About this series

This series of tutorial articles is a joint project of the American Society for Healthcare Engineering and Health Facilities Management.

Health care systems understand that sustainability efforts provide multiple benefits, but the challenge in an uncertain economy and regulatory climate is finding the resources and time to invest in such projects.


Returning value through sustainability seems to be more important than ever.

"Hospitals are increasingly moving toward sustainability, which provides real improvements for the environment and furthers the health care industry's goal of creating healthier communities," says Dale Woodin, CHFM, FASHE, executive director of the American Society for Healthcare Engineering (ASHE). "But unless sustainability efforts also can reduce operational costs, they may be short-lived. To ensure that sustainability initiatives are sustainable, they need to deliver value back to their organizations on multiple fronts."

Whether a health care facility is struggling with inefficiency or has a top energy rating, the key is to keep moving forward on the path toward sustainability.

Sustainability drivers

Hospital leaders, like CEOs in other fields, set out on the journey to sustainability for all sorts of reasons. Several surveys, including the United Nations Global Compact survey in 2010, have asked CEOs and other business leaders about factors driving their decisions to invest in sustainability. Some said they want to demonstrate corporate responsibility. Others want to build their reputation or foster a better public image. Some simply want to save money or improve efficiency. Many times there are multiple, overlapping reasons.

Whatever the underlying cause, sustainability efforts should be backed by clear business decisions. This is especially true in health care as hospitals work to make the shift from volume-based to value-based reimbursement.

There are many factors to evaluate when considering sustainability projects beyond any up-front and long-term costs. Projects certainly can provide environmental and community health benefits by reducing the amount of energy and water used or reducing waste produced, which, in turn, also reduces utility bills. Efficiency projects such as commissioning can provide significant returns on investment. Some projects also have the potential to play a role in patient satisfaction. Better regulation of patient room temperatures, for example, can improve patient satisfaction scores, which are becoming more important.

Taking the next steps

Although more and more health care facilities understand the benefits of sustainability projects, finding solutions that work in the real world sometimes can be a challenge.

Laura Brannen, senior sustainability consultant at the engineering firm Mazzetti, San Francisco, says she no longer has to convince health care leaders that sustainability projects provide tangible benefits. "Now the discussion centers on how to get the work done," she says.

Some health care facilities are hiring sustainability managers or coordinators to manage projects, Brannen says, but not every hospital or health care system has created such a position. She predicts that these jobs will become more common in the future, showing growth similar to that of safety officers who handle safety compliance issues.

"One of the barriers facilities face right now is that they don't have someone in charge to coordinate sustainability efforts," Brannen says. "Those positions more than pay for themselves. We're going to look back in 15 years and ask ourselves how we managed all this without a sustainability manager."

Regardless of the resources a facility has available for sustainability, there always are projects that can help a facility become more efficient. Several useful tools exist to help hospitals become more sustainable, including:

Portfolio Manager. One of the first steps in creating better energy efficiency is to understand current energy use through tracking. The Environmental Protection Agency's (EPA's) free Portfolio Manager is a top benchmarking tool for commercial buildings, housing more than 70,000 individual accounts. The EPA's Energy Star program recommends the new Portfolio Manager as an easy way to ramp up energy savings.

Getting a handle on the data is important, Brannen says, because trends quickly emerge when facilities professionals look at data across various buildings in a hospital, across various hospitals in a health system, or across geographic regions. "It's worth the effort," she says of managing the numbers. "Understanding your data will make everything else become clear."

In July, the EPA revamped the Portfolio Manager tool to improve functionality and make collaboration easier through advanced sharing and reporting functions. New custom tabs allow users to plan and set goals on both current and future projects. More information is available at www.energystar.gov/PortfolioManager.

Sustainability Roadmap. The Sustainability Roadmap for Hospitals website at www.sustainabilityroadmap.org is a comprehensive resource devoted specifically to the health care field, which can be helpful since health care facilities are unique environments. This site was created by three professional membership groups of the American Hospital Association — ASHE, the Association for the Healthcare Environment, and the Association for Healthcare Resource & Materials Management.

The Roadmap includes case studies and how-to guides called performance improvement measures (PIMs) on specific projects applicable to health care facilities. Facilities managers can visit the website for instructions on various projects, including how to install variable-frequency drives on pumps and motors, perform economizer maintenance or minimize water use for grounds maintenance [see sidebar this page].

The Roadmap also provides feedback opportunities so hospitals around the country can share what projects have worked for them, and what projects fell short of expectations. Facilities can rank the PIMs, leave comments or submit case studies. By gathering information from the field, the website can become a place to share proven solutions.

ASHE commissioning process. Commissioning new buildings — and retrocommissioning existing buildings — is another important step in improving efficiency. The commissioning process ensures that a facility operates as it is designed to operate. When a facility pays for top-of-the-line, energy-efficient equipment, commissioning ensures that the system performs as intended. This process can be especially valuable in health care facilities, which require specialized systems. Because hospitals operate 24 hours a day and have a vulnerable population, they often require different systems from those of typical commercial buildings and require a commissioning process designed for health care.

In 2010, ASHE published the Health Facility Commissioning Guidelines — the first commissioning guidelines specifically tailored to health care facilities. In 2012, ASHE published a companion book called the Health Facility Commissioning Handbook. This step-by-step guide provides information on implementing the ASHE commissioning process and includes a sample commissioning document. Both publications can be purchased at www.ASHEstore.com.

In addition to the guidelines, ASHE also is offering a course on commissioning, which includes information on how to make the business case for commissioning and how the process returns value to an organization. Information about the class is available at www.ashe.org/learn.

Energy Efficiency Challenge. The Portfolio Manager, Sustainability Roadmap website and commissioning information are all resources hospitals can use to improve their energy performance. Facilities can find some additional motivation through ASHE's Energy Efficiency Challenge (E2C) program.

The program recognizes health care facilities that achieve energy savings of at least 10 percent over a 12-month span [see sidebar, Page 48]. Celebrating successes through the program can help provide a boost to energy programs and reward those working to reduce energy use.

Formerly called the Energy Efficiency Commitment, ASHE's E2C program recently was renamed to reflect more opportunities for competition. Health care facilities can participate in team challenges, modeled after the EPA's Battle of the Buildings.

The E2C recognition program is available to facilities that are tracking data through the EPA's Portfolio Manager. More information is available at www.ashe.org/e2c.

Moving forward

These sustainability resources can help health care facilities professionals provide real savings and efficiencies to their organizations.

"Investing in performance improvement will pay off," Brannen says. "Sustainability is a solution that provides value."

Deanna Martin is senior communications specialist for the American Society for Healthcare Engineering. She can be reached at dmartin@aha.org.

Sidebar - A sample performance improvement project

The following is an edited excerpt of a performance improvement measure (PIM) from the Sustainability Roadmap for Hospitals website:

Variable-frequency drives. Install variable-frequency drives (VFDs), also called variable-speed drives, on HVAC system pumps and motors to enable torque and speed to vary in response to system demand.

Project talking points. The horsepower required to run a motor varies with the cube of its speed, resulting in large energy and cost savings when the motor speed is allowed to modulate in response to demand. In a 1995 report on variable air volume systems, the Environmental Protection Agency estimated that installing VFDs can result in 52 percent average annual energy savings.

The life of building systems equipment can be extended by gradually ramping up pumps and motors when increased capacity is required and by reducing the percentage of time pumps and motors work at full capacity.

Triple bottom-line benefits. Cost benefits include energy savings, and increased equipment life, which also reduces costs significantly; environmental benefits include reducing energy, which decreases the environmental impact of emissions; and social benefits include improvements in thermal comfort control, which can enhance patient and staff experiences.

How-to. The improvements can be implemented by using the following steps:

• Determine the members of the team, including the building engineer, HVAC maintenance personnel and building automation system manager.

• Consult with users who will be affected by the installation or will need to understand and approve procedures to override the system. This may include the manager or director of the area affected by the change, the infection preventionist, the safety officer and the chief operating officer.

• Review energy usage data generated by the facility's building automation system to calculate the variability of the facility's load profile and establish baseline energy use. VFDs generate the highest efficiency benefits in variable load conditions.

• Catalog which pumps and motors should have VFDs installed. Consider equipment such as supply and return fans, booster fans, fan coil units, DX units, exhaust fans, cooling tower fans, liquid coolers, condenser fans, secondary chilled-water pumps, and domestic and hot-water pumps.

• Verify that existing pumps and motors are appropriate for retrofitting a VFD. In general, VFDs function best when installed on high-efficiency equipment.

• Remove inlet guide vanes or remove the actuator, and pin vanes open to avoid counteracting the VFD's modulation of airflow.

• Use a harmonics calculator to identify whether harmonic filters should be installed to prevent filter loading.

• Install and program VFDs to avoid operating equipment in the critical-speed range. (Consult the pump or motor manufacturer for information about optimal speed, vibration and resonance.)

• Sequence control of the VFDs to either run the maximum or minimum number of motors consistent with loads and energy savings.

• Upgrade electrical wiring and controls, if necessary, to modulate fan capacity according to the position of zone dampers.

• Incorporate VFDs in the facility's commissioning program and preventive-maintenance program.

• Assure that areas with specific minimum code-required air exchanges are not adversely affected by implementation of the VFD program.

The Sustainability Roadmap for Hospitals website includes full details on this and other projects, including tools, calculators and case studies.

Sidebar - E2C helps hospitals to lower energy use

Many health care facilities have been recognized by the American Society for Healthcare Engineering (ASHE) through the Energy Efficiency Challenge (E2C) program for lowering energy consumption. These leading facilities and their results include:

• Bethesda North Hospital in Cincinnati reduced energy use by 25 percent.

• St. Elizabeth Edgewood (Ky.) Hospital reduced energy use by 25 percent.

• St. Elizabeth Ft. Thomas (Ky.) Hospital reduced energy use by 10 percent.

• St. Elizabeth Florence (Ky.) Hospital reduced energy use by 10 percent.

• Good Samaritan Hospital in Cincinnati reduced energy use by 30 percent.

• Froedtert Hospital in Wauwatosa, Wis., reduced energy use by 20 percent.

• Middle Tennessee Medical Center in Murfreesboro reduced energy use by 10 percent.

• Saint Thomas West Hospital in Nashville, Tenn., reduced energy use by 15 percent.

• Bon Secours St. Francis Downtown in Greenville, S.C., reduced energy use by 10 percent.

• Memorial Hermann Westside Hospital in Houston reduced energy use by 5 percent.

• Advocate BroMenn Medical Center in Normal, Ill., reduced energy use by 20 percent.

• Advocate Christ Medical Center in Oak Lawn, Ill., reduced energy use by 10 percent.

• Advocate Illinois Masonic Medical Center in Chicago reduced energy use by 20 percent.

• Advocate Lutheran General Hospital in Park Ridge, Ill., reduced energy use by 20 percent.

ASHE also congratulates hospitals recognized in late 2012 and early 2013 for energy savings, including:

• Baptist Hospital in Nashville, Tenn., reduced energy use by 25 percent.

• Texas Children's Hospital–West Tower in Houston reduced energy use by 15 percent.

• Aurora Sheboygan (Wis.) Memorial Medical Center reduced energy use by 15 percent.

• Aurora St. Luke's Medical Center in Milwaukee reduced energy use by 15 percent.