healthcare development magazine | issue 6

DEVELOPMENTHEALTHCARE MAGAZINEYOUR GUIDE TO SUSTAINABLE HEALTHCARE & DESIGNIS

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Ensuring ProjectsAre Completed

On-time and On-BudgetPG 6

10 Values to Meet theTriple Bottom Line

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Healthcare’s Dual DemandsFiscal Responsibility

and Quality CarePG 13

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11 FEATURES

Sustainable Healthcare

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Energy Conservation in the Department ofDefense MHS Replacement Hospital at Ft. Riley

16By Jennifer R. DuBose, Joshua Crews and Brad A. Schaap

Kalispell Regional Medical CenterA Case Study of Energy-Saving Improvements

20By David Ray

HealthcareDevelopment

Ensuring Projects Are CompletedOn-time and On-Budget

By Henry Korn, Greg Korn and James Gillette

Healthcare’s Dual DemandsFiscal Responsibilityand Quality Care

By Cagri KanverHospital Challengesin the Millennium

38By Dr. M. Balasubramanian

10 Values to Meet theTriple Bottom Line

By Komal Kotwal

The Evolution of Waste andLinen Removal in Hospitals:The Dawn of the New Pneumatic Age

26

By Harry Pliskin

Tracking Sustainability: Metrics Critical for Higher Performing Organizations

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By Jeff Burks

Solar PanelsFrom Homes to Hospitals

31By Olivia Goodwin

Making a Bridge between Holistic Therapistsand One Billion People without Healthcare

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By Natasja Sproat

There are tens of thousands of healthcare projects waiting to be developed by healthcare providers and developers globally. The only thing delaying these projects from being started and completed is funding and

investment. Billions of dollars are needed to fund these healthcare projects and in today’s economic climate it is very difficult to get the funding. I consistently get requests for help by organizations with a development project looking for the right investors or a source of funding who simply do not know who to talk to or reach out to.

Since we have a great relationship with healthcare investors we decided to bring these two industries together this year, by creating the 1st ever International Healthcare Investment Conference, http://www.HealthcareInvestmentConference.com which will run side by side with the Healthcare Development Conference, October 26-28th, 2011 in Chicago. The purpose is to bring in healthcare investors interested in investing in healthcare and hospital projects globally and allow developers and healthcare providers to network and find the right partner for their project. I feel the addition of this healthcare investment conference will bring the one necessary ingredient that is missing to allow the healthcare development and sustainable healthcare industries to grow.

See you in Chicago in October!

Renée-Marie Stephano, EsquireEditor-in-chiefHealthcare Development [email protected]

By Renée-Marie Stephano

Healthcare Development Projects Lack Resources and Funding

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COPYRIGHT © 2011Healthcare Development Magazine.All rights reserved. Healthcare Development Magazine is published monthly. Material in this publication may not be reproduced in any way without express permission from Healthcare Development Magazine. Healthcare Development Magazine is in no way responsible for the content of our advertisers or authors.

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DEVELOPMENTHEALTHCARE MAGAZINEYOUR GUIDE TO SUSTAINABLE HEALTHCARE & DESIGN

S O C I A L N E T W O R KGLOBAL GREEN HEALTHCARE COMMUNITY

HEALTHCARESUSTAINABLE

www.HealthcareDevelopmentMagazine.com www.SustainableHealthcare.com


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Ensuring ProjectsAre Completed

On-time& On-Budget

By Henry Korn, Greg Korn and James Gillette

FEATURE

Regional and metro hospitals appear to be increasingly turning to affiliated and decentralized healthcare clinics to provide services to patients. The

affiliations can be financially beneficial to the hospital and healthcare system, as well as to the physicians and surgeons who are principally involved in launching and operating the clinics.

This article discusses effective solutions to ensuring control over the construction process. Through design/build of healthcare clinics with the added requirement of fixed price contracts for construction, the owner can be certain the project will be completed on time and on budget.

COnSTRUCTIOn

Hospital outpatient clinics are complex buildings to construct. They deliver a wide range of services and contain discrete and different functional units.

They may contain clinical laboratories, imaging and housekeeping modalities. The clinic calls for the design of highly complicated mechanical, electrical and structural systems.

There is a distinct advantage to the design/build integrated project delivery system for such clinic construction. Design build typically requires extra-diligent, minimum weekly back-and-forth sit down meetings between the architect and contractor. Design build removes what may otherwise be an adversarial context in how the design professional and construction team typically build out a facility. Design/build also requires a conscientious effort by the client facility owner or operator to participate in the design and build review process, presupposing a facilities manager directly involved in the process.

The nation’s hospitals and healthcare systems must address the effect of the passage of the federal health legislation (the Patient Protection and Affordable Care Act, Pub.L. 111-148, 124 Stat. 119 (2010)). The Act is estimated to add an additional 30 million patients to their existing healthcare facilities, translating to an immediate need for a minimum of 60 million square feet of facility construction. With the Act’s passage, it is even more imperative that the institutions insure that construction costs are controlled, and projects are completed on time and on budget.

1 Based on the authors’ recent interview of the chief operating officer of a major regional metropolitan health care system, who served as former commissioner of a state department of health, it is apparent there are distinct financial advantages to decentralization of regional and metro hospitals through affiliated clinics that benefit from construction through the design/build delivery system.2 The design/build project delivery system involves coordination of the design team (architects, engineers and landscape architects) and the construction team (general contractor or construction manager and trade subcontractors who assist them) working together from the initial response to an owner solicitation, the request for proposal, to project completion. 3 The traditional approach for construction projects consists of the appointment of a designer on one side, and the appointment of a contractor on the other side. The design-build procurement route changes the traditional sequence of work. It answers the client's wishes for a single-point of responsibility in an alleged attempt to reduce risks and overall costs. It is now commonly used in many countries and forms of contracts are widely available.

Healthcare institutions are particularly vulnerable to unanticipated cost overruns in three ways – (a) incomplete plans because of the complexity and redundancy of their MEP and life safety systems, (b) the amount of time needed to successfully

coordinate construction, and (c) end of project material and equipment substitutions that can shorten the lifespan of the facility. Use of the design/build modality insures the concerted cooperation to avoid such cost overruns.

AvOIdInG COST OvERRUnS

HealthcareDevelopmentMagazine.com 7

As a single-source provider that encompasses architectural, engineering and construction services, the design/build team can provide a facility for a fixed sum. The consolidation of responsibility eliminates contractor claims of alleged errors and omissions by the design team. Change orders are limited to owner-initiated changes from the initial design, or unforeseen site conditions. To eliminate the traditional checks and balances that otherwise separate A/E exercises over the contractor, carefully drawn contracts with the single source provider are required.

Through design/ build, bids will come from the construction team, and work will follow, based on 100% complete Construction Documents. Through a coordinated effort with the owner and design professionals, the contractor will represent, prior to commencing construction, that the Construction Documents are in fact complete. To the extent the contractor identifies certain risks in the construction process; those risks will be allocated a certain value and bargained for up-front in the fixed price. In this structure, the contractor and owner are assured of a fixed-price for the completion of the project, only to be increased by scope changes at the election of the owner.

Through design/build, the client saves money. This translates to lower overall construction costs, but involves considerably more work on the part of the design team and contractor to coordinate early in the design phase and regularly through construction. The client medical facility will see considerably lower overall construction costs when the architect and contractor work all the details out in the design and drawing phase of the project. The savings may be as much as 30% on medical facility projects.

To mitigate construction cost overruns, healthcare institutions would benefit by taking the necessary time to fully define the project by entering into agreements with all team members—architects, engineers and the construction members —for fixed prices that would only be permitted to rise if the owner modifies the scope. This means requiring the design team to prepare bid documents that are fully detailed, complete in all respects with each discipline. Similarly, construction managers need the opportunity to thoroughly review construction documents and field conditions to identify errors and omissions during the bid process. If conflicts or errors are found, the design team should correct them. Only then will contractors be ready to provide true, fixed-price proposals.

In today’s economy, owners and lenders can no longer accept the risk that comes with funding projects that are destined to soar over budget. No standard AIA or AGC industry contract provides a strategy that allows owners and their lenders to reduce their risk on multi-million dollar loans by providing the certainty that construction loans will cover all completion and contingency costs on capital projects. The current economic environment, and particularly given the strict limitations lenders place on credit availability to finance such projects, design/build works best when the contracts with the construction team are based on (a) fixed prices, (b) clear terms that the construction team have reviewed all the plans and drawings of the design team and confirm that they are able to build the project based on the plans and drawings, and (c) clear agreement that proscribes the narrow instances when change orders will be approved.

At the end of the day the strategy for healthcare systems is a project based on securing 100 percent complete project designs—which demands that contractors bid a fair price with fair profits. Owners will be provided with control of the their projects through the use of powerful contract tools that provide strong assurances that projects will be completed for a true fixed price without unwarranted cost overruns.

HealthcareDevelopmentMagazine.com8

Greg Korn, AIA, Leed Accredited, and Henry H. Korn, Esq., collaborated together on this article with the assistance of James Gillette. Greg Korn is a licensed architect with offices in Los Angeles and New York City whose practice includes design and build out of medical clinics. James Gillette has almost three decades professional experience in design, development, technical management and construction administration for hospitals, medical centers, large-scale additions, medical offices and outpatient clinics, O.R. and E.R. additions, surgery suites, biology laboratories and central plants. Henry Korn is one of the senior partners of LePatner & Associates LLP, headquartered in New York City. LePatner is a nationally recognized law firm that represents owners undertaking sophisticated construction projects. Henry Korn, with nearly four decades experience in construction law and other disciplines, heads the LePatner practice group involved in representing health care systems involved in construction.

ABOUT THE AUTHORS

Greg Korn Henry Korn James Gillette


FEATURE

What does incorporating Sustainable Design in a project mean to you?

This is an important first question to ask before engaging in the sustainable design process. While the usual responses are energy savings or recycling programs, they are but part of a holistic approach to sustainable design rooted in the fundamentals of a triple bottom line that includes economic, environmental, and social benefits. Today, the healthcare sector, which has traditionally been slow to embrace many aspects of sustainability, is uniquely positioned to drive the green movement towards the recognition of the interdependence between a healthful environment and the individual wellbeing. To spur the acceptance of this concept and encourage development of environmentally respectful architecture, which is restorative to human health and economically viable, architects and designers are developing sustainability models to educate the design team and users, to guide decision making, and to accelerate the achievement of holistic healthcare.

Values to Meet theTriple Bottom Line

By Komal Kotwal

10


Project Approach to Sustainability

While there are any number of green building products and technologies available in the market that offer sustainable solutions to design problems, and rating systems

that provide good tracking and certification tools, what project teams and clients are looking for comes down to two critical questions:

A set of guiding principles that facilitate the integration and monitoring of sustainability. The framework, which seeks to balance the triple bottom line goals, is comprised of ten synergistic values:

1. How do we incorporate sustainability as a best practice in each of our projects?

2. How do we achieve sustainably designed facilities and green operations that are more than the sum of add-on green technology and products?

10 VALueS

SITe

BIOPHILIC DeSIGN

WATeR

SOCIAL SATISFACTION

eNeRGY - CARBON

ADOPTABILITY - LONGeVITY

MATeRIALS

HeALTHY eNVIRONMeNT

ReSPONSe TO LOCALITY

FINANCIAL SuCeSS

1. SITE: Sustainable site practices begin with choosing the right location and densities, sound master planning practices, designs that nurture eco-systems and minimize construction impact.

2. ENERGY: Healthcare projects inherently require higher energy consumption increasing the need for efficient and high-performing design solutions that consider optimum massing, form, orientation, efficient building envelope and an integrated systems approach.

3. WATER: Implementing strategies directed towards reduce or reuse/recycle water in buildings and the surrounding landscape help to save this vital natural resource.

4. MATERIAL: Material choices impact not only the environment but also human health and activity and waste reduction.

5. RESPONSE TO LOCALITY: Solutions that respond to climate, context, culture and ecology of a region are a means to advance practice of sustainable living.

6. BIOPHILIC DESIGN: Designs that provide a connection to nature and the outdoors have proven to facilitate healing, enhance productivity and answer the human instinct to be biologically inclined towards nature.

7. SOCIAL SATISfACTION: Conducting pre-design and post-occupancy surveys and verifying a client's sustainability goals from project start up are means to ensure social satisfaction. further, the data collected helps pave the way for future projects extending the practice of evidence based design to realm of sustainability.


8. HEALTHY ENvIRONMENTS: Designing for elevated indoor environmental quality encourages physical activity. fosters healing, productivity and improves the livelihood of the people who interact and inhabit the building.

9. fINANCIAL SUCCESS: Designing with a life-cycle approach, an understanding of operational savings and verified performance, when combined with financial gains for enhanced productivity and patient satisfaction help to ensure economic sustainability.

10. Adaptability- Longevity: Healthcare development projects bring a long-term commitment on the part of hospital owners, healthcare providers and facility managers to make designing for resilience an important aspect of sustainable design for healthcare. It is important that designers anticipate and position for the future by incorporating flexibility to meet long-term needs.

The first five values – Site, Energy, Water, Materials and Response to locality –address the environmental aspects of sustainability, while Biophilic Design, Social Satisfaction and Healthy Environments speak to the Social aspect, which, in turn, are balanced by the emphasis on economic sustainability provided by financial Success and Adaptability.

ExAMPlES In ACTIOn

The strength of this framework is that it encourages integrative solutions. While each of these values are important individually, together they guide design teams to think holistically about incorporating sustainable design strategies in their projects.

The Center for Science & Health Professions design competition team used the Project Approach to consider appropriate, encompassing sustainable strategies for the project rather than drilling down into a checklist.

Starting with an eco-charrette based on the 10 values, the team developed a design concept that responds to site and climate, incorporating strategies that simultaneously work towards reduced environmental impact and reduced energy consumption while providing maximized daylight and air-quality, connections to outdoors and an increased green cover, which will contribute to a healthy building that is comfortable for the occupants. A proposed roof trellis is a good example of a synergistic response to four of the ten values- site, energy, biophilic design and adaptability. Designed to reduce building energy loads by shading and, at the same time, provide a connection

to nature with its green cover, which emulates the existing dense and shady tree canopy around the site, the trellis further serves as infrastructure for a photovoltaic array on the building in the future.

In addition to a design tool, the Project Approach serves as a documentation tool upon project completion. At the Jersey Shore University Medical Center, early sustainable design integration positioned the project to earn a LEED® Gold Certification. following the project's completion and certification, the 10 values framework has provided a means to document sustainability features, the targets, and milestones achieved by the project as well as the lessons learned in each of the categories. This creates a case study tool that demonstrates ways to incorporate sustainable design on future projects. Though in the early stages of development, this aspect of the system paves the way for a connection between evidence-based design and sustainability.

COnClUSIOn

Though developed with a focus on the triple bottom line, the model is influenced by commitment to strengthen the connection between human health and environment espoused by sustainable healthcare practitioners. The system provides a structure for integrating sustainable design as a best practice on projects, before there is a decision on a rating system or certification process. Such models, tailored to the specifics of practice and firm culture, can serve as powerful tools for goal setting, tracking and documentation. As importantly, they provide a design-driven, holistic approach for incorporating sustainability.

Komal Kotwal, is the Sustainable Design Coordinator, for WHR Architects. She is responsible for facilitating and coordinating Sustainable Design/LEED efforts for complex healthcare facilities, education, science and technology projects.

Komal brings to the table a dual Architectural Design and Master planning background, lending to a holistic approach and understanding of Sustainability at various scales.

She may be reached at: 713-665-5665www.whrarchitects.com

ABOUT THE AUTHOR


FEATURE

The US healthcare system consumes approximately 32 billion gallons of water and $6.5 billion in energy per year while producing 2 million tons of waste. Every day that a healthcare provider burns more energy, uses more water and creates more waste than it requires is another day of pouring both money and resources down the drain. Every unit of energy, water, and waste processing is purchased at the expense of an investment directly enhancing the quality of patient care.

By Cagri Kanver

Healthcare’s Dual Demands Fiscal Responsibility and Quality Care

for healthcare managers striving to balance the competing demands of fiscal responsibility and quality care, the elimination of unnecessary operating expenses and the increased allocation of resources into patient care is a demonstration of good management. However, decisions relative to energy and water are mission critical for a hospital. Because it requires the highest level of expertise in many different areas of inquiry, the challenge is daunting.

Successful development of an Environmental Action Plan requires a team equipped to draw upon state-of-the-art technology and design concepts and an ever-expanding knowledge base followed by financial analysis, project management, stakeholder engagement, metrics and data management and communication skills focused on implementing the plan.

We approach the task in a continuous improvement context that utilizes a team of global specialists. We bring the best talent to the table only as and when needed for the specific task at hand.


EnERGY/WATER RESOURCE MAnAGEMEnT

We assess existing energy and water utility consumption and costs by setting a baseline to be measured against and then identify alternative energy and water efficiency measures with a focus on decision quality. A technology assessment would determine whether existing systems can accept and manage the data necessary to measure and report performance, then a team will implement actions necessary to support the plan’s success. We maintain decision quality by properly framing the problem, establishing clear decision criteria and well-articulated institutional values. We focus on achievable options and clean tradeoffs, utilizing meaningful information and logical reasoning based upon the data at hand and improvement targets selected. We strive to ensure that the process is transparent to stakeholders and we seek a commitment to action. One way this is accomplished is by making the information and data analysis available to stakeholders at appropriate levels.

CARBOn EMISSIOnS PlAnnInG

Carbon emissions planning benefits progressive institutions that (1) recognize the significant cost exposure associated with a future price on carbon, and/or (2) want to brand themselves as leaders and innovators. for institutions desiring to brand themselves as leaders and healthcare’s dual demands fiscal responsibility and quality care healthcare’s dual demands fiscal responsibility and quality care innovators, we will augment the Environmental Action Plan analysis with the potential risk of financial exposure due to carbon emissions. We will develop a comprehensive strategy that addresses the implications of alternative carbon metrics (carbon- or energy-intensity per patient or per bed, rather than the per-square-foot metric used by the building industry). This approach would shift the focus from the building to the patient, expanding the audience from facilities to operations. And likely drive very different solutions.

WASTE STREAM MAnAGEMEnT

Approximately 23% of hospital waste streams consist of medical and hazardous waste with the remaining waste classified as trash or recyclable. Any waste streams that are not separated can be 100% medical. We assess the current waste stream and benchmark that against peer organizations as part of a preliminary assessment. Next, internal waste control processes are assessed along with procurement policies, regional pricing and regional regulatory requirements. Next, utility allowances, hospital waste infrastructure, recycling and repurposing opportunities are further explored to increase efficiency and lower costs. We then identify alternative options using the decision quality process described above. Results include a reduction in waste separation errors through mechanization of the waste stream, lower storage and cartage costs and lower fTE costs related to waste stream management.

METRICS And InFORMATIOn MAnAGEMEnT

following the assessment of energy, water and waste protocols and data management, we recommend alternative solutions and, working with the procurement organization, assist in selection, procurement and implementation of technology solutions. A typical solution would interface with an existing Integrated Workplace Management System (IWMS) or Computer Aided facility Management (CAfM ) system to manage

data for reporting at facility management, operations and executive dashboard levels in the organization. We identify current inputs and outputs of energy, carbon, water and waste and assign costs per unit, using industry-specific metrics. This forms the benchmark against which we will measure savings and efficiency.

EMPlOYEE EnGAGEMEnT PROGRAM

To ensure the successful implementation of new operating protocols, we develop an employee engagement program that enlists and encourages employees to engage in new behaviors supportive of the organizational goals. Employees are asked to share their innovative idea to reduce operating costs. Utilizing the technology applications implemented at the outset of the engagement, cost savings affected through the implementation of employee innovations are measured, reported and recognized, building support and enthusiasm among the employee population.

Cagri Kanver - MBA, MS Space Management. Senior Associate, HOK Advance Strategies

Cagri Kanver has eight years of progressive experience in the field of global real estate development as a senior consultant. He advised global corporate clients in multiple areas of strategy and operations improvement initiatives and corporate sustainability strategies in the real estate. He led number of engagements in the areas of strategic business planning & programming, market research & analysis for global site selection and development. Cagri performed professional projects in four different continents; especially specializing in the Middle East and Asian markets for large mixed use developments. He developed key global client relationships in academic, corporate, government, healthcare, hospitality & leisure markets. Prior to joining HOK, Cagri worked for Deloitte Consulting as a senior consultant. Cagri speaks English, German, and Turkish.

ABOUT THE AUTHOR


Sustainability is not only a goal for the DoD, but it is a mandate as well. Executive Order 13423, Strengthening federal Environmental, Energy, and

Transportation Management, and Executive Order 13514, federal Leadership in Environmental, Energy, and Economic Performance, reinforced federal government commitment to existing regulations such as the Energy Policy Act of 2005 (EPAct ‘05) and the Energy Independence and Security Act of 2007 (EISA 2007) and resulted in the formation of the Interagency Sustainability Working

Group (ISWG). The ISWG developed the High Performance and Sustainable Buildings (HPSB) Guiding Principles which outline specific guidelines around the design process, energy performance, water conservation, indoor environmental quality and environmental impact of materials that apply to all new DoD construction projects and must be met by 15% of all existing agency buildings by 2015. Sustainability requirements are also embedded in the Unified facilities Criteria (UfC) documents and the recent Defense Health Board’s Achieving World Class report.

The Department of Defense (DoD) has demonstrated that it is committed to protecting and conserving the environment with mandates and policies, all while upholding its mission. Each of the Services has adopted a sustainability policy to ensure the implementation of sustainable building practices. On September 8, 2010 the DoD’s first Strategic Sustainability Performance Plan was released in which the Department established very aggressive targets for energy and water use reductions that can only be achieved by designing and maintaining their facilities in a high performance manner.

Energy Conservation in the Department of Defense MHS Replacement Hospital at Ft. Riley

By Jennifer R. DuBose, Joshua Crews and Brad A. Schaap

SUSTAInABIlITY In HEAlTHCARE MAkES SEnSE

The DoD also uses the third party, U.S. Green Building Council (USGBC), Leadership in Energy and Environmental Design (LEED) certification process to verify that all building projects in new construction as well as major renovations meet their sustainability goals. The federal government is the industry leader and the single largest owner of LEED certified buildings.

As part of the DoD, the Military Health System (MHS) hospitals have shown a commitment to sustainability and have provided performance standards for other facilities in the industry to model. The sustainability movement has increasingly focused on reducing the significant impact that healthcare has on the environment. By some estimates 4% of all energy in the U.S. is consumed by healthcare facilities (Better Bricks, 2010) and this energy consumption adds over $600 million a year in healthcare costs due to the effects of pollution in the U.S. alone (World Health Organization & Health Care Without Harm, 2009).

Healthcare projects have generally been slower than other market sectors to adopt sustainable building practices. Traditionally, industry professionals have placed primary focus on the safety and well being of patients and felt that attention to environmental issues would compromise their efforts. However, keeping patients safe and doing no harm is consistent with sustainability. Others have resisted

applying green building strategies to healthcare because the existing guidance and tools, such as the USGBC’s LEED standard, were not until recently tailored to unique characteristics of healthcare facilities.

Despite these apparent barriers the Military Health System has been forging ahead with sustainable design in their newest hospital projects. The Hospital Replacement project

at ft. Riley, located in Kansas, was designed by Joint venture firms Leo A. Daly and RLf and is scheduled to be delivered through a series of five design packages, with expected completion in 2012: civil and site, foundation, structure, building envelope, and fit out. The design will include 263,000 square feet of in-patient services as well as 289,000 square feet of outpatient clinic services (U.S. Army Corps of Engineers, 2009). Sustainability design and implementation is unique to each individual package and therefore bi-weekly sustainability meetings are scheduled throughout the project to discuss and maintain environmental conservation and energy reduction methods. Additionally, the design team and the owner have been particularly proactive to ensure the implementation of sustainable features. Leo A. Daly/RLf and the US Army Corps of Engineers permitted U.S. Army officers to actively participate in the production and development of project documents. The Health facility Planning Agency (HfPA) is also actively involved in the project development. ft. Riley personnel attend the design and sustainability meetings as well to achieve collaboration across the entire team from designers to user groups. The following table shows the remarkable achievements that are anticipated in this leading edge MHS project.


TRACkInG lEEd SIlvER

• Expected energy savings: 17% below ASHRAE standards

• Central Energy Plant Design (heat recovery chillers)• Energy Saving Engineering Strategy (variable

speed drive premium efficiency motors and fans, airside economizers on AHU, and direct digital control systems)

• Energy Saving Lighting Strategy (LED lighting in corridors, minimal incandescent use, occupancy sensors, and exterior lighting with photocell and time clock operation)

• Enhanced building envelope design• Tracking all IAQ LEED credits

dESIGnInG An EARTH FRIEndlY HOSPITAl

The ft. Riley replacement hospital exhibits several examples of sustainable design elements as well as energy efficiency operations and maintenance. Energy efficiency is achieved through many avenues including heat recovery chillers, lighting design, fritted glass, and spray foam insulation in the air cavities of the exterior wall construction. The building envelope also utilizes triple pane glazing to increase R-value at vision panels. Additionally, all of the LEED-NC Indoor Air Quality (IAQ) Credits are being closely tracked by the designers with a desire to achieve each individual credit. The team has a multifaceted approach to achieving superior indoor air quality: ventilation rates are increased above minimum requirements; a specific Construction IAQ plan will be initiated during all phases of work; and, low volatile organic compound (vOC) materials are specified throughout the project, including terrazzo flooring and carpet cleaning products.

In addition to the replacement hospital, a central energy plant is included in the design of the new facility. This plant, along with several active energy conscious lighting design features and heating and cooling engineering strategies, will reduce the energy load of the facility below the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standards. The lighting design features include LED lighting in corridors, a daylight harvesting

system, utilization of incandescent fixtures only where dimming is required and fluorescent fixtures cannot be provided, exterior lighting control by photocell on and time clock off operation, and occupancy sensors in low occupancy room types. The heating and cooling engineering strategies include variable speed drive premium efficiency motors for fans and pumps, minimized chilled water need with airside economizers on air handlers, and direct digital control (DDC) systems for equipment control. This combination of energy saving systems results in an estimated 17% to 18% reduction in energy consumption over the ASHRAE 90.1 baseline calculations using LEED criteria and over 30% using EPAct ‘05 criteria. When modeled, the energy saving design features and engineering strategies produce the following graph of predicted usage.

Proposed Design versus Baseline Case Energy Performance by End Use (Leo A Daly, 2010)

When designing for energy efficiency and compliance to government mandates, a few sustainable features were not found to be cost effective over the estimated 40 year life span of the facility. for example, geothermal energy and solar photovoltaics were explored and found not to deliver sufficient benefits when evaluated with a traditional life-cycle cost analysis. Even without the use of these two technologies the new hospital at ft. Riley has been designed to outperform traditional designs in terms of energy consumption providing a model for others to follow.

• Better Bricks. (2010, May 12). Energy in Healthcare fact Sheet. Retrieved May 28, 2010, fromhttp://www.betterbricks.com/graphics/assets/documents/Energy_in_Healthcare_Fact_Sheet_FINAL_5.12.10.pdf

• Cassidy, R. (2006). 14 Steps to Greener Hospitals. Building Design & Construction Retrieved March 29, 2010, fromhttp://www.bdcnetwork.com/article/382583-14_Steps_to_Greener_Hospitals.php

• Leo A Daly. (2010). ft. Riley Replacement Hospital Sustainable Design Narrative. Omaha: preliminary report.• U.S. Army Corps of Engineers. (2009). fort Riley Replacement Hospital. Retrieved July 19, 2010, from

https://www.fbo.gov/index?s=opportunity&mode=form&id=81d60bf29cf8352c385d4aaa764802ff&tab=core&_cview=0• World Health Organization, & Health Care Without Harm. (2009). Healthy Hospitals, Healthy Planet, Healthy People:

Addressing Climate Change in Healthcare Settings. Retrieved May 28, 2010


Jennifer DuBose, is a Research Associate with the College of Architecture at the Georgia Institute of Technology where she is responsible for project development and management. She has worked with government and private sector clients to help them develop policies and strategies for greening their facilities and operations. She may be reached [email protected]

Joshua Crews is a Graduate Research Assistant at the Georgia Institute of Technology. He is currently conducting research on sustainability in the Military Health System and flexibility in healthcare architecture, he is also part of the Healthy Environments Research Group within the Health Systems Institute

You can contact Josh [email protected].

Brad A. Schaap is the Corporate Director of Sustainability for Leo A Daly and a licensed Professional Structural Engineer in California. He is the Chairman of the AIA Large firm Round Table-Sustainable Design Leaders Group and a Regional Leader of the Architecture+Design Sustainable Design Leaders Group. He served as the LEED and Sustainability Coordinator for the ft. Riley Hospital Replacement Project for the design team.

ABOUT THE AUTHORS

As part of agreement partnership with the Northwest Energy Efficiency Alliance’s (NEEA) BetterBricks initiative, KRMC committed to a Strategic Energy Management

(SEM) Plan and an energy savings goal. SEM is a comprehensive set of business tools and practices that enable hospitals to reduce energy consumption maximize resource efficiency and lower costs. The organization incorporated SEM into many aspects of the medical center’s business including: operations and maintenance practices, capital projects, and purchasing practices. An initial scoping study of the facility was also conducted to estimate the energy savings potential and identify likely areas for further investigation.

HISTORICAl EnERGY USE BEFORE SEMTotal Annual Energy Cost $1,149,000 Kalispell Energy Use Index• Electricity 100,980 Btu/sf• Natural Gas 202,480 Btu/sf• Total 303,460 Btu/sf

Hospitals constructed according to today’s energy codes typically have an Energy Use Index (EUI) between 180,000 and 200,000 Btu/sf/year. (Commercial Buildings Energy Consumption Survey)

ExISTInG EnERGY USInG SYSTEMS

HvAC systems and operations represent about 50-60 percent of the total energy used at the facility. Lighting and miscellaneous other use (computers, medical equipment, cooking, laundry, etc.) make up the remainder of the annual energy use.

Lighting• T8 linear fluorescent with electronic ballasts as

retrofit. Primary Heating, Ventilating, and Air-conditioning (HVAC) Systems• Central steam plant and a central water-cooled

chiller plant. Secondary HVAC Systems• 23 air handling units of various sizes.• Six water-source heat pumps remain in service from

an earlier generation secondary system. Chilled Water Plant• 400-ton centrifugal chillers piped within a primary-

secondary chilled water hydronic system. Steam Plant• Three large steam boilers. • Controls• Direct Digital Controls. Potable Water Heating Systems• Steam-driven instantaneous water heaters.

Kalispell Regional Medical Center (KRMC), located in Kalispell, Montana, is both a community hospital and a regional referral center, offering the area’s most advanced health services and medical technology. The hospital has 174 beds and over 400,000 square feet of conditioned space. Many of the buildings date back to 1975. In the last decade, the hospital launched an expansion program adding a patient tower, a new lab and expanding its central plant, cath lab and OB capacity.

Kalispell Regional Medical Center- A Case Study of Energy-Saving Improvements

By David Ray


STRATEGIC EnERGY MAnAGEMEnT (SEM)

By implementing a strategic energy management plan, KRMC could evaluate future opportunities in context across the whole organization. The organization set annual savings goals of 1,100,000 kWh and 150,000 therms by year four, which would reduce its energy costs by up to 30 percent. SEM impacts the entire organization and covers all applications of resource management— facility master planning; new construction and major renovations; existing facility operations and upgrades; the financial analysis and procurement practices that support these activities; and measurement and reporting of results. It requires strong support across the organization for organizational and behavioral change and a dedicated internal champion to drive the process.

Mark Chitwood, facilities Manager at KRMC, worked to develop a business case for SEM. In September 2006 the team focused on system-wide operations and maintenance improvements and conducted a thorough building performance scoping estimate of overall savings potential. The report identified numerous energy and cost-savings opportunities that projected yearly energy savings of $77,000 or 1,204,000 kWh and 26,800 therms for operations and maintenance improvements and retro-commissioning.

RESUlTS

To date a number of operational improvements have been identified and implemented. These include:

• Scheduling off air handlers for the laundry, carpentry shop, welding shop and general shop during nights and weekends.• Correction of return fan in one air handler which was

operating inefficiently in reverse.• Cleaning of air flow sensors to restore accuracy,

resulting in slower fan speeds.• Reduction of static pressure.• Adjusting heating coil lockout temperature.• Lowering differential pressure set point of hot water

loop from 8 psi to 6 psi.• Lowering differential pressure set point of chilled

water loop from 20 psi to 15 psi.• Raising the discharge air temperature for the surgery

AHU from 50 f to 55 f to avoid unnecessary reheat.• Programming vAv boxes to close or go to minimum

flow when the areas they serve are unoccupied.• Reworking boiler controls to improve sequencing

and improve combustion efficiency.• The facility saved 550,000 kWh and 32,000 therms

in 2010 versus the base year from implementation of these measures, most of which were low or no-cost improvements.


MEASURInG EnERGY SAvInGS

The energy savings from the KRMC project are now tracked with the help of a commercially available product called Energy Expert (EE). Hourly consumption data, from utility meters or other sources such as the building automation system, is captured over a period of time and the tool ‘learns’ how the building performs under various conditions. The tool is then able to compare to this learned baseline and tell a building operator how the building is performing.

The CUSUM Energy view of Energy Expert allows KRMC to view savings trends for the Central Plant building (Not included here is the graph for the West Switchgear Room.). for the period following the incorporation of several low-cost energy savings measures, the energy savings is 256,398 kWh (7.2 percent) and the total consumption is 3,581,399 kWh for the period January 1-November 28, 2010.

OPERATIOnS & MAInTEnAnCE EnERGY SAvInGS: lESSOnS lEARnEdNEEA’s BetterBricks has found that the potential for energy savings from operations and maintenance of the HvAC systems at most hospitals are 10% of facility electricity use and 25% of facility gas use. The improvement measures are not capital intensive and are normally funded through the operations budget. following are some common areas to make O&M improvements:

CHIllEd WATER: Usually the most efficient strategy for operating a central chiller plant is to provide chilled water at the warmest temperature that will satisfy the demands of the building. The chiller compressor operates more efficiently, and there are fewer heat gains to the chilled water during distribution. At 50 degrees outdoor

air temperature, 50 degrees chilled water may be sufficient. As the outdoor air temperature increases toward 90 degrees, the supplied chilled water should be reset toward the minimum recommended by the manufacturer or design engineer.

Within limits, it is better to operate with cooler chiller condenser water. Each one-degree drop in condenser water temperature will improve chiller compressor efficiency by approximately one percent. Generally, the increased fan energy required to produce cooler condenser water will be more than offset with reduced chiller compressor energy.

BOIlERS/ HOT WATER: Boilers can be retrofitted with a control package that improves efficiency. New systems with “oxygen trim” reduce the quantities of excess air in combustion and raise the overall combustion efficiency by two to five percent. Boiler fans should be equipped with vfDs to gain a modest savings in electricity from fan motors.

Many boilers are equipped with blow down heat recovery. for instance, at KRMC city water flows through the heat exchanger at approximately two gallons per minute and is heated from approximately 50 degrees to 90 degrees. The water is then wasted to the drain. This warmed water can be recovered as make-up water to the boilers or some water heating system to save energy and reduce water and sewer expense.

The hot water supplied to the HvAC systems should be at the minimum temperature that will satisfy heating demands. Usually a reset schedule for hot water is based on outdoor air temperature. The colder the outdoor air temperature, the warmer the heating water will need to be. for instance, 190f water may be required at an outdoor air temperature of 10f, but at 90-degree outdoor air temperature 115f reheat water may suffice.

from an energy management perspective, minimizing the temperature of the HvAC hot water is very important for the following reasons. first, the hotter the water, the greater the heat loss from the pipes will be. If these pipes are running through conditioned space, the heat loss from the pipes is heat gain to the conditioned space (thus requiring more air conditioning). Second, running very hot water may mask the opportunity to reduce air conditioning. When a reasonable hot water temperature is supplied to reheat coils and a space cannot be kept warm, this suggests that the supply air temperature may be set too low or that the terminal box air volume may be set too high. By adjusting the


supply air temperature upward or the terminal box air flow downward, both air conditioning and reheat will be reduced.At some hospitals, the heating coils are programmed by the building automation system to have hot water flow whenever the outdoor air temperature is below 30 degrees. A small but still significant amount of heat will be lost from the coil if the face and bypass dampers are not sealing well.

AIR HAndlERS: Air handlers that serve clinical areas are designed to provide a high degree of comfort through extremes of outdoor air temperatures while also conditioning large amounts of ventilation air. Consequently, the heating, cooling, and ventilating capacities are huge. Efficient strategies to operate the air handlers when all of this capacity is not required– especially during mild weather, nights, and weekends–will reward the

operators with large energy savings with very little capital investment. The following is a list of the best strategies.

• Shutdowns: If areas served by an air handler are unoccupied and there are no minimum ventilation or pressure relationships to be maintained, turn the unit off.

• Partial Shutdowns: Oftentimes an air handler cannot be shut down because part of the space it serves remains occupied on nights and/or weekends. If the supply and return fans are equipped with vfDs, it may be possible to reduce or eliminate conditioning to unoccupied spaces while still conditioning the occupied areas. for spaces served by addressable vAv boxes, the controls may be scheduled to reduce flow to the boxes when the area is not occupied. If controls to boxes are local (not schedulable), dampers may be installed in main supply and return ducts to allow a partial shutdown.

• Reduce Supply Duct Static Pressure: Supply duct static pressure is sometimes set arbitrarily and is higher than necessary, requiring more fan power. If an air handler serves non-clinical areas where ventilation and pressure relationships are not proscriptive, it is permissible to reduce supply duct static pressure in off-peak times.

• Adjust Air Handler Supply Air Discharge Temperature: In theory, the design discharge air temperature for an air handler, typically 55 degrees should be capable of conditioning a space during peak activity (internal heat gains) and design conditions (high outdoor air temperature and humidity). In all other situations of lower activity and milder outdoor conditions, a higher discharge air temperature will be capable of cooling the spaces adequately.

• Make Good Air filter Choices: ASHRAE and the AIA guidelines on construction in hospitals both list air filtration efficiencies required for air handlers serving various patient care areas of hospitals. Hospital maintenance staff tends to


standardize on a few models of filters in some cases using a higher efficiency than necessary. However, using a higher efficiency filter generally causes a greater pressure drop, thereby requiring more fan horsepower.

• Maintain Air Handler Economizer Dampers and Controls: Economizers are designed to allow cool outdoor air to be used to reduce or eliminate the need for mechanical cooling. Mechanical cooling may not be required until outdoor air temperatures approach 55f. Conversely, when the outdoor air temperature exceeds the space return air temperature, the economizer dampers should adjust to use maximum return air and minimum outdoor air. Malfunction of economizer dampers and controls may introduce too much cool outdoor air in cold weather and too much warm outdoor air in hot weather. Maintenance staff should carefully monitor mixed air temperatures of air handlers via the building automation system, and visually inspect dampers during regular rounds to equipment rooms.

nExT STEPS

As it became clear that many of the savings opportunities at KRMC required more staff time, the hospital management recognized it needed a staff member dedicated to managing energy efficiency opportunities system-wide. Given the number of energy improvements and their cost-savings, Kalispell has hired a Resource Conservation Manager (RCM) to manage the energy improvements, measure their performance and communicate goals and successes system-wide. By setting energy performance targets and aligning them to mission-critical goals, the organization has elevated energy management across facility maintenance and capital projects. Continuous preventative maintenance, monitoring and even commissioning are required to ensure long-term success and savings.

David currently works as a business advisor to BetterBricks/Northwest Energy Efficiency Alliance developing business and marketing plans for the healthcare sector initiative focusing on sustainability planning at large hospitals.

Kalispell Regional Medical Center, Northwest Energy Efficiency Alliance, BetterBricks.

ABOUT THE AUTHOR


With the development and deployment of automated waste and recycling management systems powered by air technology, we are at the dawn of a

new age -- the pneumatic age. These new systems are quickly becoming the waste, linen and recycling infrastructure system of choice for forward-thinking developers of healthcare facilities. They keep waste and soiled linen where it belongs -- out of sight -- and provide the hospital with significant improvements to

operating efficiency, cost-savings, infection control, and sustainability.

AUTOMATEd REMOvAl OF WASTE IS ClEAnERMany hospitals today continue to use an antiquated and arcane system for the removal of waste, recyclables and linens - manual disposal, overflowing roller carts, waste bins-gravity chutes, and trash closets. These systems are highly inefficient, labor-intensive, and potentially unhealthy in terms of disease and infection

Healthcare facilities have a waste problem generating up to 25 pounds of waste per day, per patient. Moreover, the transport and removal of waste, linen and recyclables from a hospital is a critical component of its logistic and sustainable operations efficiency. And yet, the systems that transport and remove waste, soiled linen, and recycling have remained virtually unchanged for the last hundred years - and have not kept pace with infrastructure and technology improvements in healthcare facility construction. That is, until now.

The Evolution of Waste and Linen Removal in Hospitals: The Dawn of the New Pneumatic Age

By Harry Pliskin


control. In evaluating the current traditional logistics for removing waste and soiled linen, hospital team leaders are finding a number of problems including: • Increased costs due to required labor for

transporting waste and soiled linen • Increased exposure time of infectious materials

to patients, staff and the public during transport of contaminated linens through hallways and elevators

• Environmental and cleanliness concerns associated with the transport of waste and recycling through corridors and elevators

Systems for automated removal of waste, soiled linen and recyclables are cleaner, safer and more economical than these traditional systems. Automated systems transport the materials in a separate, closed pipe system from every department/floor to a single collection point which can be located in a discrete location. The inlets are positioned optimally to keep manual handling to a minimum. The materials are then transported via a computer-controlled pneumatic system that moves the soiled linen, waste and recyclables quickly, safely -- and out of sight. This results in a quiet, hygienic, environmentally friendly setting for patients and guests. These automated systems have other important benefits as well.

TIME SAvInGA recent study analyzing the exposure time of infectious materials through hospitals compared the exposure of soiled linen using manual collection versus an automated pneumatic solution. Exposure time by manually removing waste was 1,344 minutes compared with 132 minutes for an automated process in a 200 bed hospital. Automated transportation of trash, linens and recycling typically minimizes patient, staff and guest exposure time by at least 80 percent; transport time is limited due to automating and sealing the removal process. Other quantifiable benefits of an automated system include: • Reduction in hospital fTEs • Payback in 3-5 years

• Ongoing cost-savings - for some hospitals, in the millions of dollars

• Increased management tools via secure log-ins for system access

HOSPITAl’S ARE AlREAdY IMPlEMEnTInGAUTOMATEd REMOvAlLeading hospitals such as Rush University Medical Center and Brigham & Women’s have discovered that this technology can greatly improve material transport performance and also lower operational costs, improve cleanliness and aesthetics while also limiting exposure to infected material.

St. Anthony’s Hospital in Denver, Colorado designed and constructed their new facility embracing "smart building" technology to ensure superior conditions to both personnel and patients. This included Colorado’s first automated pneumatic solution that provides unit-level sorting/transport of linens, trash and recyclables. It’s proven to be cleaner, healthier, and quieter than any other waste management process available, there’s nobody walking around with dirty sheets, no loud trucks parked outside of the building. In addition, there’s less wear and tear on the building, lower housekeeping costs and everything happens out of sight.

St. Anthony’s Administrative Director of Support Services agreed, saying, “ The automated pneumatic solution provides enormous benefits. This includes reduced need for staff. further, it cuts down on infections that can be spread when someone drags a trash cart full of soiled linen through a hospital floor and makes the building neater.”

Automated waste and recycling management provides an opportunity for hospitals to ensure sustainability, improve efficiency, and reduce costs. It is the dawn of the pneumatic age, the way of the future.

Harry Pliskin is President of Transvac Systems LLC - the world leader in automated waste, recycling and soiled linen handling systems for hospitals in the US and abroad (www.transvacsys.com). Previously, Harry was founder and CEO of TeleWeb Worldwide, one of the first business process outsourcing companies focused on providing services from locations around the world.

ABOUT THE AUTHOR


“Sustainability Metrics are tools that measure the benefits achieved through the implementation of sustainability” according to the Center for Sustainability at Aquinas College, in Grand Rapids Michigan. Sustainability metrics tracking can tell you what you should do and as a result you will be measuring your successes, including energy and cost savings.

Are you challenged to lead your hospital to develop a “culture of sustainability”? Does your organization already feel overburdened by administrative duties which don’t seem to directly impact the bottom line? Well, you’re not alone. As the sustainability movement in healthcare continues to grow and more organizations are looking for performance benchmarks, they are left empty handed. Certainly the healthcare industry provides benchmarks touting diseases, length of stay and others. But, when it comes to sustainability little is available. Today, however, managing the internal data that you have and organizing that data in a format that yields information, is essential. Although cliché, “You are what you measure” and “What gets measured gets managed” excelling in measurement of certain key metrics not only cuts energy costs but separates higher performing organizations as they grow their sustainability programs. There are sustainability metrics tracking tools which help lighten your administrative load, converting cumbersome spreadsheets to automated, web-based software which includes communication tools designed to effectively share data throughout the organization.

Tracking Sustainability: Metrics Criticalfor Higher Performing Organizations

By Jeff Burks


HOSPITAlS ARE UTIlIzInG THE SOFTWARE

Hospitals pay their electricity, natural gas, water and waste bills just like we do at our homes…they simply write the check. The central accounting department pays the bill, but do they track or measure Kwh? There is minimal or no reviews of the bill. Therefore, hospitals are putting their faith and trust in the utility vendor to report and invoice correctly.

If your hospital is currently focused on either energy or waste, that is a good first step, but as any energy or environmental manager will tell you, there is a lot of data that must be analyzed. Most hospital systems have hundreds of locations that are typically conducting a manual review of the bills. The better performing organizations have complex spreadsheets to identify trends or anomalies. This is a challenging approach not only because of the evolving complexity, but also because of the various invoicing schedules. Most of the energy and water bills are invoiced on a monthly or quarterly basis, but the various waste streams (Solid Waste, Recycling, Regulated Medical, Hazardous, Pharmaceutical, etc.) are invoiced very differently. There are even waste programs, such as donations, that if included, provide a more accurate sustainability picture. It is therefore critical that the data is analyzed accurately and consistently or the data will not result in useful information, assisting you in making wise business decisions leading to energy and cost savings.

It will simply be a mass of data collected. Sophisticated systems such as Spectrum Health System, a leading health system in West Michigan, are taking a cutting edge approach and have utilized advanced software. for an organization like Spectrum Health System, with nine hospitals, over 100 off-site facilities and 16,000 employees, gathering the right data to provide useful information can be an immense undertaking. However, Spectrum Health has specific sustainability goals and automation is helping them to efficiently achieve their goals.

Metro Health is another success story where sustainability metrics tracking has helped the hospital achieve its cost savings and energy management goals. Alison Waske, Sustainable Business Officer with Metro Health says, “We needed a robust tracking system to quantify how much waste there is and how much it is costing. The financial part of sustainability is extremely important.” Waske states that benchmarking and identifying metrics that work for a given business are the key to tracking performance.

Carroll Hospital Center in central Maryland has a progressive sustainability program and uses sustainability metrics to track their performance. Robert White, Assistant vice President of Professional and Support Services, says “the dashboard provides the latest information for facility management and the in-depth reporting provides the information we need on key usage and performance metrics. We want to continue to enhance the facility performance and provide our patients with a green and efficient facility.”

HOW IT WORkS

These sophisticated health systems have successful sustainability programs because they not only collect invoice data (usage and costs) on energy, water and waste, but also collect and analyze the facilities’ many performance indicators such as square footage, patient days, adjusted patient days, discharges, licensed beds, occupied beds, and fTE’s. Both data collections are essential in order to provide the health system with the complete picture which will more effectively assist in hospital’s business decisions. This information provides hospitals with benchmarking data. The question, “How are we doing compared to others?” is finally answered.

There are many tangible and intangible cost savings opportunities when utility data and metric data are correctly measured and managed. One hospital


Jeff Burks is the Relationship Manager for Key Green Solutions. He has consulted for many organizations on implementing software solutions for their sustainability programs. Key Green Solutions offers its software suite to hospitals, shared hospital laundry facilities and insurance companies to improve the efficiency and reduce the operating costs.

He may be reached [email protected].

Key Green Solutions web site can be found atwww.keygreensolutions.com.

ABOUT THE AUTHOR

identified a $600,000 pricing error due to an erroneous electric meter setting. Another hospital identified lower utility rates by comparing facilities rate programs within the system. Most energy companies offer electronic invoicing. The electronic invoice is automatically loaded into the software when the invoice is ready from the vendor. By processing the vendor’s electronic invoice detail directly into the software, this reduces the errors and costs associated with manual keying of data.

SHARInG THE InFORMATIOn

One of the biggest challenges hospitals face is encouraging a “bottom up” or grass roots system wide campaign around sustainability. One of the many reasons is that the “sustainability leader(s)” do not have effective communication tools such as dashboards and sustainability scorecards where they can share the information throughout the organization. Additionally, if the scorecards are integrated with a project management tracking system, real time reporting is established and best practices can be shared.

GOAl SETTInG

It is almost inevitable that expectations and requirements for disclosure around sustainability for hospitals will increase. Therefore, setting measurable and attainable sustainability goals is essential. When vendor data and metric data tracking is a priority, a hospital can effectively set the goals around the evaluation of energy, GHG emissions, solid waste and water use, to name a few. At the next level, some hospitals are evaluating

each indicator on a relative basis, like assessing the GHG emissions per unit of product, or water used in a specific process. This level of granularity is critical to understand where areas of opportunity may be and measuring the performance of specific initiatives.

Leading hospitals are using this type of thinking to understand where the greatest opportunities and potential risks exist in their operations.

In today’s health care industry, success depends on having the correct set of metrics in place to measure progress in meeting short and long-term objectives. Measuring progress with a sustainability lens is just one of the new responsibilities that hospitals need to embrace.


Sustainability, now a mainstream word is continuously carrying more weight in the world. Even in just the last five years it has had a significant impact on food, clothes, hospitals, buildings, and all kinds of tangible products. It’s almost a trendy word. Companies have formed, conferences are held and the government has jumped onboard all in the name of “greening” the environment. Energy conservation plays a huge role in the success of going “green”. Emergency Planner/ Safety Engineer at the McHale Report, and member of the Green Building Council, Karen McHale has become an expert on energy conservation, as her home in Colorado runs completely on solar panels.

Solar PanelsFrom Homes to Hospitals

By Olivia Goodwin


IT BEGAn AS A nECESSITY

Purchasing a house in the mountains in Colorado is ideal for living a quaint and quiet life it isolates you from everything, including a power company. Once the McHale’s found

out that they couldn’t get electricity up in the mountains, they started developing plans to run their house off of solar panels.

“Solar power isn’t cheap, it took $20,000 to make it work for our house, but we have more than made our money back, McHale said, the microwave, dryer, computer, refrigerator and all necessities run off of this power, we don’t want for anything.”

HOW IT WORkS

The success of solar panels depends on many things; two of the basics are how much direct energy they absorb from the sun and controlling the amount of energy used in the house. Everything in McHale’s house is plugged into a power strip, once they are done using something they turn the power completely off. Conserving energy throughout the day is a major part of using solar panels successfully. Appliances such as a microwave stays on all the time, and all of that energy is wasted, the same goes for a television, the remote control is constantly sending out signals. “These are everyday things that people wouldn’t consider it wasting so much energy, if a person without solar panels took the same measures they could cut their energy bill by 40%,” McHale said. While the panels absorb the sun and produce direct electricity, batteries are in place to absorb enough sunlight to power the house throughout the night, the energy they make from an eight hour day will run the house for 24 hours.

THE BEnEFITS

In addition to saving money and helping the environment, you can also keep your power running during a storm or natural disaster, there are no power lines to get destroyed. “We never lose power in snow storms, we just brush the snow off the panels and we have power, it really works great for homes,” McHale adds.

Homes that run on solar power require backup generators for those just in case incidents. If you have plenty of propane stored up for the generator you really can’t lose power. Most homes that run off of electricity don’t have backup generators. In the event of a major disaster solar powered homes will be

prepared. McHale’s experiences with having a solar powered house have led her to become an Emergency Planner, in which she trains people how to perform daily functions during a natural disaster. She has also written a fictional account of her findings in the book, Economic Meltdown: A family Preparedness Plan for Disaster.

SOlAR PAnElS And HOSPITAlS

Several hospitals around the world are starting to go green, either building a hospital following the LEED guidelines, incorporating sustainable products, or vegetated roofing for example. There is so much energy used in a hospital that the thought of running


it solely off of solar panels seems impossible with the technology currently available, but some are just about there.

Some hospitals have implemented solar panels to power certain parts of hospitals or just derive a percentage of their power from solar panels in order to reduce costs and have more money available for other necessities. According the U.S. Department of veteran Affairs, in Arizona this spring, the vA along with Southern Arizona vA Health Care System will have installed a new 2.9-megawatt, covered carport parking solar Pv array project on its grounds. This solar project will provide 18% of the total medical center’s annual electric requirements, which will save the medical center over $319,000 in electric costs annually.McHale predicts that if a hospital was to run solely off of solar panels the best way to implement that would be to build a solar farm in a town, every house would run off of this and the hospital could be put on that grid. Atriums in the middle of hospitals and windows in the middle of walls could create “passive solar” which would be a major part of making solar power successful for hospitals.

THE OnlY OPTIOn

Homes such as McHale’s are not the only buildings that lack the accessibility to electricity.Gambia, a country in West Africa has five hospitals and several clinics with very qualified doctors, staff and equipment, the only problem, these healthcare facilities have limited access to electricity, many only get power a few hours a day. Generators are used, but most facilities can only afford to run them certain hours of the day. Sulayman Junkung General Hospital for example, was only able to have electricity for seven hours a day, due to fuel costs and maintenance issues with the generator.

An American student traveled to a hospital in Gambia, and witnessed doctors scrubbing in without running water, performing surgeries by candlelight and she saw just how devastating the effects of no electricity were, when she got back home she decided to do something about it. Kathryn Hall founder of Power Up Gambia a non-profit organization raised $300,000 to power Sulayman Junkung General Hospital off of solar panels. Those funds went to a 12 kW system that supplies the hospital for 17 hours a day, while charging a battery bank that runs the hospital during the night. from 7:00 p.m. until 2:00 a.m. an on-site generator provides the power, once that shuts down the solar deep cycle batteries take over. There are 90 solar panels installed on six trackers on an open

ground next to the hospital, they feed power to a small “solar house” where the inverters, battery chargers and batteries are stored. The project is complete and the hospital can now serve 20,000 patients annually and effectively.

“This system has been amazingly reliable and has worked with no down time since it’s installation in early 2009,” said Lynn McConville Executive Director for Power Up Gambia.

Power Up Gambia has helped Somita a village clinic get electricity from panels as well, and they are currently working on “powering up” Bansang Hospital, which provides healthcare to 600,000 people in Gambia.[i] fortunately the sun in Gambia is very bright which provides a perfect condition for powering solar panels.“This work succeeds in uniting the two great struggles of our time: the struggle for social justice and that for ecological justice,”- Power Up Gambia.

Olivia is the Assistant Editor for Healthcare Development Magazine, and travels around networking and developing new ideas for the magazine.She may be reached [email protected]. Check outwww.SustainableHealthcare.com, the first social network dedicated entirely to that industry!

ABOUT THE AUTHOR

[i] http://www.powerupgambia.org/about_mission.php


MEETInG THE MIllEnnIUM dEvElOPMEnT GOAlS

To counter these statistics the United Nations (UN) held its largest event ever in Australia on the 30th of August to the 1st of September 2010 in Melbourne to host the world’s health

experts on how we can globally meet the Millennium Development Goals (MDG’s). The MDG’s are a global action plan to achieve the eight anti-poverty goals by the 2015 target date. The UN announced a new major commitment in women and children's health by focusing on Goal 4, reducing child mortality and Goal 5, improving maternal health.

More than 300 non-government organizations (NGO’s) from 70 countries attended the convention to discuss the world's progress towards reaching the MDG’s. The NGO’s who attended the conference made an fevered plea for all governments, agencies, corporations and individuals to deliver on their human rights obligations to more than a billion people living in poverty, by committing the financial and political resources necessary to achieve the Goals. Issues highlighted at the DPI/NGO Conference leverages discussion and policy making at the UN Assembly related to Global Health.

Today, one billion people around the world do not have access to any kind of healthcare.1 ‘Nearly nine million children die before the age of five’; two and ‘at least 529,000 women die each year of pregnancy-related causes’.2 There are people around the world, who are in dire need of help, and sadly this reality is not confined to countries abroad; the health status of our own indigenous people is alarming. ‘Aboriginal people can expect to live up to twenty years less than non-Indigenous Australians. Indigenous life expectancy is so low because Aboriginal health standards in Australia are now so bad that 45% of Aboriginal men and 34% of women die before the age of 45, and 71% percent die before they reach the age of 65.’3

Making a Bridge between Holistic Therapistsand One Billion People without Healthcare

By Natasja Sproat


UTIlIzInG HOlISTIC THERAPISTS TO SOlvETHE nEEd FOR MORE HEAlTHCARE WORkERS

At the conference the UN made a commitment to increase the number of health workers required to achieve the MDGs and incorporate this into the Action Agenda for achieving the MDGs. According to the World Health Organization (WHO), ‘4.3 million extra health workers (doctors, nurses and midwives) are needed worldwide to make essential healthcare accessible to all’. 4

The colossal challenges we face to tackle our global health crisis is very clear. finding enough healthcare workers to meet the demand of 1 billion people is an overwhelming situation, however if more NGO’s and the UN bridged the gap between Allopathic medical doctors and Holistic medical practitioners then the wealth of support would be paramount.

Of the 300 NGO’s who attended the conference in Melbourne, unfortunately only two utilized qualified holistic healthcare volunteers in projects for the disadvantaged and vulnerable.

The World Health Organization claims that ‘85% of all healthcare workers around the world are complimentary therapists or use Traditional Medicines.’6 In the face of this statistic one can see that there is a huge force of therapists in the world that can help meet the MDG’s, but are not being utilized.

The major disparity between the current model being used for aid work today, and the model that could be used if holistic therapists were integrated, is that holistic therapists could also treat presenting ailments alongside allopathic doctors, but can also provide preventative measures and education, addressing the deeper causes of the health concerns around the world.

EdUCATIOn In HEAlTHCARE

Knowledge is the most sustainable and cheapest healthcare known to man, which is currently lacking in the current Healthcare NGO model. Given that many conditions are preventable, every healthcare interaction should include prevention support and education on self-management. Healthcare teams that stimulate education of healthcare into communities, and that treat the whole person rather than the disease could likely change the alarming and disappointing statistics of failed healthcare systems today. Holistic therapists working within aid work could compile

preventative healthcare information for the media to spread to disadvantaged areas of the world.

As stated at the Melbourne conference by James Wagwau from Kenya - Education Editor for New vision, Uganda’s leading newspaper – healthcare education is enormously lacking in disadvantaged areas around the world, and suggested that the media should be taken advantage of to play a critical role in informing and educating masses of people on:

1. Where they can receive treatment, 2. How to prevent disease,3. Bringing major health issues to light.

Wagwau believes that by using the media, information could easily and quickly be received, especially in rural areas. This is a relatively easy and cost effective preventative healthcare measure that the UN should seriously consider.


If holistic healthcare practitioners could mobilize preventative health information to provide for radio or newspapers in developing countries this could be spread into small and rural communities who are without any healthcare information. This information could also be supplied as handouts or booklets to NGO’s working in poverty and health around the world.

A nutritional and lifestyle guideline for pregnant women alone could be useful for saving lives of unborn children as well as mothers by reducing complications. In India for example, pregnant woman are forced to collect heavy water on top of their heads and carry it from a well to home. Many women miscarry from this type of work, and can hemorrhage to their deaths. Men do not do this work, as its taboo, and they still do not believe it hurts their wives to do it. It is not our jobs to change century old taboos, but we may challenge them by providing healthcare information that can save many lives.

Holistic therapies can help combat the world’s health crisis, and could play a large part at combating two of the main key MDG’s, both 4 &5, reducing child mortality and improving maternal health. By researching ways in how holistic healthcare can help meet just goals 4 &5, we can make a definite change in perspective for NGO’s, policy makers, and the UN by the next conference. Holistic healthcare should not just be reserved for people who can afford to pay for our services when so many are dying without any healthcare.

The healthcare industry can support NGOs and holistic therapist to deliver healthcare to over a billion people living in poverty, publicizing aid work opportunities and by committing the finances and donations of old stock to NGOs for use. Practitioners can volunteer their time in Australia and abroad, or they can use their skills in collating research to publicize, so there can be a paradigm shift in the use of holistic therapists knowledge into more NGOs to meet the needs of more people, and one day make a shift into global healthcare policy making.

References

1 Action for Global Health. viewed on the World Wide Web on the 20/10/10: actionforglobalhealth.eu/filead-min/AfGH/Publications/HRH_briefing_paper.pdf2 UN Information Officer, 1/9/10, UN Press release, NGO/708, PI/1958. ‘Millennium Development Impera-tive, but largely off-track for Poorest’, retrieved 19/9/10 from:http://www.un.org/News/Press/docs//2010/ngo708.doc.htm3 five By fifteen. viewed on the World Wide Web on the 20/10/10, fivebyfifteen.org/#/overview/4 Creative Spirits, viewed on the World Wide Web on the 13/1/2010: creativespirits.info/aboriginalculture/health/aboriginal-life-expectancy.html.5 Action for Global Health. viewed on the World Wide Web on the 20/10/10:actionforglobalhealth.eu/index.php?id=180&cHash=2c47176e3d0af65f9a0931dd290fd125&tx_ttnews%5Btt_news%5D=3546 World Health Organization. viewed on the world wide web on the 30/10/10:who.int/medicines/publications/traditionalpolicy/en/in-dex.html

Natasja is a registered Traditional Chinese Herbalist and Acupuncturist. She completed her training in Melbourne - Australia, then trained at Shen Yang Hospital - China, and has worked with hundreds of patients around India. She works from Discover Chinese Medicine in Richmond - Melbourne. She is the Secretary and co-founder of Traditional Healthcare.You can contact her at [email protected].

Traditional Healthcare is a collaborative partner with One Health Organization, which is the only registered associate of the UN/DPI with a holistic and integrative health focus, who emphasis’s sustainable and community driven initiatives in consultation with multi disciplinary health care professionals in the field of humanitarian aid work. www.th.org.au

ABOUT THE AUTHOR


New Opportunities. Investors can’t afford to miss out on learning about some of the emerging trends in healthcare such as:

CHICAGO, ILLINOIS USA

OCTOBER 25TH - 28TH 2011Marriott Renaissance Schaumburg Convention Center Hotel

Part of the World Medical Tourism & Global Healthcare Congress

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AN INTERNATIONAL HEALTHCARE DEVELOPMENT CONFERENCE

I N T E R N A T I O N A L

C O N F E R E N C EHEALTH WELLNESS&

P A R T O F W O R L D M E D I C A L T O U R I S M & G L O B A L H E A LT H C A R E C O N G R E S S

The Healthcare Investment conference is a part of one of the leading conferences in the world that brings together up to 1,500 attendees from over 87 countries. The Healthcare Industry globally is experience significant growth and investment. With healthcare spending in the trillions in the US and in other countries, the investment in the healthcare sector is expected to have great return for investors.

The Theme of this year’s conference is Emerging Healthcare Investment Opportunities in a Global World. The conference will have a heavy focus on some of the emerging markets and trends and provide case studies of emerging investment opportunities in the healthcare sector.

• Hospital Development• Sustainable Healthcare• Medical Technology, Equipment, Supplies and Drugs• Global Wellness Programs• Medical Tourism• Employer Global Benefits and Insurance Programs• And New and Emerging Sectors

HEAlTHCARE IS COMPETITIvE

In the metropolitan city of Mumbai there is a chain of corporate hospitals delivering quality healthcare at competitive rates. With the advent of medical tourism and health insurance it is imperative that

the hospitals deliver standard care at competitive rates.High quality healthcare is only possible with the latest state of the art technology backed by the best medical brains. Healthcare technology is undergoing a rapid metamorphosis. What was latest yesterday could become redundant today.

Hence, the need for acquiring the best available technology. Some of the corporate hospitals of Mumbai have the latest state of the art technology backed by some of the best brains in the business, with the latest state of the art interiors. Some of them are so well designed that one does not feel it is a hospital. Within hospitals, the unnecessary use or overuse of antibiotics encourages the selection and proliferation of resistant and multiply resistant strains of bacteria. Once selected, resistant strains are favored by antibiotic usage and spread by cross-infection. Where resistance is encoded on transmissible plasmids, resistance can also spread between bacterial species.

There is a link between antibiotic use (or abuse) and the emergence of antibiotic resistant bacteria causing hospital-acquired infections. It is not possible to completely eliminate this evolutionary phenomenon, but it can be slowed or modified by prudent antibiotic use. This requires the inclusion of an antibiotic policy in the infection control program.

An AnTIBIOTIC POlICY WIll:

• Improve patient care by promoting the best practice in antibiotic prophylaxis and therapy.

• Make better use of resources by using cheaper drugs where possible

• Retard the emergence and spread of multiple antibiotic-resistant bacteria.

• mprove education of junior doctors by providing guidelines for appropriate therapy

• Eliminate the use of unnecessary or ineffective antibiotics and restrict the use of expensive or unnecessarily powerful ones

HOSPITAl AnTIBIOTIC COMMITTEE

The medical director and hospital administrator should ensure that the hospital plan for prevention and control of nosocomial infection includes an official committee that has responsibility for the formulation and supervision of an antibiotic policy. This might be a subcommittee of the hospital Drugs and Therapeutics Committee or of the Infection Control Committee. The Antibiotic Committee should have the support of the Medical Director and the authority to ensure that its policies are implemented throughout the hospital. Membership of an antibiotic committee may vary according to local conditions and needs.

The committee should be responsible for producing general guidelines and policies for the healthcare areas after wide consultation with the users. The following key persons should be included in the committee:

Since times immemorial hospitals are considered as temples of healing and people all over the world literally worship the doctors. However rapid industrialization and advancement in technologies have made hospitals more commercial in their outlook and more business oriented. Health insurance coverage is increasing and with better awareness and more funds at their disposal people have a wider and better choice of health care providers.

Hospital Challenges in the Millennium

By Dr. M. Balasubramanian


• The Pharmacist who will report back to the Antibiotic Committee at each meeting on drug utilization and cost.

• The Microbiologist who will report on antibiotic susceptibility patterns of bacteria isolated from major infections.

• Clinical doctors and nurses responsible for direct patient care who provide a link between clinical practice and the Antibiotic Committee.

• Managers that will ensure the resources are available for implementation of the antibiotic policy.

• Reciprocal Membership between the Infection Control Committee and the Drugs Committee should be ensured.

The Antibiotic Committee will have to make rational choices amongst "equivalent drugs" and classes of drugs in order to select the least expensive, most effective agents. Cost should determine the selection, when microbiological, pharmacological, and other relevant properties are similar.

A major task of the Antibiotic Committee will be to establish guidelines for antibiotic use. This will lead to

production of a formulary that restricts agents available to the minimum number needed for most effective therapy. The guidelines should:

• Contain guidance on antibiotic prophylaxis (e.g. in surgery with details of timing, route, dosage and frequency)

• Contain guidance on the choice of antibiotics for empirical and targeted therapy of major infections

• Indicate first and second line therapy for common infections (might limit the use of certain second line drugs to consultant prescription only)

GOOd PRACTICES

• Consider whether or not the patient actually requires an antibiotic.

• Avoid treating colonized patients who are not actually infected.

• In general do not change antibiotic therapy if the clinical condition is improving.

• If there is no clinical response within 72 hours, the clinical diagnosis, the choice of antibiotic and/or


the possibility of a secondary infection should be reconsidered.

• Give the antibiotic for the minimum length of time that is effective.

• Consider the use of pharmacy ‘stop' policies, where drugs are written up for a specified period and are then only continued if a new prescription is issued.

• for surgical prophylaxis start the antibiotic with the induction of anesthesia and continue for a maximum of 24 hours only.

The clinician should receive reports of antibiotic susceptibility based on the drugs available in the agreed formulary. The testing should be performed with a limited number of antibiotics selected to optimize patient care and cost effectiveness. The report should also indicate where organisms are invariably resistant. An effective antibiotic policy also provides and ensures education on the use of antibiotics at undergraduate and postgraduate level for medical and nursing staff.

FUTURE dEvElOPMEnTS

In a fast moving city like Mumbai healthcare is a booming business and the competition is fierce and sometimes cut –throat. People want the best possible care at the most competitive prices. It is therefore imperative for healthcare providers to be aware of the latest trends in the healthcare segment.

future technological developments will continue to have a major impact on design. As technology advances and new care models emerge, it will be increasingly important for architects and interior designers to be specialized in the needs of healthcare. Technological advances also have a clear impact on healthcare engineering and information systems. Development of Integrated Electronic Medical Records will help physicians make better, faster decisions. And it will assist in public health efforts, making it easy to identify and contact, for example, patients who were prescribed a certain drug.

Radio-frequency identification (RfID) as an important part of such data-gathering systems because RfID tags can collect information automatically without

giving busy hospital staff another task to complete. Hospital environments are going to be created around the patient, rather than the patient being taken to specific locations for services. This will entail rooms with “substantially more intense” infrastructure systems, along with the engineering design challenge of turning those systems on and off as needed.

Designing integrated technology systems will result in enhanced patient care. Technology applications are no longer self-contained silos. In the past, we installed individual applications, such as pharmacy, lab and radiology. Today, we track the information flow from one system or application to another to know how the care team will use that data. Such collaboration by the IT staff will continue on all aspects of the systems development life cycle, from identification of needs to post-implementation needs. A pro-active management coupled with a positive approach can play a major role in establishing a world class center of excellence.

Dr. Balasubramanian has been in charge of the Medical Administration at both Saifee and Bhatia Hospitals. At Saifee Hospital he was in charge of the Renal Transplant Program and developing various Health Checkup Packages. He has ensured proper Infection Control Practices and regular meetings of Drugs and Therapeutics Committee and Infection Control Committee.He may be reached at [email protected]

ABOUT THE AUTHOR


www.HealthcareDevelopmentConference.com

Marriott Renaissance Schaumburg Convention Center Hotel

Chicago, Illinois, USA. October 25th-28th, 2011



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