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Institute of Medicine (US) Roundtable on Environmental Health Sciences, Research, and Medicine. Green Healthcare Institutions: Health, Environment, and Economics: Workshop Summary. Washington (DC): National Academies Press (US); 2007.

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Green Healthcare Institutions: Health, Environment, and Economics: Workshop Summary.

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4The Health Aspects of Green Buildings

The previous chapter discussed green healthcare institutions in the framework of economics, ethics, and employment. This chapter explores the relationship between green healthcare institutions and human health. It includes information from four presentations by professionals with a broad range of expertise: Todd Schettler, Anthony Bernheim, Judith Heerwagen, and Derek Parker.

Buildings are complex and dynamic systems producing a heterogeneous indoor environment consisting of many microenvironments. Many factors, including temperature, humidity, light, noise, chemical pollutants, odors, personal health, job or activity requirements, and psychosocial factors, interact to influence the comfort and health of building occupants, said Ted Schettler of the Science and Environmental Health Network. The interactions among these factors and the dynamic heterogeneity of microenvironments within buildings, including temperature and humidity gradients, make the indoor environment a complex area to study, noted Schettler. However, many indoor air quality studies are not designed to address these complexities, thus contributing to the conflicting information that is often found in the scientific literature. To better understand the health impacts of indoor environments, new statistical techniques, such as principal component analysis, which consider multiple variables simultaneously, are necessary, said Schettler.


According to studies by the Environmental Protection Agency (EPA), Americans spend an average of 90 percent of their time in an indoor environment in which low air circulation can concentrate pollutants to two to five times higher than in outdoor air (EPA, 2006). Chemicals that define indoor air quality can also affect health. Outside air, which comes through natural ventilation as well as mechanical systems, contributes to the quality of the indoor air. The tightness of the building determines the circulation of air (and air contaminants) in and out of the building. If the ventilation system is not efficient enough at dissipating the pollutants that are brought into the building, they will stay there longer, thus affecting health, said Anthony Bernheim, principal of green design at the architectural firm of SMWM. According to Bernheim, several major factors affect indoor air quality: the quality of the outside air, the location of outside air intakes, construction materials, furnishings, equipment, filtration and ventilation efficiency, occupants, and maintenance. The following types of chemical compounds are found in indoor air:

  • Volatile organic compounds, which may be emitted from building materials and fabrics, new furniture, cleaning materials, vinyl wall coverings, and office equipment
  • Microbial volatile organic compounds, such as mold and mildew
  • Semivolatile organic compounds, which come from fire retardants and pesticides
  • Inorganic gases, such as ozone, carbon monoxide, and nitrogen dioxide
  • Particulate matter from burning fuels in cars and from burning combustion products

In the early 1990s, a Scandinavian researcher, Lars Molhave, introduced the term total volatile organic compounds to reflect the burden of volatile organic compounds in indoor air. This term has received considerable acceptance among indoor air quality experts, noted Bernheim (Hudnell et al., 1992).

Building-Related Health Effects

Building-related illnesses include symptoms associated with sick building syndrome as well as specific building-related illnesses, such as Legionnaire’s disease. Symptoms associated with sick building syndrome include headache, nausea, nasal and chest congestion, wheezing, eye problems, sore throat, hoarseness, fatigue, chills and fever, muscle pain, and neurological symptoms, such as difficulty remembering or concentrating, dizziness, and dry skin. These symptoms do not necessarily keep people away from work, but they are often a source of complaints and undoubtedly contribute to lost productivity and dissatisfaction with the work environment, said Bernheim. The symptoms are not easily attributable to any particular chemical in the building and generally subside when people leave the building.

Sharp distinctions between health and comfort are not always readily apparent and may not be appropriate. Attempts to draw distinctions contribute to contradictory and inconsistent research findings, noted Schettler. Many researchers in this field think that complaints of building-related symptoms are worthy of investigation, even if a definable disease cannot be identified, said Schettler.

Sharp distinctions between health and comfort are not always readily apparent and may not be appropriate.

—Ted Schettler

Some building-related diseases, such as Legionnaire’s disease, can ultimately be traced to a well-defined cause that can be addressed. More often, building occupants experience a variety of vague symptoms that may change over time, which makes their analysis difficult, noted Schettler.

As an added complexity, some people in the general population seem to be disproportionately sensitive to various environmental exposures. Multiple chemical sensitivity is a condition in which people report sensitivity or intolerance to a number of chemicals. According to Schettler, multiple chemical sensitivity is somewhat controversial because its pathophysiology, the natural history of the disease, and how to respond to it are not well understood. Nonetheless, an increasingly robust scientific database supports the importance of this phenomenon.

Design Principles in Healthy Buildings

It is important to design and build in ways that reduce the probability of mold growth, avoid moisture accumulation, consider cleaning requirements, and reflect an understanding of the influence of factors such as low-emitting materials, ventilation, humidity control, and surface temperatures on indoor air quality. It is important to understand buildings and the indoor environment as complex dynamic systems, as well as to consider the full life cycle of materials, said Schettler.

According to Bernheim, there are four principles for good indoor air quality design:

  1. Source control: keep the source of pollutants out of buildings or reduce the sources when they cannot be prevented.
  2. Ventilation control: provide adequate ventilation to dissipate the pollutants and get them out of the building.
  3. Building commissioning: define performance specifications in advance and test the building at various stages of construction and operation in order to ensure that it performs as designed.
  4. Maintenance: ensure that the building is kept clean and maintained during its operational life.

Bernheim observed that source control has been the focus of most of the indoor air quality initiatives in the past 5 years. In 1981, the American Society of Heating, Refrigerating, and Air Conditioning Engineers created guidelines for source control, which were used until the early 1990s. In 2000, the firm of SMWM, in collaboration with the state of California, created health guidelines based on chemicals of concern such as carcinogens, reproductive toxicants, chemicals with acute reference exposure levels (ARELs), and chemicals with chronic reference exposure levels (CRELs). ARELs refer to 1 to 7 hours of exposure, and CRELs refer to approximately 12 to 15 years of exposure. The California EPA created a list of CRELs that includes 80 chemicals commonly found in buildings (Lent, 2006).

These CRELs can be linked to the standard industry format for building specifications, the Construction Specifications Institute’s MasterFormat™. MasterFormat™ is structured as a standardized outline form with 16 divisions. For example, Division 1 contains general administrative and procedural requirements, and Divisions 2 through 16 address technical specifications for building materials. A section on environmental protection procedures can be added to Division 1. This section, often referred as Section 01350, provides a forum for identifying environmental requirements, such as sustainable site planning, construction recycling, energy efficiency, indoor air quality, and others (CIWMB, 2007). Bernheim described a Section 01350 requirement that a building may not expose occupants to more than half of the material’s CREL. Based on the quantity of material used in the project and the volume of air in the system, analysts produce a modeled concentration that is matched against the Section 01350 list, said Bernheim.

Using existing data has enabled researchers to begin to analyze more closely what is happening in a building. According to Bernheim, the Section 01350 specification has led to significant industry transformation. For example, based on Section 01350 testing, a national ceiling tile manufacturer has completely modified its ceilings to reduce formaldehyde emissions, and an international manufacturer of linoleum flooring has reduced emissions of chemicals from linoleum. As another result of Section 01350 testing, trade organizations for building materials created their own certifications, such as the Carpet and Rug Institute’s Green Label Plus Carpet program for the carpet industry, and the Resilient Coverings Institute’s Floor Score certification for flooring. The Collaborative for High-Performance Schools in California has used Section 01350 as a guideline. The Green Guide for Health Care referenced Section 01350, as did version 2.2 of the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) for new construction, said Bernheim.

While concentrating on the indoor environment, green healthcare advocates also need to understand public, occupational, and environmental health impacts beyond the building. Such issues as materials extraction, manufacturing, transport, and disposal have potential health effects for people and communities, noted Schettler.

Beyond building green, the healthcare industry has a responsibility to address its contribution to unsustainable material throughput, growth, and natural resource depletion and degradation. In their book The Ethics of Environmentally Responsible Health Care, Jessica Pierce and Andrew Jameton (2004) argue that health care has a particular ethical responsibility and that marginal improvements in building materials’ policies are insufficient. A fundamental reexamination of the scope of clinical services is also required if health care is to do its part to restore and maintain resources and ecosystems on which life depends. This creates concerns about healthcare rationing; according to Pierce and Jameton, rationing should be thought of as sustainable optimal care rather than less than optimal care in order for the healthcare industry to meet its ecological responsibilities.

Beyond building green, the healthcare industry has a responsibility to address its contribution to unsustainable material throughput, growth, and natural resource depletion and degradation

—Ted Schettler

Schettler added that it is important to think about how the greening of medical care might be introduced in medical education. Medical students should understand the links between individual health, community health, and ecological health in a way that helps to develop an integrated ecological consciousness.


In her presentation, Judith Heerwagen of J.H. Heerwagen and Associates drew heavily from Australian biologist Steven Boyden’s theory of human ecology. Boyden (1971) defines biological determinants of optimal health as “those various conditions which tend to promote or permit optimal physiological, mental, and social performance in an animal in its ‘natural’ or evolutionary environment.” Boyden argues that environments need to fully satisfy both survival needs and well-being needs, which are different. Survival needs have to do with clean air and water—people are very likely to get sick without these assets—while well-being needs have to do with psychosocial adjustment, stress reduction, and quality of life (Boyden, 1971). There are several evolved well-being needs and experiences. Heerwagen described scientific evidence that social support is connected to being healthy. Neuroscientists are learning that creativity has been a survival function in the evolution of the human brain, suggesting that opportunities for creative activity are also very important. Variety in daily experience also enhances well-being, as does behavioral control (the ability to react and adjust one’s behavior in response to different environments). People need an interesting and aesthetically pleasing environment, sensory stimulation similar to that found in the natural environment, and connection to the natural world. These needs may vary slightly across different age groups and different healthcare problems; however, they are relevant to most healthcare environments and contexts, reflecting people’s need to be healthy in a psychosocial sense.

Psychological and Social Aspects of the Environment in Healthcare Facilities

In a qualitative survey of 50 hospital inpatients in the United Kingdom, participants identified a need for a hospital environment with personal space; a homey, welcoming atmosphere; a supportive environment; good physical design; access to external areas; and facilities for recreation and leisure (Douglas and Douglas, 2004). These results demonstrate the need for attention to the psychological and social aspects of the healthcare facility environment. Currently, hospital environments confront patients with psychosocial deprivation that creates negative health consequences, said Heerwagen. Patients in healthcare facilities experience pain, discomfort, and anxiety. Boredom is a very common complaint in hospitals, reflecting the lack of creative activity and mental stimulation. According to the survey, patients also say that isolating hospital environments lead to a loss of emotional support, social support, and behavioral control, noted Heerwagen. The television is often the only thing that patients can control in most healthcare facilities. Generally, they cannot control the thermal environment, lighting, or ventilation. There has been a great deal of research in psychology that examines increased patient control in interactions with physicians. Patients who take part in decision making and become more informed report an increased sense of control. Thus green healthcare advocates should consider whether greater control over the environment could contribute to positive medical outcomes, said Heerwagen.

According to Heerwagen, sunlight in healthcare facilities is associated with substantial reductions in medical costs. Researchers who study the benefits of sunlight found evidence that lighter and brighter rooms in hospitals contribute to stress reduction and that patients experience less pain and use less analgesic medicine (Walch et al., 2005). Studies involving patients with depression or bipolar disorder have shown that sunlight in patient rooms contributes to shorter hospital stays and reduced symptoms (Beauchemin and Hays, 1998; Benedetti et al., 2001). Further evidence suggests that people with seasonal affective disorder prefer more brightly lighted spaces and that such spaces are linked with the reduction of their symptoms (Eastman et al., 1998). A study by Beauchemin and Hays (1998) showed a reduced mortality rate among heart attack patients who were hospitalized in bright, sunny rooms.

Technology, rather then nature, is the main source of stimulation in a hospital setting. Hospitals are rather noisy places, noted Heerwagen, and the sounds in hospitals are primarily technical, because they are used to provide signals to care-givers about patient status. These noises are particularly constant in intensive-care units and in postsurgical or postanesthetic units. These noises are amplified by the hard surfaces and the lack of acoustical tiles and treatment in most hospitals. Although carpeting has a real acoustical value, nurses and maintenance workers dislike it because it is more difficult to clean.

Noise has been associated with disturbed sleep in patients (Topf, 1992); increased stress among staff, particularly in intensive-care units (Blomkvist et al., 2005); and headache, irritability, and increased sensitivity to pain (Biley, 1994). A study by Shertzer and Keck (2001) found that patients perceived less pain when noise was reduced and replaced with music. Heerwagen stressed that healthcare facility leaders should consider the impact of noise as they engage in building design.

Theory of Positive Design

A key challenge for specialists in healthcare facility design is how to increase a sense of well-being without compromising ongoing medical care. Conflict arises when decisions that may improve the psychosocial situation interfere with caregiving. Knowing how, when, and for whom to provide psychosocial stimulation is critical, noted Heerwagen.

A key challenge for specialists in healthcare facility design is how to increase the sense of well-being without interfering with ongoing medical care.

—Judith Heerwagen

Improving the psychosocial state of patients is an important consideration in hospital design, she said. Hospitals should address the following key environmental factors: aesthetic pleasantness of the building, sunlight, noise reduction and positive sound stimulation, connection to nature, socially supportive spaces where patients can be with family, and increased behavioral control. The first principle in the theory of good design is reducing health and safety risks. Creating an atmosphere that is supportive psychologically, cognitively, emotionally, and socially is also important and should be incorporated in positive design principles, said Heerwagen. Reduction of noise (which acts as a stressor) and the use of music therapy to enhance the patients’ well-being are one example. The benefits of positive design include reductions in pain, emotional anxiety, and other physiological indicators of stress (Cabrera and Lee, 2000).

Quality improvements to the hospital environment may involve costly additions to space and furnishings. However, this should be viewed as a cost-benefit trade-off that has other values, said Heerwagen. Aesthetic pleasantness reduces the “institutional” atmosphere and makes people feel that they are valued and worth investing in. Job satisfaction is much higher in places with aesthetically pleasant environments, noted Heerwagen. The links between sustainability and psychosocial outcomes are clear; however, there is still much to learn in this area, she concluded. She closed by emphasizing that “it is not how green you make it that counts, but how you make it green.”

It is not how green you make it that counts, but how you make it green.

—Judith Heerwagen


The Fable Hospital

In an attempt to find out how much a better building would cost, Derek Parker of Anshen + Allen Architects and his associates invented the imaginary Fable Hospital to measure experience using evidence-based design. The Fable Hospital was based on the Center for Health Design’s Pebble Project, a research program that was initiated with San Diego Children’s Hospital and Health Center in 2000. Located on a limited urban site, the Fable Hospital provides a comprehensive range of inpatient and ambulatory services, including medical/surgical, obstetrics, pediatrics, oncology, cardiac, and emergency medicine. It was built to replace a 300-bed regional medical center at a cost of $240 million. The hospital values quality, safety, patients, families, staff, cost, value, and community responsibility. In fact, the hospital collaborates with the Institute for Healthcare Improvement and has an unusual culture; it is obsessed with quality and safety, driven by values, patient focused, family friendly, a good corporate citizen, determined to be ecosensitive, willing to benchmark, and committed to being held accountable.

The Fable Hospital client is data-driven and engages in participatory planning as it designs its new facility. A wide range of stakeholders was engaged, including not only hospital management and staff, but also architects, engineers, interior designers, contractors, and landscape architects. Participants considered evidence-based ways to improve safety and performance, improve patient satisfaction, and save money. The resulting design features readily available hand-washing stations, improved air filtration systems, better separation of “clean” and “dirty” areas on patient floors, transportation modalities that separate patients from potentially infectious materials and wastes, standardization and consistency of layout, and glare-free lighting. Other innovations include oversized, windowed, single rooms with dedicated space for patient, family, and staff activities and sufficient capacity for robots and in-room surgery. Patient rooms and work spaces have plenty of daylight. Variable acuity rooms are standardized in shape, size, and headwall; this reduces errors and eliminates the need to move patients as their condition improves.

There are decentralized, barrier-free nursing stations, computerized order entry using a bar code system and handheld computers, plentiful hand-washing facilities, and high-efficiency particulate absorbing filters. The Fable Hospital also has healing art, music, gardens, consultation spaces, a patient education center, and staff support facilities, noted Parker.

As with most hospitals, the Fable Hospital consumes large amounts of power and confronts such pathogens as Staphylococcus aureus, Candida albicans, and Enterococcus faecalis. It produces large amounts of solid, medical, contaminated, and hazardous waste. This waste has to be stored and transported or recycled using fuel cells. Currently, fuel cells are not economical; however, this could change if the money spent on disposing of waste was spent instead on treating waste as energy in a different form. Waste can become heat and power, and can produce commercially viable and ecologically sound products (mostly carborundums and additives to concrete and asphalt) that are never burned in their life cycle, stated Parker.

Detailed Cost and Savings Estimates for the Fable Hospital

Fable Hospital has private patient rooms that are 100 square feet larger than typical hospital rooms. At a cost of $185 a square foot, the larger rooms increase construction costs by $4.7 million. Overall, the construction cost premium for Fable Hospital is $12 million, or 5 percent of the construction budget, said Parker. A hospital chief executive officer would require evidence of benefits before approving such additional expenditures.

Reduction of patient falls is one of the benefits found by the Pebble Project. When patients (especially elderly patients) fall, they risk fractures and complications, such as pneumonia, that result in longer hospital stays. According to Parker, the average cost of an unlitigated fall in the United States is $10,000. A Pebble Project study found that an 80 percent reduction in patient falls can be achieved by installing double doors in bathrooms and moving telephone cords and nurse-call cords out of the way (Hendrich et al., 1995).

Based on the Pebble Project results, Parker suggests that better design may result not only in fewer patient falls, but also in fewer patient transfers, fewer nosocomial infections, reduced nurse turnover, and reduced drug costs. Based on these savings, the initial investment of $4.7 million would be recovered in a few years (Table 4-1). Parker further asserted that increasing market share and philanthropy would add to the hospital’s revenues, thus justifying the construction premium (Table 4-2). Cost avoidance savings alone, if invested at 3 percent for 30 years, would pay the capital costs of the hospital many times over.

TABLE 4-1. One-Year Savings on the Fable Hospital.


One-Year Savings on the Fable Hospital.

TABLE 4-2. One-Year Revenue Gains of the Fable Hospital.


One-Year Revenue Gains of the Fable Hospital.

According to Leonard Berry’s book Discovering the Soul of Service, leading service organizations have nine drivers of success: strategic focus, executional excellence, control of destiny, trust-based relationships, investment in employee success, acting small, brand cultivation, generosity, and value-driven leadership (Berry, 1999). Although the Fable Hospital has not been built yet, it will be, said Parker. They are close to achieving that goal. Parker closed with the hope that this workshop has helped contribute evidence to make a powerful business case for quality, safety, and sustainability in American health care.

Copyright © 2007, National Academy of Sciences.
Bookshelf ID: NBK54149


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