by Greg Murphy

**** With soaring energy prices worldwide, expanding international conflicts, and a protracted global pandemic recovery, the importance of energy efficiency—especially in industries known for producing waste at higher rates—is higher than ever before. The healthcare industry, and thus healthcare-related construction, is one of the highest producers of waste and energy consumption in the United States.

The value of healthcare facilities was highlighted during the height of the pandemic, with many major cities across the country overrun with sick patients. One of the hardest-hit cities was New York. With one of the highest concentrations of healthcare facilities, New York City has 61 hospitals in its metro area. An average healthcare facility produces 5 million tons of waste annually, so it is essential that the industry strive to become more energy-efficient and reduce its carbon footprint. Along with the healthcare industry, the construction industry also plays a significant role in waste production, averaging 13,500 tons of waste per day.

As the world evaluates remaining resource deposits, the need for more sustainable construction and maintenance of healthcare facilities is greater now than ever. These industries together must take several vital steps to get the level of sustainability needed to reduce waste and energy consumption. The first step is to identify the challenges in constructing a Leadership in Energy and Environmental Design (LEED)-certified healthcare facility. Evaluating current healthcare facilities that have achieved LEED status and the differences between them will shed light on which practices work best. Reviewing the current LEED certification process and checklists for healthcare facilities will also assist in creating a process that not only ensures the buildings are energy efficient but also is specifically curated to address the complex demands of building a multifaceted structure.

The importance of infrastructure such as hospitals has been highlighted over the past two years during the global pandemic. New York City, among the world’s most densely populated urban areas, has one of the highest concentrations of healthcare facilities and was one of the hardest-hit with COVID-19-infected patients. Without these pieces of critical infrastructure, the pandemic could have been exponentially worse. Addressing the reduction of the consumption of natural resources and fossil fuels has become an increasingly important global endeavor. Many industries have adjusted their priorities over the past several years, conducting day-to-day business virtually and thus reducing their carbon footprint. Yet the healthcare industry, despite its centrality in fighting COVID, has been unable to shift its sustainability measures in a similar way. Striking a balance between constructing and maintaining healthcare facilities that both are sustainable and provide the same top-quality care is the most formidable challenge that the industry faces to date.

Related Work  Maryam Golbazi and Can B. Aktas identified in their study, “LEED Certification and Patient Wellbeing in Green Healthcare Facilities” (2022), “Healthcare facilities have strict and intensive criteria due to the sensitivity of operations and vulnerability of occupants. Healthcare facilities are distinctly different from other types of buildings and require day-round operations, have intensive energy and water use (CBECS, 2012), have specific infection control requirements (Sehultzer et al., 2003), and a heightened need for patient privacy” (Golbazi and Aktas, p. 3). Determining if the LEED certification criteria are the most appropriate for buildings with such demands will indicate whether requiring healthcare facilities follow such regulations will even produce more sustainable and quality patient care. There are numerous challenges that a healthcare facility faces that other building types do not. Greg L. Roberts, the author of “Shades of Green: The Evolution of Hospital Sustainable Design Standards” (2011), listed a number of requirements that healthcare facilities must adhere to in order to maintain the proper environment for patient care. These include system redundancies, regulatory compliance, operational hours, infection control, ventilation rates, and intense energy and water use. In New York City, several large healthcare providers have constructed new buildings utilizing the LEED certification process to achieve a more sustainable facility. New York Presbyterian Hospital, New York University Langone Medical Center, and Gotham Health are some of the city’s largest healthcare facilities, and all of these have their own processes of reducing their carbon footprints. While these hospitals and organizations have been successful in achieving the highest possible sustainability ratings, considerations remain, such as cost and the length of time before an institution sees a return on its energy savings before endeavoring in a new project. Taking a quantitative approach, we hope to review and assess the current LEED requirements for a healthcare facility, healthcare facilities in New York City and their LEED status, and whether the costs for a LEED-certified facility are feasible for these types of institutions.

A healthcare facility’s primary goal is to provide an environment where patients can receive care and promote healing. LEED’s goal is to promote green building through a framework of various criteria to reduce energy consumption. These two competing priorities contradict each other and make achieving both high LEED certifications and high patient care difficult. Golbazi and Aktas noted in their study, “Green buildings have gained public support due to the benefits they provide to the environment, society, as well as economic gains during the construction and operation of the building. Hospitals and healthcare facilities deal with sensitive populations: the sick and the vulnerable” (Golbazi and Aktas, p. 2). They continue, “Beyond their environmental, societal, and direct economic benefits, green buildings also appeal to institutions due to their other indirect benefits such as improved public image, environmental stewardship, or in some cases simply as a marketing tool. Therefore, hospitals may become certified green buildings, but that may not necessarily indicate an ideal healthcare environment from a patient wellbeing point of view” (Golbazi and Aktas, p. 4). Striking a balance between green building and quality patient care is important not only for the facility but for the environment as well.

New York City has the largest concentration of healthcare facilities in the world. As the population grows, so does the demand on critical infrastructure, such as healthcare facilities, as well as the strain on natural resources and energy consumption. With more research pointing to the negative impacts of fossil fuel usage, reducing the amount of energy consumed and water used has become an increasing priority, especially in the healthcare industry. Hospitals in general consume more energy and water than any other facility, which makes the LEED certification process unique. Privately and publicly run hospitals have different approaches to tackling this challenge.

Kristen Ashourian and Scott Young, the authors of “Greening Healthcare: The Current State of Sustainability in Manhattan’s Hospitals” (2016), summarized the major categories that LEED requires to become certified: “The topics that LEED-HC require are: water efficiency, energy and atmosphere, materials and resources, indoor environmental quality, innovation in design, and regional priority. Adhering to the requirements set forth in these categories earns healthcare facilities LEED acknowledgements, but it also improves environmental health and the subsequent health of surrounding populations” (Ashourian and Young, p. 74). Sustainability, reduction of energy consumption, and patient care represent a balancing act that all healthcare facilities must juggle.

In New York City, there are both public and privately run healthcare facilities, each with their own ideas, approaches to greener practices, and funding sources. New York University Langone Health, a privately run healthcare facility, has had major success in their reduction of energy and water consumption. NYU states that, “NYU Langone is a proud participant in the New York City Carbon Challenge and has committed to a 50% carbon reduction goal by 2025. Since 2005, we have achieved a 36% reduction in carbon emissions for our fully owned portfolio and major sites, and are on track to meet our goal of 50%” (NYU Health, p. 1). New York Presbyterian, a not-for-profit hospital, has had similar success to NYU Langone Health, in they have been able to greatly reduce their carbon output. New York Presbyterian stated, “As part of the ENERGY STAR program, the Hospital pledged to reduce more than 3.5 million pounds of greenhouse gas emissions for 2009 and exceeded this amount by 185% — among the four greatest reductions for a non-profit organization in the nation, according to the EPA” (New York Presbyterian, p.1).  When institutions review how to approach constructing a new facility or manage their operations, one of the first questions that is asked is how can we make our day-to-day more efficient. The LEED certification process and criteria are designed to enhance efficiency in order to reduce energy consumption. Healthcare facilities pose a unique challenge, due to certain criteria needed to maintain proper care of patients. The challenge is whether or not the cost for LEED-certified processes is worth it in comparison to non-LEED-certified facilities. Hassam Sadatsafavi and Mardelle M. Shepley, the authors of a study on green hospitals, “Performance Evaluation of 32 LEED Hospitals on Operation Costs” (2016), reviewed numerous facilities across the country and their energy efficiency. They found, “Finally, in one of the few healthcare studies, Matthiessen et al. [19] compared nine LEED-certified ambulatory care hospitals with eight non-LEED ambulatory care projects and found that LEED facilities do not cluster in the upper range of cost per square foot when compared with non-green facilities” (Sadatsafavi and Shepley, p. 1235).

Research Objective  Reduction of water consumption, lowered greenhouse gas emissions, and overall improved sustainability in most buildings and construction have made leaps and bounds in improving energy efficiency. The healthcare industry, due to many of its patient care requirements, does not have the same ability to reduce its resource consumption. A healthcare facility consumes twice as much energy as a similarly sized office building; healthcare facilities in Europe produce 5% of the continent’s carbon dioxide emissions.

Not only do healthcare facilities produce a lot of waste, but some of that waste is also extremely toxic and infectious. Pandemic-era surges have highlighted the importance of healthcare infrastructures, especially in some of the hardest hit cities, like New York. Simultaneously, as gas prices surge, green energy and the reduction of fossil fuel consumption come to the forefront of people’s attention. There are some healthcare facilities already reviewing their energy consumption and considering how to reduce their consumption of natural resources. If we can identify key characteristics, processes, and concepts from already LEED-certified healthcare facilities, then the industry will be able to establish a standard of sustainable construction and maintenance of such facilities within the city of New York.

Many of the already established facilities, in particular facilities in New York City, with LEED certifications utilize the same set of standard requirements, established by the U.S. Green Building Council, which dictate what is considered to be a sustainable facility. From these standards, we will be able to understand which requirements are most difficult for healthcare facilities to achieve. Specifically, we will review the difference between the private and public healthcare facilities and their abilities to become more energy efficient. In many instances, especially in New York City, there are existing healthcare facilities built decades prior with materials and techniques that today are considered to be not sustainable. Overall, this research will allow current healthcare facilities to better understand how to become more sustainable. We will identify which criteria are difficult to achieve and which facilities have the best techniques and procedures to achieve sustainability. Finally, we will explore how to improve existing facilities in terms of sustainability.

Research Methodology  In this study we will be utilizing a quantitative research methodology to collect statistics and information on healthcare facilities in New York City. From this collection of data, we will be able to determine key characteristics, processes, and concepts from LEED-certified healthcare facilities with the goal of establishing an industry standard of sustainable construction and maintenance of such facilities within the city of New York. Our quantitative research will encompass data on relatively new facilities as well as existing current operational performances to determine whether the LEED requirements for healthcare facilities are appropriate and attainable. The data will derive from current open sources of information such as the LEED requirements for healthcare facilities, the processes and procedures major healthcare facilities in New York City practice in order to achieve LEED certification, and a comparison of each major facility to the other.

In order to maintain consistency with the data collected, we will utilize the LEED requirement system in order to have the same type of data collection system. We will compare New York Presbyterian Hospital, New York University Langone Medical Center, and Gotham Health in their abilities to become LEED certified, which requirements were difficult to achieve, which requirements were achieved, and how they went about achieving what they did. Some of the limitations that will arise are the publicly available information from the major hospitals with regard to their sustainability as well as the determination of which of the specific LEED criteria have been met.

With natural resources quickly becoming less abundant, the world has shifted its policies and priorities toward building with sustainability. In the United States and more specifically in New York City, organizations and individuals who are constructing a new building, or updating an existing one, will typically use U.S. Green Building Council LEED certification criteria to achieve the highest level of sustainability. The U.S. Green Building Council created a system of qualification and certification in order to achieve LEED certification, “A project earns points by adhering to prerequisites and credits that address carbon, energy, water, waste, transportation, materials, health and indoor environmental quality” (USGBC, p. 1). The U.S. Green Building Council continues to explain the rating system, “Projects go through a verification and review process by GBCI and are awarded points that correspond to a level of LEED certification: Certified (40-49 points), Silver (50-59 points), Gold (60-79 points), and Platinum (80+ points)”  (USGBC, p. 1). These are the criteria healthcare facilities must meet in order to achieve these ratings.

The LEED system only applies to specific projects or sections of facilities and not an all-encompassing view. This current system of evaluation does not mandate a facility to include any and all existing structures that might be connected to or tie in new pieces of infrastructure to existing. New York City healthcare facilities are a prime example of the shortcomings of an evaluation system when constructing new buildings associated with and connected to existing structures. In this study, we will only evaluate organizations that constructed new facilities utilizing the LEED New Construction 2009 Second Edition criteria, focusing on water efficiency, energy and atmosphere, and material and resources. These three out of eight total categories represent healthcare facilities’ largest negative environmental impacts.

Data Analysis

Water Efficiency  Healthcare facilities consume an enormous amount of water, all of which is not completely contributed to patient care. Jennifer Silvis, in “Hospitals Can Tap Into Savings Through Water Conservation” (2015), stated, “U.S. hospitals are water hogs, using an average of 570 gallons of water per staffed bed, per day. To put this figure into perspective, consider that the average American citizen uses around 150 gallons of water per day; the average Briton, 44 gallons; the average African, just 5 gallons” (Silvis, p. 1). The U.S. Green Building Council has recognized this and created a category dedicated to conserving water. Utilizing the U.S. Green Building Council’s new healthcare construction criteria of 2009, New York University Langone Medical, New York Presbyterian Hospital, and Gotham Health have all built new healthcare facilities. Each facility utilizes the same criteria, and each facility was funded by a different type of funded organization.  NYU Langone Medical Center built the new Helen L. and Martin S. Kimmel Pavilion and was awarded the platinum level certification for sustainability in 2019. Despite being awarded the highest level of certification, NYU Langone Medical Center only achieved a 6 out of 10 in the water efficiency category. Looking more closely at the section, they only were able to achieve a 2 out of 4 for the WEc3 water use reduction section and a 0 out of 2 in the WEc2 innovative wastewater technologies. The requirements for the WEc3 category are as follows, “Employ strategies that in aggregate use less water than the water use baseline calculated for the building (not including irrigation) after meeting the Energy Policy Act of 1992 fixture performance requirements (or as modified to the 2006 UPC and IPC in LEED 2009). Calculations are based on estimated occupant usage and shall include only the following fixtures (as applicable to the building): water closets, urinals, lavatory faucets, showers and kitchen sinks (with prerinse spray valves also included in LEED 2009)” (Haselbach, p. 124).

Utilizing the same standards as NYU Langone Medical, New York Presbyterian constructed the David H. Koch Center. The David H. Koch Center was awarded a gold certification for sustainability in 2019. New York Presbyterian was awarded a 6 out of 9 in the water efficiency category. Specifically, New York Presbyterian received a 1 out of 3 for the WEc3 water use reduction and a zero out of one for the WEc4.2 water use reduction for cooling towers. The LEED requirements for the WEc4.2 section demand facilities “develop and implement a water management plan for the cooling tower or evaporative condenser that addresses chemical treatment, bleed-off, biological control and staff training as it relates to cooling tower maintenance. Improve water efficiency by installing and/or maintaining a conductivity meter and automatic controls to adjust the bleed rate and maintain proper concentration at all times” (USGBC, p. 1).

New York Health and Hospital followed suit and utilized the same criteria as the other organizations when they constructed Gotham Health. Gotham Health received a silver award for sustainability in 2021 and only achieved a 4 out of 10 for water efficiency. They scored a 0 out of 4 for the WEc3 water use reduction category as well as a 0 out of 2 for WEc2 innovative wastewater technologies.

Looking more closely at these data, we take the average of gallons of water used per hospital bed and multiply each facility by the number beds it has. Then to find the total percentage of inefficiency, we divide the credits earned to the total credits and subtract from 100. The 350 gallons of water per day per bed is from a U.S. Department of Energy study in 2011. New York University Langone Medical Center Kimmel Pavilion has 374 total beds for a total of 130,900 gallons per day. NYU earned 6 out of 10 total credits, which is a total of 40% inefficiency and is a total of 52,360 excess gallons of water per day. New York Presbyterian David H. Koch Center has a total of 135 beds for a total of 47,250 gallons per day. NY Presbyterian earned 6 out of 9 credits, which is a total of 36% inefficiency and is a total of 16,065 excess gallons of water per day. Gotham Health has a total of 295 beds for a total of 103,250 gallons per day. Gotham only earned 4 out of 10 total credits, which is a total of 60% inefficiency and is a total of 61,950 excess gallons of water per day. See Figure 1 for a comparison.