In November 2012, Adelante Healthcare, a system of seven federally qualified healthcare facilities serving the Phoenix metropolitan area and surrounding communities, opened the nation’s first LEED-Platinum community health center in Mesa, Ariz. Driven by a commitment to provide sustainable healthcare, Adelante Healthcare sought to understand the impact of LEED certification on the organization by conducting research designed to address gaps within current literature and develop a baseline for further investigation on green building within ambulatory environments.

Adelante’s initial report regarding the investment and implementation of sustainable building practices at Adelante Healthcare Mesa, a Pebble Project facility, was delivered in an educational session at the Healthcare Design Conference, held Nov. 16-19 in Orlando.

Prior research surrounding LEED certification has primarily focused on financial savings related to energy efficiencies and capital cost premiums in office and acute care environments. However, many research papers cite the U.S. Green Building Council definition of green buildings as “ones that have significantly reduced or eliminated negative impacts on the environment and the occupants.”

Unfortunately, the focus on more easily quantifiable measurements, such as water and energy use, provides minimal insight into the indoor environmental quality (IEQ) and its effect on occupants. Alone, this focus isn’t compelling enough for many providers, especially smaller clinic-based healthcare organizations, to commit to the process of attaining third-party certification for green design.

Addressing this narrow view, research conducted in 2013 by Guy Newsham and colleagues, in association with the National Research Council Canada, identified areas in need of further investigation, such as the measurable impact green buildings have on occupant health and well-being, job satisfaction, and satisfaction with the environment for factors including speech privacy, noise, light, access to windows, thermal comfort, and air quality.

A report prepared by the Institute for Innovation in Large Organizations for Practice Greenhealth further suggests the next generation business case should address areas like the economic benefit of staff outcomes that are linked to turnover and recruitment, and the community benefit of improved public perception that can boost philanthropic support for an organization. Doing so, the report states, would create a business case that’s “more persuasive for hospital executives and boards, especially in nonprofits that need to demonstrate community benefit to governmental funding.”

The concept
In response to this, Adelante Healthcare decided to conduct an extended business case focused on what’s often called the triple bottom line, using the factors of people, planet, and profit to create the study’s framework.

However, these factors were then expanded to include outcomes through both direct and indirect measures related to the mission, vision, and goals of the organization in the areas of staff, community, stewardship, and influence.

For the study, Adelante Healthcare decided to compare the Mesa facility to another of its newest outpatient clinics. Adelante Healthcare Surprise opened in December 2011 in Surprise, Ariz., and influenced the design of Mesa, which opened in November 2012.

Both facilities were built using evidence-based design (EBD) principles, such as decentralized nurses’ stations, natural daylight in public areas, the use of art as a positive distraction, and culturally relevant design. They both also offer similar comprehensive services through a medical home model of care.

However, Adelante Healthcare Mesa is unique to the organization in its incorporation of sustainable initiatives to earn a LEED Platinum certification for commercial interiors (LEED CI), through credits associated with accessibility to public transportation, increased daylighting throughout, Energy Star appliances, LED lighting, sustainable heating and cooling strategies, low-VOC materials with increased recycled content, and the use of local materials.

To gain insight into how sustainable initiatives that are represented within LEED certification impact occupant health and well-being, Adelante considered several staff-related outcomes in its study: satisfaction, turnover and absenteeism, engagement, and stress.

Staff satisfaction
To measure staff satisfaction related to the environment, an occupant IEQ survey developed by the Center for the Built Environment (CBE) at the University of California, Berkeley, was distributed to both the Adelante Healthcare Mesa and Surprise sites to measure occupant response to the built environment surrounding satisfaction and perceived productivity over a range of criteria.

This anonymous, Web-based survey was initially developed by CBE to measure thermal comfort and has since been expanded to capture measures in nine subjective IEQ categories for healthcare facilities, including several LEED-related areas like air quality, acoustics, thermal comfort, and lighting (electric and daylight). A comparison of respondent demographics across the two sites showed similarities: mostly female clinicians and other hospital staff of comparable age, experience, and hours worked.

When asked about the LEED CI-related building aspects, such as lighting and air quality, respondents reported higher levels of staff satisfaction at the Mesa LEED facility compared to the Surprise non-LEED facility, with statistically significant differences for lighting. The most dramatic differences were related to daylighting, with 82 percent of the Mesa staff feeling that the building’s daylighting had a positive effect on their ability to do their job (perceived productivity) compared to only 33 percent in Surprise.

This increase in satisfaction for lighting can be partially attributed to the use of sustainable initiatives, such as access to natural daylight to both reduce energy use and promote employee health and wellness. These were more deliberately approached in Mesa through features such as clerestory lighting, natural light in exam rooms, and occupancy sensors.

Thermal comfort for staff in Mesa, however, scored lower than Surprise, likely due to learning curves for both staff and facilities personnel who access the thermostats that regulate the high-efficiency mechanical systems required to achieve LEED Platinum certification.

While not a point category in LEED CI v.3, acoustics and speech privacy constitute two possible points in LEED for Healthcare. These points are now included in LEED CI v.4 in an effort to provide workspaces that promote occupants’ well-being, productivity, and communications through effective acoustic design.

In this study, Mesa outperformed Surprise with statistically significant differences for satisfaction related t
o the acoustical environment through the use of soft-surface flooring, high-performance ceiling tiles, and extensive soffit design at waiting and reception.

The results across all categories led to an overall IEQ satisfaction score in Mesa of 86 percent, compared to a 62 percent satisfaction score in Surprise, a statistically significant difference. As respondents from both sites uniformly agreed on the importance of all environmental categories surveyed, the differences in staff satisfaction suggest some correlation with several of the LEED initiatives to increased overall satisfaction with the IEQ.

Staff engagement
While surveys were used to measure increases in satisfaction and perceived productivity due to the environmental quality associated with sustainable initiatives, direct measures were also considered to gain insight into the impact LEED certification might contribute to employee engagement.

Voluntary and involuntary turnover rates for the first year of operation at the new Mesa facility remained consistent with turnover rates from the prior year at the old facility. However, upon moving to the new facility, Adelante Healthcare Mesa saw a 46 percent decrease in absenteeism from the previous year. Within the same year, Adelante Healthcare Surprise reported a 21 percent increase in turnover and a 29 percent decrease in absenteeism.

Additionally, each year Adelante Healthcare distributes an online employee engagement survey to all employees. Over the last four years, Adelante Healthcare Mesa has consistently had the lowest employee engagement score of all seven sites within the organization, trending a 4 percent increase in employee engagement year over year.

For 2013, the Mesa site reported a 5 percent increase in employee engagement during a year where employees saw their benefit shares increase and their merit pool decrease. These same organizational challenges contributed to a 21 percent decrease in employee engagement at the Surprise facility, an overall spread of a 26 percent difference for the year between the two sites.

These results suggest that the reduced stress on staff and the increased satisfaction with the interior environmental quality of their workspace associated with the features of LEED certification may contribute to how employees cope with challenging organizational issues.

This increased satisfaction and engagement at the Mesa location is aligned with Adelante Healthcare’s belief that “employee engagement is the truest measure of an employee’s commitment to the organization’s mission, vision, and goals,” correlating to a greater commitment to the organization as a whole.

Staff stress
Adelante Healthcare also conducted a survey on staff stress levels. This research leveraged work conducted in 2010 by Carol Kleihauer that compared nurse stress levels in LEED-certified facilities with nurse stress levels found in non-LEED facilities using the Nursing Stress Scale (NSS), a validated 34-question survey developed in 1981 by Pamela Grey-Toft and James Anderson to assess nurse stress within the acute care environment.

Kleihauer’s prior research reported a statistically significant difference between all factors and the overall weighted average for a LEED-certified acute care facility versus that of a non-LEED acute care facility.

The online survey, which was distributed to the nursing staff at the Surprise and Mesa locations, revealed a decrease in staff stress within both facilities of approximately half the stress level of those reported in the prior research associated with non-LEED acute care environments, but didn’t show any statistically significant differences between the stress levels at Surprise and Mesa.

These results suggest an alignment between features associated with LEED certification and EBD principles of access to light and reduced noise levels that correlate to reduced stress levels for nurses. These findings create a baseline for further research to explore the associations between LEED and EBD as they relate to staff stress in outpatient environments.

Advancing the baseline
The advent of healthcare reform has led to an increasing trend to ambulatory care, and a 2009 literature review by Gowri Betrabet and colleagues revealed the paucity of research in ambulatory care environments. Federally qualified health centers serve an even more specialized niche, providing care for underserved populations, and research in these environments is even scarcer.

Adelante Healthcare has committed to sharing its experiences in building new facilities to further the discussion about research and opportunities to advance a baseline understanding within this sector.

The case study initiative was revealing in showing that in addition to typically quantified outcomes such as a 20 percent reduction in energy use over the Surprise facility and a 70 percent decrease in water consumption, the most impactful LEED design components were related to lighting, with improved staff outcomes in satisfaction, turnover, absenteeism, engagement, and stress. Features such as light and acoustics are also typically considered as part of an evidence-based design process, but the focus on LEED certification offered additional incentives to more thoroughly develop these initiatives in the facility design.

Additionally, Adelante Healthcare has embarked on understanding the relationship that LEED certification has on expected energy efficiencies over the building life cycle and what, to date, have been considered the intangible benefits associated with third-party validation.

Adelante Healthcare has done so by evaluating the impact the certification has had on the community through mutually beneficial partnerships, additional patient resources, and influence within the business community. While these may not have a direct correlation to specific design features, the LEED certification has allowed Adelante to align its mission of sustainable healthcare with sustainable design. This alignment has given the organization the opportunity to communicate its story in a different way to a wider range of constituents.

Through the findings of this study, Adelante Healthcare believes that LEED certification has had a both a quantitative and qualitative impact on the organization, especially in regards to creating an environment that has a positive effect on staff health and well-being.

Based on these results and the community-based accomplishments to date, Adelante will continue to develop and renovate sites using LEED certification due to the positive impact the Platinum distinction has had on the organization.


Deborah Wingler, MSD-HHE, EDAC, is the owner of Healing Design Integration (Scottsdale, Ariz.). She can be reached at Ellen Taylor is director of Pebble Projects for The Center for Health Design (Concord, Calif. ). Research for this project was conducted in collaboration with Carol Moore, MSD-HHE, LEED-CI, EDAC.