By: Dale A. Anderson

Healthcare facilities have trends that also may be observed in other facilities, including sustainability, evidence-based design, and lean construction. The question is how these are applied and combined -- which may be unique to the healthcare world.


This topic has been thoroughly reviewed in thousands of discussions and articles across the media over the past 10+ years that it has truly been in the limelight. The concepts range from optimal site utilization, through energy efficiencies, material resource management, to operational issues and facility maintenance -- many of these seemingly very obvious. That hasn't made it any easier for the healthcare world to adopt the concepts and strategies that are available.

Recent studies have identified hospitals as the second most energy-intensive sector in the U.S., behind only the fast food industry. Statistics show hospitals spend nearly $8.5 billion per year on energy, consume twice the energy per square foot compared to traditional office space, and produce more than 30 pounds of CO2 per square foot. The good news is that hospital managers are starting to realize that they can reverse this trend.

Over the past year many articles in healthcare journals have highlighted case studies of organizations that have made the swing to sustainability once they understand the benefits of the business case it offers. Partnering with the U.S. Dept. of Energy's 'EngerySmart Hospitals' initiative has created an opportunity for the increased use of energy efficient technologies across the 8,000 hospitals in the U.S. Efficiency levels targeted include 20% improvements for existing facilities and 30% improvements for new construction. Much of this success can be attributed to the use of newer, more energy efficient HVAC systems and controls, plus implementation of commissioning services to finely tune the operation of these systems. Increased costs to implement these systems typically have a payback of five to eight years, depending on utility incentives and projected increased annual energy costs. Other concepts being adopted include increased use of daylighting, which has multiple benefits, and healthier construction materials for occupied spaces.

Most organizations are now realizing to achieve the highest levels of results with these strategies requires hiring Sustainability or Resource Conservation Managers for their campuses. Another process to minimize the pain of adoption is through Energy Service Contracts (ESCO) with organization that help analyze existing building conditions, look for opportunities for improved system efficiencies, and, in most cases, provide the funding for the building modifications required (revenue is generated through operational savings).

For the truly committed organization, there is always the option of third party certification by either the Green Guide for Health Care or upcoming LEED for Healthcare.


Having somewhat paralleled the development of sustainability in the built environment, the practices of this trend are regularly explored in various healthcare journals as well. These are concepts that promote facility design based on actual research and evidence of betterment to patients, staff and visitors. This trend has its own set of major challenges applied to healthcare design, although they are not the only challenges existing. The basic philosophy is that Evidence-Based Design can influence these challenges by paying attention to medical error impacts, functions of caregivers and other staff members, physical facility designs related to equipment and functional processes, and maximizing design response to the natural environment.

The application process starts with a thorough understanding of the needs of a facility and its function. Research is conducted to find documented evidence of similar situations and the responses that were presented, plus results achieved. Once analyzed the operations and design team is able to identify those key components that made the the responses both a success and a failure. Adopting the positive results, looking for similarities, and developing improvements allows the new facility design to take shape with the hopes of their own successes. The final step is documenting the results of the new facility once in operation and testing the theories that were used. This is done so others may learn from the results achieved, successful or not, and provide for the next betterment thought process.

From steps such as using single patient rooms, better sanitization of staff, medical record computers at the bedside, and standardization of room design for flexibility, healthcare facilities are improving the well-being of the patient. These types of features are also resulting in nurse providers who actually have more time to care for their patients -- the main reason they got into healthcare to begin with.

The difficulty in applying this type of process relates to two main hurdles -- time and money. To conduct the type of research and set up test theories for a new facility design can force the project to take substantially longer to design and build, and require additional capital funds to make happen. In today's economy time nearly always equals cost and any delay has a compounded cost increase, let alone from the additional efforts to go through these steps.

Again, for the truly committed project team, guidelines are available and case studies illustrate how to follow just such a process.


This trend is probably the newest kid on the block, at least compared to the others, as it has now been applied to the design and construction industry. Most folks in the design and construction world will have heard something about lean, but they may not realize where it came from, what it's all about, and how the applications go far beyond the built environment.

Generally speaking, the Toyota Production System is credited with the development of lean methods after World War II. The system was actually a new form of assembly line streamlining for fabrication and assembly of their automobiles. The term "lean" came from the pursuit of perfection by Toyota engineers. They defined perfection as the elimination of waste. The goal of Toyota's production plant was to deliver a car meeting the customer's exact specifications through mass production, while eliminating any remaining parts inventory. Parts would be delivered exactly when required to match the progress of the assembly line effort (i.e. a just-in-time delivery process).

As the concept continued to evolve and was adopted into the construction industry it took on a slightly different focus -- an integrated approach to decision-making early in the overall development process and full sequencing of design and construction activities to match the project schedule need for results (still a just-in-time response). Lean construction can be considered as a different delivery method for buildings by four distinct differences from conventional delivery: decentralized decision-making, controlled processes, management for throughput and not speed, and improvements to reliability. As with both sustainability and evidence-based design the comment might be heard that this process is simply "common sense". If that were the case for all of these, they would have been applied across the board many years ago -- yet, all of these still have their adoption challenges. What most designers, including healthcare, may not realize, is that lean has taken the medical world by storm in another direction as well -- through the day-to-day operations of newer healthcare facilities and the resulting changes in facility design.

Lean healthcare is developing in response to the critical conditions being found in many patient facilities. Hospital organizations are struggling with cost increases, poor quality of patient care, staff shortages, and general employee unrest. The combination of these results would indicate problems are deeper than possibly realized by management. Lean healthcare studies are finding ways to improve patient delivery through a detailed review of what current conditions are and how they might be modified. One example of such studies is called a "spaghetti diagram" that maps the walking paths of nurses as they provide their daily routine of patient care. Not surprising, the studies found nurses walking many miles during the day, most of which had little to do directly with patient care. By looking at alternative layouts to the floor plan shorter routes can be identified and more time dedicated to being in the patient rooms themselves.

This same process has been applied to nearly every aspect of hospital operations and patient delivery. Results are beginning to be published in healthcare journals noting improvements to operations and reductions in patient errors. Examples of improvements noted include better access to supplies and linens for patient rooms, elimination of surfaces promoting infections, just-in-time distribution of medications and supplies to patient floors, decentralized nurse stations, common acuity patient rooms, and other changes. There is little doubt that the concepts are working and proving themselves when applied -- it simply remains to be seen how quickly the concepts will be adopted throughout the system (sound familiar to the challenges of the other trends?).


While the above trends clearly have their own benefits in various ways, what is it about them that make implementing all of them desirable? In the end it's all about the business case for adopting these trends. Let's face it, healthcare organizations have to be in business and make money or they have to close their doors. Several of the trends and approaches certainly provide the justification for the facility results in a financial manner. It also just happens that a major side effect (what's a healthcare condition without side effects?) of these trends are a better environment for the building occupants, especially the patient world. What hospitals have found, amazingly is that patients who recover quicker are healthier, and allow for a target patient load to be accommodated -- this all translates into more revenue, and , and, the justification based on the business case.


1. "Healthcare: A Business and Ethical Case for Sustainability". BetterBricks, an initiative of the Northwest Energy Efficiency Alliance (NEEA), 2010

2. "Targeting 100!", University of Washington's Integrated Design Lab and BetterBricks, 2010

3. "An Introduction to Evidence-Based Design", The Center for Health Design, 2008

4. "What is Lean Construction", Lean Construction Institute, 1999

5. Healthcare Design Magazine 08.10, Vendome Group LLC