A Systems Approach for High Performance Hospitals Harvard Extension School April 18, 2007

1. A Systems Approach for High Performance HospitalsHarvard Extension School April 18, 2007 John F. McCarthy, Sc.D., C.I.H. Environmental Health & Engineering Newton, MA

2. Hospitals are: • Complex • Mission driven • Technically sophisticated • Mechanically intensive

3. Environmental Impactsof Hospitals Energy Consumption kBTU / ft2

4. Hospital Mission • Excellence in clinical practice • Evolving practice • Efficiency • Environment of care Supported by infrastructure

5. Implementing Sustainable Principles • Vision • Process • Commitment • Execution

6. Multiple Constituencies Patients Clinical Staff Operational Staff Facility Global Community Regulators Local Community

7. FINANCE DESIGN ROUTINE O&M NON ROUTINE O&M CONSTRUCTION 100 Green Strategies 87 8.0 80 78 Cumulative Cost(%) 60 Relative Cost ($) 40 2.7 1.5 1.5 1.8 1.8 20 1.0 1.1 1.1 0.9 3 2 1 0.8 0.8 0.8 Distribution of Life Cycle Costs

8. Building Phases Cost & Schedule Performance Design Phase Construction Phase Operation Phase

9. Green Guide for Health Care (GGHC) Integrated Design Integrated Operations

10. How do we ensure a connection to health mission in the design process? How do we optimize the design process to consider the facility’s operations? What protocols are necessary to maintain healthy building operations?

11. LEED vs. GGHC Project Phases DESIGN CONSTRUCTION OPERATIONS LEED Sustainable Sites Water Efficiency Energy & Atmosphere Materials & Resources Indoor Environmental Quality Innovation in Design • GGHC - CONSTRUCTION • Integrated Design • Sustainable Sites • Water Efficiency • Energy & Atmosphere • Materials & Resources • Indoor Environmental Quality • Innovation in Design GGHC – OPERATIONS Integrated Operations Transportation Operations Energy Efficiency Water Conservation Chemical Management Waste Management Environmental Services Environmental Preferable Purchasing Innovation in Operations

12. Alignment Strategy Processes Stakeholders Design / Operations Team

13. Systems Thinking The relationship between parts becomes as important as the parts themselves. Integrated design is one component –integrated business is key.

14. Why LEED for BWH-70F ? Drivers for Change Constituencies Patients • Committed Leadership • Clinical Excellence • Commitment to People • Life Cycle Costing • Process Improvements through Sustainable Design • Community Influence Clinical Staff Operations Staff Local Community Global Community

15. What Are Your Goals? Tie them into opportunities to solve problems • High performance • Standard budget • Energy savings • % > ASHRAE • Water use • Reuse water, e.g., reverse osmosis (RO) • 100% capture and reuse of rainwater falling on building

16. Targets for Improvement Constituencies • Improved Health Outcomes • Level of Care • Higher Satisfaction • Greater Productivity • Improved Sensory Environment • Reduced Lost Work Days • Improved Energy Efficiency • Compliance • Reduced Service Calls • Harmonious Design/ Operations • Good Neighbor • Code Compliance • Compliance with ASHE/LEED Programs • Exemplary Project Recognition Patients Clinical Staff Operations Staff Local Community Global Community

17. Prioritized Constituencies Key Performance Indicators • Shorter Stays • Level of Infection • Satisfaction Surveys • Staff Time with Patients • Staff Surveys • Lost Work Days • Benchmarks Against Energy Star • Energy Utilization Reviews • Service Calls • Neighborhood Relations • Regulatory Complaints • Media Coverage • LEED Certification • Public and Industry Award Recognition Patients Clinical Staff Operations Staff Local Community Global Community

18. Structured Facilitation Agree on goals For High Performance (recognize constraints) Specify design requirements ID participant roles ID Opportunities (energy efficiency, heat recovery, load mgmt, controllability, IAQ, synergies ID System Dependencies (energy, water, materials, equipment, air flow) Assess Feasibility (modeling, merits) Integrate into Design

19. Examples of System Interdependencies

20. People Patients/ Staff Interior Spaces Programming Indoor Environmental Quality Materials/ Furnishings Lighting Site Equipment Non-HVAC HVAC Water Demand Building Envelope Energy Demand

21. People Patients/ Staff Interior Spaces Programming Indoor Environmental Quality Materials/ Furnishings Lighting Site Equipment Non-HVAC HVAC Water Demand Building Envelope Energy Demand

22. Example 1: Energy Modeling and Simulation • OBJECTIVES: • Simulate the predicted overall energy use for the building • Evaluate by category (e.g., lighting, equipment, space heating and cooling, fan operation, etc.) • Quantify dominant energy use areas • Evaluate dominant areas to identify potential energy-saving opportunities

23. Contribution to Building Cooling Load by Component 100% Peak Load, 24 Hours Continuous 100% Peak Load Day, Reduced Load Night Equipment Lighting Occupants Ventilation Window Solar Window Conduction Roof Conduction Wall Conduction 0 5000 10000 15000 20000 25000 30000 35000 40000 MBTU/yr

24. Energy Modeling and Simulation Key Findings • Dominant use categories: equipment (43%) and lighting (22%) • Space cooling and fan systems are lower (~15% each) • Major contributor to cooling load is equipment, with equal contribution from lighting, occupants, and ventilation • Cooling load from solar gain through window is <5% • To save energy costs and reduce space cooling load, optimize lighting and equipment energy use (controls, dimming, etc.) • Opportunities to reduce fan system energy use and space cooling load: optimize ventilation, reduce airborne heat load

25. Example 2: Identify OpportunitiesWater Conservation Strategies • Using Amory RO reject water to flush valves, sterilizers, wall hydrants,cooling tower through a dedicated pumped distribution system in BWH-70F (Goal: Evaluate for LEED innovation credit) • Electronic faucets in public restrooms (Include) • Waterless urinals (Include) • Minimization of filter backwash (Pending) • Use of make-up water meter included for the cooling tower (Analysis required) • Low flow and/or waterless medical air and vacuum systems (Analysis required) • Equipment spec to include flow control devices on sterilizers (Approval required)

26. Design Elements • High deck to ceiling clearance • High efficiency glazing • Large window expanse • Significant concrete massing • Large equipment load

27. High efficiency (Low E) glazing Upwardly deflecting “window blinds” High room ceiling heights (~11 feet) Clerestory windows Reflect daylight deeper into the central core hallways Reduce glare inpatient rooms and radiant heat gain on patients Reduce artificial light demand (variable) Reduce electrical demand Reduce needed cooling capacity Design Elements Outcomes

28. Utilize T5/T8 lights Automatic dimming control (to compensate for changing ambient light levels) Further reduces cooling capacity and electrical demand Design Elements Outcomes

29. High ceilings allow for a low wall displacement ventilation system Improve IAQ by providing cleaner/fresher air to occupied zone Reduced cooling capacity needed (~50% of heat from lights does not reach occupants Requires less fan horsepower since less total air is needed Provides expanded use of economizer mode Less room noise (due to reduced exit velocities) Design Elements Outcomes Outcomes • Provide a more comfortable and draft free room (supply higher temperature, lower velocity air) • Individual room VAVs are not needed

30. Radiant surfaces More comfortable environment for patients and staff Permits a generally lower room air temperature (minimizes thermal loss to floor decking) Facilitates effectiveness of displacement ventilation under low occupancy Reduces operating costs by using water rather than air to thermally condition Design Elements Outcomes

31. Core Principles Guiding Mechanical System Design • Optimum health • Reduced energy use • Liability avoidance • Risk aversion

32. Anticipated LEED submittals to U.S. Green Building Council (USGBC): Design package (Aug 2006) 17 points Construction package (2008) 14 points Innovation credits 5 points Current Goal 36 points LEED- Silver range 33 – 38 points Projected BWH-70F LEED Goals

33. High Performance Design Features of BWH-70F • Community/Site: • Exemplary commuter choice program for alternative transportation and parking • Exemplary construction waste management by recycling over 90% • Exemplary neighborhood rebuilding and community development by relocation of six houses

34. High Performance Design Features of BWH-70F • Water Conservation: • Landscape irrigation needs met 100% by reclaimed water from hospital • Use of high-efficiency drip irrigation technology to minimize water wastage • Use of waterless medical equipment and CPD sterilizers with water-saving technologies

35. High Performance Design Features of BWH-70F • Indoor Environment: • Access to day lighting from over 75% of interior spaces • Use of low-emissions paints, adhesives, sealants inside building • Minimization of indoor and ambient impacts by program control and monitoring • IAQ pre-occupancy monitoring

36. High Performance Design Features of BWH-70F • Energy Conservation: • Energy savings by high-efficiency light fixtures, variable speed pumps, drives, etc.

37. 80 70 60 69 50 # Max Available 40 Points # Points 30 20 35 15 14 10 13 17 12 9 5 6 5 2 1 0 SS WE EA MR EQ ID Total Category LEED Credit Distribution by Category

38. Evidence Based Design • Relevant HVAC research • Full size mockups • Regulations and codes • Infection control issues • Curtain wall/HVAC issues • Light shelves • Understand demand

39. Aids to Success • Support hospital mission • Centralize costs • Identify true costs • Train proactively • Involve directors in training design • Develop common goals, vocabulary, and key performance indicators

40. A Systems Approach for High Performance HospitalsHarvard Extension School April 18, 2007 John F. McCarthy, Sc.D., C.I.H. Environmental Health & Engineering Newton, MA