Hospitals exist to save people, but they can play an important role in saving the planet as well. And in doing so, they may improve their own wellbeing.
Like any business, hospitals contend with the need to control costs, attract loyal customers and comply with regulations while generating customer success stories and maintaining a leadership position. And these factors are driving them to consider sustainable strategies.
“They want to be the place people want to go to have their babies, have their surgeries or get emergency treatment,” said Dee Dee Bonds, associate senior interior designer for HOK’s healthcare practice. To that end, she explained, they want good scores on HCAHPS, a customer rating system that affects everything from marketing to payments. Infection control is an important part of the good outcomes that prompt high scores, and sustainable strategies can help with infection control.
Similarly, they can help contain costs. Bonds pointed to the durability of some greener materials and furniture, for example, while mechanical engineer Tariq Amlani noted the energy savings of equipment such as efficient HVAC and heat pumps. Amlani, LEED AP, is a senior principal with Stantec and serves as the company’s health sector lead for Canada.
“The primary drivers of hospital sustainability are energy costs, carbon costs and peer relationships,” he said, referring to the categorization of hospitals for comparison—urban vs. rural, large vs. small, primary vs. secondary vs. tertiary, etc. Not wanting to be left behind, hospital officials try to keep abreast of what those in their peer group are doing, including any environmentally friendly measures.
When one hospital undertakes a green strategy, others often eventually follow, noted Paulina Czajkowski, LEEP AP BD+C, a Stantec associate who focuses on hospital sustainability. She said when approaching a new project, contractors and others will ask what the best hospitals in their peer group are doing to see what they can emulate.
The experts also note that project teams feel a fiduciary responsibility to investors or government agencies funding the hospitals. That responsibility prompts them to put money to use in ways that are efficient and environmentally responsible, such as specifying low-flow water fixtures and LED lighting. “These are little things hospital administrators may not realize are sustainable, but we as architects and designers are doing it,” Bonds said.
Symptoms of the Problem
Hospitals can be more challenged to go green than their built environment counterparts in other sectors. Clinical requirements often dictate conditions that can be energy intensive.
“If a patient has hypothermia, for instance, the hospital needs to be able to get sufficient heat to them. Or healthcare workers may need to be able to adequately cool a burn victim without using ice,” explained Amlani.
With a hospital’s air purification needs, the personal controls common in hotels won’t do. A centralized system is needed, and that system may need to be heating one area while cooling another. So, hospitals have traditionally been exempt from requirements such as ASHRAE 90.1’s prohibition against heating and cooling at the same time, he said.
In addition to the need for a room or area to maintain an exact temperature, clinical demand can result in other HVAC system requirements. Engineers may be told that a room needs all outside air, or that an area needs 20 air changes per hour. Some of the demands, Amlani said, are not based on scientific evidence, but rather on “the ways things have always been done.”
In contrast, many studies have been performed on the effects of humidity levels on human health, and Amlani believes in investing in energy consumption where needed to ensure the right levels for patients and other occupants.
Another challenge hospitals face in operating sustainably is that their systems often have redundant capacities. Code may require that, and it allows for excessive need in emergency situations. But more redundancy may be added during a project by each responsible party as each adds to the capacity set by the previous party to provide a margin of error.
An auditor may later find that the size of the system is not needed for the facility, or worse, a cooling system may not be designed to run at the low load the facility uses, Amlani explained.
And codes and standards don’t get updated easily. “People are risk-averse,” Amlani said. “They do not want to risk changing a code and then having people die.” So, when more efficient methods of accomplishing mechanical objectives are discovered, they may not necessarily end up replacing more energy-intense methods quickly.
Lack of infrastructure also hinders sustainable operation, Amlani added.
“Eighty percent of all healthcare building stock is existing buildings. A lot of hospitals were built in the ‘80s, and there is no code that makes people change the energy system to be more efficient,” he said.
Most of these older hospitals were built with dual-duct systems. One air handler made hot air, and the other made cold air. The two air streams were then mixed in every room to reach the desired temperature, similar to the way a shower mixes hot and cold water to reach the desired water temperature. The system is not efficient by today’s standards.
The Effect of the Pandemic
The COVID-19 pandemic has affected these challenges in several ways. “Early in the pandemic, energy reduction was not on the table in discussions. It was just about saving lives. We were using every trick in our bag to get the circulation rates we needed with the new situation,” Amlani recalled. “But later, the conversation shifted to: Now that we know we need to operate like this, how do we do it?”
The result of these industry discussions was an ASHRAE Position Document on Infectious Aerosols offering specific mechanical recommendations.
Another effect of the pandemic is increased usage of ultraviolet light. With UV light devices, rooms can be cleaned of germs quickly, said HOK’s Bonds. She also sees more antimicrobial surfaces being used.
Bonds has seen increased demand for anterooms and negatively pressurized rooms. Used to isolate patients with highly contagious airborne illnesses such as tuberculosis, negatively pressurized rooms help contain the germs within the room. (Positively pressurized rooms, on the other hand, prevent particles from adjoining areas from entering the positively pressurized rooms. Operating rooms are positively pressurized, as are rooms for patients with severe immune issues such as stem cell transplant patients.)
While COVID patients were not required to be in negatively pressurized rooms, many hospitals wanted the ability to treat them that way to help contain the virus. “Usually there’s one or two such rooms, but now hospitals want to be able to change out how they’re providing care, so some want 50% or so of the rooms to have that capability,” Bonds said. The capability allows hospitals to use rooms as they normally would, but then quickly ramp up available isolation beds when needed.
Barriers to Improving Environmental Health
It might seem that as technology advances and needs change, hospitals would hasten to upgrade in order to reduce their consumption. “They already acknowledge that they generate the most trash, they have hazardous materials, they use a lot of water, so they are aware of the need to look at ways to reduce this,” said Bonds. But upgrading, too, has its challenges.
“It’s not difficult to upgrade; it’s just expensive,” said Czajkowski. Amlani noted that it can be, in fact, cost-prohibitive to change air handling systems. “Existing facilities have what they needed to meet the coldest day of the year and the hottest day of the year. Now we just use what we need, but for older buildings, it’s very expensive to change the systems.”
The expense in and of itself is not the only hurdle. Bonds noted that siloed budgets hamper upgrade decisions. “Sometimes I try to show how something can save them on maintenance in the years to come and they don’t care because they say there is a separate budget for maintenance,” she said. Sometimes the timing of a project helps, as hospitals may have larger budgets earlier on or, conversely, may be looking for tax write-offs in the final fiscal quarter, she adds.
Infection control issues also can pose a challenge to upgrading, Amlani said. “There might be mold or dust when you open things up, and that can affect infection control. It’s a challenging environment because you can’t just say, ‘Let’s close off this area while we do this.’” A hospital needs to be able to provide the services of each area regardless of project needs.
Surgical Strikes in the Battle to Save the Planet
Strategies to make hospitals greener are multiple and varied. Building rating systems such as LEED and WELL can help hospitals develop comprehensive programs. Here are a few specific strategies suggested by the experts:
Modular construction: Touted as being faster and cheaper, modular construction has been gaining attention for both temporary and permanent healthcare projects. One hospital, for instance, recently had all its bathrooms built off-site and then slid into place on-site, Bonds recalled.
“Others have whole patient rooms built off-site and then brought to the site. Without realizing it, they are becoming sustainable at that point because with the modular systems, everything is done quickly and there is less waste.”
Heat recovery: Simultaneous heating and cooling wastes energy, and hospitals can save energy by recovering heat from the process. Amlani suggested use of either exhaust air heat pump recovery or a heat recovery wheel, depending on the climate. A Stantec research study shows the benefits of these solutions. “We found that with energy recovery, we use less energy at the maximum setting than we use at the minimum setting without the energy recovery. So, it’s possible to operate much better than we have been,” Amlani said.
Good maintenance practices: Keeping things as pristine as possible can help hospitals operate as sustainably as they can with their existing facilities, Bonds noted. “Stay ahead of issues before they become dangerous or unhealthy,” she advised.
ASHRAE audit: The organization outlines three levels of energy audits. Auditors can recommend retrofits, but Amlani cautioned against taking an auditor’s word about the cost of retrofits at face value. “Many auditors lack technical design skills,” he said. Unaware of all implementation requirements, they’ll sometimes inadvertently misrepresent the cost of a solution, he noted. For a clearer picture of the real costs, hospitals can consult an engineer specializing in such solutions.
The Prognosis for Those Implementing Changes
For hospitals that move forward with greener solutions, the rewards can be significant. Experts point to:
Operating cost savings: “We can’t afford not to. The cost to operate inefficiently will be cost-prohibitive,” Amlani said. At the Ottawa Hospital Research Institute, replacement of deep freezers that store items such as vaccines with ones that use 85% less power saved the hospital $20,000 annually.
Marketing advantage: A 2020 JLL report found that 44% of U.S. adult patients surveyed would prefer a provider that possessed environmentally friendly certifications over one that doesn’t. The preference was even higher among those aged 18-34, women, urban dwellers and residents of the western region.
Patient healing: While the results can’t be quantified, products such as materials with minimal offgassing are better for the healing process, Czajkowski said. And studies have suggested that lighting adjusted for patients’ circadian rhythm may produce better outcomes, Bonds added.
Staff retention: Employees feel better about working in environments that feel clean, safe and appropriately lit, Bonds noted. This can be particularly important during medical personnel shortages.
Experts believe two things can grow the greening of hospitals: more scientific evidence of results and more incentive funding. They believe education plays an important role and agree that the sharing of what works helps the entire industry.
“It is up to us as designers and architects to educate the C-suite to support being sustainable,” Bonds said. “Many are starting to think building wellness, but they wonder how much it will cost, how it will affect their HCAHPS scores and how it will affect the bottom line. If they are already educated and swayed, it’s an easier sell because they look at the long-term benefits.”
About the Author:
Jo Rossman, LEED AP ID+C, is the former editor/publisher of Retail Environments magazine.