With the advent of the 21st century, health care experienced a surge in design and construction with a new focus on a holistic healing environment. This was far different from simply providing basic space needs, as was the case during the health care building boom following World War II.

With interest in green building, some of these initial health care projects pushed the healing environment envelope by applying the early releases of the U.S. Green Building Council's (USGBC's) Leadership in Energy and Environmental Design for New Construction (LEED-NC) rating system and a few projects were able to achieve silver and even gold recognition.

But designers and health care administrators quickly realized health care facilities posed unique challenges (see sidebar on page 48) to LEED-NC and that performance metrics specific to health care were missing from the LEED toolkit.

Health care focus

With a growing focus on green health care design, the American Society for Healthcare Engineering (ASHE) convened a green building task force in late 2001 to develop guidance criteria for the ASHE Vista Awards committee to use in assessing project award applicants.

The ASHE "Green Healthcare Construction Guidance Statement" was released by the task force in January 2002 and introduced three basic principles for assessment:

  • Protecting the immediate health of building occupants;
  • Protecting the health of the surrounding community;
  • Protecting the health of the larger global community and natural resources.

With an added sense of urgency, architects, engineers and health care administrators advocated that the time had come to develop a specific green building tool to guide the next decade of health care facility design.

In March 2003, a professionally and geographically diverse group of green health care industry leaders convened as an independent steering committee by the Center for Maximum Potential Building Systems and Health Care Without Harm with initial funding from the Merck Family Fund.

Because development of a LEED tool customized for health care was not forecast to begin by USGBC until 2005, the committee recognized its task as development of a best practice guide to jump-start the process toward a health care-oriented green building tool.

The work of the committee became known as the Green Guide for Health Care (GGHC) or, as it's sometimes called, the Green Guide. This was released in a draft for public comment in December 2003. After input from 114 pilot projects and numerous public comments, GGHC version 2.2 was released in January 2007.

Although the Green Guide is not a product of the USGBC, the committee realized it could influence future USGBC development of a health care-rating tool. From the committee's inception, a liaison from USGBC staff was a valuable member of the steering committee. This relationship helped to forge an agreement that the GGHC could borrow the organizational structure from the USGBC's LEED rating system, which already was familiar, effectively in use, and understood in the design and construction community.

Many credits in the GGHC directly incorporated language from parallel LEED credits from the family of LEED rating systems; other LEED credits were modified to respond to the unique demands of health care facilities.

With the LEED structure and credits to inform the GGHC, the underlying principles of the ASHE Green Healthcare Construction Guidance Statement focused the committee's content on protecting and enhancing individual and community health. Unique to the GGHC was a statement for each credit of health issues.

The GGHC's intent was to provide the health care community with a free, voluntary, self-certifying metric toolkit of best practices to inform and guide users in evaluating their progress toward high-performance healing environments. It was neither intended to establish regulatory requirements, nor to be viewed as a minimum standard of design, construction or operations. Nor was the document intended to meet the strict definition of a consensus-based standard.

As the popularity of LEED-NC continued to evolve, and seeing the increased activity in the educational and health care facilities markets, the USGBC accelerated its focus on developing rating systems to serve those building types. In January 2004, the USGBC board appointed six members to the newly formed core committee of the LEED Application Guide for Healthcare Facilities (later to be known as LEED for Healthcare or LEED-HC); seven additional committee members were elected from the corresponding committee membership.

Adhering to an approved development cycle that guides all LEED rating systems, the committee began the demanding task of crafting a rating system addressing the unique demands of health care while maintaining close alignment to LEED-NC.

This monumental task was streamlined by the two-year relationship between the USGBC and the GGHC and would be further accelerated over the next few years by this close collaboration. Eight of the core committee members were also GGHC steering committee members, which augmented the committee's efficiency.

The GGHC also served as the foundational document for evolving the health care-specific rating system. The USGBC board of directors further approved the use of the GGHC pilot projects to inform the rating systems development, making it possible to bypass the much more lengthy pilot process that is required of each LEED rating system.

Under the unique framework of the LEED family of rating systems, a number of issues added pressure to development of LEED-HC. Maintaining a consistent point total across rating systems evolved into new approaches to credit options since GGHC contained many more credits than LEED-NC and did not provide achievement-level threshold rankings unique to LEED.

Credit development was impacted further by the LEED version 2009 move to a 100-point scale and credit weighting. A pilot credit library also was established after the first round of LEED-HC public comments to further refine and test certain credits, pioneered in GGHC, before full inclusion into the rating system.

Operational language also was removed from the credit framework of the foundation document since LEED-HC is intended strictly for new construction and major renovations. Overall, six prerequisites and 25 credits were modified and three prerequisites and 15 credits were added to the rating system.

After addressing thousands of comments during three public comment periods, in addition to review and input from the LEED Steering Committee and the Technical Advisory Groups (TAGs), LEED-HC was balloted by the membership, receiving an 87 percent approval rate. Culmination of the LEED-HC development was announced April 8 at the CleanMed conference in Phoenix. Shortly thereafter, the full complement of collateral materials, including reference guide and LEED online letter templates, were introduced.

Sustainable projects abound

As GGHC and LEED-HC evolved during the decade, health care institutions and project teams struck a balance between known established practices and emerging concepts, applying the rating systems and guidelines in facility design and construction across the country.

By 2010, more than 600 health care projects had been registered with more than 125 achieving various levels of LEED certification. Currently, according to the USGBC database, 21 projects have been registered under the LEED-HC version 2009. However, because health care projects take several years to complete, it may be a while before any of those projects achieve certification under LEED-HC.

Projects currently registered under LEED-NC version 2009 have until December 31 to move registration to LEED for Healthcare version 2009 at no additional cost. Projects registered under previous versions of LEED can upgrade to LEED for Healthcare by paying a registration fee. Starting on January 1, 2012, projects that meet the requirements outlined in the "Rating System Selection Guidance" must use LEED for Healthcare.

Generally, those are projects where medical treatment is administered, including licensed and federal inpatient or outpatient care facilities, and long-term care facilities. But LEED-HC also can be applied to other medical-related facilities at the discretion of the project team.

With the launch of the GGHC and the health care industry's drive toward more sustainable facilities, the GGHC and USGBC entered into a formal agreement in December 2007 to help further green the health care industry by fostering best practices and ensuring the industry has the tools and resources it needs to build green. This agreement established that USGBC would administer the LEED-HC certification process and that GGHC would continue to act as a change agent and tool developer to empower continued growth of sustainable health care facilities.

In this supporting role, GGHC in collaboration with Practice Greenhealth has conducted a series of educational green design and construction webinars, authored technical briefs and launched an expanded version of the GGHC version 2.2 Operations. Because LEED-HC only applies to new construction or major renovations, the GGHC operations guide offers health care administrators a tool tailored to the day-to-day operations and maintenance issues unique to health care projects.

After a decade of leadership in advancing green building practices for health care, the GGHC will conclude its mission at the end of 2011. The operations pilot program will be finalized and the webinar series will be concluded in June. The www.gghc.org website will be retained as an archival holder of the GGHC's publications and resources.

GGHC and LEED impacts

The development of GGHC and LEED-HC have had far-reaching impacts beyond the bounds of health care. Many of the credit categories and formatting of GGHC and LEED-HC have influenced the next generation of LEED version 2012 rating systems expected to be released in November 2012.

The rigorous materials evaluation requirements introduced in GGHC and later in LEED-HC with regard to persistent bioaccumulative toxic chemicals are appearing in a proposed new credit for LEED version 2012. Additionally, a whole new category — Integrative Process — has been added to LEED version 2012, a credit type first introduced in GGHC and LEED-HC to promote an integrated design process. Moreover, the bundling or combining of credits of a similar nature, first presented in GGHC and later in LEED-HC, is now seen in several LEED version 2012 credits such as MR4 Environmentally Preferable Non-Structural Products and Materials and EQ2 Low-Emitting Interiors.

GGHC's emphasis on human health has established connections between health care choices in construction and operations and the impacts those choices may have on human health. This same focus has accelerated market transformation toward a richer palette of methods and materials informed by health-related outcomes influencing construction product manufacturers to reformulate products with an increased focus on health care-specific issues such as infection control, indoor air quality and toxicity.

The issues addressed in GGHC and LEED-HC have influenced adoption of human health and environmental criteria in the Facility Guidelines Institute's Guidelines for Design and Construction of Health Care Facilities and other standards focused on the healing environment.

Evolution to continue

The evolution of green health care will continue to advance these bold initiatives under the capable guidance of USGBC and the inaugural LEED-HC.

The efforts of these projects will further the goals of waste reduction, toxic chemical reduction, carbon neutrality and water conservation — qualities necessary for 21st-century health care.

Greg L. Roberts, FAIA, FCSI, ACHA, LEED AP BD+C, is a principal and specifications manager with WHR Architects, Houston. He served on the steering committee of the GGHC and the core committee of LEED-HC. Roberts can be reached at groberts@whrarchitects.com.

Sidebar - A brief history of green building

Publication of Rachel Carson's Silent Spring in 1962 and the 1973 oil crisis are credited widely with launching environmental thinking and energy conservation in U.S. building design.

Concurrently, concerned architects and designers at the 1972 American Institute of Architects (AIA) convention in Houston set the stage to form the AIA energy committee. The committee evolved into the Committee On The Environment (COTE), which introduced one of the first environmental references for designers, The Environmental Resource Guide, in 1992. Frustrated by the slow pace of AIA to advocate a strong environmental design policy for the profession, many of these early environmental pioneers gathered in the Washington, D.C., offices of AIA in April 1993, together with others of a similar mind, to lay the foundation for the U.S. Green Building Council (USGBC).

Following the oil crisis, a number of architects and designers had implemented projects with solar design features and other forms of energy conservation, along with reused building materials, but there had not been a comprehensive or holistic definition of what constituted a green or sustainable building.

Launched in August 1998, the USGBC developed a framework and metrics to measure and define green buildings known as Leadership in Energy and Environmental Design (LEED) version 1.0.

Following a pilot program in which 12 projects were recognized for their implementation of the rating system, LEED for New Construction (LEED-NC) version 2.0 was released in March 2000, incorporating the lessons learned from the pilot projects. Amended versions of LEED-NC together with LEED for Existing Buildings and LEED for Commercial Interiors soon followed.

The LEED family of rating tools initially was focused on transforming the design and construction practices of the largest portfolio of U.S. building types — commercial buildings. As the use and implementation of LEED-NC became accepted in the market, the USGBC planned to launch other specific building-type rating systems, including one for health care.


Sidebar - Barriers to green health facilities

As guardians of the community's health status, health care facilities face significant obstacles in the implementation of sustainability protocols. They include the following:

  • System redundancy — Secondary and tertiary backup systems are required to ensure operation during emer­gencies.
  • Regulatory compliance — Facilities face demanding and overlapping health and safety regulations and building codes.
  • Operational hours — Health facilities function 24 hours a day, seven days a week and 365 days a year.
  • Infection control — Preventing health care-asso­ciated infections often runs counter to many green protocols.
  • Ventilation rates — Hospital air change rates can be 1.5 to 3 times greater than commercial office space.
  • Accreditation and licensing demands — Facilities must comply with federal, state and association regulations and standards.
  • Intense energy and water use — Health care uses 2.1 times more energy per square foot than commercial buildings, and hospitals typically use 80-150 gallons of water per bed per day.
  • High-volume waste stream — Health care sends 6,600 tons of solid waste each day to landfills.
  • Chemical use — Hazardous chemicals are used to clean and disinfect; sterilize equipment; treat certain diseases; and for laboratory
    research and testing.
  • Patient privacy — It is necessary to protect individuals' medical records and other personal health information.
  • Life cycle — Health facilities are normally owner-occupied and durably designed for long-term use; conversely interior space plans typically have a high "churn" rate.

As demonstrated by the Green Guide for Health Care and the U.S. Green Building Council's Leadership in Energy and Environmental Design for Healthcare programs, however, these barriers can be overcome.