Building Design and Construction

Sustainable building design and construction is the practice of creating structures and using processes that are environmentally responsible and resource efficient throughout the life cycle of a building– from selecting the site to design, construction, operation, maintenance, renovation, and finally, deconstruction.

Sustainable building expands on and complements the classical building design considerations of economy, utility, durability, and comfort. Other terms for sustainable building include green building, high performance building, or sustainable or green construction.

The Impact of Buildings on the Environment

According to the U.S. Environmental Protection Agency and the U.S. Green Building Council, construction and operation of all buildings in the United States result in the following consumption of resources:

  • 72 percent of electricity resources
  • 39 percent of total energy used
  • 3 billion tons of raw materials annually (40 percent of raw stone, gravel, sand, and steel; 25 percent of virgin wood)
  • 17 percent of freshwater flows

As well, construction and operation of all buildings in the United States result in the following generation of waste materials:

  • 25-40 percent of municipal solid waste
  • 50 percent of CFCs
  • 30 percent of CO2 production
  • Other air emissions and water discharges

Given the extent to which buildings affect the environment, the opportunities for improvement through sustainable planning, design, construction, and operations and maintenance practices are significant.

Although an organization may choose to prioritize energy reduction, water conservation, waste minimization, or any number of individual initiatives, the practice of sustainable building is really about an integrated approach to planning, design, construction, operations, and maintenance. It is an overarching philosophy or commitment that influences decision-making in every phase of a project. Sustainable building goes beyond simple return-on-investment (ROI) analysis of the first costs of specific improvements; rather, it evaluates an improvement over its entire life cycle, including first costs and subsequent operations, maintenance, and disposal costs.

The health care industry seeks to protect, restore, and enhance health. As a result, it is important for health care organizations to adopt an approach to design, construction, and operations and maintenance that supports a healthy environment, both in their facilities and in their communities.

How Buildings Affect Health

Building design, construction, and operation practices affect public health on three levels (adapted from the Green Health Care Construction Guidance Statement of the ASHE Green Building Committee):

The immediate health of building occupants. The health of patients, staff, and visitors is affected by the quality of indoor air, which in turn is dependent on a building’s physical and mechanical design (e.g., ventilation, airflow and pressure, location of wastes and toxins), choice of building materials, management of construction emissions, and building operations and maintenance. In addition, access to daylight has been found to favorably affect staff productivity and patient outcomes.

The health of the surrounding community. Local air and water quality is affected by building design choices for both new construction and renovation projects). Off-gassing (release of chemicals into the air through evaporation, sometimes over a number of years) of building materials and finishes, fumes from construction equipment, and exhaust from HVAC systems can emit VOCs (volatile organic compounds), particulates, and other materials into the air of the surrounding community that can contribute to formation of ground-level ozone (smog) and induce allergic attacks, respiratory problems, and other illnesses. Thoughtful land use and transportation planning, landscape and water management on the grounds, and responsible air filtration, waste disposal, and energy and water conservation efforts within the building all influence the amount of toxic emissions released to the water and air throughout the life of the building.

The health of the larger global community and natural resources. The health impact of a building stretches far beyond its immediate community. The production of building materials can release persistent bio-accumulative toxic compounds, carcinogens, endocrine disruptors, and other toxic substances. The compounds in these materials threaten not just the communities where they are manufactured; in fact, many of them potentially threaten the health of communities and ecosystems far from their place of manufacture and use because of their long life and disposal hazards.

Energy use and associated greenhouse gas emissions contribute to climate change. Climate change resulting from the burning of fossil fuels is expected to increase the spread of disease vectors far beyond their current regions, destabilize ecosystems, and ultimately, to threaten worldwide food supply and quality. Rainforest depletion from unsustainable forestry practices may result in the loss of medicines and important genetic information that could help fight diseases. Moreover, the release of chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs) damages the stratospheric ozone layer, allowing increased levels of ultraviolet rays to reach Earth’s surface, where they cause heightened potential for skin cancer.

For more information about climate change, read Climate Change Law 101. To learn more about climate change mitigation strategies, refer to the Roadmap Strategies sections on energy and water conservation measures, waste reduction measures, and chemicals policy.

The other topic areas in this section explore specific aspects of sustainable buildings in greater detail. Click the links on the left to learn more.

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The Precautionary Principle

Prevention is a fundamental principle of providing quality health care and protecting public health. Indeed, preventing disease is vastly preferable and more effective than treating disease after it has occurred. In the face of uncertainty, precautionary action is appropriate to prevent harm. This public health approach makes sense both in the clinical setting and in response to environmental and public health hazards. Similarly, a precautionary and preventive approach is an appropriate basis for decisions regarding material selection, design features, mechanical systems, infrastructure, and operations and maintenance practices.

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Integrating Sustainable Principles into Project Delivery

The ASHE Green Building Committee developed a construction guidance statement to answer the question of what sustainable design and construction means in the context of a health care facility. Although this material is intended as a guideline for new construction, many of the principles can be applied to existing buildings as well. The Roadmap covers most of these principles in greater detail throughout the site, with an emphasis on improving existing facilities.
Common practices for integrating sustainability into the design process address those aspects of planning, design, construction, and operations listed below. For descriptions of these practices, read the ASHE board's guidance statement.

  • Integrated design
  • Site design
  • Water
  • Energy
  • Indoor environmental quality
  • Materials and products
  • Construction practices
  • Commissioning
  • Operations and maintenance
  • Innovation

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Compliance and Policy Considerations

Many states and cities have adopted some form of sustainable building standard as part of their local building codes. For example, the 2010 Oregon Energy Efficiency Code, which applies to all new building and renovation projects requiring a building permit, is a local adaptation of the International Energy Conservation Code.California has recently enacted the first statewide green building code, and Massachusetts requires compliance with LEED requirements or self-certification through the Green Guide for Health Care in order to obtain a Determination of Need for a health care facility. This trend is gaining momentum. Your local building code office is a good place to start to determine what will be required for your project.

In June 2010, the U.S. Conference of Mayors endorsed the International Green Construction Code (IgCC), which was developed by the International Code Council in collaboration with the American Institute of Architects, ASTM International, ASHRAE, the U.S. Green Building Council, and the Illuminating Engineering Society (IES). This code references ASHRAE Standard 189.1-2009: Design of High-Performance Green Buildings, Except Low-Rise Residential Buildings and includes requirements in the following categories:

  • Site development and land use
  • Material resource conservation and efficiency
  • Energy conservation, efficiency, and atmospheric quality
  • Water resource conservation and efficiency
  • Indoor environmental quality and comfort
  • Commissioning, operations, and maintenance
  • Existing buildings
  • Existing building site development

Also, be mindful of related climate change legislation, as this will impact both the types of projects you may pursue and the way you implement them. For an outline of the breadth of current and expected climate change legislation, see the material on regulatory requirements under the Drivers tab on this website.

Opportunities and Benefits

Planning for a construction project offers health care organizations an opportunity to formulate overall sustainable building goals, if these are not already in place. These goals can include such actions as using sustainable materials in a renovation project or adding more green space around the facility. Your organization should agree on goals and then develop and implement strategies to achieve them. Work with an experienced sustainable building team specializing in health care facilities to implement advanced sustainable building strategies that will realize additional gains. The Green Guide for Health Care rating system is a good tool for incorporating sustainability into hospital design and construction. Many hospitals also refer to the USGBC LEED certification system for guidance in greener building and construction.

A number of incentives and policies exist to support sustainable building practices. To learn what may apply to your organization’s project, explore the following areas:

Energy-efficient commercial buildings tax deduction: The federal Energy Policy Act of 2005 established a tax deduction for energy-efficient commercial buildings applicable to qualifying systems and buildings placed in service from January 1, 2006 through December 31, 2007. This deduction was subsequently extended through 2013 by Section 303 of the federal Energy Improvement and Extension Act of 2008 (H.R. 1424, Division B), enacted in October 2008.
A tax deduction of $1.80 per square foot is available to owners of new or existing commercial buildings that make improvements to (1) interior lighting; (2) building envelope, or (3) heating, cooling, ventilation, or hot water systems. These improvements must be part of a plan to reduce the building’s total energy and power cost by 50 percent or more in comparison to a building meeting minimum requirements set by ASHRAE Standard 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings.
For more information, visit

State and local incentives and regulations: Several states, counties and municipalities have implemented financial incentives, expedited permitting programs, and instituted regulations to promote sustainable design and construction. For a searchable, up-to-date listing, visit the Database of State Incentives for Renewables and Efficiency (DSIRE) website at

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Triple Bottom-Line Benefits

Given the significant benefit to the environment that can result from instituting sustainable building practices across the country, the potential contribution of the health care sector is proportionally large. Sustainable building practices contribute to “triple bottom line” benefits; in other words, greener buildings result in improved performance in three areas: environmental, economic, and health and community. For each building project, your organization should identify, qualify, and quantify the benefits in each bottom line area. Examples in each of the three areas are listed below:

Environmental Benefits

  • Enhancement and protection of ecosystems and biodiversity
  • Improved air and water quality
  • Reduced solid waste
  • Conservation of natural resources

Economic Benefits

  • Reduced operating costs
  • Enhanced asset value and profits
  • Improvements in employee productivity and satisfaction
  • Optimized economic performance throughout the building’s life cycle
  • Increased resiliency against unstable energy markets

Health and Community Benefits

  • Improved air, thermal, and acoustic environments
  • Enhanced occupant comfort and health
  • Minimized strain on local infrastructure
  • Contributions to overall quality of life 

How Buildings Work

ASHE is committed to enhancing the professional knowledge of building systems or, simply put, to adding to the body of knowledge of how stuff works. When considering new technologies and sustainable systems, understanding how buildings work is important. To that end, we plan to draw on ASHE’s Maintenance Management for Health Care Facilities. We also want to add your experiences to the discourse, so if you have materials or stories to share, please contact the roadmap coordinator.

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The ASHE Health Facility Commissioning Guidelines (HFCx Guidelines) defines “commissioning” as a process intended to ensure that building systems are installed and perform in accordance with the design intent, that the design intent is consistent with the owner’s project requirements, and that operations and maintenance staff are adequately prepared to operate and maintain the completed facility. The HFCx Guidelines offer a commissioning (Cx) process structured to meet the specific needs of the health care industry. By providing a standard set of terms, definitions, and processes, the guidelines bring a consistency to the commissioning of health care facilities—referred to as HFCx—that helps optimize the return on investment (ROI) realized from a project.

Many buildings designed for high performance fail to achieve high-performance results. ASHE is convinced that commissioning is critical to the success of every health care facility project. The guidelines are intended to help health care organizations achieve the facilities they want. ASHE has also produced the Health Facility Commissioning Handbook to provide practical information to help those launching a health facility commissioning or retrocommissioning effort.

The value derived from commissioning can be shown as a simple relationship in which the benefit obtained from commissioning is divided by the cost to deliver it: Value = Benefits / Cost. The greater the benefit derived from a specific cost, the greater the value to leadership. A properly commissioned project lowers the cost of operating a facility, often as a result of lower utility demands and costs. Be sure not to confuse contract administration services provided by the design team during construction with commissioning. The fundamental element that separates the two is the benchmarking documentation of equipment installation and performance involved in commissioning.

Similar to the benefit/cost relationship for commissioning, the value of sustainability is measured by improvements in environmental performance and satisfaction, and reductions in energy and water consumption and costs, divided by the cost of the improvements. Sustainability is focused on cost-effectiveness, quality, satisfaction, and environmental performance. Commissioning is fundamentally in alignment with these objectives. To that end, the Roadmap’s performance improvement measures (PIMs), where appropriate, link to specific and targeted commissioning and retrocommissioning topic areas found in the ASHE Health Facility Commissioning Guidelines.

For more information about commissioning, see the page on commissioning under the Strategies tab on the Sustainability Roadmap.

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Using the Roadmap to Develop Sustainable Buildings

The Roadmap identifies opportunities for health care organization to improve their facility’s sustainability performance for energy, water, waste, supply chain, and chemical management through both facility design and operations. It helps health care organizations develop customized short- and/or long-term management strategies to achieve sustainability goals. Your organization can customize its goals and plans based on your facility’s baselines and benchmarks in sustainability performance and on how aggressively the organization wants to pursue its goals.

Roadmap resources that can be applied to sustainable building design and construction efforts include the following:

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