The Architect’s Sustainable Approach Johathan Hoffschneider, AIA, LEED AP Perkins + Will

1. The Architect’s Sustainable ApproachJohathan Hoffschneider, AIA, LEED APPerkins + Will

2. AgendaIntroducing Perkins+Will, Economic Context, Meeting Today’s Challenge: Reform, Creating a Healing Environment, Case Study: The Patient Room, The Integrated Design Team, Questions? Agenda

3. Introducing Perkins + WillFounded in 193518 OfficesProjects in 49 states + 43 countries1600+ Staff (700 in Healthcare)Healthcare Facilities from Clinics to Academic Medical CentersRecipient: 2008 Practice Greenhealth Champion for Change Award Founders Larry Perkins and Phil Will

4. 2. Economic Context Outlook One Year Ago: Construction spending $36.8 billion by 2011 1 72% of CFOs expected hospital capital spending to increase in the next 4 years 2 58% of hospitals plan to add beds in next several years 3 Source: 1 Centers for Medicare and Medicaid Service 2 2007 Survey of Healthcare Executives 3 Nurse Executive Center CNO Survey

5. 2. Economic Context …what a difference a year makes

6. 2. Economic Context Outlook in 2008: 31% experienced a decrease in elective procedures in the past 3 months 38% reported a decrease in admissions during the same period Uncompensated care up 8% from July to September vs. same period last year. Source: AHA 2008 Hospital CEO Survey Including 736 Hospitals (November 2008):

7. 2. Economic Context What Clients are Saying: Investment balances hammered “Just lost next year’s capital budget” Growing pockets of softening/declining utilization “Elective surgery volume is down” Capital projects put on hold “We’ve canceled all projects through 2010” Capital budgets reduced to bare necessities “I hope that chiller lasts 2 more years” What Clients are Doing: Cutbacks made or considered: Administrative costs (60%) Reducing staff (53%) Reducing services (27%) Facility investments reconsidered or postponed (56%) Source: AHA 2008 Hospital CEO Survey Including 736 Hospitals (November 2008) …What are the Architects Doing?

8. POLICY 3. Meeting Today’s Challenge: Reform • Healthcare Policy • Healthcare Delivery Methods • Comparative Effectiveness Research • Four Interrelated Pillars for Reform: • Improve value through better information and tools to be more effective. • Reward improvements in quality and reductions in cost growth; provide support for health care delivery reforms that save money while emphasizing disease prevention and better coordination of care. • Reform health insurance markets and restructure government subsidies to create competition and improve incentives around value improvement rather than risk selection. • Give greater support to individual patients for improving their health and lowering overall health care costs, including incentives for achieving measurable health goals. Source: Engelberg Center for Health Care Reform “Bending the Curve: Effective Steps to Address Long-Term Health Care Spending Growth,”

9. FACILITY POLICY 3. Meeting Today’s Challenge: Reform • Healthcare Policy • Healthcare Delivery Methods • Comparative Effectiveness Research • Four Interrelated Pillars for Reform: • Improve value through better information and tools to be more effective. • Reward improvements in quality and reductions in cost growth; provide support for health care delivery reforms that save money while emphasizing disease prevention and better coordination of care. • Reform health insurance markets and restructure government subsidies to create competition and improve incentives around value improvement rather than risk selection. • Give greater support to individual patients for improving their health and lowering overall health care costs, including incentives for achieving measurable health goals. Source: Engelberg Center for Health Care Reform “Bending the Curve: Effective Steps to Address Long-Term Health Care Spending Growth,” • Facilities Modernization • Advances in Technology • Application of Sustainability and Evidence-Based Design • Facility Design Impact on Capital Strategies • Disciplined operation / strategic plan • Leading evidence-based capital design • Tangible improvements in quality and patient safety • Improved information connectivity and operational efficiency • “Hospitals that actively distinguish themselves in clinical quality and patient safety will benefit from increasing volumes and improved financial position” • “Quality and efficiency outcomes may offset any additional debt incurred to finance projects” Source: Fitch Ratings Special Healthcare report, May 22, 2007

10. POLICY FACILITY 3. Meeting Today’s Challenge: Reform • Facilities Modernization • Advances in Technology • Application of Sustainability and Evidence-Based Design • Healthcare Policy • Healthcare Delivery Methods • Comparative Effectiveness Research • Facility Design Impact on Capital Strategies • Disciplined operation / strategic plan • Leading evidence-based capital design • Tangible improvements in quality and patient safety • Improved information connectivity and operational efficiency • “Hospitals that actively distinguish themselves in clinical quality and patient safety will benefit from increasing volumes and improved financial position” • “Quality and efficiency outcomes may offset any additional debt incurred to finance projects” • Four Interrelated Pillars for Reform: • Improve value through better information and tools to be more effective. • Reward improvements in quality and reductions in cost growth; provide support for health care delivery reforms that save money while emphasizing disease prevention and better coordination of care. • Reform health insurance markets and restructure government subsidies to create competition and improve incentives around value improvement rather than risk selection. • Give greater support to individual patients for improving their health and lowering overall health care costs, including incentives for achieving measurable health goals. A Healing Environment

11. 4. Creating a Healing Environment Sustainable and Evidence-Based Design “…the built environment has a profound impact on health, productivity and our natural environment…” • References LEED & GGHC • Top Reasons for Green Hospitals: • 58% Enhanced Staff and Patient Health and Well-being • 46% Operational Cost Savings • 41% Increased Building Function Efficiency • 18% Being Part of the Healthcare Sector that Values the Environment • 9% Public Relations Benefits of Being a Green Leader Source: McGraw-Hill Construction Research & Analytics 2007

12. Sustainable and Evidence-Based Design 4. Creating a Healing Environment Framework for Evaluating Sustainable Design Options High-Cost, with Potential Downstream Savings “Lower on the Priority List” “Worth Strong Consideration” • Biomass-fueled cogeneration plant • Rainwater storage cisterns • Photovoltaic arrays • Charging stations for hybrid vehicles • High proportion of outdoor air ventilation2 • Operating rooms with direct line of sight to vision glazing3 • Daylit prep/recovery units • Vegetated rooftops Financial Impact “Assess Relative Environmental Impact” “Low-Hanging Fruit” • Waterless/low-flow urinals1 • High ratio of open space • Native, drought-tolerant plants • Locally manufactured construction materials • Low-VOC paint • Non-vinyl backed carpeting • Low-emitting adhesives and sealants • Bicycle storage and changing facilities No/Minimal Cost Premium Direct Impact No/Minimal Direct Impact Impact On Patient and Staff Health Source: Advisory Board/ Innovations Center interviews and analysis. 1 Used in public restrooms. 2 Feasibility of increasing outdoor air dependent on infection control regulations. 3 Vision glazing refers to windows (or portion of windows) connecting to the outdoors.

13. 5. Case Study: The Patient Room Applying Sustainable and Evidence-Based Design • Patient Environment: • Reduce Patient Falls • Provide Access to Daylight & Views • Improve Indoor Air Quality • Consider Ergonomics/ Accessibility • Reduce Infection Risk • Reduce Noise • Staff Environment: • Reduce Staff Lifting Injuries • Facilitate Hand Cleaning • Increase Patient Visibility • Reduce Travel Distances • Provide Appropriate Lighting • Provide Easy Access to Information • Create Restorative Spaces

14. 5. Case Study: The Patient Room Patient Room Design • Decentralized Nurse Work Area • Improved Patient Visibility • Bacteria-Resistant Surfaces • Easy Access to Handwashing • Non-Slip Floor Finish • Improved Indoor Air Quality • Patient Bathroom on Headwall • Room to Room Sound Isolation • Handrails from Bed to Toilet • Two-Way, Hands-Free Communication • Bedside Controls • Single-Bed Patient Rooms • Positive Distractions (Art, Views) • Family Participation • Patient/Family Access to Health Information • Increase Direct Daylighting Source: Multiple References, Summarized in RING Paper: Hospital Safety by Mardelle McCuskey Shepley/ Texas A&M/ ART+Science August, 2008 A B C D E F G H I J K L M N O P

15. 5. Case Study: The Patient Room Patient Unit Design • Staff Restorative Space • Separation of Clean and Soiled • Auto-Dispensing of Medications • Unit Layout to Reduce Staff Travel • Ergonometric Work Areas • Decentralized Patient Supplies • Standard Room Design • Oversized Patient and Toilet Room Doors • Improved Wayfinding Q R S T U V W X Y Source: Multiple References, Summarized in RING Paper: Hospital Safety by Mardelle McCuskey Shepley/ Texas A&M/ ART+Science August, 2008

16. 5. Case Study: The Patient Room Analysis of Evidence Based Design Strategies: Cost vs. Effectiveness Source: Patient Safety Design Integration Study: St. Cloud Hospital East Addition - April 2009

17. Analysis of Evidence Based Design Strategies: Cost vs. Effectiveness 5. Case Study: The Patient Room V S R U W Y T K Q Source: Patient Safety Design Integration Study: St. Cloud Hospital East Addition - April 2009 L P A C B H N D X J G M F I E O

18. 6. The Integrated Design Team New Photo MDs Nursing/ Support Facilities Design Team Design Team Design Team CLIENT Admini- strators Patients Design Team Design Team Design Team Design Team Design Team Vendors/ Suppliers Families/ Public Industry