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green@work : Magazine : Back Issues : July/August 2006 : Building

Greening the Environment of Care
Willingness to embrace sustainable design and evidence-based design is essential in enhancing healthcare facilities and the care of their patients.

by Bruce Maine

No architect or engineer has ever worked on a healthcare project without consulting the American Institute of Architects (AIA) Guidelines for Design and Construction of Hospital and Healthcare Facilities. The guidelines, originally published in 1947, are referenced by architects, engineers and healthcare professionals worldwide who are planning new or renovated healthcare construction. Authorities in 42 states, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and several federal agencies use the guidelines as a reference code or standard when reviewing healthcare facilities’ construction plans. The guidelines are currently in the midst of a revision cycle, in which the AIA revisions committee accepts and scrutinizes public comments for possible inclusion.

I decided to take advantage of this opportunity to submit my comments on sustainability. When I began defining which of these modest issues I wanted to address, I assumed most would fall under Article 7.28—General Standards for Details and Finishes. My recommendations typically dealt with minimum Volatile Organic Compound (VOC) requirements for paints, sealants, adhesives, carpeting and wall coverings. I recommended prohibitions against antimicrobials, Perfluorooctanoic Acids (PFOAs) and Polybrominated Diphenyl Ethers (PBDEs). Additionally, I included language to help contractors coordinate air quality during construction programs with Infection Control Risk Assessment (ICRA) requirements.

In the 1996-1997 guidelines, paragraph 7.28.B5 reads, “... Wall finishes shall be washable. In the vicinity of plumbing fixtures, wall finishes shall be smooth and water-resistant.” This would have been the appropriate place to insert language that restricted VOC content and still met the washable and water-resistant criteria. However, the process has not proven as seamless or transparent as I had hoped; the revisions committee all but segregated comments to the guidelines’ Chapter 2.

So, off to Chapter 2. In the 1996-1997 Guidelines, Chapter 2 is titled, “Energy Conservation.” It is characterized by a brief article that addresses the importance of energy conservation and alludes to “planning of mechanical and electrical systems and design for energy conservation that does not adversely affect patient health, safety or accepted personal comfort levels.” In the 2001 guidelines, Chapter 2’s title was changed to “Environment of Care.” While the language referencing energy issues is unchanged, the appendix at the bottom of the page notes, “... For access to research on the effects of the built environment on health outcomes and related information, contact the Center for Health Design.”

The Center for Health Design
So, what is the Center for Health Design (CHD)? What does it do? And what does it have to do with greening the guidelines?

The CHD is a research and advocacy organization of healthcare and design professionals whose mission is to improve healthcare quality through building architecture and design. In 1993, the CHD first initiated an effort to heighten these professionals’ awareness of the built environment’s positive effects on health and well-being. In 1998, these efforts influenced a series of recommendations to JCAHO to modify the “Management of the Environment of Care Guidelines.” As a result, key elements and issues related to improving the built environment’s quality were incorporated into JCAHO’s 2003 standards.

For the 2006 revision cycle, the CHD submitted a draft to the AIA. The goal was to create a chapter outlining the environmental factors that contribute to patient, staff and family satisfaction—along with increased safety, fewer medical errors and a better financial bottom line. These key elements and issues are:

• People—facility and service users
• Systems
• Layouts/Operational Planning
• Implementation
• Physical Environment

Within the physical environment, the CHD deemed the following elements essential to an environment that supports the intended delivery of care model:

• Light and views: Use and availability of natural light, illumination and views shall be considered in the design.

• Clarity of access (wayfinding): Clarity of access shall be addressed in the overall facility plan, individual departments and clinical areas.

• Control of environment: Patient, resident and staff ability to control their environment shall be addressed in the overall facility plan. This must be consistent with the functional program.

• Finishes: The effect of materials, colors, textures and patterns on patients, residents, staff and visitors shall be considered in the overall facility plan and design. Maintenance and performance shall also be considered when selecting these items.

• Cultural responsiveness: The culture of patients, residents, staff and visitors shall be considered in the overall facility plan.

• Sustainability

Finally, the six elements of sustainable design were identified as:

• Site selection and development
• Waste minimization
• Water quality and conservation
• Energy conservation
• Indoor air quality
• Impact of selected building materials

Language in the proposed new “Environment of Care” chapter further acknowledges sustainable design. “(A) growing body of knowledge is available to assist design professionals and healthcare organizations,” it observes, “in understanding how buildings affect human health, how they affect the environment, and how these effects can be mitigated through a variety of strategies.” The chapter references Leadership in Energy and Environmental Design (LEED) and the Green Guide for Health Care (GGHC), suggesting they should be utilized as “best practices” design and operations tools. The document further suggests that in order to meet specific objectives identified in this chapter, “healthcare organizations should develop an integrated design process to guide facility design.”

Sustainable design and Evidence-based Design
A result of aging hospitals, aging baby boomers and new technologies, the United States faces one of its largest healthcare building booms in history. In 2004, the federal government spent more than $16 billion on new hospital construction; by 2010, it expects annual capital expenditures of $25 billion on healthcare facilities. Total healthcare spending may exceed $3 trillion by 2012. Thus, the architecture that can best serve the healthcare industry should be influenced by those who understand the link between the built environment and the healing environment.

Many of the CHD-recommended strategies are a direct result of the concept of evidence-based design. This is a philosophy used to create environments that are therapeutic, supportive of family involvement, efficient for staff performance and restorative for workers under stress. Evidence-based design, not unlike sustainable design, appeals to those who seek to maximize quality of life. Their designs are based on practical evidence, from a multitude of resources, which derives from a general quality-of-life experience. Evidence-based design, used as a template to design healthcare facilities, can improve both the quality of healthcare and healthcare facilities’ built environment.

Evidence-based design research is divided into five areas:

Access to Nature. This area focuses on human response to indoor plants and gardens, outdoor gardens, views of nature (both artificial and real), and natural light.

Control. This area focuses on patient options and choice, access to privacy and wayfinding. Research on hospitalized patients, as well as hospital employees and workplaces, has demonstrated that a sense of control is important to people’s feelings of self-esteem and security. Lack of control can lead to results such as depression, passivity, elevated blood pressure and reduced immune function.

Positive Distractions. Nature, water, play areas, art, music, etc. provide a moderate level of positive stimulation and foster a sense of engagement and well-being.

Social Support. This area includes support for family members and cultural sensitivity. Healing environments provide space and structure for social interaction. Environmental psychologists researching healthcare and workplace situations have found that individuals with much social support experience less stress and greater wellness.

Environmental Stressors. This area encompasses research on noise, light levels and indoor air quality. Environmental elements can increase stress if their disturbance is difficult to minimize. A patient who is awakened by the hospital paging system, for instance, or has his/her sleep disturbed by employees talking in the hallway is likely to experience negative stress.

The introduction to the GGHC notes that as the “healthcare sector develops a design language for high-performance healing environments, it has the opportunity to highlight the associated health-based benefits.” Certainly part of that “design language” is evidence-based design, because it originates within the institutional framework of modern healthcare without relying on anecdotal data from other, non-healthcare building sectors.

In fact, the five elements of evidence-based design constitute inherently sustainable design goals in general, and the GGHC specifically. The other factor that enhances the GGHC’s credibility is the acknowledgement that operations and maintenance protocols are critical to maintaining healthcare facilities’ health and environmental profile. As part of the GGHC’s operations section, for example, design teams are encouraged to collaborate with facility staff to evaluate the impact of protocols such as pollution prevention, chemical management and water conservation.

The fact shouldn’t be dismissed that LEED is too constraining to be used for a project that meets all construction criteria for a hospital facility. Of the more than 1,600 buildings currently registered in the LEED program, only 49 are healthcare buildings. The Boulder Community Foothills Hospital in Boulder, Colo., and the Providence Newberg Medical Center in Newberg, Ore., are the only certified hospital projects, although some healthcare facilities, such as the Discovery Center, have received certification. But Joe Howard, facilities director at Boulder Community Foothills, insists, “You don’t have to give up anything for a LEED rating.” What is required more than anything to achieve a successful project is integrated design—a critical element in sustainable design, required in the GGHC, and inherent in evidence-based design.

Looking to the Future
Because healthcare is so regulated, it has been assumed that any fundamental change would be tediously slow, since multi-layered organizations tend to resist change on both institutional and personal levels. Certainly, the challenges to green healthcare building are much more significant than in other building sectors. However, the merits of resources available to designers, practitioners, administrators and builders in the healthcare industry are much more genuine. The fundamental value of any healthcare facility is its capacity to enhance those elements crucial to a healing environment and demonstrate that the maxim “do no harm” might be replaced by a more positive dictate of “do great good.” Our willingness to embrace sustainable design and evidence-based design as essential tools will ultimately be the energy toward greening the environment of care.

Bruce Maine is research director of sustainable design services at HDR Architecture, Inc., and can be reached at

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