Values-Driven Design and Construction: Enriching Community Benefits through Green Hospitals

by Robin Guenther, FAIA, Gail Vittori, and Cynthia Atwood 

Paper presented by The Center for Health Design and Health Care Without Harm at a conference sponsored by the Robert Wood Johnson Foundation, September 2006.

INTRODUCTION

For the past decade, the healthcare industry has been engaged in a transformation of design, construction, and operational practices with a goal of reducing environmental impacts. Quietly and without much fanfare, early industry leaders have begun a radical journey toward a new vision of the industry's health mission. Ten years after the founding of Health Care Without Harm and with early adopters having completed their first sustainable buildings, this is a pivotal moment to assess the state of sustainable design and construction in the healthcare industry from a leadership perspective. Why have organizations taken this on? What challenges have they faced? How have they framed the benefits to their communities? What have been the anticipated, and unanticipated, outcomes?

Healthcare leaders and their organizations engaged in sustainable design and construction are doing so largely because it aligns with their humanitarian and stewardship mission and vision. They've been able to harness their community and/or personal attitudes about the environment toward this end and, very often, their concerns about the environment's effect on their patients' health. They are not primarily motivated by pristine wilderness and resource conservation for its own sake, but for the sake of their mission to serve and steward resources and health. For them, it's more than saving energy. It's fundamentally connected to health or to a basic human value.

In the paper that follows, we have identified healthcare leaders and allowed those leaders to tell this story in their words. Of the many organizations and teams engaged in sustainable design, we have located a key group of early adopters who are reaching beyond measures that have economic payback and who are achieving community benefit beyond their four walls. And for a disparate set of reasons, they've been able to overcome certain obstacles that could be framed as having to take on and/or embrace an environmentalist agenda and change the status quo. Those who have made it through the process are emerging transformed—both personally and on an organizational level.

Why this topic and approach?

Sustainable design is driving both market transformation and organizational change. Each is necessary for the healthcare industry to sustain itself. There are many reasons the industry is overburdened and slow to change, but this paper begins with the notion that the industry is increasingly recognized as an outmoded system that pollutes. In fact, when viewed in this particular light, the system not only pollutes, it potentially participates in creating the very illnesses it is trying to cure.

Sustainability, or green building, calls into question the purpose of the healthcare system. Does it treat sickness or promote the conditions of health? Does it create sickness and prevent health? Is it a paradoxical situation that can be resolved and, if so, how? Do healthcare organizations that undertake green building recognize this paradox, and, if so, are they acting on it?

Can an ecological framework assist organizations in redesigning themselves to "rekindle a commitment to healing, hope, optimism, innovation, and creativity" as Hamilton and Orr (2006) describe it? Does a building program—in this case, a green building program, have the capacity to more broadly model change?

Organizations such as Health Care Without Harm that focus on operational initiatives to reduce environmental footprint think so. This paper supports the notion that building programs are agents of these— they are the vehicle by which organizations can transform themselves and/or much of the operational complexity that prevents them from changing course.

Not all green buildings are profoundly impacting the healthcare organizations that create them, but many are. Those are the leaders we sought for this paper, and their experiences confirm the power of sustainable design to guide transformation. They say it permeates their organizations. It affects everything that they do. And that the difference in capital costs between conventional and sustainable building practices is, in many instances, equal to the difference in time they have to spend persuading people to go forward with it. They often devote a lot of personal energy and political capital getting and keeping their organizations on board with this and contend that, if sustainable design practice was normalized, they could devote their organization's energy to modeling this change more broadly in ways that would fundamentally affect healthcare, society, and global health.

Leaders recognize the high cost of inaction on matters of the environment—such as climate change and chemical contamination—on the health of our families, neighbors, and communities at hand and globally. By embedding sustainable design in a broader vision of leadership and mission, these projects and organizations are succeeding in delivering the first generation of sustainable healthcare projects.

We term these Tier 3 organizations, and for people in policy and philanthropy, these are the healthcare organizations worth investing in to model broader social and societal change.

Part 1: Background

Status of sustainable design in healthcare

Since 2000, the healthcare sector's engagement in sustainable design has moved at an impressive rate. What was ever so slightly registering in the minds of healthcare industry leaders just six years ago has emerged as a hallmark of better buildings, reflecting a commitment to create physical facilities that support improved patient care, staff productivity and well-being, and environmental stewardship—healthcare's triumvirate. The Setting Health Care's Environmental Agenda (SHEA) conference, held in San Francisco in October 2000, marked the starting line for this short history of remarkable accomplishment. As the first gathering of healthcare leaders to explicitly address environmental stewardship, SHEA set out to "inspire ambitious achievements in every healthcare institution" (Brody 2001, page v). Since then, the industry response to Brody's challenge "to transform the healthcare industry into a model of environmental responsibility" has been overwhelming, creating the essential elements of twenty-first century hospital design.

In the years since 2000, a steady progression of practical, nuts-and-bolts green building tools and resources—customized for the healthcare sector and informed by health-driven values—along with inspirational, on-the-ground accomplishments, have coalesced to create a body of knowledge and know-how that has been set in motion.

In 2002, the American Society for Healthcare Engineering (ASHE) published the Green Healthcare Construction Guidance Statement, the first sustainable design guidance document emphasizing a health-based approach (ASHE, 2002). The Green Guide for Health Care, the healthcare industry's first best-practices, voluntary green building tool, modeled with permission after the U.S. Green Building Council's Leadership in Energy and Environmental Design (LEED) rating system, was initiated in 2002, followed by periodic updates and the registering of pilot projects to bolster participation (Green Guide, 2004). While emphasizing the importance of integrated design, the Green Guide is organized in two sections—construction and operations—to facilitate its use. Using the Green Guide for Health Care as a foundational reference document, the LEED for Healthcare Application Guide development process began in 2004. With its release anticipated in 2007, LEED-Healthcare will represent the first third-party green building certification tool customized for the healthcare sector.

The rapid market uptake of these tools and resources is manifested today in more than 40 million square feet of green healthcare facilities, representing about 180 healthcare projects. These include more than 100 Green Guide pilots, six LEED-certified projects, and about eighty LEED-registered projects. By embracing a life-cycle view of human health and environmental stewardship as strategic definers of success, this new generation of healthcare tools—and the buildings they guide—is poised to accelerate the adoption of health-based green building standards in other sectors.

Tiering environmental performance

In a paper presented at CleanMed 2001, Ted Schettler, MD, MPH, identified three tiers of operational environmental performance evolving in hospitals.
• 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


He contended that applying "triple bottom line" approaches to pollution-prevention initiatives—i.e., measuring economic, social, and environmental benefits—would deliver significant benefits for healthcare organizations and the communities they serve (Schettler 2001). Early Tier 3 hospitals supported this notion. Named one of the state's top four recyclers, the University of Michigan Health System described its program's social benefit as an institutionwide initiative that engages everyone (University of Michigan 2005). A 25 percent solid-waste reduction yielded $30,000 in year 2000 annual savings and diverted more than 830 tons of waste from the community landfill.

As building initiatives accelerate, it is clear that we can apply the same system of tiered performance to organizations engaged in sustainable building. Tier 1 organizations will not undertake green building until they are mandated to do so through legislative policy initiatives. They will not make the link, or the organizational leap, between the health of their facility and the patients they serve.

Tier 2 organizations—lacking perhaps leadership, the necessary internal structure to produce change, and/or the necessary decision support mechanisms to help move beyond regulatory compliance—can move no further than to embrace sustainable building strategies that deliver proven economic performance benefits. Where there is no business case, the effort falls short of its potential; that said, these organizations see the value of having a sustainable healthcare facility and grasp its potential community value.

Finally, Tier 3 organizations create leadership vision and harness all available talent in uniting construction and operations together in transforming their organization's approach to the environment—resource use and stewardship. Comprehensively, they move toward a more fully realized and integrated performance level that achieves both patient and environmental health and returns those benefits back to the building occupants and the community. These organizations recognize that they can't build a green building and still have Styrofoam cups in their cafeteria. They create authentic stories of stewardship that spring from many levels simultaneously.

For the most part, this paper focuses on the experience of Tier 3 leaders and their organizations, based on the belief that these organizations will drive the necessary market transformation and social change. Their success is pivotal to moving the sustainable design and operational agenda in healthcare forward and forming the foundation for the next generation of Tier 3 leaders. While some Tier 3 leaders have used LEED as a green building framework and third-party certification tool, others have not, believing that it falls short of addressing the complex, overlapping design and operational improvement agenda unique to healthcare or not explicitly connecting buildings and human health. It is anticipated that LEED-Healthcare, with significant reliance on the healthcare-specific, health-based Green Guide for Health Care, will provide an important building and operational improvement tool for these leaders.

A perspective on community benefit

Hospitals and healthcare represent an essential societal function, with a fundamental mission to care for and heal the sick. In many respects, healthcare institutions are held to a higher ethical standard than virtually any other enterprise, as Hyman and Sage (2005) put it: to do good, not merely to do well.

Moreover, the public perception of a hospital's mission and purpose is generally independent of whether it is for-profit or nonprofit. Commenting on the blurred perception of hospitals' legal status, Everson (2005) stated, "We at the IRS are now faced with a healthcare industry in which it is increasingly difficult to differentiate for-profit from nonprofit healthcare providers." While only tax-exempt healthcare institutions are legally obligated to provide and document community benefit, the healthcare sector as a whole is embracing an extended view of community benefit as aligned with its core mission and as a means to create a competitive advantage in an increasingly competitive marketplace.

The term community benefit, rooted in an 1891 legal decision, is defined as "charitable activities that benefit the community as a whole" (Everson 2005). For more than thirty years, nonprofit, tax-exempt hospitals in the United States have been required to provide community benefits in the public interest, expanding what constitutes community benefit beyond the original definition of providing indigent care. In 1969, the Internal Revenue Service (IRS) established a community benefit standard, later revised in 1983 (Everson 2005): "…the promotion of health…is deemed beneficial to the community as a whole." The standard provides for broad latitude including any activity deemed as promoting health. Many states require nonprofit hospitals to submit annual reports beyond those required by the IRS. In California, for example, nonprofit hospitals are required to prepare a community benefit plan and an annual document describing activities undertaken "to address community needs within its mission and financial capacity and the process by which the hospital developed the plan in consultation with the community" (IOM 2004). Similarly, in New York, since 1990, nonprofit hospitals are required to prepare community-service plans including the hospital's mission statement, publication of assets and liabilities, assessment of community needs and strategies to address them, and solicitation of input from community stakeholders (IOM 2004).

In light of the formidable financial advantages that come with tax-exempt status—most notably, property-tax exemption1 (Keehan 2005)—hospitals have been subjected to increased scrutiny as to what constitutes community benefit. To this point, in May 2006, the IRS issued questionnaires to more than 500 tax-exempt hospitals and healthcare organizations seeking, in part, details about the organizations' provision of community benefits—services that "…promote health for the benefit for the community" (Pear 2006). The final question in the Community Practices section of the questionnaire—Did your hospital have any other programs or activities that promoted health for the benefit of the community?—opens the door for hospitals to take credit for the multifaceted and measurable community benefits resulting from the implementation of green building practices increasingly playing out in healthcare today.

A study by Schlesinger and Gray (1998) offers a typology of community benefit, highlighting four different, but overlapping, perspectives:

•  Legal/historical addresses historical responsibilities of nonprofit hospitals.

• Market failures addresses the cost and benefits of medical care.

• Community health addresses ways to develop evidence-based relationships between medical services and triggers of health problems.

• Healthy community addresses ways to strengthen the social institutions that influence health and quality of life in local communities.


Of the four perspectives, the community health and healthy community ones are intimately connected to green building. Community health is associated with offering preventive services and promoting health in local communities, with the benefit of reducing hospitalizations and demand for emergency services for what are often preventable illnesses. For example, promoting asthma awareness through community education on common building materials that are asthma triggers, as is the case with Children's-Pittsburgh, supports community health.

Healthy community has a broader frame, extending to "support and sustain optimal health and quality of life" (Schlesinger and Gray 1998). Again, drawing from Children's-Pittsburgh, employees are encouraged to consider moving to a neighborhood adjacent to their new facility, with the multiple benefits of neighborhood revitalization, ability to walk or bike to work, and reducing air emissions associated with automobile commuting.

In her May 2005 testimony to the House Committee on Ways and Means, Carol Keehan, chairperson of the Board of Trustees of the Catholic Health Association of the United States, Pensacola, Florida, and board chair of Sacred Heart Health Systems, also in Pensacola, addressed the issue of benchmarks for community benefit (Keehan 2005). Rather than establishing quantitative benchmarks, Keehan recommends assessing community benefit based on "the value we are providing to our communities," which, as she points out, is not always well-measured by numeric benchmarks.

While we find many community benefits of green buildings can be quantified, others are more challenging. Those that can be quantified include a reduction in electrical-energy use and reduced storm-water runoff with an increase in permeable surfacing. Those with a less direct corollary include a measurable increase in health indicators by creating a walkable campus or a shortening in the patient's length of stay with the addition of natural daylight. In such instances, it is difficult to isolate causal variables.

Study methodology

The goal of this study was to identify a group of participants who express an array of sustainable health-care pursuits. We sought both geographic diversity, as well as project type differentiation in both scale and program. We included acute-care facilities, ambulatory and cancer centers, and children's hospitals that may or may not include women's services. We also sought those who had completed the first thirdparty-certified sustainable projects (BC Cancer, Boulder, Discovery, The Lacks Center) and heard stories of their unintentional leadership in this realm and the charmed consequences that followed.

Interview subjects also included representatives of the next generation of leaders and a range of completed (Boulder, Discovery), near completed (Dell Children's, San Juan Regional, Dublin Methodist), and early-stage (Palomar, Spaulding) projects. We found it useful to compare and contrast stories within similar project types (Dell Children's, U-M Mott), while others add intrigue and variety or are noted for a particular position on public health and the environment (Arkansas COPH, BC Cancer).

We conducted one-hour interviews via conference call. Each call was professionally recorded and transcribed by third-party groups; the content from these are presented in Part 2 of this paper. The complete list of participants, their organizations and their projects are identified in the appendix. We've included an alphabetized listing of our interview subjects, by project name. Throughout the report, we have attributed quotes to the organization, followed by the speaker's last name.

The findings are organized into three sections: "Section A: Mission and vision," "Section B: Connection to community," and "Section C: Framing the benefits back to communities." "Mission and vision" looks at motivation, leadership, organizational change management, and the move toward reuniting construction and operation. "Connection to community" explores how these leading organizations key into community values and their explorreation of community benefit, whether those benefits accrue to patients, staff, the surrounding neighborhood, or global health. "Framing the benefits back to communities" examines how organizations frame the benefits that derive from the pursuit of sustainable design and construction, whether those are financial or expressed through enhanced community reputation.