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A critical analysis of building sustainability assessment
methods for healthcare buildings
Maria de Fa
´tima Castro •Ricardo Mateus •Luı
´s Braganc¸a
Received: 8 June 2014 / Accepted: 8 December 2014
Springer Science+Business Media Dordrecht 2014
Abstract The healthcare building project contains different aspects from the most
common projects. Designing a healthcare environment is based on a number of criteria
related to the satisfaction and well-being of the professional working teams, patients and
administrators. Mostly due to various design requirements, these buildings are rarely
designed and operated in a sustainable way. Therefore, the sustainable development is a
concept whose importance has grown significantly in the last decade in this sector. The
worldwide economic crisis reinforces the growing environmental concerns as well as
raising awareness among people to a necessary and inevitable shift in the values of their
society. To support sustainable building design, several building sustainability assessment
(BSA) methods are being developed worldwide. Since healthcare buildings are rather
complex systems than other buildings, so specific methods were developed for them. These
methods are aimed to support decision-making towards the introduction of the best sus-
tainability practices during the design and operation phases of a healthcare environment.
However, the comparison between the results of different methods is difficult, if not
impossible, since they address different environmental, societal and economic criteria, and
they emphasize different phases of the life cycle. Therefore, the aim of this study was to
clarify the differences between the main BSA methods for healthcare buildings by ana-
lysing and categorizing them. Furthermore, the benefits of these methods in promoting a
more sustainable environment will be analysed, and the current situation of them within the
context of standardization of the concept sustainable construction will be discussed.
Keywords Assessment methods Healthcare buildings Life cycle Sustainability
M. F. Castro (&)R. Mateus L. Braganc¸a
Territory, Environmental and Construction Research Centre (C-TAC), University of Minho, Campus
de Azure
´m, 4800-048 Guimara
˜es, Portugal
e-mail: info@mfcastro.com
R. Mateus
e-mail: ricardomateus@civil.uminho.pt
L. Braganc¸a
e-mail: braganca@civil.uminho.pt
123
Environ Dev Sustain
DOI 10.1007/s10668-014-9611-0
1 Introduction
The health sector has a strong influence on the economy of nations and their policies,
incorporating a group of buildings where the quality of the indoor environment is quite
significant. The intensive operation of this equipment for 24 h, the high number and
movement of people, the existence of distinct work zones with different energy needs, the
existence of different functions such as treatment, education, research, rehabilitation,
health promotion and disease prevention, the need for the existence of systems strategic
reserve of equipment for constant energy supply, and the size of facilities are the key points
that differentiate these from other types of buildings and make it a specific case study
(Johnson 2010).
According to the Environmental Protection Agency (EPA), a healthcare facility is the
second most energy-intensive commercial building type, after the food service industry
(Johnson 2010). The high-energy consumption in healthcare buildings is mainly due to
their continuous operation, requiring light, heat, energy-intensive ventilation, sterilization
and preparation of food. Together with these facts, this type of buildings is responsible for
generating a great amount of waste. For example, in the USA, five million tons of solid
waste is produced on an annual basis (Johnson 2010). In Portugal, a recent study concluded
that hospitals consume an average of 10,000,000 kW/h of energy, 120,000 m
3
of water and
produce 800,000 kg of waste (Pereira 2013) per year.
At present, there are several studies concerning the sustainable development of
healthcare units. However, most of them are oriented to business management or to waste
management and energy efficiency, as in the study developed by Murray et al. (2008).
Sustainable practices in these buildings are not widespread mainly due to the fact that they
are not conventional. Additionally, the implementation of sustainable practices, normally
related to the concept of ‘‘reduction’’, is not always very well perceived by society and can
generate some resistance (Castro et al. 2012). Several studies and professionals, such us
Malkin (2006), also agree that it is possible to work through the weaknesses of actions and
measures. Some of them are simple and inexpensive, but capable of reducing the envi-
ronmental impact. These actions and measures will be presented and discussed in this
paper.
1.1 Importance of sustainability assessment tools and standardization of sustainable
construction
The major reason that promoted the development of systems to support environmental
performance assessment of buildings was the effective realization in some countries that
they were unable to say how sustainable a building was. This is even true for countries and
design teams, which believed that they were experts in the sustainable construction design
concept. Later, researchers and government agencies understood that rating systems are the
best method to demonstrate the level of sustainability of all types of constructions,
including buildings (Haapio and Viitaniemi 2008). These can improve the education for
sustainable society, because it can promote understanding between the principles of sus-
tainable construction and the user (Cars and West 2014). Through the years, these systems
have contributed to the growth of the awareness about criteria and objectives of sustain-
ability, and they have become a reference to assess the sustainability of buildings in
particular and construction in general. According to these systems, a building is a sus-
tainable building when it is built in an ecologically oriented way that reduces its impact on
the environment (Berardi 2013).
M. F. Castro et al.
123
Nevertheless, the search for better methods and assessment tools is still ongoing. At
present, there are still some uncertainties beyond the constant confusion about the meaning
of sustainable construction, which cover, most often, only energy and water efficiencies.
Therefore, to clarify and emphasize the best design options, it became essential and urgent
to integrate sustainability assessment experts in the design team (Forsberg and von
Malmborg 2004).With regard to assessment methods, most of them are based on a holistic
sustainability approach, considering only the most representative sustainability indicators,
given that the assessment of all links between the natural and artificial environments would
lead to an extremely time consuming and impractical process (Conte and Monno 2012).
Within this, several countries have developed their own systems for sustainability
assessment adapted to their reality and presenting them as capable of guiding the overall
performance of this sector. Most of these systems are based on local rules and legislation,
in locally conventional construction technologies, with the default weight of each indicator
set according to the actual local socio-cultural, economic and environmental contexts
(Crawley and Aho 1999).
These systems are above all oriented to the evaluation of environmental sustainability of
buildings, and several authors have discussed their indicators, structure and methods of
assessment. For example, Forsberg and von Malmborg (2004) carried out comparative
studies of contextual and methodological aspects of tools, Haapio and Viitaniemi (2008)
performed a study that analysed and categorized a group of sixteen environmental impact
assessment tools, Fowler and Rauch (2006) provided a study that summarized the existing
sustainable building rating systems, and Berardi (2011) published a study about sustain-
ability assessment criteria in the construction sector. Additionally, for instance, Mateus and
Braganc¸a (2011) and Ali and Al Nsairat (2009) developed a study about the adaptation of
global tools to specific countries.
Regarding these studies, it is possible to conclude that the differences between the lists
of indicators of the assessment tools make the definition of ‘‘sustainable construction’’
subjective and make it difficult to compare the results obtained from each of the meth-
odologies (Mateus and Braganc¸a 2011). In this context, the International Organization for
Standardization (ISO) and the European Committee for Standardization (CEN) have been
active in defining standard requirements for the environmental and sustainability assess-
ments of buildings.
The International Organization for Standardization (ISO) has a Technical Committee
(TC) 59, ‘‘Building and Civil Engineering Works’’, and a Subcommittee (SC) 17, ‘‘Sus-
tainability in Building Construction’’, which published several standards that are aimed to
raise consensus in the definition of sustainable construction. At the same time, CEN has a
technical committee (TC) 350, ‘‘Sustainability of Construction Works’’, which is devel-
oping standard methods for the assessment of the sustainability characteristics of con-
structions and standards for the environmental product declarations (EPD) of construction
products.
1.2 Aims and objectives
At the present time, there are some building sustainability assessment (BSA) tools covering
healthcare buildings and there are also studies concerning the structure and content of
building environmental and assessment tools in general (indicated in Sect. 1.1). Never-
theless, after analysing the state of the art, it is possible to conclude that there are no
specific studies that have analysed and categorized the existing Healthcare Building Sus-
tainability Assessment (HBSA) methods.
A critical analysis of building sustainability assessment methods
123
As a result, the aim of this paper was to improve this situation, by analysing and
categorizing the existing tools developed specifically to address the sustainability of
healthcare buildings. Furthermore, the current situation of these tools in the context of the
recent work developed in this field at the CEN and ISO standardization bodies will be
analysed, and some development needs will be discussed.
In order to simplify the analysis and understanding of methods, they are analysed in
parallel, to allow comparisons and to highlight the main differences. In this context, the
tools are going to be categorized according to their goals, users and phases of application,
among others, simplifying the understanding about this context and allowing the com-
parison between them. Additionally, the current situation concerning the methods is dis-
cussed and critically analysed in order both to identify their potential in contributing to the
sustainability of healthcare buildings and to present some future developments needed to
improve their comparability. Finally, topics for further research are discussed.
In summary, the specific objectives of this paper are to:
•analyse and categorize existing HBSA methods;
•study how these methods address the sustainability of healthcare buildings;
•study the similarities and differences between the HBSA methods and how they meet
the existing CEN and ISO standards in the context;
•discuss whether the existing HBSA methods address the real needs and specificities of
healthcare buildings; and
•discuss the development needs of the BSA methods in the field of healthcare buildings.
2 Existing healthcare buildings sustainability assessment tools
There are a growing number of sustainability assessment tools developed for the building
sector all over the world focusing on new constructions, existing buildings and refurb-
ishment/rehabilitation operations. But inside these three groups, most assessment tools
specify different methods for different types of buildings. In this context, some systems
developed specific methods for healthcare buildings. Analysing the state of art concerning
HBSA methods, it is possible to identify the following: BREEAM New Construction,
LEED for Healthcare, Green Star—Healthcare and CASBEE for New Construction. At the
moment, DGNB is still developing a specific methodology for hospitals, but the tool is not
finished yet (DGNB 2014), and therefore it was not included in the analysis.
LEED and Green Star have specific methodologies to analyse and evaluate healthcare
buildings, with a particular manual and tool: LEED for Healthcare and Green Star—
Healthcare, respectively. These methodologies have only the specific criteria, benchmarks
and weighting system to evaluate and analyse this kind of buildings. On the other hand,
BREEAM and CASBEE have a different approach since they have only one manual and
tool to be applied to different types of new constructions, including healthcare buildings:
BREEAM New Construction and CASBEE for New Construction, respectively. In this
second group, there is a list of sustainability criteria to be applied to new constructions, and
at the level of each criterion, it specifies the type of building where it must be applied.
Nevertheless, in this second group of tools and like in LEED for Healthcare and Green
Star—Healthcare, it is also possible to identify the specific criteria, benchmarks and
weighting system for healthcare buildings. Therefore, in this paper, LEED for Healthcare
and Green Star—Healthcare are compared with the specific criteria, benchmarks and
weighting systems to be applied in healthcare buildings according to the other two
M. F. Castro et al.
123
assessment methods. This comparison requires categorizing the tools comparatively.
However, such comparisons are not straightforward because while Green Star is a close
relative of LEED; on the other hand, CASBEE evaluated the healthcare buildings within a
more comprehensive method such as BREEAM.
The tools versions on which this study is based are the latest at the time of submitting
this study, namely:
•BREEAM New Construction UK 2011, which was updated in March 2013;
•LEED 2009 for Healthcare, approved in November 2010 and updated in October 2012;
•Green Star—Healthcare v1, originally released in June 2009 and updated in November
2012;
•CASBEE for New Construction 2010 edition.
3 Categorizing tools by characteristics
All HBSA tools presented in the last section are being applied. LEED and BREEAM are
two of the most popular assessment tools making claims to represent the continents to
which they belong, the America and the Europe. The Australia’s Green Star is the
equivalent of America’s LEED, and CASBEE is the Asia’s system with wider world
presence. All of them are of the same type and belong to the same framework of the
assessment tools that are classified in the ATHENA and IEA Annex 31 classification
systems. The four tools are integrated in level 3 and class 3, respectively, of these two
classification systems: Whole Building Assessment Frameworks or Systems (level 3
ATHENA); Environmental Assessment Framework and Rating Systems (class 3 IEA
Annex 31) (Haapio and Viitaniemi 2008). In addition to this classification, it is possible to
categorize these four assessment tools according to their contents and characteristics.
Analysing the different tools, it is possible to identify several differences (e.g. goal,
users, phase of application, among others), and therefore the emerging role of these kinds
of tools encourages discussing them more thoroughly and categorizing them. In this study,
it is intended to point out the similarities and the differences between the abovementioned
tools to promote their analysis and study, their own development and international con-
sensus and to support the development of future HBSA tools. So, in the following sections,
the HBSA methods are categorized by:
•Types of healthcare buildings that are assessed;
•Users of methods;
•Phases of life cycle under assessment;
•Structure and weighting;
•Specific sustainability criteria for healthcare buildings; and
•Classification and communication format of results.
3.1 Types of healthcare buildings that are assessed
The healthcare buildings vary greatly according to the medical specialties that are covered,
to the activities that are developed in the building, the location of the building, the com-
munity that it serves and the economic and financial characteristics that support it. The
Green Star, BREAM, LEED and CASBEE rating tools are specifically oriented to the
context of their own country of origin. Therefore, there are specific rules for each tool. For
A critical analysis of building sustainability assessment methods
123
example, the building class defined by the Australian National Construction Code (NCC)
establishes the type of buildings that are eligible to be rated under the Green Star rating
tools.
Bearing this in mind, the four HBSA methods studied are oriented towards inpatient and
outpatient care facilities and licensed long-term care facilities. Table 1presents the several
types of healthcare buildings that can be assessed by each of the abovementioned methods.
Unlike the LEED and BREEAM tools, Green Star and CASBEE do not specify specific
topics for each type of healthcare building. However, they are all equal regarding the
treatment they attach to their criteria, because none of them has specific parameters for any
of the different type of healthcare building. There exists only a single analysis grid for all
of them.
3.2 Users of methods
HBSA methods are being developed for different purposes and for being used for com-
mercial and research proposes, and/or to support decision-making in the construction and
rehabilitation of this building typology.
In this context, it is possible to identify the professional groups for which the different
tools that are being analysed in this study are oriented. In this paper, the following groups
of users are identified: construction professionals (architects, engineers and constructors);
producers of building products or materials; building owners and investors; consultants;
building users; researchers; and authorities.
The tools studied are of most value to the following groups: construction professionals;
consultants; researchers; and authorities (Table 2). LEED for Healthcare tool and BRE-
EAM New Construction tool are the ones that cover the greater number of groups.
Analysing the available information, it is not possible to conclude which of the listed
groups use more often these tools. However, it is known that researchers, authorities,
construction professionals and also building owners and investors have proven to be the
most interested in the potential of study, analysis, response and commercial effects of these
tools. Therefore, there is an obvious need to conduct surveys on users of these
Table 1 Types of healthcare buildings considered in the studied HBSA methods
Types of healthcare buildings Assessment methods
LEED for
Healthcare
BREEAM
New
Construction
CASBEE for
New
Construction
Green Star—
Healthcare
Teaching/research/specialist hospitals X X X
General acute hospitals X X X X
Community and mental health hospitals X X X
GP surgeries X
Health centres and clinics X X X X
Homes for elderly X X X
Family support facility X X X
Medical device supplier X
Home healthcare service provider X
Healthcare support agencies X
Rehabilitation facility X X X
M. F. Castro et al.
123
sustainability assessment tools, in order to perceive and analyse which factors influence the
choice of a particular tool for each group defined above. The undertaking of those surveys
will lead the researchers to important data that influence the users’ decision, for example,
the importance of rating prices, the degree of access to the tool, the used language and the
coverage of the different life cycle phases. Additionally, it is even more important to
analyse how each tool and its results are affecting the stakeholders’ decision-making.
It is fundamental to highlight that stakeholders’ experience together with their opinion
must be considered in developing tools, as well as in CEN and ISO standards.
3.3 Phases of life cycle under assessment
The building life cycle is divided into different phases. The case of healthcare buildings is
not different from other building constructions. However, in each cycle phase, there are
specific characteristics that should be taken into account. Regarding the HBSA tools, it is
possible to note that they incorporate the phases of life cycle that seem most important to
evaluate these kinds of buildings. In this context, and to allow a comparison between all of
them, Table 3shows the life cycle stage considered in this study and assessed by the four
tools analysed. Although all the four methodologies include most of the life cycle phases,
BREEAM New Construction and LEED for Healthcare have the greater coverage. Curi-
Table 2 Users of methods
Users of the tools Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for New
Construction
Green Star—
Healthcare
Construction professionals X X X X
Producers of building products X
Building owners and investors X X X
Consultants X X X X
Building users X X
Researchers X X X X
Authorities X X X X
Table 3 Life cycle phases considered by tools
Life cycle phases Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for New
Construction
Green Star—
Healthcare
Project/design X
Production X X
Construction X X X X
Use/operation X X X X
Maintenance X X X X
Demolition/deconstruction X X
Disposal X X
A critical analysis of building sustainability assessment methods
123
ously, they are distinguished by the fact that one embeds the initial project/design phase
and the other the final demolition or deconstruction phase. Differences are primarily
related to the specific context of the country for which these methodologies have been
developed. To become real work tools, these systems take into account the existing laws in
each country, existing standards and the life cycle phases with lower development and
support at the level of sustainable development. Although a life cycle phase can be covered
by more than one tool, the way it is considered varies from tool to tool. Each system has
different criteria to evaluate the sustainability at each phase of the healthcare buildings’ life
cycle. Consequently, each criterion is differently presented and evaluated, and each tool
has its own whole list of criteria. For this reason, it becomes difficult to compare the
criteria of each methodology.
3.4 Structure and weighting
According to Lee et al. (2002), the structure is the heart of all assessment systems, as it is
responsible for establishing the overall performance score. In general, the BSA tools being
analysed have the same structure. They all have sustainability assessment categories and
indicators and allow the calculation of a single overall score based on a set of weights. The
weights are based on the relevance of each category for the sustainability of healthcare
buildings, and higher weights are given to indicators of greater importance.
However, there is no unanimity in the weighting considered in these rating systems,
since they are not only based on scientific knowledge, but also take into account the
experience of various professionals and stakeholders in the area of construction, such as
architects, engineers, owners, labour, customers, users, etc. So the weight assigned to each
category is different. BREEAM New Construction, LEED for Healthcare and Green Star—
Healthcare have a similar structure and an identical weighting system. Therefore, they can
be compared and Fig. 1shows how the weight is distributed among each sustainability
category in the three HBSA methods.
By analysing CASBEE for New Construction methodology, it is possible to conclude
that this is not structured as the other tools, since the assessment is based on the relation
between two main groups of criteria: the ‘‘building environmental quality’’ (Q) and the
‘‘building environmental load’’ (LR) (CASBEE 2010). The final weights of these two
groups vary according to the final scores obtained at the level attributed of each indicator
according to CASBEE coefficients. Therefore, Table 4presents the weighting coefficients
of CASBEE for New Construction.
BREEAM New Construction and Green Star—Healthcare tools are similar regarding
the sustainability categories that they cover. Nonetheless, in terms of weight, the distri-
bution of the weights in Green Star—Healthcare tends to resemble LEED for Healthcare,
where ‘‘energy’’ and ‘‘indoor environmental quality/well-being’’ categories have more than
50 % of the weight. On the other hand, the same categories in BREEAM New Construction
have a weight of around 30 %.
Moreover, the BREEAM New Construction tool stands out by having a more balanced
weight distribution and for covering a larger number of categories. In second place, it is
Green Star—Healthcare. Analysing the different tools, it is possible to conclude that the
categories can be structured in the following list of sustainability criteria: (1) management;
(2) indoor environmental quality/well-being; (3) service quality; (4) energy; (5) transport;
(6) water; (7) materials; (8) waste; (9) sustainable sites; and (10) pollution.
It is also necessary to highlight that in LEED for Healthcare BREEAM New Con-
struction, LEED for Healthcare and Green Star—Healthcare tools are the ‘‘innovation’’ and
M. F. Castro et al.
123
‘‘regional priority’’ categories, which recognize projects that achieved innovation and
regional priority standards in one or more of the other categories. These two categories
allow an additional recognition for a building that innovates in the field of sustainable
development and is concerned about the promotion and sustainability of the region,
showing a performance above and beyond the level that is currently recognized and
rewarded by each methodology. The answer to these categories allows an increase of 10 %
Fig. 1 BREEAM New Construction, LEED for Healthcare and Green Star—Healthcare weights
distribution
Table 4 Weighting coefficients
of CASBEE for New Construc-
tion (CASBEE 2010)
Assessment categories Non-factory Factory
Q1 Indoor environment 0.40 0.30
Q2 Quality of service 0.30 0.30
Q3 Outdoor environment on site 0.30 0.40
LR1 Energy 0.40 0.40
LR2 Resources and materials 0.30 0.30
LR3 Off-site environment 0.30 0.30
A critical analysis of building sustainability assessment methods
123
in the final score, in the case of BREEAM New Construction and LEED for Healthcare and
3 % in case of Green Star—Healthcare (Fig. 1).
For a better comparison between the categories of each methodology, Table 5presents
the main indicators that are embedded in the sustainability categories listed above.
3.5 Specific sustainability criteria for healthcare buildings
Analysing the abovementioned methods, it is possible to conclude that they can be divided
into two main groups, according to the way they address the criteria for healthcare
buildings. In the first group are the methods that have a transversal list of criteria that can
be applied to different building types. In the second group, the list of indicators was
specifically developed or adapted to only address the sustainability of healthcare buildings.
BREEAM New Construction and CASBEE for New Construction belong to the first
group, since they present a single list of criteria that can be applied to all types of new
constructions, including healthcare buildings. LEED for Healthcare and Green Star—
Healthcare belong to the second group, since they only address sustainability criteria
related to healthcare buildings.
In the case of BREEAM New Construction, the framework is based on a common list of
criteria for different building types. The differences are inside each indicator, since the
assessment method, evaluation factors and assigned credits can vary according to the
building type.
For example, in the criteria ‘‘visual comfort’’, the credits assigned for the best practices
for daylight depend on: ‘‘area type’’, ‘‘daylight factor required’’ and ‘‘area to comply’’. In
the case of healthcare buildings, there are still differences between ‘‘staff and public areas’’
and ‘‘occupied patient’s areas’’. Additionally, in the criterion ‘‘public transport accessi-
bility’’, the number of credits available for allocation depends on the number and type of
public transportation that, according to the evaluation process, each type of buildings
should have nearby. In the case of healthcare buildings, its size and importance have also
influence in this definition.
Other example is the criterion ‘‘proximity to amenities’’ which assessment also depends
on the type of building. For example, in the assessment of the ‘‘maximum car parking
capacity’’, the best practice is based on the minimum number of parking spaces allocated
for each professional or patient.
The CASBEE for New Construction differs somewhat from the previous method, in the
sense that there are some criteria that are only applied to certain building types. Never-
theless, in some indicators such as ‘‘sound insulation of partition walls’’, ‘‘daylight factor’’
and ‘‘perceived spaciousness and access to view’’, the building type influences the
assessment process, as in the BREEAM New Construction method.
The methods of the second group, LEED for Healthcare and Green Star—Healthcare,
are based on the same core method used in the other methods of each system, but the list of
sustainability categories and indicators was developed to specifically address healthcare
buildings.
Table 6presents the criteria of each of these two methods that were developed to
specifically address the sustainability of healthcare buildings. These criteria are not present
in the core method of each system, namely in the ‘‘LEED for New Construction and Mayor
Renovations 2009’’ and in the ‘‘Green Star—Multi Unit Residential v1’’, respectively.
The first group of methods allows easier understanding about the approach used in each
system to assess the sustainability, since the sustainability criteria are common to different
building types. In this group, the main objective was to standardize the sustainability
M. F. Castro et al.
123
Table 5 Main indicators of the studied HBSA methods
Assessment indicators Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for New
Construction
Green Star—
Healthcare
Management
Sustainable procurement X X
Responsible construction practices X
Construction site impacts X X X
Stakeholder participation X
Service life planning and costing X X
Indoor environmental quality/well-
being
Visual comfort X X X X
Indoor air quality X X X X
Thermal comfort X X X X
Water quality X X
Acoustic performance X X X X
Safety and security X X
Indoor chemical and Pollutant source
control
XXX
Service quality
Flexibility and adaptability X
Service ability X
Durability and reliability X
Energy
Reduction of CO
2
emissions X X
Energy monitoring X X X X
Low- or zero-carbon technologies X
Efficiency in building service system X X X X
Natural energy utilization X X
Renewable energy utilization X
Building thermal load X
Efficient operation X X X X
Transport
Public transport accessibility X X X
Cyclist facilities X X X
Car parking capacity X X X
Travel plan X X
Fuel-efficient transport X X
Water
Water consumption X X X X
Water monitoring X X
Water leak detection and prevention X
Water efficiency X X X X
Landscape Irrigation X X
A critical analysis of building sustainability assessment methods
123
Table 5 continued
Assessment indicators Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for New
Construction
Green Star—
Healthcare
Materials
Life cycle impacts X
Recycled content of materials X X X
Hard landscaping and boundary
protection
X
Responsible sourcing of materials X X X X
Insulation X X
Designing for robustness X
Reducing usage of non-renewable
resources
XXX
Avoiding the use of materials with
pollutant content
XXX
Building reuse X X X
Furniture and medical furnishings X X
Design for disassembly X
Low-emitting materials X X X
Waste
Construction waste management X X X
Non-hazardous waste X
Hazardous waste X
Recycled aggregates X X
Operational waste X
Speculative floor and ceiling finishes X
Sustainable sites
Site selection X X X
Ecological value of site/protection of
ecological features
XX X X
Mitigating ecological impact X X X X
Enhancing site ecology X X
Heat island effect X X
Long-term impact on biodiversity X X X X
Townscape and landscape X X
Local characteristics and outdoor
amenity
XX
Pollution
Impact of refrigerants X X
Emissions X X X X
Storm water design X X X
Light pollution reduction X X X X
Noise attenuation X X X
M. F. Castro et al.
123
Table 6 Specific sustainability criteria for healthcare buildings, considered in LEED for Healthcare and
Green Star—Healthcare
Specific sustainability criteria for healthcare buildings Assessment methods
LEED for
Healthcare
Green Star—
Healthcare
Management
Maintainability X
Construction indoor air quality plan X
Sustainable procurement guide X
Indoor environmental quality/well-being
Hazardous material removal or encapsulation
(renovations only)
X
Acoustic environment X
Low-emitting materials X
Ventilation rates X
Air change effectiveness X
CO
2
monitoring and control and VOC monitoring X
Mould prevention X
Daylight glare control X
High-frequency ballasts X
External views X
Exhaust riser X
Air distribution system X
Outdoor pollutant control X
Places of respite X
Energy
Community contaminant prevention—airborne releases X
Energy sub-metering X
Lighting zoning X
Car park ventilation X
Efficient external lighting X
Transport
Transport design and planning X
Water
Minimize potable water use for medical equipment
cooling
X
Water use reduction: measurement and verification X
Water use reduction—building equipment, cooling
towers and food waste systems
X
Water metres X
Potable water use for equipment X
Materials
PBT source reduction—mercury, mercury in lamps and
lead, cadmium and copper
X
Furniture and medical furnishings X
Resource use-design for flexibility X
A critical analysis of building sustainability assessment methods
123
assessments among different building types, simplifying the use and understanding.
Nevertheless, it leaves apart criteria that are only important in buildings of this nature.
The second approach aims to get closer to the specific needs of this kind of buildings,
presenting specific criteria for their assessment.
3.6 Classification and communication format of results
In general, BSA methods are characterized by assessing a number of partial building
features and aggregating these results into an environmental rating or sustainability score
(Assefa et al. 2010). Nevertheless, the classification methods and the communication
format vary from tool to tool.
In the assessment methods studied, the classification methodologies are similar since
they are all based upon credits, i.e. there are a number of credits allocated to each sus-
tainability criterion. In LEED and Green Star, the maximum number of credits available
for each criterion is related to its weight in the overall score, which is expressed by a rating.
When, at a level of a criterion, a project satisfies a certain level of performance, a number
of credits are gained. The overall performance is based on sum of all gained credits. In
LEED, the overall performance level (rating) is expressed in four qualitative levels (from
Certified to Platinum) and in Green Star in three ratings (from 4 to 6 star), according to the
conditions presented in Table 8.
In BREEAM, the classification methodology is slightly different from the two last
methods, since besides the credits assigned to each criterion, there is a specific weight for
each sustainability category. The overall score, expressed through the Environmental
Performance Index (EPI), is then a weighted average of the credits obtained in each
sustainability category. Based on this index, it is possible to obtain the overall qualitative
sustainability level of a healthcare building. There are six qualitative sustainability levels,
from unclassified to outstanding (a star rating from 1 to 5 stars is also provided), according
to the conditions presented in Table 7.
Table 6 continued
Specific sustainability criteria for healthcare buildings Assessment methods
LEED for
Healthcare
Green Star—
Healthcare
Loose furniture X
Celling, walls and partitions X
Waste
Construction waste management X X
Non-hazardous waste X
Hazardous waste X
Recycled aggregates X
Sustainable sites
Connection to the natural world-places of respite and
direct access for patients
X
Pollution
Watercourse pollution X
Trade waste pollution X
M. F. Castro et al.
123
CASBEE emerges in an odd position since every assessment criterion is weighted in a
way that the sum of the weights of the criteria inside each sustainability category is equal
to 1. The score of each indicator is multiplied by the corresponding weighting coefficient
and aggregated into total points per category of ‘‘Q’’ or ‘‘L’’ (Table 4) to give the eco-
efficiency indicator (BEE), the result of the ratio between ‘‘Q’’ and ‘‘L’’ (CASBEE 2010).
Based on the BEE value, the overall sustainability score is expressed in five qualitative
levels, from C to S (Table 7).
In the end, the way the results are communicated is different in each tool and is based on
graphs, tables, grades, certificates and reports. The communication systems are developed
in such a way that building occupants or owners easily understand and interpret the
performance levels. At the same time, it is easy for clients, designers and other stake-
holders to work with.
The final presentation of results and classification is similar in the assessment methods
studied. These four tools have grades and certificates accompanied by reports, in most
cases. LEED for Healthcare, BREEAM New Construction and Green Star—Healthcare
have analogous certificates that present the final score accomplished with the rating of each
criterion. In these certificates, we still have a brief presentation of the building and the tool
version used for the evaluation. These certificates can be accompanied by a report indi-
cating improvement measures that can be applied to increase the classification of the
indicators with the worst performance. In case of CASBEE for New Construction, the
system creates in the end a chart that summarizes the results and shows the final score. This
chart is presented in a certificate similar to the other three.
The communication of an overall performance level, usually together with the perfor-
mance level at the level of each category, allows effective comparison between different
buildings or design approaches under assessment, when using the same BSA method. The
Table 7 Rating scales of the analysed HBSA methods
Rating scale Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for New
Construction
Green Star—
Healthcare
1level (higher level) Platinum
80 points and above
Outstanding
5 star
C85 %
S
BEE =3.0 or more and
Q=50 or more
6 star
45–59 points
2level Gold
60–79 points
Excellent
4 star
C70 %
A
BEE =1.5–3.0
or
BEE =3.0 or more
and Q is less than 50
5 star
60–74 points
3level Silver
50–59 points
Very good
3 star
C55 %
B?
BEE =1.0–1.5
4 star
45–59 points
4level Certified
40–49 points
Good
2 star
C45 %
B-
BEE =0.5–1.0
5level Pass
1 star
C30 %
C
BEE =less than 0.5
6level (lower level) Unclassified
\30 %
A critical analysis of building sustainability assessment methods
123
comparison of the overall result from different methods is very difficult, because the
sustainability criteria and weights are different. According to Cole (1999), the comparison
of results should always be done at different levels, listing four types of possible
comparisons:
•comparison at the level of each criterion between the declared performance and the
specific benchmarks;
•comparison between the performance levels obtained in the several criteria within the
same building;
•comparison between the performance level obtained in the same criterion from the
assessment of different buildings; and
•comparison of the overall sustainability level of different buildings.
This is only possible if a thorough analysis covering each sustainability category and
criterion is made. For this purpose, it is necessary that the communication documents
(labels, certificates and reports) objectively present, for all criteria, sustainability categories
and each assessed life cycle stage, the partial performance levels together with the overall
performance. This is not possible in most of the HBSA methods analysed, since the main
communication format (sustainability certificate) used is above all based on an overall
single qualitative score. The communication formats should also evolve in order to easily
allow the users not only to identify the criteria with the worst performance levels, but also
to understand which building features and design choices are contributing more to those
results. With these developments, it would be possible to easily compare the results from
different HBSA methods and optimize the design approaches in order to achieve higher
levels of performance.
4 The ongoing standardization and the development needs in the field of HBSA
methods
In the last years, ISO and CEN have been very active in developing a definition for the
sustainable construction concept. As a result, they have been publishing the set of stan-
dards. Analysing these standards, it is possible to conclude that sustainable construction
does not only mean improving the environmental performance but also, and above all,
seeking an optimized balance between environmental, societal and economic aspects.
Nevertheless, from the analysis of Table 5, it is possible to conclude that the four
assessment methods under study have an unbalanced amount of criteria within the three
sustainability dimensions. Additionally, Table 8outlines the relation between the sus-
tainability categories of the studied HBSA methods and the three sustainability dimensions
(and related potential impacts), according to the division proposed by ISO/AWI 21929
(ISO TS 2010).
Regarding Table 8, there are two columns that stand out immediately for opposite
reasons: the ‘‘cultural value’’ aspect with no core sustainability categories in the analysed
HBSA methods covering it and the ‘‘use/depletion of resources’’ aspects that is considered
by most core sustainability categories. Overall, it is possible to conclude that the envi-
ronmental dimension is the one with the greater presence in all core categories, except
‘‘indoor environmental quality/well-being’’. After the environmental dimension, the
aspects with more relevance in the analysed core sustainability categories are the ‘‘satis-
faction’’ (social dimension) and ‘‘economic value’’ (economic dimension).
M. F. Castro et al.
123
Table 8 Potential impacts of the core categories of the studied methods, according to ISO/AWI 21929
Core categories Potential Impacts
Environmental Economic Societal
Change/
deterioration
Use/depletion of
resources
Economic
value
Productivity Health Satisfaction Equity Cultural
value
Management X X X X
Indoor environmental
quality/well-being
XX XX
Service quality X X X X X
Energy X X
Transport X X X X X X
Water X X
Materials X X
Waste X
Sustainable sites X X X
Pollution X
A critical analysis of building sustainability assessment methods
123
Nevertheless, it is necessary to note that this is a global appreciation that covers the four
methodologies being analysed. The individual examination of each one could present some
differences, but this is not significant. For example, the ‘‘service quality’’ category is only
included in CASBEE for New Construction.
In summary, it is possible to highlight that each indicator or sustainability category can
directly or indirectly address more than one economic, environmental or societal impact.
For example, the indicators of the category ‘‘transport’’ are related to: the environmental
impacts for pollution issues; economic impacts of matters related to fuel costs; and societal
impacts because of the need for equal availability and accessibility of transport.
One can say that this is the main cause for the differences between the framework of the
BSA methods developed so far, since in one hand, some methods allocate their indicators
and sustainability categories into each sustainability dimension, and in other hand, the
major part of methods do not do it.
Regarding the standards published in CEN and ISO, a comparative analysis between the
methodologies studied and existing standards will be made.
According to CEN/TC 350 mandate, the assessment of the environmental, societal and
economic performances of buildings have the following goals (CEN TC 350 2010): to
quantify the environmental, societal and economic impacts and aspects of the building and
its site; to identify the impacts and aspects of the building and its site; and to enable the
client, user and designer to make decisions and choices that will help to address the need
for sustainable buildings.
ISO/TC 59/SC 17 (ISO TS 2011) indicates that there are environmental loadings related
to environmental, societal or economic impacts. However, it is also possible to use con-
sequential indicators to quantify or qualify the impacts of a building. Taking this into
account, Tables 9and 10 list the environmental, societal and economic aspects that
according to ISO/TC 59/SC 17 (ISO TS 2011) and CEN/TC 350 (CEN TC 350 2011,
2012a,b) mandates, respectively, should be considered when assessing the sustainability of
construction works. They also present how the four HBSA methods cover the list of the
standardized sustainability criteria.
Analysing both Tables 9and 10, it is possible to conclude that, in order to be in line
with standardization developments, the HBSA methods must be restructured in a way that
users can have a clear overview about the criteria used to assess the performance at the
level of each sustainability dimension. Furthermore, this will allow the development of
more balanced weighting systems (within the three dimensions of sustainability),
according to the specific context of these types of buildings and country of origin of the
HBSA method.
Although the HBSA methods analysed do not address the environmental criteria that
describe environmental impacts according to EN 15804: 2012 (CEN TC 350 2012c), they
cover directly and indirectly most of the environmental criteria of the other categories:
indicators describing resource input; indicators describing resource use, secondary mate-
rials and fuels, and use of water; other environmental information describing waste cate-
gory; and other environmental information describing output flows. From this, it is possible
to conclude that these methods have simplified the life cycle impact assessment (LCIA)
approach in order to allow non-LCA experts to use them.
In the case of core indicators presented in the ISO standard, it seems that the methods
cover almost completely the indicators present in the standard, but this is only due to the
fact that these are less detailed. The tools cover some of the concerns presented in one
indicator, but not always all the issues.
M. F. Castro et al.
123
Table 9 Sustainability indicators of construction works according to ISO/TC 59/SC 17 (ISO TS 2011)
mandate
Core indicators
ISO 21929-1: 2011
Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for New
Construction
Green Star—
Healthcare
Access to services
Public transportation X X X
Personal modes of transportation X X X
Green and open spaces
User relevant basic services X
Aesthetic quality
Integration with the surrounding
Impact of building in site
Local concerns
Land
Site selection X X X
Accessibility
Building site X X X
Building X
Harmful emissions
Potential impact on climate X X X X
Potential impact on the depletion
of stratospheric ozone layer
XX
Non-renewable resources
Use of resources X
Fresh water
Use/consumption X X X X
Waste
Production X X X
Indoor environmental
Indoor conditions X X X X
Indoor air quality X X X X
Safety
Stability X X
Resistance X X
Fire safety
Serviceability
Planning/measurement X X
Adaptability
Adaptability for changed use purpose X
Adaptability for climate change
Costs
Planning/measurement X X
Maintainability
Planning/assessment X X
A critical analysis of building sustainability assessment methods
123
Table 10 Sustainability indicators of construction works according to CEN/TC 350 (CEN TC 350 2011,
2012a,b) mandate
Core Indicators
CEN EN 15643-2: 2011
EN 15643-3: 2012; EN 15643-4: 2012
Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for
New Construction
Green Star—
Healthcare
Environmental performance
Environmental impacts
Global warming potential X
Depletion potential of the
stratospheric ozone layer
XX
Acidification potential of soil and
water sources
Eutrophication potential
Formation potential of tropospheric
ozone
Abiotic depletion potential
Resource input
Use of renewable primary energy X
Use of non-renewable primary
energy
XX X X
Resource use
Use of secondary material X X X
Use of renewable secondary fuels
Use of non-renewable secondary
fuels
Use of net fresh water X X X X
Waste
Hazardous waste disposed X
Non-hazardous waste disposed X
Radioactive waste disposed
Use of net fresh water
Output flows
Components for re-use X
Materials for recycling X X X
Materials for energy recovery
Exported energy
Societal performance
Accessibility
For people with specific needs
To building services X X
Adaptability
To accommodate individual user
requirements
XX
To accommodate the change of user
requirements
XX
To accommodate technical changes
To accommodate the change of use X
M. F. Castro et al.
123
Table 10 continued
Core Indicators
CEN EN 15643-2: 2011
EN 15643-3: 2012; EN 15643-4: 2012
Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for
New Construction
Green Star—
Healthcare
Health and comfort
Acoustic characteristics X X X X
Characteristics of indoor air quality X X X X
Characteristics of visual comfort X X X X
Characteristics of water quality X X
Electromagnetic characteristics
Spatial characteristics X X X X
Thermal characteristics X X X X
Loadings on the neighbourhood
Noise X X X
Emissions to outdoor air, soil and
water
XX X X
Glare and overshadowing X X X
Shocks and vibrations X
Localized wind effects X X X
Maintenance
Operations X X X X
Safety/security
Resistance to climate change X
Resistance to accidental actions X
Personal safety and security X X
Security against interruptions of
utility supply
XX
Sourcing of materials and services
Responsible sourcing and traceability
of products and services
XX X
Stakeholder involvement
The opportunity for interested parties
to engage in the decision-making
process for the realzation of a
building
X
Economic performance
Economic impacts and aspects at the
before use stage
Costs directly related to the purchase
or rental of the site
Cost of products supplied at factory
gate ready for construction
XX
Costs incurred between factory and
site
Professional fees
Temporary and enabling works X X
Construction of asset X X
Initial adaptation or fit out of asset
A critical analysis of building sustainability assessment methods
123
Table 10 continued
Core Indicators
CEN EN 15643-2: 2011
EN 15643-3: 2012; EN 15643-4: 2012
Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for
New Construction
Green Star—
Healthcare
Landscaping, external works on the
curtilage
Taxes and other costs related to
permission to build
Subsidies and incentives
Economic impacts and aspects
excluding the building in operation
at the use stage
Building-related insurance costs
Leases and rentals payable to third
parties
Cyclical regulatory costs
Taxes
Subsidies and incentives
Revenue from sale of asset or
elements, but not part of a final
disposal
Third party income during operation
Repairs and replacement of minor
components/small areas
Replacement or refurbishment of
major systems and components
Adaptation or subsequent fit out of
asset—fitting out or modification
of existing buildings
Cleaning X X
Grounds maintenance
Redecoration
Disposal inspections at end-of-lease
period
End of lease
Planned adaptation or planned
refurbishment of asset in use
Building-related facility management
costs
XX
Economic impacts and aspects of the
building operational use
Operational energy costs X X X X
Operational water costs X X X X
Taxes
Subsidies and incentives
Economic impacts and aspects at the
end of life
M. F. Castro et al.
123
The development of LCA databases with the environmental criteria that describe the
environmental impacts of both different building elements and building integrated tech-
nical systems (BITS) is a way to overcome this scenario and to allow the use of more
consistent LCA methods, when assessing the environmental performance of buildings. As
an example, the SBTool
PT
method is based on this approach (Mateus and Braganc¸a 2011).
Analysing the societal criteria, it is possible to conclude that all tools are almost con-
sistent with the EN 15643-3: 2010 and ISO 21929:2011, since they cover most of the listed
criteria. Furthermore, from the analysis of Tables 9and 10, it is also possible to highlight
that Green Star—Healthcare is the method with lower development needs and LEED for
Healthcare is the one that must be further developed in order to meet all standardized
societal criteria. However, the most relevant differences are found at the level of the
economic dimension, since most standardized economic criteria are not directly addressed.
Rather than assessing directly the standardized economic criteria, the approach used
considers that these are implicitly in some environmental principles, such as: reduction of
resource consumption; energy management; and water efficiency. Bearing in mind the
specific characteristics of healthcare buildings and the differences between the standards
and the approaches used, these methods should be developed in order to accommodate
clearly the economic criteria. Other important differences between the BSA European
Standards (EN 15643-1: 2010, EN 15643-2: 2011, EN 15643-3:2012 and EN
15643-4:2012) and the approach used in the abovementioned HBSA methods are the life
cycle stages considered and the way the results are communicated.
According to EN 15643-1: 2010, the building life cycle information model is based on
following life cycle stages: product stage (including raw material supply, transport and
manufacturing); construction processes (including transport and installation of building
materials and products); use stages (including use, maintenance, repair, replacement,
refurbishment and both operational energy and water consumption); end-of-life stage
(including deconstruction, transport, waste processing and disposal); and benefits and loads
beyond the system boundary (including the reuse, recovery and recycling potentials).
According to ISO/TR 21932: 2013, the six phases of decision-making process are: strategic
planning; project definition; design; construction and handover; operation and mainte-
nance; and end-of-life strategy.
Table 10 continued
Core Indicators
CEN EN 15643-2: 2011
EN 15643-3: 2012; EN 15643-4: 2012
Assessment methods
LEED for
Healthcare
BREEAM New
Construction
CASBEE for
New Construction
Green Star—
Healthcare
Deconstruction/dismantling,
demolition
X
All transport costs associated with
the process of deconstruction and
disposal of the built asset
Fees and taxes
Costs and/or revenues from reuse,
recycling, and energy recovery at
end of life
Revenue from sale land
A critical analysis of building sustainability assessment methods
123
In the light of these frameworks, the building life cycle starts with the acquisition of raw
materials. It proceeds through the manufacture of products, construction work processes,
actual use including maintenance, refurbishment and operation of the building, and finally
at the end of life, deconstruction or demolition, waste processing in preparation for reuse,
recycling and energy recovery and other recovery operations, and disposal of construction
materials. Information from these activities is needed to assess the environmental impacts
and aspects of the building. Only the benefits and loads beyond the system boundary are
considered supplementary information (optional), while all the others are mandatory.
Analysing the list of criteria of the HBSA methods, it is possible to conclude that they
not cover all the abovementioned life cycle stages since they are primarily oriented to the
product and use stages and roughly address the impacts and benefits resulting from the
construction processes and end-of-life stages. According to the CEN/TC 350 standards, the
results of an assessment should be expressed using all the criteria given in the environ-
mental, societal and economic standards without any further aggregation of the defined
indicators and sustainability dimensions. Furthermore, the results of the assessments shall
be organized in the following two main groups: I) impacts and aspects specific to building
fabric and site and II) impacts and aspects specific to building in operation. Optionally,
supplementary information may be provided in a separate information group: benefits and
loads beyond the building life cycle.
The approach considered in the HBSA methods is more in line with ISO stan-
dardized requirements, because they present their indicators divided into much broader
sustainability categories that cover issues that are related to the three dimensions of the
concept of sustainable development (Table 8). But this line is not consistent, because
the HBSA methods do not include all categories set out in ISO 21929-1: 2011, and the
answer for most categories is not complete, namely: access to services category; aes-
thetic quality category; safety category; and adaptability. Additionally, from the ana-
lysis of the communication format, it is possible to highlight that the HBSA methods
are not consistent with the CEN standardized requirements, since they are above all
based on a global sustainability score (i.e. the aggregation of sustainability criteria) and
do not organize the results in the groups or categories presented. This approach can be
justified by the fact that, as a rule, most stakeholders prefer a single, graded scale
measure to represent the overall score for a building and to compare different design
approaches.
Other important issue is to analyse whether these methods consider all sustainability
aspects that are considered relevant by the researchers and practitioners in the specific
field of the sustainability of healthcare buildings. This can be made by comparing the list
of criteria of these methods with the aspects considered in the design and operation of
shining examples of sustainable healthcare buildings. Analysing the abovementioned four
HBSA methods, it is possible to conclude that they are based on a holistic sustainability
approach, considering only the most representative sustainability criteria, most of them
not specific for healthcare buildings. Reasoning for this could be the fact that these
methods are the result from the adaptation of methods used to assess conventional
buildings types.
5 Discussion
In general, the sustainable design of healthcare buildings will result in competitive
advantage strategies, as well as better economic, environmental and social efficiency. As
M. F. Castro et al.
123
presented in Fig. 2, more aspects should be considered and integrated during the different
life cycle stages of a healthcare building. This multidisciplinary and complex task is only
possible through a holistic and systematic approach. At this level, BSA methods play an
important role, since they:
1. are developed to consider the most important connections between the built
environment and the sustainable development aims;
2. convert the sustainable development aims into objective goals;
3. establish world/regional/national reference and outstanding sustainability practices;
and
4. are useful to gather and report information to be used in decision-making processes.
Despite sustainability assessment, this is still an emerging issue in the context of
healthcare buildings, because most stakeholders understand BSA methods as an important
contribution to support the design, construction and operation phase s and to recognize the
sustainability of residential, commercial and office buildings.
Analysing the BSA methods for healthcare buildings, it is possible to conclude that
they:
1. assess the life cycle performance in a different perspective;
2. are based on different sustainability criteria;
3. have different benchmarks;
4. can be applied in different types of healthcare buildings;
5. cover different life cycle stages;
6. use different environmental life cycle assessment databases;
Fig. 2 Life cycle phases of healthcare buildings (Castro et al. 2013a)
A critical analysis of building sustainability assessment methods
123
Table 11 Comparative analysis of pros and cons of the fours HBSA methods in study
Assessment
methods
Critical analyse
Pros Cons
LEED for
Healthcare
This method can be applied in almost different types of healthcare buildings
Considers a wide range of users of the tool, increasing their likelihood of use
Covers almost all life cycle phases, promoting their applicability in any stage
of the building life cycle
Has already a high number of certified buildings that can promote and
validate the applicability of the method
Includes a singular category (regional priority), that demonstrates a different
approach regarding the specific regional context, comparing to the others
methods
It has a specific method and tool for healthcare buildings, which turns the
assessment more comprehensive
There are some criteria that are not included and that can improve the global
evaluation structure, like: aesthetic quality aspects and ‘‘management’’
category
Do not considers the ‘‘environmental impacts’’ according to the indicators
proposed by CEN
Do not considers the ‘‘serviceability’’, ‘‘costs’’ and ‘‘maintainability’’
according to the indicators proposed by ISO
Despite the proposed method is specific for healthcare buildings, the list of
criteria is shorter when compared with the LEED methods for other type of
buildings
BREEAM
New
Construction
Has only one method to be adapted in different types of new constructions
that can facilitate the analysis made by qualified evaluators
Cover almost all life cycle phases, including design/project phase, allowing
the application of this method in the earlier design stage and promoting
best results in the next stages
Balanced weighting system, showing the importance of all categories that are
included in the method
This method is being adapted to be applied in different regional contexts,
promoting a general system that can allow the comparison between the
assessed buildings in different countries
It is one of the methods that is more consistent with the indicators proposed
by CEN and ISO standards
There are some criteria that are not included and that can increase the global
evaluation structure, like durability flexibility, adaptability and aesthetic
quality aspects
Being also an advantage, a global method for different types of new
buildings can make difficult the understanding of the priorities to consider
in the design of a sustainable healthcare building
M. F. Castro et al.
123
Table 11 continued
Assessment
methods
Critical analyse
Pros Cons
CASBEE for
New
Construction
Has only one method to be adapted in different types of new constructions
that can facilitate the analysis made by qualified evaluators
The assessment is based on ‘‘building environmental quality’’ (Q) and on the
‘‘building environmental load’’ (LR), allowing a better understanding about
the relation between the performance and environmental loads of each
different design scenario
It is the only method that includes ‘‘service quality’’ category, showing the
relevance of service ability and durability in the sustainability assessment
It is the method that the core categories are more consistent with the ISO
standards
The assessment if above all based only on the operation phase
There are some criteria that are not included and that can increase the global
evaluation structure, like: aesthetic quality aspects; ‘‘transport’’ and
‘‘waste’’ categories
Do not consider the ‘‘environmental impacts’’ according to the indicators
proposed by CEN
Do not consider the ‘‘safety, costs’’ and ‘‘maintainability’’ according to the
indicators proposed by ISO
The weighting system is more complex, and therefore it is difficult to
perceive the weight of each criterion in the global score
Green Star—
Healthcare
Considers a more specific sustainability criteria regarding the operation
phase of healthcare buildings (which is the more relevant phase in this type
of buildings): ‘‘management’’; ‘‘indoor environmental quality’’; ‘‘energy’’;
‘‘pollution’’
It is one of the methods that is more consistent with the indicators proposed
by CEN and ISO standards
It has a specific method and tool for healthcare buildings, which turns the
assessment more comprehensive
Unbalanced amount of criteria within the three sustainability dimensions
There are some criteria that are not included and that can increase the global
evaluation structure, like durability, flexibility, adaptability and aesthetic
quality aspects
It can be only applied to fewer types of healthcare buildings
A critical analysis of building sustainability assessment methods
123
7. use different rating levels; and
8. communicate the results in different ways.
It is also necessary to highlight that according to the intended use, each of the analysed
HBSA methods have their own pros and cons, as presented in Table 11.
These differences are above all related to the specific socio-cultural, economic and
regulation contexts of the country where each method is being developed and applied. For
these reasons, it is possible to conclude that it is very difficult to compare the results from
different assessment methods.
In addition to the listed factors, the use of these methods is not yet simple and user-
friendly. It is not clear who can use them and how they can be used, where and when they
should be used and how the results should be used to support the decision-making in
healthcare buildings. Probably, all these aspects are hindering the widespread use of HBSA
methods in the design, construction and operation phases of this type of building.
Moreover, there is still an important issue that should be discussed and overcome in
order to improve the tools that are studied and presented in this paper: these methods are
mainly focused on the environmental issues of the sustainable development concept. Issues
between conventional concepts and sustainability make sometimes the mistake of talking
only about environment (Buclet and Lazarevic 2014). This can be seen from the way most
stakeholders normally refer to these methods: Building environmental assessment tools
instead of BSA tools. At the moment, many stakeholders still consider that green building
and sustainable building are synonyms. Nevertheless, as presented in Fig. 3, the
•Fuel consumption of non-renewable fuels
•Water consumption
•Soil use and biodiversity
•Energy
•Materials consumption
•Greenhouse gas emissions
•Other atmospheric emissions
•Impacts on site ecology
•Solid waste / liquid efluents
•Indoor air quality, visual, acoustics and thermal
•Climate change outdoor air quality and pollution
•Maintenance of performance
•Management
•Comfort and health of users
•Longevity, adaptability, lexibility
•Accessibility
•Eficiency
•Service ability
•Transports
•Earthquake & other forms of security
•Urban / planning issues
•Life cycle costs and impacts
•Other Social and economic considerations
•Stakeholder involvement
GREEN BUILDING
SUSTAINABLE BUILDING
Fig. 3 Green building versus
sustainable building
M. F. Castro et al.
123
sustainable building concept is much broader and includes several criteria related to the
environmental, societal and economic dimensions of sustainable development.
In the case of healthcare buildings, societal issues like comfort and well-being become
even more relevant. It should be highlighted that patients should always be in the spotlight
and the staff (doctors, nurses, administrative personal, etc.) must have all the necessary
conditions to perform their jobs to a high standard. This way, they can evolve to be real
BSA methods and to promote a better compatibility between the healthcare buildings and
the sustainable development aims.
Therefore, this research work shows that there are emerging aspects that are challenging
the future developments in the HBSA methods. First of all, they have to evolve to
accommodate the recent standardization works published in the field of the assessment of
sustainable construction. From the comparative analysis of the HBSA methods, it is
possible to conclude that it is difficult to compare the results from the use of different
methods, since they are not based on the same sustainability criteria and use different
weighting systems in the aggregation of all criteria for the calculation of the global sus-
tainable score. This barrier can be overcome if the HBSA methods are developed in order
to be more consistent with the recent standardization works in the field of the sustainability
assessment of construction works, mainly at the level of their structure, list of criteria,
process of assessment and the way they communicate the results. Additionally, the way as
these methods consider the different sustainability dimensions in the assessment is not the
same nor consistent with the standardized definition of sustainable construction. At this
level, it is important to highlight that these methods are above all focused in the societal
dimension, do not quantify the environmental performance based on the indicators that
describe the environmental impacts and the economic dimension is almost ignored. Some
solutions to overcome these problems are presented and discussed in the course of this
paper.
Other important barrier is that there are some specific sustainability aspects in this type
of buildings that are not considered in the best-known HBSA methods and those who
design, manage and use this type of buildings consider that important. This can be con-
cluded through the analysis of some recognized case studies (i.e. Boulder Community
Foothills Hospital, Providence Newberg Medical Center, Evelina Children Hospital and
REHAB Basel) and from the results of previous studies, e.g. Castro et al. (2013b,c).
The four abovementioned case studies are internationally recognized as good practices
at the level of sustainable healthcare buildings. Nevertheless, some of the sustainability
principles considered relevant by the intervenient in the design process are not recognized
by the HBSA methods that exist.
The Boulder Community Foothills Hospital (BCFH) in Colorado, USA, was the first
hospital to be assessed by the LEED Healthcare method and was awarded with the ‘‘Sil-
ver’’ label. One of the main sustainability principles of this project was to regenerate a
decayed industrial area in the city of Colorado, and this positive aspect for the sustainable
development is not directly accessed by the analysed HBSA methods. The Providence
Newberg Medical Centre was awarded with the rating ‘‘Gold’’ by the LEED method
(Gold), and the design process was based on a financial feasibility model (that included all
life cycle costs as benefits) for every alternative design scenario. Although the economic
performance was considered a very important sustainability principle, as presented in
Table 5, none of the studied methods have a life cycle costs sustainability category. The
Evelina Children Hospital built in London, UK, was awarded with the NHS Building
Better Health Care Award for Hospital Design. The design process included surveys to the
young patients of this kind of services, which highlighted an aim for: more user-friendly
A critical analysis of building sustainability assessment methods
123
design; nice views to the outside; better interaction and socialization among patients and
visitors spaces; and the absence of long corridors, where the patient’s expectation grows as
they pass through these spaces. These results show, for example, that the indoor pro-
gramme and spatial organization is an aspect of most importance in the assessment of the
societal performance of this kind of buildings. The REHAB Basel hospital located in
Basel, Switzerland, is other example that shows that there are some specific societal
indicators that should be considered when assessing the sustainability of healthcare
buildings. This rehabilitation centre was designed for patients that are hospitalized for an
average period of 18 months, usually after a serious accident, aiming a good environment
where patients can learn to cope with their new condition of life and to be as independent
as possible. Therefore, this building shows the importance of adding some indicators in the
sustainability category ‘‘quality indoor environment’’, such as natural lighting and venti-
lation and organization and interrelation between indoor and outdoor spaces (Guenther and
Vittori 2013).
In addition, previous studies developed by Castro et al. (2013b,c) concluded that it is
necessary to encourage design teams to incorporate in the programme concerns related to
the specific spatial and volumetric organization of indoor and outdoor spaces of this kind of
buildings. This is essential to improve ‘‘flexibility’’ and ‘‘adaptability’’ of these buildings
and to avoid future problems related to the implementation of new equipment and changes
in patients’ requirements.
6 Conclusions
This paper is the result of a critical review, aimed at comparing the best-known Healthcare
Building Sustainability Assessment (HBSA) methods.
The sustainable design, construction and use of buildings are based on the best trade-off
between environmental pressure (relating to environmental impacts), social aspects
(relating to users’ comfort and other social benefits) and economic aspects (relating to life
cycle costs). Sustainable design strives for greater compatibility between the artificial and
the natural environments without compromising the functional requirements of the
buildings and the associated costs.
Based on the environmental, societal and economic relevance of healthcare buildings,
different countries and institutions have developed or are in the process of developing
domestic assessment methods for this type of buildings.
Facing the challenges highlighted in the discussion chapter of this paper, it is expected
that the existing HBSA methods should evolve in order to accommodate some aspects,
such as:
•recent developments in the standardization of the sustainability of construction works
and buildings (i.e. their sustainability categories, considered life cycle stages and
boundaries should be in line standardization works of CEN and ISO);
•a list of sustainability criteria and weighting system that is more balanced between the
three dimensions of sustainable development (rather than focusing more in one or two
dimensions);
•energy efficiency of the building (considering both renewable and non-renewable
consumption during operation phase and in situ renewable energy production);
•specific adaptability and flexibility requirements (for different needs and climate
change);
M. F. Castro et al.
123
•life cycle cost analysis of the project (considering the financial costs and benefits of the
adopted design principles);
•well-being of patients, medical and administrative staffs (considering in the design
phase the health of professionals and patients, who are the users of these buildings, live
it and experiment the day-by-day problems);
•and aesthetical quality of building (including the integration of building in the
surroundings and impact in site).
Although there are aspects to overcome in all HBSA methods, hindering their adoption,
they still have an important role to play, not only in evaluating the impacts of an actual
building, but also, and even more importantly, in guiding the appropriate design for the
attainment of performance objectives. Adding these criteria to the others presented in
Table 5, the HBSA methods can become closer to the essential needs of healthcare
buildings.
As final remark, it is expected that the results presented in this paper can contribute to a
better understanding in the field of sustainability assessment of healthcare buildings and
that can boost further international exchange and coordination in the development of a new
generation of HBSA methods.
Acknowledgments The authors acknowledge the Portuguese Foundation for Science and Technology and
POPH/FSE for the financial support for this study under the Reference SFRH/BD/77959/2011.
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