Therapeutic Impact of LEED

Scott Abernethy

Therapeutic Impact of

LEED on Patient Outcomes

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Contents

Contents 01. Current Healthcare Landscape

02

02. Evidence-Based Design

05

03. Therapeutic Environments

08

04. LEED

14

05. Conclusions

17

06. Appendix

20

07. References

28

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Current Healthcare Landscape

Current Healthcare Landscape

01 HKS Architects

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Current Healthcare Landscape

Current Healthcare Landscape Introduction Among industry-wide popularity in sustainable design and construction, the concept of designing therapeutic, healthcare environments is latent. Traditionally, efficiency in relation to operational cost, clinical, and technological aspects governs the design of these environments and typically results in sterile, often unhealthful environments for patients, employees, and the community at large. However, an emerging compendium of evidence-based design research will make designers reconsider the role of the built environment: healthy buildings, healthy people.

This research report will analyze the correlation of an ever increasing evidence base of environmental impacts on healthcare building performance, patient well-being and medical outcomes to LEED certified construction. It will also identify key environmental parameters, as well as identify topical healthcare building interior and exterior environmental-related issues for further study in new and emerging LEED for Healthcare projects.

Context The healthcare environment is a work environment for the staff, a healing environment for patients and families, a business environment for the provision of healthcare, and a cultural environment for the organization to fulfill its mission and vision (Stichler, 2003). Clearly, these environments involve complex interdisciplinary teams working synergistically toward improving public health. Currently, healthcare organizations are primarily concerned with maximizing operational efficiency; the system supports diagnostic care. Moving forward, these organizations must focus on building design as a vehicle for promoting positive human experience and outcomes while simultaneously transitioning to a preventive care model.

Representing a substantial share of annual design and construction activities in the United States, the healthcare sector is well-positioned to highlight the potential that buildings have to reverse environmen-

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tal decline and to create environments for people that enhance health, patient outcomes, and workplace performance. (Vittori, 2002). Healthcare facilities, averaging between 70 and 75 million square feet of construction per year, have unique programming criteria that guide design decisions and material, product and equipment specifications. Understanding the complexity of human health implications of these decisions is critical. For example, the Academy of Architecture and Health cites research indicating that natural lighting, indoor landscaping, rooftop gardens, solariums, and small atria have a healthful impact on hospital staff and can improve the feeling of well-being and medical outcomes in patients.

AAH recommends maximizing views of nature and landscaping from all patient environments, and increasing the use of skylights, interior transom windows, and natural light (Vittori, 2002).

The entire life cycle of building materials and products, as well as the building as a whole relative to its physical, environmental and human contexts on the local, regional and global scales, must be evaluated for environmental and health considerations. Establishing life cycle health and environmental considerations as evaluative criteria for design decisions and material and product specifications yield measurable benefits in enhanced patient outcomes, improved worker productivity, and reduced operations and maintenance costs, to name a few (Vittori, 2002).

Aim of this Report Investing in people requires a dual approach of reducing risks and promoting positive experience. Today, most building practices and standards focus on avoiding health and safety risk, such as illnesses and absenteeism associated with poor indoor air quality (Fisk & Rosenfeld, 1997). There are no standards, or even guidelines, on how to design to promote health, well-being, and other positive experiences such as engagement with place, work effectiveness, and sense of community (Heerwagen, 2006).

This report will focus on building design as a vehicle

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Current Healthcare Landscape

02 for promoting positive human experience and outcomes. Furthermore, it provides an opportunity to rethink hospital design, and especially to consider how improved hospital design can help reduce staff stress and fatigue and increase effectiveness in delivering care, improve patient safety, reduce patient and family stress and improve outcomes and improve overall healthcare quality (Ulrich, 2004).

Conclusions contribute to an ever-increasing evidence base of environmental impacts on healthcare building performance, patient well-being and medical outcomes. They aslo identify key environmental parameters and their multiple variables, as well as identifying topical healthcare building interior and exterior environmental-related issues for further study in new and emerging LEED for Healthcare projects (Price & Shikder, 2011). Finally, the report assesses the applicablity of the LEED for Healthcare rating system to therapeutic impacts on patient outcomes in the healthcare setting.

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Evidence-Based Design

Evidence-Based Design

03 University of Iowa State Hygienic Laboratory Coralville, Iowa | OPN Architects LEED Gold

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Evidence-Based Design

Evidence-Based Design Introduction Evidence-based design (EBD) is a process for the conscientious, explicit, and judicious use of current best evidence from research and practice in making critical decisions, together with an informed client, about the design of each individual and unique project (Stichler and Hamilton, 2008).

The process [of evidence based design] works especially well in the healthcare field. It appeals to physicians, who practice based on medical evidence. It gives patients and families higher-quality experiences. It appeals to business-minded administrators by reducing costs and improving organizational effectiveness. It helps hospital boards as they seek evidence to justify costly decisions. And it benefits the public, consumer groups, and those paying the bills as they seek effective, lower-cost healthcare (Hamilton 2003).

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EBD Benefits There is an ever-increasing evidence base of environmental impacts on healthcare building performance, patient well-being and medical outcomes. Some of the positive impacts are as follows:

• Encourage effective-provision of services based on scientific knowledge to all who can benefit; not providing services to those not likely to benefit (CHD, 2008).

• Reduce medical errors and, therefore, costs of care that emanate from latent conditions within the physical design (CHD, 2008).

• Support efficient-avoidance of waste, including waste of equipment, supplies, ideas, and energy (CHD, 2008).

• Improve satisfaction and efficiency of caregivers, especially aging caregivers, thereby helping recruitment and retention of a scarce and essential resource (CHD, 2008).

• Safe-avoidance of injuries to patients from the care that is intended to help them (CHD, 2008).

• Design a supportive physical environment for health information technology, reengineered work processes, and new diagnostic and interventional technologies (CHD, 2008).

• Provide innovative, adaptable designs to maximize response to natural and human-made disasters (CHD, 2008).

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• Timely-reduction of waits and harmful delays for both those who receive and those who give care (CHD, 2008).

• Equitable-provision of care that does not vary in quality with respect to gender, ethnicity, gegraphic location, and socio-economic status or other personal characteristics (CHD, 2008).

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Evidence-Based Design

Business Case for Better Hospitals The need to balance one-time construction costs against operating savings and revenue enhancements is central to making the business case for evidencebased design decisions. (CHD, 2008).

The first attempt to analyze this balance was published in 2004 by a multidisciplinary team that reviewed published research and the actual experience of healthcare organizations that utilized EBD in portions of their construction projects (Berry et al., 2004). Many of these organizations were pioneering hospitals that were part of a collaborative research program initiative called The Pebble Project, which was founded by The Center for Health Design (CHD, 2008).

The team designed a hypothetical hospital. When they analyzed the Fable’s operating cost savings resulting design innovations that could be shown to reduce infections, eliminate unnecessary patient transfers, minimize patient falls, lower drug costs, lessen employee turnover rates, as well as improve market share and philanthropy, they concluded that, with effective management and monitoring, the financial operating benefits would continue for several years (Berry et al., 2004). This result would make the additional innovations a sound long-term investment. In short, there was a compelling business case for building better, safer hospitals (CHD, 2008).

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Therapeutic Environments

Therapeutic Environments

06 National Intrepid Center of Excellence (NICoE) Bethesda, Maryland | Smithgroup JJR Prospective LEED Silver

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Therapeutic Environments

Therapeutic Environments Introduction

existing facility performance; and improved design guidelines for the elderly (Price & Shikder, 2011).

For healthcare, the compelling links between buildings and health, the irony of a healthcare system that may contribute to environmental illness, and a strong connection to healthcare’s fundamental mission to “first do no harm” make sustainable building an important goal that is impossible to ignore (Roberts and Guenther, 2006).

The healthcare industry is appropriately positioned to invest in research and demonstration projects to evaluate, make recommendations and implement policies and procedures to enhance the therapeutic qualities of healthcare facilities, and minimize material- and labor-intensive remodeling and renovation practices. Moreover, investments should extend to enhance the environmental performance of their buildings by adopting and implementing green building guidelines and establishing health and environmental performance parameters for all planning, design, specification, operations, maintenance, and post-use decisions (Vittori, 2002).

Facility design quality can significantly impact staff and patients’ health and well-being: empirical studies have shown that design attributes such as the ambient environment (e.g. sound, light and art) and physical features (e.g. windows, spatial layout, interior design corridors and circulation) can all influence patient recovery and staff performance (Price & Shikder, 2011).

Many of the projects under this topic have highlighted key issues that require further attention/research targeted at improving the healthcare facility planning and processes; thus delivering more therapeutic healthcare spaces/environments which in turn leads to increased staff performance and better patient outcomes. These issues include: the advanced use of building performance simulation tools to support the evaluation and optimization of therapeutic healthcare environments; developing more robust evidence that establishes an intrinsic link between the built healthcare environment and health outcomes (efficiency, quality and safety); improved evaluation of 09

The provision of high quality healing environments very much depends upon the selection of appropriate planning, design, construction and operational processes that contribute to the quality of care and recovery process by promoting therapeutic goals and enhancing operational efficiency. Previous research has linked quality of care, patient health and well-being with the physical characteristics of the healthcare environment (Douglas and Douglas 2004). More specifically, there is clear evidence that the physical environment of hospitals can affect the healing process, for example by: reducing the level of anxiety and stress (Beauchemin and Hays, 1998; Pattison and Robertson, 1996); shortening recovery periods following surgery through improved views of the external environment (Ulrich, 1984); increasing social interaction through improved building layout; positioning of furniture to increase patients’ wellbeing (Somner and Ross, 1958; Baldwin, 1985); significantly diminishing pathological behaviors by creating supportive building environments; establishing links between built environments and patients’ recovery (Gabb, et al, 1992); and by the provision of appropriate space and conditions to decrease patients’ recovery time and maximize the benefits from therapeutic environments (Price & Shikder, 2011).

According to Ulrich (2000), healthcare building design has traditionally been based on decisions focused on achieving efficiency in relation to operational cost, clinical and technological aspects. However, they have seemingly overlooked key aspects related to creating conducive healthcare environments capable of facilitating good patient wellbeing, experiences, and positive outcomes. Ulrich (1992) and Horsburgh (1995) further stated that the emphasis on erecting hospital edifices portraying profiles of formality does appear to unduly limit the development of calm, enabling healthcare environments for effective therapeutic impacts on patients. The Centre for Health Design (2011) defines evidence-based design as the process of basing decisions for the development of effective built healthcare environments on 12.12

Therapeutic Environments

credible research in order to achieve the best possible outcomes (Price & Shikder, 2011).

The benefits of appropriately designed environments, though implicit, are far reaching and can: improve medical outcomes; reduce work related stress, reduce infections and the intake of costly analgesics; and improve job satisfaction thus resulting in less staff absenteeism and lower staff turnover. According to Gesler et al (2004), the therapeutic value of hospitals relates to their physical, social and symbolic design.

The contribution of the physical environment to the performance (hence value) of any healthcare facility is highly complex as many qualitative and qualitative factors need to be taken into account. Several studies have investigated the influence of building layout, ward location and views on the performance of healthcare facilities (Vogt, 1990, Touran and Lopez, 2005). However, as highlighted by Toole (2001), performance is not only affected by physical characteristics, but also by the behavior of users and surroundings. Although previous research has emphasized the

potential influences of design characteristics (such as vision, building layout and lighting), there are also many claims that better healing environments can also have a positive influence on staff (doctors and nurses) productivity (Price & Shikder, 2011).

There is a growing need for healthcare infrastructure to be more sustainable. Sustainably built environments which offer green surroundings can also help improve: the healing environment and patients’ rate of recovery (CICA 2002, SDC 2005 and Shelbourn et al. 2006); the overall performance of healthcare service through reduced running costs; and user satisfaction through more occupant-friendly facilities (Bosch and Pearce 2003). Designing, constructing and managing a hospital in accordance with principles of sustainable development can also benefit the local community, the economy and the environment.

It can also improve public health as well as reduce the demand for health services (Kats & Capital, 2003).

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Therapeutic Environments

and providing appropriate space and conditions to decrease patients’ recovery time and maximize the use of therapeutic environment (Price & Shikder, 2011).

According to Gesler et al (2004): the therapeutic environment of hospitals relates to their physical, social and symbolic design; and the aim should be to produce facilities that are: “clinically efficient; well integrated within the community; accessible to consumers and the public; and encourage patient and staff well-being” (Price & Shikder, 2011).

08 However, there have been many missed opportunities regarding the integration and advancement of sustainability to reduce long-term costs of healthcare services (Price & Shikder, 2011).

The provision of innovative healing environments very much depends upon the design and construction of healthcare facilities that contribute to the quality of care and recovery process while promoting therapeutic goals and enhancing operational efficiency (Price & Shikder, 2011).

More specifically, there is clear evidence that the physical environment of hospitals can affect the healing process, for example: reducing the level of anxiety and stress; shortening recovery periods following surgery through better views of the surrounding environment; increasing social interaction through improved building layout; positioning of furniture to increase patients’ wellbeing; significantly diminishing pathological behaviors through the creation of supportive building environments; establishing links between built environments and patients’ recovery; 11

The relationship between healthcare infrastructure and sustainability is very strong in terms of impact on whole life value, health and well-being. Delivering a sustainable health system, with sustainable healthcare facilities, requires a good appreciation of the value of sustainable design solutions in relation to the environment, economy, policy and strategy. Most healthcare sustainability projects deal with a single aspect of sustainability (reduction of CO2 emission) and fail to take into consideration the broader sense of sustainability. This research focusses on the six aspects of sustainable healthcare infrastructure: outlined in Table 1 (Price & Shikder, 2011).

Human Benefits Research A growing body of research in diverse fields is beginning to identify positive outcomes associated with the building features and attributes shown in Table 1.

Studies show reduced adaptive load (less effort needed to adjust to an environment), reduced stress, improved emotional functioning, increased social support, reduced fatigue, and improved ability to focus attention on important activities (Heerwagen, 2006).

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Therapeutic Environments

wall. Patients with the nature view stayed in the hospital fewer days, took fewer strong medicines, and had more positive notes from nursing staff about their recovery process. (Heerwagen, 2006).

Although the mechanisms underlying the links between nature and cognitive performance are not currently known, there are several hypotheses. The first, proposed by Kaplan (1995) focuses on attention. Kaplan argues that visual contact with everyday nature reduces fatigue associated with intense concentration, and thereby replenishes the attentional system enabling people to refocus easily after short nature breaks (Kaplan 1995).

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Connection to Nature Over the past several decades, research in a variety of fields shows that contact with nature generates emotional, physiological, social, and cognitive benefits. Research on this topic has been conducted in a variety of settings including workplaces, hospitals, urban environments, and experimental laboratories.

Further, the findings point consistently to the value of particular nature features such as large trees, flowers, gardens, and water. Studies also show that benefits of nature occur in many ways—through direct contact (sitting in an outdoor garden), indirect contact (through a window view), and from simulations using nature decor (such as posters or paintings) (Heerwagen, 2006).

Ulrich’s research (1984) was the first to focus on the links between nature, emotional functioning and health associated with window views. His study found that hospital patients in rooms with views of trees had a more positive recovery from surgery than a matched group of patients whose view was a brick 12

The other leading hypothesis, proposed by Ulrich (1993), argues that nature contact improves cognitive performance through impacts on mood. He draws heavily on research by Isen (1990). In numerous experiments, Isen’s research shows that subjects in positive moods perform better on tests of creative problem solving than those who are in neutral or negative moods. Isen speculates that positive moods increase the tendency to “break set” and to see relatedness between divergent events or appearances.

This is because feeling good promotes diffuse rather than focused attention and this leads people to see things differently (e.g. people notice more details) or to search more broadly for solutions and alternative interpretations. Joseph LeDoux (1996), one of the nation’s leading brain researchers, cites neurological evidence to support this hypothesis. He has found that positive feelings lead to heightened activity of the right parietal brain region—the section of the brain that is associated with a more global, expansive cognitive style. Thus, positive feelings directly affect brain processes related to performance on tasks requiring creativity and novel problem solving. Daily irritants, on the other hand (such as discomfort) tend to generate high negative affect and thus are likely to interfere with higher level cognitive functioning (Clark & Watson, 1988). In contrast, daily perks— such as a window view of an outdoor landscape— ameliorate stress (Heerwagen, 2006).

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Therapeutic Environments

min and Hays (1996) found that patients in sunny rooms stayed in the hospital fewer days than those in dimly lit rooms.

A more recent study in Pittsburgh assessed patient outcomes in bright hospital rooms compared with those in rooms in which a building wing blocked sunlight access (Walch et al., 2005). The researchers found that patients in the bright rooms, who were exposed to 46 percent higher light levels, experienced less perceived stress, took less analgesic medication per hour, and had 21 percent less pain medication costs than patients who underwent the same type of surgery but were housed in the dimmer rooms (Heerwagen, 2006).

Sensory Change and Variability

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Outdoor Nature and Gardens There is also growing evidence that both active and passive contact with gardens provides psychological, emotional and social benefits. Cooper-Marcus and Barnes (1995) found that benefits of gardens included recovery from stress, having a place to escape to, and improved moods. Benefits also occur with horticulture therapy, especially in clinical settings and nursing homes. Studies described in Morris (2003) show that dementia and stroke patients show improved mobility and dexterity, more confidence, and improved social skills as a result of gardening activities (Heerwagen, 2006).

Daylight and Sunlight Benefits of daylight and sun have been studied in work and clinical settings. Sunlight in patient rooms is associated with reduced experience of pain as well as reduced stress and depression, more positive moods, and/or reduced hospital stays. In a study of patients hospitalized for severe depression, Beauche13

Increasing evidence shows that people like moderate levels of sensory variability in the environment, including variation in light, sound and temperatures, (Humphrey, 1980; Platt, 1961). An environment devoid of sensory stimulation and variability can lead to boredom and passivity (Cooper, 1968; Schooler, 1984).

Personal Control Personal control has assumed such a powerful place in psychology (Langer, 1983) that few question what it means or what people really want to control. Some argue that perceived control is more important than actual control; that is, if people think they have control over environmental conditions (as with a sham thermostat), they will be satisfied (Heerwagen, 2006).

Given the high personal variation in ambient preferences as well as variability within a given person over time, it is likely that control over temperature, noise, air movement, and lighting are an important component of an effective work environment (Heerwagen, 2006).

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LEED

LEED

11 National Intrepid Center of Excellence (NICoE) Bethesda, Maryland | Smithgroup JJR Prospective LEED Silver

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LEED

LEED Introduction The LEED (Leadership in Energy and Environmental Design) Green Building Rating Systems are voluntary, consensus-based, and market-driven. Based on existing and proven technology, they evaluate environmental performance from a whole building perspective over a building’s life cycle, providing a definitive standard for what constitutes a green building in design, construction, and operation. The LEED rating systems are designed for rating new and existing commercial, institutional, and residential buildings.

They are based on accepted energy and environmental principles and strike a balance between known, established practices and emerging concepts. Each rating system is organized into 5 environmental categories: Sustainable Sites, Water Efficiency, Energy and Atmosphere, Materials and Resources, and Indoor Environmental Quality. An additional category, Innovation in Design, addresses sustainable building expertise as well as design measures not covered under the 5 environmental categories. Regional bonus points are another feature of LEED and acknowledge the importance of local conditions in determining best environmental design and construction practices (USGBC, 2010).

ing System is a set of performance standards for certifying healthcare facilities. The intent is to promote healthful, durable, affordable, and environmentally sound practices in building design and construction.

The LEED for Healthcare rating system represents a culmination of seven years of close collaboration between the Green Guide for Health Care (GGHC) and USGBC. GGHC, a joint project of Health Care Without Harm and Center for Maximum Potential Building Systems, has helped to streamline the LEED for Healthcare development schedule by aligning with the LEED for New Construction rating system’s organizational structure. The GGHC is the first voluntary, self-certifying toolkit of green building best practices customized for the healthcare sector. The GGHC conducted a pilot program that included more than 100 healthcare facilities that informed the development of the LEED for Healthcare rating system (USGBC, 2010).

In LEED 2009, the allocation of points between credits is based on the potential environmental impacts and human benefits of each credit with respect to a set of impact categories. The impacts are defined as the environmental or human effect of the design, construction, operation, and maintenance of the building, such as greenhouse gas emissions, fossil fuel use, toxins and carcinogens, air and water pollutants, indoor environmental conditions. A combination of approaches, including energy modeling, life-cycle assessment, and transportation analysis, is used to quantify each type of impact. The resulting allocation of points among credits is called credit weighting (USGBC, 2010).

LEED for Healthcare The LEED 2009 for Healthcare Green Building Rat-

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LEED

LEED Designations

Certified 40-49 Points

Gold 60-79 Points

Silver 50-59 Points

Platinum 80-Above

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Conclusions

Conclusions

13 Health Sciences Education Building & Arizona Biomedical Collaborative II Phoenix, Arizona | CO Architects Prospective LEED Silver

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Conclusions

Conclusions Sustinable Construction

essential cornerstones of quality and value (Vittori, 2002).

Fueled by the success of the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) rating system, growing federal and state tax credit programs, and public and private financial energy incentives, more than 4.5% of construction activity in the United States is seeking to define sustainable building (Lounsbury, 2003). The healthcare sector faces unique opportunities and challenges as the construction industry increases its understanding of the impact of the built environment and operations on the health of building occupants, local communities, and global ecosystems (Roberts and Guenther, 2006).

Redefining buildings through their life cycle as integral parts of a healthy regional ecosystem, and as environments that directly impact human health, are basic principles of green building. Minimizing wastes, pollution, and toxics associated with the construction and operation of buildings and pursuing every opportunity to optimize indoor environmental quality are measurable performance goals. This agenda is consistent with the fundamental mission of healthcare professionals and should be reflected in their building portfolios (Vittori, 2002).

Future Agenda This shift in practice towards green and healthy buildings is fundamentally consistent with the core value of health care professionals – first, do no harm.

To this end, healthcare practitioners should assume a public health oriented position relative to the facilities in which they operate, and ensure that these buildings do not degrade the health of individuals or of the general public by implementing sustainable design, operation, and maintenance practices (Vittori, 2002).

These emerging strategies redefine the way buildings are designed, built, and operated, and extend the conventional notion of building performance to include human health and environmental quality as

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The first step is to recognize that the initial capital costs of a facility are a small portion of its running costs. Over the lifetime of a building, the design costs are likely to be only .3-.5% of the whole-life costs, and the capital costs themselves scarcely more than 5%, but both significantly affect – and indeed to a large degree determine – the costs of running the services (Rechel, 2009).

Healthcare practitioners must grasp the concept of preventive maintenance and integrated, anticipatory design. Finally, they must embrace the concept of partnering with their suppliers and design professionals to continue to explore the linkages between the nature of the physical environment and the impact the environment – including the built environment – has on medical outcomes, user satisfaction and productivity (Vittori, 2002).

Therapeutic Design A cross-comparison of therapeutic design characteritics to the LEED for Healthcare rating system clearly illustrates the shortcomings of the current trends in sustainable healthcare construction. While there are currently over 200 certified LEED for Healthcare projects, there still exists a disparity between LEED certified construction and therapeutic design. The following conclusions illustrate the apparent discrepancy (See Appendix for further analysis).

The ever-increasing compendium of evidence-based design research will make designers and health practitioners reconsider the role of the built environment and its therapeutic effects on patient outcomes.

While slow in its adoption, the LEED for Healthcare rating system encourages the profession to move in the right direction, and ultimately initiated a shift in practice toward therapeutic architecture. Healthy buildings, healthy people.

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Conclusions

Conclusions Measures

Therapeutic Design

LEED

Sustainable Sites

06

16

Water Efficiency

00

09

Energy and Atmosphere

01

39

Materials and Resources

02

16

Indoor Environmental Quality

18

18

Innovation in Design

00

06

Regional Priority

00

04

27

110

Total 19

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Appendix

Appendix

14 The Nebraska Medical Center Bellevue, Nebraska | HDR Prospective LEED Certified

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Appendix

Sustainable Sites LEED 2009 FOR HEALTHCARE PROJECT CHECKLIST Sustainable Sites

18 Possible Points

; Prerequisite 1

Construction Activity Pollution Prevention

Required

; Prerequisite 2

Environmental Site Assessment

Required

Credit 1

Site Selection

1

Credit 2

Development Density and Community Connectivity

1

Credit 3

Brownfield Redevelopment

1

Credit 4.1

Alternative Transportation—Public Transportation Access

3

Credit 4.2

Alternative Transportation—Bicycle Storage and Changing Rooms

1

Credit 4.3

Alternative Transportation—Low-Emitting and Fuel-Efficient Vehicles

1

Credit 4.4

Alternative Transportation—Parking Capacity

1

Credit 5.1

Site Development—Protect or Restore Habitat

1

Credit 5.2

Site Development—Maximize Open Space

1

Credit 6.1

Stormwater Design—Quantity Control

1

Credit 6.2

Stormwater Design—Quality Control

1

Credit 7.1

Heat Island Effect—Nonroof

1

Credit 7.2

Heat Island Effect—Roof

1

Credit 8

Light Pollution Reduction

1

Credit 9.1

Connection to the Natural World—Places of Respite

1

Credit 9.2

Connection to the Natural World—Direct Exterior Access for Patients

1

Water Efficiency

9 Possible Points

; Prerequisite 1

Water Use Reduction

Required

; Prerequisite 2

Minimize Potable Water Use for Medical Equipment Cooling

Required

Credit 1

Water Efficient Landscaping—No Potable Water Use or No Irrigation

Credit 2

Water Use Reduction—Measurement and Verification

1-2

Credit 3

Water Use Reduction

1-3

Credit 4.1

Water Use Reduction—Building Equipment

1

Credit 4.2

Water Use Reduction—Cooling Towers

1

Credit 4.3

Water Use Reduction—Food Waste Systems

1

Energy and Atmosphere

1

39 Possible Points

; Prerequisite 1

Fundamental Commissioning of Building Energy Systems

Required

; Prerequisite 2

Minimum Energy Performance

Required

; Prerequisite 3

Fundamental Refrigerant Management

Required

Credit 1

Optimize Energy Performance

Credit 2

On-site Renewable Energy

1–8

Credit 3

Enhanced Commissioning

1-2

Credit 4

Enhanced Refrigerant Management

1

Credit 5

Measurement and Verification

2

Credit 6

Green Power

1

Credit 7

Community Contaminant Prevention—Airborne Releases

1

1–24

2009 FOR HEALTHCARE NEW CONSTRUCTION & MAJOR RENOVATIONS

21

vii

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Credit 4.1

Alternative Transportation—Public Transportation Access

3

Credit 4.2

Alternative Transportation—Bicycle Storage and Changing Rooms

1

Credit 4.3

Alternative Transportation—Low-Emitting and Fuel-Efficient Vehicles

1

Credit 4.4

Alternative Transportation—Parking Capacity

Credit 5.1

Site Development—Protect or Restore Habitat

Credit 5.2

Site Development—Maximize Open Space

1

Credit 6.1

Stormwater Design—Quantity Control

1

Credit 6.2

Stormwater Design—Quality Control

1

Credit 7.1

Heat Island Effect—Nonroof

1

Credit 7.2

Heat Island Effect—Roof

1

Credit 8

Light Pollution Reduction

1

Credit 9.1

Connection to the Natural World—Places of Respite

1

Credit 9.2

Connection to the Natural World—Direct Exterior Access for Patients

1

Water Efficiency Water Efficiency

1

Appendix 1

9 Possible Points

; Prerequisite 1

Water Use Reduction

Required

; Prerequisite 2

Minimize Potable Water Use for Medical Equipment Cooling

Required

Credit 1

Water Efficient Landscaping—No Potable Water Use or No Irrigation

Credit 2

Water Use Reduction—Measurement and Verification

1-2

Credit 3

Water Use Reduction

1-3

Credit 4.1

Water Use Reduction—Building Equipment

1

Credit 4.2

Water Use Reduction—Cooling Towers

1

Credit 4.3

Water Use Reduction—Food Waste Systems

1

Energy and Atmosphere

1

39 Possible Points

; Prerequisite 1

Fundamental Commissioning of Building Energy Systems

Required

; Prerequisite 2

Minimum Energy Performance

Required

; Prerequisite 3

Fundamental Refrigerant Management

Required

Credit 1

Optimize Energy Performance

Credit 2

On-site Renewable Energy

1–8

Credit 3

Enhanced Commissioning

1-2

Credit 4

Enhanced Refrigerant Management

1

Credit 5

Measurement and Verification

2

Credit 6

Green Power

1

Credit 7

Community Contaminant Prevention—Airborne Releases

1

1–24

2009 FOR HEALTHCARE NEW CONSTRUCTION & MAJOR RENOVATIONS vii

22

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Credit 8

Light Pollution Reduction

1

Credit 9.1

Connection to the Natural World—Places of Respite

1

Credit 9.2

Connection to the Natural World—Direct Exterior Access for Patients

1

Appendix 9 Possible Points

Water Efficiency ; Prerequisite 1

Water Use Reduction

Required

; Prerequisite 2

Minimize Potable Water Use for Medical Equipment Cooling

Required

Credit 1

Water Efficient Landscaping—No Potable Water Use or No Irrigation

Credit 2

Water Use Reduction—Measurement and Verification

1-2

Credit 3

Water Use Reduction

1-3

Credit 4.1

Water Use Reduction—Building Equipment

1

Credit 4.2

Water Use Reduction—Cooling Towers

1

Credit 4.3

Water Use Reduction—Food Waste Systems

1

Energy and Atmosphere Energy and Atmosphere

1

39 Possible Points

; Prerequisite 1

Fundamental Commissioning of Building Energy Systems

Required

; Prerequisite 2

Minimum Energy Performance

Required

; Prerequisite 3

Fundamental Refrigerant Management

Required

Credit 1

Optimize Energy Performance

Credit 2

On-site Renewable Energy

1–8

Credit 3

Enhanced Commissioning

1-2

Credit 4

Enhanced Refrigerant Management

1

Credit 5

Measurement and Verification

2

Credit 6

Green Power

1

Credit 7

Community Contaminant Prevention—Airborne Releases

1

1–24

2009 FOR HEALTHCARE NEW CONSTRUCTION & MAJOR RENOVATIONS vii

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Appendix

Materials and Resources Materials and Resources

16 Possible Points

; Prerequisite 1

Storage and Collection of Recyclables

Required

; Prerequisite 2

PBT Source Reduction—Mercury

Required

Credit 1.1

Building Reuse—Maintain Existing Walls, Floors and Roof

Credit 1.2

Building Reuse—Maintain Existing Interior Nonstructural Elements

Credit 2

Construction Waste Management

1-2

Credit 3

Sustainably Sourced Materials and Products

1-4

Credit 4.1

PBT Source Reduction—Mercury in Lamps

Credit 4.2

PBT Source Reduction—Lead, Cadmium and Copper

Credit 5

Furniture and Medical Furnishings

Credit 6

Resource Use—Design for Flexibility

Indoor Environmental Quality

1-3 1

1 2 1-2 1

18 Possible Points

; Prerequisite 1

Minimum Indoor Air Quality Performance

Required

; Prerequisite 2

Environmental Tobacco Smoke (ETS) Control

Required

; Prerequisite 3

Hazardous Material Removal or Encapsulation (Renovations Only)

Required

Credit 1

Outdoor Air Delivery Monitoring

Credit 2

Acoustic Environment

Credit 3.1

Construction Indoor Air Quality Management Plan—During Construction

Credit 3.2

Construction Indoor Air Quality Management Plan—Before Occupancy

Credit 4

Low-Emitting Materials

1 1-2 1 1 1-4

Credit 5

Indoor Chemical and Pollutant Source Control

1

Credit 6.1

Controllability of Systems—Lighting

1

Credit 6.2

Controllability of Systems—Thermal Comfort

1

Credit 7

Thermal Comfort—Design and Verification

1

Credit 8.1

Daylight and Views—Daylight

Credit 8.2

Daylight and Views—Views

Innovation in Design

2 1-3

6 Possible Points

; Prerequisite 1

Integrated Project Planning and Design

Credit 1

Innovation in Design

Credit 2

LEED Accredited Professional

1

Credit 3

Integrated Project Planning and Design

1

Regional Priority Credit 1

Required 1-4

4 Possible Points Regional Priority

1-4

________________________________________________________________________ LEED 2009 for Healthcare 100 base points; 6 possible Innovation in Design and 4 Regional Priority points Certified

40–49 points

Silver

50–59 points

Gold

60–79 points

Platinum

80 points and above

24 2009 FOR HEALTHCARE NEW CONSTRUCTION & MAJOR RENOVATIONS

12.12

Materials and Resources

16 Possible Points

; Prerequisite 1

Storage and Collection of Recyclables

Required

; Prerequisite 2

PBT Source Reduction—Mercury

Required

Credit 1.1

Building Reuse—Maintain Existing Walls, Floors and Roof

Credit 1.2

Building Reuse—Maintain Existing Interior Nonstructural Elements

Credit 2

Construction Waste Management

1-2

Credit 3

Sustainably Sourced Materials and Products

1-4

Credit 4.1

PBT Source Reduction—Mercury in Lamps

Credit 4.2

PBT Source Reduction—Lead, Cadmium and Copper

Credit 5

Furniture and Medical Furnishings

Credit 6

Resource Use—Design for Flexibility

Indoor Environmental Quality Indoor Environmental Quality

Appendix 1-3 1

1 2 1-2 1

18 Possible Points

; Prerequisite 1

Minimum Indoor Air Quality Performance

Required

; Prerequisite 2

Environmental Tobacco Smoke (ETS) Control

Required

; Prerequisite 3

Hazardous Material Removal or Encapsulation (Renovations Only)

Required

Credit 1

Outdoor Air Delivery Monitoring

Credit 2

Acoustic Environment

Credit 3.1

Construction Indoor Air Quality Management Plan—During Construction

1

Credit 3.2

Construction Indoor Air Quality Management Plan—Before Occupancy

1

Credit 4

Low-Emitting Materials

Credit 5

Indoor Chemical and Pollutant Source Control

1

Credit 6.1

Controllability of Systems—Lighting

1

Credit 6.2

Controllability of Systems—Thermal Comfort

1

Credit 7

Thermal Comfort—Design and Verification

1

Credit 8.1

Daylight and Views—Daylight

Credit 8.2

Daylight and Views—Views

Innovation in Design

1 1-2

1-4

2 1-3

6 Possible Points

; Prerequisite 1

Integrated Project Planning and Design

Credit 1

Innovation in Design

Credit 2

LEED Accredited Professional

1

Credit 3

Integrated Project Planning and Design

1

Regional Priority Credit 1

Required 1-4

4 Possible Points Regional Priority

1-4

________________________________________________________________________ LEED 2009 for Healthcare 100 base points; 6 possible Innovation in Design and 4 Regional Priority points Certified

40–49 points

Silver

50–59 points

Gold

60–79 points

Platinum

80 points and above

2009 FOR HEALTHCARE NEW CONSTRUCTION & MAJOR RENOVATIONS viii

25

12.12

; Prerequisite 2

Environmental Tobacco Smoke (ETS) Control

Required

; Prerequisite 3

Hazardous Material Removal or Encapsulation (Renovations Only)

Required

Credit 1

Outdoor Air Delivery Monitoring

Credit 2

Acoustic Environment

Credit 3.1

Construction Indoor Air Quality Management Plan—During Construction

Credit 3.2

Construction Indoor Air Quality Management Plan—Before Occupancy

Credit 4

Low-Emitting Materials

Credit 5

Indoor Chemical and Pollutant Source Control

1

Credit 6.1

Controllability of Systems—Lighting

1

Credit 6.2

Controllability of Systems—Thermal Comfort

1

Credit 7

Thermal Comfort—Design and Verification

1

Credit 8.1

Daylight and Views—Daylight

Credit 8.2

Daylight and Views—Views

Innovation in Design Innovation in Design

1 1-2

Appendix 1 1 1-4

2 1-3

6 Possible Points

; Prerequisite 1

Integrated Project Planning and Design

Credit 1

Innovation in Design

Credit 2

LEED Accredited Professional

1

Credit 3

Integrated Project Planning and Design

1

Regional Priority Credit 1

Required 1-4

4 Possible Points Regional Priority

1-4

________________________________________________________________________ LEED 2009 for Healthcare 100 base points; 6 possible Innovation in Design and 4 Regional Priority points Certified

40–49 points

Silver

50–59 points

Gold

60–79 points

Platinum

80 points and above

2009 FOR HEALTHCARE NEW CONSTRUCTION & MAJOR RENOVATIONS viii

26

12.12

Credit 4

Low-Emitting Materials

Credit 5

Indoor Chemical and Pollutant Source Control

1

Credit 6.1

Controllability of Systems—Lighting

1

Credit 6.2

Controllability of Systems—Thermal Comfort

Credit 7

Thermal Comfort—Design and Verification

Credit 8.1

Daylight and Views—Daylight

Credit 8.2

Daylight and Views—Views

Innovation in Design

1-4

1 Appendix 1 2 1-3

6 Possible Points

; Prerequisite 1

Integrated Project Planning and Design

Credit 1

Innovation in Design

Credit 2

LEED Accredited Professional

1

Credit 3

Integrated Project Planning and Design

1

Regional Priority Regional Priority Credit 1

Required 1-4

4 Possible Points Regional Priority

1-4

________________________________________________________________________ LEED 2009 for Healthcare 100 base points; 6 possible Innovation in Design and 4 Regional Priority points Certified

40–49 points

Silver

50–59 points

Gold

60–79 points

Platinum

80 points and above

2009 FOR HEALTHCARE NEW CONSTRUCTION & MAJOR RENOVATIONS viii

27

12.12

References

References

15 Kenya Women and Children’s Wellness Centre Nairobi, Kenya | Perkins + Will Prospective LEED Certified

28

12.12

References

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02 Beauchemin, K.M. & Hays, P. (1998) Dying in the Dark: Sunshine, Gender and Outcomes in Myocardial infarction. Journal of the Royal Society of Medicine 91, 352-354.

03 Berry, L., Parker, D., Coile, R., Hamilton, D.K., O’Neil, D., & Sadler, B. (2004). The Business Case for Better Buildings. Frontiers in Health Service Management, 21 (1), 3-21.

04 Bosch, S., & Pearce, A. R. (2003) “Sustainability in Public Facilities: Analysis of Guidance Documents.” Journal of Performance of Constructed Facilities 17(1), 9–18.

05 Brown, J. (2011, Nov. 7). Ten-Plus Years in Healthcare Sustainability. Retrieved December 9, 2012, from: http://www.healthcaredesignmaga zine.com/article/ten-plus-years-and-many-analo gies-healthcare-sustainability

10 Cooper, R. (1968). The Psychology of Boredom.

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11 Douglas, C.H. & Douglas, M.R. (2004) “Patient-Friendly Environments: Exploring the Patients’ Perspective”, Journal of Health Expectation 7, 61-73.

12 Fisk, W.J., & Rosenfeld, A. H. (1997). Estimates of Improved Productivity and Health from Better Indoor Environments. Indoor Air. 13 Francis, S. & Glanville, R. (2001). Building a 2020 Vision: Future Health Care Environments.

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14 Frumkin, H. (2007). Green Healthcare Institutions Health, Environment, and Economics: Workshop Summary. Washington, D.C.: National Academies Press.

15 Gabb, B. S., Speicher, K. & Lodl, K. (1992) “Environmental Design for Individuals with Schizophrenia: An Assessment Tool”, Journal of Applied Rehabilitation Counsel 23, 35-40.

06 Carpman, J. & Grant, M. (1986). Design that Cares: Planning Health Facilities for Patients and Visitors. Chicago, IL: American Hospital Pub.

16 Guenther, R. & Vittori, G. (2008). Sustainable Healthcare Architecture. Hoboken, N.J.: John Wiley & Sons.

07 CICA (2002) “Industry as a Partner for Sustain able Development; Construction”, Report for the United Nations Environment Programme, Confederation of International Contractors Associations, Washington, DC.

17 Heerwagen, J. (2006). Investing in People: The Social Benefits of Sustainable Design. Retrieved December 9, 2012, from: www.haworth.com/.../ Investing%20in%20People%20Abstract_C3.pdf

08 Clark, L.A., & Watson, D. (1988). Mood and the Mundane: Relationships Between Daily Events and Self-Reported Mood. Journal of Personality and Social Psychology, 54, 296-308.

09 Cooper-Marcus, C., & Barnes, M. (1995). Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: Wiley.

29

18 Horsburgh, C.R. (1995) “Healing by design”, The New England Journal of Medicine 333(11), 735740.

19 Humphrey, N. (1980). Natural Aesthetics. In B. Mikellides (Ed.), Architecture for people. Lon don: Studio Vista.

20 Illich, I. (1976). Medical Nemesis: The Expropriation of Health. New York: Pantheon Books.

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22 Kaplan, S. (1995). The Restorative Benefits of Nature: Toward an Integrative Framework. Journal of Environmental Psychology, 15, 169-182.

23 Kats, G., & Capital E. (2003) “The Costs and Financial Benefits of Green Buildings”, A Report to California’s Sustainable Building Task Force, October 2003.

24 Langer, E.J. (1983). The Psychology of Control.

Beverly Hills, CA: Sage.

25 Langston, S. (2011, Oct. 11). LEED for Healthcare. Retrieved December 9, 2012, from: http:// www.healthcaredesignmagazine.com/article/ leed-healthcare 26 LeDoux, J. (1996). The Emotional Brain. New York: Simon and Schuster.

27 Marberry, S. (1996). Healthcare Design. New York: John Wiley and Sons.

28 Morris, N. (2003). Health, Well-being and Open Space. Edinburgh, Scotland, Edinburgh College of Art and Heriot-Watt University. OPENSpace Research Center for Inclusive Access to Outdoor Environments.

29 Pattison, H.M. & Robertson, C.E. (1996) The Effect of Ward Design on Well-Being of PostOperative Patients. Journal of Advanced Nursing 23, 820-826 30 Platt, J.R. (1961). Beauty: Pattern and Change. In D.W. Fiske & S.R. Maddi (Eds.), Functions of Varied Experience. Homewood, IL: Dorsey Press.

30

31 Price, A. & Shikder, S. (2011). Design and Decision Making to Improve Healthcare Infrastructure. Leicestershire: Loughborough University.

32 Rechel, B. (2009). Investing in Hospitals of the Future. Copenhagen, Denmark: World Health Organization.

33 Sadler, B., DuBose, J., Malone, E. & Zimring. C. (2008). The Business Case for Building Better Hospitals Through Evidence-Based Design.

Retrieved December 9, 2012, from: http://smart ech.gatech.edu/handle/1853/25462 34 Schooler, C. (1984). Psychological Effects of Complex Environments During the Life Span: a Review and Theory. Intelligence, 8, 259-281 35 SDC (2005) On the Move Review 2006-2006, Sustainable Development Commission. Available online at: www.sd-commission.org.uk/data/ files/ publications/OnTheMove.pdf 36 Shelbourn, M.A., Bouchlaghem, D.M., Anumba C.J., Carillo, P.M., Khalfan, M.M.K. & Glass J. (2006) “Managing Knowledge in the Context of Sustainable Construction,” ITcon, 11, 57-71 Retrieved December 9, 2012, from: www.itcon. org/2006/4 37 Somner, R. & Ross, H. (1958) “Social Interac tion on Geriatric Ward”, International Journal of Social Psychiatry 4, 128-133.

38 Stichler, J.F., & Hamilton, K.D. (2008). Evidencebased design: What is it? Health Environments Research and Design. 1 (2), 3-4.

39 The Center for Health Design. (2008). An Introduction to Evidence-Based Design. Concord, CA: The Center for Health Design.

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References

Documents 40 The Commonwealth Fund Commission on a High Performance Health System. (2006). Why Not the Best? Results from a National Scorecard on U.S. Health System Performance. Retrieved December 9, 2012, from: http://www.common wealthfund.org/Publications/Fund-Re ports/2011/Oct/Why-Not-the-Best-2011. aspx?page=all

48 Vittori, G. (2002). Green and Healthy Buildings for the Healthcare Industry. Retrieved December 9, 2012, from: http://www.healthybuilding. net/healthcare/

41 Thompson, D. (2012, Aug. 13). Greening Rockingham. Retrieved December 9, 2012, from: http://www.healthcaredesignmagazine.com/ar ticle/greening-healthcare

50 Walch, J.M., Rabin, B.S, Day, R., Williams, J.N., Choi, K., & Kang, J.D. (2005). The Effect of Sunlight on Postoperative Analgesic Medication Use: a Prospective Study of Patients Undergoing Spinal Surgery. Psychosomatic Medicine, 67, 156153.

42 Touran, A. & Lopez, R. (2005) “Modelling Cost Escalation as a Risk Factor in Construction Project”, I.D. TOMMELEIN, ed. In: April 5, 2005, ASCE pp. 66.

49 Vogt, B. (1990) “Evacuation of Institutionalized and Specialized Population”, Oak Ridge National Laboratory, Tennessee. ORNL/SUB-7685 & T23.

43 Ulrich, R. (1984) “View through a Window may Influence Recovery from Surgery”, Science 224, 420-421.

44 Ulrich, R. (1993). Biophilia, Biophobia, and Natural Landscapes. In S.K. Kellert & E.O. Wil son (Eds.), The Biophilia Hypothesis. Washing ton DC: Island Press, Shearwater Books.

45 Ulrich, R. (2000) “Evidence based environmental design for improving medical outcomes”, Proceedings of the Healing by Design: Building for Health Care in the 21st Century Conference Montreal, Quebec, Canada, March, pp. 1–10.

46 Ulrich, R. (2004). The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity.

Retrieved December 9, 2012, from: http://health design.org/ 47 U.S. Green Building Council. (2010). LEED 2009 for Healthcare. Washington D.C.: U.S. Green Building Council, Inc.

31

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References

Images 01 Enhancing the Human Experience [Photgraph].

(2012). Retrieved December 9, 2012, from: http://hksinc.com/#

10 Dell Children’s Medical Center [Photograph].

(2012). Retrieved December 9, 2012 from: http:// www.karlsberger.com

02 Peter & Paula Fasseas Cancer Clinic [Photo graph]. (2012). Retrieved December 9, 2012, from: http://www.coarchitects.com/

11 National Intrepid Center of Excellence [Photo graph]. (2012). Retrieved December 9, 2012, from: http://www.archdaily.com/274743/aia-se lects-four-projects-for-national-healthcaredesign-awards/

03 University of Iowa, State Hygienic Labortory [Photograph]. (2012). Retrieved December 9, 2012, from: http://www.opnarchitects.com/in dex.php?option=com_photo_gallery&Itemid =111\ 04 Cleveland Clinic Abu Dhabi Hospital. [Rendering]. (2012). Retrieved December 9, 2012, from: http://www.hdrinc.com/portfolio/clevelandclinic-abu-dhabi-hospital 05 EBD Research Initiatives Identified at the EBD 2.0 Collaborative Research Workshop Proceed ings in March 2008 [Table]. (2008). Retrieved from: An Introduction to Evidence-Based De sign.

12 LEED Scorecard [Table]. (2012). Retrieved December 9, 2012, from:https://new.usgbc.org/ leed/rating-systems 13 Health Sciences Education Building & Arizona Biomedical Collaborative II [Photograph].

(2012). Retrieved December 9, 2012, from: http://www.pdc.arizona.edu/projects/projectlist. aspx 14 The Nebraska Medical Center [Photograph].

(2012). Retrieved December 9, 2012, from: http://www.hdrinc.com/portfolio/bellevuemedical-center

06 National Intrepid Center of Excellence [Photo graph]. (2012). Retrieved December 9, 2012, from: http://www.archdaily.com/274743/aia-se lects-four-projects-for-national-healthcaredesign-awards/

15 Kenya Women and Children’s Wellness Centre [Rendering]. (2012). Retrieved December 9, 2012, from: http://www.perkinswill.com/work/ kenya-women-and-childrens-wellness-centre. html

07 Features and Attributes of Buildings Linked to Well Being Needs and Experiences [Table].

(2006). Retrieved from: The Social Benefits of Sustainable Design.

16 Kaiserslautern Military Community Medical Center [Rendering]. (2012). Retrieved December 9, 2012, from: http://www.hok.com/design/ type/healthcare/kaiserslautern-military-commu nity-medical-center/

08 Willson Hospice House [Photograph]. Retrieved December 9, 2012, from: http://www.perkinswill. com/work/willson-hospice-house.html 09 Willson Hospice House [Photograph]. Retrieved December 9, 2012, from: http://www.perkinswill. com/work/willson-hospice-house.html

32

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Scott Abernethy

16 Kaiserslautern Millitary Community Medical Center Kaiserslautern, Germany | HOK Prospective LEED Silver

33

12.12