Green Health-Care Buildings

April 1, 2008
Editor's note: Following is the third in a series of excerpts from The Green Building Revolution, the latest book by Jerry Yudelson, PE, MBA, LEED AP,

Editor's note: Following is the third in a series of excerpts from “The Green Building Revolution,” the latest book by Jerry Yudelson, PE, MBA, LEED AP, who will serve as keynote speaker for HPAC Engineering's fifth annual Engineering Green Buildings (EGB) Conference and Expo Oct. 21 and 22 at Mandalay Bay Resort and Casino in Las Vegas. To register, visit Those who register by April 15 will receive a complimentary copy of “The Green Building Revolution.”Following is the third in a series of excerpts from “The Green Building Revolution,” the latest book by Jerry Yudelson, PE, MBA, LEED AP, who will serve as keynote speaker for HPAC Engineering's fifth annual Engineering Green Buildings (EGB) Conference and Expo Oct. 21 and 22 at Mandalay Bay Resort and Casino in Las Vegas. To register, visit Those who register by April 15 will receive a complimentary copy of “The Green Building Revolution.”

The business case for health care is different than that for other projects. For one thing, about 76 percent of private, or nongovernmental, hospitals (employing 83 percent of health-care workers) are nonprofit organizations, which means that the profit motive is less imperative and that access to capital for new projects is more difficult. Many hospitals are affiliated with universities and serve teaching and research functions that require accommodation in each project. Of the total number of hospitals, government hospitals represent about 20 percent, private nonprofits 60 percent, and private for-profits 20 percent.

(The “Drivers for Green Buildings and Operations” sidebar) shows some of the business-case drivers for green buildings (and green operations) in health care. The primary driver for health care, as for most large institutions, is money — specifically, the return on energy-savings investments. Favorable community public relations come in second.

The rest of the business-case benefits are slowly gaining acceptance, particularly among the more progressive institutions. Some of the possible business-case benefits, such as recruiting and retaining nurses and other key staff, while more accepted in other building types, are still seen as speculative advantages of green health-care facilities.

What will it take to get green buildings into the health-care design and operations system? First of all, chief executive officers (CEOs) must push sustainability to the top of the agenda. The opportunities for cost savings and positive community relations are often the primary drivers from a top executive's point of view. Second, the facilities staff and project-management staff need to be fully educated about green design and operations. Third, the organization must contain an internal champion for sustainability, preferably reporting directly to the CEO or chief operations or finance officer. Fourth, each project must start with a vision for sustainability, something that the design, construction, and operations team can keep returning to when the project starts to devolve into something more “familiar.”


The world of health-care design changes slowly, but it is changing. Robin Guenther (principal of a commercial-architect design firm) says, “I think there's a huge driver in the mission connection. People can talk about having to make the economic argument for which strategies they do or don't do. But what really brings them in the door is getting the connection between the built environment and human health, and recognizing that they can't go on being part of the problem, that they have to reconceptualize around this connection between mission and health. Over and over again, that's what the CEOs of the innovators say: ‘It's the right thing to do. As soon as we heard about it, we had to do it because we are in the health-care industry.’”

This transformation of attitudes among CEOs and boards of directors is critical to promoting green buildings in the health-care industry. When top management makes the connection between the hospital's or clinic's mission and the healing power of green buildings, they often become the most effective advocates for sustainable design and operations. Kim Shinn, a mechanical engineer who works on a lot of health-care projects in the Southeast, echoes this sentiment: “A couple of our health-care-system clients are getting enthused about green construction, having us do projects that are both “Green Guide for Health Care”-compliant and Leadership in Energy and Environmental Design- (LEED-) compliant. We have even had a couple of our projects that were well into design go green as a result of boardroom directives — health-care systems are realizing and committing to green building as a part of their mission of, ‘First, do no harm.’”

Walter Vernon leads an engineering firm in San Francisco focused on health-care design. He thinks the time may be right for the health-care industry to apply green principles. He argues for use of the term “greener” design, recognizing that the real task is to improve what we already have in health care, rather than to replace it outright. He argues that, “Good green design has to support the goals of the organization.”

One of his recommendations is to take advantage of utility rebates and transferable tax credits, as well as third-party financing options for cogeneration, solar, and microturbine systems. Because hospitals are round-the-clock operations with a fairly predictable demand for electricity and hot water or steam, they are attractive to third-party “energy-service companies,” which invest in energy-saving measures and on-site generation, sharing the savings with the hospitals. Vernon concludes that in the end, “Resistance to green design approaches may be more about culture than technology.”


“I think evidence-based design is the most significant design trend that has happened in the hospital-design business in my career — in the past 30 years,” says Kim Shinn. “It is truly a watershed opportunity to change the way that health-care facilities are designed. Green design is very much a part of evidence-based design, because many of the design practices that we think of as green design are associated with healthy indoor environmental quality. That's exactly the question asked by evidence-based design: How much can the building environment positively affect health-care outcomes?”

(The “Barriers to Green Buildings in Health Care” sidebar) presents some of the barriers to green health-care design, construction, and operations. The restrictive environment of health-care design is certainly a major factor: The need to prevent and control disease and to meet stringent building-code requirements drives a lot of design decisions.

But the primary barrier is still cost. In 2005, green-building activists at a major Midwestern university called me asking for help in advising their new $500 million hospital on the benefits of green building and LEED certification.

The design team had already quoted a price increase of 10 percent ($50 million) to green the building. I knew this was way out of line, and I also knew that the design team was saying to the activists and the university: “Don't bother me with this green stuff. I've got enough on my plate just trying to build a hospital.”

Jerry Yudelson, PE, MBA, LEED AP, is principal of Yudelson Associates. Chair of the 2008 Greenbuild International Conference and Expo, he has trained more than 3,300 building-industry professionals on the LEED rating system. He is the author of six books and many research studies, white papers, and articles on green buildings. He can be contacted through his Website,

Copyright © 2008 by Island Press. Excerpted by permission of Island Press. All rights reserved. No part of the preceding excerpt may be reproduced or reprinted without permission in writing from the publisher.

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  1. Drivers for Green Buildings and Operations

    Economic return on energy- and water-efficiency investments; protection against future increases in energy prices through peak-shaving and other demand reduction measures.

  2. Barriers to Green Buildings in Health Care

    Consistency with the health and healing mission of health-care institutions — for example, designing healthier buildings for patients and staff.

  3. Economic gain from faster healing (and quicker discharge) of patients who have views of the outdoors and healing gardens on premises.

  4. Public-relations benefits, considering the many stakeholders in the hospital and health-care universe.

  5. Health benefits to the workforce from use of less-toxic chemicals in facility management.

  6. Recruitment and retention of key employees (nurses and other skilled practitioners).

  7. Evidence-based health care should be seen in evidence-based green buildings.

  1. The LEED rating system is difficult to apply in health care because it was designed primarily for office buildings.

  2. The health-care industry is highly regulated and risk-averse. As a result, innovations must meet many tests before being adopted.

  3. Initial cost is the driving force for all decisions. It is difficult to make a case for investing extra money in operations vs. patient treatment and staff compensation, for example.

  4. LEED is perceived to add significant costs to projects.

  5. Evidence of benefits such as productivity and healthier working conditions is inadequate.

  6. Health-care building codes restrict options such as natural ventilation and underfloor air-distribution systems because of their focus on disease prevention.

  7. Long lead times for project design and construction, together with cost escalations in materials and labor, make it difficult to keep a focus on green design decisions.

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