From what I recall, in all of the debates surrounding healthcare costs over the past few years, we have heard plenty of discussion about the financials tied to providing and obtaining care on a practitioner and patient level—but not nearly as much about the cost of building and operating our healthcare facilities.

This is a shame, as healthcare facilities provide a great challenge—and opportunity. With 24–7 operations and multitiered stages of treatment in one location, healthcare facilities, especially acute-care structures, are often giants both in terms of their physical and environmental footprints. According to the U.S. Department of Energy (DOE), hospitals use 836 trillion Btu of energy each year (yes, that’s trillion, with a “t”!), and produce more than 2.5 times the energy intensity and carbon dioxide (CO2) emissions of commercial office buildings. They produce more than 30 pounds of CO2 emissions per square foot and spend over $5 billion each year on energy. Often, these energy costs account for 1 to 3 percent of a typical hospital’s operating budget or 15 percent of profits.

Recognizing this, in 2009, the DOE launched the Hospital Energy Alliance to work toward improving energy efficiency and reducing greenhouse-gas emissions of healthcare systems. Doing so, according to the agency, would not only reduce the systems’ environmental impact and carbon footprints, but also would improve profitability, lower operations and maintenance costs, and create healthier healing and work environments.

Facility designers, operators, and owners also are increasingly recognizing the importance of addressing energy use in this market sector. In its 2011 Energy Efficiency Indicator, the Institute for Building Efficiency—which is an initiative of Johnson Controls—found that 64 percent of healthcare respondents find energy use is very or extremely important (up from 58 percent in 2010).

But reducing the environmental footprint of healthcare facilities remains a challenge. In 2010 and 2011, the Corporate Realty, Design & Management Institute and the Health Care Council of the International Facility Management Association surveyed 1,251 architects, designers, engineers, hospital facility managers, and other healthcare-related building professionals in 20 major metropolitan areas. The survey found that the perception of progress in greening facilities in the healthcare industry remains far below that of other market sectors. When asked, “Compared to other industries, how effective is healthcare in implementing sustainable solutions?” 54 percent of respondents said it was worse. Only 8 percent said it was better. In addition, 64 percent reported that they worry most about the reliability of infrastructure in the operations of their facilities.

If energy is such a huge concern, what’s the holdup in investing in building techniques, technologies, and equipment to address it? According to the 2011 Energy Efficiency Indicator cited earlier, there are two simple answers: lack of funding and insufficient payback or return on investment (ROI).

The need to demonstrate sufficient return on sustainable investments is not unique to the healthcare sector. In the 2011 Energy Efficiency Indicator, which includes additional building sectors beyond healthcare, the top three barriers to pursuing energy efficiency as reported by respondents in the United States and Canada were available capital (38 percent), financial criteria (21 percent), and certainty of savings (10 percent).

And while the government is supporting green initiatives, such as those required by Executive Order 13514 (“Federal Leadership in Environmental, Energy, and Economic Performance,” signed Oct. 5, 2009), it, too, is struggling with cost justification. As we reported online and recap in this issue’s Greenscene section (page 12), the recently passed National Defense Authorization Act requires the U.S. Secretary of Defense to submit to Congress a cost–benefit analysis for the Department of Defense’s (DoD) use of standards including ASHRAE 189.1-2011, ASHRAE 90.1-2010, and LEED Silver, Gold, and Platinum certifications. The report must show the return on investment and long-term payback from adhering to the aforementioned standards and certification systems. In addition, the DoD is prohibited from pursuing LEED Gold and Platinum certifications during fiscal year 2012 unless a cost–benefit analysis can demonstrate payback for the sustainable features and show that pursuing the certifications will not require the DoD to pay additional costs.

With all of this in mind, I think this issue of eco-structure will be of high interest, specifically the project in our cover story: Fort Belvoir Community Hospital (“Research and Rehabilitation,” page 36).

In designing the government facility, architecture firm HDR used its sustainable return on investment (SROI) analysis framework to evaluate the monetary value of sustainability programs and projects. Design options are measured from a life-cycle cost perspective, rather than first-cost, and the methodology incorporates data such as utility rate pricing structures to create a detailed financial analysis. The process is fascinating and much more involved that I can adequately describe here. So, after you have read that feature story, head over to to read more about the process in a Web-exclusive essay from the folks at HDR—titled, simply, “Measuring Sustainable Return on Investment.” I guarantee it will be worth the investment of your time.