ABOUT THE HFM/ASHE 2008 DESIGN & OPERATIONS SURVEY

Health Facilities Management and the American Society for Healthcare Engineering of the American Hospital Association surveyed a random sample of 4,027 hospital executives to learn about the use of more environmentally friendly materials and practices in hospital construction. The response rate was 15 percent, or 607 completed surveys. Health Facilities Management thanks the sponsors of this survey: Amerinet, the Air-Conditioning, Heating and Refrigeration Institute, the American Society of Heating, Refrigerating and Air-Conditioning Engineers, ASSA ABOLOY and Phoenix Controls.

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Never mind that it’s not easy being green—just getting going in that general direction has been a slow process for not-for-profit hospitals. As with technology and other areas, the health care industry has lagged other sectors in environmental initiatives and sustainability.

Now, though, there’s increasing evidence of momentum building behind such efforts in hospital construction as well as on the operations side. Motivated in part by soaring energy costs and public concerns about climate change, organizations are embracing more environmentally friendly building practices and trying to be more energy-efficient in new and renovated facilities.

'A Green Tsunami'

Robin Guenther, FAIA, an architect specializing in sustainable health care design, says it’s clear that green is finally becoming mainstream among hospitals.

“We’re having a green tsunami in our culture and it’s washing over the hospital world now,” says Guenther, principal at the New York commercial architect design firm Perkins+Will. “Even in the hospital engineering community, you’re beginning to see a real broadening of sustainability issues beyond energy to embrace everything from environmentally preferable purchasing to indoor air quality.”

The progress is confirmed by a new survey conducted for Health Facilities Management and the American Society for Healthcare Engineering (ASHE) of the American Hospital Association. The survey was conducted online in March and April to gauge hospitals’ sustainability efforts in current construction and renovation projects and energy efficiency programs. A total of 607 ASHE members participated, so the results carried a margin of error of plus or minus 5 percent.

Among the results, 70 percent of respondents said their hospitals were specifying green or environmentally friendly materials in some or all construction and renovation projects. High percentages of those surveyed also said their hospitals had recently installed, were currently installing or soon would be installing systems to recycle or conserve energy—particularly high-efficiency building controls, lighting controls, high-efficiency HVAC, chiller plant optimization and building insulation. Even assuming no installations by those who chose not to answer that question, it means each of those five systems was being installed by 35 percent to 45 percent of the surveyed hospitals, either currently or in the last 12 to 24 months.

Yet there also was evidence of continued caution, if not foot-dragging. Only 11 percent said they have designated a single title or position with responsibility for green or sustainable efforts. Among the feedback, the respondents also indicated that the environmentally friendly or sustainable practices they have adopted are spread over a wide range, showing a lack of unified focus or commitment in various areas. And there was a widespread lack of measuring key energy metrics.

The ongoing wariness is understandable, according to Clark Reed, director of the health care facilities division for the Environmental Protection Agency’s Energy Star® program. “This is a traditionally conservative sector, and certainly evidence-based, so it’s not surprising that they’re coming a little late to the game,” he says. “There’s a healthy amount of skepticism out there.”

Still a Hard Sell

Worries about possible costs are holding back hospitals more than anything else from plunging deeper into green and sustainability spending.

Money is at the root of most of the five biggest challenges or barriers to environmentally friendly practices cited by survey respondents: higher initial cost (78 percent), increased cost over traditional materials and systems (73 percent), competing investment and spending priorities (72 percent), a perceived lack of immediate return on investment (47 percent) and lack of information or evidence on the benefits of green construction (28 percent).

Numerous experts argue that green is a financially sound investment. But while the return on investment on many environmentally oriented initiatives is getting steadily better, Dawn LeBaron, CHFM, a member of ASHE’s sustainability task force, says they remain a hard sell. “Everyone has the best intentions,” says LeBaron, vice president for hospital services at Fletcher Allen Healthcare in Burlington, Vt. “But in the health care area, cost containment is a [particularly] huge issue.”

Green construction can cost anywhere from 1 percent to 7 percent more than using traditional methods, according to various estimates. But such notable organizations as Kaiser Permanente, Oakland, Calif., say the overall costs for a green facility are comparable to those for a conventional facility.

Advocates say the higher initial outlay can be made up over the long term because green hospitals use up to 30 percent less energy and because environmentally friendly designs lead to better patient outcomes and shorter stays.

“The business case for sustainable design shows that green buildings really have lower life-cycle costs, they use less energy, they use less water, they require less maintenance in the selection of green materials and they last longer,” says Joseph Sprague, FAIA, senior vice president and director of health facilities at HKS Inc. in Dallas. He cited lighting, heating, ventilation and variable-volume systems versus constant-volume systems as areas being increasingly addressed through green design.

The initial costs of a building and HVAC system that achieve a 30 percent reduction in annual energy costs can usually be recouped within three to five years, according to Kent W. Peterson, P.E., FASHRAE, who is president of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) and vice president and chief engineer of P2S Engineering Inc., a consulting engineering firm in Long Beach, Calif. Getting the highest potential energy savings may require more effort and collaboration among the design team, he says, touting the benefits of using the integrated building design process.

Terry Townsend, P.E., FASHRAE, says U.S. hospitals could learn a few things from Europe, where sustainability is further along because of pressure to respond to higher costs and the integrated design process. “No longer can the contractor, the architect and the owner work separately,” says Townsend, vice president of Townsend Engineering Inc. in Chattanooga, Tenn. “We have to work together as a team on the design construction startup and operation process. … It’s a way you can control not only construction costs but operation costs.”

Hospitals that have recently undertaken innovative green projects include Memorial Health Care System in Chattanooga, which installed no-wax flooring. Robin Vasa, project manager at Memorial, says increased patient comfort is the chief benefit, but pluses include the elimination of fumes associated with stripping and waxing and swifter placement of patients in rooms since turnaround time to prepare a room for occupancy is much faster.

In another project illustrative of recent advancements, the St. Mary’s/Duluth (Minn.) Clinic Health System consumes 22 percent less energy than ASHRAE standards, water usage was reduced by 52 percent by creating a landscape that does not require irrigation, a green housekeeping program reduces exposure to indoor chemicals, and shielded outdoor light fixtures emit less light pollution.

Elsewhere, the more than 1 million-square-foot C.S. Mott Children’s and Women’s Hospital, under construction in Ann Arbor, Mich., is pursuing the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED®) certification. The green roof’s native grass will provide nearly 100 percent storm water retention, to be used for landscape irrigation, and it saves on energy bills by lowering the building’s heat absorption.

Energy Gains

Energy efficiency has not been the highest of priorities for most hospitals over the years, especially with costs comparatively cheap. That is changing as a result of energy prices soaring dramatically over the past couple of years—currently climbing at about 60 percent a year.

Not only are hospitals the second most energy-intensive building type after food service, Guenther notes, they use twice the energy of commercial office buildings. So the fact that the price rise doesn’t look like a one-time spike has set off alarm bells in executive suites. “Why should we think that energy prices are going to settle down?” she says. “We may be looking back at $150-a-barrel oil in a couple of years and thinking it was cheap.”

The survey found that lower energy costs were, in fact, the No. 1 reason that hospitals pursue environmentally friendly construction and renovation, singled out by 78 percent of respondents. The next four were quality of indoor environment (65 percent), long-term cost benefits/sustainability (59 percent), access to financial incentive programs (47 percent) and because it’s the right thing to do environmentally (46 percent).

“Energy savings are the most easily documentable return on investment that you can have,” says Reed. “The other types of sustainable investments that you might be able to make in materials, in siting construction and in other aspects of what it means to be green are a little less tangible.”

Energy also topped the list of measures undertaken by hospitals recently. Poll participants cited conducting an energy audit as the most common step taken to become more environmentally friendly, at 59 percent, followed by selecting energy-efficient or Energy Star-qualified products for equipment and appliance replacement and/or new purchases (52 percent); promoting environmentally friendly practices among employees, patients and the community (49 percent); purchasing environmentally friendly products (46 percent); and commissioning or retro-commissioning of their facility’s systems (41 percent).

More than half of the respondents said they are using the Green Guide for Health Care (a free, self-certifying toolkit that steers facilities through greener design, construction and operations) or LEED at least on some projects, and most are using Energy Star.

Such programs are all voluntary, and that’s something that should change, according to Douglas Erickson, FASHE, CHFM, HFDP, ASHE’s deputy executive director. ASHE is in the initial stages of developing a sustainability program that will provide more resources to its members and may ultimately establish its own rating system and requirements, Erickson says. “It’s time for ASHE to step up to the plate.”

ASHE President John Wood, CHFM, SASHE, says one of his top priorities is to make sure members are well-informed as to just what “green” and “sustainability” mean and how to get there. Toward that end, ASHE established a sustainability task force this year. “We have been struggling to operate our own buildings in a more green direction, in terms of people not necessarily knowing what to do,” says Wood, director, facilities management, Mercy Medical Center, Roseburg, Ore. “There are a lot of things we can do aside from fitting or retrofitting a building to a LEED standard, in terms of energy conservation, upgrading the finishings of our buildings with products or materials that are more green-oriented.”

Energy Star, a voluntary program that promotes energy benchmarking, identifies best practices and recognizes the nation’s most energy-efficient buildings. Fully 50 percent of survey respondents said they follow Energy Star either often or all the time, using such simple strategies as installing energy-efficient windows and adding motion sensors to control lighting. It has proven effective: Buildings with the Energy Star label use almost 40 percent less energy than average buildings and emit 35 percent less carbon, according to a recent study by CoStar Group, Bethesda, Md.

Both Energy Star and LEED, a program closely synonymous with the term “green building,” have extra appeal during times of economic stress. Eighty hospitals are now among the more than 4,700 buildings across the country that have earned the Energy Star label. “With the rising energy prices and this newfound desire to constructively and cost-effectively address climate change, we’re seeing a lot of our [Energy Star participation] records going through the roof,” Reed says.

The commitment and participation, however, often are not backed by efforts to closely monitor usage and track savings. Asked what improvements have occurred as a result of their hospitals’ pro-environment initiatives, those responding cited a wide array of evidence but scarcely agreed with each other—no single category was named by a majority of hospitals.

Documented energy savings was the top answer with 50 percent, followed by reduced waste/cost (41 percent); improved indoor air quality (34 percent); improved staff satisfaction (32 percent); reduced waste streams (30 percent); improved or extended equipment life (26 percent); improved patient satisfaction (22 percent); improved community relations and documented water savings (19 percent each); and increased savings from green materials or systems (16 percent).

Experts attribute the scattered answers to the difficulties experienced in measuring some gains and an absence of tracking. The responses to a subsequent question appear to back them up. Only 55 percent of respondents said their hospitals measured energy efficiency, 35 percent tracked waste reduction and 28 percent monitored water efficiency.

“Energy consumption and water consumption are probably the two metrics that are most often tracked since they can be validated with energy and water bills,” says ASHRAE’s Peterson. “The industry is beginning to track these other metrics as green building construction becomes more the norm.”

The energy-related findings also encourage another industry executive, Stephen Yurek, who notes that more than half of all respondents said high-efficiency HVAC systems were being installed in their hospitals now or in the next one to two years or already had been installed during the previous two years. “Considering about 40 percent of the energy consumed by buildings is used to power HVAC systems, making sound upgrade decisions based on certified performance ratings is critical to saving energy,” says Yurek, president of the Air-Conditioning, Heating and Refrigeration Institute (AHRI).

On another topic, the survey found that segregating construction and demolition waste is the most common step taken to recycle it (40 percent). Cited next most often were reusing demolition materials (25 percent), requiring the builders to follow LEED requirements (22 percent) and ordering materials with less packaging or contracting to remove packaging (17 percent).

Leadership Crucial

Hospital leaders are seen as a key element in determining green progress. Survey respondents said the primary drivers for green/sustainable efforts in hospital construction and renovation projects are facilities management (75 percent), architect/design team (51 percent), administration (46 percent), environmental services (24 percent) and health and safety department (20 percent).

“The hospitals that have made the strongest commitment to the environment have strong leadership,” says Janet Brown, partner program manager for Practice Greenhealth (formerly Hospitals for a Healthy Environment) in Amherst, Mass. “The leadership has to be on board.”

Leo Gehring, CHFM, FASHE, past president of ASHE, says the rising cost of energy is making it much easier to persuade health care organizations to decide in favor of environmentally friendly options on a hospital construction project. But it’s not all about money, he says, especially as a new generation of leaders emerges.

“What I’m finding is that the senior [management] folks now care but they’re not willing to pay to be more environmentally friendly,” says Gehring, vice chancellor for campus operations at the University of Arkansas for Medical Sciences in Little Rock. “They’re saying, ‘How will this make me money?’ But the next generation is saying it doesn’t matter, it’s just the right thing to do. It’s a much, much easier sell to them to provide a more environmentally friendly construction project.”

If hospitals remain on the fence concerning pursuit of sustainable initiatives on their construction projects, they may want to consider the prospect of an outside mandate to follow some kind of green guidelines. “With the cost of fossil fuels going up at the rate it’s going, there’s probably going to be a regulatory movement to force projects to be more green than in the past, rather than being all voluntary,” says Sprague.

'One Program at a Time'

In the meantime, Brown recommends that hospitals not pursuing LEED standards because of perceived cost reasons might want to take more modest initial steps such as composting their food waste or trying a different kind of flooring material instead.

Among the many tools available to help with such projects, the Green Guide for Health Care can be downloaded for free at http://gghc.org.

“There is no perfectly green hospital out there,” says Brown. “We see pockets of success, and they are growing. Wherever they are in the process, they should be proud if they’re making progress and recognize that the only way to get there is one program at a time. They can’t do it all at once.”

Dave Carpenter is a Chicago-based freelance writer who frequently covers the health care industry. Suzanna Hoppszallern is senior editor of data and research for Health Facilities Management’s sister publication, Hospitals & Health Networks.

This article first appeared in the July 2008 issue of HFM magazine.

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