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

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.

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.

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.

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,

• 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.

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.

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.

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

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.

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—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.

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-

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.

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.

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

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.

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.

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.

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.

Anthony Bernheim FAIA, LEED AP

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.

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

• 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.

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)

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

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.

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

these specification requirements into several of our upcoming projects, including a medical office building for the University of California, San Francisco; the Osher Center for Integrative Medicine; a large San Francisco hospital complex; and a new, 1.5 million-sq.-ft. State office building, the West End Office Complex. The guidelines have been incorporated into the California Collaborative for High-Performance Schools program, and they are referenced in the Green Guidelines for Health Care and the USGBC LEED green building rating system for new construction, version 2.2.

Numerous building products, including ceiling tiles and floor materials, have been reformulated by their manufacturers to reduce chemical emissions based on these specifications, and more recently, many industry trade groups have developed or are in the process of developing certifications to indicate some level of compliance. Examples include the Carpet and Rug Institute’s Green Label Plus program and the Resilient Flooring Institute’s FloorScore Seal (CRI, 2004; SCS, 2005). Recently, the GreenGuard Environmental Institute introduced its Standard for Children and Schools, which is a certification program for low-emitting products and materials commonly used in school buildings, classrooms, and day care facilities. Scientific Certification Systems has developed indoor air quality certifications for building products called Indoor Advantage and Indoor Advantage Gold.

Over the last 25 years, much attention has been given to improving indoor air quality as a result of the practical application of scientific research. Based on studies, papers, and conferences, the new high-performance buildings of today are an embodiment of this work. Architects and engineers are responding with a new consciousness about occupant health, producing new building designs, systems, and specifications. The manufacturing industry is responding with reformulated and new green products. Some independent third-party material certifications are now becoming available to give building material specifiers more confidence in selecting healthy materials, and the construction industry is responding by incorporating green construction methods and adhering to the requirements of the USGBC LEED rating system.

However, much more research is needed to better understand the complex nature of indoor air quality and the human response to specific environments. For example, one area of study that has so far been overlooked is the design of good air quality in healthcare facilities, where the staff spends long hours and where the patients may be more sensitive to the air quality because of their own compromised health conditions. These environments present special challenges based on high-ventilation rates, code-mandated ventilation requirements, and 24-hour operation. It is also important for physicians to be trained to identify and diagnose the health effects of indoor air quality on their patients. Scientific researchers are

beginning to establish these connections, and it is now very important to continue to verify this work in practice.

Despite the work yet to be done, there is a major national shift toward green building with significant new knowledge in building-occupant health. With the unfolding of the 21st century, sustainable design and green buildings will become the norm rather than the exception as their design requirements and efficacy are better understood. When this happens, both global ecological health and individual health will have taken an enormous leap forward.

Judith Heerwagen, Ph.D.

Hospitals are in the business of caring for ill or injured patients and returning them to a more positive state of health. Although there are many institutional and technological factors that influence patient outcomes, it is worth asking how the physical setting and, in particular, sustainable design practices can support patient recovery during hospitalization.

Although there is a growing body of literature on the relationship between the physical hospital setting and patient outcomes, theory and practice has progressed without attention to sustainable design (Ulrich et al, 2004; Rubin et al., 1998). This presentation focuses on how the two fields can be more effectively integrated through application of positive design principles.

Positive design integrates risk reduction with experiences that promote emotional, psychological, and social well-being. As noted by Antonovsky in his development of a “salutogenic” approach to health, reducing illness factors does not by itself lead to positive states of health (Antonovsky, 1987). He sees health and illness/disease as lying on a continuum, with different factors contributing to one’s location on the continuum. In other words, being healthy and in a state of well-being is not just the absence of risk factors. Health and well-being are supported by a different set of factors.

Although Antonovsky focuses primarily on personal coping factors, his general framework is useful for conceptualizing how the hospital physical environment can be health promoting. First, a brief discussion of well-being is valuable because the concept is not well integrated into sustainable design. The health concerns in sustainable design have centered on a limited number of factors, especially improved indoor air quality. However, there is increasing evidence that a host of building features have positive effects on well-being.

A recent study of people’s perceptions of well-being by Schickler found three key domains:

• Feeling—experiencing positive emotions and sensations, feeling happy and optimistic

• Doing—being actively engaged, moving toward goals, participating in decision making, and experiencing a sense of control

• Being—a state of quiescence, being reflective, or experiencing peace and quietness (Schickler, 2005)

These domains are consistent with the “positive” psychology movement that focuses on the antecedents and consequences of well-being and happiness (Seligman and Csikszentmihalyi, 2000). The positive psychology movement emerged in the 1990s with the growing realization that psychologists knew much about mental and behavioral pathologies, but relatively little about positive behavioral and emotional experience that underlie quality of life and sense of well-being.

The arena of positive psychology is highly relevant to patients, staff, and visitors in healthcare settings. As noted before, the links between health and sustainable design currently focus on improved physical health through improved indoor air quality and reduced exposure to airborne biological or chemical substances. Much less attention is paid to how sustainable design can support positive mental, emotional, and social experiences that underlie concepts of well-being. For design applications, two questions need to be addressed: (1) what experiences underlie a sense of well-being, and (2) what features and attributes of the environment support these experiences?

Theory and research in biology and behavioral ecology suggests that well-being needs have a strong evolutionary basis (Boyden, 2004; Orians and Heerwagen, 1992) and are linked to specific environmental features and attributes. Well-being needs relevant to the hospital environment include the following:

• Emotional and social support

• Low levels of sensory stimulation similar to those in natural habitats (absent storms or extreme weather)

• An interesting, aesthetically pleasing environment

• Opportunities for recreational activities, including music, dance, and art;

• Connection to nature and natural processes

• Privacy when desired

• Opportunities for rest and psychological recovery

These needs are consistent with surveys of hospital amenities and features that patients want. A recent study by Douglas and Douglas found that patients wanted personal space, a homey atmosphere, a supportive environment, good physical design, access to external areas, and provision of facilities for recreation and leisure (Douglas, 2004). In contrast to the desired environment, many patients experience loss of emotional and social support, boredom, loss of control, absence of natural stimulation, presence of technological stimulation, noise, and feelings of isolation. According to Boyden such environments are in a state of psychosocial deprivation (Boyden, 2004). How can the hospital environment be transformed to create more positive, healthy conditions for patients as well as for staff, and visitors?

Research in hospital settings shows that a number of environmental features identified in Table AB-1 are associated with improved patient health and wellbeing outcomes, including improved mood, improved sleep, reduced stress, lower pain levels, and reduced length of stay in the hospital (see extensive reviews of the literature in Rubin et al., 1998; Ulrich, 1991, 1999 ; Ulrich et al., 2004). For instance, key environmental factors influencing health and wellness include the following:

• Sunlight in patient rooms

• Views to sunny spaces outdoors

• Increased individual control over ambient conditions

• Reduced noise with acoustical surface treatments in patient rooms and intensive care units

• Improved privacy and social support with single-bed rooms, more homelike settings for patients and families in hospital rooms, and social spaces that encourage conversation and interaction

• Connection to nature through windows, outdoor gardens, and simulated nature (videos, posters, and paintings)

• Carpeting to soften noise and provide a more comfortable and less slippery surface for walking, especially for elderly or infirm patients

• More pleasing aesthetics and layout, especially a more “homey” or hotellike room as compared to the institutional look of traditional hospital spaces

Returning to Antonovsky’s concept of a health continuum, with disease/illness at one end and health/well-being on the other, it is possible to develop a framework for positive hospital design linked to reduction of health risks and the addition of health and well-being benefits. See Table AB-2.

The approach to hospital design suggested in this presentation is not a to-do list. Rather, it suggests a central organizing perspective that begins with theoretical concepts of what it means to be healthy and in a state of well-being. As such, it suggests a system of design interventions and a rationale for their incorporation into hospital design. Hospitals need to do more than avoid harm. As has been rightly pointed out by Ulrich, a hospital needs to provide supportive factors also (Ulrich, 1991, 1999). Whereas Ulrich’s supportive design perspective centers on stress reduction and coping, the ideas presented here are derived from theory and research in positive psychology and evolutionary biology. The two perspectives are highly compatible, but look at the hospital situation through different lenses. The value of starting with evolved well-being needs is that the focus is on the patient’s experience in a more general way; the process of design then works outward from this central concern. Well-being needs are relevant to all healthcare settings. However, the specific needs that should be emphasized are likely to vary, as will the solutions depending upon the context (type of health care facility, patient demographics, culture).

At this time, it is not clear how many of the positive features need to be incorporated into health care buildings in order to move patients and staff to the positive end of the continuum. Do all well-being needs have to be fulfilled or just some? What needs are most important in different contexts or at different ages?

Many of the design features associated with both risk reduction and health promotion are incorporated into sustainable design approaches, including improved indoor air quality, control of toxic exposures, daylight, and views. However, other factors may run counter to sustainable principles. For instance, noise reduction through use of soft surfaces (carpeting, acoustical tiles, panel systems) may reduce air quality because of increased surface area for particulates to gather as well as a greater need for cleaning. Single-bed rooms and other social amenities, both in patient rooms and elsewhere, may increase the overall footprint of the space and require additional materials. However, if these factors are important to patient recovery, they should be provided in the most sustainable way possible.

Robin Guenther, AIA LEED AP

“If there is one universal truth about hospitals, it is that they are drab, dismal places, not at all designed to soothe and heal” (Alvarez, 2004). This article headlined the health section of the New York Times late in 2004 in a cover story that compared the state of U.S. hospital design to hospitals recently constructed in Europe. Specifically, the article showcased the Rikshospitalet in Oslo, Norway, as a “model hospital.” Why? What is it about the Oslo structure that yields such a critical comparison to U.S. initiatives? Interestingly, in a 2004 presentation to the American Institute of Architects (AIA) Academy on Architecture for Health, Paul Hyett, RIBA, a UK healthcare architect, summarized the major differences as follows: new technologies in modern architecture produced the high-rise, deep plan, sealed environments that characterize U.S. healthcare buildings, resulting in buildings that are inappropriately low in thermal mass and too heavily dependant on artificial systems.

Architecture is a product of social, economic, political (and yes, environmental) systems and culture. Buildings, ultimately, reflect the goals and values of a society. As Winston Churchill so aptly put it: “We shape our buildings, and then our buildings shape us.” Why have our hospitals lost the connection to nature and the vitality that inspires the Rikshospitalet? Does sustainable design have the capacity to transform healthcare architecture? And if so, how do we get there from here?

The annals of Bellevue Hospital tell the history of the development of American medicine. The first public hospital in the United States, Bellevue relocated to

the banks of the East River in the early 1800s, away from the dense city, on a site that afforded clean river breezes, fabulous views, and, not incidentally, a convenient river in which to dump the waste. Public health emerged with compelling ideology about the relationship between social conditions in urban environments and disease. By the late 1800s, the city had hired the most famous architects of the day—McKim Mead and White (famous for designing Newport mansions for the wealthy)—to design a major series of pavilion structures to provide health care for the teeming immigrant population of New York City. These pavilions, based on what were known as “Nightingale/Lister principles,” featured clean air and fresh water, access to light and views, and focused on allowing nature to heal—with some able assistance from physicians.

By the 1970s, less than 50 years after the completion of the pavilion plan, Bellevue had demolished three of the four pavilions in order to complete the “high-rise hospital,” a 22-story hospital building of 1.5 acres per floor (56,000 sq. ft.)—a massive building where fewer than 10 percent of the space had access to natural light, and no space had operable windows. In this generation of healthcare construction, the technological advances in medicine and surgery drove larger and larger contiguous floor plates to accommodate the rigors and requirements of the machine. “Systems thinking” (note the diagrams alongside the Bellevue plan) reduced healthcare planning to a series of flow diagrams—flow of people, equipment, and supplies. At the same time, advances in artificial lighting technology and mechanical ventilation supported the redefinition of buildings as “machines for healing.” In the span of two generations, we relegated 19th-century ideas about nature and healing, as well as an underlying framework of public health, to “nice if you can achieve it” status while we moved on to the serious work of defining the modern hospital and modern medicine, according to the “machine metaphor.”

At the same time, the rapid pace of technological change in health care has outstripped healthcare construction, resulting in facilities that are poorly suited for their function. In urban areas, multiple building campuses spanning a century or more of construction activity are commonplace. The sheer volume of U.S. healthcare construction activity, at more than 100 million sq. ft. annually, attempts to keep the industry current in meeting the growing healthcare needs of citizens. As this happens, the sector consumes an ever-growing segment of the U.S. annual energy bill. As long ago as 1995, healthcare buildings were estimated by the Department of Energy (DOE) to be responsible for 6 percent of total annual energy use (EIA, 1995). Growing concerns about seismic activity on the West Coast has triggered a major healthcare reconstruction program, and the aftermath of Hurricane Katrina will have a huge impact on Gulf Coast healthcare reconstruction.

At the same time that this fascination with technology has consumed the healthcare design world, a quiet transformation has begun in medicine. AIDS, cancer, and the mind-body movement have each challenged mainstream Western medicine’s continued stratification into treating “disease” rather than “people.” Medicine must increasingly respond to multiple-cause conditions that require multiple therapies. As management of chronic disease replaces the focus on curing the episode, the healthcare industry is entering a period of radical transformation.

The disciplines of public health, environmental medicine, and ecological medicine are emerging as physicians come to understand that our chronic health problems are linked to the environment. Already, we can begin to see the programmatic impacts of these understandings. In design, evidence-based research into the impact of the built environment on therapeutic outcomes and the sustainable design movement are coalescing into a powerful new vision for healthcare architecture.

With regard to planning, evidence-based research surrounding the effect of the built environment on therapeutic outcomes is challenging the prevailing planning models of hospital architecture. In the early 1980s, Edward Wilson’s classic book, Biophelia, made a strong scientific argument that our affinity for life is the essence of our humanity and binds us to all other living species. This important reconnection informed a wide body of environmental design theory and research into human response to nature, particularly in times of acute stress.

More recently, the work of the Center for Health Design has reinvigorated the discourse concerning linkages between the quality of the built environment and therapeutic outcome. Important evidence-based research by Roger Ulrich linking views of nature to improved recovery rates among cardiac patients has long been recognized in the healthcare planning community. Claire Cooper Marcus’ work on the programming and development of healing gardens for healthcare settings is a related area of intense study. Yet despite these important studies, hospitals continue to place more importance on direct horizontal adjacency between operating rooms and recovery spaces than on the therapeutic impact of daylight on patient recovery rates.

As the sustainable design movement generates similar research findings from other building types that promotes closer harmony between buildings and nature—landscape, views, and daylight—evidence-based design and sustainability will coalesce to create a powerful new planning archetype for hospital buildings. The impact of this work on building form can not be underestimated and may provide the impetus for more radical revision of the shape of healthcare buildings far beyond the 20th-century metaphor of “building as machine.”

Likewise, public health increasingly links the built environment to health status of the nation’s citizens. For example, Urban Sprawl and Public Health is concerned with the connections between suburban development and obesity (Jackson and Frumkin, 2004). The media continues to press these linkages: a 2001 cover

story of Business Week asks the provocative question: “Is Your Office Killing You?” in relation to a myriad of indoor air quality concerns (Conlin, 2000). In fact, building design, materials, and construction practices are responsible for a wide variety of environmental issues that affect human health. Buildings account for somewhere between 40 and 50 percent of fossil fuel emissions (more than the transportation industry, once we reassign transport of building materials), more than 30 percent of raw material extraction, more than 25 percent of potable water usage, and buildings generate more than 30 percent of the solid waste stream. The Metropolis magazine cover, in October 2003 proclaimed a truth many of us would rather not be reminded of: “Architects Pollute.”

The federal government recognizes these linkages when it defines green building as “the practice of increasing the efficiency with which buildings and their sites use energy, water, and materials, and reducing building impacts on human health and the environment through better siting, design, operation, maintenance and removal—the complete building life cycle.”

In response to the need for a tool to assist in defining green buildings in the marketplace, the nonprofit U.S. Green Building Council (USGBC), founded in 1993, launched LEED, a third-party certification system for defining and rating sustainable buildings. LEED is not only a point-based metric tool for defining best practices in sustainable design and construction but also a third-party certification system for verifying achievement. Through a rigorous registration, documentation, submission, and certification process, new buildings attain a rating at one of four levels: LEED certified, silver, gold, or platinum. The USGBC sought to attract the top 25 percent of the green buildings in the for-profit commercial building marketplace; almost immediately, however, state and municipal governments began adopting the rating system as a minimum standard of construction (Progress Report on Sustainability, 2003). LEED is not explicitly health focused.

Although the LEED program has been successful in registering and certifying commercial office buildings, university buildings, and the like, its adoption by health care has been relatively limited. In December 2003, Boulder Community Foothills Hospital became the first healthcare facility to achieve LEED Silver certification. This 60-bed, $53 million, 200,000-sq.-ft. facility was followed less than one year later by the Discovery Health Center (LEED certified at 28,300 sq. ft.). In February 2005, the Emory Winship Cancer Center (LEED certified with 260,000 sq. ft., costing $75.7 million) became the third healthcare facility LEED certified. Each manifests core principles of using healthy and low-emitting materials, abundant daylight, efficient energy systems, and careful regard to site considerations, among other green design features. At this writing, there are a total of 57 healthcare projects registered in the program, representing just over 17 million sq. ft.

The reasons for this, we believe, lay in three important areas:

• There was no explicit connection to human health; green building was viewed as being “good for the environment”—no explicit value connection.

• Substantive differences exist between commercial office buildings and acute care facilities that the LEED rating tool did not recognize—a poor fit.

• Healthcare construction is accomplished by a specialized segment of the architecture and design field that was relatively disconnected from the environmental building movement—lack of education.

The Green Guide for Health Care was developed to address the challenge of moving the green building agenda into health care. The charge: to make an explicit “health value” connection through a tool that “fit” the sector, and educate the industry to use the tool.

To develop a tool to fit the sector, it was necessary to understand the environmental footprint of the healthcare industry. So, what is the environmental footprint of the healthcare industry? How is it measured?

In 1996, medical waste incineration was named as the second leading source of dioxin emissions in North America (EPA, 1996). Since then, the number of medical waste incinerators has decreased from 5,600 to just over 100, as the industry has moved to clean up its operation. The use of mercury in the healthcare sector has sharply declined since the late 1990s, with a voluntary goal of virtual mercury elimination set for 2005. In operations, the industry has achieved compelling victories. As a result of that work, we knew that many hospitals had “environmental champions” that were making great progress in pollution prevention initiatives.

In October 2000, Health Care Without Harm, Kaiser Permanente, and Catholic Healthcare West came together at a landmark conference, “Setting Healthcare’s Environmental Agenda” (SHEA), in Oakland, California. The conference began with a challenge issued by Michael Lerner, Ph.D.: “The question is whether healthcare professionals can begin to recognize the environmental consequences of our operations and put our own house in order. This is no trivial question” (Lerner, 2000).

David Lawrence, chairman and CEO of Kaiser Foundation Health Plan, the largest nonprofit healthcare system in the United States, said, “Just as we have responsibility for providing quality patient care [and] . . . keeping our facilities and technology up to date, we have a responsibility for providing leadership in the environment” (Lawrence, 2000). Lloyd Dean, president and CEO of Catholic Healthcare West, agreed, adding this challenge: “We will not have healthy individuals, healthy families, and healthy communities if we do not have clean air, clean water, and healthy soil” (Dean, 2000).

As pollution prevention initiatives took hold, explicit connections between

health care’s environmental footprint and human health were being increasingly recognized. Greener Hospitals, published in Germany by Bristol Myers Squibb, included the triangular diagram linking environmental impacts of healthcare delivery to increased environmental stress and illness.

It is imperative for the design of “high-performance healing environments” that the alignment between sustainability and health care’s primary mission—to heal—is explicit. In 2002, the American Society for Healthcare Engineering (ASHE) issued a green healthcare construction guidance statement that made just such an explicit statement. The introductory statement of principles asserts the importance of protecting health at three scales:

• Protecting the immediate health of building occupants

• Protecting the health of the surrounding community

• Protecting the health of the larger global community and its natural resources

How will we measure our performance in the area of environmental stewardship? How will we objectively assess the size of our environmental footprint? The Green Guide for Health Care was developed to respond to these questions. It is the first healthcare-specific metric self-certification tool for guiding continuous environmental improvement in the healthcare construction and operations world.

Conceived of as a tool for organizations and their project teams to use in designing and operating facilities, the Green Guide emphasizes environmental and public health issues in evolving strategies for creating “high-performance healing environments.” It synthesizes program, planning, and materials/systems strategies, as outlined above, to provide the most comprehensive guide to the design of healing environments yet undertaken by this industry.

The Green Guide adopted ASHE green healthcare construction guidance statement of principles. It reaffirmed a principle of precaution, echoed in medicine and international sustainable design policy. From LEED, with permission, it gained credit structure, content, and organization. Building upon the work of Hospitals for a Healthy Environment (H2E), it reinforced the commitment to the EPA memorandum of understanding and defined a comprehensive approach to healthcare operations. From the early healthcare green building adopters, it evolved rigorous materials evaluation requirements, particularly with regard to emissions and persistent, bioaccumulative, and toxic (PBT) compound avoidance. It reinforced principles of evidence-based design, through emphasis on daylighting, acoustics, and places of respite.

Finally, the Green Guide recognizes that the healthcare industry is in the early stages of sustainability development and is adverse to regulatory enactment.

The Green Guide does not establish minimum achievement thresholds. It is a self-certification tool with an emphasis on promoting best practices within the industry by instilling a culture of internal assessment, evaluation, and continuous improvement. Since its initial release in 2003, the Green Guide’s goal of transforming the healthcare sector’s building portfolio into healthy, high-performance healing environments is being realized through a measured approach grounded on best practices, industry partnerships, and implementation feedback. As an evolving document, it continues to be refined through an update process.

First, the healthcare industry is largely uninformed about the explicit linkages between sustainable building strategies and human health. Pilot participants and registrants consistently report that the health issue and resource information contained in the Green Guide is important new information for many of them. More education within the medical, nursing, and healthcare executive communities is required to continue to complete the linkage between sustainability, health, and mission.

Second, we are learning that sustainable building measures are happening in the industry outside of the LEED tool, particularly projects with this explicit health mission. However, we need to develop educational tools and market incentives to move hospitals and healthcare organizations from tier 2 to tier 3, as defined below:

• Tier 1—Minimum local, state, and national environmental regulatory compliance

• Tier 2—Beyond compliance to measures that save money

• Tier 3—Informed by the inextricable link between environment and human health and moving beyond both compliance and monetary savings with a long-term plan to reduce environmental footprint—a “triple bottom line” approach (Schettler, 2001)

Third, that as a market transformation tool, the Green Guide is pivotal at informing product development. Many of the Green Guide registrants represent product manufacturers eager to be proactive in producing healthier, sustainable products for a range of applications. The number of product innovations such as PVC avoidance, brominated flame retardants (BFR) elimination, and sustainably forested and recycled or rapidly renewable products are increasing.

Finally, we are learning that project success may be related to the explicit understanding and development of an approach that prioritizes health and integrates design and operation into an environmental health mission statement. LEED implies that an “integrated design” process yields greater project success; the Green Guide requires the development of a mission statement and rewards

an “integrated design process.” More explicit research and guidance tools that link design and operations for a reduced environmental footprint is necessary to empower teams to embrace both aspects of building performance.

We must begin, as an industry, by demanding life cycle solutions from the manufacturers and industries that service and support us. We must vote with our specifying and purchasing power (which, incidentally, is significant), and support approaches that “solve rather than alleviate the problems that industry makes” (McDonough, 1998). The initiatives that Kaiser Permanente has shown in using the power of their contract dollars to drive significant environmental improvements for building products is a shining example of the power of our collective voice for healthier, sustainable building materials. We must not be forced to resolve insoluble statistical conflicts in which materials are competing on the basis of being the lesser of many evils rather than on the basis of being good.

Secondly, we must support the development of clear, universal materials assessment methodologies that take into account the “hidden” health costs associated with toxic materials and industrial processes. Life cycle assessment methodologies, as currently developed, can offer objective measurement of raw materials and energy flows, but are silent or scientifically inadequate regarding inclusion of environmental health and toxicity issues. The healthcare industry must assist in evolving life cycle tools that appropriately include full health costs.

Finally, the industry must seek to evolve cost models that recognize health costs as an important component of the price we pay for our buildings today; these models must also show health benefits as creating value. In so doing, the industry can author a powerful tool for the wider real estate industry and support market transformation at the forefront of innovation and building materials development.

Gregory Kats

Some 50 million students spend their days in schools that are too often unhealthy and that restrict their ability to learn. A recent and rapidly growing trend is to design schools with the specific intent of providing healthy, comfortable, and productive learning environments. These green, high-performance schools generally cost more to build, which has often been considered a major obstacle at a time of limited school budgets and an expanding student population.

A December 2006 national review of 30 green schools and an analysis of available research demonstrate that green schools cost 1.5 to 2.5 percent more

than conventional schools, but they provide financial benefits that are 20 times as large (Kats, 2006). These financial benefits include energy and water savings, reduction in costs associated with waste and emissions, increased student learning and future earning, reduced incidence of student asthma and other illnesses, reduced costs of teacher turnover, and net employment gains for the state. Most of these benefits relate to improved health, enhanced student learning, test scores and earnings, and reduced teacher turnover.

Conventional schools are typically designed to just meet the building codes, which are often incomplete. The design of schools to meet minimum code performance tends to minimize initial capital costs but delivers schools that are not designed specifically to provide comfortable, productive, and healthy work environments for students and faculty.

Few states regulate indoor air quality in schools or provide for minimum ventilation standards. A chronic shortage of funds in schools means that schools typically suffer from inadequate maintenance, resulting in degradation of basic services such as ventilation and lighting systems. Not surprisingly, a large number of studies have found that nationally, schools are unhealthy, which increases illness and absenteeism and brings down test scores. Green school design provides an extraordinarily cost-effective way to enhance student learning, reduce health costs and, ultimately, increase school quality and competitiveness at both the student and state level.

The main reason for cities and states to adopt green building requirements is to cut costs, improve services, and address a broad array of challenges, such as

• the high and rising cost of energy,

• worsening power grid constraints and power quality problems,

• increasing cost of waste, water, and waste disposal and associated costs of water pollution,

• continuing state and federal pressure to cut air pollution,

• rising concern about global warming,

• reversing the alarming rise of asthma and allergies in children, and

• increasing state competitiveness in quality-of-life indicators such as air and water quality, quality of schools, and the skills of its workforce.

This analysis finds that green schools provides an extremely cost-effective way to help address all these challenges. The financial benefits of green schools are 10 to 20 times as large as the cost. Green school construction costs 1.5 to 2.5 percent more than conventional school construction, almost $4 more per sq. ft. for a typical $25 million, 125,000 sq. ft. school built for 900 students. The financial savings are about $70 per sq. ft., 20 times as high as the cost of going green (Table AB-3) (Kats, 2006). Only a portion of these savings accrue directly to the school. Lower energy and water costs, improved teacher retention, and lowered health costs save green schools directly about $15/sq. ft., about four times the

additional cost of going green. Financial savings statewide are significantly larger, and include lower energy costs, reduced cost of public infrastructure, lower air and water pollution, and a more skilled and better compensated workforce. The majority of these savings results from improved health, comfort, and learning performance in green schools.

Green schools provide a range of additional benefits that were not quantified in this report, including reduced teacher sick days, reduced operations and maintenance costs, reduced insured and uninsured risks, improved power quality and reliability, increased state competitiveness, reduced social inequity, and educational enrichment. There is insufficient data to quantify these additional benefits, but they are significant and, if calculated, would substantially increase the recognized financial benefits of greening schools.

Despite limits in data and need for additional research, there is now very substantial experience with high-performance schools in Massachusetts and nationally. A large body of documented studies and experience allows quantification of costs and benefits of green schools. For example, there are over 1,000 studies that examine the impact of high-performance design features such as better lighting, temperature control, and improved indoor air quality on health or productivity. Analysis of the costs and benefits of 30 green schools nationally, and use of conservative and prudent financial assumptions in analyzing available data, provides a clear and compelling case that green schools today are extremely cost-effective from a financial standpoint. Largely because of improvements in health, attendance, test scores and learning environment, building green schools is today significantly more fiscally prudent and lower risk than building conventional unhealthy, inefficient schools.

Roger A. Oxendale

In the late 1940s, Frank Lloyd Wright offered an abrupt, two-word answer when asked how he would improve Pittsburgh. He said: “Abandon it.” Fortunately, our city leaders took that excessive assessment as the metaphor I believe it was—not to abandon an entire city, but to rid itself of old ways of thinking; that is, to create a new environment that would clear our region of the industrial waste, heavy smoke, and soot created by the massive steel mills that were turning Pittsburgh into an industrial wasteland of putrid air and contaminated waterways.

History bears out the foresight of Pittsburgh’s government and civic leaders who moved to sustain the long-term health of a people and the region in which they live. They did that with bold strokes, such as requiring businesses and homeowners to switch from using pollution-causing coal to gas or other smokeless fuels for heating.

Those were great strides that enabled Pittsburgh to move forward with courage and conviction—all the while creating an extraordinarily livable, diversely economic region, which now has one of the most highly regarded, sophisticated healthcare systems in the world.

For this progress to continue as we move ahead in this rapidly changing century, we have a responsibility to improve the health of our region, a responsibility we took seriously as we began making plans for construction of the new Children’s Hospital of Pittsburgh as part of the University of Pittsburgh Medical Center (UPMC).

Our vision was to create a model that would lead to the transformation of health care in areas of chemical and hazardous waste management; air quality; green construction and retrofits; renewable energy; energy and water conservation; and housekeeping (Dick Corporation, 2006).

From the early stages of planning we realized that few, if anyone else, in health care were thinking as broadly as we were about what it means to be green. Yes, there are hospitals in the country that incorporate significant environmentally sustainable improvements using green materials; optimizing energy performance; and reducing, reusing, and recycling chemicals and supplies.

We decided to go well beyond that because our commitment to health care stretches from our hospitals’ walls into the community and region in which our patients and families live.

At Children’s Hospital, we held a series of internal forums on pediatric environmental health to begin to look at how we could provide our community with comprehensive environmental health education through community projects and programs.

We will do this by linking our extraordinary scientific research to advanced treatments for our children; training our residents and providing continuing

medical education to our physicians to incorporate green practices and treatment for the improved health of our kids, their homes, and communities; and educating—within family units, in the schools, in communities—so that that the UPMC healthcare system is integrated into how we think and live in western Pennsylvania.

Thanks to a commitment to green by the Pittsburgh-based Heinz Endowments—our partner in building a national model of children’s environmental health and hospital sustainability—we at Children’s Hospital were afforded the opportunity to dream big and then to develop a careful plan for our leadership. Our vision also was endorsed by Pennsylvania’s elected officials when Governor Ed Rendell awarded Children’s Hospital $5 million toward construction of a green pediatric hospital.

So, we proceeded, embracing the knowledge offered by other like-minded institutions, including the University of Pittsburgh’s School of Engineering, Sustainable Pittsburgh, the Pittsburgh Green Building Alliance, and the University of Pittsburgh Cancer Institute’s Center for Environmental Oncology.

We are the first pediatric hospital in the country to register for LEED certification. By doing that, we are helping to establish a LEED guide for healthcare institutions. Moreover, we are creating a healthcare model for environmentally sustainable engineering in a city that is recognized as a leader in the worldwide green building movement.

Pittsburgh is home to the world’s first and largest certified green convention center—the David L. Lawrence Convention Center. Not only that, Pittsburgh now has 40 buildings that are either LEED certified or registered.

Our challenge, as we strive for silver and gold LEED certification, is for Children’s Hospital to incorporate construction of a new, technologically advanced research building, the retrofitting of a partially demolished building for an equally high-tech clinical facility, as well as the renovation and retrofitting of older buildings throughout the UPMC system.

At the same time, we know we can not work in a vacuum; that is, we can not expect to move into our new Children’s Hospital of Pittsburgh in late 2008, the expected date of completion, without having already incorporated environmentally sustainable practices at our existing facilities.

For that, we hired a team of researchers at the Center for Building Performance and Diagnostics at Carnegie Mellon University to investigate greening opportunities for the operation and maintenance of Children’s Hospital and other UPMC hospitals today.

This has provided us with an opportunity to establish benchmarks for environmental sustainability as well as identify benchmarks for innovation as we plan for the future. These are significant measures that will enable us, through the University of Pittsburgh’s School of Engineering, to develop baseline data so we ultimately will be able to track the environmental impact of the new Children’s Hospital—one that is a highly efficient, sustainable facility that incorporates

water and energy conservation, improved indoor air quality, and green building materials and cleaning practices.

In preparation for LEED certification, we are proceeding with key environmental considerations at our new hospital. And, given the work being done at the University of Pittsburgh Cancer Institute and the Graduate School of Public Health, we are moving ahead in building relationships in multiple areas, including an environmentally preferable purchasing policy; reductions in the use of toxic chemicals, the consumption of water and energy, and the volume of all waste streams; improvements in indoor air quality and work atmosphere; and coordination of efforts to reduce all forms of pollution, including vehicle emissions.

The measures that Pittsburgh’s leaders took almost 60 years ago to clean up our region enables us throughout UPMC to promise a future where hospitals will be models of disease prevention and cure.

And, we begin with construction of the new Children’s Hospital of Pittsburgh—where the greening of this pediatric institution will enable us to continue to transform the lives of our young patients so they can return home to a healthy future.

Derek Parker FAIA, RIBA, FACHA

Building a new facility is usually the biggest capital investment a chief executive officer, medical staff, and board of trustees will ever make. Hospitals will spend more than $12 billion this year on new construction and, by 2010, spending on new hospital construction is expected to increase to $16 billion to $20 billion annually (Sadler, 2004). With so much at stake, the time is right for hospital leaders to spend a little more time and money to not just build a new hospital, but a better hospital—one that will actually save significant dollars in the long run. It costs a lot of time and money to build a poor hospital. It costs only a little more time and money to build a hospital that contributes to clinical, financial, and satisfaction outcomes based on evidence-based design.

But, in the current health care economic environment with capital so difficult to obtain, you might ask: Are these good ideas affordable? Is there a business case for building better hospitals? The answer is yes. Based on published evidence and the experience of pioneering organizations using evidence-based design to construct new facilities, we have analyzed the data and designed a hypothetical “Fable Hospital.”

A healthcare executive or trustee who wishes to follow a path similar to Fable Hospital might ask, “How best to begin?” It begins with the vision that positive effects on patients, staff, and the community will occur through a collaborative commitment to combining the best design evidence with the core values and belief systems of the organization. Thus a first step is to formally define and widely disseminate this vision and keep it in front of organizational members at all times.

The next step is to become familiar with the work of the pathfinders who are blazing the trail for others. This can include reading, attending conferences, and taking benchmarking tours of exemplary projects. One wise measure would be to assure that the organization’s guiding coalition grasps the importance of an evidence-based course for decision making on design and construction projects. Another would be to assemble a strong collaborative team of advisors who have the complementary skills and experience to rigorously follow such a course. A team of programming consultants, architects, engineers, and interior designers who value evidence-based design might be bolstered with social scientists, such as an environmental psychologist or an expert in performance improvement. The prudent executive should be prepared to invest extra time preparing a sophisticated description of the project that goes beyond a simple listing of proposed space requirements. It is helpful to be able to describe a project’s goals and objectives with clarity, including hypotheses concerning outcomes expected from the design.

Resistance to a process that differs from prevailing practice can come from almost any source. In addition to the predictable resistance to any form of change, the team can expect to be challenged at first by skeptics who will question the evidence, the financial assumptions, and the link between facility design and clinical outcomes. This is why a certain amount of study and a team accustomed to rigor will be useful. The challenge to financial assumptions will require careful analysis and cautious budgeting that avoids overreliance on previous budget or cost models. It would be wise to involve the external consultants early in the process to gain the maximum benefit from their experience.

A typical barrier to success is expecting a project to neatly fit into the same budget and schedule as a conventional project, when in fact it likely will require an extended predesign phase to properly define the scope; identify, analyze, prioritize, and integrate design innovations; and plan an assessment protocol. The team should be prepared to do more sophisticated life cycle costing than occurs in a conventional project, as fewer decisions will be based exclusively on the lowest first cost. A savvy executive will insist on using multiple before-and-after measures to assess the project, including financial, clinical, and satisfaction indicators.

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.

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-

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).

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.

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.

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.

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.

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).

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 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).

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.

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.

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.

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

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-

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

(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

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.

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

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.