Healthy Hospitals Q&A
For the Greener Good
How can green design make hospitals healthier?
On March 23, 2009, experts on public health and hospital design spoke at the National Building Museum as part of the For the Greener Good lecture series. The presentation, titled "Healthy Hospitals", featured Bob Eisenman, executive director of the Global Health and Safety Initiative; Robin Guenther, an architect and co-author of Sustainable Healthcare Architecture; Roger S. Ulrich, Ph.D., director of the Center for Health Systems and Design at Texas A&M University; and moderator Joanne Silberner, health policy correspondent for NPR. The panelists discussed a wide range of issues, including the reasons hospitals are such large energy consumers, how eco-friendly design can improve both patient health and staff morale, what health care reform might mean for the future of health care facilities, and why hospitals have a unique potential to influence greener and healthier living throughout their surrounding communities.
After the program, the panelists answered selected questions from audience members and online visitors submitted through an online Q&A Forum. Here are the answers:
Q: Hospitals—particularly older ones—have historically been large consumers of energy to heat/cool outside air. What research, testing, and code changes are anticipated to improve air filtration such that engineers can design more energy efficient recirculating air systems?
Bob Eisenman: I don't know about air filtration per se. However, there is some existing work being done on displacement ventilation, which could result in considerable energy saving and better infection control; also, interesting work [is being done] on natural ventilation and more energy efficient medical equipment. Hospitals are also benefiting from energy audits, commissioning, and recommissioning—i.e. tuning energy systems and making sure hospital engineering staff are trained in using and maintaining the latest energy components and systems.
Robin Guenther: First, I agree with Bob's remark that the ongoing research on displacement ventilation systems—a system widely used in Europe—has enormous potential to save energy while providing equal or better thermal comfort and air quality. Many new hospitals are installing 100% outside air systems (Providence Newberg, the first LEED Gold hospital, is an example of this) to eliminate any real or perceived air quality issues with recirculated air—given concerns about rising energy costs, these are now coupled with heat recovery technology. Heat recovery technologies have been restricted by high installation costs in an era of cheap energy, but that is now changing. Finally, research and development of high performance building envelope technologies (both wall and glazing) are beginning to impact the construction marketplace. These high performance facades allow teams to eliminate perimeter radiation systems.
Q: What role would in-home health care services (for older people, the chronically ill, and/or in case of emergencies) play in creating "healthier and greener" health care? Do you believe it could have a significant impact and is there interest in such services?
Bob Eisenman: There is already significant interest and efforts towards providing care and services in the home. In-home health care and services could have a significant impact if the volume of such services becomes great enough. If you think of health in the broadest sense, keeping people healthy and preventing illnesses and accidents in the first place has the biggest payoff.
Robin Guenther: In-home health care services have a significant role in reducing transportation, as well as large-scale development impacts inherent in our current system of health care service delivery. As we move to more home computer and Internet technologies, data transmission, video links, and communication between provider and patients at home will improve—the necessary ingredients to fuel this transformation. Kaiser Permanente has done successful trials of "virtual visits" with primary care physicians; the inclusion of medical care in retail settings is a further example of a trend to allow health care professionals to work from home and patients to travel less. We will need to be mindful of waste disposal practices—from pharmaceuticals to clinical supplies—to mitigate the impacts of this shift, but it will be increasingly possible to do.
Q: Much of the discussion seemed to center on creation of new hospitals and other treatment facilities, but my question has to do with the possibility of retrofitting existing hospitals with some of the features described. What changes can be most easily and effectively made to older buildings?
Robin Guenther: Many of the strategies we discussed are relevant to existing buildings. One of the key aspects of greening hospital campuses is addressing the concern associated with a new building that is "green and healthy" on a campus with older structures. Many hospitals are addressing this by implementing a series of campus-wide operational initiatives that are applied alongside of, or in advance of, opening a green building or addition. These initiatives include strategies such as implementing green cleaning protocols, recycling programs, etc. See the operations section of the Green Guide for Health Care for more than 110 strategies for existing buildings. Many hospitals are undertaking interior finish standards development—selecting greener flooring, paints, and cabinet components that can be used in all ongoing renovation projects—in order to bring existing buildings along the path. Finally, ongoing energy efficiency programs continue to gain ground. Gunderson Lutheran's pledge to be carbon neutral by 2014 is being implemented across existing campuses in three states; the Clinton Climate Initiative is focusing on retrofitting of existing building stock in urban areas—we are likely to see increased focus on these efforts in public policy.
Bob Eisenman: It really depends on the specific building. If you are talking about improving energy efficiency, improvements often include lighting retrofits, variable frequency drives, LED exit signs, lighting controls, and HVAC controls. Recommissioning, combined with needed repairs and maintenance, usually has the fastest payback. Many other changes and improvements are possible if and when a building is retrofitted. And there is the whole area of safer and greener products and goods used in healthcare—all of which could be adapted to existing buildings.
Q: Given our aging population and the increasingly serious and complicated illnesses you discussed, it seems clear we will need to build more hospitals in the coming years, and hopefully they will be more green than not, but do we have enough architects and builders and equipment providers and so forth with the necessary know-how to create green hospitals? Are there certain regions or specialties where we lack the expertise to make these kinds of facilities a reality?
Robin Guenther: What a great question! Certainly, interest in sustainable building is not uniform in all regions of the country and experience matters. I have seen a tremendous shift in interest and experience in the last 10 years, but there is a formidable learning curve. It is extremely difficult to innovate in health care, given the perceived risks, liability, and structure of the health care architectural services marketplace. Moreover, the underlying contractual and fee structures of service delivery do not necessarily support the level of innovation, research, and study implied in many of these technologies. Sustainable design remains the territory of leaders who are willing to take some risk and co-learn with their design teams. However, that is changing every day, as more regions incentivize and legislate green building, and the health care design community increases its experience and understanding. As of this month, there are 41 LEED certified health care projects and more than 540 registered project. Only six months ago, the registered number was 360. Six months ago, the certified project list was dominated by 16 projects in the Great Lakes region, while the Southeast had only two.
On the matter of equipment, we desperately need major medical equipment manufacturers to participate in EnergyStar—major diagnostic equipment operates 24/7 with tremendous electrical consumption and associated heat generation. This is a huge area of innovation and improvement—just look at the progress made by the elevator companies in developing technologies that harness energy generated through braking systems to reduce energy consumption by 90%. As an industry, we need to push our equipment vendors to weigh energy use as an important factor in emerging equipment design.
Bob Eisenman: Creating greener and healthier hospitals is really about utilizing a body of knowledge. The evidence about what to do is growing and we have enough professionals to adopt the approaches. Whether or not we will need more hospitals depends on the extent we make decisions and implement plans and policies that protect and promote the health of the population.
Q: This was touched on somewhat tangentially during the forum, but I'm curious to hear more about your thoughts on the obesity epidemic in this country—both how it is affecting health, and on how healthy hospitals might have an effect by modeling better eating, exercise, etc in their communities.
Bob Eisenman: There are good examples of hospitals hosting farmers markets, serving local, healthier, and sometimes organic food and many efforts at promoting exercise. These are all good and the right thing to do. However, obesity, lack of exercise, stress and a number of other factors affecting health represent broader social policy issue than just hospitals. Hospitals can be good examples, but it will take a larger social effort to significantly improve the health of the population.
Robin Guenther: There is no question that the built environment plays a significant role in the US obesity epidemic. Sedentary behavior and car dependence, coupled with an industrialized food system, are major issues. Hospitals have not traditionally engaged in the debate about sprawl—they have participated in the suburban expansion of cities and towns by engaging in the quest for low-cost real estate at urban edges—moving to the intersections of major arterial highways, without much awareness of how their presence, as major employers and public destinations, supports sprawl.
The good news is that change is in the air. First, hospitals are realizing that their presence, traffic, and 24-hour employment patterns are good foundations for expanding public transportation options in communities. New hospitals are, in many instances, making site decisions to remain in urban areas rather than moving to suburban zones—UPMC's Children’s Hospital and Dell Children’s Medical Center of Central Texas, the first LEED Platinum hospital, are examples of this.
The New York City Department of Health recently received a LEED Innovation Point on an urban clinic project for a very innovative Physical Activity Credit, where the project team placed stairs more prominently than elevators, finished the stairs to the quality level of the corridors, and made additional measures to model a higher level of physical activity within the facility and engage in community education on healthy eating and weight management.
Hospitals that are signing the Healthy Food in Health Care pledge are sending signals that non-therapeutic use of antibiotics in livestock and hormones in dairy products are no longer acceptable purchasing practices. Hospitals that encourage farmers markets on site and serve organic food (as major food purchasers) signal the market and use their downstream influence to impact purchasing behaviors.
Watch the video of the "Healthy Hospitals" For the Greener Good program.
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For the Greener Good lecture series is presented by The Home Depot Foundation. The Museum's online Q&A Forums are made possible by a grant from the U.S. Institute of Museum and Library Services. |
