Building Sustainability Assessment: The Case of Hospital Buildings

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Building sustainability assessment: the case of hospital buildings

Castro M. F.1, †

Universidade do Minho, Departamento de Engenharia Civil


Azurém, P - 4800-058 Guimarães, Portugal

Mateus R.2, Bragança L.3


Universidade do Minho, Departamento de Engenharia Civil
Azurém, P - 4800-058 Guimarães, Portugal

ABSTRACT

The hospital project contains different aspects from the most common projects of
residential, office or service buildings. Designing a hospital environment is based in a
number of criteria related to the satisfaction and well being of the working team, the patient
and the administrators. This kind of project has a strong social responsibility and impact on
the city. Mostly due to various design requirements, these buildings are not designed and
operated in a sustainable way. Based on this context it is important to study the best practices
of a sustainable hospital design that should be taken into account in the design phase (to
support the decision to adopt solutions that contribute to the building sustainability) and
lifetime operation (supporting users and managers for the operation and equipment
maintenance at an high level of efficiency). This paper will discuss the importance of the
hospital buildings for the sustainable construction and will present some indicators that could
support the sustainable design, operation and maintenance of a hospital building.

1. THE URGENCY FOR SUSTAINABILITY

1.1. The impacts of the Portuguese construction sector

The concept of sustainable development acts through diverse meanings and common
activities to humanity that have an implicit mutual goal: a society that might persist
throughout many generations with a flexible and whole vision which will allow it to maintain
the social and physical system that sustains it. Cities can and should be an open field to
sustainable guidelines since its scale complexity becomes an impact (positive or negative) on
the environment as deep as its dimension.
On this scenario, the aim of construction industry is to achieve a product that fulfils
the functionality requirements, being at the same time profitable, safe and durable throughout

1
Architect / PhD Student

Corresponding author (info@mfcastro.com)
2
Civil Engineer / Assistant Professor
3
Civil Engineer / Associate Professor
its life cycle. The product must be integrated in the natural system with the lowest negative
environmental impact.
These principles are leading to a multi-criteria sustainable construction concept, which
is based in many different scientific and technical areas and research fields. Bringing this
concern to the humanization of hospitals brings up the question of what is a sustainable
hospital and which are the best practices to create this type of buildings.
In Portugal, the construction in the sixties and seventies of the twentieth century was
much less than the rest of Europe. This rhythm has intensified in the nineties and today the
built environment is very similar to the European average. Between the late seventies and
nineties, there were built over two million housing units and the growth of the housing units
was higher in the nineties. The industry of this sector contributed for about 6% to GDP and
employed about 10% of the workforce in the country (Piedade, 2003).
Meanwhile, the population has been steadily increasing. Between 2001 and 2011 the
total population grew about 1.9%, from 10,336,000 residents to 10,555,853, while the number
of dwellings and buildings increased 16.3% and 12.4% respectively. (INE 2011)
It should be noted that the construction of new housing has been to date the most
important component, corresponding in 2003 to 83% of interventions in the built environment
(INE, 2004). For this reason is justifiable the main focus of the different concerns and studies
on residential buildings, since it corresponds to the biggest share of the construction.
However, it is important to note that this significant increase in the building stock, was not
reflected in a similar evolution neither on the environmental concerns nor in the search for
efficiency in terms of energy consumption and materials. Therefore, these facts introduced an
agenda for a more proactive approach on the environmental dimension to achieve a balance
between this and the other two dimensions of sustainable development: society and economy.
In the national scene of the construction industry it is possible to clearly identify the
problems and also a huge potential for improvement. Building with the least environmental
impact as possible, respond to social demands and contribute to better economic management
is the right path to follow. Nowadays this is challenging the construction sector and all its
stakeholders, mainly the design teams. To achieve sustainability in this sector is essential to
use good practices guided by indicators and performance targets, able to assess and balance
the three main dimensions of Sustainable Development: environment, society and economy.
In Portugal, the issue of sustainability is still in its infancy. Mostly buildings present
problems that result in thermal discomfort, visual and poor indoor air quality. This situation is
linked, during the buildings’ operation phase, with increased consumption of resources
(energy and water) and situations that affect occupants’ health and comfort. Although there is
a big passivity of the occupants, for example, with respect to what happens in cold rooms in
their homes, the same does not happens in respect to discomfort in the workplace and in
public spaces. This is mainly due to the fact that only now people are beginning to be aware
about their rights in relation to the building environment.
The conventional buildings are characterized by excessive use of natural resources, i.e.
the use of large quantities of materials and the huge energy consumption. Consequently, this
traditional model is responsible for producing large amounts of carbon dioxide and other
harmful emissions to the different ecosystems. In this sense, there are already tools that
promote more sustainable construction practices. However, there are still few mechanisms (e.
g. taxes, credits and penalties) that facilitate and promote the practical application of the
sustainable building concept. There are two distinct policies that governments can implement
to control the adverse environmental impact continuously imposed to the planet by the
construction, use and demolition of buildings (Bento, 2007): i) through rules and regulations
and ii) through financial incentives for specific purposes.
Analysing the graph presented in Figure 1, it is possible to conclude that the peak of
the general trend of production tends to coincide with an average environmental conscience.
Additionally, the combined effect of the regulations and financial incentives is deviated from
the trend of peak production for a larger and higher environmental awareness. Thus it is
necessary that buildings are healthy, not forgetting that they seem like a small world that
represents small-scale relations between it and the environment.

Figure 1 – Variation of environmental awareness as a function of production rate


(Bento, 2007).

1.2. Sustainability in hospitals buildings

Michael Lerner (2000) formulated the following question: “The question is whether
healthcare professionals can begin to recognize the environmental consequences of our
operations and put our own house in order” (Robert & Guenther, 2006). This is not a trivial
question, but the foundation of all other issues that may arise around this same concern
(Robert & Guenther, 2006). Based on this principle, Figure 2 illustrates the relationship
between human health, medical treatment and environmental pollution that directly affects the
mission of the health care industry.
The hospital buildings, not because they are more abundant in the territory, but
because they are large consumers of natural resources and energy, should be a major focus of
study in the evaluation process of the buildings life cycle (Guenther, 2008). The activity
implied to the healthcare industry, require a lot of energy for heating, refrigeration, etc.. On
the other hand it is necessary to take into account the use of renewable and non-renewable
resources, disposable products, toxic substances and the production of a large quantity of
waste (Short & AL-Maiyah 2009).
The health sector has a strong influence on the economy of nations and their policies,
incorporating a group of buildings where the quality of the indoor environment is quite
significant. The impacts of this type of buildings are more significant than any other because
they are directly related to human health (Guenther & Vittori, 2008). The operation of these
equipments for 24 intensive hours, the high number of movement of persons, the existence of
distinct work zones with different energy needs, the existence of different functions such as
treatment, education, research, rehabilitation, health promotion and disease prevention, the
need for the existence of systems strategic reserve of equipment for constant supply of energy,
and size of facilities, are key points that differentiate these from other types of buildings and
make it a specific case study (Dias, 2004; Bitencort, 2006).
The motivation and research opportunity of the abovementioned studies were based in the aim
of studding design enhancements that can be introduced on this type of buildings to improve
its life cycle’s sustainability. Based on case studies of successful design approaches it is
possible to conclude that the ability of evolution of these buildings is great.
Figure 2 – Relationship between environmental performance and health care
(Robert & Guenther, 2006).
On average, a hospital has energy consumption per square meter, ten times more than
an office building with research laboratories (HSJ, 2009; INEGI, 2009) and consumes more
electricity per year than any other existing building in a Portuguese city. These figures are due
to the fact that these buildings act as authentic machines developed to maintain the patient’s
health and life. Additionally, they need to embrace all the innovations that arise in medicine
(for example in the Hospital of S. João, in the period between 2007 and 2009 there was an
increase of 8% in energy consumption due to the introduction of new equipment, ventilation
systems and other works still in progress (HSJ, 2009)). Moreover, and according to the
comparative analysis of some activity and budget reports from the Portuguese hospitals, it is
possible to note that in most cases sustainability initiatives are reduced to the separation,
treatment and possible waste recycling and, in exceptional cases, to the reduction of electricity
and water consumption. At present, there are several studies about the sustainable
development of hospitals. However, most of them are oriented for business management.
Sustainable practices are not widespread mainly due to the fact that these buildings are
exceptional. Additionally, the implementation of sustainable practices, normally related to the
concept of reduction, is not always very well perceived by society and can generate some
resistance.
Several studies and professionals agree that it is possible to work through the
weaknesses of actions and measures, some of them simple and inexpensive, but capable of
reducing the environmental impact. In order to introduce sustainable practices in the design of
healthcare buildings, several countries have published guidelines to promote improved design
approaches. Among them, it is possible to highlight recommendations for hospital projects
that the Green Building Committee of the American Society of Healthcare Engineering
(ASHE) published in 2002 (Robert & Guenther, 2006). This partnership between the
American Hospital Associations and the United States Environmental Protection Agency,
pointed out the principles of sustainable architecture that are intended to reduce waste and
other impacts associated with hospitals (Robert & Guenther, 2006). The ASHE proposes an
architectural development of these recommendations in order to develop buildings capable of
improving the health concerns at three scales (Robert & Guenther, 2006):
− Protecting the immediate health of building occupants;
− Protecting the health of the surrounding community;
− Protecting the health of the larger global community,
2. HOSPITAL PROJECT

2.1. Place, form and function

The hospital project contains different aspects from the most common projects of
residential buildings, offices or services. In common buildings, sometimes the user and the
client are the same and when they are not, setting the requirements is not difficult since they
are common to most inhabitants. In the case of hospital buildings this is not the reality and the
project team is usually hired for the purpose of designing a building that includes different
spaces and different users, such as doctors, nurses, patients, visitors, cleaning staff,
administrators, and others. In this sense it is important to combine different spatial needs,
which are always subject to constant changes throughout its period of use due to new features,
innovations, needs expansion and new treatment methods (Figueiredo, 2008).
With the evolution of such buildings, it appears that the patient is increasingly
occupying a central place of every concern and attention. Thus, there is contemporary in
hospitals it is the patient as the final customer, dictating how should be thought of the life
cycle of these structures (Figure 3).

Figure 3 – Life cycle of hospital buildings (Figueiredo, 2008).

3. SUSTAINABILITY ASSESSMENT

3.1. Methodologies to support the design of sustainable buildings

The first major reason that led to the emergence of the need to evaluate the
environmental performance of buildings was born with the realization that no country had the
ability to say how sustainable it was a building, even when they believed that dominated the
design concept and sustainable construction. Later researchers and government agencies
understand that the certification systems would be the best method to demonstrate the
sustainability performance of all types of constructions and buildings (Haapio & Viitaniemi,
2008). Nevertheless, the search for better methods and evaluation systems is still in the
process. At the present there are still some uncertainties beyond the constant confusion about
the meaning of sustainable construction, which binds, most often, only the reduction of
energy or water consumption. Therefore, to clarify and emphasize the best design options, it
became essential and urgent to integrate sustainability assessment experts in the design teams
(Mateus & Bragança, 2006).
In what regard to assessment methods, most of them are based in a holistic
sustainability approach, considering only the most representative sustainability parameters.
Considering in the assessment all links between the natural and artificial environments would
lead to an extremely time consuming and inapplicable process (Mateus & Bragança, 2006). In
the sustainability assessment, it is also essential to take into account the variety of intervening
factors, such as: the type of buildings; their specific requirements; climatic and geological
conditions of each region; the different construction processes; and the cultural and economic
values of each region (Haapio & Viitaniemi, 2008).
On the other hand, the evaluation involves quantitative and qualitative indicators,
which are not always correlated, and that have necessarily to express the same magnitude for
any possibility of comparison (Mateus & Bragança 2011). After the establishment of
sustainability indicators, difficulties arise for the adoption of different classification levels to
be considered, in the definition of the benchmarks (best and conventional practices for each
sustainability indicator) and in the aggregation method to be used. Nevertheless, these are key
issues to assess the overall sustainability performance and to compare the performance of
different buildings (Mateus &Bragança, 2011).
In Portugal, the delay on the implementation of sustainable design practices means
that this situation can be examined in two ways: one that tends to cover the minimum required
by law, and another that would tend to make the requirement higher in order to increase also
the responsibility of the sustainable construction in the country. According to Mateus and
Bragança (2006), the second option would make the leap to an urgent shift in mentality and
building design. As a result of the abovementioned difficulties, currently there is not an
internationally accepted building sustainability assessment tool or methodology. Nevertheless,
analyzing the main objectives of existing methodologies, it is possible to distinguish three
different types: support tools for the sustainable building design (Performance Based Design);
tools for life-cycle analysis (LCA) of products and building materials; systems and tools for
building sustainability assessment and certification (Mateus &Bragança, 2006). The tools to
support the sustainable building design (Figure 4) are a good base of guidelines to support the
design teams. With this approach it is possible to describe the best sustainability practices for
a building through a hierarchy of performance levels, which, when considered in design
phase, will lead to more sustainable buildings (Bragança et al., 2007).

Figure 4 – Generic model of a support tool for the design of sustainable buildings
(Bragança et al., 2007).
3.2. Sustainability assessment and certification of hospital buildings

There are some countries either developing or implementing sustainability assessment


methodologies focused on hospital buildings. The first approach to be developed, in 2008,
was the Building Research Establishment Environmental Assessment Method Healthcare
(BREEAM Healthcare). The main objectives of this specific methodology are: improve the
sustainability of buildings for healthcare; improve conditions for patients; enable economic
progress; and improve the working conditions of the entire hospital team (Guenther, 2009).
Besides BREEAM Healthcare, other example is the Leadership in Energy &
Environmental Design (LEED Healthcare), which final version was released in 2009. Figure 5
present the differences between these two methods at the level of the sustainability categories
and respective weight in the overall sustainability level.

BREEAM for Healthcare LEED for Healthcare

Figure 5 – Assessment categories of the methodologies BREEAM and LEED for Healthcare
(www.breeam.org; www.usgbc.org).

The Boulder Community Foothills Hospital (BCFH) in Boulder, Colorado was the
first hospital to achieve certification at the level of sustainable construction (Figure 6). The
assessment is based in the LEED approach.

Figure 6 – Boulder Community Foothills Hospital (Verderber, 2010).

The Providence Newberg Medical Center (Figure 7) was the first hospital to receive
the highest rating awarded by the LEED method (Gold), in the United States of America.
Beyond this distinction, in 2007this hospital received the award for environmental leadership
given by Hospitals for a Healthy Environmental (H2E) (Guenther & Vittori, 2008). Table 1
presents the design practices taken into account in the two abovementioned examples, which
enabled a sustainability certification.
Figure 7 – Providence Newberg Medical Center (Verderber, 2010; Mahlum, 2011).

In Portugal, during 2008, the Ministry of Health developed a document that lists the
recommendations and technical specifications for the hospital buildings, where there are
recommendations for several issues, such as architecture, facilities and equipment for water
supply and drainage, electrical and mechanical systems, centralized technical management,
outdoor spaces, integrated management of solid waste, maintenance, etc.. Together with this
document, there are other regulations that specify the requirements of each specific space at
the level of lighting, indoor air quality, temperature and ventilation. Nevertheless, in which
regards to the sustainable management of the hospitals there is not any document with the
force of law or recommendation.
The sustainable design of hospital buildings will achieve competitive advantage
strategies, as well as better economic and social efficiency. Thus, grouping the principles
advocated by several authors, the goals that are intended primarily achieve with the
sustainable design and construction of this kind of type of buildings are:
- Improve the quality of patient care;
- Reduce the time of patient recovery;
- Improve operational efficiency and productivity;
- Create increased facilities for users and surrounding communities;
- Contribute to the satisfaction and consequent fixation of employees and the
experience positive patient (system performance evaluation of the complex);
- Develop quality and safe indoor and outdoor environments;
- Reduce operational risks associated with the project
- Increase the lifetime of the building;
- Reduce construction, operating and maintenance costs;
- Educate the understanding for the need to use a sustainability certification, allowing
it to assess the pros and cons of introducing these design practices.
Table 2 presents the indicators that should be taken into account when it comes to
implementing sustainable design practices in hospitals.

Table 1 – Design principles considered in the two case studies.


Design practices to improve the sustainable Boulder Providence
Dimensions
construction Community Newberg
Reduce site disturbance (use of local and
• •
Environmental regional materials)
Use of high-reflectance, low-emissivity roofing • •
Reduce the density of construction •
Reduce the rate of net available land use •
Reduce the consumption of non-renewable
• •
primary energy in operation phase
Reduce the consumption of non-renewable

primary energy in the construction phase
Table 1 (cont.) – Design principles considered in the two case studies.
Design practices to improve the sustainable Boulder Providence
Dimensions
construction Community Newberg
Reuse materials •
Environmental Use of materials with recycled content •
Use of organic-based products which are
• •
certified
Recycling of construction waste • •
Reduce water consumption in the building • •
Use of native vegetation in green areas to
• •
reduce water consumption
Social Maximize the use of indoors natural ventilation • •
Maximize the use of natural light and shade • •
Use the site potential to promote thermal
• •
comfort
Maximize solar building orientation • •
Use of materials with a low content of VOCs • •
Maximize acoustic comfort • •
Encourage the use of alternative transportation • •
Maximize accessibility to activities spaces • •
Availability of green spaces with easy access
• •
for users
Maximize access to living areas, gym •
Maximize views to outdoor spaces • •
Maximize flexibility and adaptability of indoor

Economic Reduce operating costs related to energy
• •
consumption

Table 2 – Dimensions, categories and indicators to support the implementation of sustainable


practices in building design hospital.
Dimensions Categories Indicators
Climate change and outdoor air Environmental impact associated
Environmental
quality with the life cycle of buildings
Soil use and biodiversity Urban density
Reuse of previously built or
contaminated soil
Use of autochthonous plants
Site Selection
Heat island effect
Energy Non-renewable primary energy
Renewable primary energy
Energy produced locally
Electricity
Table 2 (cont.) – Dimensions, categories and indicators to support the implementation of
sustainable practices in building design hospital.
Dimensions Categories Indicators
Materials and Solid Waste Reuse of materials
Environmental Use of recycled materials
Use of certified materials
Use of cement substitutes in concrete
Use of local materials
Coating materials
Storage conditions of solid waste
during the building’s use phase
Construction Waste
Use of mercury
Furniture
Water Water consumption
Reuse and use of non-potable water
Pollution Reduction of CO2 emissions
Monitoring of energy used for each
order
Monitoring the energy used by the
user area
Social Comfort and health of users Efficiency of natural ventilation in
indoor spaces
Toxicity of finishing materials
Thermal comfort
Visual comfort
Acoustic comfort
Indoor air quality
Indoor Environmental quality
Design quality
Local development
Equipment
Accessibility Accessibility to public transport
Low impact mobility
Accessibility to amenities
Space distribution
Awareness and education for
Education of occupants
sustainability
Innovation Innovation of the project design
Economic Life cycle costs Initial cost
Operation costs

4. CONCLUSIONS

Due to various design requirements, healthcare buildings are not designed and
operated to meet the sustainable development requirements. This paper pointed out that the
main factor contributing for this reality is the absence of an effective method to support
design teams to consciously introduce sustainability on their projects. In addition,
conventional design teams do not have the necessary skills that allow optimizing the life-cycle
sustainability at the design phase and building managers are not aware about the measures
that they should adopt for efficient operation.
This raises the importance to develop a methodology that includes the indicators
discussed in this paper, to support the decisions of players in two phases: design (supporting
the decision to adopt solutions that contribute to the sustainability of the building) and
operation (user support for the operation and maintenance of equipment are executed with the
highest efficiency level possible). For that purpose, future research on sustainability
assessment of hospital buildings should be focused in finding the best parameters and
assessment method for assessing the proposed indicators. At the end, it is necessary to
develop a manual to guide the practical implementation of the methodology by conventional
design teams.

5. REFERENCES

ASHE, Green Healthcare Construction Guidance Statement (2002) [online edition].


Retrieved July 24, 2011, from
http://www.healthybuilding.net/healthcare/ASHE_Green_Healthcare_2002.pdf
Bento, P., Novos Edifícios - Um impacte ambiental adverso, Parque Expo, Lisboa
(2007).
Bitencourt, Fábio. Hospitais Sustentáveis. Revista Ambiente Hospitalar, Exclusivo os
melhores da arquitectura corporativa | saúde [online edition] 2006 Dezembro [Novembre 1,
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assessment In Proceedings of the sustainable construction, materials and practices
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Haapio, A; Viitaniemi, P., A critical review of building environmental assessment
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HSJ, Relatório & contas [relatório], Hospital São João, Porto (2009).
INEGI, Relatório de actividades e contas [relatório]. Instituto de Engenharia
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Mahlum. Mahlum. Disponível em <http://www.mahlum.com/default.asp>. Retrieved
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Mateus, R., Bragança, L., Tecnologias construtivas para a sustentabilidade da
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Piedade, C., Edifícios para viver melhor, Curso de Construção Sustentável –
Estratégias, Projectos e Sistemas de Apoio, FUNDEC/IST, Lisboa (2003).
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