By nature of their function, healthcare facilities are intensive energy users, spending approximately $5.3 billion on energy costs per year. Given this massive level of expenditures, combined with the unrelenting and rapidly escalating costs of energy, there is a significant opportunity to benefit from making healthcare facilities less energy consumptive — particularly through the use of use Leadership in Energy and Environmental Design (LEED) design criteria.

However, given the primary mission of healthcare facilities, the challenge is this: Every design consideration must first be weighed against their potential impact on patient care — and compromises are not acceptable.

The unique needs of healthcare facilities make them ideal candidates for seeing the health-enhancing and cost-reducing results of sustainable design. Photos courtesy of Brigham and Women’s Hospital.

In May of 2008, the Brigham and Women’s Hospital (BWH) Carl J. and Ruth Shapiro Cardiovascular Center, a 440,000-square-foot state-of-the-art tertiary care facility, opened in Boston. In its ten above-grade levels and three below-grade levels, the facility houses 136 private patient rooms (40 intensive care beds and 96 regular inpatient beds) and 16 operating rooms (robotic surgery and image-guided surgery rooms) as well as outpatient facilities, clinical and research laboratories, and imaging rooms.

BWH sought to continue to advance patient care by centralizing all of its cardiovascular care and by increasing the number of operating rooms by 50 percent. With the new facility, all the related clinical services are now in a single location, thereby streamlining the patient experience. Patients can go to one facility to see their doctor, to receive treatments, and for both inpatient and outpatient operations. From a clinical care perspective, all supporting staff is now in a centralized facility.

From the initial design concept, BWH also sought to create a sustainable clinical environment and reduce site energy consumption. BWH registered the Shapiro Cardiovascular Center for LEED in early 2004, making BWH one of the early adopters of LEED in healthcare.

Environmental Health & Engineering, Inc. (EH&E) was selected as the LEED agent on the project.

Facing the Challenges

While the number of healthcare facilities registering for LEED certification is growing significantly today, healthcare facilities present unique challenges that had not yet been addressed in the LEED rating systems at the time of this project. (A separate LEED healthcare rating system is under development that will specifically address the issues for construction and operation of healthcare facilities.)

Those unique challenges were evident in the BWH project. Some of the unique characteristics and challenges posed by the Shapiro Cardiovascular Center (and generally shared by many acute care institutions) include the 24 hours/day, 7 days/week operations of the intensive care rooms and operating rooms; the intensive energy consumption demanded throughout the facility by the imaging equipment, medical equipment cooling and conditioned space needs; issues relating to infection control, including immuno-compromised patients and standard policies; the requirement for redundant energy supplies; and external community concerns ranging from traffic, construction, lighting, and air quality.

Photo courtesy of Brigham and Women’s Hospital.

As the LEED agent, EH&E’s biggest challenge was to determine how to best achieve the LEED goals while maintaining the aggressive construction schedule and clinical goals. The EH&E project team found a holistic approach was the best strategy — view the building and internal activities as a system and not just bricks and mortar. This approach allowed the EH&E team to better identify opportunities for improved performance. The team also identified several processes as key to bringing the project to success.

One of the first processes, identifying and engaging stakeholders early, was a critical initial step since implementing LEED in this building type is definitely a collaborative process. At BWH, the stakeholders included: patients (inpatient, ambulatory, visitors); staff (clinical, operations, support staff); local community (immediate neighbors and the City of Boston); various regulators; and the global community.

The early engagement of stakeholders allowed EH&E to identify several opportunities. BWH conducted a study asking nurse managers what factors would improve their responsibilities and patient care. Nurses identified indoor air quality (IAQ), acoustical noise, ventilation and natural lighting. All represent potential components of LEED design, and by placing a premium on these focus areas in the final design we found strong support during subsequent evaluation meetings and improved stakeholder engagement.

In terms of the other processes, all members of the project team had to agree on performance metrics. In addition, the team worked to identify potential opportunities. This included identifying areas where green building and green design can improve factors deemed crucial to hospital function, such as improved health outcomes, improved level of patient care, higher patient satisfaction, improved infection control and required emissions. All the potential initiatives or products were rated against these factors, life-cycle costs were calculated, and those rated highly were relatively easy to justify in the final design.

Coordinating and tracking initiatives within the project required a truly data-intensive process. The EH&E team incorporated the use of a Web-based project management and collaboration platform (constructed using Microsoft Office SharePoint) to create a centralized portal that facilitated communication among the stakeholders and design team as well as a task-tracking mechanism to ensure the project remained on schedule. The team found this software coordination tool crucial to ensuring team members could access timely information as needed and help maintain the construction schedule. This also provided a constantly updated repository of information that significantly improved the preparation of lead submittals.

Implementing the Green

Input from staffing led to a maximized amount of daylighting in interior spaces, including patient rooms. Photo courtesy of Brigham and Women’s Hospital.

Based on the processes described thus far, proposed initiatives were analyzed, and those found to meet the design/clinical impact criteria were integrated into the Shapiro Cardiovascular Center.

For example, BWH had previously implemented a stringent low volatile organic compounds (VOC) policy. This is also a key LEED credit and resulted in the focus on low-VOC emitting products throughout the hospital. During the required pre-occupancy air quality testing of the facility, VOC levels were found at levels far below those typically found in similar facilities — easily meeting LEED requirements and resulting in a point of pride for the hospital.

The lessons learned at BWH has helped others in their goal of introducing sustainability to healthcare. Photo courtesy of Brigham and Women’s Hospital.

In another example, nurse manager input resulted in a maximized amount of natural light to interior spaces, including patient rooms. Surveys of patients and staff confirmed a high level of satisfaction with the lighting quality while saving the hospital significant costs in lighting as well as improving caregivers’ visual communication with patients.

Innovative design points were obtained in the area of materials and resources. In this case, the hospital implemented a program that resulted in 95 percent of construction waste being recycled. Six homes on the construction site were relocated to vacant lots in the neighborhood. This provided much-needed housing for low- to moderate-income families, helped maintain the fabric of the neighborhood, and improved community relations by continuing to show the level of commitment BWH has to its neighbors.

Two other design factors were successful in achieving additional green benefits for both the facility and the community. One, addressing the various negative issues of personal transportation (pollution, congestion, noise, etc.), included the decision not to add any new parking to the facility. Instead, BWH leveraged the location and maximized the use of public transportation and shuttle buses. A sky bridge was constructed over the main roadway to further reduce congestion and improve safety. The other addressed the issue of development density. Here, the design called for three stories of the Shapiro Cardiovascular Center to be constructed underground and to connect with BWH’s existing campus buildings. The end result reduced the building’s height and created a structure that is more in scale with the surrounding neighborhood community.

Conclusion

Based on the experience with the Shapiro Cardiovascular Center, EH&E finds the approach to implementing LEED in healthcare different from other types of buildings in several key areas. First, it is extremely important to identify and engage key stakeholders early and to fully understand the processes and critical needs of each group as they relate to patient care in order to select the proper LEED credits for further in-depth review. Second, although the Shapiro Cardiovascular Center achieved a 20 percent reduction in energy usage, there are limits to what can reasonably be achieved at this time. This requires that the entire team be vigilant in identifying other areas in which sustainable goals can be incorporated into the new construction. Finally, LEED implementation must be approached in smaller steps due to the number of stakeholders and the deliberate way that they must evaluate “new” concepts or initiatives. However, once convinced of the validity of these as an asset to patient care they are rapidly accepted into new projects with the hospital.

Sidebar: Carl J. and Ruth Shapiro Cardiovascular Center

Location: Boston

Size: 440,000 square feet

Opened: May 2008


Selected Green Products Summary

Roof: Sarnafil EnergySmart ENERGY STAR-rated roof. This roofing material has high reflectivity and high emissivity, which results in cooler surface temperatures in the summer. This reduces the urban heat-island effect and the cooling load of the building.

Paint: Sherwin-Williams “GreenSure” designated interior paint meets the Green Seal 11 criteria for volatile organic compounds in paints.

Carpet: InterfaceFlor Veneer GlasBac Carpet Tile with 40 percent post-industrial recycled content and meets the CRI Green Label Plus low-VOC criteria.

Adhesives and Sealants: All products meet the South Coast Air Quality Management District (SCAQMD) Rule #1168.

Gypsum Wall Board: U.S. Gypsum with 5.6 percent post-consumer, 94 percent post-industrial recycled content, manufactured 300 miles away and extracted 450 miles away.