Photo Credit: BBH Design - West Facade During Construction
When's the last time you questioned the design practices hospitals? Never? Well, you should - of all the building types in the world, hospitals should be a symbol of good health, sustainability, and wellness. But they are not. On average, it takes between five to ten years for a facility to go from the drawing board to its grand opening. The question is how to design the most state-of-the-art facility today so it will still be state-of-the-art when it opens a decade later? This is a challenge most healing environments are not meeting. They throw flexibility at the problem which downgrades the quality of the facilities as well as the patient experience. And it is costing them billions of dollars that could be spent to improve care. Right-sizing a facility is the most effective and sustainable acts to save energy, money and create better surroundings for people.
Photo Credit: BBH Design - Image of Full Scale Mock-Up of Patient Room
Normal Modus Operandi
The normal modus operandi for healthcare systems is to make spaces overly flexible to deal with the quick pace of technological changes. Though in some regards flexibility is seen as a positive, green approach for architecture, it translates into hospitals as patient rooms that are too big and ineffective interiors. Trying to accommodate the future by merely making spaces larger is costly in terms of energy, capital, people, time and the environment. In some cases, facilities are 10 to 20 percent bigger than they need be. In context, healthcare spends around $16 billion on new facilities each year. Right sizing these buildings would size billions of dollars for the sector.
Not only that, once the buildings are in place, you have to operate them. The energy needed dwarfs all other commercial building types such as offices or schools. On average, offices use around 19 kWh and educational facility use just over 8 kWh per square foot of electricity. Healthcare facilities on the other hand use between 26 to 30 kWh per square foot of electricity and 143 to 160 cubic feet of natural gas per square foot. Offices and schools use less than 25 percent of the natural gas as healthcare.
Photo Credit: BBH Design - Full Scale Mock-Up of Patient Room
This means that for every unneeded square foot within a hospital a tremendous amount of resources are consumed. The negative implications are in the form of emissions, energy and operational costs. Each square foot costs about $4-9 to operate, nearly the same amount as the cost of staff member. More effective design would allow expenditures go to people that can give patients more care than to power bills and utility companies. Flexibility is not the answer.
Photo Credit: BBH Design - View from Patient Room during Construction
In-Depth Patient Room Design
During the design of UPMC-East, we wrestled with these questions because a large portion of the program was going to a patient tower housing 156 beds, so we decided to take an in-depth look their size. The leadership at UPMC echoed the challenge to optimum the rooms. The concept is counter to everything the industry has taught for the last ten years. We started by collecting precedents from twenty different facilities across the country. Though the 2006 Guidelines for Design and Construction of Health Care Facilities recommends 250 square feet of clear floor area for a patient/family-centered care rooms, we find that the typical patient room is generally 300-400 square feet.
Photo Credit: BBH Design - Tour of Mock-Up of Patient Room
More interior space does not pay for itself - reimbursements for long-term stays are declining and most people would prefer to be at home during recovery. The extra cost falls on the healthcare provider which is either passed to the consumer or is reflected in a reduction of services at the hospital. We found a solution by compared patient rooms with two and three star hotel rooms. From that evaluation alone, a 220 square foot model began to emerge. We then overlaid environmental criteria like daylighting, energy efficiency, controllability of systems, indoor comfort and views outdoors. We used state-of-the-art whole building simulations to quantify all qualitative assumptions such as natural light variation, energy usage and position of furniture.
Image Credit: Chambers Design, Inc - Daylight Simulation for glazing options for Patient Room
This in turn began to influence the exterior skin. At first, the envelope was designed as a thin skin, but using computational analysis as a design tool, we re-imagined it as a deeper zone that regulated glare and solar heat gain throughout the seasons. This approach was highly effective for passive solar heating and external solar shading devices.
Image Credit: Chambers Design, Inc - Daylight Study for Patient Room
From Simulation to Reality
Simulation tools are great to a point. To test the final design, a full-scale mock-up was built. Once completed, nurse providers and hospital leaders were asked to kick the tires. Through a series of meetings where comments were recorded, design changes drawn, and the mockup reconstructed, a final typology took shape - and measured less than 220 square feet. Other features such as the latest SmartRoom technology, expansive windows and inboard bathrooms were included. Environmentally, less energy and better interiors were created.
From the perspective of people, the rooms give greater mobility and comfort for provider, patient and visitors. The economic outcomes reinforced we had taken the correct path. Resizing the rooms saved $3 million of capital construction costs and saves more than a million dollars on energy every ten years of operation. The project proves that green buildings can cost less than conventional construction, and yet they still pay you back.
Photo Credit: BBH Design - Tour of Mock-Up of Patient Room
Flexibility is a solution for some building types, say, laboratories or education. For hospitals, it often results in unforeseen negative effects. When you consider the waste that comes from too much space within healthcare, conventional concepts of design need to be scrutinized. Green design is not just about technological fixes - it is about better design. Healthcare has a long way to go to reduce its ecological footprint. If embraced by more providers, green building can be a very powerful tool in meeting the challenges of the future. Seen from the bigger picture, it is easy to see that the reason our healthcare system is in crisis is because it has yet to go green. The positive outlook is that some systems are leading the way, and could foster a strong competition to see which systems can be the greenest first.
(This article was co-written by Timothy J. Spence, AIA, LEED AP BD+C, Principal and Healthcare Studio Lead at BBH Design)
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