Integrating environmental principles into the planning, design, construction, and operations of healthcare facilities has shown a direct and indirect impact on human health and wellbeing. As an industry that employs so many Americans and drives such a large percentage of the gross domestic product, activities related to healthcare building greatly affect not only the building occupants and the surrounding community but also those involved in resource harvest and extraction and product manufacturing. As such, there is growing acceptance in the healthcare industry of the need to transform the way that healthcare designs, builds, and operates its facilities, as well as the products used within those facilities.

Implementing this kind of innovation is not without challenges. As The Green Guide for Health Care (GGHC) states:

Healthcare facilities present both a challenge and opportunity in the development and implementation of sustainable design, construction and operations practices. Issues such as 24/7 operations, energy and water use intensity, chemical use, infection control requirements and formidable regulatory requirements can pose significant obstacles to the implementation of currently accepted sustainability protocols (GGHC 2007).

In spite of these issues, or perhaps more because of them, many of The Center for Health Design’s Pebble Partners are designing their facilities with sustainable, eco-friendly practices as a focus. Pebble Partners continue to make ripples and are leading the way to greener healthcare, whether by pursuing a level of certification from LEED or the GGHC, or becoming a member hospital of Health Care Without Harm, Practice Greenhealth, EnergySmart, or the Global Health and Safety Initiative.

Several Pebble Partners-Palomar Pomerado Hospital, Queen of the Valley Hospital, Laguna Honda Hospital, Affinity Health System, Ann & Robert H. Lurie Children’s Hospital of Chicago, Vancouver Island Health Authority’s Royal Jubilee Hospital, Susquehanna Health, Jersey Shore University Medical Center-have identified benefits to building green, including environmental conservation and projected operational savings. In addition, studies show that sustainable design can have a significant impact on patient and staff health and safety. By implementing green design strategies into their building projects to improve safety and documenting their outcomes, these Pebble Partners continue to add to the current body of knowledge, and help make the business case for going green stronger.

Encouraging a healthy lifestyle for patients, their families, and staff is an important aspect of building green. Others include reducing stress and anxiety; alleviating respiratory illnesses from worsening; minimizing risk factors for skin, bladder, lung, and stomach cancers and immune system depression; lessening the adverse impact on the neurological development of fetuses, infants, and children; and lowering the likelihood of microbial growth exposure in which multiple symptoms can occur including eye and skin irritation, fever, and shortness of breath.

From the outset, controlling the pollution from construction activities helps reduce the dispersion of dust and particulate matter that can exacerbate respiratory illnesses (Karol 1991; Raad, Hanna et al. 2002; Qian, Li et al. 2006; EPA 2007). Other strategies that several Pebble Partners are putting into their projects include:

  • metering and monitoring outdoor air intakes and ventilation systems;

  • ensuring 100% outside air is supplied to occupants;

  • selecting low-emitting building materials including paint, carpet, and wood products;

  • choosing specialized exhaust controls and high efficiency air filters;

  • developing an indoor air quality plan;

  • becoming a nonsmoking campus; and

  • surveying patients, staff, and visitors on the building’s heating, cooling, and ventilation performance.

The benefits derived from visual connections to the natural environment such as a reduction in stress and anxiety (Altimier 2004; Sadler 2004; Soderback, Soderstrom et al. 2004; Dijkstra, Pieterse et al. 2006; Levine 2006; Rappe, Kivela et al. 2006; Shepley 2006; Berto 2007) can be enhanced through protecting or restoring health ecosystems. Providing outdoor places of respite have positive health benefits for both patients and staff such as improved wellbeing and other clinical outcomes (Ulrich 1999; Whitehouse, Varni et al. 2001; Hartig and Cooper Marcus 2006; Edwards 2008). Many of the Pebble Partners are incorporating:

  • an open space protection or restoration program to reduce site disturbance;

  • green roofing on low-lying buildings;

  • places of respite such as a healing and/or meditative garden;

  • trees and other plantings that provide natural shading where needed; and

  • direct line of sight to the outdoor environment for patient spaces.

Encouraging the use of bicycles not only contributes to a healthy lifestyle and may be an important contributor to delayed mortality (WHO 2000), but also offsets reliance on motor vehicles. Many Pebble Partners will be providing secure bicycle storage, showers, and changing facilities to promote daily physical activity and alternative modes of transportation. A few Pebble Partners are providing dedicated parking spaces for low-emission and fuel efficient vehicles. In addition, one Pebble Partner is developing a program that incorporates environmental education into the campus through a Get-Well network.

Mercury is a major environmental polluter that is dangerous to the health of patients and staff; prenatal exposure to mercury has been linked to deficits in language, memory, and attention. Eliminating mercury from hospital equipment will not only improve the health of patients and staff, but also the environment as a whole. A number of studies demonstrate the negative effect of mercury on the environment (Guerrier, Weber et al. 1995; Zeitz, Orr et al. 2002; Sattler 2003; Karliner 2007). In the past few years, U.S. hospitals have been striving to eliminate the use of mercury and Pebble Partners are among them. When produced or burned, polyvinyl chloride (PVC) plastic releases dioxins, the most potent synthetic chemicals ever tested, which can cause cancer and harm the immune and reproductive systems. Studies have shown plasticizers such as phthalates have migrated out of PVC consumer products, exposing people to toxic additives linked to reproductive defects and other health problems (Blais 1989; Daschner and Dettenkofer 1997; Uhde, Bednarek et al. 2001; Wienhold 2001; Sattler 2003; Bornehag, Lundgren et al. 2005; Greiner 2006; Tuomainen, Stark et al. 2006). In addition to eliminating mercury and PVC, several Pebble Partners are aiming for:

  • 100% of wood products that are urea-formaldehyde free;

  • 100% of adhesives, sealants, paints, coatings, and carpets that are low-volatile organic compound (VOC);

  • specifying flooring and wallcoverings from natural materials including rubber and cellulose; and

  • engaging environmental services that use green chemicals and low-maintenance materials.

Evidence-based patient and staff health and safety improvements are most effective when they intersect with environmental sustainability efforts. Much work has been done in the last decade to improve both patient and worker safety but there is still more to be done to link these safety issues to environmental health. Pebble Partners, in conjunction with other organizations, are working to build a movement in healthcare that marries safety and sustainability. HD


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The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at


With funding from the Robert Wood Johnson Foundation, The Center has partnered with Health Care Without Harm (HCWH) to author a series of five white papers that addressed sustainability and environmentally responsible practices in healthcare. The papers, which are available for free download from The Center’s Web site, cover the following topics:

  • The Community Benefits of Sustainable Healthcare Construction

  • Healthier Communities: Toward Sustainable Materials Selection Policies

  • Good Neighbors: Environmentally Preferable Community Health Practices

  • Ecological Medicine, Wellness, and the Healthcare Sector

  • An Ecological Health Approach to Food Production, Distribution, and Procurement

Healthcare Design 2009 April;9(4):16-20