The Operational Side of Sustainability – Sustainable Landscapes

Any Owner with a significant portion of lawn, natural, and/or impervious surfaces – typically Educational, Healthcare, Government, Hotel/Lodging, Transportation, and Recreational organizations – needs to consider a  landscape management strategy.

Maintenance costs, energy/water usage, security, carbon footprint, and aesthetics are all directly linked to sustainable landscape strategies.

Initial implementation is, of course important, long term operational aspects and adaptation, however, are the keys to success.  Beyond initial design work (renderings, plant selection, overall strategies), a HANDBOOK OF BEST MANAGEMENT PRACTICES FOR THE LANDSCAPE (Ground Maintenance Handbook) is a requisite component.    The Ground Maintenance Handbook should include step-by-step strategies for installing and maintaining the landscape designs over time. It must be a living document that is updated as new discoveries and adaptations are made by the landscape crew. It is grounded in the concept of adaptive management, where the goal is to plan responses to multiple outcomes (e.g., deer eating the seedlings and invasion by bittersweet).

While this may be a lot to ask from a traditional landscape firm,  and is the piece that is often missing from landscape plan, the Ground Maintenance Handbook is a requirement for success.

Sustainable Landscape - Adapative Maintenance Strategies

Sure, everything might look great when it’s installed at full maturity for completion photographs. But what happens afterwards?

See more at ….

New LEED for Existing Buildings – LEED EB Draft 2010



This credit applies to:

Existing Buildings: Operations & Maintenance

EB:O&M Schools

EB:O&M Retail

EB:O&M Data Centers

EB:O&M Hospitality


Develop an early understanding of the relationships between technical systems, natural systems and occupants within a building project, its site, its context, and its intended use.  Engage all key project team members for the purpose of making cost- and environmentally-effective integrated decisions throughout the design and construction process.



Demonstrate that key systems interactions are explored and analyzed in a way that informs basic building renovation/reconfiguration, envelope modifications, site-related modifications, technical systems operations, and maintenance decisions while determining EBOM credits to pursue, by implementing the following:

Water Synergies: (x points) Develop an implementation plan (roadmap) that schedules tasks and activities to identify and analyze cost and performance synergies between systems relative to water use and water quality. This analysis must identify interactions between no less than 5 credits across no less than three credit categories (SS, WE, EA, MR, IEQ). Document projected cost and performance benefits for at least 8 years of future operations relative to the benchmarks established for each of the germane credits.  AND  Implement the above Water Synergies Plan over the performance period (no less than 2 years) and document resultant quantified cost and performance benefits by utilizing ongoing performance data and integrated cost bundling to analyze the effectiveness of the plan.

Energy Synergies: (x points) Develop an implementation plan (roadmap) that schedules tasks and activities to identify and analyze cost and performance synergies between systems relative to energy use. This analysis must identify interactions between no less than 5 credits across no less than three credit categories (SS, WE, EA, MR, IEQ). Document projected cost and performance benefits for at least 8 years of future operations relative to the benchmarks established for each of the germane credits.   AND  Implement the above Energy Synergies Plan over the performance period (no less than 2 years) and document resultant quantified cost and performance benefits by utilizing ongoing performance data and integrated cost bundling to analyze the effectiveness of the plan.

via – Premier Construction Cost Estimating and Project Management Software for Facility Renovation, Repair, and Sustainability – JOC, SABER, SATOC, MATOC, IDIQ ….

Why DBB – Design Bid Build is Dead – Or Should Be!

Facilities ” Sustainability ”  must be viewed from two perspectives simultaneously – environmental and economic.
In higher education, just as an example, colleges and universities need to change there ” facilities business model” just to survive.   Colleges and universities must  reduce their carbon footprint to deal with global climate change, however, they also need to address total cost of ownership to survive financially.
Second to personnel/labor costs, facilities represent the second largest operating expenditure for this sector… and many, if not most, others.

To deal with facility renovation, repair, and sustainability an alternative to design-bid-build (DBB)  is required.

DBB is inefficient,  too costly and too slow and is not performance-based, nor does it encourage collaboration or quality.

Total Cost of Ownership (TCO) of the building, not just construction costs including renovation, repair costs,  and associated modifications have to be factored over the next 10-20 years at a minimum, as well as life-time operations costs.

While IPD and BIM offer the promise of collaboration among owners, constractors and AE’s to a plan construct, or modify a building that meets long-term needs; otherwise not possible with design-bid-build; JOC / Job Order Contracting is a proven method deployable today for facility repair, renovation, and sustainability construction project that meets all criteria for collaborative, quality, time shortening, an a performance-based approach.

With a supporting software technology, the JOC process can be consistently deployed and critical domain information relative to project costing and management retained for future use.

Furthermore, from a “green” sustainability perspective, there isn’t a single larger (multi-building) portfolio owner that can meet future energy reduction requirement via new “LEED” or similar building alone.

Existing building retrofit will be the key, and JOC is well suited to the task of associated shell, HVAC, lighting, and other energy related projects.

BIM will certainly play a role, especially as 4D, 5D BIM becomes are reality.  That said, however, an efficient CONSTRUCTION DELIVERY METHOD MUST be integrated with any BIM strategy.  Again… JOC meets the performance requirements.

With 66% of facility owners primarly using  DBB / use design-bid-build yet only 23% believing it offers the best value, the accelerating adoption of JOC isn’t surprising.

It’s time for ALL facility owners to be rid of the status quo…. and bury DBB.
By Estimators For Estimators

Stimulus Package not Improving Health Care Facility Construction ?

With $33B in the hospital and clinic pipeline, the health care buidlign boom is officially over.   In 2009, nearly 20% of heathcare site construction project already in process, 36% scaled back and 32% cancelled items in the planning stage.

It currently appears that 2010 could be worse than 2009.

It doesn’t appear that the Stimulus Bill, BIM, or Sustainability willl drive growth in the Health Care sector.

Healthcare strategic planning

This article describes a systematic process of strategic planning for healthcare services, as part of a national development plan, using the Galilee’s plan as a case study.

Healthcare strategic planning as part of national and regional development in the Israeli Galilee: a case study of the planning process.


Regional development usually involves population growth and changes in population distribution. This process occurs in tandem with the availability of health, social and other community services, and has the potential to significantly affect the health and wellbeing of communities, both existing and new (McMicheal & Powles1999; Parliament of Australia House of Representatives 2005).

In March 2005, the Israeli government declared a national plan for its northern region, theGalilee. The region was to become an advanced, established and competitive society, economically strong, attractive to new residents and sustaining a civil society with a high quality of life. The plan’s goals were to consolidate a perennial strategic plan encompassing economic, social and infrastructure factors, with the aim that these plans would be be adapted and considered by policy makers. From the beginning of the process, the plan’s taskforce recognised the significant role the healthcare system plays in the region. The healthcare delivery system is a major employer of high quality manpower, and has a significant impact on the wellbeing of existing and new populations. Thus, the aim of the healthcare strategic plan was to suggest initiatives and actions to be taken in order to improve healthcare supply and the health and wellbeing of all local residents.
This article describes a systematic process of strategic planning for healthcare services, as part of a national development plan, using the Galilee’s plan as a case study.

Background: the Israeli Galilee

The Galilee is the northern region of Israel, comprises 1,185,000 inhabitants

, and spreads over 4,474 square kilometres (22% of national land) (Central Bureau of Statistics 2007). According to

demographic analysis, the population is expected to expand in the next decade (i.e. until 2020) by up to 1,558,500 due to natural growth and by up to 1,756,000 according to the national plan authorised by the Government.

For many years the region has experienced inequities and inequalities in the availability and accessibility of healthcare services as well as in health and welfare indicators, which have been well documented in Israeli studies (Nirel et al. 2000; Horev & Epstein 2007; Ministry of Health 2008). These studies indicated that in only 20% of the region’s households are all adults employed, 43% of whom earn only the minimum national wage. The average number of persons per household is 4.01, in comparison with a national average of 3.3 (Central Bureau of Statistics 2007).

Infant mortality rates for the years 2003-2005 averaged 4.1 deaths per one thousand live births, compared with a national average of 3.3. The rate for birth malformations was 20 per thousand live births in 2005, compared with a national rate of 16. Mortality due to cardiac and cerebralvascular diseases were higher in the Galilee compared with the national average; only cancer mortality rates were lower in comparison with national figures (Central Bureau of Statistics 2007). Nine percent of the adult population in the Galilee reported in 2003-2004 that a physician diagnosed them as having cardiovascular disease

compared with 7%- 8% in other Israeli regions. Forty-eight percent evaluated their personal health status as being ‘very good’ compared with 60% in other regions. Only 60% evaluated their mental health as ‘very good’ compared with 70% in other regions across the country (Ministry of Health n.d.). Physicians and hospital bed rates in the Galilee region are the lowest throughout the country (Nirel et al. 2000; Horev & Epstein 2007; Ministry of Health 2008). These figures probably indicate poor access to healthcare services or presence of pre-conditions, which significantly affect adequate use of healthcare services.


The planning process

Theoretical structure

Johnson (2005) describes organisational strategic planning as a cyclical

process with three dimensions:

a) Assessment of needs and demands. For assessing the needs and demands of an organisation, in our case, of a regional health care delivery system, we need information about the existing resources and the external forces that should be considered during the planning process.

b) Prioritisation. The prioritisation phase adds value to the planning process by asking why and how one solution or project will be initiated before the others.

c) Scheduling. The scheduling phase takes theoretical priorities derived in the assessment phase and introduces them to reality.

These three stages are essential especially when the planning process is aimed to ultimately allocate scarce resources among competing demands (Johnson 2005).

Figure 1 illustrates our planning cycle, which is based on data acquisition and analysis, prioritisation among all demands raised from data and experts opinions, and scheduling initiatives according to priorities: that is, what should be done in the immediate time and along the coming years up to 2020.


Stage One–assessment

When assessing the area’s healthcare needs, services were analysed according to the three levels of the Israeli healthcare system:

* primary services, which are community services provided by four Israeli Health Maintenance Organisations (HMOs) (under a National Health Insurance Law), and by public health services via regional officers

* secondary services, which are expert and consultant medical services, provided byHMO

specialists and outpatient clinics in local hospitals

* tertiary services, which are provided by five public and three non-profit hospitals.

Primary and secondary services

Data about primary and secondary services including manpower, workforce needs, infrastructures and existing facilities, were gathered by open and deep interviews with medical officers and other decision- and policy-makers. Figures on quantitative questions, such as the number of doctors in each specialty available in the region, were obtained from the Israeli Medical Association (Israeli Medical Association 2008).

The results show that physician numbers in Galilee are very low compared with national figures, as well as those of specific regions in Israel (Figure 2). The information obtained revealed a shortage in high quality and well-trained manpower, especially in community and family medicine and paediatrics. All of the HMO management boards emphasised the difficulties they face to convince skilled and well trained physicians to move their practicesnorthward

from established practices in central Israel.

Tertiary services

Data concerning tertiary services were gathered from national registries, and focused mainly on hospital bed numbers and regional and national bed rates, in addition to activity indicators for each local hospital, such as average length of stay (LOS), occupancy percentage and bed circulation (i.e. number of hospitalisation days in a specific period multiplied by occupancy rate divided by LOS) (Ministry of Health 2008; Central Bureau of Statistics 2007). The calculations of present and future hospital bed needs were based on national bed rates for seven selected wards (Internal Medicine, ICCU

, NICCU, Paediatrics, General Surgical,Rehabilitation, Obstetrics) and demographic forecasts with activity measurements taken into consideration.

Situated in the nearby region is Haifa, the third largest Israeli city which is located on the coast south of Galilee. In Haifa there are three general hospitals with a total of 1741 beds. All our calculations for hospital bed needs took into account the possible contribution of Haifa’s beds to the figures for the Galilee. It does not mean that beds will necessarily be allocated to Galilee, but services could potentially be provided to the Galilee population if required.

Needs for diagnostic and treatment technologies and infrastructures, manpower, relationships between providers, HMOs and the population, other special needs and major problems were thoroughly discussed with all eight hospital management boards. The information about incremental hospital beds was analysed separately for the region and with respect to bed needs and those that exist in a neighboring

region (Haifa district). During the planning process, it was hypothesised that:

* The Israeli mean for bed rates will stay constant (more or less) for the next decade.

* The age distribution for the region will not change dramatically in the coming years.

* The hospital length of stay will decrease, especially in surgical wards, due to innovation in sophisticated surgical techniques.

Throughout our discussions with the Israeli Ministry of Health, all of our analyses were compared with records of the analyses performed by the Ministry.

Results for Stage One

The results suggest a need for an additional 1,158 hospital beds by the year 2020. This comprises 377 additional beds that are needed immediately for closing gaps and addressing inequalities, 512 beds by the year 2020 due to natural growth and 269 additional beds by the year 2020 due to the national plan to increase the northern population.

All health providers’ boards–hospitals, HMOs and social and community organisations–noted an urgent need for the following:

* Rehabilitation. For a population of more than a million inhabitants there is no rehabilitation facility available within reasonable distance and traveling time. Thus, the Galilee inhabitants are in urgent need of two rehabilitation centres for cardiology

neurology and orthopedic rehabilitation.

* Neurosurgical wards. None of the eight hospitals in the Galilee have neurosurgical services. Patients with trauma and other acute and non-acute conditions travel 30 to 90 minutes to Haifa in order to obtain neurosurgical treatment. Our analysis revealed an urgent need for at least one neurosurgical service, especially for trauma patients. There is professional capability and willingness to operate neurosurgical services in few of the northern hospitals. They all lack the appropriate licence which we suggest, should be urgently provided to at least one of them.

* Radiation therapy. Oncology patients need to travel two hours each way to receive radiation therapy due to the absence of this type of service in the Galilee. None of the eight northern hospitals has radiation therapy services because of budget insufficiency and absence of licenses. All medical boards stated the need of at least one radiation therapy centre for the benefit of the northern population.

* Long-term care. Our analysis revealed sufficient nursing bed rates for ageing patients, most of them located in rural settlements (kibbutzim

and moshavim). The northern rates for long-term beds are 8.5 per 1,000 inhabitants aged 75+ years compared with a national mean rate of 6.8. However, there is a shortage in complicated long term care beds for chronic illnesses. The northern rates are 2.5 beds per 1,000 inhabitants aged 75+ compared with a national mean rate of 7.7 (Table 1) (Ministry of Health 2008).

* Mental care. Both community and inpatient psychiatric care are provided by one psychiatric hospital located near the city of Acre (in the western part of the Galilee). This is a very old facility built in the beginning of the 20th century. It is generally accepted that this hospital should be rebuilt; however, the different approaches to this plan are under dispute. We evaluated objectively all alternatives for rebuilding this hospital based on economic, professional and good practice measurements and judgment (see the suggestions in the next section).

Stage Two–prioritisation

Primary and secondary services

The need for highly skilled physicians to relocate their practices to the northern region will be met only if robust and bold regulation measures are taken by the government in several areas:

* Skilled physicians will relocate their practices to the Galilee, if they are given the opportunity for private practice in addition to their public service: most Israeli physicians work in public hospitals or HMOs as their main practice, but are allowed to conduct some private practice as specialists and/or surgeons. This is a result of the fact that most Israeli public hospitals are not licenced to provide private health services. We suggest therefore that northern hospitals should be uniquely licenced to allow for inclusion of private practice as a means of attracting skilled practitioners to the region. This step would need active regulation which could only be decreed by the Ministries of Health and Law.

* We recommend that the Ministry of Health and HMOs offer economic incentives for skilled physicians who relocate their practices to the north, These incentives could include cheaper housing, tax reduction and attractive specialising programs.

Hospital beds

As stated, 1,158 additional hospital beds for short-term care are needed in the Galilee by the year 2020. Given scarce resources and the fact that the number of Israeli public hospital beds has not increase in many years, we suggest an urgent and immediate supply of 134 hospital beds in addition to the contribution of another 243 beds by the Haifa district. An additional 287 hospital beds should be added by the year 2020 to meet the population’s natural growth. By 2020, according to the national plan, another 269 beds should be added to the region. In this phase, Haifa will contribute 278 beds (see Table 2).

The cost of providing a new bed in an existing facility in Israel (2007-2008) is US$100,000, in comparison with US$250,000 for one in a new facility. We suggest that the additional hospital beds by the year 2020 be provided in existing facilities and not in new ones, thus saving resources, empowering northern hospitals, and creating centres for excellence.

Rehabilitation and long-term care

In Israel, rehabilitation and long-term care facilities are not economically viable, and hospitals are confronted with financial difficulties in operating these wards for the benefit of the population. As there is no rehabilitation facility in the north, there is a shortage in high dependency care beds. We suggested that regulatory measurements and actions should be taken in order to support rehabilitation and chronic care services.

Our suggestions included dramatic changes in fees and the pricing method: currently Israeli public hospitals charge fixed prices set by the Ministry of Health. These prices, in some cases, do not cover actual costs. However, a funding method using diagnosis related groups (DRG

), for instance, could be one of the solutions to this problem. However, such a solution, which would involve changes in national health insurance and pricing methods, is in the hands of the Ministry of Health.

Neurosurgical wards

The Israeli Neurosurgical Society insists on high surgical volumes in order to sustain high performance, and, for many years objected to the opening of new neurosurgical services in the north, arguing a lack of sufficient patient volumes. Taking into consideration these arguments, the following solutions were suggested:

* Assigning one of the neurosurgical wards in Haifa as a superior ward to a new ward that will be opened in one of the northern hospitals, with the roles of supervision, support and training of new staff.

* Staff from the northern hospitals will rotate service with Haifa neurosurgical professionals. In this case, Haifa hospitals will respond to elective procedures while the northern staff will respond to trauma and acute events.

Psychiatric care

We offered two solutions to the need of rebuilding an old psychiatric hospital in Acre. The first was to retain the independence of the hospital and the existing hospital board. The second one was to finance a new facility as part of Naharia medical campus (situated close to neighbouring Acre), through assigning part of the expensive and valuable real estate and land they own. This solution would create a large health campus with significant centres of excellence. The Ministry of Health support the second solution but unfortunately local political issues presented serious obstacles to the plan.

Stage Three–scheduling

The scheduling phase takes theoretical priorities derived in the assessment phase, and introduces them to reality (Johnson 2005). The worst-case scenario for us in this project was that our plan would remain unimplemented. It was realised that for such an ambitious plan traditional scheduling is not enough, especially where many public arms need to become involved, including central government, philanthropy, non-governmental organisations (NGOs), local municipalities, community leaders with different interests and public agendas, and other public representatives. Therefore, while focusing on this phase we decided to schedule three operational steps.

The first step was to validate the plan’s conclusions and suggestions, its analysis and results. To achieve this, we were introduced to a panel of major caregivers and policy makers who had been invited to an open discussion. By the end of this intensive discussion, most of the suggestions were approved and priorities were scheduled. The scheduling process assisted in developing a compromise between conflicting needs; for example, the recommendation to add 1,158 hospital beds was primarily constructed as a suggestion for a new hospital located in the centre of the Galilee; however, the panel insisted on the distribution of these additional beds between eight existing public and private hospitals. By the end of the process, this suggestion was accepted by the planners.

The second step was to publicise

the plan. A book, describing the planning process, results and recommendations in detail was published and distributed among a wide range of professionals. A short summary of the main conclusions was prepared and presented to governmental decision makers – the Prime-Minister’s Chief of Staff, the Ministry of Health’s General Director, the Minister for Regional Development and, finally, to the President, the former Minister for Regional Development, Mr. Shimon Peres, who has been a strong promoter of the development of the Galilee.

The third step was to create a coalition and a taskforce to lobby for the plan. This group included leaders in the region’s healthcare system, including hospitals, HMOs, public health services and academics. This group’s role was to coordinate the implementation of the plan, and work with governmental ministries on the proposed solutions, especially where regulatory measurements are needed. In order to accelerate the process, the planners initiated the taskforce activities; however, the goal was to eventually hand over all project responsibilities to the taskforce within a year.

Conclusion: lessons learned

Strategic planning achieves optimal allocation of scarce resources by proper execution of three phases: the assessment phase which encompasses the needs of the entire region and its environment; the prioritisation phase, where priorities are established; and the scheduling phase where an implementation timeframe and actions are assigned. Collectively, these tasks comprise the planning cycle (Johnson 2005).

Our planning process, especially during Phase One, explored a wide range of needs for a well-functioning healthcare delivery system. These needs range from broad system changes to local issues such as reductions in local taxes, employment of additional technology and upgrading certain infrastructures. The plan’s mission was to evaluate each need and each demand from a broad perspective, taking into consideration spatial, political and regulatory issues, costs, cost benefit diversity and inequalities into considerations The result of this process is a reasonable and achievable list of five main suggestions as described earlier.

A number of preconditions are necessary to influence policy: political will, sustained funding to encourage methodological rigour

and build decision makers’ confidence, and the development of sufficient capacity and skills (Hall & Viney 2008).

Political will is crucial, implying both receptiveness to new ideas and readiness to change thestatus quo. This must be combined with an appropriate and sustained level of investment over time, and a time frame that allows for the development of rigour and confidence from policymakers and players in the health system. In order to achieve the political will, the plan has to be available, acceptable and affordable by all key political players, and this is the main reason why they all should take part in the planning process. They should be heard, and their visions, needs and perspectives should be taken into consideration while decisions are made. In addition, planners should be aware of political sensitivities and conflicts of interest, and address them professionally.

Half of the Galilee population is made up of Israeli Arab citizens, who conduct a lifestyle that is different from that of the Jewish population. Therefore, it is crucial to approach the planning process with an open heart and mind, especially if the region is ethnically diverse. During the planning process we made a point of analysing special health and morbidity data concerning the Israeli Arab population, and were in close discussions with its community leaders in order to remain sensitive to the region’s diverse needs.

Lobbying activity should occur on behalf of, and in collaboration with, service users and providers equipped with the skills necessary to do so (Cutcliffe & Hannigan 2001). In regional planning, adequate lobbying activity, carried out by professional lobby groups and political activists working in the parliament, is of great help in ensuring political and budgetary support.

Another critical precondition

is that there should be sufficient capacity among independent academic researchers to provide the evidence-base that supports and informs the policy initiatives of government (Hall & Viney 2008). From our long years of experience, we know that if a regional healthcare plan consists of good evidence-based research and is supported by validated data analysis, decision makers are more likely to support the plan.

Summing up

The regional healthcare strategic plan for the Galilee is now in a stage of political and governmental approval. It is our hope that the plan will be confirmed and implemented and that an equal healthcare system will soon be created for all Israel: The north and the south thou hast created them: Tabor and Hermon shall rejoice in thy name (Psalms 89.12).


The authors would like to thank Ms. Ayala Peled Ben-Ari for her contribution to this article.


Central Bureau of Statistics (2007). Statistical Abstract of Israel. 2007-No. 58. Available at: il/reader/shnatonenew_site.htm

Cutcliffe, J.R. and Hannigan, B. (2001). Mass media, ‘monsters’ and mental health clients: the need for increased lobbying. Journal of Psychiatric and Mental Health Nursing

8(4): 315-321.

Hall, J.P. and Viney, R.C. (2008). National health reform needs strategic investment in health services research. Medical Journal of Australia 188(1): 33-35.

Horev, T. and Epstein, L. (2007). Inequality in health and in the health system. Taub Institute for Social Policy Research in Israel. Available at: http://www.taubcenter.

Israeli Medical Association (2008). Available at: http://www. udId=51. English version available at: http://www.ima.

Johnson, W. (2005), The planning cycle. Journal of Healthcare Information Management 19(3): 56-64.

McMicheal, A.J. and Powles, J.W. (1999). Human numbers, environment, sustainability and health. British Medical Journal 319: 977-980.

Ministry of Health (2008). Statistical Data 2008, Available at: asp?maincat=1&catId=2&PageId=43

Ministry of Health (n.d.). National Health Survey 2003-2004. Available at: asp?maincat=1&catid=98&pageid=4331

Nirel, N., Pilpel, D., Rosen, B., Zmora, I., Greenstein, M. and Zalcberg, S. (2000). The accessibility and availability of health services in the south of Israel: has the gap between the south and other regions in Israel been reduced in the wake of the national health insurance law? Brookdale Institute Jerusalem. Available at: http://brookdale.jdc.

Parliament of Australia House of Representatives. (2005). Standing Committee on Environment and Heritage. Inquiry into sustainable cities. Canberra,: The Parliament of the Commonwealth of Australia. Available at: http://www.

Ronit Peled MPH PhD

Senior Lecturer

Faculty of Health sciences

Department of Health Systems Management

Ben Gurion

University of the Negev

Beer Sheva



Jerry Schenirer LLB


Vice CEO

Tzafona Idan Ha Galil

PO Box 12




Table 1: Long term care:
bed rates regional comparison

                             MEAN     GALILEE   CENTRAL   JERUSALEM

Long-term care               68.1      85.0      99.4       66.7
Geriatric rehabilitation      2.8       0.5       6.6        0.8
long-term care                7.7       2.5       8.3        4.9
Long-term geriatric          48.8      69.6      65.4       47.1

Table 2: The need for hospital beds in selected wards

                                        BED NEEDS      BED NEEDS
                                      NATIONAL PLAN     NATURAL
DEPARTMENT                                2020        GROWTH 2020

Internal Medical                         1,001             888
ICU                                         70              62
Cardiology ICU                              70              62
Pediatrics                                 263             234
General Surgical                           421             374
Obstetrics                                 351             312
Rehabilitation                             228             203
Total                                    2,404           2,135
Aggregated Bed needs                     1,158             889
Bed needs in Ranks                         269             512
Haifa Contribution                          53             225
Total need in accordance with Haifa        216             287

                                       BED NEEDS
                                      CLOSING GAPS   EXISTING BEDS
DEPARTMENT                                2005           2005

Internal Medical                              676             506
ICU                                            47              26
Cardiology ICU                                 47              28
Pediatrics                                    178             217
General Surgical                              284             165
Obstetrics                                    237             257
Rehabilitation                                154              47
Total                                       1,623           1,246
Aggregated Bed needs                          377
Bed needs in Ranks                            377
Haifa Contribution                            287
Total need in accordance with Haifa           134

DEPARTMENT                             RATES

Internal Medical                       0.57
ICU                                    0.04
Cardiology ICU                         0.04
Pediatrics                             0.15
General Surgical                       0.24
Obstetrics                             0.20
Rehabilitation                         0.13
Aggregated Bed needs
Bed needs in Ranks
Haifa Contribution
Total need in accordance with Haifa

Figure 2: Physician rates (per 1,000 population)
for the Galilee region compared with
National rates and rates for Tel-Aviv

Tel Aviv     4.7
National     3.4
Galilee      2.2

Note: Table made from bar graph.

via Healthcare strategic planning as part of national and regional development in the Israeli Galilee: a case study of the planning process. – Free Online Library.

Healthcare : Facilities : High-Performance Buildings for High-Tech Industries

The healthcare sector represents a great opportunity and a great challenge for high-tech energy efficiency.

Hospitals are among the most energy intensive of all buildings owing to 24/7 operation, intensive ventilation and air filtration requirements, complex and varied thermal conditioning needs, the extensive and expanding use of electronic medical equipment, disinfection and other special processes, and the life-safety imperative of uninterrupted building operations.

Outpatient surgery centers, skilled nursing facilities, and clinics share some of these challenges and are increasingly being used to provide care once reserved for inpatient hospitals.


Benchmarking is an assessment approach in which energy-related metrics measured or estimated at one facility are compared to those from other facilities and/or specific performance targets. Benchmarks can be derived from distributions of metric values obtained from facilities having similar functionality or characteristics, from engineering analysis or building simulation modeling, or from expert knowledge of standard and best practices. Energy benchmarking allows building owners, managers, and facilities engineers and managers to view how their energy use compares to that of their “peer buildings” (buildings similar in size, function, or another service metric). Based on the performance of an individual building relative to the benchmark, facilities managers can identify potential best practices at their facility (e.g., where they perform better than the benchmark) as well as areas for improvement (e.g., where they perform worse than the benchmark).

The research team at LBNL developed an energy benchmarking system for hospitals to provide information to better understand hospitals’ energy performance and identify energy savings opportunities. While many benchmarks begin with information available from utility bills, the LBNL benchmark works with more resolved energy use data. Singer (2009) presents Version 1.0 of the Hospital Energy Benchmark

This benchmarking system is designed to understand energy use through metrics associated with the following major building energy services and systems:

  • Cooling (including space and equipment)
  • Space heating
  • Domestic hot water (DHW)
  • Steam
  • Ventilation (air movement)
  • Lighting
  • Miscellaneous equipment and plug loads (including distributed medical equipment and computers).

Additionally considered are the following services and spatial resolutions of specific relevance to hospitals:

  • Large (“Group I”) medical equipment.
  • Patient room areas.
  • Other large, resolvable loads (e.g. data centers, kitchens), as feasible.

Energy Efficiency Roadmap

The Energy Efficiency Roadmap presents a road map for improving the energy efficiency of hospitals and other healthcare facilities. The report compiles input from a broad array of experts in healthcare facility design and operations. The initial section lists challenges and barriers to efficiency improvements in healthcare (see below). Achieving energy efficiency will require a broad set of activities including research, development, deployment, demonstration, training, etc., organized around 48 specific objectives. Specific activities are prioritized in consideration of potential impact, likelihood of near- or mid-term feasibility and anticipated cost-effectiveness. This document is intended to be broad in consideration though not exhaustive. Opportunities and needs are identified and described with the goal of focusing efforts and resources.


  1. Challenges related to the provision of medical services: Many parts of a hospital must be operational 24 hours a day, 365 days a year, making it difficult to apply some of the same energy management strategies that have been successful in other environments. Hospitals also have larger HVAC energy use than other commercial buildings, due to stricter ventilation and filtration requirements (an infection control measure). Further, hospitals have unique electric loads (e.g., medical equipment), may need to operate “off the grid,” requiring additional power supplies (e.g., generators), and are often designed for future flexibility.
  2. Challenges related to healthcare organization, structure, and culture: The major mission of hospitals is healthcare. Given that energy costs represent a small fraction of operation costs (usually <5%), hospitals are typically built with limited capital, and most hospitals need to cut costs, which means energy-efficiency measures compete with other capital investments.
  3. Challenges related to the legacy of current facility stock: Hospital buildings between 50-100 years old will be responsible for most US hospital energy use over the next two decades. Construction in an existing facility (e.g., a new wing, a retrofit, etc.) is an infection risk and may trigger more extensive upgrades to meet newer codes, thus it may be more effective to concentrate on how to save energy in these buildings through energy-efficient operations that require minimal, if any, retrofit.
  4. Challenges related to codes and standards: Hospitals often need to meet stricter structural and HVAC provisions than other commercial buildings, making some energy-efficiency strategies (e.g., natural ventilation) more difficult to design and permit.


  1. Understand and Benchmark Energy Use: Develop standard performance metrics, begin to collect data for these metrics, and thus advance performance benchmarking. Energy monitoring and management system best practices should also be documented.
  2. Best Practices and Training: Document best practices and provide training in their implementation to hospital designers, operators, and facility engineers. Specifically, provide guidance for commissioning, information on energy performance of building products, improved maintenance, and strategies to reduce reheat through HVAC system management.
  3. Codes and Standards: Develop performance-based criteria for ventilation standards and research the effect of mixed mode ventilation on medical outcomes.
  4. HVAC System Design (Utilization of Existing Technologies): Assess various HVAC systems, and document performance evaluations of these and other energy-related design elements. Develop guidance documents for designs that minimize reheat and use alternative HVAC systems, including 100% outside air systems, and displacement ventilation systems, among others.,
  5. HVAC Technology and Design Innovation: Demonstrate energy-efficient HVAC technologies and equipment, including alternative dehumidification systems, chilled beam cooling, air filtration and cleaning systems, and others, through test bed facilities.
  6. Electrical System Design: Design electrical systems that support efficient sub-metering and on-site renewable and co-generation power sources, and work to improve the efficiency of distribution systems.
  7. Lighting: Implement lighting best practices, including lighting controls and utilization of daylight.
  8. Medical Equipment and Process Loads: Document the energy use and operational patterns of stationary and distributed medical equipment to inform an energy-efficiency rating system. Also, document process loads in hospitals to better understand the impact of medical equipment on these loads.
  9. Economic and Organizational Issues: Develop design tools to evaluate cost and energy implications of efficiency improvements as a means of motivating efficiency investment. Simultaneously, develop strategies to overcome structural challenges to efficiency investment.
  10. Designing Sustainable Hospitals: Document the effects of building form on patient outcomes and use human factors engineering to illustrate the benefits of sustainable hospital design.

Medical Equipment

Efforts to improve energy efficiency in hospitals can be aided by an accurate apportionment of energy use by building service. Distinct and clearly identifiable end-uses include space cooling, space heating, ventilation (fan energy), lighting, domestic water heating, and steam for sterilization and humidification. There is substantial interest and much uncertainty about the contribution of medical equipment and other miscellaneous electric loads (MELs) to overall energy use in hospitals. This project aims to develop methodologies to assess and quantify these loads and to advance understanding of their magnitude.

It is important to first define the loads that are being examined in this study. The term “medical equipment” is commonly used to describe devices or instruments that contribute to patient care e.g., through diagnosis or treatment. Medical equipment is categorized into three groups. Group I comprises high-voltage imaging devices (e.g., X-rays, MRIS) that are typically stationary and may include multiple components installed in a designated facility. Group II is major moveable equipment that requires special utilities (e.g., patient monitors, EKGs). Group II devices may be the major power users in a hospital because they draw moderate levels of power, but they operate often. Minor medical equipment, also referred to as distributed equipment, includes battery-operated equipment, like IV pumps. EPRI suggests a different classification system, classifying equipment based on function rather than power draw. EPRI groups equipment into eight categories: (1) Patient monitoring, (2) Diagnostic, (3) Medical imaging systems (largest single load type), (4) X-ray, (5) Surgical, (6) Therapeutic, (7) Life-support, and (8) Laboratory equipment. Our study focuses on Group II and Minor Movable equipment, and includes primarily patient monitoring, diagnostic, therapeutic, and life-support equipment. Where possible, we consider surgical and laboratory equipment.

In addition to devices with uniquely medical purposes, there are more common appliances and other equipment that serve medical functions. These include refrigerators, microwaves, computers, etc. There also are many electrically-powered devices that are not directly used in medical care but contribute to overall power use. These include vending machines, televisions, water fountain chillers, etc. The total power consumption of miscellaneous electrical loads includes both medical equipment and devices without clear medical purposes.

Framework for Quantifying Medical Equipment Energy Use

Framework for quantifying medical equipment energy use


Data and Tools for Building Energy Use


  1. AHA TrendWatch
  2. AHA Chartbook
  3. Commercial Building Energy Consumption Survey (CBECS)
    1. CBECS for Healthcare
    2. Modeling approach
  4. California Commercial End-Use Survey (CEUS)
    1. Additional information about modeling
    2. Number of healthcare buildings sampled (pp. 81 – 82 of report)
    3. Pacific Gas & Electric (PG&E) CEUS


  1. Energy IQ for system-level benchmarking (includes CBECS and CEUS data)
  2. Cal-Arch benchmarking tool
  3. EPA Healthcare Benchmarking Tool (Portfolio Manager for facility-level benchmarking)
    1. Technical Description for Hospitals [PDF]
    2. Technical Description for Medical Offices [PDF]


Industry Associations
American Hospital Association (AHA)

Professional Societies
American College of Healthcare Executives (ACHE)
American Institute of Architects (AIA)
American Society for Healthcare Engineering (ASHE)
American Society of Heating Refrigerating and Air-Conditioning Engineers (ASHRAE)
California Society for Healthcare Engineering (CSHE)
Illuminating Engineering Society of North America (IESNA)
International Facility Management Association (IFMA)

Regulatory Organizations
California Office of Statewide Health Planning and Development (OSHPD)
Joint Commission on Accreditation of Healthcare Organizations

Health Care Sustainability Groups
The Center for Health Design
Global Health and Safety Initiative (GHSI)
Health Care Without Harm
Practice Greenhealth

Government Programs

Department of Energy (DOE)
Hospital Energy Alliance

Environmental Protection Agency
ENERGYSTAR for Healthcare


LEED® for Healthcare
PG&E Hospital Project
Northwest Energy Efficiency AllianceBetter Bricks Program for Healthcare/Hospitals


Design Guides

AIA (2010). “Guidelines for Design and Construction of Health Care Facilities“, American Institute of Architects, Washington, DC.

ANSI/ASHRAE/ASHE (2008). “Standard 170-2008: Ventilation Standards for Healthcare Facilities“, American National Standards Institute, Washington, DC.

ASHE (2004). “Healthcare Energy Guidebook: Results of the Healthcare Energy Project“, American Society for Healthcare Engineering, Chicago, IL.

ASHRAE (2007). “Advanced Energy Design Guide for Small Hospitals and Healthcare Facilities“, American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc., Atlanta, GA, 199 pp.

ASHRAE (2007). “Standard 90.1-2007: Energy Standard for Buildings Except Low-Rise Residential Buildings“, American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Atlanta, GA.

ASHRAE (2004). “Standard 55-2004: Thermal Environmental Conditions for Human Occupancy“, American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Atlanta, GA.

ASHRAE (2001). “Standard 62-2001: Ventilation for Acceptable Indoor Air Quality“, American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Atlanta, GA.

Carr, R. F. (2008). “Whole Building Design Guide: Health Care Facilities“. Accessed 19 Nov, 2009.

Department of Veterans Affairs. (2008). “HVAC Design Manual for: New Hospitals, Replacement Hospitals, Ambulatory Care, Clinical Additions, Energy Centers, Outpatient Clinics, Animal Research Facilities, Laboratory Buildings”, Office of Construction & Facilities Management, Facilities Quality Service (00CFM1A), Department of Veterans Affairs,, Washington DC, 379 pp. [PDF]

Frumkin, H., and Coussens, C. (2007). “Green Healthcare Institutions: Health, Environment and Economics, Workshop Summary“, National Academies Press, Washington DC, 128 pp.

Guenther, R., and Vittori, G. (2008). “Sustainable Healthcare Architecture“, John Wiley & Sons Inc., Hoboken, NJ, 448 pp.

Houghton, A., and Guttmann, S. (2007). “A Prescriptive Path to Energy Efficiency Improvements for Hospitals.” White Paper, The Green Guide for Healthcare, Austin, TX. (free download)

IEEE. (2007). “Standard 602-2007: IEEE Recommended Practice for Electric Systems in Health Care Facilities”, IEEE, Piscataway, NJ.

IESNA. (2000). “The IESNA Lighting Handbook: Reference and Applications“, Illuminating Engineering Society of North America, New York, NY.

Kobus, R., Skaggs, R., Bobrow, M., Thomas, J., and Payette, T. (2000). “Building Type Basics for Healthcare Facilities“, John Wiley & Sons, New York, NY, 368 pp.

Sehulster, L., and Chinn, R. Y. W. (2003). “Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)“. Accessed 19 Nov, 2009.

Technical Reports

Burpee, H., Loveland, J., Hatten, M., and Price, S. (2009). “High Performance Hospital Partnerships: Reaching the 2030 Challenge and Improving the Health and Healing Environment.” American Society of Healthcare Engineering Annual Conference and Technical Exhibition, Anaheim, CA, 24 pp., 2-5 Aug. [PDF]

Cramer-Krasslet (2007). “Energy Efficiency Indicator Research — Final Report.” Johnson Controls and International Facility Managers Association, 47 pp.

Deru, M., and Torcellini, P. (2006). “Source Energy and Emission Factors for Energy Use in Buildings.” NREL/TP-550-38617, National Renewable Energy Laboratory, Golden, CO. 39 pp. [PDF]

EPA (2001). “ENERGY STAR® Performance Ratings: Technical Methodology for Hospital (Acute Care/Children’s)”. Accessed 19 Nov, 2009. [PDF]

EPA (2004). “ENERGY STAR® Performance Ratings: Technical Methodology for Medical Office Buildings”. Accessed 19 Nov, 2009. [PDF]

EPA (2007). “ENERGY STAR® Performance Ratings: Technical Methodology for Medical Office Buildings”. Accessed 19 Nov, 2009. [PDF]

Gillespie, K. L., Haves, P., Hitchcock, R. J., Deringer, J., and Kinney, K. L. (2006). “A Guide for Specifying Performance Monitoring Systems in Commercial and Institutional Buildings.” National Conference on Building Commissioning, April 19-21, 14 pp. [PDF]

Itron Inc. (2006). “California Commercial End-Use Survey.” CEC-400-2006-005, Prepared for the California Energy Commission, 339 pp. [PDF]

Pacific Gas & Electric Company (PG&E) (1999). “Commercial Building Survey Report 1999.” 34 pp. [PDF]

Reed, J. H., Johnson, K., Riggert, J., and Oh, A. D. (2004). “Who Plays and Who Decides: The Structure and Operation of the Commercial Building Market.” Contract Number DE-AF26-02NT20528, U.S. Department of Energy Office of Building Technology, State and Community Programs, Innovologie LLC, Rockville, MD, 323 pp.PDF]