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

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

Founders Larry Perkins and Phil Will

1. Introducing Perkins + Will

Founded 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

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

…what a difference a year makes

2. Economic Context

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):

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?

•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,”

3. Meeting Today’s Challenge: Reform

•Healthcare Policy

•Healthcare Delivery Methods

•Comparative Effectiveness Research

•Facilities Modernization

•Advances in Technology

•Application of Sustainability and Evidence-Based Design

Facility Design Impact on Capital StrategiesDisciplined operation / strategic planLeading evidence-based capital designTangible 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

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,”

3. Meeting Today’s Challenge: Reform

• Healthcare Policy

• Healthcare Delivery Methods

• Comparative Effectiveness Research

• Facilities Modernization

• Advances in Technology

• Application of Sustainability and Evidence-Based Design

Facility Design Impact on Capital StrategiesDisciplined operation / strategic planLeading evidence-based capital designTangible 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

3. Meeting Today’s Challenge: Reform

“…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-being46% Operational Cost Savings41% Increased Building Function Efficiency18% Being Part of the Healthcare Sector that Values the Environment9% Public Relations Benefits of Being a Green Leader

Source: McGraw-Hill Construction Research & Analytics 2007

4. Creating a Healing Environment Sustainable and Evidence-Based Design

Source: Advisory Board/ Innovations Center interviews and analysis.

Framework for Evaluating Sustainable Design Options

Impact On Patient and Staff Health

•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

•High proportion of outdoor air ventilation2

•Operating rooms with direct line of sight to vision glazing3

•Daylit prep/recovery units•Vegetated rooftops

Financial Impact

•Biomass-fueled cogeneration plant•Rainwater storage cisterns•Photovoltaic arrays•Charging stations for hybrid vehicles

“Lower on the Priority List”

“Worth Strong Consideration”

“Assess Relative Environmental Impact”

“Low-Hanging Fruit”

No/Minimal Direct Impact

Direct Impact

No/Minimal Cost Premium

High-Cost, with Potential

Downstream Savings

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.

4. Creating a Healing Environment 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

5. Case Study: The Patient Room Applying Sustainable and Evidence-Based Design

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

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Source: Multiple References, Summarized in RING Paper: Hospital Safety by Mardelle McCuskey

Shepley/ Texas A&M/ ART+Science August, 2008

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

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Source: Multiple References, Summarized in RING Paper: Hospital Safety by Mardelle McCuskey

Shepley/ Texas A&M/ ART+Science August, 2008

5. Case Study: The Patient Room

Source: Patient Safety Design Integration Study: St. Cloud Hospital East Addition - April 2009

5. Case Study: The Patient Room Analysis of Evidence Based Design Strategies: Cost vs. Effectiveness

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Source: Patient Safety Design Integration Study: St. Cloud Hospital East Addition - April 2009

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5. Case Study: The Patient Room Analysis of Evidence Based Design Strategies: Cost vs. Effectiveness

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MDs

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Nursing/

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Patients

Families/

Public

Industry

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6. The Integrated Design Team