This article was originally published on August 30, 2023, and is among Healthcare Design’s most-read articles of 2023. To see a full list, click here.

When the healthcare industry first started discussing climate change nearly two decades ago, conversations focused on addressing how much energy the sector—including hospitals, doctor’s offices, and clinics—uses.

“We always felt like there was a big opportunity for healthcare organizations to reduce not only the environmental impacts of that energy use, but also the operating cost associated with it,” says Kim Shinn, principal and sustainability wizard at TLC Engineering Solutions (Brentwood, Tenn.).

Climate change, which refers to long-term shifts in temperatures and weather patterns, can be caused by natural factors, such as fluctuations to the sun’s activity or volcanic eruptions, as well as human activities, primarily due to the burning of fossil fuels like coal, oil, and gas. These emissions, particularly carbon dioxide and methane, trap the sun’s heat, raising temperatures.

As understanding about climate change and the effects of greenhouse gas emissions on people and the planet has evolved, the healthcare sector, which accounts for approximately 8.5 percent of U.S. emissions, realized its potential to play a more significant role in addressing it.

“We’ve begun to understand that climate change has health impacts,” Shinn says. “Higher temperature events can put people in danger from heat exhaustion, the changing climate can introduce new diseases into places where they didn’t exist before, and the downstream effects of energy generation in terms of air pollution have negative impacts on populations.”

Sustainability’s role in population health

Concurrent with this connection was a shift in the industry toward population health. Healthcare organizations now consider how their services and facilities impact the health of the communities they serve, spurred by value-based reimbursement models where they’re rewarded for keeping people healthy and out of hospitals.

“If we reduce the negative health consequences of the climate crisis, the healthcare system is less burdened,” says Ramé Hemstreet, vice president of operations for national facilities services at Kaiser Permanente (Oakland, Calif.). “There are both ethical and financial reasons to do so.”

As a result, the industry is moving beyond lower energy consumption to a much broader aim to decarbonize healthcare. This involves addressing the overall carbon dioxide and other greenhouse gas emissions that its buildings and associated activities release into the atmosphere. (The term “decarbonization” reflects the shorthand use of “carbon” to represent the full range of greenhouse gas emissions, which includes carbon dioxide, methane, and nitrous oxide.)

To accomplish these goals, healthcare systems are considering new technologies and strategies, including all-electric hospitals and microgrid systems. Such moves would help lower or eliminate the burning of fossil fuels such as natural gas in power plants and boilers, which releases emissions into the atmosphere.

Systems are also being moved to action by new voluntary or mandated building codes and local and state regulations targeting building performance or efficiency standards.

Since last year, many organizations have also signed on to the White House and Department of Health and Human Services’ (HHS) Health Sector Climate Pledge. The pledge calls on healthcare stakeholders to help tackle the climate crisis through goals such as reducing their emissions by 50 percent by 2030 and achieving net zero (where a company reduces its emissions across its entire supply chain) by 2050.

“Many of our clients who are participating in that are now coming back to the A/E/C industry and saying, ‘You need to help us figure this out,’ ” Shinn says.

State of decarbonization in healthcare

The Greenhouse Gas Protocol, a widely accepted metric for accounting and reporting emissions, classifies these substances as Scope 1, 2, or 3. Traditionally, as healthcare organizations have worked to reduce their emissions, their main focus has been on direct emissions from facilities, known as Scope 1, and indirect emissions that result from the production of energy by utility providers, known as Scope 2.

For example, Scope 1 strategies for healthcare can involve being better stewards of anesthesia gases, using refrigerants that have a lower global warming impact, and employing equipment that reduces the amount of energy needed for space heating.

Addressing Scope 2, organizations can contract with energy providers that use renewable energy, such as wind or solar, to produce electricity instead of fossil-fuel based energy.

To get to net zero, systems must employ strategies targeting Scope 3: supply chain emissions or those related to business activities such as pharmaceuticals, construction materials, transportation, and investments.

“In the U.S., about three-quarters of the greenhouse gas emissions associated with a healthcare business like a hospital system is Scope 3,” Shinn says, adding that the remaining 25 percent is almost evenly divided between Scope 1 and 2 emissions.

Addressing Scope 3 emissions in healthcare projects

For more than a decade, Kaiser Permanente has been on the front lines of addressing climate change and in 2020 achieved carbon neutral status (when an organization’s carbon dioxide equivalent emissions are the same as the amount removed from the atmosphere).

The organization employs a variety of strategies to achieve success, including an aggressive energy efficiency campaign that’s resulted in an 8 percent reduction in overall energy intensity since 2013 and an onsite solar program.

It also utilizes four virtual power purchase agreements for renewable energy projects (two are solar, two are wind), which commit the organization to purchasing new green electricity for 20 years to offset the “brown electricity” used to run its facilities. The power purchase agreements, Hemstreet says, has been the number one contributor to the organization becoming carbon neutral.

Now, as it sets its sights on achieving a net zero goal as part of the HHS pledge, Hemstreet says the organization is targeting the embodied carbon of its facilities. Specifically, this is the greenhouse gas emissions attributed to materials extraction, supply, and the manufacture of equipment for building and maintaining of a facility.

A big target within this category for healthcare buildings is structural materials, which have a large carbon footprint associated with their production. “Because the carbon dioxide emissions associated with the concrete, steel, aluminum, and glass get emitted into the atmosphere before they get to the building, that building’s carbon footprint is huge at day zero, before it even starts to operate and have greenhouse gas emissions associated with its operation,” Shinn notes.

Hemstreet says efforts are already underway in the construction industry to decarbonize the manufacturing of certain materials. “

There’s hope in the future that we’ll be able to purchase low or no-carbon steel and concrete, but those efforts are still in their infancy,” he says.

Kaiser Permanente is also eyeing the potential of mass timber, an engineered, smooth-surface product that has reduced off-gassing, which translates into better air quality.

While obstacles exist related to the use of wood in healthcare settings, Hemstreet says he’s hopeful the method could be used in primary care facilities, with the aim for the organization to have a pilot project launched this decade.

As with all strategies in healthcare design, Hemstreet says any new approach must be reviewed for its affordability as well as its ability to support decarbonization efforts. “We need to ensure that we’re not adding cost to those new facilities,” he says.

Are electric hospitals the answer?

One idea gaining momentum on the path to decarbonization in healthcare is electrification, which replaces technologies that use fossil fuels with ones that use electricity as a source of energy.

Specifically, more healthcare systems are looking to replace boilers or water heaters with heat pump systems for domestic water heating and space heating. This equipment helps eliminate a big source of Scope 1 emissions for healthcare facilities—burning fossil fuel (usually natural gas) for heat.

“Reducing or eliminating the use of natural gas not only avoids the carbon dioxide from the combustion process, but also the leakage of the potent greenhouse gas methane, which is a big component of natural gas,” Shinn says.

Where steam is still needed, such as in sterile processing, facilities can utilize small steam generators to serve specific departments and run the equipment only when steam is needed as opposed to a central steam system that covers the entire hospital.

Some are already moving the industry toward this goal. For example, the all-electric UCI Medical Center Irvine-Newport in California, expected to open in 2025, will feature an essential utilities plant that does not rely on carbon combustion or natural gas.

Mazzetti, a decarbonization, technology, financial, and engineering consulting firm specializing in healthcare, has been working with clients to develop and implement sustainable strategies. The firm recently released  the California Energy Commission’s A Guidebook for Decarbonizing Healthcare with technology,  design, and finance strategies to help  healthcare organizations minimize natural gas use and reduce greenhouse gas emissions.

Challenges to electrification in healthcare facilities

One of the authors, Walt Vernon, CEO at Mazzetti (San Francisco), says there are several challenges to overcome in the shift to electrification, including regulatory obstacles. “The National Electrical Code contains demand factors that are decades old and don’t reflect today’s reality,” he says.

This results in facilities being required to build electrical systems that are significantly larger than needed. “We’re spending money we don’t need to spend, and electrification is more expensive than it needs to be,” he says.

Another issue is emergency power requirements for healthcare. In the past, the National Fire Protection Association (NFPA) code required a fossil fuel generator to supply emergency power. Because of increasing air quality management restrictions, this solution most often can operate only during a utility power outage, making the per unit cost of electricity very expensive.

“It’s not very economically efficient,” Vernon says. “And the newer technologies can operate all the time, making them more economically beneficial and, at the same time, reducing environmental impacts.”

As more recent versions of the NFPA code evolved to allow fuel cells, batteries, photovoltaic panels, and microgrids to serve as sources of emergency power, the Centers for Medicare & Medicaid Services (CMS) continued to enforce the stricter codes for healthcare facilities.

Then, this spring, CMS issued a Categorical Waiver allowing  healthcare organizations to adopt the most recent NFPA standards that permit these new clean energy technologies for emergency power generation. “It’s critically important because now owners can access these newer technologies,” Vernon says.

Microgrid adoption in healthcare

Despite the previous limitations, some healthcare organizations had already been testing the application of microgrids to provide resiliency and/or reduce utility costs at their facilities.

In 2018, Kaiser Permanente installed a solar-powered microgrid with battery storage at its Kaiser Permanente Richmond Medical Center in Richmond, Calif. The system’s power was stored in a 1 megawatt battery, funded as a pilot project by the California Energy Commission. It’s backed up by an onsite diesel generator in case of a long power outage.

By the end of the year, the organization expects to complete the installation of an even bigger microgrid, with 9 megawatts of battery storage, at its Ontario Hospital in Ontario, Calif., Hemstreet says.

“We’re piloting the addition of green microgrids (solar plus battery storage) to demonstrate that there may be a sustainable alternative for emergency power generation,” he says. “This facility is the next step in our overall plan.”

Hemstreet notes that microgrids aren’t yet cost-competitive with diesel generators, but the technology is getting there. “The only reason we’ve been able to do the two large-scale green microgrid projects here in California has been because of state grants,” he says. “But the intent of these investments is that it will help those lines converge.”

Pediatric care facility Valley Children’s Hospital in Central California in Madera, Calif., was recently awarded a $55 million grant from the U.S. Department of Energy to build a renewable energy microgrid on its campus to accelerate and expand the healthcare network’s clean energy storage capabilities. (For more on a healthcare campus microgrid, go here to read “Valley Children’s Healthcare To Install Microgrid On California Hospital Campus.”)

Continued momentum

Looking ahead, Shinn says he expects the regulatory component to become a bigger piece of the decarbonization puzzle as jurisdictions from coast to coast, including Colorado, Washington state, California, New York state, and Maryland, start to impose regulations associated with greenhouse gas emissions.

“That will become a big driver for healthcare organizations in those locations,” he says.

For those looking to move down the decarbonization path, Kaiser Permanente’s Hemstreet says facilities should start by understanding their utility usage and costs, as well as the carbon emissions associated with them.

“Understanding your energy use, reducing it if possible, and understanding the regulatory environment in your local area that will help or hinder reducing emissions are good first steps,” he says.

On the A/E/C side, Shinn encourages the industry to use its buying power to encourage the supply chain and suppliers to provide products and materials with less greenhouse gas impact, and then, using environmentally preferable purchasing practices, favor those products over others with a higher carbon footprint.

One challenge the industry will continue to face in addressing climate change is time, adds Mazzetti’s Vernon. “The urgency of the situation calls us to act aggressively … [which] may result in unanticipated issues,” he says. “But managed well, these risks can be overcome, leading to improved performance over time. It’s part of getting to a better solution, and that takes courage and a commitment to the greater good.”

Anne DiNardo is executive editor of Healthcare Design. She can be reached at


2023 HCD Conference Session  Spotlight:  New Tools, Strategies for Decarbonization

The 2023 Healthcare Design Conference, to be held Nov. 4-7 at the Ernest N. Morial Convention Center in New Orleans, will include several educational sessions focused on decarbonization in healthcare and some of the new tools and strategies available to help projects achieve their emission-reduction goals.

Here are a few sessions on the agenda. For the full conference lineup and schedule, visit


E45: The Decarbonization Guidebook for Healthcare—Tell Me More!

Speakers: Austin Barolin, Senior Energy Analyst, Mazzetti; Troy Savage, Director of Strategic Projects & Innovation, Mazzetti; Geoff Glass, Director of Facility & Technology Services, Providence Healthcare

The healthcare industry is responsible for a significant percentage of carbon emission—both in the U.S. and globally—and continues to fuel the carbon fire.

Speakers will discuss a new guidebook for decarbonization of hospitals. This reference tool will help hospital owners, operators, designers, architects, engineers, and regulators understand the benefits of using advanced technologies and designs to minimize natural gas use, reduce greenhouse gas emissions, reduce healthcare costs, and provide benefits for investor-owned utility rate payers.


E55: Attaining Net Zero and Flexible Resiliency at Massachusetts General Hospital

Speakers: Peter Alspach, Director of Design Performance, NBBJ; Paul D. Biddinger, Chief Preparedness and Continuity Officer, MassGeneral Brigham; Andy Martino, Licensed Professional Electrical Engineer, Director of Facilities Engineering, Massachusetts General Hospital; Jacob Knowles, Principal, Director of Sustainable Design, BR+A Consulting Engineers

With the combined goal of a net zero carbon future and bolstered resiliency in the face of increasingly volatile global climatic conditions, the design, construction, and operation of healthcare facilities is challenged to perform at much higher levels than ever before.

Located next to Beacon Hill on a more than 200-year-old Massachusetts General Hospital campus, the Cambridge Street Project requires a sensitive response to the neighborhood context while meeting the city of Boston’s goal of 65 percent carbon emissions reduction by 2050. The experts on this panel will discuss this case study and the process of achieving carbon neutrality on this complex project.


E65: We’ve Designed the First All Electric Hospital in the U.S.—Want to See How?

Speakers: Gary Hamilton, USA Director of Healthcare, Senior Vice President, WSP USA; Jonathan Hunley, System Director of Facilities Infrastructure, Bon Secours Mercy Health

Decarbonization of the healthcare sector is a pressing and difficult challenge on a global scale. Is electrification part of the solution? Ultimately, if hospitals across the globe can become fully electric or incorporate greater use of electrified energy into their buildings and operations, it could create a virtuous circle.

As the electricity grids continue to decarbonize, greater use of electricity in healthcare will valuably contribute to achieving crucial operational net zero outcomes. This presentation will walk through all the design considerations that are needed to create an all-electric hospital and will illustrate the operational cost benefit of implementing the all-electric hospital as opposed to the current hybrid hospitals.