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1 PATH TO SUSTAINABILITY
1.1 Background of the national 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 phys-
ical 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 func-
tionality requirements, being at the same time profitable, safe and durable throughout its life cy-
cle. The product must be integrated in the natural system with the lowest negative environmen-
tal 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 envi-
ronment 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
The importance of the hospital buildings to the sustainability of
the built environment
M. F. Castro
University of Minho, Guimarães, Portugal
R. Mateus
University of Minho, Guimarães, Portugal
L. Bragança
University of Minho, Guimarães, Portugal
ABSTRACT: The project of a hospital environment requires a number of concerns 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. Due to various design require-
ments, it turns out that these buildings are not designed and operated in a sustainable way. This
is because there is no effective method to support the design teams to consciously introduce
such measures. Consequently they don’t know which are the best practices to follow and build-
ing managers are not aware of the measures that must be adopted for efficient building opera-
tion. Based on this context it is important to study the best practices of a sustainable hospital de-
sign 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 should be maximized when designing, operating or maintain-
ing a sustainable hospital.
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 resi-
dential 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 simi-
lar evolution neither on the environmental concerns nor in the search for efficiency in terms of
energy consumption and materials. So, these facts place on the agenda the need for a more pro-
active 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 pos-
sible, respond to social demands and contribute to better economic management. 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 De-
velopment: environment, society and economy.
In Portugal, the issue of sustainability is still in its infancy. Mostly buildings present prob-
lems that result in thermal discomfort, visual and poor indoor air quality. This situation is asso-
ciated, 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 pas-
sivity 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 have awareness of 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 large consumption of energy. Consequently, this tra-
ditional 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 continually imposed on the planet by the construction, use and demolition
of buildings (Bento, 2007): i) through rules and regulations and ii) through financial incentives
partners for the specific purpose.
Analyzing the graph presented in Figure 1, it is possible to conclude that the peak of the gen-
eral trend of production tends to coincide with an environmental conscience average. Addition-
ally, 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) released 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 foun-
dation 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 indus-
try.
Figure 2. Relationship between environmental performance and health care (Robert & Guenther, 2006)
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, incor-
porating 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 direct-
ly 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, re-
search, 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 im-
prove its life-cycle’s sustainability. Based on case studies of successful design approaches it is
possible to conclud that the ability of evolution of these buildings is great.
On average, a hospital has energy consumption per square meter, ten times more than an of-
fice building with research laboratories (HSJ, 2009; INEGI, 2009) and consumes more electrici-
ty per year than any other existing building in a Portuguese city. These figures are due to the
fact that these buildings are authentic machines to maintain the health and live of the patients.
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 is an increase of 8% in energy
consumption due to the introduction of equipment, ventilation and works in progress (HSJ,
2009)). Moreover, and according to the comparative analysis of some activity and budget re-
ports from the Portuguese hospitals, it is possible to note that in most cases sustainability initia-
tives are reduced to the separation, treatment and possible wasrt recycling and in punctual cases
to the reduction of electricity and water consumption. Currently, there are several studies about
hospitals that invoke the sustainable development concept. 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, nor-
mally 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 envi-
ronmental impact.
In order to introduce sustainable practices in the design of healthcare buildings, several coun-
tries have published guidelines to promote imprived design approaches. Among them, it is pos-
sible to highlight recommendations for hospital projects that the Green Building Committee of
the American Society of Healthcare Engineering (ASHE) published in 2002 (Robert & Guen-
ther, 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 de-
velop 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 ASSESSMENT OF SUSTAINABILITY
2.1 Methodologies to support the design of sustainable buildings
The first major reason that led to the emergence of the need to evaluate the environmental per-
formance 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 certifi-
cation 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 con-
sumption. 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 ap-
proach, 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 as-
sessment, 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 possibil-
ity of comparison (Mateus & Bragança 2011). After the establishment of sustainability indica-
tors, 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 over-
all 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 respon-
sibility 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 de-
sign.
As a result of the difficulties mentioned above, currently there isn’t an internationally accept-
ed assessment tool or methodology. Nevertheless, analyzing the main objectives of existing
methodologies, it is possible to distinguish three different types: support tools for the sustaina-
ble 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 3) 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 that when considered in de-
sign phase will lead to more sustainable buildings (Bragança et al., 2007).
Figure 3. Generic model of a support tool for the design of sustainable buildings (Bragança et al., 2007)
2.2 Sustainability Assessment and certification of hospital buildings
There are some countries either developing aor implementing sustainability assessment method-
ologies 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; enabling economic progress; and im-
prove 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 4 present the dif-
ferences 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 4. 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 is the first hospi-
tal to achieve certification at the level of sustainable construction. The assessment is based in
the LEED approach.
Figure 5. Boulder Community Foothills Hospital (Verderber, 2010)
The Providence Newberg Medical Center 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 3 presents the the design prac-
tices taken into account in the two abovementioned examples, which enabled a sustainability
certification.
Figure 6. Providence Newberg Medical Center (Verderber, 2010)
Table 1. Design principles considered in the two case studies
Dimensions
Design practices to improve the sustainable construction
Boulder
Community
Foothills
Providence
Newberg
Medical
Center
Environmental
Reduce site disturbance (local and regional materials used)
•
•
High-reflectance, low-emissivity roofing
•
•
Reduce the density of construction
•
Reducing the rate of net available land use
•
Reduced consumption of non-renewable primary energy in
use phase
•
•
Reduced consumption of non-renewable primary energy in
the construction phase
•
Reuse materials
•
Recycled-content materials employed
•
Use of organic-based products which are certified
•
•
Construction-waste recycling
•
•
Reduction of water consumption in the building
•
•
Xeriscaping with native vegetation reduced water consuption
•
•
Social
Indoors natural ventilation
•
•
Natural light and shade
•
•
Thermal comfort through effective construction solutions of
the surrounding
•
•
Solar building orientation
•
•
Reducing the weight of the use of construction materials and
finishing with a low content of VOCs
•
•
Acustic confort
•
•
Alternative transpotation encouraged
•
•
Accessibility to activities spaces, library, conference room
and pharmacy
•
•
Existence of green spaces with easy access for users
•
•
Access to living areas, gym
•
Views
•
•
Flexible design and adaptable spaces with the possibility of
increase due to future needs
•
Economic
Reduction of operating costs related to energy consumption
•
•
In Portugal, during 2008, the Ministry of Health developed a document that lists the recom-
mendations and technical specifications for the hospital buildings, where there are recommenda-
tions 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 documents, 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 isn’t 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 sever-
al authors, the goals that are intended primarily achieve with the sustainable design and con-
struction of this kind of type of buildings are:
- Improve the quality of patient care;
- Reduce time to recovery of the patient;
- 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 posi-
tive patient (system performance evaluation of the complex);
- Quality and safety indoor and outdoors environment;
- Reduced risk of use associated with the project
- Increased life of the building and timeliness of the same;
- Reduce operating costs, maintenance and construction;
- Educate the understanding for the need to use a sustainability certification, allowing it to as-
sess the pros and cons of introducing these design practices.
Table 2 presents the indicators that should be taken into account when it comes to implement-
ing sustainable design practices in hospitals.
Table 2. Dimensions, categories and indicators to support the implementation of sustainable
practices in building design hospital
Dimensions
Categories
Indicators
Environmental
Climate change and outdoor air quality
Environmental impact associated 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
Materials and Solid Waste
Reuse of materials
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 us-
er 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
Local development
Equipments
Accessibility
Accessibility to public transport
Mobility of low impact
Accessibility to amenities
Programmatic organization
Awareness and education for sustainability
Formation of occupants
Innovation
Innovation of the project design
Economic
Life cycle costs
Initial cost
Usage costs
3 CONCLUSIONS
Due to various design requirements, it appears that 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 to optimize the life-cycle sustainability at the
design phase and building managers are not aware about the measures they should adopt for ef-
ficient operation.
This raises the importance to develop a methodology that includes the indicators of table 2, to
support the decisions of players in two phases: design (supporting the decision to adopt solu-
tions that contribute to the sustainability of the building) and use (user support and gen-stores
for the operation and maintenance of equipment are executed with the highest efficiency level
possible). For that, is necessary in a future works develop the indicators presented and find the
best method for evaluating the parameters found. In the end is necessary to draw up a guide to
using the methodology that is easily understood by conventional project teams.
4 REFERENCIES
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