Presentation Abstracts*

THE CONFLICT BETWEEN GROWTH AND GOING GREEN: THE EXPERIENCE AT EMORY

R. Wayne Alexander M.D., Ph.D.


Emory University has broadly embraced the principles and practice of sustainability, which is recognized in the university strategic plan. The sustainability vision was developed in the context of the strategic plan implementation and summarizes the goal that: “We seek a future for Emory as an educational model for healthy living, both locally and globally—a responsive and responsible part of a life-sustaining ecosystem” (Sustainability Commitee, 2005) The primary themes of the sustainability vision are a healthy ecosystem context; healthy university function in the built environment; healthy university structures, leadership, and participation; healthy living, learning, and working communities; and education and research. Emory has initiated a plan for realizing a “sustainable architecture for health.” There are currently 11 Leadership in Energy and Environmental Design (LEED)-registered projects at Emory. The first LEED building in the Woodruff Health Sciences Center was the 321,000 sq. ft. Whitehead Biomedical Research Building. This building was the LEED pilot project at Emory. It was highly successful, LEED Silver certified, and came online ahead of schedule and under budget. The LEED concept has been supported by the board of trustees. The first healthcare building was the Winship Cancer Institute, which is LEED registered. Plans are for all future construction of major buildings to be LEED registered, with the goal of reaching Silver certification for all construction at the very least. These standards are to be applied to the new Emory University Hospital and the Emory Clinic buildings, which are in the planning stages.

*

This chapter contains individually authored abstracts that were submitted to the roundtable by presenters prior to the workshop.



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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Presentation Abstracts* THE CONFLICT BETWEEN GROWTH AND GOING GREEN: THE EXPERIENCE AT EMORY R. Wayne Alexander M.D., Ph.D. Emory University has broadly embraced the principles and practice of sustainability, which is recognized in the university strategic plan. The sustainability vision was developed in the context of the strategic plan implementation and summarizes the goal that: “We seek a future for Emory as an educational model for healthy living, both locally and globally—a responsive and responsible part of a life-sustaining ecosystem” (Sustainability Commitee, 2005) The primary themes of the sustainability vision are a healthy ecosystem context; healthy university function in the built environment; healthy university structures, leadership, and participation; healthy living, learning, and working communities; and education and research. Emory has initiated a plan for realizing a “sustainable architecture for health.” There are currently 11 Leadership in Energy and Environmental Design (LEED)-registered projects at Emory. The first LEED building in the Woodruff Health Sciences Center was the 321,000 sq. ft. Whitehead Biomedical Research Building. This building was the LEED pilot project at Emory. It was highly successful, LEED Silver certified, and came online ahead of schedule and under budget. The LEED concept has been supported by the board of trustees. The first healthcare building was the Winship Cancer Institute, which is LEED registered. Plans are for all future construction of major buildings to be LEED registered, with the goal of reaching Silver certification for all construction at the very least. These standards are to be applied to the new Emory University Hospital and the Emory Clinic buildings, which are in the planning stages. * This chapter contains individually authored abstracts that were submitted to the roundtable by presenters prior to the workshop.

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Justifications for the university’s commitment to the LEED program include the following: It supports the environmental mission. It provides the framework to build high-performance buildings. It provides third-party validation of the sustainability vision. It makes good business sense (use life-cycle cost analysis, not first cost, to make decisions on equipment and building features). It supports Emory’s desire to be leaders in sustainability initiatives and in stewardship of the environment. Emory’s facility development program is an integral part of the overall sustainability initiative. The commitment to this initiative to date has not limited growth but has powerfully informed planning. Programmatically, all facilities will support healthy lifestyles, not only for the ill but also for the well who work or study at, or visit, the university. The general emphasis on health preservation will be guided by the Emory/Georgia Tech Institute for Predictive Health Care. FRAMING THE PROCESS: INSTITUTIONAL CHANGE TO GREENING A CAMPUS: SUSTAINABLE CONSTRUCTION AND BUILT ENVIRONMENT AT THE UNIVERSITY OF FLORIDA Bahar Armaghani, B.S., LEED AP The University of Florida’s Facilities, Planning and Construction Division (FP&C) is committed to developing a sustainable campus and delivering sustainable buildings to the University of Florida (UF) in support of maximizing efficiency, productivity, and good health and comfort of the faculty, staff, and students. The University of Florida was thinking green and testing green before green practices were even on the radar for most educational institutions. In the late 1990s, sustainable design and green building concepts were being tested on several new projects. In 2000, sustainable design elements were incorporated into the UF master plan and construction program documents. In 2001, FP&C adopted LEED criteria for design and construction of all major new construction and renovation projects. The UF faculty committees followed this effort with full endorsement. In 2005, FP&C raised the bar on this arena and established a minimum goal of silver LEED certification for all university projects. The University of Florida has made significant strides toward the goal of being a leader in sustainable development and incorporated this into the UF fabric to serve the interest of the students, staff, faculty, our community, and the world. We were proactive in taking this posture and adopted LEED when it was at its infancy in support of building a healthy environment on campus.

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Since 2000, FP&C has achieved the following milestones: LEED-certified buildings (totalling 79,107 GSF) including: Rinker Hall—LEED Gold certified McGuire Center for Lepidoptera and Biodiversity Research (butterfly museum)—certified LEED-registered buildings in design and construction phase (totalling 1.1 million GSF) including: Cancer and Genetics Research Center Pavilion Orthopedic Surgery and Sports Medicine Institute Shands Biomedical Research Laboratory Nanoscale Institute Research Facility Food Animal Veterinary Medicine Facility Powell Structures and Materials Laboratory Legal information and phase II law building Library West addition and renovation Baseball locker room facility Mary Ann Cofrin-Harn Pavilion (museum) Hub renovation (technology center) We have enhanced the construction standards to incorporate LEED criteria and have raised the bar in delivering a healthy building environment. The unique and challenging aspect of the green buildings on our campus is that every building is different in size and function. Also, the university’s FP&C has taken the lead to work with Shands Hospital on their new hospital construction to bring the hospital component into sustainable design. The success of building green on campus has generated a ripple effect throughout the campus manifesting in a desire to look into other sustainable practices such as zero waste by 2015, reducing carbon emission, and green purchasing. These are a few of the new initiatives that the university president announced last October on Campus Sustainability Day. The University of Florida is leading our state in the design and construction of green buildings. This has been made possible by the support of the university administration, the faculty senate, and the tremendous enthusiasm of the staff, faculty, and students. Earlier green practices have played an important role in creating a sustainable campus including converting campus-wide irrigation to use reclaimed water generated by the UF-run water reclamation facility that processes over 2 million gallons of reclaimed water per day, a mass transit system, a no smoking policy, maintaining over 300 acres of conservation land,

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary a full recycling program, commissioning, and an indoor air quality program. We have come a long way, but we know that we have a long way to go. Our green building approach has evolved and expanded from using LEED for new construction (LEED-NC) to using LEED for existing buildings (LEED-EB) and for health facilities. Over the years, our commitment has strengthened, and our enthusiasm has grown to build more sustainable and healthy buildings. With this commitment, we strive to include our campus community and other surrounding communities in this process. We involve our students in the process and teach them unforgettable hands-on lessons. When they graduate, they will be prepared to make the right decisions as consumers and conservers toward saving the environment. BUILDING GREEN AND INTEGRATING NATURE: RIKSHOSPITALET UNIVERSITY, OSLO, CASE STUDY Knut H. Bergsland This case study was presented because of its qualities in terms of humanizing the hospital environment, integrating nature, and giving access to direct daylight to all patient rooms and most of the functional working spaces. Natural materials were utilized as far as possible according to the LEED-NC version 2.2 registered-project checklist, as such Rikshospitalet would probably achieve certification. Building Green Regardless of the scope of the definition of green building, it is imperative to seek the most important indicators in terms of individual, environmental, and community health. Green building must include a vast array of subjects. Still, there is a need to pinpoint the most important indicators, the ones that most benefit the health of the patients and personnel with the least effort and use of resources. In terms of hospital operating, it is imperative to establish a committed culture for operating and maintaining a sustainable building concept, including all its support systems throughout the entire life cycle. What is needed is a hospital concept for maximum, long-term performance on the most important indicators. Integrating Nature The importance of nature as a stress-reducing trigger for the healing process has been an established fact for quite a long time. To take a few shortcuts, it may

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary follow from this that planning for maximum daylight and integrating nature in the hospital concept by as many means as possible is a right thing to do in both the patient and work environments. Seeking the most crucial elements in terms of health return (environmental and medical outcome) is important also in this respect. Background to the Case Study Norway spends 10 percent of its gross domestic product on health care (Johnsen, 2006), as opposed to the 16 percent in the United States (CIA, 2007). The health-care system is 90 percent public and tax based; hospital inpatients do not pay for their stay (Bergsland, 2005). Hospitals are owned by the state, but they are run as trusts. Competition between hospitals was introduced a few years ago, and doctors are employed by the hospital. The Norwegian healthcare system is driven by the same forces as most other Western countries—demographic change, technology, and demands for efficiency; but the system is still run within the framework of a national healthcare system based on equal access to and distribution of services as the main principle. Rikshospitalet University Hospital Rikshospitalet—built on a virgin site just outside the city center—is a tertiary teaching and referral hospital, and covers all clinical specialties, except for geriatrics and psychiatry. The 1,233,000 sq. ft. building, completed in 2001, has 585 beds, excluding intensive care. There are 35,000 inpatients, 20,000 day patients, and 160,000 outpatients per year, with a workforce of 4,000 full-time equivalent (FTE) positions. A substantial clinical production growth from 2001 to 2004 has been absorbed by the building; however, this has not occurred without straining the ventilation and energy systems. Productivity levels are up more than the 15 percent above the rise in staffing levels. Absenteeism decreased from 8 percent to 6 percent. The location of the site was chosen by the Norwegian Parliament. The hospital was built on cultivated land, despite protests from environmental activists. The site itself is sloping and saucer shaped, which was utilized by the architect to make the 5- to 6-story building appear as a nonfrightening 3- to 4-story set of buildings. Village Structure Rikshospitalet is conceived as a village structure, with a main square and a landmark tower, a street hierarchy and separate, but interconnected buildings. The dominant, slightly curved, 280-meter long circulation artery has a glass roof, which lets daylight into a bigger proportion of indoor spaces than in simi-

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary lar covered spaces. Glimpses of nature, plus sculptures and other art objects, aid wayfinding by making it easy to draw a mental picture of the route to one’s destination. The curvature hides the length of the corridor, gives no long drab vistas, and reduces the need for signage. The art and glimpses of nature at intersections helps one remember and aids recognition, which facilitates patients’ and relatives’ trip to their destination. Stress-Reducing Qualities The circulation artery, with its dense pedestrian traffic, integrated art, frequent art exhibitions and concerts, and access to a grand piano—also for patients, obviously fills one important requirement for stress-reducing factors in hospital environments (Ulrich, 1991): A place for positive distractions in physical surroundings Access to social support A sense of control with respect to physical and social surroundings The low, nonfrightening appearance of the building volumes and frequent access to nature and daylight may contribute to a sense of control in patients and visitors. There have, however, been no studies so far to confirm this. Art is integrated in the building. Nine percent of the total building budget was earmarked for art in the hospital. One may ask whether art as a background for activity can have similar effects as nature on stress reduction and healing. Some effects of pictures of nature and smiling human faces on stress reduction in patients have been documented (Ulrich, 1991). In Rikshospitalet, such pictures are not much used in patient areas. Daylight in as many spaces as possible is a positive contribution to staff wellbeing, according to a preliminary study on the effects of the building concept on activity and productivity (Bergsland, 2005). On the other hand, daylight requirements result in longer walking distances, more circulation space, slightly lower space efficiency, and higher energy needs. Daylight vs. Energy Use The glass roof brings ever-changing daylight into the main street. It could be called a lovely energy drain, as the street is kept at a temperature of 17°C during the winter season. This requires extra heating, which, however, is more than outweighed by the positive effects on staff morale. The hospital’s technical systems still need some upgrading. But to introduce such systems visibly in the main street volume was flatly rejected. Rikshospitalet uses more energy per square meter than most other Norwegian hospitals, a little more than 400 kWh per square meter per year, versus under 200

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary kWh in new hospital projects (energy use is calculated as energy supplied by the outer wall of the building per intentionally heated area). Still there has been a more than 10 percent reduction in total energy use from 2002 to 2004, even with a substantial growth in clinical production. The hospital administration has committed itself to an ambitious program of saving energy. Nature’s Materials Norwegians love nature’s materials—especially wood. Rikshospitalet is showing the patient respect through the use of high-quality, lasting materials. Natural stone is used in the floor of the main street, on some other floors, and in street furniture. Wood is used for benches, chairs, reception desks, and in special rooms, such as libraries and auditoria. Cafeteria and other common rooms frequently have parquet flooring. Trees are incorporated in some indoor spaces and may aid biofiltration of indoor air. Integrating Nature in Practice The virgin site location is the major reason for the ability to integrate nature and daylight in the project: from the use of the surrounding woods for activities, access to (most) courtyards, glimpses of nature at intersections, to the preservation of existing, big trees, and so on. The trees also play a role in achieving a human scale in the project. Partly Green and Integrating Nature In terms of the LEED checklist version 2.2. Rikshospitalet seems to meet some of the criteria for sustainable sites, but not all. The hospital’s strongest points seem to be daylight to as many spaces as possible, worth both the extra first cost and the extra operating costs—and a key to achieving the humanistic goals of the project; the village main street creates a place with identity and interest, generating a sense of high quality, without showing off; and the seemingly low building counters the impression of the hospital as a big, clinical machine. The architects’ strong will, empathy, and commitment to human values seem to be the reasons behind the success of the project as a healthcare setting. In terms of green building, there are still goals to be achieved.

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary THE CASE FOR GREEN BUILDINGS II: HEALTH DESIGN PRINCIPLES IN HEALTHY BUILDING Anthony Bernheim FAIA, LEED AP Global and Local Ecological Health Life on earth is dependant on clean air, fresh water, biological diversity, and healthy soil (for growing food and, more recently, the raw materials for rapidly renewable building materials). Because the way we design, construct, and operate buildings has a major impact on the earth’s environment, we need to focus our attention on sustainable, green, and high-performance building as a way to ensure that future generations may also enjoy equal or improved health and environmental benefits. When we think of green building, we generally think about energy efficiency and the U.S. Green Building Council’s (USGBC) LEED green building rating system (USGB, 2006). However, sustainable, green, and high-performance buildings are much more complicated than this. They involve an integrated approach to energy conservation and efficiency; indoor environmental and air quality; and the efficient, effective use of site, water, and material resources. Genuine long-term environmental sustainability means more than the mainstream construction of buildings according to outdated conventions. It entails designing and constructing deep green “restorative” buildings, those that enhance the environment by producing more energy than they consume, and those that provide comfortable indoor environments with healthy indoor air quality (IAQ) (McLennan, 2004). These restorative buildings support and promote improved occupant health and reside at the highest level of the “green thermometer,” a relative measure of both a building’s environmental sustainability and its contributions to its occupants’ physical well-being. Health in Buildings Because we breathe without conscious effort, we spend little time thinking about what enters our systems with those breaths. We do not see, and only sometimes smell, the chemicals and particulates that endanger our health. Yet indoor air quality is not a primary focus of contemporary building design. The U.S. Environmental Protection Agency (EPA) estimates that Americans spend almost 89 percent of their time indoors (at home and at work), 6 percent in vehicles, and only about 5 percent outdoors. They further tell us that the air indoors is about 2 to 5 times more concentrated with chemical pollutants than the air outdoors, with the result that we are being exposed to high levels of chemical concentrations for the vast majority of our lives. Our bodies, not designed for this, are responding with health afflictions such as

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary sick building syndrome (short-term health effects with coldlike symptoms that can not be traced to specific pollutant sources), building-related illnesses (diagnosable illness whose symptoms can be identified and whose cause can be directly attributed to airborne building pollutants), and multiple chemical sensitivity (a condition in which a person reports sensitivity or intolerance to a number of chemicals and other irritants at very low concentrations). Indoor air quality is dependent on a number of factors, including the quality of the outside air that we bring into the building; the chemical emissions from the materials, furnishing, and equipment that we place in our buildings; the efficacy of the ventilation systems that we use to purge the indoor air; the activities of the building occupants; and the long-term maintenance of the buildings and their contents. These factors contribute volatile organic compounds; microbial organisms and microbial volatile organic compounds from mold; semivolatile organic compounds from fire retardants, pesticides and plasticizers; inorganic chemicals such as carbon monoxide, nitrogen dioxide, and ozone; and particulate matter generated outdoors by fuel combustions and indoors by occupant activities and equipment. Four Principles of Good Indoor Air Quality Design In the early 1990s, my firm began an earnest exploration of the role of design in improving indoor air quality. Our work was influenced by and tested during a major civic project, the San Francisco Main Library. Through extensive research, analysis, and real-life applications, we concluded that building owners, operators, architects, interior designers, and engineers can have a major impact on a building’s indoor air quality. Our experiences with that project and numerous others since then have confirmed that healthier buildings result from the adherence to four basic principles: Source control (reducing the indoor chemical concentrations by reducing or eliminating the pollutant source) Ventilation control (providing adequate ventilation to dissipate and purge the indoor air pollutants) Building and IAQ commissioning (a process used to check and verify that the building is constructed as designed and operates as intended) Building maintenance (regular inspection, maintenance, and cleaning of the building and its contents)

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary From Science to Practice: Source Control There have been many developments in the science and practical applications leading to improved indoor air quality. Most recently, those developments have been in the area of source control, the principle on which I will focus in this article. Significant scientific research has been published in the area of source control and the reduction of potentially harmful substances in indoor air. Although more research is needed to build on the current body of IAQ knowledge, the collective data has provided some guidance to building designers that, combined with practical building experience over the last 20 years, has led to the current state of IAQ knowledge. Beginning in the early 1980s, the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) developed IAQ guidelines as a rule of thumb limiting building occupants’ long-term exposure to a small percentage of the occupational exposure (one-tenth the threshold limit value). Little was known at the time about the effectiveness of this guideline, and concerns were raised regarding the factor of safety of the indoor air chemical concentrations. Lars Mølhave of Denmark developed a total volatile organic compound (TVOC) approach to selecting indoor building materials based on the odor, irritation, memory, task performance, and other effects of these chemicals on the building occupants (Levin, 1998). An early application of this work took place in the state of Washington’s East Campus building projects (Black et al., 1993). Concerns were still raised, however, about the health impacts of individual chemicals and the synergistic effects of a combination of chemicals in the air. In 1989 my firm was selected as part of a large team to design the new 381,000-sq.-ft. San Francisco Main Library. We were concerned about the building’s health impact on the library staff and patrons and incorporated IAQ into the project design criteria. We developed specifications limiting the emission of a few volatile organic compounds that were known to be odorous and have some health impacts, and we selected the building materials based on a careful analysis of technical data provided to us by the materials’ manufacturers. The most important information that we requested and eventually obtained for analysis was the chemical emissions test reports that provided us with data on each material’s TVOC emissions and some of the individual volatile organic compound emissions (Bernheim and Levin, 1997). Although the library staff was originally skeptical that we could design for good indoor air quality, the building opened in April 1996 with very positive response from the staff about the IAQ. The unfortunate lesson that we learned on this project was that, although we were able to have material manufacturers eliminate some odorous and potentially harmful chemical emissions from their products, they replaced them with others about which the health effects were less well established. By 1999, work had begun on the design of a 479,000-sq.-ft. California State office building located in the Capitol Area East End Complex of Sacramento, to be occupied by the Department of Education. An engineer working in the State

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Health Department and a national IAQ expert developed a procurement specification for the building’s furniture, which was intended to help the state acquire large quantities of office systems furniture with high-recycled content and low individual chemical emissions. My firm was selected to join the team that would design and build the project. We formed a green team (including the national IAQ expert, Hal Levin of the Building Ecology Research Group) within the larger team to enhance the project’s sustainability and long-term performance. We were requested by the state to give particular attention to delivering a building through the design-build process with good IAQ. We built on the previously prepared furniture procurement specifications and subsequently adapted their methodology for the building materials (Bernheim et al., 2002). The goal was to reduce indoor chemical concentrations by reducing or eliminating chemicals of concern that are carcinogens, reproductive toxicants, and chemicals with long-term or chronic health effects. To do this, we needed to better understand the contribution of these materials to overall indoor chemical concentration and the potential health impacts of these concentrations. The California Office of Environmental Health Hazard Assessment (OEHHA) has developed a list of about 80 chemical compounds and has, through evaluation of the available science, determined the impact on the human body of long-term exposure to these chemicals. It has further developed a chronic reference exposure level (CREL) for each chemical, which is the concentration or dose “at or below which adverse health effects are not likely to occur from a chronic exposure to hazardous airborne substances. They are intended to protect individuals from chemical injury, including sensitive sub-populations” (Alexeeff et al., 2000). Our team developed a special environmental requirements construction specification, now known as section 01350, for this project. This specification requires chemical emission testing for interior materials and sets maximum chemical concentrations based on the OEHHA CRELs, minimum material recycled content based on the State Agency Buy Recycled Campaign (SABRC), and procedures for dealing with mold on the construction site. Section 01350 also establishes an airing out period prior to substantial completion. Postoccupancy air testing in the Capitol Area East End Complex was performed, and the results indicated that the section 01350 material testing was effective in limiting the chemical concentrations in the completed building, which achieved a USGBC LEED gold rating. Market Transformation As design for healthy indoor air quality gains a foothold, these early projects are becoming a baseline for standards that are being followed in many industries. Section 01350 has now been incorporated into the California Department of General Service’s standards for all future state buildings. My firm is incorporating

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary BUILDING-RELATED HEALTH EFFECTS: WHAT DO WE KNOW? Ted Schettler Hospital buildings provide space for health care, employment, residence, shelter, and comfort. Building design, construction, operations, and maintenance influence the indoor environment and the health and well-being of staff, patients, visitors, and other occupants. Design and construction decisions also affect the environment and public health regionally and even globally. Materials extraction, product manufacturing, transportation, use, recycling, and disposal influence air and water quality, land use, and can contribute to ozone depletion and climate change. The health of workers in the supply, production, and disposal/recycling chain, as well in building construction, operations, and maintenance, is also affected. This paper primarily addresses the influence of buildings on the health of occupants. It briefly touches on more far-reaching concerns, including the appropriateness of certain activities related to health care. The Indoor Environment Building-related comfort and health are directly related to indoor environmental quality, which is determined by combinations of temperature, temperature gradients, humidity, light, noise, odors, chemical pollutants, personal health, job or activity requirements in the building, and psychosocial factors. That is, buildings are complex dynamic systems of multiple interacting factors that determine the state of the system at any given time. Microenvironments within buildings may be highly relevant determinants of health impacts among occupants. Spatial heterogeneity among a mixture of relevant variables makes it difficult to study and understand causal health-related relationships (Spengler and Chen, 2000). Much work on building-related health focuses on combinations of temperature, humidity, ventilation, and indoor air pollution. Air pollutants include volatile organic compounds (VOCs); semivolatile organic compounds (SVOCs); microbial VOCs (MVOCs); particulates; nitrogen oxides; ozone; carbon dioxide; and biological agents such as bacteria, viruses, and fungal spores. Many air pollutants are generated indoors, and others infiltrate from the outdoors. These factors interact in multiple combinations that vary over time and place, even within the same room or building, making it difficult to understand the extent to which each contributes to health outcomes. For example, assessments of exposure to indoor air pollutants that assume homogeneous concentrations in a room will miss important concentration gradients around point sources of emissions. Concentrations may vary by several-fold, depending on proximity to an emitting source (Furtaw et al., 1996). Building design, operations, and maintenance must be considered collec-

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary tively. Design and construction choices will influence operations and maintenance in ways that make building-related complaints more or less likely. Many studies that attempt to examine building-related illness are limited by their design (e.g., cross-sectional surveys are common and are limited by several kinds of bias), lack of quantitative exposure information, subjectivity in outcome measures, and uncertainty about what potentially causal factors should be measured. Further, because of interactions among multiple building related factors, commonly used statistical techniques do not lend themselves to the analysis. Models based on principal component analysis or structural equation modeling show some promise, but will need further work before being generally applicable (Pommer et al., 2004). Building-Related Illness, Building-Related Symptoms, Sick-Building Syndrome, and Multiple Chemical Sensitivity Sharp distinctions between health and comfort are not readily apparent and may not be appropriate. Building-related illnesses include specific diseases such as Legionnaire’s disease, which can be traced to a single source or cause. Building-related symptoms include (EPA, 2006) mucous membrane symptoms (blocked or stuffy nose, dryness of the throat, rhinitis, sneezing, dry eyes), headache, confusion, difficulty thinking and concentrating, and fatigue; cough, wheeze, asthma, and frequent respiratory infections; and allergic reactions, such as dry skin. The term sick building syndrome (SBS) is used to describe situations in which building occupants experience acute health and comfort symptoms that appear to be linked to time spent in a building, but often no specific cause can be identified. Complaints may be localized in a particular zone or widespread throughout the building. SBS is sufficiently common and has been sufficiently described to have attained robust stature in medical and architectural disciplines. To further complicate analyses, some people seem to be particularly sensitive to a wide variety of environmental contaminants at relatively low concentrations. In some of these people, a diagnosis of multiple chemical sensitivity (MCS) suggests that it is virtually impossible to separate assessments of the quality of the indoor environment from the unique vulnerability of some building occupants. The pathophysiology of MCS is uncertain and controversial, although an increasingly robust scientific database supports the importance of this phenomenon (National Research Council, 2002). It is, therefore, difficult to draw a distinct line between a building with an unhealthy indoor environment and one in which a subset of building occupants appear to have heightened sensitivity to often poorly defined but ordinary environmental contaminant levels.

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Building-Determinants of Indoor Environmental Quality, Comfort, and Health Building Material Emissions and Reactivity Building operating conditions and products used in building design and operation create an environment in which complex emissions and chemical reactions can occur. Direct emissions from building materials (primary emissions) are generally highest soon after manufacture and construction and diminish thereafter. Secondary emissions are caused by the actions of other substances or activities on the material. For example, moisture, alkali in concrete, ozone from electronic equipment, or cleaning materials can influence emissions from building materials. Secondary emissions may be a chronic problem (Sundell, 1999). Cooler surfaces on a wall can increase local relative humidity facilitating emissions from wall-covering material. Humidity or dampness in concrete floor construction facilitates alkaline degradation of di-ethyl-hexyl phthalate (DEHP), a plasticizer used in polyvinyl chloride (PVC) floor covering as well as other PVC products. Ozone that gains entrance from the outdoors or that is emitted from photocopiers or laser printers can react with unsaturated double bonds in various polymers to create aldehydes and ketones. These secondary emissions may be highly reactive, and irritate skin and mucous membranes of building occupants (Wolkoff et al., 1997). Nitrogen oxides from outdoors or generated from photocopiers or laser printers can also react with a variety of VOCs to form irritant compounds, including aldehydes (Wolkoff et al., 1997). Highly reactive free radicals are also formed by reactions of NO2 and ozone with unsaturated compounds. Many of these compounds are not easily measured, yet they may be highly relevant in terms of health effects. Indoor Pollutants Associated with Building Operations and Maintenance Building design decisions can also influence which products are used in routine building operations and maintenance, and thus influence indoor environmental quality. Some cleaning products contain respiratory tract sensitizers or irritants. Even cleaning products promoted as “greener” sometimes contain citrus or pine-based materials that can themselves, or in reaction with oxidants such as ozone, contribute to indoor air pollution. Occupants of buildings cleaned more often that once weekly tend to report fewer building-related symptoms (Skyberg et al., 2003). Building and landscape design can influence the likelihood of indoor pest problems. Routine use of integrated pest management strategies can reduce indoor and outdoor pesticide use, thereby contributing to improved indoor environmental quality.

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Ventilation High- or low-ventilation rates can have a significant impact on symptoms. Limited evidence suggests that ventilation rate increases up to 10 L/s per person may be effective in reducing symptom prevalence and occupant dissatisfaction with air quality; higher ventilation rates are not effective (Spengler and Chen, 2000). But because of complex relationships among ventilation rates, contaminant levels, and building-related health complaints or satisfaction with air quality, the use of ventilation as a mitigation measure for air quality problems should be tempered with an understanding of its limits. Dampness and Humidity Building dampness can facilitate mold growth, particularly on surfaces with organic material that can serve as a nutrient source. MVOCs can also be emitted from heating, ventilation, and air-conditioning (HVAC) systems. Fung and Hughson reviewed all English language studies (n = 28) on indoor mold exposure and human health effects published from 1966 to 2002. They concluded that excessive moisture promotes mold growth and is associated with increased prevalence of symptoms due to irritation, allergy, and infection. However, methods for assessing exposure and health effects are not well standardized (Fung, 2003). Surface Materials Several studies show a correlation between certain materials on interior building surfaces and risks of asthma, wheezing, or allergy. Materials that may be causally related to these symptoms include PVC flooring and wall coverings, new linoleum, synthetic carpeting, and particle board (Jaakkola et al., 2004). Increased risk of childhood risk of bronchial obstruction, wheezing, and allergic symptoms is reported associated with PVC plastic and plasticizer-containing surfaces. (Bornehag et al., 2004a; Jaakkola et al., 1999; Norbäck et al., 2000; Oie et al., 1999; Tuomainen et al., 2004). Particulate Air Pollution Particulate indoor air pollution is of variable size and composition. Particulates may contribute to building-related symptoms in occupants, but the relative contributions of particle size, particle mass, and particle composition are uncertain (Christensson et al., 2002). High-speed floor polishing can contribute significantly to airborne particulates, depending on the equipment used and the nature of the surface material (Bjorseth et al., 2002; Roshanaei and Braaten, 1996).

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Health Impacts Beyond the Building It is also important to acknowledge that hospital design, construction, and operating decisions can have far-reaching public environmental health effects from water and energy consumption, materials transportation, and occupational health concerns throughout the materials supply chain. Releases of environmental pollutants from materials extraction, manufacturing, and disposal practices can have regional and even global consequences for public environmental health. Building designers have an opportunity to influence worker and public environmental health through informed materials selection and attention to worker and social justice concerns. In addition, it is essential to begin to address explicitly the long-term public and environmental health impacts of healthcare activities themselves. Those activities are rarely subject to the same scrutiny to which we subject the building infrastructure. In the United States, expenses related to health care make up about 15 percent of the gross national product. This amount is growing annually, and much of the growth can be attributed to the development of new technologies, each with its own implications for public environmental health. Resource extraction, materials manufacture, and disposal are responsible for most human impacts on the natural world. The scale of healthcare activities and life cycle impacts of related flows of materials contribute substantially to environmental degradation. High-tech equipment, pharmaceuticals, transportation, and water and electricity consumption in health care have major environmental impacts. Despite the commitment of most countries to growth, material throughput must be drastically scaled back in order to achieve sustainability. The healthcare system must do its share. Pierce and Jameton have made a strong argument for health care’s particular ethical responsibility (Pierce and Jameton, 2004). Marginal improvements in materials policies may help, but a fundamental reexamination of the scope of clinical services is also required. This may inevitably lead to concerns about rationing, but rationing, according to Pierce and Jameton, should not be thought of as less than optimal care but rather as sustainable optimal care, if the healthcare industry is going to meet its ecological responsibilities. Conclusions Buildings are complex dynamic systems composed of multiple materials assembled and operated in ways that create an indoor environment with considerable heterogeneity in space and time. Building-related illnesses result from multiple factors that are often difficult to quantify and that interact in complex ways. Considerable additional research is necessary in order to advance the understanding of building-related health effects. Statistical techniques used in the analysis of complex dynamic systems may be helpful and should be further explored.

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary Although it is difficult to establish clear-cut evidence-based guidelines for all aspects of building design, construction, and operation, several themes emerge from the published literature. Low-emitting materials should be selected. Materials that might support mold growth should be reduced. Building design, construction, and operations should ensure that moisture does not accumulate. Material selection should be influenced by cleaning requirements and the extent to which cleaning may contribute to VOC and particulate concentrations. Low-emission materials, along with appropriate ventilation, temperature and humidity control, will contribute to improved indoor air quality. Individual, community, and ecological health are interpenetrating. They are influenced by building design, construction, and operating decisions and should be routinely assessed during planning stages. Along with attention to direct and indirect impacts of building design, construction, and operating decisions, a fundamental reexamination of the scope of clinical services is also required, if the healthcare industry is going to meet its ecological responsibilities. BUILDING GREEN ON A LARGE SCALE Scott Slotterback Often culture drives decision making. Typically we get answers to only the questions we ask. At Kaiser Permanente we believe it is time to start asking different questions. It is time to imagine a future filled with potential and ask the questions that will help us realize that vision. We plan on being a part of that positive future. As Marshall McLuhan said, if we drove the way we typically plan we would spend most of our time looking into our rearview mirrors and we would all crash our cars. All too frequently when we plan the future, we focus on the past, so we can build on a strong foundation, correct our prior mistakes, and gradually make transitions. In slower times this was quite effective. However, with today’s rapid pace of change, we need to look into the future just to stay current. This is especially true when building green on a large scale. As we set out to design and construct buildings that embody Kaiser Permanente’s vision for environmental performance, we seek answers to questions the marketplace has not been asking. We ask for products that do not yet exist. We create incentives for manufacturers to provide these products. And we buy the products that meet our grueling criteria. Building on a large scale does have its advantages, and we are using these advantages to facilitate a market transformation in green buildings for health care. How big is the “large scale” I am talking about? I must admit being in Washington, DC, where people commonly talk about trillions of dollars being spent, it is a little intimidating to talk “large scale.” I am not talking about trillions, but I am talking about billions and millions. Kaiser Permanente plans to spend more than $20 billion on its capitol program over the next 10 years. We currently have

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary 8.3 million members in nine states and the District of Columbia. We have 60 million sq. ft. of occupied space in over 900 buildings. We are planning to build 14 seismic replacement hospitals, six new hospitals, three major hospital bed expansion projects, and numerous hospital renovation projects and new medical office buildings along with the central utility plants and the parking structures needed to support them. So to me, that seems to be reasonably large scale. Because six million of the of the eight million members of Kaiser Permanente reside in California, my colleagues here in the mid-Atlantic region often point out that we are somewhat less of a household name here in Washington than we are in my home town of San Francisco, California. So I will give you a quick overview of how we are structured, since even though we are large, we may not be familiar to you. The organization known commonly as Kaiser Permanente is actually three companies in one. Kaiser Foundation Health Plan, Inc. is a nonprofit insurance company. Kaiser Foundations Hospitals is also a nonprofit company that manages the hospitals, and the Permanente Medical Groups are the for-profit associations of physicians. Together, these three organizations make up our integrated model of care; from insurance carrier, to physician, to hospital and staff. So those of us, like me, who are focusing on the design and construction of the hospitals and other buildings are very closely tied to the users of these buildings: our physicians, staff, and members. As a result we care a great deal about their health and safety. Building green on a large scale is not only about the health and safety of our physicians, staff, and members, but it is also about the health of our communities. To lead this effort Kaiser Permanente established an Environmental Stewardship Council, which is charged with achieving Kaiser Permanente’s vision for environmental performance. Our vision is stated in one far-reaching sentence: We aspire to provide healthcare services in a manner that protects and enhances the environment and health of communities now and for future generations. For us green building is not limited to impacts our buildings have on the people who use them. Green building also includes the downstream impacts on the communities that make the building materials and our community at large. How do we define green? Actually, we have turned to others to help us clarify that concept. In 2002 we used the ASHE Green Guidance statement as the foundation for our own Eco Toolkit, a document that links Kaiser Permanente’s robust design standards program to the green practices identified in the ASHE statement. Today we are using the Green Guide for Healthcare (GGHC) as a green training tool, a success-measuring tool, and as the foundation for our next generation of our Eco Toolkit. The GGHC provides us with a national standard to objectively measure our success. What are we doing to implement our grand vision of a positive future? Let me give you a few examples. I would like to talk to you about the numerous green initiatives Kaiser Permanente is implementing on building projects, but there is not time in this presen-

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary tation, so I will summarize a few of them and discuss one or two in more detail to illustrate how we are overcoming institutional barriers to building green. Before I focus on specific examples, I would like to discuss how we are dispelling one of the institutional barriers to sustainable design—increased costs. How many of you have been told at one point or another that building green costs more? Does this have to be true? We do not think it does, and we are proving that many green measures can be implemented without adding costs. Many of the green measures we are testing on projects that we are building today are cost neutral, and some are significantly reducing costs. Here is a quick summary of the results of some of these efforts. Since 1998 we have had an alliance program that brings together architects, engineers, and contractors to work with our physicians, staff, and other owner representatives, starting in the early phases of the project to provide an integrated design process. Having all these stakeholders working together builds a shared understanding of the value of green measures and enhances their continued implementation when the building is completed and occupied. Permeable paving, which allows water to filter back into the aquifer, is currently being tested on a 50-acre new medical campus. Although the paving is more expensive than conventional paving, when we looked at the issue systemically we found that using permeable paving eliminated the need to connect the project to the city’s storm water drainage system. This saved us the cost of running almost a quarter mile of storm water piping which saved us a significant amount of money. Our design standards recommend that drought tolerant native species be used in landscaping to reduce our water consumption, which saves water costs and maintenance costs. We are increasing the access to daylight and views of the natural environment for our patients and staff, improving the quality of the work environment with little or no additional costs. On one project we are using a photovoltaic array to screen views of rooftop mechanical equipment. By taking advantage of state-sponsored energy credits, this system costs less than a conventional mechanical screen. We have also taken significant steps toward eliminating the use of PVC in building materials. That is a quick overview of just a few of our efforts. Today I would like to focus on some of our materials and resources initiatives because they have direct health impacts on our staff, patients, and communities. And it is an area that would benefit from additional research. This is a story that illustrates how we were able envision a future that is quite different from the present and ask for products that did not exist at the time. As large-scale consumers, we were able to create incentives to transform the market place. Kaiser Permanente’s National Facilities Services (NFS) division manages the design, construction, and operation of all our buildings. NFS has a robust standards program to control quality, facilitate design, ensure operational efficiency, and promote our green buildings program. The national purchasing agreement

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary (NPA) program was established in 1991 and is an integral part of this effort. The NPA is comprised of 25 contracts with manufacturers of contractor-furnished and installed systems and materials. It includes a wide variety of items from lighting and HVAC equipment to flooring and ceiling tiles. The intent of the program is to partner with the manufacturers to realize the goals of our standards program while reducing our first and life cycle costs. Compliance with the NPAs is mandatory for our designers, and our strategic alliance allows us to help develop products and systems that meet our specific needs. In 1993 Kaiser Permanente negotiated the first NPAs for carpet. We included in our request for proposal (RFP) a requirement that bidders state what they were doing to reduce waste and support recycling. We were not pleased with the responses we received. The responses either omitted recycling or included programs that sent carpet to road construction contractors for curing concrete, a onetime reuse, then it was thrown away. Only one company was actually recycling carpet. The rest did not comprehend why we were even asking the question. That one company, C&A, was successful in becoming part of the NPA along with two other companies. In the next nine years we dropped one of the three companies, continued to partner with C&A, and tried to work with the other company to enhance recycling and landfill diversion. In 2002, when the NPA contracts for carpet came up for renewal, Kaiser Permanente decided to focus on sustainability in looking at our current and potential partners. Our negotiating team included interior designers, a representative from our environmental services (janitorial) division, as well as our director of environmental stewardship. We also included two other members of our green buildings committee: an outside architect and a representative from the Healthy Building Network. The team was charged with focusing on three main criteria in evaluating current and potential bidders: sustainability, product performance, and aesthetics. The negotiating team conducted research into the carpet industry to identify which companies were truly leading the charge to sustainability. We also met with fiber manufactures to try to better understand the environmental impact of carpet fiber. After sorting out the facts from the “greenwashing,” the team decided to look at five carpet companies, including the two under contract. The three other mills were included based on their leadership in the industry for sustainable practices. The negotiating team then prepared an RFP, which was sent to all five companies. The Healthy Building Network helped us by developing a very detailed questionnaire that looked at the environmental impact of carpet from manufacturing to the end of its life and beyond. The RFP contained an extensive product performance questionnaire that included a requirement for impact test results for the backing. This is because we needed to determine if their backing was truly impermeable. They were also required to submit carpet samples of the products that they proposed for inclusion in our standards. Each company was then invited

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary to make a presentation to the team that focused on sustainable practices, their healthcare product line, and product performance. The team then met and scored each company based on the selection criteria. Sustainable issues were given 45 percent weight, product evaluation was given 45 percent weight, and green innovation was given a 10 percent weight. As with Microsoft and Hewlett-Packard, a major issue for Kaiser Permanente is eliminating PVC from products because it contributes to dioxin pollution (Microsoft is curbing use of PVC, 2005). Based on our assessment of carpet in our existing facilities, there was no question that vinyl-backed carpet outperformed broadloom and had the advantage of potentially being recycled into new carpet at the end of use. Our hope was to find non-PVC backed carpet that would have similar performance characteristics to the vinyl-backed products we were using. However, none of the non-PVC-backed products passed the dynamic impact tests we required. So the team focused on what companies were doing in their research and development to create an alternative to PVC and how likely they were to partner with Kaiser Permanente in that quest. Based on our analysis of the five companies, Kaiser Permanente did not renew the contract with one of the original two companies and added a new one. These two manufacturers were C&A and Interface. Both carpet manufactures were given two years to develop a non-PVC-backed carpet. We monitored each company’s progress, pilot tested PVC-free carpets as they were developed, and reviewed the lab tests we required. Last year C&A developed Ethos, a carpet with backing that has the same level of performance as PVC without the PVC. Ethos uses a backing material that is reclaimed from laminated safety glass. As a result, the backing has 96 percent postconsumer recycled content. Needless to say, our carpet NPA is now solely with C&A. The market has been transformed. Kaiser Permanente is paying the same amount for its carpeting, and Ethos is now available to other healthcare carpet consumers. Where Do We Go from Here? We have revised our standards to require the use of sheet flooring and tile flooring that do not contain PVC. Currently these products are not less expensive than the products they are replacing. However, as we explore the health impacts of these products and the products used to clean and maintain them we are finding other advantages. The alternative flooring products we are using, Stratica by Amtico and Nora rubber flooring, have a higher coefficient of friction, and early studies of facilities where they have been used are indicating a significant reduction in slip, trip, and fall injuries as compared to our facilities with vinyl flooring. Stratica and Nora rubber floors also do not require waxing and buffing, which results in lower maintenance costs. We believe eliminating waxing and buffing also results in less asthma-triggering particulates and harsh chemical fumes

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Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary in our facilities, which should have a beneficial health impact on our patients, physicians, and staff. There already is some research and scientific literature to support these conclusions, but there certainly is room for more (Bornehag et al., 2004b). Consumers, like us, would benefit from additional research on the health impacts of the products we use to build and maintain our facilities. We also would benefit from a product content labeling system that reveals the chemicals that are in the materials we use to build and furnish our facilities. This would enable consumers to make informed choices. It will help us fulfill our environmental mission and facilitate our ability to make informed decisions that will benefit our health and the health of generations to come.