The Business Case for Green Buildings

by Jim Molar
im Moler, Manager, Engineering Systems, Turner Construction: In the early days of green
building, we always tried to make the case for green based on how much energy we were
going to save in terms of reduced operating cost. That didn't get a lot of attention in the
hospital executive suite because the energy budget for a hospital amounts to less than 1% of
the operating cost. Saving 20% of something that was less than 1% of the hospital executives'
overall “headache” didn't get a lot of attention.

The exciting thing about what is happening today is that the issues relating to the things we
care about—sustainable design, green building—are starting to become important to the
people who occupy the hospital executive suite. Thus, if executives want to recruit and retain
the best staff, a green facility is a way to do that. If they want to have better outcomes for
patients, a green facility can contribute to faster and better recovery. If they want to avoid
risks, a green facility can help avoid patient infections and staff illnesses and injuries. If they
want to improve public perceptions of the hospital, a green facility can help do that. Lastly, if
they want to balance operational costs against the revenue stream, a green facility can help
improve that balance.

Another benefit: Building green has opened up new channels of capital infusion into healthcare
design by philanthropy, by government participation, and even by utility participation in
supporting certain features of the building.

Lisa Fay Matthiessen, AIA, Associate Principal, Davis Langdon: I am presenting the
preliminary findings of a cost study that Davis Langdon is doing with the Green Guide for
Health Care (GGHC). We are a cost planning firm, and we work with building projects around
the country to figure their cost implications. We look primarily at first costs. Our task was to go
through the GGHC and to try to understand point by point, prerequisite by prerequisite, what
the cost implications might be for a given project sponsor trying to implement this system.

The GGHC has 42 different credits, which are broken down into 96 points. We know that no
project is going to try to get all 96; the project will decide which ones make sense in its context
and go after those. There are, however, 11 prerequisites that are chosen because they seem
to be so basic, so elemental to the process that, indeed, if you didn't do them, you really
couldn't claim to be doing sustainable design. There are also 7 “categories of concern,” which
break down the bigger topic of sustainable design into individual items such as water use,
energy, materials, and resources.

If a facility has achieved approximately 40% of the points, we would call that a starting level for
GGHC, which should be achievable at little or no additional cost. To go higher for GGHC
points can get a bit challenging. There will be issues of first cost, features that may add cost to
the baseline and, with hospitals, certain other issues that can pose real obstacles, such as
those relating to infection control, security, maintenance, and regulations unique to hospitals.
Perhaps the biggest obstacles involve established, accepted practices—the “that is not how
we do that” in hospital design and construction. I don't want to be critical, but I think the
tendency to go with what we already know, especially when working on a hospital project,
should be looked at critically.
The cost situation in hospital construction is complicated. We have been tracking costs for the
hospital projects that we work on and, in Northern California during the past 10 years, costs
have gone from about $200 per square foot to about $550 per square foot. Although
construction costs may be the biggest problem confronting any hospital project today, that has
nothing to do with building green. Green is a drop in the bucket compared to other cost issues
a project will face.

Moler: To add a perspective from across the country, we are seeing projects on both coasts
that are approaching $700 per square foot. Through the midsection of the country, costs are
slightly above $300 per square foot on average. This relates to the kinds of clients that Turner
works for—generally the larger projects for major suburban hospitals and urban teaching
institutions. These costs are not a result of pursuing a green agenda.

Matthiessen: In any case, facilities cannot think of green as an added cost, as an “add-on,”
which only means it will become an item to delete.

In doing our study, we went through each credit prerequisite and identified what we thought
the cost issues were. We broke them down into categories: construction costs, soft costs (e.g.,
design costs), and documentation costs, which are always a requirement with GGHC,
although they are minimal—less than 0.25% of either construction cost or design cost. Beyond
“minimal,” we also categorize costs as “minor” (less than 1% of total construction or design
cost), “moderate” (less than 2%), and “substantial” (more than 2%). I want to emphasize that,
even within categories, costs will vary with the project—where the project is, what its program
is, who the project team is.

Even so, for construction costs alone, there are 23 GGHC points that essentially cost nothing,
6 points that are minimal, and 10 that are minor. There are a number of ways to achieve
points. If, for example, a facility wants to do efficient irrigation on a project, it could install
native, drought-tolerant plants and just not have irrigation, or it could capture all rainwater, filter
it, and use it to irrigate. This might represent a fairly substantial cost, but it depends. Overall,
though, most of the costs involved with GGHC are low to minimum, and there are only a few
credits for which the costs start to become significant.

The cost situation is not going to be about actual dollars per square foot; it is going to be about
the building management process. You have to be committed to green building, and you have
to share that vision with all the stakeholders. You have to be clear about its goals and
expectations. You have to write that mission statement, and you have to write an integrative
design process plan.

At the programming phase, you're going to develop a budget, and you need to know exactly
what you plan to do for sustainability. You might increase something or decrease something in
the budget along the way, but you've got to draw a line on this and stay on track all the way
through. Remember, sustainability is not something you “add,” it is something that you build
into the program. Never ask your planner to tell you what more it would take to make your
project green, because the minute you do that, you're going to lose focus. If it is done right,
green is not going to be a major cost driver; it is just part of the overall project.

Jan Stensland, MS, IIDA, LEED AP, Kaiser Permanente: At Kaiser Permanente, we have
had a commitment to sustainability for more than 40 years. We have made it formal and
involved high-level management in the process so that it is more integrated throughout our
system. Our vision addresses and incorporates our values as a company. We truly do aspire
to provide healthcare in a manner that protects and enhances the environment and the health
of our communities.

Our decision-making criteria are based on three basic safety categories: (1) workplace safety
—how does it affect our staff? (2) patient safety—accounting for those who are
immunocompromised and acutely ill; and (3) environmental safety. We consider these issues
when applying our environmentally preferable purchasing criteria to our decision making
concerning what to review.

As part of this, we have equipment standards, furniture standards, and national purchasing
agreements. The national purchasing agreements are with a specific company or companies
for a specific product, and our teams are not allowed to use anything else without an in-depth
justification of alternatives. The contractors know that they cannot substitute anything in those
product lines, although they will try. They might say, for example, that they can get you a
cheaper chiller, and we'll respond that our standard chiller is 25% more energy efficient,
besides which the one being proposed uses refrigerants that we don't allow. We deeply
research our products so we can respond in detail like this.

We have used an integrated design process at Kaiser for years. We will hire general
contractors to advise us at the conception of a project. We will pay them for their time as
consultants—they may not be the general contractor that gets the bid, but they are hired for
their expertise to help us make sure we have an integrated approach and are hearing from all
voices from the start.

We have a high-performance building committee, with representatives from all of our regions
and our national facilities services group, as well as outside consultants of approved
architects, engineers, interior designers, and general contractors. This committee researches
new products and systems and reviews a tool in our green building tool kit called the
“innovation project request form.” If a particular project team is really excited about green
roofs, for example, they can submit an innovation project request form, do some preliminary
investigation and research, put the project plan together, and submit it to the high-performance
building committee for approval to proceed further.

Cool roofs are already in our standard and have been for a couple of years, but we are about
to change to a thermopolyolefin (TPO) roof, which uses a non-PVC roofing material.
Traditional built-up roofs are really toxic. When we have had roofs repaired, a few people have
felt ill from the fumes; it all depends on the way the wind blows. We also found that TPO lasts
longer and is easier to maintain. PVC cool roofs tend to get sticky over time because PVC
reacts with ultraviolet light and starts attracting dust and dirt. The efficacy of a PVC roof and its
reflective properties starts dissipating within the first couple of months of the roof's life. Bottom
line, the TPO material costs about the same or less than other roofing materials.

There's an interesting story about how we developed our flooring standard. We spent two and
a half years on research; a committee of experts reviewed all kinds of non-PVC resilient
flooring. Pilot projects were done at several sites using different materials, and in-house
chemical testing of volatile organic compounds and staining compounds was completed. Client
references were checked, and site visits were made to view installations. We had our
manufacturers complete an in-depth questionnaire, probably the most robust questionnaire of
its type that we know of in this country. After all that, only two products met all our
maintenance, operational, and performance criteria: nora rubber flooring and the Stratica Eco-
Polymeric flooring. As it happened, these were the only two that resisted Betadine stains, a
bottom-line requirement imposed by our nursing staff.

We have had challenges and we have learned lessons. First of all, it's important to educate
your capital project teams about why you are going, for example, from a cheap flooring
material to a high-performance flooring material. You have to have training for the flooring
contractors. For example, there is a reason that a trowel comes with every 1,000 square feet
of the Stratica flooring tiles—because it is a different trowel than the one used on a vinyl-floor
installation. You also need to train and support the maintenance staff, who will have to live with
this material for a long time. They need to know that they don't have to use those nasty
cleaning chemicals, and how easily and quickly they can get the right kinds of products to
clean those floors.

There is a learning curve to all this, but the bottom line is the people factor. We are in this
business to serve people. The best, most heartwarming result of these changes is the staff's
appreciation of our efforts. Recently we had new Ob-Gyn staff touring our new Modesto
Medical Center, and at the end of the tour they stopped, turned to the project director, and with
tears in their eyes said, “We can't believe what you have done for us, to go to all this effort to
get rid of these toxins and have these better materials.” Our project director said it was the
best moment of his 25-year history at Kaiser Permanente; someone fully got the message of
what he was trying to do. That is what it is all about for us. CD

Jim Moler is Manager, Engineering Systems, for Turner Construction in Brentwood,

Tennessee. Lisa Fay Matthiessen, AIA, is Associate Principal at Davis Langdon in Santa
Monica, California. Jan Stensland, MS, IIDA, LEED AP, works in strategic planning and design
for national facilities services at Kaiser Permanente in Oakland, California.

Mandates and available incentives for building green healthcare facilities

by Joyce K. Hackenbrach
Much has been written about the advantages of designing and building facilities—including
healthcare facilities—to be sustainable or green. Proponents of green building argue that
green building is not only justified because of the healthcare industry's core mission of
protecting human health, but also because of the more hard-headed operational
considerations. They contend that green building promotes objectively better patient outcomes
and improves professional and staff efficiency. They also point to potentially large cost savings
due to increased efficiency in the use of water, energy, and other resources.

These claims may well be true. Moreover, they are likely to be increasingly valid as industry
participants gain greater experience in effective greening, initial cost premiums for greening
are reduced, and the cost of energy, water, and other resources increases.

Meanwhile, though, governments are not waiting for further hard data to justify greening. They
are increasingly passing legislation that requires a broader and broader range of buildings to
meet identified green goals, and that offers financial and other incentives for meeting such
green goals. This article briefly discusses these developing requirements and incentives,
which healthcare facility managers should now take into account whether or not they are fully
convinced of the intrinsic financial, marketing, and other benefits of greening.

Mandatory green building laws are

proliferating at a great rate
There has been a veritable explosion of federal, state, and local laws aimed at promoting
green goals. Initially, these laws tended to apply only to public buildings, or to buildings that
were being financed using public funds. For example, at least 12 federal agencies have
required that new federal buildings and federally funded projects achieve LEED certification.
The 2007 Energy Independence and Security Act also requires that federal buildings be
designed to reduce fossil-fuel-generated energy consumption progressively over the years, as
compared with a benchmark established as of fiscal 2003 (ultimately achieving carbon
neutrality by 2030; See § 305(a)(3) of the Energy Conservation and Production Act (42 U.S.C.
6834(a)(3), as amended in 2007). In late 2007, the Office of Federal Procurement Policy also
proposed new government-wide “green purchasing policies and affirmative procurement
programs” for all government contracts and acquisition.1 The intention of these new federal
policies is to give preference to green products and services, to green buildings when the
government leases facilities, and to construction contractors who follow green practices. For
the government's purposes, green is measured using a variety of different yardsticks and
definitions, including LEED certification at various levels, EnergyStar awards (administered by
EPA), and products designated by the Federal Energy Management Program.

Despite strong federal policies mandating or favoring green practices, there is no

comprehensive federal regulatory framework governing the greening of U.S. building design
and construction. Much of the burgeoning green building legislation is, instead, coming from
the states and municipalities. At least 15 states and 90 municipalities now specifically require
that new construction of public or publicly funded buildings achieve LEED certification. The
legislators are also tending to phase in higher standards, including requiring that, after a
specified period, all publicly funded buildings be LEED certified at the Silver level or higher.2
Some have, moreover, begun to expand their regulations to apply to private sector buildings
as well.

One prominent example of this is California's new Green Building Standards Code (California
Code of Regulations, Title 24, Part 11). The code, initially enacted to be voluntary, will become
mandatory in 2010. It covers “every building or structure or any appurtenances connected or
attached to such building structures throughout the State of California.” The new code allows
existing state agencies currently overseeing construction of specific kinds—such as the Office
of Statewide Health Planning and Development (OSHPD)—to continue to oversee that
construction. Thus, the OSHPD was authorized to adopt only identified portions of the overall
code as applicable to general acute care hospitals, acute psychiatric hospitals, skilled nursing
facilities, and intermediate-care facilities. The portions that OSHPD has elected to adopt,
though, include a broad range of mandatory green requirements on building commissioning,
use of EnergyStar equipment and appliances, building orientation, construction waste
diversion, selection of green materials, building acoustics, sustainable site selection, and
stormwater runoff.

While the specific requirements imposed on healthcare facilities may not be particularly severe
under the new code, the state's willingness to reach out to regulate private sector uses,
including healthcare facilities, is something that the healthcare industry cannot ignore. This is
particularly true given the increasing state and local legislative activity to regulate carbon
emissions from buildings, as well as strong federal, state, and local policies to promote energy
efficiency for both financial and political reasons. While hospital energy costs are generally
dwarfed by other costs (such as those for professional staff and specialized equipment),
healthcare facilities are famously heavy energy users. Healthcare, per se, may have been out
of the governmental greening cross-hairs thus far, due to the heavy technical and regulatory
burdens such institutions already face, but that is increasingly likely to change, and it is
increasingly likely that green requirements will be imposed on them as well.

Financial and other incentives have also

proliferated
As federal, state, and local governments have passed mandatory green building laws, they
have also offered a wide variety of incentives to build green. These incentives include priority
for plan approval and permitting purposes, density bonuses, rebates of building permit fees,
grants to help fund green development costs, green building tax credits, property tax or
income tax credits, free technical assistance in greening efforts, loans, and loan guarantees. In
addition, many utilities offer rebates and similar incentives for installation of more energy-
efficient equipment and other energy conservation measures.
While a number of the incentives are aimed at residential or commercial developers, many
also offer benefits to healthcare facilities—even though they may not be explicitly listed in the
legislation as among the beneficiaries. For instance, an applicable incentive may be labeled as
one for nonprofits, institutions, or commercial projects, and not specifically for healthcare
facilities, even though they qualify. An excellent example of what such incentives can be, and
how they can benefit a healthcare project, is provided by the Providence Newberg Medical
Center, in Newberg, Oregon.

The medical center's planners estimated that they would incur a first-cost premium of about
$550,000 to go green, but did not have the added funds available in their budget. The medical
center, completed in 2006, nevertheless became the first hospital in the United States to earn
a LEED Gold certification. It did this, in part, by hunting down and using available financial
incentives. One incentive was from the Energy Trust of Oregon, an entity created by the
Oregon Public Utility Commission and funded by state-mandated charges on customers of the
state's largest utilities. The Energy Trust supplied a grant of $199,858 for specified energy
efficiency improvements, meeting the Trust's own published performance measures. Another
increment came from the Portland General Electric's Earth Advantage Program. Earth
Advantage supplied $156,000 to fund a generator upgrade. Additional grants from other
sources funded energy modeling, financial analysis, building commissioning, and an eco-
charette. Finally, Oregon's Office of Energy allowed the project a $141,969 Business Energy
Tax Credit. This was of benefit, even though the hospital was a nonprofit, because Oregon
permitted nonprofits to transfer their tax credits through to another taxable organization, in
exchange for the net present value of the credits. The project's total green incentives totaled
nearly the entire estimated first-cost premium, and made it easy to justify the greening effort.3
Providence Portland, part of the same healthcare system, similarly obtained a $217,278
Energy Trust incentive in 2007, for major renovation of its central utility plant (See Case Study,
EnergyTrust of Oregon, Inc., available at http://www.energytrust.org).

The Providence projects, while notable, are far from the only examples of third-party incentives
available for healthcare greening. Minnesota Power gave St. Mary's/Duluth Clinic rebates for
reducing peak load by upgrading to energy-efficient mechanical equipment. Austin Energy
assisted Dell Children's Medical Center in building a 2.5 MW natural gas-fired turbine
generator with absorption chillers, heat-recovery equipment to produce steam, and back-up
equipment. The hospital's parent thus avoided building its own central plant, and saved $6.8
million, much of which was reinvested in other green measures.4 Sierra View District Hospital
in California obtained low-interest loans and grants from the California Energy Commission for
lighting refits, chiller and cooling tower replacement, and installation of high-efficiency motors.
The Energy Partnership Program also provides technical assistance to eligible applicants
(including hospitals), including energy audits, design review, and assistance in developing
equipment performance specifications. Some further illustrations of incentives for which
hospitals have been eligible include:

 a West Virginia Development Office lighting grants program offering lighting analysis
and a matching grants of up to $30,000 for lighting improvements;
 a utility rebate by Northern Utilities in New Hampshire for 50% of the cost of installing
energy-efficient equipment of specified types (up to $50,000), 50% of the cost of a
scoping study (up to $7,500), and certain other equipment rebates;
 New York State's $mart Loan Program, providing commercial and institutional facilities
interest rate reductions on loans by participating lenders for energy-efficiency
 improvements meeting Energy $mart requirements (currently subject to a maximum
loan of $1.5 million);
 Florida's Renewable Energy Technologies Grants Program, offering matching grants
for projects relating to renewable energy technologies; and
 New York State's cost-shared assistance for retro-commissioning of existing buildings
and commissioning of new buildings, and related incentives (expressly available to
hospitals, among others, with current limits in the New Construction Program of
$400,000 per building).

These and many other available incentives can be identified by searching online databases,
such as the Database of State Incentives for Renewables and Energy (DSIRE)
(http://www.dsireusa.org) the LEED Initiatives data maintained, and regularly updated on the
U.S. Green Building Council's Web site.

Conclusions
Healthcare facilities have, for many reasons, been relatively slow to join the green movement.
But, given the increasingly aggressive development of green legal requirements, and the
availability of potentially significant financial incentives, healthcare facilities should now
consider greening each time they embark on a new project or major renovation. Taking
advantage of available incentives can make it easier to justify greening on purely financial
terms (even setting aside legal requirements), so healthcare facilities should seek out such
incentives in their normal project planning. To be really effective, the project team must
develop a game plan early in planning to identify possible green incentives for the project,
carefully research the particular green standards that the programs would apply, and apply
early for available incentives. The planners must take into account that each city, county, utility
district, and state tends to tailor incentives to its own particular needs and resources.
Moreover, incentive programs tend to change quickly over time. One program can end and
another can begin with the same or different requirements, and funding for programs can run
out. So a project team must do detailed research each time it embarks on a project, and for
each location in which a project is to be located. But the effort to go green, and to seek
financial incentives to help pay for the effort, has now become prudent for every forward-
looking healthcare facility. HD

Joyce K. Hackenbrach is a Partner at Pepper Hamilton, LLP.

For more information, visit http://www.pepperlaw.com.

References
1. Office of Federal Procurement Policy; Acquisition of Green Products and Services,
Proposed policy letter on the acquisition of green products and services, 72 Fed. Reg.
73,904 (December 28, 2007) (“Proposed Green Products and Services Acquisition
Policy”), available at http://edocket.access.gpo.gov/2007/pdf/e7-25211.pdf.
2. See, e.g., Ordinance 2008-93 passed by the Anchorage, Alaska Assembly (municipal
 buildings), Resolution 08-0371 passed by the Stockton, California City Council
(municipal and private non-residential buildings exceeding a stated size); San
Francisco Green Building Ordinance (signed in August 2008, requiring LEED
certification of residential and commercial buildings over a stated size, Silver
certification of commercial buildings over a stated size, as of January 1, 2009, and
Gold certification for those buildings as of January 1, 2012.
3. Zimmerman G, Healthy Grants Help Justify Green, Green Health Care (August 2007)
(available at http://www.facilitiesnet.com/bom/article/asp?
id=7216&keywords=green+building); Providence Health System, “The Nation's
Greenest Hospital,” available at http://www.
providence.org/yamhill/new_medial_center/green/htm); Providence Newberg Medical
Center Project Overview, available at http://www.betterbricks.com.
4. Cassidy R, 14 Steps to Greener Hospitals, Building Design and Construction (Feb. 8,
2006)(available at http://www.bdcnetwork.com/article/CA6305831.html).

Healthcare Design 2008 December;8(12):16-18

The greening of a critical access hospital

by Brent Castillo
If you have driven through the Midwest, you have seen dozens of towns similar to Greensburg,
Kansas. The main streets of these towns are lined with historic buildings that a generation ago
housed thriving businesses that were the backbone of the local economy. Their simple,
dignified architecture stirs our nostalgia for simpler times and a slower pace of living.

The tallest building is the local grain elevator, and its towering white shape defines the town's
skyline. The houses are modest, yet well-maintained. Pickups and American-made cars are
the preferred transportation. The residents are down-to-earth, friendly and work hard for their
wages; and most of the towns are lucky to each have a couple thousand who still call it home.

But in spite of the similarities, each town has something that makes it unique. For Greensburg
and its 1,500 residents, it was being home to the “World's Largest Hand-Dug Well” and a
1,000-pound Pallasite Meteorite. They were sources of pride for the community, and signs
along the highway beckoned travelers to stop and take a look.

But everything changed for Greensburg on a stormy spring night last year. It was May 4, 2007,
and the streets were quiet except for the wind and rain that had descended upon the city.

In the darkness 20 miles southwest of town, a massive tornado was forming. It first touched
down and started moving toward Greensburg at 9:04 PM. The severe weather was being
tracked by an astute weatherman with the National Weather Service. Moments after
confirming the tornado, he issued the first warning. Two more urgent warnings were issued as
it became clear that the tornado was heading directly for Greensburg. A final “emergency”
warning was issued less than 10 minutes before impact. By the time the fearsome tornado
entered Greensburg at 9:49, it churned with wind speeds of 205 miles per hour, and was more
than a mile-and-a-half wide. It was the first EF5 to hit Kansas, and the only tornado of that
magnitude to hit the United States in eight years.

Greensburg was destroyed. Eleven of its citizens were killed, and 95% of the buildings were
no longer standing, including the hospital.

The next weeks would find the dazed people of Greensburg picking up the pieces of their lives
and belongings. This small town was no longer like the others with which it had shared so
much common ground. Now, to live in Greensburg meant to survive.

Greensburg goes green

The citizens of Greensburg had a decision to make: To stay and rebuild, or to leave? Most
chose to stay. “You've got a lot of people here who've said there's no way they can let this city
disappear,” says Steve Hewitt, city administrator for Greensburg.

But it quickly became clear that for Greensburg to succeed it would have to reinvent itself. The
city was struggling to survive before the disaster, and the tornado could have been its death
knell. But a few people, including the former mayor, Lonnie McCollum, had an idea: What if we
make this town green?

It's an idea that Hewitt, who was born in Greensburg, is passionate about. “There's a good
strong core of people who want to see this thing through,” Hewitt says. “Because of that, this
community will make it.”

The city council approved a plan to make all of the public buildings in Greensburg conform to
the Platinum level of the U.S. Green Building Council's Leadership in Energy and Design
(LEED) standards. It will be the first city in the country to do so. The town's efforts have
garnered national attention. Movie star Leonardo DiCaprio has produced a series currently
airing on the Discovery Channel that chronicles the rebuilding of the city.

“If green wants to go beyond a trend, then Greensburg has to show it can be done,” Hewitt
says. “If Greensburg can do it, why can't any other town do it?”
Critical decisions
The rebuilding efforts of the community are also exemplified in Greensburg's medical facility,
Kiowa County Memorial Hospital (KCMH), a Critical Access Hospital (CAH).

After the tornado, little of it remained: the walls were smashed, the equipment scattered and
patient beds were strewn around the property (figure 1). In one of the many miracles that
night, none of the patients or hospital staff were injured. They had been safely sheltered from
the storm in the basement of the facility.

The powerful EF5 tornado devastated

the city of Greensburg, Kansas, and
destroyed Kiowa County Memorial
Hospital. Its roof and many precast
concrete beams were torn off, walls
collapsed, and equipment was
scattered. In spite of the destruction, all
staff, patients, and some residents
remained safe in the basement shelter
of the hospital

Photography by Mary Sweet, Kiowa County Memorial Hospital

About three years before, Mary Sweet, the hospital's administrator, had implemented changes
in the emergency procedures that made the basement, not the hallways, the center of refuge.
Now, the new hospital will be built for strength, and will also include a storm shelter in the
basement. A recent reminder of its importance occurred in May 2008, when a funnel cloud
passed directly over Greensburg and killed two people traveling on the highway east of town.

Sweet knows she needs that same foresight to make beneficial choices for the future hospital.
“We are trying to make wise decisions that are 50-year decisions for the future of this hospital
and for our world, too,” she says (figure 2).

The replacement facility for the Kiowa

County Memorial Hospital will be 48,500
sq. ft. and will be licensed for 15 acute-
care beds. The new Critical Access
Hospital will include a five-provider
clinic, a specialty clinic, an emergency
room, a physical/occupational therapy
department, a radiology department,
lab, and other support areas including
an on-site daycare facility
Courtesy of Health Facilities Group

One such decision is economical use of resources, which is of utmost importance to small
rural CAH facilities. Services will be consolidated and integrated to make the most of hospital
staffing. Spaces must also be designed for multi-use to maximize reimbursement rates. Some
parts of the hospital will also serve as meeting rooms for community groups.

“It's good to be building the hospital around how we are as a community, our values and
needs, and at the same time provide for how we practice medicine today,” Sweet says (figure
3).

The hospital is currently housed in

three trailers, and is still using four of
the nine (M.A.S.H.) army medical tents
that were set up in the aftermath of the
storm

Courtesy of Health Facilities Group

In the LEED
Some of the decisions getting the most attention at KCMH will involve energy efficiency,
sustainability, and use of recycled materials. Decisions regarding these elements are intended
to make KCMH the first LEED Platinum-rated CAH in the nation. A platinum rating requires
that the facility earn 52 points out of a possible 69 on the LEED rating scale. Because a
number of LEED credits are not available because of the project location and circumstances,
and with a margin of only 17, each point matters.

A project goal is to have 30% of the aggregate material cost be for recycled material. To
calculate and recalculate this figure each time adjustments are made using a spreadsheet and
manual takeoffs would require days. Using the BIM feature of Autodesk Revit, though, it takes
only seconds. The medical architect, Health Facilities Group of Wichita, Kansas customized
this Revit quantity of materials feature to automatically track materials attributes, including the
percentage of recycled material and the weighted monetary cost of each item. Design
decisions could then be quickly evaluated for their impact on aggregate cost of recycled
material in the overall project.

To achieve a LEED Platinum rating for a hospital, the architects, engineers, and construction
management team have been challenged to maximize efficiency in the systems while still
providing a constructible product. “Doing so compensates for the high energy consumption in
the normal medical facility that is necessary to meet code-mandated requirements for air
quality, ventilation, and infection control—it just makes good business sense,” says Phillip
Schultze of Murray Company, construction manager. The team found one solution through a
combination of heat recovery strategies and cutting edge HVAC technology.

“The way we approached it, some elements of a normal system were able to be eliminated
because of the high efficiency of the selected systems and the specific combinations used,”
says Tim Dudte, AIA, Health Facilities Group project manager.

Here's how it worked: In this region, there is typically a redundancy in the heating and cooling
systems that involves three sources of power. Because of utility costs, natural gas is often
used to heat boilers, while electricity is used to power the chilled water system used for air-
conditioning. Fuel oil is usually the choice to provide redundancy as a backup fuel for the
generator and boilers. This requires separate storage for both backup systems.

Because of the efficiency of the building envelope design, it became feasible to use electric
boilers and electricity for all of the primary systems. The fuel oil boilers and all of the natural
gas systems could be eliminated, significantly reducing the system first cost. This cost savings
offset the additional expense of the heat recovery systems and a high efficiency magnetic
chiller.

There are several other project highlights:

 The new building will take advantage of natural light for daylighting 75% of the facility.
This is made possible by optimizing sun angles, while the latest generation of high-
performance glass also provides high insulation and blocks harmful UV radiation.
 An on-site wind turbine will generate a portion of the power needed to operate the
hospital.
 To avoid the heat-island effect, the roof and parking lot will use lighter-colored
materials to reduce heat absorption and improve reflectance.
 The hospital will reduce waste water by 50% by processing it through a natural bio-
swale filtration system. Rain water will also be captured and then used to flush toilets.
 The interior finishes will incorporate recycled materials. For example, the majority of tile
used throughout the building is manufactured regionally, made from recycled content,
and has been evaluated for future recyclability.
 By partnering with the National Renewable Energy Laboratory (NREL), the team was
able to consult with experts on energy analysis and the latest technological advances.
NREL modeled design options and provided energy analysis options for the building
designed by the team.

None of these achievements would matter unless they allowed the hospital to sustain its most
important resource: people. Research demonstrates that sustainable elements in healthcare
environments both provide a better, healthier working environment for employees and support
the mission of the hospital to promote healing.

The future
For Greensburg, the hand-dug well and meteorite will always be part of its uniqueness. But if
the city achieves its goal of becoming the nation's model “green” community, those attractions
will be the icing on the cake.

Sweet's hopes and aspirations for the new hospital exemplify the care and effort being put into
the rebuilding of Greensburg. “Even with the devastation of a tornado, we have to make
something good come out of this,” she says.

So far, Greensburg is succeeding (figure 4)—with green. HD

The new hospital is designed to be the
nation's first LEED Platinum Critical
Access Hospital. Green features include
on-site energy generation via a wind
turbine and multiple reuse of water
sources, including rain water. The
construction will maximize the use of
recycled materials. The shell of the
building is designed to make the best
use of daylighting and natural views
and to control solar gain

Courtesy of Health Facilities Group and Mid-Kansas Engineering Consultants

Brent Castillo is Art & Communications Director for the Health Facilities Group, a medical
planning and architecture company in Wichita, Kansas.

Contact him at 316.262.2500, brentc@healthfacilitiesgroup.com, or visit

http://www.healthfacilitiesgroup.com.

Sidebar
Facility: Kiowa County Memorial Hospital
Architect and Planner: Health Facilities Group, Wichita, Kansas

Mechanical/Plumbing Engineers: Midwest Engineering, Inc.

Civil Engineering: Mid-Kansas Engineering Consultants, Wichita, Kansas

Electrical/Structural Engineers: Professional Engineering Consultants, Wichita, Kansas

Kitchen Design Consultant: Montgomery Hoffman Associates, Topeka, Kansas

Healthcare Design 2008 August;8(8):16-22