Sustainability in Hospitals

EXTENDED ABSTRACT

This dissertation addresses the topic Sustainability in Hospitals. The issue of climate change
and scarcity of natural resources of the planet requires the implementation of measures and
promotion of behaviours that develop into a building with less negative impact on ecosystems. It
is important to guarantee that even if an area has been exploited and all the needs of a
population are fulfilled, the area will continue to provide the necessary resources for the
economic and social welfare of the community, and therefore keeps the balance between the
environment and the human community.

Objectives

The purpose of this dissertation is to examine the principles of sustainability for the three
dimensions (environmental, social and economic) by applying them to a specific public facility -
the Hospital.

The aim was, in fact, recognize and explore the importance and implications that the notions
and concepts of sustainability have and / or add something new in the construction of hospitals,
not only in physical terms (new materials, energy, ...) as well as in social terms (if the user is
comfortable, if he was given proper attention, ...) and in economic terms.

We therefore intend, on one hand, to check what can be done, based on the principles of
sustainability applied to a specific public facility - the Hospital, so that it can improve its
environmental performance and, moreover , whether it can improve the conditions that a public
facility like a hospital provides to its users as much as their workers.

The case study chosen was the Hospital da Luz in Lisbon.

Initially, we tried to perform, conduct interviews to users, families, workers and the
administrative body of the Hospital da Luz. Then we picked up a rating system for sustainable
construction and proceeded to collect the information needed to fill it. Through these
techniques, it was intended:

Assess the environmental comfort of the user in the Hospital inpatient unit, location and
environmental comfort of the Hospital by relatives of the users, and the degree of agreement
that the hospital staff has when promoting sustainable behaviours in the workplace.

Propose changes or give directions on how to improve the hospital on account of some of the
basic notions of sustainability, such as the basic principles of Bioclimatic Architecture.

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

However, due to some external constraints, we could not carry out interviews with users,
families and workers. Thus, the collection of information necessary to implement the evaluation
system for sustainable construction chosen, was eventually conditioned, limiting, therefore the
access to certain data necessary to fulfil the evaluation criteria.

Because we have encountered certain external constraints and it has not been possible to
perform the interviews / questionnaires, it was not possible to have the information necessary to
address the social and economic components of the case study. We had to reset the primary
aim of this dissertation, proceeding then to the principles of the physical dimension of
sustainability in the case study, instead of three dimensions initially contemplated.

Structure of Dissertation

The paper is organized into five chapters.

Chapter 1 – Introduction

Chapter 2 - Bioclimatic Architecture and Sustainability

The second chapter presents a theoretical approach to the issue of sustainability. To

understand this phenomenon and its promotion, it was necessary to undertake a study of the
genesis of the theme. Based on the history and the study of various content related to the
theme (as the main drivers) we could follow the development of some key concepts.
In this chapter we make an approach to evaluation systems for sustainable construction, or
"guide lines" inherent to it, specifically at a public facility - the Hospital.

This chapter is organized into two parts, namely

2.1) The historical context
2.2) Bio-Climatic Architecture
2.3) Evaluation Systems for Sustainable Construction

Chapter 3 - Sustainability in Hospitals

This chapter presents international examples of quality in order to illustrate the main objectives
of sustainable practices in hospital buildings.

This chapter consists of a single part

2.1) Good practice

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

Chapter 4 - Case Study - Hospital da Luz

This chapter is devoted to the subject under study. It is introduced by a summary of a factsheet
relating to the subject - Hospital da Luz. An exhaustive study of the building follows, in order to
enable the knowledge of its background characteristics as well as the functional description of
each floor – valuing principles such as shape and orientation of the building, ventilation, lighting,
materials used, among others. After a detailed knowledge of the building it is then possible to fit
it into the LiderA system and subsequent verification of the criteria that constitute it.

This chapter is organized into three parts, namely

4.1) Factsheet
4.2) The Hospital
4.3) Critical Analysis

Chapter 5 - Conclusion

Methodology

We carried out consequent literature review, systematization of sustainability principles, review

of international affairs and implementation of an evaluation system for sustainable construction
and a national case study.

This study was conducted in four phases:

Phase 1) Collection of information on the concepts of sustainability assessment, systems

assessment construction, bio-climatic architecture, as well as recommendations and / or
specifications of the Hospital Building;

Phase 2) Review and processing of data collected in Phase 1;

Step 3) Preparation of questionnaires and / or interviews to be held for the guests, relatives,
employees, management, collection of information necessary to implement the evaluation
system of sustainable construction chosen;

Stage 4) Case Study - work on the spot. Analysis of the object of study and application of
questionnaires and / or interviews, using a Likert scale, and the evaluation system of
sustainable construction - LiderA ®, (we used this system because this is the rating system
applied to Portugal within the ones revised) in a case - Hospital da Luz gathering and analyzing
data, and suggestions for further recommendations / proposed solutions.

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

Framework for the theme

Sustainability and sustainable development are concepts that emerge from the man is urgent
need of finding ways to remain stay on the planet.

The damage to the environment as a habitat, have impacts in all dimensions of life, and only
through effective environmental management can we meet the challenge posed by the scarcity
of resources, destruction of ecosystems, pollution of air and water and the toxic waste.

The most used definition for sustainable development is that which appeared in 1983 in the
Brundtland Commission:

"The development that seeks to meet the needs of the present generation without
compromising the ability of future generations to meet their own needs, means enabling people
now and in future, to achieve a satisfactory level of social and economic development and
human achievement and cultural, making, at the same time, a reasonable use of land resources
preserving species and natural habitats. "
Sustainability will thus highlight the importance of the economic, social and environmental
dimensions1 as well as seeking a balance among these, taking into account that the decisions
taken should not be considered only according to one of these criteria alone.

The development of design models, methods of construction, renovation and demolition of

buildings can enable significant improvements in the economic and environmental performance
of the built environment, thus increasing the quality of spaces built in terms of environmental
and economic performance and the quality of life of the population.

The environmental dimension has already gained great importance, beyond legal requirements,
being dominant in terms of construction. Therefore, it is increasingly urgent to consider the
potential impacts associated with the built environment, seeking solutions to minimize them and
if possible, eliminate them, such as quantification of land use, resource consumption (such as
water and energy ), the large scale production of waste and the change of natural ecosystems.

The interdependence between the economic and social dimensions aims to satisfy the needs
of a population in exponential growth in a limited physical space, with the preservation of the
environment, demands for durable solutions for the maintenance of natural resources and the

1
http://www.un.org/documents/ga/res/42/ares42-187.htm - United Nations. 1987."Report of the World Commission on
Environment and Development."

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

capacity of production and distribution of the wealth produced Man. On the other hand the
social sphere can be represented as the "human element" that will reprogram the direction of
society in this whole equation that aims at the development and sustainable construction. Thus,
the social component seeks equality and social inclusion, and awareness of issues such as
preservation of the environment that surrounds the society in which everyone belongs. It surges
important momentum at the level of the society, contributing to a strengthening of urban
communities and their interrelationships. If properly addressed these issues together with an
environmental and economic development, will create wealth, employment and contribute to an
expectable sustainable progress. The social aspect is often incorrectly forgotten. There is little
point in a cared environment and preserved natural resources, if the basic conditions observed
and quality of life for people in the context of this environment are not met. It appears also
essential that the different social groups participate in finding solutions and act in its
accomplishment by encouraging the development of these concepts.

The architecture has a role to play in order to minimize some of the problems stemming from
human mismanagement of the planet. When designing "green building"2 we are contributing
significantly to sustainable development.

Critical Analysis

After the study was completed and evaluation of different criteria was made, after assigning the
performance levels and their weighting factors, it was found that the performance of the case
study corresponds to Class A, whereas there was a 22.2% improvement in relation to practice

2
Practice that creates structures and uses environmentally responsible and efficient processes in the building of an
entire life cycle of a building: since the conception phase to the project, building, operation, maintenance, renovation
and deconstruction. This practice expands and complements the concerns about the economy, utility, durability and
comfort of the traditional building design.

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

As it was observed by applying the LiderA system to Hospital da Luz, it was found that there are
areas and, consequently, criteria whose applicability is feasible for hospital buildings.

One can therefore highlight some of the criteria, not only for having a high level of performance
- A, A + or A + +, but also because they are a part of areas with higher percentage of influence
in LiderA.

According to RSECE3, energy certification, along with levels of air quality, lighting levels and
thermal comfort are among the highest ranked criteria in the assessment made, all of which
were classified as A +. It is understood that all of these criteria will have had a considerable
influence on the final classification of Hospital da Luz the set of criteria of the dimension
environmental comfort, all rated A+ or A, has weighting of 15% on the overall rating.

It should also be highlighted all the criteria of the socio-economic strand, whose evaluation can
be considered, in general, very positive - the most frequent classifications are A +, and only two
of the thirteen criteria are ranked E (one of which, due the lack of information). Given the
relative weight of this part of the overall evaluation of the Hospital, it should be noted that this
has a weighting of 19%.

Oder areas should as well be referred, thought with a less significant weighting, but whose
evaluation is at a level that, given the usual practice, stands out: light thermal pollution (A),
external noise (A) and innovation (A +).

Although the classification of the criteria of Hospital da Luz is, in general, quite satisfactory, we

3
Portuguese acronym for Regulamento dos Sistemas Energéticos de Climatização em Edifícios.

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

identified some areas where rehabilitation could significantly improve the overall performance of
the complex. So that the process of identifying issues to be rehabilitated could become more
complete, more coherent and consistent, we used a comparison with Providence Newberg
Medical Center (PNMC) - USA4.

The aspect of local integration is one that is considered less satisfactory, with only one of the
criteria obtaining an A. Within this strand the area of soil, which is weighted by 7%, it is one that
needs to be improved to enable the increase of their assessment. Also the area of natural
ecosystems, with a weighting of 5% should be improved, since it could overcome the current
classification (D), therefore contributing to improving the overall performance of Hospital da Luz

Within the area of energy, which represents 17% of weighting, the criterion on the passive
design has been identified as one that needs to be improved, since an increase in its class (C)
would have a significant impact on the overall performance.

Also the area of environmental management is considered one of those that should be targeted
for improvement, since its weight is 6% and its current rating is E. In this area, one of the criteria
is rated E for lack of information, and the other - terms of environmental use - could easily be
improved through greater availability of information.

Following the comparison with PNMC, the most important results follows suit.

As for the interior layout, both HL as PNMC resemble more doctors practices, then hospitals,
which, coupled with a strong presence of location plans, facilitates navigation of individuals
(users and not only) by space.

HL and PNMC are also similar as far as the existence of several strategies for natural lighting is
concerned. These strategies contribute to, first of all, a good performance of some of the LiderA
criteria and, secondly, for greater indoor comfort of users and health professionals within the
complex. Both complexes have the existence of inner courtyards, which means that natural light
inside the building increases, as well as glazing in all rooms.

Local individuals took part in the building of PNMC; they carried out the excavations at the site,
and the terrain modelling was performed by re-using the land taken. The materials were
produced locally, which contributed positively to the reduction of costs associated with
transporting them. Also worth mentioning is the reuse of building materials.

Construction of HL is close to that of PNMC to the extent that it sought to use local materials as
much as possible in order to reduce the costs associated with transport.

4
The PNMC complex will be further detail in chapter 2.1

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

The PNMC has sensors to control lighting and air conditioning, which contributes to minimizing
energy consumption of the complex when it is not in use. HL has a similar system. It only differs
from that of PNMC’s to the extent that this only applies to lighting.

The high efficiency construction system used in PNMC makes for an excellent environmental
performance, which is not the case in HL.

The air circulating inside the complex of PNMC comes 100% from the outside, whereas in HL
the situation is not the same.

Also, the type of treatment applied to fenestration differs between PNMC and HL: in the PNMC
case they are subject to special treatment, which provides better efficiency in terms of heating -
use of solar gains - and cooling.

Given the comparative analysis between the two hospitals, as well as the evaluation system
LiderA - HL - and LEED - PNMC – we identified a number of ways to increase and improve the
performance of the HL. It should be noted that these measures would only be feasible after
some operations to improve and / or rehabilitate the Portuguese complex. The proposals for
improvement focus on passive design measures:
Building based on bioclimatic principles;
Decrease in nominal energy needs through the implementation of passive design
practices:
o solar orientation;
o controlling the size of the spans;
o shades - interior, exterior, adjustable;
o natural ventilation - cross ventilation;
o materials used - insulation, window frames, double glazing

Another measure that could contribute to improving the performance of HL would pass through
a greater presence of green spaces - an expansion of green spaces would contribute to an
improvement in the aspect of local integration.

The implementation of the proposals mentioned above would also contribute to a further
adjustment to the LiderA system to hospital complexes, since their suitability for this type of
equipment is not yet optimal.

Conclusions

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

The findings reported emerge following a comprehensive verification of compliance with the
objectives initially established. Therefore, an initial review of the objectives outlined in the
Introduction of this dissertation will be carried out, followed by a reflective analysis about its
effective fulfilment.

The work served, overall, for the performance analysis of a sustainable public infrastructure,
more specifically a hospital complex. This analysis assumes a collection of data and information
covering the three dimensions of sustainability - environmental, social and economic.

The process of data collection - whose methodology can be found in the Introduction - for the
environmental dimension elapsed in a relatively satisfactory manner, although some difficulties
have been encountered, particularly in recording the observations and access to information. In
general, it is considered that the data collected served for the stated purpose, as far as the
environmental analysis is concerned.

To perform the analysis of data on the environmental dimension, we used the LiderA5 system,
whose suitability for the type of equipment in question has been discussed before in chapter 3.3
- Critical Analysis.

The analysis of social and economic dimensions has been compromised by difficulties in
accessing information - remember the impossibility of interviewing clients, family members and
workers as well as the obstacles faced in accessing data imposed by the confidentiality policy of
Hospital da Luz.

However, the use of living socio-economic dimension of LiderA system allowed for an
examination (albeit not very detailed)of these two dimensions. Since we do not consider the
data sufficiently detailed and robust, we chose not to draw conclusions from them, and only
stated that the criteria of this part have good ratings.

In response to some of the questions raised initially, it was observed that, in fact, the
introduction of certain concepts, notions and measures of sustainability, when applied to a
hospital equipment, include benefits at various levels.

The existence of natural light - made possible by the presence of fenestration of generous
length, use of soothing colours, use of skylights and reflective surfaces - not only contributes to
energy saving but can also have positive effects on worker performance and on the recovery of
users.

Considering both the performance analysis of Hospital da Luz as the later comparison with the

5
LiderA system will be introduced in detail in chapter 2.2

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11

 Sustainability in Hospitals

Providence Newberg Medical Center we can conclude that a hospital - even if it is a public
facility with high energy consumption - can reduce its energy consumption considerably if the
principles of sustainability are applied.

The Providence Newberg Medical Center is a case of successful application of sustainable

measures and gives some solidity to the findings presented.

Raquel Ribeiro 56093 Mestrado Integrado em Arquitectura 2010/11