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Workshop Summary

Buildings are designed, constructed, and operated for a variety of purposes. At the most basic level, buildings provide their occupants with physical protection from the weather and from natural and man-made hazards. At a higher level, they enable myriad activities: factories enable the production and distribution of goods; hospitals enable healing and recovery from illness and injury; schools enable learning at many levels; and workplaces enable productivity and the delivery of services to communities and countries. At the highest level, buildings symbolize and convey status, values, and power; memorialize people and events; and inspire people to specific behaviors, to create, and to formulate ideas.

Leading proponents in the building and health care industries envision a future in which buildings are designed, constructed, and operated from initial move-in to disposal to promote their occupants’ health or wellness, security, comfort, and satisfaction; to enable their occupants to achieve organization missions and functional requirements; and to do these things cost effectively. A range of factors drive this vision:

  • Greater awareness of health issues;

  • Increasing costs of health care;

  • An emphasis on physical security in response to terrorism as well as natural and man-made hazards;

  • Growing recognition of the role of buildings as enabling environments for worker productivity, healing, and learning;

  • Increasing concerns about energy conservation;

  • The movement toward sustainability and sustainable building practices;

  • Pressures to reduce the costs of owning, operating, and maintaining buildings;

  • Lack of timely or adequate maintenance and repair of buildings;

  • Increasing costs of litigation related to occupational safety and health; and

  • Defective components and improperly installed equipment in buildings.

To fully achieve a vision of buildings that promote occupants’ health and productivity, numerous issues must be resolved and barriers overcome. These include the lack of commonly accepted definitions or parameters for indoor environmental quality; limitations in the state of knowledge about links between building design, operations, and practices and occupants’ health; and barriers to knowledge dissemination. Nevertheless, some aspects of the available knowledge are sufficient for building owners, occupants, and operators to immediately begin to



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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings 1 Workshop Summary Buildings are designed, constructed, and operated for a variety of purposes. At the most basic level, buildings provide their occupants with physical protection from the weather and from natural and man-made hazards. At a higher level, they enable myriad activities: factories enable the production and distribution of goods; hospitals enable healing and recovery from illness and injury; schools enable learning at many levels; and workplaces enable productivity and the delivery of services to communities and countries. At the highest level, buildings symbolize and convey status, values, and power; memorialize people and events; and inspire people to specific behaviors, to create, and to formulate ideas. Leading proponents in the building and health care industries envision a future in which buildings are designed, constructed, and operated from initial move-in to disposal to promote their occupants’ health or wellness, security, comfort, and satisfaction; to enable their occupants to achieve organization missions and functional requirements; and to do these things cost effectively. A range of factors drive this vision: Greater awareness of health issues; Increasing costs of health care; An emphasis on physical security in response to terrorism as well as natural and man-made hazards; Growing recognition of the role of buildings as enabling environments for worker productivity, healing, and learning; Increasing concerns about energy conservation; The movement toward sustainability and sustainable building practices; Pressures to reduce the costs of owning, operating, and maintaining buildings; Lack of timely or adequate maintenance and repair of buildings; Increasing costs of litigation related to occupational safety and health; and Defective components and improperly installed equipment in buildings. To fully achieve a vision of buildings that promote occupants’ health and productivity, numerous issues must be resolved and barriers overcome. These include the lack of commonly accepted definitions or parameters for indoor environmental quality; limitations in the state of knowledge about links between building design, operations, and practices and occupants’ health; and barriers to knowledge dissemination. Nevertheless, some aspects of the available knowledge are sufficient for building owners, occupants, and operators to immediately begin to

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings improve indoor environmental quality by implementing a variety of relatively simple, practical actions. Over the long term, leadership on the part of building owners and operators and health-care professionals, training, educational initiatives, and additional research are required. DEFINITIONS, STANDARDS, AND METRICS FOR INDOOR ENVIRONMENTAL QUALITY Indoor environmental quality (IEQ) is an undefined term. To date, a definition and standards for IEQ that could be commonly accepted across the diverse group of building stakeholders—owners, operators, users, designers, engineers, researchers, health care professionals, educators, and the general public—have not been developed. Because these stakeholders have differing technical expertise, education, responsibilities, and values, lack of a common definition and standards hinders communication about and collaboration on IEQ issues and solutions. Implicit in the development of guidance and standards is the development of performance indicators to measure how well the standards are being met. A fundamental issue is whether the quality of an indoor environment should be evaluated against a series of technical, building-related factors and standards—ventilation rates, for example—or against factors relating to the health of occupants, or some combination thereof. Overall, there are no specific limits for exposures to measured volatile organic chemicals or microorganisms that serve as a breakpoint between acceptable and unacceptable indoor conditions. Identified risk factors, like dampness or the presence of certain exposure sources, are often used to indicate unmeasured causal exposures in indoor air. Because certain specific exposures are not measured, it is difficult to characterize indoor environmental quality in terms of whether exposures are acceptable. Building-related factors that affect IEQ include the amounts and components of air pollution (indoors and outdoors); sources and rates of ventilation (i.e., outdoor air supply); temperature and humidity ranges; levels and sources of lighting; noise and vibration; building and furnishing materials; and operations and maintenance practices. Although IEQ is a result of the interrelationships of all of these factors, the systems used (heating, ventilation, etc.) and the management practices implemented are typically treated separately, rather than in an integrated or a holistic manner. Guidelines and standards for controlling these various aspects of IEQ are typically promulgated by nationally recognized technical and trade organizations. These include the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), the American National Standards Institute, ASTM International (formerly the American Society for Testing and Materials), and others. The guidelines are developed independently and in some cases may conflict. Development of standards related to the health of building occupants poses a different set of issues. A fundamental issue is the state of knowledge about the links between building design, operations, and maintenance and occupants’ health. STATE OF KNOWLEDGE: WHAT DO WE KNOW ABOUT HOW BUILDING DESIGN AND OPERATIONS AFFECT THE HEALTH OF NONINDUSTRIAL INDOOR WORKERS, HOSPITAL PATIENTS, STUDENTS, AND OTHERS? Cause-and-effect relationships have been scientifically documented between waterborne pathogens in natural and man-made water systems and Legionnaire’s disease and Pontiac fever in individuals; between microorganisms growing in contaminated ventilation and humidification systems and buildings with water damage and hypersensitivity pneumonitis and humidifier fever; between the release of carbon monoxide and carbon monoxide poisoning; and between the presence of radon and environmental tobacco smoke (also called secondhand smoke) and lung cancer. Poor or dim lighting in stairways and slight elevation changes in ramps can cause slips and falls that result in work-related injuries. Persuasive evidence exists that links a variety of sources—endotoxins found in humidifiers; visible moisture and mold in buildings or building ventilation systems; poorly maintained air-conditioning drainage pans; environmental tobacco smoke; and chemicals emitted from building materials, furnishings, and cleaning products—to the exacerbation of asthma and other respiratory symptoms in individuals.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Available research studies also suggest that the risk of developing allergies, asthma, and some lower respiratory tract symptoms is increased by the presence of moisture or contamination in heating, ventilation, and air-conditioning systems, low concentrations of formaldehyde, and materials that emit plasticizers (additives that keep them soft and pliable) into the air. However, more study is required to better document and understand these relationships and establish safe exposure limits. Building-related symptoms, sometimes referred to as “sick building syndrome,” are a set of nonspecific symptoms that are reported subjectively by occupants of a building and that often improve once the occupants leave. The symptoms include eye, nose, and throat irritations; headaches; fatigue; difficulty breathing; itching; and dry, irritated skin. Building-related symptoms are associated with a variety of factors, including low ventilation rates, high temperatures, organic compounds emitted from building materials, carpets and fleecy materials used in furnishings, and inadequate cleaning practices. Such symptoms are difficult to study because they do not indicate a specific disease. BARRIERS TO KNOWLEDGE DISSEMINATION: WHY DO ORGANIZATIONS FAIL TO IMPLEMENT BUILDING FEATURES AND PRACTICES THAT HAVE BEEN SHOWN TO IMPROVE INDOOR ENVIRONMENTAL QUALITY? Although building-related diseases and symptoms are substantially preventable, there are many reasons why the necessary intervening actions do not occur. These reasons, which are interrelated, can be generally categorized as awareness and motivation; financial considerations; accountability; and risk, liability, and lack of innovation. Awareness and Motivation The current state of knowledge about the links between occupants’ health and indoor environments is a barrier in motivating owners and other stakeholders to implement health-protective features and practices in buildings. Much of the available research is reported in scientific and engineering journals and does not reach building owners, operators, managers, and users until it is more widely reported in the news media. For example, although some of the causes and potential effects of indoor mold and fungi on building occupants have long been discussed within scientific, research, and building engineering circles, the issue has only come to the attention of the general public with the widespread reporting of catastrophic situations and subsequent litigation. Organizations, with some exceptions, have not implemented reporting and feedback systems to track problems occurring in their own facilities. Information about building-related problems and health complaints is not systematically gathered and analyzed, making it difficult to establish baselines for IEQ-related conditions or to identify recurring problems, patterns of problems, or trends. Without such information, efforts to recognize and address building-related health issues tend to be haphazard at best. To date, providing for health-related features and practices in buildings is largely left to individual organizations and people who are willing to take a leadership role in championing them. Few standards, codes, or regulations are in effect that are strictly health based, although some life-safety codes and insurance underwriting requirements for fire protection and occupational safety do provide some health-related safeguards. In day-to-day operations, many organizations and people focus only on complying with existing regulations and standards and do not initiate voluntary practices, even if such practices would likely result in improved workplaces. Financial Considerations Information is also lacking to make a compelling “business case” for investment in health-protective features or to change existing practices. Building owners and others typically have limited resources to invest in buildings and many competing demands for those resources. Owners and organizations often choose to invest their resources where the benefits will be immediately visible, in response to an emergency or breakdown situation, or in a project or activity whose costs and benefits can be readily quantified into dollars.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings The available evidence linking occupant health and IEQ is not easily quantifiable, nor are the results of implementing health-protective features and practices immediately visible. As a consequence, it is difficult for building operators, users, designers, and others to make a compelling business case to demonstrate the return on investment to be received from a particular health-related action. Similarly, it is difficult to compare and evaluate the costs and benefits of particular design features and conduct trade-off analyses. When acquiring new buildings, the federal government and other organizations typically focus on the first costs (design and construction) and give less emphasis to the life-cycle costs (design, construction, operations, maintenance, repair, disposal). Implementing some health-protective design features in new buildings can lead to higher first costs, although the life-cycle costs may be lower. The financial value of future avoided illnesses or of improved work performance are seldom considered explicitly in decision making about building design or operations. Thus, the focus on first costs tends to devalue the benefits of long-term cost avoidance—investing more money today to prevent future problems and thus avoiding the costs of mitigation. Accountability In the construction and building management industries, the processes for design, construction, operations, and maintenance are typically discrete rather than integrated activities. Thus, for most facility projects, one group of stakeholders is responsible for programming and funding, another for design, still another for construction, and a fourth for maintenance, preservation, and operations. When these functions are separate, there are few incentives for those designing a facility to consider its life-cycle costs or to evaluate alternative materials, systems, or other components in terms of their impact on occupant health, long-term operations, and management. The groups responsible for design are rarely held accountable for the subsequent total operating costs of the facility. The group overseeing construction is responsible for and held accountable for completing the facility on time and on budget but not necessarily for ensuring that the facility will perform well, operate economically, and satisfy user requirements. In this type of operating environment, accountability for decisions and actions tends to be dispersed, so no one person or business unit can be held accountable for the results of particular actions, positive or negative. Similarly, the stakeholders involved in the various processes—senior executives, chief financial officers, facilities managers and operators, architects, engineers, program and project managers, users, and occupants—tend to have different roles, responsibilities, technical expertise, and values. This hinders communication and collaboration across the stakeholder groups throughout the life cycle of a building. Furthermore, architects, interior designers, engineers, and facilities managers and operators receive little or no formal training or coursework in the health sciences and are not generally prepared to evaluate the consequences of their decisions about building materials, systems, and so forth on the health of a building’s occupants. Risk, Liability, and Lack of Innovation All decisions and actions entail some level of risk: a measure of the probability and potential degree of positive or adverse effects. When acquiring a new building, owners, lenders, designers, engineers, and project managers all assume some level of financial or professional risk in bringing the project to fruition. Typically all will seek to mitigate or manage their risk through market analysis, by their choice of projects and means of achieving them, or by shifting the risk to others. They also purchase insurance against losses resulting from liability for injury to persons or the property of others. In the area of building technology, liability issues are not clear, due, in part, to the dispersion of accountability. Owners, architects, and other stakeholders do not always know if they will be held liable for the performance of particular building systems and new technologies or innovative features or for any harm that may come to people or property as a result of their use. As a consequence, owners in particular seek to avoid the risk of liability by choosing to operate as they always have until litigation or directives from higher authorities force them to act in a different manner. In a similar vein, one reason that organizations have not systematically collected data on occupants’ complaints about IEQ in their own buildings is concern that the organization might be held liable for actions taken or not taken on such complaints.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings METHODS FOR IMPROVING KNOWLEDGE DISSEMINATION: WHAT METHODS, STRATEGIES, AND PRACTICES COULD BE USED TO OVERCOME BARRIERS TO IMPLEMENTING HEALTH-PROTECTIVE FEATURES AND PRACTICES IN BUILDINGS? During the course of the workshop, the participants identified a number of activities that could be implemented to overcome the aforementioned barriers and to provide lasting benefits for building occupants, owners, and the environment. Implementation of all of the activities will require leadership from the top levels of organizations as well as champions at all levels of management. When top management commitment to an initiative is present, changes in organizational behavior and practice are much more likely to occur. Awareness and Education Initiatives Raising public and owner awareness of IEQ issues was identified as a critical first step toward gaining broad support and facilitating improvements in the building and health care industries. Organizations such as the American Institute of Architects, ASHRAE, and others can play a significant role in educating the general public. The Environmental Protection Agency (EPA) or other appropriate organizations could develop public service announcements that take a complicated issue such as IEQ and occupant health and package it in a way that informs and inspires people to act. The federal government, which is the largest owner of built facilities in the United States and abroad, could play a significant role in outreach efforts and as the early adopter of change. This is not a new role for government. Recently, government agencies have taken the initiative to adopt sustainable building designs and practices, in some cases using the U.S. Green Building Council’s LEED (Leadership in Energy and Environmental Design) building rating system. Another strategy for raising awareness of IEQ programs is to bundle them with successful existing programs. For example, energy savings performance contracts offer an opportunity to take advantage of ongoing building audits and financing potential by linking IEQ problems to an energy savings program and combining resources and functions. An information clearinghouse could serve as a “one-stop” source of technologies and best practices related to IEQ and occupant health (see Chapter 7). The Whole Building Design Guide (www.wbdg.org) was cited at the workshop as an example of an information clearinghouse on buildings and their systems that could be expanded to handle IEQ issues. Indoor quality programs and practices could also be promoted with incentive programs such as those used by the Federal Energy Management Program. This program motivates and recognizes people for activities they do on a day-to-day basis and for projects in which they implement practices that foster a healthier building environment and enhance occupant well-being and productivity. In addition to raising awareness, workshop participants suggested that initiatives are also needed to motivate people to commit funds to health-related building programs and practices. Rating systems and labeling programs were both cited as nonregulatory means of stimulating awareness and changes in behavior and practices. They can also stimulate some competition and peer pressure—“If Joe down the street does it, I will”—which can drive adoption and use. The LEED building certification program was discussed in some detail as a potential model for such an effort. LEED was thought to be simple enough to be easily understood by people with a wide range of backgrounds and responsibilities, while at the same time conferring some sort of status that has enough appeal to attract funding. Some participants suggested that health-related issues could potentially be incorporated into the LEED rating system although others disagreed. A labeling program for buildings, similar to the Energy Star labeling program for appliances, was also suggested as a potential strategy to encourage building owners and others to invest in buildings and to incorporate health-protective features. Another model cited was the Center for Health Design’s “Pebble Project” (see Chapter 5). An opportunity exists for the National Research Council’s Board on Infrastructure and the Constructed Environment to be the integrator, facilitator, sponsor, and dispenser of research that makes a convincing case for

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings large holders of property, including the federal government, to create, design, operate, and manage a new generation of buildings that enhance health and well-being and support superior performance and efficiency. This could take several forms: brochures, guidelines, checklists, workshops, symposia, or an Internet-based clearinghouse. Financially-Based Information and Metrics There is a great need for measured data on the relationship of building design and operation practices to health and worker performance. Performance measurement is a central issue because it is difficult to manage and improve processes and practices that are not measured. One of the metrics needed for an IEQ program is return on investment for building owners. Owners need to be able to justify in financial terms investments in the types of strategies being suggested for improving the performance of indoor environments. Some participants noted that EPA’s Energy Star efficiency program is successful because it generates measurable phenomena and outcomes: If an organization changes its lighting or installs occupancy sensors, not only is there a change in the building environment, there is also a demonstrable change in the energy bill. This is a result that can convince an owner of the efficacy of a program and can lead to long-term change and acceptance. A matrix could be developed to demonstrate how one feature in a new building might be traded off with another and the potential economic results. Such a matrix would help owners and others to recognize the values and consequences of trade-offs. Initial versions of such a matrix would not necessarily need to explicitly value individual items in terms of dollars, but could discuss qualitative values. However, explicit valuations for cost-benefit modeling are preferred. Other metrics should reflect what people aspire to in buildings beyond thermal comfort, air quality, acoustics and lighting, and return on investment. It was noted that the United States spends billions of dollars on medical research. A return-on-investment analysis is not a driving factor in disease research because people implicitly know that it is the right thing to do. Implementing health-protective measures in buildings is also the right thing to do. Communication, Monitoring, and Feedback Communication is an important element in identifying problems, addressing them, and possibly avoiding more costly lawsuits, work-related illnesses and injuries, and declining productivity. The occupants of a building may be the most valuable monitoring “system” of indoor environmental quality, if there is a process and system in place for receiving input, responding to it, and tracking the response and results. In its 2002 report, The Maryland State Task Force on Indoor Air Quality (IAQ) found that many if not most IAQ problems stem from a few basic causes: “(1) a failure to perform routine preventive maintenance on HVAC systems; (2) inappropriate balancing and reassessment of HVAC systems when buildings are renovated or modified; (3) inadequate housekeeping and maintenance of buildings particularly with respect to moisture control; and (4) failure to respond to employee IAQ complaints and communicate the findings and corrective actions back to the employees” (p.4). Regarding this last point, the Secretary of Maryland’s Department of General Services noted that, in their experience, the best way to handle IAQ complaints is to “take them seriously, investigate the concerns, and communicate openly with the employees involved” (p. 15). The full report is available at http://www.dllr.state.md.us/labor/indoorairfinal/iaqfinalreportjuly12002.doc Training and Guidelines A common complaint about IEQ practices is the lack of adequate training and guidelines for many of those involved in the design, construction, use, and maintenance of a building. So there is a need for easy-to-use guidelines to correct problems in buildings and for widespread training of building professionals on how to best manage indoor environmental quality.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Federal agencies could use the best-value contracting process as opposed to lowest bid to get the best contractors to do the work. Contracts could emphasize the quality of training for personnel who install and commission the specified products. Furthermore, the contractor could also be required to provide appropriate training for the facilities people who will be operating the building systems. Additional Actions Additional suggestions for long-term strategies and activities to overcome existing barriers included: Changing the way materials and products are specified and developing coherent guidelines for their application and installation; Partnering with the insurance and banking industries and other large owner-investor organizations to demonstrate financial opportunities in building a certain way or adopting certain innovations; Looking for best-practice case studies and building on those success stories; Improving training programs for building professionals, operators, owners, maintenance staff, occupants, health care providers, and insurance providers; and Creating contract language for projects to include IEQ-friendly provisions. PRACTICAL ACTIONS THAT COULD BE IMPLEMENTED BY THOSE IN THE BUILDING, HEALTH CARE, AND OTHER INDUSTRIES TO IMPROVE INDOOR ENVIRONMENTAL QUALITY Many buildings, even the best-designed ones, will develop problems that can affect the health of some occupants if operations and maintenance practices are inadequate. During the course of the workshop, participants identified a wide range of actions that could be implemented immediately by those in the building, health care, and other industries to create more healthful indoor environments: Monitor buildings to ensure they remain clean, dry, well ventilated, well lit, acoustically sound, and comfortable in terms of temperature and vibration. Develop a checklist of items that should be monitored regularly to aid operations and maintenance staff. Eliminate indoor environmental tobacco smoke by prohibiting smoking inside a building or restricting smokers to physically isolated, depressurized smoking rooms that exhaust air to the outdoors. Implement a proactive program to prevent indoor dampness and mold and remediate existing moisture problems. Keep heating, ventilation, and air-conditioning (HVAC) systems clean and dry—first by design and then by operation and maintenance. Maintain HVAC and other mechanical equipment, following installation and maintenance specifications, and proper cleaning, such as regularly changing filters and cleaning cooling coil drainage pans. Provide adequate outdoor air ventilation and use natural ventilation where feasible. Meet, at a minimum, ventilation rates in existing codes and maintain those over the life of a building. Control Legionella in building water systems (guidelines available from ASHRAE and others). Keep indoor relative humidity below 70 percent. Maintain temperatures within the range specified in thermal comfort standards. Limit, control, or eliminate indoor sources of volatile organic compounds, such as formaldehyde. Develop an IEQ management plan and assign a person to implement it. Minimize pesticide use. Check the credentials of contractors installing HVAC and other equipment. Establish a reporting, correction, and feedback system that encourages building occupants and others to identify problems early. If or when the problems are corrected that information should be communicated back to

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings the occupants. Once a decision has been made about whether the problem can or will be corrected, the activities and timeframe for correcting it should also be communicated back to the occupants. Commission new buildings and recommission existing ones. Building Commissioning and Recommissioning Many workshop participants suggested that if building owners and operators routinely commissioned new buildings and recommissioned existing ones, many IEQ issues could be prevented or mitigated. This suggestion is based on logical expectations but has not been scientifically documented. Building commissioning is a process that encourages and measures quality. Draft ASHRAE Guideline 0-200X describes the commissioning process as: …a quality-focused process for enhancing the delivery of a project. The process focuses on verifying and documenting that the facility and all of its systems and assemblies are planned, designed, installed, tested, operated, and maintained to meet the Owner’s Project Requirements. The scope of building commissioning includes integrated performance of the building envelope and architectural systems; site utilities; fire protection and suppression; special equipment; mechanical (HVAC, plumbing, piping); electrical (power, lighting, low voltage); and controls. The process, however, goes beyond mechanical systems, promoting a cradle-to-grave approach for optimal long-term building performance. The National Institute of Building Sciences (www.nibs.org), the Building Commissioning Association (www.bxca.org), and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (www.ashrae.org), among other organizations, have developed guidelines related to building commissioning and recommissioning.