State of Sustainable Design in Healthcare

A commentary

Douglas D Pierce

Douglas D Pierce

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Robin Guenther

Robin Guenther

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Robin Guenther designs and advocates at the intersection of healthcare architecture and sustainable policy. She is Senior Advisor to Health Care Without Harm and co-authored Sustainable Healthcare Architecture and Primary Protection: Enhancing Health Care Resilience for a Changing Climate available from US Department of Health and Human Services at toolkit. climate. gov.

A more transformative vision of ‘living’ and ‘regenerative’ hospital buildings is beginning to coalesce worldwide. Primarily, this vision finds its roots in the connection between buildings and health.

The buildings that support the delivery of healthcare services encompass a broad range of building types—ranging from small community outpatient clinics to large acute care hospitals—and an equally broad range of owners—philanthropic non-profits to corporate entities. Globally, healthcare is a significant service economy—while the percentage of the Gross Domestic Product (GDP) varies widely between nations, there is general agreement that the healthcare sector has the capacity to define markets through what they build, purchase and how they operate.

The US healthcare building sector is making explicit links between the built environment and health. The American Society of Healthcare Engineering (ASHE) framed green building initiatives as early as 2002 around protecting health at three scales: the immediate health of building occupants, health of the surrounding community, and health of the larger global community and natural resources. The Green Guide for Health Care, in defining green strategies for the healthcare sector, includes specific ‘health issue’ statements that introduce each construction and operation topic—the Green Guide is the foundation for the US Green Building Council’s LEED for Healthcare. Providence Health and Services CEO John Koster, MD, in describing their new LEED® Gold Certified hospital in Newberg, Oregon, summed it up this way: “In healthcare, sustainable building represents a bold move toward precaution and prevention. The building stands for health. In creating it, the organisation is essentially saying, ‘We’re investing in keeping people healthier.’ Being attentive to sustainability, wellness and resource stewardship presents a holistic view of healthcare that has an impact. We may not be able to measure or test, but I’m convinced it has a tremendous impact on a person’s ability to attain health. Not just to be not sick, but to be in health” (Guenther and Vittori, 2007).

Beginning with operations, healthcare organisations globally are moving towards total elimination of mercury and implementation of Environmentally Preferable Purchasing (EPP). EPP practices prioritise less-toxic cleaners and disinfectants, phthalate-free medical devices, elimination of flame retardants and formaldehyde in furniture and casework, and solvents in labs. Waste reduction efforts combine non-incineration technologies for regulated medical waste disposal with substitution of mercury-containing devices and PVC plastics. Healthcare Without Harm is a global campaign assisting healthcare organisations in this important work.

State of the industry
Many healthcare organisations in the US have begun environmental stewardship programme by focussing on operations and then have moved into sustainable building. The US healthcare built environment is highly developed—at the time of writing this article, it is the second most energy-intensive US building sector (consuming energy at an average of twice the intensity of commercial office buildings). Acute care hospitals drive this excessive consumption, although they represent only 25 per cent of the total area of healthcare buildings. The average age of a US hospital building is 27 years—for the most part, the hospital infrastructure is completely mechanically conditioned, and is characterised by deep floor plate, non-daylit diagnostic and treatment blocks, with little regard to orientation or passive system design. These buildings operate continuously, 365 days per year, with multiple back-up and redundant mechanical and electrical systems, and only increase in energy intensity as medical diagnostic equipment with large heat loads continue to enter the market place.

In 1996, a comparative study of energy consumption between hospitals in Europe and North America revealed that North American buildings operate at approximately twice the energy intensity of their European counterparts. While the study did not look at system differences, the most important ones are obvious: European hospitals require daylight in all occupied spaces, leading to enclosed courtyard planning in lieu of deep floor plates. Nursing units continue to be naturally or passively conditioned, and when mechanical conditioning is installed, the prevalent system is displacement ventilation (which introduces air at the floor rather than the ceiling). As the US healthcare market seeks ways to reduce energy consumption, the examples of European healthcare buildings, as well as leading sustainable buildings in other regions, provide important ‘best practices.’

Since the introduction of the Green Guide for Health Care and the US Green Building Council’s LEED® programme, the more than 340 healthcare buildings have registered and more than 30 have certified. This year, in a survey conducted by Health Facilities Management and ASHE, more than 50 per cent of the 600 respondents indicated they were using the Green Guide or LEED on some of their projects. The first LEED®-Platinum medical office building, Oregon Health and Science University’s Center for Health and Healing, opened in 2006, and the first LEED-Platinum hospital is anticipated to receive certification this year. Collectively, the first 30 projects have reported energy demand reductions ranging from 15 to 30 per cent, potable water reductions in the range of 30 per cent, successful integration of local and regional materials palettes alongside a host of environmentally preferable material choices, and report improved indoor air quality through enhanced ventilation and occupant controls, low-emitting materials, and an increased focus on connection to nature (often through the integration of outdoor places of respite, or healing gardens). While the majority of LEED-certified projects are new constructions, a number of major renovations or adaptive reuse projects have achieved certification. These early adopters have reported limited capital cost ‘premiums’ associated with their green building achievements. For many, the basic design parameters of total mechanical conditioning and deep floor plates remain unchallenged—only those that are achieving Platinum appear to have optimised passive design elements and floor plate depth.

What lies ahead
A more transformative vision of ‘living’ and ‘regenerative’ hospital buildings is beginning to coalesce worldwide. Primarily, this vision finds its roots in the connection between buildings and health that opened this article. Practically, it is manifested in a small group of projects globally, including the Sambhavna Clinic in Bhopal, India and Embassy Medical Center in Sri Lanka (profiled here). It is informed by The Living Building Challenge, a framework developed by the Cascadia Green Building Council in the US , and Health Care Without Harm, a global non-profit that has taken up the challenge of transforming healthcare infrastructure from today’s standard practice to zero-energy, toxic-free, zero-waste, water-balanced solutions. The long-awaited LEED® for Healthcare, with increased focus on daylighting, material health, and energy demand reduction, will assist hospitals in North America in beginning the journey to this transformation.

The healthcare sector should not need to argue that delivering high quality healthcare requires a passport for waste and energy intensity—or that saving lives is somehow outside of broader ecosystems and ecological concerns. The authors of Sustainable Healthcare Architecture conclude, “By critically reinventing the hospital as a regenerative place of healing, marshalling purchasing power, and modelling health and wellness ... the healthcare industry can signal a new relationship to healing and health.” Through green construction and operations initiatives, hospitals can demonstrate a broad commitment to more than high quality patient care. They can demonstrate a commitment to save lives and improve health without undermining ecosystems or diminishing the world.

Embassy Medical Center
Healing institutions have a core mission to regenerate the health of those they serve. ‘Living’ or ‘Regenerative’ hospital design builds from that mission to include nurturing the environment and people in ways that extend deep into the community. Social equity, environment, economics and education are the four chambers of regenerative design and they are much like threads in a piece of cloth, woven together into a uniform fabric that becomes an inseparable whole.

Waste management at embassy medical center

The Embassy Medical Center is taking the next step in design consciousness to become a regenerative influence in the city of Colombo, Sri Lanka. The Hospital will synthesise knowledge and perspectives from around the world, merging local needs, customs and bioregional influences with appropriate technologies and global financing to form a balanced union of regional and global connectivity.

Much of Sri Lanka’s population is challenged to meet their basic daily needs, making the project’s regenerative goals extensive. The project will create a state-of-the-art hospital and healing centre in an environmentally distressed urban area; to serve effectively a broad population of varying economic means; to act as a regional economic incubator; to educate its own staff and the technical trades that assist in their design and construction; to be a self-maintaining place of community refuge; and to provide all of their own power, water, sewage and medical waste recycling in ways that are beneficial to the environment and the surrounding neighborhood.

Few things are as regenerative to individual and community health as access to clean water. In 2007, the World Health Organization (WHO) reported that there are 4 billion cases of diarrheal disease and 1.8 million deaths each year globally from unsafe water and hygiene. Thus, one regenerative thread at the heart of the Embassy project is to act as a ‘clean water center,’ providing sewage treatment and potable water to several of Colombo’s underdeveloped neighborhoods.

The medical centre will use living roofs to capture and pre-filter rainwater. A reverse osmosis system, coupled with carbon and ultra-violet filters, will purify the rainwater for use in the hospital and distribution to underdeveloped neighborhoods. Water from showers and lavatories will be filtered through constructed wetlands and ultra violet filters for use in flushing toilets.

Another essential clean water strategy involves converting sewage from the hospital and Colombo’s underdeveloped neighborhoods into carbon-neutral renewable energy using a high-temperature thermophilic anaerobic digester. Used in Western European cities, this hi-tech compost system will naturally create bio-methane that will be polished into Bio-Natural Gas (BNG). The BNG is then used in a co-generation plant to power the hospital and water purification systems. Excess BNG will be generated by the hospital and used to seed the transformation of Colombo’s transportation sector to this clean burning fuel, improving the respiratory health of the community and ultimately providing an improved environment for the medical centre itself.

Sustainability Concept for Energy, Water and Sewage

Water and energy efficiency are essential to the project as it is more cost-effective to conserve resources than to produce them. Water efficient toilets and lavatories will be used throughout the facility where appropriate. To improve energy efficiency and patient health, narrow floor plates, courtyards and light shafts will be used to harvest daylight and natural ventilation.

This facility will also be the first of its kind to consider high sea flooding, Tsunami, earthquake and other catastrophic issues. The facility is being designed to withstand the forces of nature and remain open and functioning during a natural disaster—not only to provide medical care for patients but to provide refuge for the community.
Of course, providing regenerative care for patients will be a key to the facilities’ success. The Embassy Medical Center will contain 180 private patient rooms as well as full-service operational medical support with a comprehensive outpatient medical clinic. The facility will include advanced medical innovations, technologies and design features to assist its doctors in offering world-class medical treatment. As a result, the facility will assist Sri Lanka in becoming a worldwide medical destination, providing a much-needed boon to the area’s economy.
Though contemporary and cutting-edge in terms of its medical advancements, the facility’s design will be appropriate to its specific location and embody culturally specific design solutions. The facility will demonstrate a fine balance between Sri Lankan culture and advanced medical design and technology that will result in a ‘healing home’ environment. For example, each private room will reflect all aspects of natural healing, offering private open air balconies so that patients and their families can take advantage of the healing benefits of nature.
Upon completion, the Embassy Medical Center will be the most sustainable and regenerative medical facility in the world. It seeks to expand the fundamental meaning of ‘Healthcare’ beyond immediate medical services, to include the much needed work of creating healthy environments and healthy communities.


Robin Guenther is a practicing healthcare Architect whose built work has been published both nationally and internationally. She has been playing an important role in defining the sustainable design agenda in healthcare through a wide range of advocacy initiatives. She coordinates the Green Guide for Health Care, serves on LEED-HC committee, is a board member of Practice Greenhealth and the Center for Health Design, and is the co-author of Sustainable Healthcare Architecture with Gail Vittori. Contact her at

Douglas D Pierce is a practicing Architect with over 25 years of experience in sustainability theory and green design. He is an advocate for carbon neutral, regenerative design within his profession and teaches graduate level classes on the subject at the University of Minnesota, School of Architecture.