Globally, healthcare is one of the most carbon-intensive industries, responsible for between 4.4 and 4.6 percent of greenhouse gas emissions and toxic air pollutants — and the U.S. healthcare industry is the largest contributor.
The U.S. healthcare system accounts for about a quarter of all global healthcare greenhouse gas emissions, more than any other nation, a 2020 Health Affairs study found. But more hospitals are starting to ramp up their sustainability efforts, and one way to do that is through capital projects.
Experts say building green doesn't just improve the health of healthcare facilities, but of the patients inside the facilities as well.
What hospitals are doing
When Oakland, Calif.-based Kaiser Permanente first started pursuing sustainability efforts in its capital projects, the overall price tag was a concern, Ramé Hemstreet, vice president of operations and chief energy officer, told Becker's.
Now, about 10 years later, the health system has 67 buildings (adding two just this year) with Leadership in Energy and Environment Design certifications from the U.S. Green Building Council, the most widely used green building rating system.
In November, the council named Kaiser Permanente the top healthcare organization in the world for its number of certified buildings, and it also has the most LEED-certified healthcare square footage, with over 6 million square feet.
Although the overall cost was an initial concern, Mr. Hemstreet said that in the long run, having a sustainable building actually saves money in energy and upkeep.
"We think the life cycle cost and total cost of ownership is actually less when you're building sustainably because you have a building that's healthier, and you have a building that's going to use less energy," Mr. Hemstreet said.
The system's hospitals have several green features, like San Diego Medical Center that uses technology to produce its own electricity, heating and cooling, or Santa Rosa Medical Offices, which was the first net-zero carbon emissions healthcare building in the U.S.
When planning for a LEED building, Mr. Hemstreet said several factors like location play a huge role. For example, building near public transportation and in locations with good water quality can help make a building more sustainable. Additionally, the system tries to identify spots where it can easily install on-site solar, which can be a money-saver, he said.
But ultimately, it comes down to having the right team.
"We select our architects, our engineers, our contractors based on their familiarity with our Kaiser Permanente design standards, which have a lot of sustainability built into them," Mr. Hemstreet said.
Penn Medicine has also focused its efforts on sustainability, with its new 1.5-million-square-foot pavilion on the Hospital of the University of Philadelphia campus achieving a LEED v4 Gold Certification, the largest certified project in the world to do so. It is also the first U.S. hospital larger than 1 million square feet to become LEED Healthcare certified.
The building cuts down on 30 percent of indoor water use.
It was constructed using recycled materials from the demolition of the former facility, and about 25 percent of materials were prefabricated and made off-site, reducing waste and traffic.
"That doesn't come to mind right away for folks in terms of the sustainability effort, but we think it made a major impact in terms of saving material waste," said Derek Tasch, Penn Medicine's architect.
Having a sustainable building also affects patient care, Mr. Tasch said. Organizing the building flow in a way that removes traffic improves healing and makes the environment more peaceful.
Additionally, lighting and noise play a role, he said.
"You won't begin your path to healing if you don't get rest or sleep, and so [it's important] to provide the most peaceful, least disruptive environment for the patient," Mr. Tasch said.
The hospital also incorporated two-sided cabinets that can be stocked from the corridor side or the patient side, which further minimizes the number of people coming into the room.
Mr. Hemstreet echoed the effect a sustainable environment has on patients.
"A healthy environment reduces the need for patient care … but of course, when our members need high-quality healthcare, sustainable design and the built environment can support that in some ways that are subtle, some that are a little more obvious," he said.
Can hospitals shift the needle?
In the U.S. alone, healthcare emissions rose 6 percent from 2010-18 and represents its dominant contribution to global emissions.
To put it in perspective, the negative health impact of the health industry's pollution output is equal to the negative health impact of preventable medical errors.
But how much can hospitals and other capital projects contribute to shifting the needle?
Much of the answer comes from when the hospital was built because, broadly, design principles have changed over the last several decades.
Most facilities built 20 or more years ago were largely designed with "disease cure" as a top priority, whereas more modern projects lean toward "person care" as a primary design principle. The idea of person care, similar to whole-person care, considers how a spectrum of factors — including traditional medical needs, but also behavioral and environmental health — contribute to a patient's well-being.
This means that historically, a hospital's environmental effects have taken the backburner to providing direct medical care. But now, modern projects are also beginning to implement a "triple bottom line" — an approach that considers the environmental practices, social and financial benefits a hospital provides within its region.
But even with a slow shift toward being more environmentally conscious, facilities' direct contributions are only a small slice of emissions.
During the spike in emissions from 2010-18, healthcare supply chains contributed to 82 percent of pollution, a much larger share compared to hospital energy purchases (11 percent) and direct facility emissions (7 percent).
However, between all three sectors, electricity use contributed the most to emissions (23 percent) — a contribution six times higher than basic organic chemical manufacturing, the next largest contributor.
Whether it be through the construction of a new facility or a review of current assets, researchers say the best way to cut down on emissions among all three sectors is to focus on electricity consumption. Shifting away from fossil fuels will play the largest role in eliminating the air pollution that is responsible for most short-term health issues.
Sustainability beyond construction
Making considerable headway on sustainability that translates to return on investment isn't limited to hospitals or systems planning capital projects. While reducing carbon load in the construction phase of a facility is important, "the construction of a hospital building is going to be a very, very tiny part of the overall impact or benefit that a hospital achieves over its lifespan," said Todd Cort, PhD, sustainability lecturer at Yale University.
"If [hospitals] are looking for big fish in terms of how to create benefits to the environment and society while also making some better returns or better margins, then [they should be] probably looking beyond the construction phase," Dr. Cort told Becker's.
There are opportunities for hospitals to embed sustainability beyond LEED certification and other similar programs, as they don't take specific applications or hospital equipment into consideration. Instead, such programs consider broader elements that every facility uses, such as electricity, lighting and air conditioning. This opens the door for hospitals to get strategic with initiatives that accrue benefits in the use phase of the building, Dr. Cort said.
Being selective about the placement of a particular piece of equipment in a hospital can be effective. If a hospital is going to install an energy-intensive cyclotron, for example, putting it in the basement can lessen the load.
"You can design in such a way that the machine that's going to be a huge load on your electricity, for example, is in the most thermally isolated room or that it's put in the basement, which would be a more stable temperature than, say, the attic," Dr. Cort said. "If it's really water intensive, you can put it in such a place that it's close to the water inlet of the building so you are not pumping water up, depending on your water source."
As hospitals progress on sustainability initiatives, they closely examine ways to cut down on waste, Dr. Cort said.
"The healthcare industry is notorious for [its dependency] on single-use materials," he said. "Single-use plastics are a really big deal in the healthcare industry, and overcoming that waste stream — either reducing the waste stream, reusing, recycling or replacing — that's one of the obvious focus areas healthcare is going to have to tackle."
Beyond internal sustainability initiatives, the healthcare industry as a whole must begin thinking about how the worsening effects of climate change may alter both its operations and societal role, as the industry will be on the front end of the impacts of climate change.
"Just like any other player in the value chain, healthcare is going to have to sort this out," Dr. Cort said. "They're going to have to start figuring out, 'What does it mean to be a healthcare organization in the time of exceptional heat? What does it mean to be a healthcare organization in the time of the spread of VectorBase diseases? How can a hospital look outside its own boundaries to mitigate these climate change impacts?'"
Environmental health is an essential part of improving human health and, therefore, needs to be at the forefront of planning for hospitals, Mr. Hemstreet said.
"Sustainability needs to be part of your DNA, the organization's DNA — otherwise you'll certainly be swimming upstream," he said.