Carpenter: One of the questions we asked of participants this year involved their use of green design. Several of the answers were interesting and showed growing involvement with this. I recall one participant noting that the trees that had been removed from the site were milled and used for the wood flooring, for example.
Green: Another entrant had installed a windmill next to a pond both to generate energy from wind and to clarify the water.
Carpenter: Yet another project indicated that while there was a 6% incremental cost for green design, this was recouped in 3.5 years.
Calkins: Which means operators are making money on the building over the course of time.
Carpenter: Research has also shown that there's a lot you can accomplish with green design without incurring large upfront costs. Improving indoor air quality could be an example. There are several easy methods that can be implemented, such as construction sequencing. Schedule a two-week time period at the end of construction when the building can be aired out to vent noxious fumes before the occupants arrive. This doesn't cost anything, especially in nursing buildings that already have a system to provide 100% outside air. Also, install all of the wet materials and allow them to off-gas before installing carpets and furniture so that noxious fumes don't get trapped in the fuzzy materials. One wonders why more people aren't taking a first step like this.
Pace: Well, although more people are thinking about these things—and I'm glad that we asked the question—sustainable design is still not foremost in many people's minds as they design new projects.
Carpenter: We're finding in our experience that more residents of CCRCs are asking about green issues, so it's going to evolve to become an important marketing issue.
Brown: With the specific “green” issue of stormwater drainage, many projects worked closely with regulators and dealt innovatively with this. Results like these validate the SAGE philosophy that collaboration with regulators leads to a better product.
Calkins: I think I saw more projects than ever before commenting on having a close working relationship with regulators.
Pace: It reflects an underlying fact, in my view, that regulations have begun to change in a direction that reflects the principles of SAGE. I think we should feel good about that.
Gregory: However, we recently reviewed regulations nationally and found that about half are very similar to each other—similar, for example, in space requirements for resident rooms. There appears to be a “common ancestor” for all these regulations and I think it's in the Southeast. This may have arisen because these states generally had a large population of elderly and adopted the Hill-Burton amended requirements that were used for licensing hospitals. In 1950, most states licensed hospitals because the Hill-Burton Act required it, but few licensed nursing homes. The 1950 amendments to Hill-Burton for the first time required states that received federal matching funds to create standards to license both nursing homes and hospitals. The common ancestor was the Hill-Burton standards for hospitals which were simply adopted and, over time, somewhat modified to apply to nursing homes. So the nursing home design standards were originally based on a medical mode and, unfortunately, have not been updated since the 1960s or ’70s. For example, nursing stations are very obviously nursing stations in facilities in these states. Even though we now have the technology to upgrade these areas, we continue to be stuck with an antiquated model based on the old Hill-Burton standards.
Calkins: It's interesting. The federal guidelines say nothing about nursing stations, but the state requirements vary quite a lot from state to state. An informative place to check on these issues is the Nursing Homes Regs Plus Web site, http://www.hpm.umn.edu/nhregsplus/.
Steinhauer: But the regulatory environment overall is dictated by the legislative environment, and we as a field haven't done enough to educate legislators or consumers.
Carpenter: Some states do work with us. But others shut the process down and go strictly by the book.
Pace: Different regulators can interpret the same things differently. Local officials, such as fire marshals, can take very different stands from state officials as well. We have to remember that we're not just preaching to the state regulators. We have to go up the ladder to their bosses in the state legislatures.
Steinhauer: And I'd have to say there has been an overall failure by the long-term care industry to demand change at the state level. SAGE workshops are very useful, but while we sit here and talk about how regulation is subjective and often ties our hands in trying to advance technologically, if you talk to professional provider associations about whether they are actively involved with state codes in the culture change that's needed to bring about reform, the answer is no. Little or nothing ever happens.
Yes, it took Wisconsin 17 years to change because it took that long for everything to line up properly, but there's no real reason why we should have any regulation of this type in the United States that's more than 10 years old. The overall lack of progress with state administrative codes is inexcusable.
Bonn: It's very difficult to change the rules. Doing so is political and painful, and confronts a lot of people who maintain an interest in the status quo. Certainly they don't look forward to regulatory updates.