Health care facility sustainability represents more than energy efficiency in the built environment. It’s also about the wise use of resources. Among other driving factors, sustainability is a function of efficiency, safety and competitiveness in a highly regulated, cost-driven health care marketplace.
Given the challenge to deliver efficient, safe, competitive care in an outdated facility, health care organizations and their architects must be prepared to quantify the desired outcomes and the array of solutions leading to a decision to renovate or to build new. For many institutions, the extension of this process is, “Do we just walk away?”
The issues are complex—and the process of addressing those issues can be daunting—but there are, in fact, methodologies that can be employed toward making the process as objective as possible. Foremost in that course of action is to define “sustainability” and to identify measurable, desired outcomes from a renovation or new construction project.
Measures of success
“The hospital’s clinical and operational priorities come first,” notes Atlanta-based health care finance and marketing consultant, Chris Press, FACHE. In order to achieve a truly sustainable building solution, planners and designers must understand the success measures of their clients.
For health care organizations, those measures can include fewer adverse safety events, financial stability, shorter patient length of stay, decreased expenses, and growth in patient volume. But aren’t those operational measures? Can an architect or an engineer contribute to the desired success?
The answer is not only, “Yes” but also, “They must.” Hospitals designed and constructed for earlier paradigms of patient care, staffing and funding struggle to achieve the aforementioned success measures.
A body of evidence is emerging that confirms that each of the previously noted operational success measures is directly and/or indirectly affected by the physical environment. Design teams can and should play a far greater role in addressing the operational outcomes of their health care clients.
But are those efforts compatible with efforts toward sustainability? Again, the answer is, “Yes.” It’s essential, however, to define the elements of sustainability in order to move forward successfully.
According to the Sustainability Discussion Group of the American Institute of Architects (AIA), “Sustainability envisions the enduring prosperity of all living things” and “Sustainable design creates communities and buildings that advance enduring public and environmental well-being.”
Yet another effort on the part of the AIA, co-published by the Facility Guidelines Institute, is the widely referenced Guidelines for Design and Construction of Health Care Facilities (2006), which identifies the following basic components of sustainable design:
- Site selection and development;
- Waste minimization;
- Water quality and conservation;
- Energy conservation; and
- Indoor air quality.
The U.S. Green Building Council (USGBC) further identifies three broad areas to be addressed:
• Environmental benefits. Enhance and protect ecosystems and biodiversity; improve air and water quality; reduce solid waste; and conserve natural resources.
• Economic benefits. Reduce operating costs; enhance asset value and profits; improve employee productivity and satisfaction; and optimize life-cycle economic performance.
• Health and community benefits. Improve air, thermal and acoustic environments; enhance occupant comfort and health; minimize strain on local infrastructure; and contribute to overall quality of life.
In 2002, the American Society for Healthcare Engineering (ASHE) issued its Green Healthcare Construction Guidance Statement that noted the manner in which building design and construction practice can be shaped to protect health at three scales:
- Protecting the immediate health of building occupants;
- Protecting the health of the surrounding community; and
- Protecting the health of the larger global community and natural resources.
In its Green Healthcare Construction Guidance Statement, ASHE further addressed nearly 100 key strategies for integrating “green” principles into the design process within the following broad areas: integrated design, site design, water, energy, indoor environmental quality, materials and products, construction practices, commissioning, operations and maintenance, and innovation.
Lastly, one measure of sustainability is the carbon footprint. A carbon footprint is a measure of the impact human activities have on the environment in terms of the amount of greenhouse gases produced.
A carbon footprint is made up of the sum of two parts: the direct/primary footprint and the indirect/secondary footprint.
1 / The primary footprint is a measure of direct emissions of carbon dioxide (CO2) from the burning of fossil fuels, including domestic energy consumption and transportation.
2 / The secondary footprint is a measure of the indirect CO2 emissions from the whole life cycle of products used (i.e., emissions associated with the product’s manufacture and eventual breakdown).
Given the depth and breadth of guidance on strategies for sustainability offered by the aforementioned leading organizations, should those strategies not lead to an unequivocal answer to the question of whether to renovate or build new? The harsh reality is that institutions for health care delivery are complex—and so are the answers.
Near and long term
Returning to the earlier view of success measures from the institution’s perspective, strong financial outcomes are imperatives. If, therefore, the single near-term result of a capital project to upgrade existing facilities were least costly, the solution would predict minimal renovation.
And from a sustainability perspective, if one were to focus on the success measures offered above—leading to a minimal carbon footprint—again, the solution would seem to predict a minimal renovation.
But it’s not that simple. If we were to take a long-term perspective and measure those same outcomes, we may arrive at a different answer.
From the perspective of the health care institution, initial capital cost may represent less than 10 percent of a full life-cycle cost—the majority of which is in labor—and only a small minority of which is directly focused on energy consumption.
And from a sustainability perspective, renovations may represent only a temporary Band-Aid, at best, toward achieving long-term reduction in the carbon footprint.
Perhaps the ultimate paradox—and challenge—lies in the well-crafted Green Healthcare Construction Guidance Statement. Of the nearly 100 strategies offered, two specifically recommended reuse and renovation of existing facilities. A cursory review of those strategies, however, could conclude that the primary means to achieve true sustainability is through new construction by a margin of two to one.
How, therefore, do health facility design professionals determine which alternative is best?
Just as it is essential to define institutional success measures and to define sustainability, it is appropriate to define the range of physical solutions to a needed facility upgrade. In the broadest sense, therefore, there are no fewer than five approaches:
• Renovation. Large-scale retention of existing building systems and large-scale replacement of existing building systems.
• New construction. Expansion of an existing facility extending an existing component, expansion of an existing facility replacing an entire existing component, and replacement of an existing facility on a new site.
Importantly, as the chart at the top of page 53 implies, any programmatic predictor of area is location dependent. Depending upon variables including availability of existing space within or adjoining the department to be upgraded and the suitability of the existing space for renovation, the actual square footage involved can vary dramatically.
In the example illustrated in the chart, for a predicted additional need of 500 departmental gross square feet (DGSF), the actual resultant building gross square feet (BGSF) may range from 700 square feet (for an expansion and related infrastructure requirements to extend an existing department) to over 3,000 square feet (for an expansion and related infrastructure requirements to replace an existing department). Notably, in some instances, to build new predictably requires fewer square feet than to expand and renovate—predicting a cascading series of outcomes (in site, building and human terms) that arguably reduce the carbon footprint.
“Some rules of thumb must be altered when considering whether to renovate existing facilities or embark on new construction,” reports Gary Vance of BSA LifeStructures, Indianapolis, in the 2006 issue of the AIA/AAH Academy Journal.
“The old rule of thumb was that expansion of departments into adjacent areas was the most cost-effective alternative,” he says. “The new rule of thumb is that new construction is often the best solution. In fact, new construction occurs in 50 percent of cases involving primary outpatient and ancillary departments and nursing units.”
And, again, it may be helpful to restate the range of institutional measures of success:
- Least initial cost (capital cost only);
- Least long-term cost (capital cost and ongoing operational costs);
- Least time to occupancy;
- Least disruption to existing operations (lost staff efficiency and lost market share);
- Increased patient satisfaction;
- Increased patient and staff safety;
- Increased staff productivity;
- Increased staff and physician recruitment and retention; and
- Increased market share.
Using the aforementioned criteria, it is then possible to evaluate a wide range of options relatively quickly and, importantly, relatively objectively.
Yet another tool available to evaluate these criteria is shown in the bottom graphic on page 53. In this example (which can be downloaded from www.bardwellassociates.com and used as a real-time tool), a series of attributes can be introduced and assigned ranks and weights. Each alternative can then be scored on three planes independently:
- The institution’s stated operational success measures (from above);
- Sustainability goals (with weight assigned); and
- Initial capital cost goals (with weight assigned).
As the example indicates—and as noted earlier in this article—operational goals, sustainability goals and initial capital cost goals may predictably not align. The true value of the exercise, nevertheless, is to promote dialogue, deeper investigation of alternatives and more informed decision-making.
Importantly, this deeper investigation may dispel notions that sustainability initiatives are costly—as evidenced in a recent McGraw Hill survey sponsored by Turner Construction Co., Johns Manville and the U.S. Green Building Council.
The report, based on a survey of 95 health care executives, indicates that many executives perceive sustainable building as costly endeavors without significant return on investment. Paradoxically, more than half of the respondents consider the lack of information about sustainability to be the biggest hurdle in the effort to go green.
Fortunately, however, with each new “green” project, the body of information increases. Notes Columbus, Ohio-based Tom Snearey, AIA, LEED AP, following completion of LEED Platinum candidate, Dell Children’s Hospital in Austin, “We feel, as a result of our experience on Dell, that this can be accomplished at no additional cost to a project.”
And the question of building new or renovating has an added dimension, offers Mike Haemmerle, P.E., LEED AP of Korda/Nemeth Engineering Inc., Columbus. “Generic or ‘universal’ design concepts for new construction can allow flexibility to limit the extent of inevitable future renovations.”
Sustainability as applied to a health care facility is more than the achievement of a “green” building. A truly sustainable solution extends to the long-term measures of success for an institution.
The decision to renovate or build new must address a broad range of characteristics and targeted outcomes—and the answers will be unique to each project and each institution. n
Peter L. Bardwell, FAIA, FACHA, is principal at BARDWELL+associates LLC, Columbus, Ohio. He serves in national leadership positions in the AIA Academy of Architecture for Health and the American College of Healthcare Architects. He can be contacted at email@example.com.
About this series …
“Architecture+Design” is a tutorial published quarterly by Health Facilities Management magazine (www.hfmmagazine.com) in partnership with the American College of Healthcare Architects (www.healtharchitects.org).
This article first appeared in the September 2007 issue of HFM magazine.
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