America's Top 10 Green Hospitals

There is a new trend in health care: greening hospitals to reduce toxins and provide a healthier, healing environment. The Green Guide sought out the top 10 in the U.S.. By Kim Weller, AIA

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Since 2000, when the U.S. Green Building Council (USGBC) started to promote its Leadership in Energy and Environmental Design (LEED) standards, green building has taken off, producing environmentally sound schools and offices. Now the trend is catching on in health care, as hospitals seek to reduce toxins and provide a healthier, healing environment.

By taking up green practices, whether incrementally or from the ground up, many hospitals are managing to lower energy bills, reduce waste and achieve healthier indoor air.

Green hospitals make good sense for the health of the entire community: patients, staff and visitors. To prevent spread of infection in hospitals, it's important to reduce exposures to germs—especially for patients with compromised immune systems—but the use of harsh chemical cleaners can cause respiratory problems. Conventional cleaning products, as well as many paints, adhesives and furnishings, can give off irritating, allergenic fragrances and toxic volatile organic chemicals (VOCs) such as formaldehyde; by choosing low-VOC products, hospitals help those in their care recover and improve conditions for staff. Simple design changes can work wonders, too. Studies have shown that poor indoor lighting increases levels of stress in hospital workers, leading to compromised medical care. "Daylighting" (that is, bringing daylight indoors with enlarged windows, light wells, clerestory windows and reflective surfaces), not only improves work performance but has been shown to improve patient recovery rates, while saving energy.

At the same time, many unique challenges are presented by the complexity of hospital operations. Infection control requires strict cleaning procedures and frequent air changes, which increase the already-high energy costs of the 24/7 operations and sophisticated medical equipment that make hospitals among the greatest energy consumers of any institution. "Hospitals are the heart and soul of the community and we need to be open for business no matter what," says Kai Abelkis, environmental coordinator for Boulder Community Hospital in Boulder, Colorado. "If the hospitals in New Orleans had solar panels, at least they could have kept the respirators going. If hospitals upgraded to more efficient lighting, we could save a considerable sum, enhance emergency preparedness and improve air quality." Through conservation, green hospitals are finding that they can reduce operating costs and keep delivering energy even in emergencies.

Green hospitals also seek to cut back on the amount of material sent to incinerators or garbage dumps. Disposables, including gloves, syringes, swabs, blood bags and intravenous tubes, swell the waste stream.

Hospitals are recycling more, and, with an eye to reducing toxic waste, many hospitals are eliminating mercury and polyvinyl chloride (PVC), which emit toxins in the air when incinerated. Mercury in landfills may also seep into ground water. They are greening their grounds with the aesthetic and therapeutic pleasures of healing gardens and providing more fresh, nutritious organic and local food choices for patients.

In order to recognize those hospitals that are taking a leadership role in environmental stewardship, The Green Guide identified a total of nearly 1,300 hospitals that are publicly pursuing environmental certifications and awards programs. We narrowed the list to the 76 leading contenders, to whom we sent questionnaires. From these we made our final selection of the top 10 healthy hospitals and runners up.

The Criteria

To recognize hospitals that are taking the lead in environmental stewardship, we referred to the criteria of three organizations: USGBC's LEED standards; the Green Guide for Health Care (no relation to The Green Guide), which adapts the LEED program to the special needs of hospitals; and Hospitals for a Healthy Environment (H2E), an organization that emphasizes reduction of mercury and waste management. LEED has established four degrees of certification with its New Construction (NC) standards: Certified, Silver, Gold and Platinum. Only one hospital has yet achieved LEED Silver status.

We considered not only new building projects but renovations, procurement, recycling, waste disposal, cleaning, food and green spaces to evaluate the overall quality of the environment. Owing to the breadth of these criteria, the hospitals chosen show varying strengths in different categories, displaying the full spectrum of this trend in green hospitals. Finally, we limited our search to hospitals and healthcare facilities in the United States.

Following are the 12 criteria that The Green Guide used to assess our top green hospital candidates:

1. Siting: Was the hospital sited with consideration for alternative transportation, storm water management, urban redevelopment and reducing any impact on the surrounding environment?

2. Water Efficiency: Is the hospital water-efficient, taking advantage of landscaping, water use reduction and innovative waste water use?

3. Energy and Air Pollution: What has the hospital done to reduce energy consumption and atmospheric pollution, including chlorofluorocarbon (CFC) reductions, renewable energy, reduced energy consumption, green power and reducing ozone?

4. Materials and Resources: Does the hospital use recycled building materials and resources (such as water), local materials or certified wood?

5. Indoor Environmental Quality: What has the hospital done to improve indoor air quality through increased ventilation and incorporating low-VOC paints, adhesives and materials to avoid offgassing of formaldehyde, toluene and other carcinogenic compounds? What steps have been taken to create comfortable temperatures and to enhance daylighting?

6. Healthy Hospital Food: Do patient and staff meals include fresh, local and organic foods?

7. Green Education: Does the hospital train staff in waste reduction, toxics reduction and recycling?

8. Procurement: Does the hospital seek out recycled paper, water-efficient laundering, energy-efficient equipment or other green products?

9. Contaminants: Does the hospital have a program for reduction of toxics such as mercury and PVC (which can leach toxic plasticizers into fluids in IV drip bags and tubing)?

10. Green Cleaning: Does the hospital use cleaning products that do not release hazardous chemicals? Are staff trained in their use?

11. Waste reduction: Does the hospital have a program to segregate medical waste and to reduce, re-use and recycle general waste and furniture and equipment that are no longer needed?

12. Healing Gardens: Does the hospital have healing gardens where patients, staff and visitors can reflect, relieve stress and reconnect with nature? Are there green roofs? Does the landscaping use native plants, which reduce water consumption and the use of pesticides?

The Top Ten Green Hospitals

Below are The Green Guide's picks for the greenest hospitals in the U.S. We did not rank the hospitals in any particular order; they are listed alphabetically.

1. First on the Block Award

Any list of exemplary green hospitals must start with Boulder Community Hospital Foothills Campus in Boulder, Colorado, completed in 2003. Boulder was the first healthcare project in the nation to achieve a LEED Silver certification, the second level of certification in the LEED system. This is an extraordinary achievement for a hospital, given that the LEED system is geared toward less complicated building types such as offices. Architects Boulder Associates, Inc. and OZ Architecture integrated the use of local, renewable, recycled, low-VOC emitting and resource-efficient materials and systems in the hospital design. The result: an inviting and nurturing setting for expectant mothers, newborns and those recovering from illness. The green design means that "children are born every day into a facility that will support their future, their quality of life," says Kai Abelkis.

Special attention was paid to constraints and opportunities presented by the mountain region: the scarcity of water and the expansive open space. Water usage was reduced through xeriscaping (gardening with plants that require little or no irrigation), waterless urinals and electric-eye faucets. The project was sited to preserve a 32-acre public open space, which includes a native wetland that the architects doubled in size during construction.

The hospital reduced energy consumption by building a central utility plant that allows for the purchase of more energy-efficient equipment, and water required for irrigation was reduced 70 percent. Alternative transportation was encouraged with the installation of bicycle paths and storage racks, showers, annual bus passes and priority parking for carpoolers. The hospital also used low-VOC paints, adhesives and carpets to improve indoor air quality.

2. The Green Team Award

Bronson Methodist Hospital in Kalamazoo, Michigan, which received the H2E Environmental Leadership Award two years in a row, has a long history of environmental stewardship. "It started in 1997 when the incinerator was shut down. We realized we would have to get serious about segregating waste and recycling," says Mike Way, vice president for materials management and facilities.

Bronson dispatched a green team to focus on energy conservation, reduction in the use of hazardous chemicals and water conservation. "We look for quick paybacks as capital is so hard to come by for hospitals," says Way. By changing to light-emitting diode (LED) flat-screen computer monitors and fluorescent lamps and by installing frequency drives, which act like thermostats so that air handlers only run when needed, the hospital made significant reductions in power usage. A new chiller plant, which cools water as needed for air conditioning, serves the entire hospital campus and is so efficient that it provides free cooling in the winter months. The hospital just tore down a 10-story building, and 75 percent of it was recycled. Bronson has a total recycling rate of 44 percent.

Enthusiasm about Bronson's environmental programs runs so high that when the hospital could not find a vendor to collect waste Styrofoam on an on-going basis, staff volunteered to take it to the local recycling center themselves.

Future building programs on the hospital will be developed along green building principles: The new birthing center and children's hospital is being constructed under LEED standards and may be submitted for certification upon completion.

3. Green Gadfly Award

Regarded by many as the West Coast industry leader in environmental innovation, Kaiser Permanente has established its own guidelines for green and ethical operations. "These are our top concerns as we look at purchasing: workplace safety, patient safety and environmental issues," says Jan Stensland, in strategic sourcing and technology for strategy, planning and design at Kaiser Permanente.

Kaiser has put its purchasing clout to work by collaborating with manufacturers on targeted products and seeking or encouraging development of less-toxic alternatives to PVC, formaldehyde and VOCs in finishes, furnishings and equipment. One of their first targets: carpet. In 2002 Kaiser Permanente required their long-term supplier Tandus Group Inc. to create a PVC-free carpet that will cover floors in most of the 20 new hospitals Kaiser Permanente will build in the next decade. "We started with carpet because we knew it was a big problem," says Stensland. And not only is Kaiser Permanente seeking to eliminate PVC in building products like flooring, roof membranes, furniture and pipes, they are removing it from medical devices such as IV bags and tubing. They have also introduced PVC-free purple nitrile gloves to replace latex, which can cause allergic reactions among sensitive populations.

Kaiser's efforts have been recognized with multiple H2E Environmental Leadership Awards for outstanding achievement in reducing waste, eliminating mercury and minimizing the use of toxic products. For example, Kaiser has introduced re-usable plastic sip bottles instead of disposable pitchers and cups and is recycling paper, toner cartridges, dental amalgam, fluorescent light bulbs and Styrofoam. All replaced medical equipment is either refurbished or donated to third world countries and all computers and electronic devices are kept in the U.S. where they are reused or properly recycled.

Kaiser Permanente has also embraced the concept of improving access to fresh, nutritious food as an extension of their core mission. They started their first farmer's market in 2003 at their Oakland Medical Center and now have 29 in operation. "In the Pacific Northwest at our Kaiser Permanente's Orchards Medical Office in Orchards, Washington, we are creating a teaching garden with non-toxic, ornamentally attractive native plants like daylilies," says Jim Gersbach, director of the education program of the poison prevention garden program at Kaiser Permanente. "The garden is part of an integrated educational outreach program that shares safer landscaping principles with new mothers, daycare centers, landscapers, gardening groups and homeschoolers and interested members of the public."

Kaiser Permanente is planning over 20 new hospitals in the West alone and is creating new standards for green healthcare buildings.

4. Urban Oasis Award

Laguna Honda Replacement Hospital and Rehabilitation Center in San Francisco, California, is a public hospital, funded by San Francisco city taxes, replacing the former hospital building on the site. Part of a pilot program for benchmarking the green design of all future City of San Francisco development, its performance will be monitored by the city's Department of Environment. Architects Anshen + Allen and Gordon H Chong Partners designed the 850,000 square foot acute- and long-term care hospital to be Basic LEED NC-certified, with a focus on indoor air quality to create a healthy environment for patients and staff. Started in July 2005, the project is scheduled for completion in 2008 and is the only uncompleted hospital on the top 10 list.

The concept that residents are healthier with exposure to natural light was embedded into the design criteria. Therefore, every resident has his or her own large operable window, and the center of the long-term care building is all glass.

Laguna Honda has been designed to achieve energy reductions to a level at least 30 percent below the state energy code and will generate at least five percent of its total power requirement with solar and fuel cells and micro turbines, which are compact generators that deliver energy on-site using renewable and recuperable fuel sources such as bio-diesel. The "heat island" effect of the building, which increases demand for cooling, will be mitigated with high reflecting roofs and parking surfaces, shading devices and planting materials.

Automobile traffic to the site will be reduced with enhanced public transit access, ride sharing, use of shuttles and alternative fuel vehicles, and encouraging the use of bicycles with bike storage and changing facilities. The residents, patients and staff will also have access to gardens on the hospital's 62-acre site.

The hospital is formulating a sustainable building operations plan that includes low-VOC emitting medical products, furniture and cleaning products.

5. Against All Odds Award

Everything on the densely populated island of Manhattan costs more, including healthcare construction, from labor to materials, logistics to transportation. At the same time, healthcare reimbursement rates in New York are some of the lowest in the country. Yet the greening of Mount Sinai Medical Center's Lauder Center for Maternity Care stands out as an impressive example of what can be accomplished in a city where hospitals struggle to keep their doors open. Designed by Guenther 5 Architects and completed in 2003, the Center is a renovation of a 20-bed unit occupying a single floor in the Klingenstein Pavillion.

Emphasizing indoor air quality, Guenther 5 reduced PVC (and the phthalate plasticizers it often gives off, which may affect the hormonal development of newborns) in several areas. Vinyl handrails were avoided by creating a unique handrail line made of recycled aluminum and Forest Stewardship Council (FSC)-certified wood. PVC-free window shades and upholstery were selected, and a cellulose-based wall covering was chosen instead of the more typical vinyl. No-wax flooring choices of quartz aggregate, recycled rubber and Stratica polyethylene tiles reduced emissions and PVC. Since the center does not use IV bags or tubing, this common PVC concern did not arise. Other indoor air improvements include formaldehyde-free substrates for cabinetry, low-VOC finishes and adhesives, and upholstery and mattresses that do not contain polybrominated diphenyl ether (PBDE) flame retardants, which are neurotoxic chemicals that have been found to cross the placenta and accumulate in human breast milk.

To increase daylighting, a reflective aluminum ceiling and glass walls bounce light deep into the interior. Further energy savings were gained through the use of low-e glass (reducing heat loss), energy-saving compact fluorescent bulbs, and LED exit signs. To reduce waste, more than 50 percent of the old interior was saved during renovation, and interior window systems are easily demounted for reuse. The Center also minimizes the use of latex, purchases only mercury-free medical devices, uses metal instruments instead of disposables and has shifted to electronic record keeping to reduce paper.

"Many hospitals used to allow formula companies to push product in maternity centers," says Kathleen Capitulo, director of the Mount Sinai's Kravis Children's Hospital and Women's Center, adding, "Lauder works to do the opposite and help make breastfeeding as easy as possible for mother and child." Recognizing the importance of breastfeeding to children's health, the Lauder Center maintains the largest lactation facility east of the Mississippi, with six full-time International Lactation Consultant Association (ILCA)-certified consultants on staff. The Center provides community outreach for prenatal care and breastfeeding, including breastfeeding stations for employees of the hospital, an educational program and reference guides on which medications can enter breast milk.

The Lauder Center for Maternity Care has worked hard to achieve its green successes on every level except for one: its location fortuitously gives it "green points" for convenient access to New York's extensive public transport system.

6. A Star for Sunlight

Legacy Health System Salmon Creek Hospital has just opened its new, 220-bed facility in the rapidly growing Vancouver, Washington area. Basic LEED certification has been applied for. "The hospital was designed with a focus on views and the ability to control daylight," says Johanna Brickman, associate partner and director of sustainability for Zimmer Gunsul Frasca Partnership, the architects for the project. The firm is working with the University of Oregon on a daylighting study for hospitals. Daylight modeling was performed for the exterior of the hospital to establish efficient energy levels. They are now studying patient control of daylight, window glazing, optimizing patient window views, reducing glare and how the shape of the room and other factors affect lighting.

The layout of the hospital building minimizes impact on the site and features restorative gardens inside and out, including a roof garden. Other environmental strategies include advanced, energy-efficient building systems and low-toxicity materials. High efficiency boilers, an air-chiller plant, low-e glazing and daylighting all provide energy savings.

7. Sustenance and Shelter Award

The Patrick H. Dollard Discovery Health Center in Harris, New York, reflects the belief "that there's an intrinsic link between environment and health, and they put it into action through their own organic farm and their healthcare clinic," says Peter Syrett, principal of Guenther 5 Architects, the firm which designed the center. The center serves children and adults with profound neurological and developmental impairments at its residential school in rural New York. Syrett says, "The farm and the clinic building act as a gateway to the broader community, inviting outsiders to purchase produce or to receive health care."

The Dollard Center was the second LEED-certified healthcare facility to be built in the U.S. with Basic level certification. Completed in 2003, the building was sited so as to preserve prime farmland and restore native vegetation. Former marshland grasses have returned. Storm water recharges a pond, which in turn feeds a sprinkler system reserve. The landscape, which is now used for farming and grazing, is not irrigated. This conservation-minded approach to water management allows for the recharging of the aquifer. Integrated pest management, substituting non-toxic methods for pesticides to control pests, is used for the landscape as well as inside all buildings.

The Center was designed to use passive solar heating in winter to complement its regular heating system. Exterior brise-soleil louver shades eliminate direct solar gain during the warm summer months and a reflective metal roof reduces heat buildup and therefore cooling demand. All occupied spaces have windows, reducing the need for artificial light.

The Center uses low-VOC products throughout, including finishes, low-maintenance linoleum and formaldehyde-free insulation and casework. Carpets were limited to further reduce VOCs from underlayment. Natural sisal wallcoverings and recycled aluminum corner guards are used instead of the PVC wallcoverings so typically found in healthcare construction.

8. Do It for Free Award

Providence Newberg Hospital's groundbreaking in 2003 was quite the event: "Over 2,400 community members showed up with shovels to turn a spadeful of earth, breaking a Guinness World Record," claims Mark May, executive director of the new hospital. It was also the start of construction of one of the first hospital buildings in the country to seek LEED certification. The hospital is officially registered as seeking a LEED Silver certification and has just received an award from H2E for waste management. While construction has been completed, the hospital will begin seeing patients in June.

Because views of the natural environment have been demonstrated to improve patient outcomes, Mahlum Architects sited the replacement hospital to take advantage of the dramatic views of Oregon's Willamette Valley and the Coast range. Healing gardens with drought-tolerant native plants will be a central feature of the new facility. Also, through a unique ventilation system, employees and visitors will breathe 100 percent outdoor air.

It is anticipated that Providence Newberg will use 40 percent less water and 26 percent less energy than a typical hospital. To achieve this level of reductions, the hospital is using flow restrictors on faucets, sunscreens over windows to reduce heat gain, and occupancy sensors to turn lights off when not needed.

One of the most exciting things about Providence Newberg is that the cost for greening the project is minimal. "The payback is virtually immediate, and will yield financial and ecological benefits for the 75- to 80-year life span of the building," says May.

9. Form AND Function Prize

"The Sarkis and Siran Gabrellian Women's and Children's Pavilion in Hackensack, New Jersey, has been a truly collaborative project that proved how beautiful, healthy and sustainable a building can be," says Suzen L. Heeley, director of design and construction for Hackensack University Medical Center (HUMC).

Throughout the facility, HUMC has avoided harmful chemicals and materials such as formaldehyde, VOCs, mercury and PVC. For example, toys, flooring and wallcoverings are PVC-free. "We have used environmentally responsible suppliers and manufacturers for construction materials, interior finish materials, furnishings and equipment needs," continues Heeley. HUMC has used products such as wheatboard instead of formaldehyde-laden particleboard for cabinetry and rubber flooring instead of vinyl. Greening the Cleaning products, developed by and used in HUMC's Dierdre Imus Environmental Center for Pediatric Oncology, preserve air quality by avoiding toxic cleansers. The facility also integrates organic and vegetarian food options into the cafeteria and room-service menus.

The new building will feature (once planted) four rooftop meadows, which lends insulating properties. Alternative transportation accommodations will enable patients and visitors to reach the hospital via trains, buses, bicycles and taxis. Electric outlets have been placed in the parking garage for electric vehicles used at the medical center. And energy-efficient heating, ventilating and air-conditioning systems reduce power consumption.

"The biggest surprise was that we did not have to compromise on the aesthetics of the project," says Heeley. "Incorporating soothing colors on the women's side, and energizing, vibrant tones on the pediatric side, the Pavilion uses color, shape and scale to create a truly healing environment. Elements such as an indoor cascading water wall and a ceiling with multicolored LED lighting set the design of this Pavilion completely apart from traditional hospital settings."

10. Green Ideals Award

Emory University's LEED NC-certified Winship Cancer Institute located in Atlanta, Georgia, is a comprehensive cancer institute dedicated both to improving treatments and applying those findings as quickly as possible to the center's patients. The seven story, 280,000-square-foot pavilion gathers patients, doctors, nurses and cancer researchers in one facility to improve cross-pollination of research and treatment. Each floor carries an ideal embedded in its stairwell's landings: Compassion, Caring, Courage, Hope, Imagination, Translation (i.e. taking research findings and applying them to patients) and Discovery.

Completed in July 2003, the building saves 19 million gallons of water per year by collecting condensed water for cooling towers, employing drip irrigation for plants and using electronic sensors on taps and toilets. The high energy demands of the laboratory have been reduced with an "enthalpy wheel" heat transfer system, the effect of which is to bring incoming air closer to the temperature and humidity of outgoing air, saving energy for the HVAC system.

To protect the patients' immune systems, which can become suppressed while undergoing treatment, all air is triple-filtered. Insulation and wood products are formaldehyde-free, no-VOC paints and low-VOC adhesives were used, and green cleaning is employed throughout. Daylighting provided by large windows, open work areas and reflective surfaces allows light to penetrate through offices into common areas. A healing garden is available for patients.

Emory's campus creates the perfect surrounding frame, maintaining good outdoor air quality by requiring electric carts and cars for ground maintenance and low-polluting buses fueled by natural gas.

Runners Up

Hospitals across the country are making the connection between healthy buildings and operations and healthy staff and patients. We'd like to highlight some other existing and planned facilities that are standouts in a number of ways:

Garbage and Mercury Out

• Dartmouth-Hitchcock Medical Center, Lebanon, NH, 2005 H2E Environmental Leadership Award winner, for its thorough staff education program on waste management. The center trains its staff in safe mercury handling, is replacing mercury devices and has set standards for low-mercury fluorescent bulbs.
  
  
• Sparrow Health System, Lansing, MI, 2005 H2E Environmental Leadership Award winner, for its admirable reduction of biological waste, from 12.7 lbs/occupied bed/day to less than 3lbs/occupied bed/day. Sparrow also received the 2005 H2E Making Medicine Mercury Free for eliminating mercury in all patient areas.
  
  
• University of Michigan Hospitals & Health Centers, Ann Arbor, MI, 2002 and 2005 H2E Environmental Leadership Award winner, for using the H2E awards program to propel advances in waste reduction, re-use and recycling. The hospitals and health centers have also replaced mercury-containing devices such as thermometers and sphygmomanometers, as well as mercury switches and gauges. Batteries and fluorescent tubes (which also contain mercury) are recycled.

Green Buildings

• Concord Hospital, Concord, NH, for seeking Basic LEED Certification for a major addition and renovation, featuring wheelchair accessible rooftop gardens and daylighting
  
  
• Children's Hospital of Pittsburgh, Pittsburgh, PA, on track for achieving Basic LEED Certification for less than five percent of total construction costs
  
  
• Mercy Suburban Hospital, Norristown, PA, for living by the guiding principle that "All places are sacred—especially the earth we live on. Excessive consumption of resources degrades the earth, impoverishes others and debilitates our spirit;" and for seeking LEED Gold certification for its new expansion and renovation project

Fresh, Local and Organic Food

• St. Luke's Hospital, Duluth, MN, for serving organic fruits, produce and dairy products at its cafeteria
  
  
• Good Shepherd Health Care System, Hermiston, OR, for replacing canned and processed foods with organic produce and hormone-free/antibiotic-free meat cooked and prepared on site
  
  
• Fletcher Allen Medical Center, Burlington, VT, for its new patient menu focusing on fresh, local food to improve patient health and support local commerce
  
  
• Duke University Medical Center, Durham, NC, for its farmers' markets and farm stands
  
  
• Allen Memorial Hospital, Waterloo, IA, for its farmers' markets and farm stands

Conclusion

Recognizing that the health of the individual, the community and the earth are inextricably linked, hospitals are rising to the challenge of creating truly healthy environments. And though healthcare facilities have made great strides in adopting green practices, building and purchasing, there is always room for improvement. "The medical industry needs to look at the direct link between the quality of the environment and the quality of health," says Kai Abelkis of Boulder Community Hospital. "We need to be better stewards of our communities, and by communities, I mean my daughter, your