing countries by building EDs and ICUs and enhancing the clinical skills of local providers. Once the ED and ICU are completed and effectively self sufficient, the facility will become part of the EPI foundation. In this way the work of the team will be truly sustainable—carried on by the local community. This project never stops. Aside from bricks and mortar there is a need to purchase equipment, secure donated equipment and obtain a lengthy list of supplies, from stretchers and IV poles to EKG machines and oxygen tanks. The people of Haiti are proud, beautiful and full of hope. The personal joys associated with putting human compassion as a priority in serving communities in need of medical care is the greatest reward possible. If you would like to learn more about the project and ways you can help, visit the websites of Medical C.A.R.E. and EPI.

ABOUT THE AUTHOR Steven Steinberg, AIA, is Principal of Healthcare at

RATCLIFF. He has more than 25 years of experience in the architecture and real estate development industries. He is a speaker at the upcoming Design & Health & World Congress and Exhibition in Boston. Recent speaking engagements include the American Institute of Architects National Convention in Miami, Fl, 2010 and the Healthcare Facilities Symposium & Expo, Chicago, IL, 2009. He is a member of the American Institute of Architects, The Center for Health Design, American Society of Healthcare Engineers, and the Urban Land Institute. He serves as Planning Commissioner for the city of Emeryville and served two terms as chairman of the City of Scottsdale Planning Commission. He may be reached at ssteinberg@ratcliffarch.com.

Notes: 1,2 http://epinternational.org/?page_id=21

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