In the past several years, architects have made significant progress in the development of healthcare facilities that incorporate sustainable design principles and initiatives. Without question, tremendous future opportunities exist for sensitive designers and enlightened facility owners. This is particularly evident when considering the entire range of physical design and operational re-engineering opportunities available in the development of next-generation healthcare facilities.

Despite this progress, the challenges inherent in future sustainable development are great. Healthcare facilities differ from their commercial counterparts in numerous ways. Hos-pitals are the fourth highest consumer of energy of all building types, accounting for 10 to 15% of all commercial consumption and totaling more than $3 billion per year. The healthcare industry also contributes 5 million tons of solid waste annually to the nation’s landfills. Hospitals must function at high performance levels 24 hours per day, seven days per week. Energy demands include not only emergency and uninterrupted power requirements, but also the assurance of “clean” electricity for optimal performance of diagnostic and therapeutic equipment. Clinical demands may require both heating and cooling throughout the year, frequently in adjacent functional spaces. Finish materials must perform to very high expectations, either from a safety or maintenance perspective.

In spite of the challenges and obstacles to “greening” healthcare facilities, recent successes have been significant. Principles of sustainable site placement (particularly the redevelopment of brownfield sites), ensuring convenient availability of transit systems, and providing ready access to natural surroundings and settings have been readily accepted from both “healing” and conservation-of-resources perspectives. Water- and energy-efficient building concepts and systems have also been incorporated into healthcare design, including high-tech building control systems and energy-efficient building envelopes. The development of cogeneration facilities for hospitals has also significantly reduced the cost of purchased power.

From an operational perspective, newly developed materials-management concepts align demand and supply availability for numerous patient and facility supplies. These concepts have drastically reduced redundancy and waste, while increasing the financial operating position of the hospital in an increasingly competitive marketplace. Within the context of nursing and supply decentralization, this has decreased the demand for, and size of, supply-storage and materials-handling rooms, while increasing caregiver efficiency and patient satisfaction. This, combined with today’s decrease in average length of patient stay, allows more volume to be served in smaller and more efficient facilities.

Improved materials-supply models have also reduced the size of medical and hazardous-waste-handling systems and have decreased the demand for landfill volume and waste incineration. Recycling programs and the growing trend toward purchasing reusable goods further reduce the waste stream. Specifically, from a materials and resources perspective, next-generation hospitals have accepted and implemented methods to reduce the use of PVC products (IV bags, waste containers, etc.) during construction and treatment.

The availability of independently certified Environmentally Preferable Products (EPPs), such as DuPont Antron® carpet fiber,*

The authors’ firm, Hellmuth Obata Kassabaum (HOK), is a DuPont Antron Sustainability Advisory Council member.

is helping healthcare facilities meet performance and sustainability expectations. EPPs are certified to have a reduced effect on human health and the environment when compared to competing products. To achieve this certification, products are evaluated on performance; total environmental impact of manufacturing; use of green energy during manufacturing; protection of health, safety, and the environment; and end-of-product-life responsibility. By specifying durable, long-lasting products, facilities also reduce the need for their replacement, creating less environmental waste and reducing life-cycle costs.

Specific hospitals have made significant progress toward sustainable design. For example, at Evansville State Hospital in Indiana, a range of sustainability initiatives has been adopted to conserve resources and improve the patient experience. Evansville State has emphasized renovating existing facilities instead of opting for all-new construction, thus reducing the waste and energy utilization involved in demolition.

Most patient rooms at Evansville State provide views to the exterior and offer operable windows. Natural lighting is provided through clerestory windows at all of the nurses’ stations and through an elongated skylight over the therapeutic “treatment mall,” which encompasses clinical treatment areas and patient activity spaces, including classrooms, a greenhouse, a library, and a game room.

Retention ponds are located on-site to control water waste and help reduce run-off problems affecting the adjacent residential neighborhood. In addition, in the development of the site, particular care was taken to avoid removing existing trees and vegetation.

The Evansville State project features a high-performance product called autoclaved aerated concrete (AAC). Manufactured using fly ash as a primary ingredient, AAC provides excellent thermal and acoustic properties. The fly ash is a by-product of coal burned in power plants to produce electricity. AAC provides a very tight building envelope, reducing the amount of pressurized air required to offset natural air infiltration. When completed later this year, the hospital will be the largest AAC project of its kind in the country.

In spite of the progress that has been made, there is much room for more. The challenge of bal-ancing first-cost with life-cycle cost savings is a key in considering sustainable initiatives, especially given the magnitude of the first costs we face in the hospital design field. As any healthcare designer can readily attest, individual unit construction costs (approaching $400 per square foot in surgical suites) are significant design parameters that must be optimized. Program requirements, given the myriad of clinical programs required, are also very high. Within this context, it is understandable that the most enthusiastic acceptance of sustainable initiatives has been experienced within the less acute healthcare settings, such as administration or public spaces, long-term or skilled nursing care, and medical office buildings.

The most apprehensive acceptance of sustainable initiatives seems to come from facilities characterized by a very high level of acuity and usage. Nevertheless, we must continue to strive to support our hospital-based clients, to the fullest extent possible, with design solutions that are consistent with significant budget constraints and unique program requirements. Life-cycle cost savings can be significant, however, and the continuing challenge for owners and their design consultants will be to think long term about this, especially since they will likely occupy their facilities for 30 to 40 years. Most recognize the long-term reduction in operating costs, materials used, and energy consumption that can be achieved with sustainable design. Many acknowledge the benefits of a proactive approach to pending environmental regulations, as well. Looking ahead, as evidence-based research evolves, we will likely be able to better quantify the value associated with diminishing building-related health risks, as well as the intrinsic value that sustainable environments offer in attracting and retaining staff. HD

Jens Mammen is a senior associate, and Paul Strohm is a senior vice-president of Hellmuth Obata Kassabaum’s (HOK) Health Care Group.

For further information, contact Mammen at (312) 782-1000 or; contact Strohm at (314) 421-2000 or; or visit

Healthcare Design 2003 May;3(2):12-14