Green Healthcare Institutions: Health, Environment, and Economics: Workshop Summary (2007)

During the general discussion, participants expanded on the presentations and the overaching scientific principles of green buildings. Russell Perry of the Smith Group facilitated the discussion by asking participants if they agreed that the implicit question in the presentations was “Can we improve human health or speed the process of healing by building higher-quality buildings?” If so, can science measure that incremental improvement and disaggregate the contributing factors to understand the effectiveness of various strategies?

During the workshop, considerable time was spent discussing the definition of green. For example, one participant questioned whether green includes daylighting or noise issues. He challenged the group to define “green” more narrowly around environmental issues, including products and materials used in the healthcare environment, and sustainability. He further suggested that people need to agree that green is more than just energy efficiency. Perry expanded this discussion by drawing from Jason McLennan’s book, The Philosophy of Sustainable Design (2004). He said that the largest difference between the environmental building movement of 30 years ago and the past 10 years is the concern about quality. The focus is now on quality environments—indoor environmental quality, water quality, the quality of light, and quality of life—and not just about energy. He credited leaders in sustainability with expanding the definition. Although participants generally agreed on the core elements (e.g., energy, low-emitting materials), the boundaries of building green were not firmly established during the discussion.

Judith Heerwagen noted that current research on green buildings happens in a stovepipe fashion. For example, people who study noise typically do not study other dimensions, such as lighting. It is the intersection of such lines of research that is likely to be very important. She further noted that health has multiple determinants, some in the social environment, others in the physical environment. She pointed out that when people move into a new building, there are the placebo and Hawthorne effects to consider. Most research to ascertain the effects of a building is performed once the individuals have adapted. She questioned if there is valuable information in this phase of adapting that warrants additional research.

Craig Zimring observed that hospitals have research advantages that should be capitalized on. First, hospitals measure a multitude of outcomes that most other buildings owners do not. They routinely measure patient satisfaction, family satisfaction, rates of infection, error rates, and staff turnover. These measures are often made at the unit level, which facilitates comparisons between units of different design. Second, there is centralization in the healthcare sector. For example, large hospital chains and healthcare design firms can facilitate data collection and provide the opportunity to do controlled studies. Third, there is an opportunity to engage academic medical centers. It is ironic that innovation has been driven by suburban hospitals of medium size and not the large academic health centers.

Science has accumulated a body of literature to support green buildings, but the information is not complete at this time. Some participants observed that this is the challenge currently facing the sustainability field. Anthony

Bernheim remarked that there is some uncertainty in the information, and that the precautionary principal is often used. In many ways, we know enough to be concerned but not enough to make the final judgment on many of the attributes of building green, he noted.

Concurring, Zimring elaborated by saying that currently available evidence does not yet support major design decisions. In other words, researchers can only state in general terms that building better buildings can improve outcomes. Researchers can support the concept of green design as a path to quality of care, environmental performance, or improved health, but they can-

not specify necessary individual elements. Similarly, researchers can say that what is needed is more light or larger patient rooms, but they cannot say how big those rooms need to be for a given patient. They cannot say how much space should be devoted to a restorative garden. Currently, clear data that would support a business case for gardens are not available. The research agenda needs to be enhanced in this area, noted Zimring. He asserted that researchers need to go beyond a simple dichotomy of bad and good. Research needs to define how individual elements operate in combination and nuanced ways.

While one participant agreed with the above position, he suggested that defining enough evidence depends on the audience. For example, evidence that suffices for the public may not be acceptable to the scientific community. Howard Frumkin expanded this idea by observing that there is both an advocacy position and a research position. Individuals who are advocates may conclude that science has amassed sufficient information to guide healthcare facilities in how to implement green building practice. However, a researcher might note how much is unknown about the effects of building green on human health. Although definitions and evidentiary standards are well understood in other parts of environmental health, for green buildings some of these issues remain unsettled, noted Frumkin.

People on the advocacy side should be straightforward about what is known and where evidence is lacking within the field, Frumkin continued. From these discussions, the scientific community needs to frame data needs accordingly,

he asserted. On the research side, the field needs to be very strategic. Researchers do not need to conduct research that simply answers questions for which answers are already available. The questions that need to be answered should guide designers and builders in what to do. The research agenda that science needs to develop should be very applied, very strategic, and very targeted. It should supplement the advocacy agenda by filling in holes, allowing progress in fusing the two agendas, noted Frumkin. Public health advocacy is necessary, but it needs to be based on data. One fundamental way to fuse the agendas is the precautionary principle. It is also necessary to identify gaps in current knowledge and to direct research accordingly.

Several participants initiated a discussion about research gaps. Perry emphasized the importance of not researching issues that are already well understood, but rather to disseminate existing information through education or publication. He noted that much research is unknown to most individuals in the architectural world and that education is an important part of solving this problem. Bernheim continued this discussion by observing that midlevel architectural and engineering professionals are important decision makers and should be informed about current research.

Another participant remarked that Kaiser Permanente and other hospitals have demonstrated not only that the changes being made are cost-effective, but also that they improve quality. However, she also suggested that it is important to disseminate results from pilot studies, which can help to guide future controlled studies.

Some of the discussion followed up on the economics of research. Perry reiterated concerns about identifying the most important benefits. He questioned how facility managers know where to spend money and if there is sufficient evidence of effectiveness to justify additional expense. Another participant suggested that the fundamental question of how much a hospital should cost should be addressed, rather than celebrating the fact that these buildings can be constructed for a premium of less than 2 percent of the cost of traditional buildings. John Poretto noted that the basis of the problems is separating capital costs and operating costs into individual silos. Generally, capital costs come from the surplus made from operations. If a building owner skimps on the capital side, it will ultimately be made up through the operational side in the indirect costs recovery scheme, noted Poretto. Perry concluded this part of the discussion by suggesting that people who are taking the greatest financial risk are those who are not following these strategies and not constructing healthy and energy-efficient buildings.

One participant said that a hospital ought to be a beacon of light for good environmental practice. Hospital and healthcare professionals often have a larger role in the community by providing credible information about public health issues. Perry agreed, adding that credit should be given to individuals who are showing leadership and giving credence to the best practices. As the field moves forward, scientists should consider what data are needed to document the importance of the green healthcare movement. A participant recommended that

healthcare facilities provide better choices about green products and chemical use to communities.

Perry concluded the general discussion by saying that the meeting should celebrate the research and data that has already been compiled, as well as the leadership of companies that provide facilities to further study best practices.

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