Theory

Health Environments Research

& Design Journal
2015, Vol. 8(4) 139-157
A Classification of Healthcare ª The Author(s) 2015
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DOI: 10.1177/1937586715575910

Development of Energy herd.sagepub.com

Performance Benchmarks for

Day Surgery Centers in Australia

Tarek M. F. Ahmed, MSc1,2, Priyadarsini Rajagopalan, PhD1,

and Robert Fuller, PhD1

Abstract
Objective: In the literature, there is no consistent classification of healthcare facilities. In order to
benchmark, assess, and compare the environmental performance of these buildings, it is important
to clearly identify the typology within the scope of a particular research. This article identifies the
different typologies within the healthcare sector, particularly in Australia, with the aim of the
development of energy performance benchmarks for day surgery/procedure centers. Background:
Healthcare buildings encompass a wide range of facilities. They all share the same purpose of healing
and offering a health service for patients. However, they vary significantly in terms of patient type and
service provided. These buildings consume a considerable amount of energy, and as a result of the
different designs and sizes, their pattern of energy consumption varies. Methods: The research used a
systematic review of the literature to determine how the term ‘‘healthcare facility’’ has been employed
in different contexts. In order to better understand the differences in healthcare facilities, definitions
and the origin of hospitals and healthcare facilities are introduced and a framework for the classification
of healthcare facilities and hospitals is proposed. Results: Healthcare facilities are classified into the
following six categories: patient type, care provided, management and ownership, level of care, facility
size, and location. Based on these classifications, a categorization for the studies of energy performance
in healthcare is introduced. Conclusions: This study provides a basis for assessment and comparison
for a particular healthcare building typology that will assist researchers working in the field of design
and energy assessment of healthcare facilities.

Keywords
healthcare facilities, services, classifications, energy assessment, day surgery

Introduction
There are studies aimed at developing and review-
ing environmental assessment tools and energy
benchmarks for commercial and residential build-
ings (Attia, Evrard, & Gratia, 2012; Hernandez,
Burke, & Lewis, 2008; Pérez-Lombard, Ortiz,
1
School of Architecture and Built Environment, Deakin
University, Geelong, Australia
2
Department of Architecture, Assiut University, Assiut, Egypt
Corresponding Author:
Tarek M. F. Ahmed, MSc, School of Architecture and Built
Environment, Deakin University, Geelong, Australia.
Email: tarek.ahmed@deakin.edu.au
140
González, & Maestre, 2009; Rajagopalan &
Leung, 2012; Wang, Yan, & Xiao, 2012). Short,
Lomas, Giridharan, and Fair (2012) stated that
commercial buildings, including healthcare build-
ings, consume a considerable amount of energy
and contribute to global emissions and that the
UK health sector is responsible for 30% of public
sector emissions. Healthcare buildings are signifi-
cantly different from other building typologies due
to their high standard of indoor environmental
requirements. However, healthcare design has
been notably lagging in addressing sustainability
(Short & Al-Maiyah, 2009). Healthcare build-
ings and hospitals encompass a wide range of
building types; and they have different design
requirements, equipment, different occupancy
rates, and operating schedules. Buildings of this
type vary significantly not only in their pattern
of energy use but also in the factors that influence
energy consumption. Most studies conducted in
healthcare are related to the assessment of retro-
fitting strategies or investigating the potential
improvement in energy consumption, mainly of
heating, ventilating, and air-conditioning (HVAC)
systems, and without reference to the importance
of building typology. On the other hand, some
studies place emphasis on the variation in the aver-
age energy consumption across the healthcare sec-
tor due to the diversity of the building typologies
encompassed by this sector (Kolokotsa, Tsoutsos,
& Papantoniou, 2012).
Due to the particular nature of these buildings,
with the main aim being to heal patients, stringent
standards for indoor environmental quality such
as thermal comfort, natural lighting, and high
ventilation rates are required to decrease and
avoid airborne infection. The role of natural
lighting and thermal comfort on the recovery rate
of inpatients has also been investigated (Choi,
Beltran, & Kim, 2012; Giridharan, Lomas, Short,
& Fair, 2013; Lomas & Giridharan, 2012; Ver-
heyen, Theys, Allonsius, & Descamps, 2011).
In order to provide suitable energy-efficiency
measures and strategies, this sector needs to be
investigated further via identifying its different
typologies, classifications, and energy consump-
tion. For the purpose of the development of
energy performance benchmarks for a particular
healthcare building typology, a proper building
Health Environments Research & Design Journal 8(4)
assessment is required. Consequently, the main
aim of this article is to establish a classification for
healthcare buildings that provides a guideline for
energy performance benchmark development for
day procedure/surgery centers. The secondary aim
of this article is to categorize the energy perfor-
mance assessment tools within the scope of health-
care buildings.
This article is organized into seven sections.
The first section identifies the problem and posi-
tions it within the healthcare context. The second
section discusses the methods used in conducting
the paper. The third section presents background
information on the notion and origin of healthcare
buildings. It also provides important definitions
and terms in healthcare systems and buildings and
an overview of healthcare system classifications
applied in different countries followed by an
introduction to day procedure centers and differ-
ent models of services provision in Australia. The
fourth section provides a critical analysis for the
classification of healthcare facilities and proposes
a classification framework for healthcare build-
ings that can facilitate the contextualization of
healthcare buildings. In the light of the proposed
classification, the fifth and sixth sections review
the energy use in healthcare buildings and cate-
gorize energy performance assessment tools
within the scope of healthcare buildings, respec-
tively. Finally, the findings are discussed and
some conclusions are drawn.
Methodology
A systematic review of literature has been con-
ducted and peer-reviewed papers and government
documents in three major fields have been identi-
fied, namely, healthcare management, healthcare
architecture, and healthcare environmental perfor-
mance assessment. Electronic databases includ-
ing medical literature such as PubMed and the
Department of Health database in the United
States, United Kingdom, and Australia and Jour-
nals such as Healthcare Engineering and Energy
and Buildings have been reviewed. The publica-
tion selection is based on papers that have dis-
cussed any of the above-mentioned fields, with
an emphasis on the concept and notion of health-
care, definitions, categories, classifications, and
Ahmed et al.
their energy performance assessment. A set of
key words, for example, healthcare definitions,
healthcare classifications, hospital characteristics,
hospital sizes and services, and phrases such as
‘‘energy consumption in healthcare buildings’’
were established to search for pertinent work. In
order to not miss ‘‘buzzwords’’ in the key words
search, a backward approach was implemented
through checking the references cited by the article
and also a forward approach via checking the
references that have cited this article. This infor-
mation is explored in the following four main
sections: healthcare background and definitions,
healthcare facility classification, energy use in
healthcare facilities, and energy assessment
tools for healthcare facilities.
Healthcare Background and
Definitions
With the evolution of medicine, medical disci-
plines, and specialities, the term ‘‘healthcare
facility’’ has emerged to represent the different
types of buildings where the main aim is to diag-
nose and heal patients. There are four main cate-
gories of healthcare services within which all
healthcare services and buildings fall, namely,
primary or community care, secondary care, ter-
tiary care, and quaternary care. Primary care is
the first point of contact. Usually, this is when the
general practitioner or physician examines and
decides to which specialist the patient should be
referred to. The World Health Organization
Alma-Ata Declaration of 1978 defined primary
healthcare as:
It is the first level of contact of individuals, the
family, and community with the national health
system bringing healthcare as close as possible
to where people live and work, and constitutes the
first element of a continuing healthcare process.
(Department of Health and Ageing, 2009, p. 22)
Secondary care is provided in healthcare facil-
ities or by a specialist following referral from a
primary care provider. Most healthcare facilities
fall within the secondary care category. Acute
care hospitals are a major branch of secondary
healthcare. They provide care and treatment for
short-term acute conditions, such as trauma and
severe injury and contain all the necessary
141
medical staff for diagnosis (Department of Pub-
lic Health, 2014).
Referral or tertiary care is provided in profes-
sional hospitals at a regional or national level, the
role of which is educational and medical treat-
ment (Department of Health, 2011). Tertiary care
encompasses a wide range of services, with a pro-
portion of cases being referred from secondary
care facilities/services due to the complexity or
serious nature of the condition. Tertiary hospitals
contain 100–500 or more beds based on their
level. They are open 24 hr everyday (Ministry
of Health, 2011). Quaternary care is an extension
to tertiary care and more specialized. They usu-
ally exist on a national level where unusual and
uncommon surgeries are performed. It can be
provided in some cases in tertiary care facilities
(Johns Hopkins Medicine, 2014).
Healthcare Facilties
Healthcare facility is a broad term used to describe
several building typologies whose primary func-
tion is to provide and deliver different health ser-
vices for patients. Facilities range from small
clinics to large complex hospitals and in the con-
text of this article the word ‘‘facility’’ means
‘‘building.’’ In the field of facilities management,
the term healthcare facilities management refers
to the management of the nonclinical areas, sys-
tems, and facilities in the building such as the
HVAC, lighting, strategic planning, customer
care, market testing, benchmarking, environmental
management, and staff (Shohet & Lavy, 2004).
Sheth (2011) defined healthcare facility as a build-
ing with particular characteristics depending on
the purpose and level of the care provided.
Hospitals. Hospitals are the most complex type of
healthcare facilities. The concept of hospitals ori-
ginated around the year 500 B.C. in Ancient
Greece, where the temples were not only built for
worship but also used to diagnose and heal peo-
ple, because during that period, people believed
in the power of rituals and sacred settings in heal-
ing (Wooley, 2003). Another significant reason
for the emergence of hospitals was for military
purposes, with the ancient Romans developing
hospitals to serve their army, where the plans and
142
designs of the hospitals were based on barracks
(Prasad, 2012). Both religious and military pur-
poses were important aspects in the development
of hospitals. The word hospital was derived from
the Latin word ‘‘hospitum,’’ which means provid-
ing shelter for the needy (Prasad, 2012). The term
has developed over time to describe a place for
the recovery of patients. The main function of
hospitals is diagnostic, medical care, and other
professional services for the patients. In the
1970s, the design of hospitals tended to be more
patient centered in a belief that patient preferences
could inform the design as an alternative to the
provider-centered approach, which was used for
almost five decades (Miller, Swensson, & Robin-
son, 2012). The motive for this transformation
was the existence of patient-centered medicine
in the 1960s. By 1980, for the first time, focus
was placed on improving patients’ experiences
while in the hospital, how to make the hospital
a better place to approach and easier to navigate,
and how this could improve the patients’ con-
dition and thus issues of indoor environmental
quality (e.g., air quality, acoustics and lighting)
were introduced (Prasad, 2012).
Throughout the literature, a wide range of clas-
sifications exist to categorize different typologies
of healthcare facilities and hospitals. Healthcare
systems worldwide use different definitions and
classifications for healthcare facilities and hospi-
tals. Even for facilities of the same type, it is hard
to find a consistent definition used across differ-
ent countries.
Healthcare buildings in United States. Tulchinsky
and Varavikova (2009) stated that healthcare
facilities in the United States can be classified
into 14 categories. The main criteria for the clas-
sification were based on the type of service pro-
vided, the population served, and the average
length of stay. The categories are as follows:
Short-stay hospitals, long-stay hospitals, nursing
homes, skilled nurse homes, hostels, hospices,
nonprofit hospitals, proprietary hospitals, gen-
eral hospitals, community hospitals, district hos-
pitals, teaching hospitals, special hospitals, and
tertiary care hospitals. Out of those facilities,
70% are nonprofit and 15% for profit, while pub-
lic hospitals comprise only 15% of the total
Health Environments Research & Design Journal 8(4)
number of hospitals (Thomson, Osborn, Squire,
& Jun, 2013).
Healthcare buildings in the United Kingdom. The
National Health Service (NHS) is the main pro-
vider of health services in the United Kingdom.
The NHS is available in England, Northern
Ireland, Scotland, and Wales. Since 2013, the
NHS has been working as an independent
authority. In England, NHS-funded services are
available through provider organizations such
as hospitals, community-based, clinical com-
missioning groups, and other providers such as
charities, private organizations, and social enter-
prises, which together constitute the NHS health-
care system. Providers are those who provide the
NHS-funded care by meeting the NHS quality and
financial standards. Hospitals are a major part of
the NHS, with the majority being the property
of the NHS trust or NHS trust foundation. Each
trust comprises a number of hospitals or sites.
The healthcare service follows the service levels
discussed earlier, that is, primary care and then
referral to a healthcare provider, that is, secondary
care (hospital and community-based; Department
of Health, 2013). Figure 1 shows the new str-
ucture of the healthcare system in England,
United Kingdom. Private healthcare facilities
are owned, run, and operated by Intuition Com-
munication, Ltd.
Healthcare buildings in Australia. In Australia, the
Australian Bureau of Statistics (ABS, 2010)
clearly classifies healthcare system into public
and private hospitals. Figure 2 illustrates the
structure of the healthcare system. The state and
territory governments own and manage the pub-
lic hospitals. Short-term acute care is provided
in public hospitals. However, some services
such as rehabilitation are provided on a long-
term basis. Psychiatric hospitals specialize in
mental health issues. The private sector is pri-
vately owned and managed by either profit or
nonprofit organizations. A large proportion of
the private hospitals are day hospitals where the
service is provided on a daily basis or with an
overnight stay. Figure 3 shows the number of
public and private hospitals in all Australian
states and territories.
Ahmed et al.
Figure 1. New healthcare system in England, United
Kingdom.
According to the ABS (2010) and the Austra-
lian Institute of Health and Welfare (AIHW,
2011), the total number of healthcare facilities
in Australia at that time was 1,326. The number
of facilities in the public and private sectors were
753 and 573, respectively. It is noted that the
greatest number of healthcare facilities were
located in New South Wales, with 226 for the
general public and 173 for private patients, fol-
lowed by Victoria with 161 for the general public
and 151 for private patients. It is clear that there is
an increasing trend in the provision of private
healthcare facilities to complement and decrease
the pressure on public hospitals, particularly with
the long waiting period existing in public health-
care facilities. This explains the trend shown in
Figure 3 where more than half of the buildings
operate as day facilities from which the patient
can be discharged on the same day as the proce-
dure or operation.
Day Procedure/Surgery Centers
Day surgery is one of the fastest growing health-
care facilities, particularly over the last two
143
Figure 2. Healthcare system in Australia.
decades. For instance, in the United States, day
surgery attendance increased by 300% from
1996 to 2006 (Cullen, Hall, & Golosinskiy,
2009). It is an alternative to acute hospitals for
operations that do not require an overnight stay
and can be undertaken on the same day. The
notion of an operating theater walk-in walk-out
surgery goes back to 1962 in the United States.
However, it was not until 1971, which witnessed
the opening of the ‘‘Surgicenter’’ in Phoenix, Ari-
zona, the first freestanding day facility, which is
considered a pioneer for today’s day surgery cen-
ters, by Reed and Ford (1976). As a result, about
3,000 operations were performed in the ‘‘Surgi-
center’’ during its first year. Under normal condi-
tions, 90% of those cases would have been
hospitalized. It was estimated that about 4,500
hospital days were saved as a result of this facil-
ity, which in turn reduced the high cost associated
with acute care hospitals, and patient claims and
lower cost of Medicare (Roberts, 1986b). The
increasing cost per bed in both public and private
hospitals was pressing these hospitals to decrease
the length of stay for patients, which in turn might
negatively result in compromising the standards
of practice (Roberts, 1999). The need for centers
144
Figure 3. Number of public and private hospitals and healthcare facilities in Australia by state.
that are able to perform minor operations without
the necessity of a stay in hospital, that is, on an
outpatient basis has risen. The outpatient savings
in day centers are a result of the absence of the
charge for room and board that exists in acute
care hospitals. Additional savings also result
from extra expenses such as laundry, cafeteria,
and 24-hr laboratory services and the absence
of 24-hr emergency services in conventional
hospitals that increase overheads (Roberts,
1986b). Other reasons behind the expansion of
day centers include reduced construction and
operating costs and fewer staff required in com-
parison to the number of staff required for sur-
gery in acute care hospitals (Towart, 2006).
Over the last decade, there has been a move to
centralize procedural services, particularly in
metropolitan hospitals, which have increasingly
developed into huge complexes.
Miller, Swensson, and Robinson (2012) noted
that day surgery is typically carried out in four
models of facility. Hospital-based integrated
units are located within hospitals and share the
same facilities with inpatient surgery character-
ized by low capital cost. Hospital-based auto-
nomous units are dedicated to day surgery;
Health Environments Research & Design Journal 8(4)
however, they still retain the advantages of
using the hospital’s equipment as a backup
whenever necessary. Hospital satellite units are
off-campus freestanding units but still operated
and owned by the hospitals. These facilities take
advantage of staff expertize and hospital rep-
utation and provide service to remote areas.
Finally, freestanding ambulatory surgery units
are free-functioning and independent hospi-
tals and/or centers. In addition, Towart (2006)
included another model of provision where the
day surgery patients are mixed with the inpati-
ents in private or public hospitals. The model
also merged the last two models of Miller et al.
(2012) to one category and identified them as
freestanding facilities either hospital managed
or independent.
Day surgery services are well established in
Australia. Roberts (1998) stated that day surgery
can be found in freestanding day centers or as day
units integrated within public and private hospi-
tals. Some hospitals have a separate functioning
unit attached to the main hospital for day sur-
gery/procedures. To achieve cost–benefit and the
prospective efficiency from day surgery services,
Roberts (1997, 1998) advises that a freestanding
Ahmed et al. 145

Table 1. Day Surgery Centers Models in Australia (Roberts, 1999).

Structure Day surgery center same day

Day surgery center with extended recovery
Medi-motel
Prototype model of day surgery/acute care complex
Professional service Multidisciplinary
Unidisciplinary
Surgical (procedural)—elective and acute/trauma
Medical—other acute care (nonprocedural)
Location Freestanding
Hospital (public or private) Separate unit (freestanding)
Integrated unit (free-functioning)

facility or separate free-functioning unit attached

to acute bed hospital be utilized. Moreover, day
surgery should have a separate management and
operating system (Roberts, 1986a). Two impor-
tant aspects are emphasized as essential for day
surgery facilities as follows: first, to have high-
quality services and safety and second is to be
cost-efficient for patients so that it can sustain
itself. In most hospitals, all operations are
carried out in general theaters and not in ones dedi-
cated for day surgery. The majority of day surgery
centers are multidisciplinary, with services offer-
ing a wide range of operations in various surgical
specialties. A minority of unidisciplinary centers
provide service for one specialty. Roberts (1999)
stated that the unidisciplinary centers are much
smaller but still financially viable. They have the
advantage of possessing high-technology equip-
ment that are dedicated to one specialty (Roberts,
1999). Table 1 shows day surgery models existing
and proposed in Australia based on the following
three criteria: structure, professional service,
and location.
Roberts (1999) emphasized the nonexistence
of a best model and the necessity for a flexible
design. The numbers of operating theaters vary
according to the size of the centers, starting from
two theaters for a small center and potentially
reaching six theaters in the case of large centers.
Day surgery also plays an important teaching
role for both undergraduate and postgraduate
medical students. With the addition of more
major operations, day surgery will continue
expanding toward its ultimate goal to undertake
70–80% of all operations and procedures (Roberts,
Figure 4. The evolution of day procedure centers
from 1993 to 2011 in Australia.
1999). Essential services should be provided such
as air-conditioning, auxiliary electricity power
unit, storage for medical gases, covered ambulance
bay, fire extinguishing equipment, emergency
exits, laundry services, delivery and waste disposal
services, food and beverage service, and security
for patients and staff (Roberts, 2005).
The number of day surgery centers in Austra-
lia has increased dramatically from 1993 to 2011
(Figure 4; ABS, 2010; Roberts, 1999). The fig-
ure does not include the data for 2001, 2002, and
2003 as this was unavailable. There has been an
increase of almost 75% in 2012 in day surgery
facilities compared to 1993. In 2005, there
were 248 freestanding day surgery centers in
Australia. This number has increased dramati-
cally over the last decades; however, almost
50% of all procedures are still practiced in acute
care hospitals. One third of private hospitals
have day surgery units. In 2005, 50% of all pro-
cedures performed were on a day-surgery basis.
However, this is still lower than the ultimate
146
Figure 5. Trends in day surgery/procedure provision
in Victoria.
projected goal. In 1999, researchers predicted
that by 2005, 82% of all surgeries in the United
States would be day surgery and 24% would be
office-based (Roberts, 2006).
In Victoria, there has been a continuous
increase in day procedure centers from 1998 to
2011. Throughout that period, Victoria ranked
second among the Australian states and terri-
tories in terms of the number of day centers. In
1998, 22% of day hospitals were found in Vic-
toria. By 2011, this had increased to almost
28% of the total, with a considerable increase
of more than 200% from 1998 (Figure 5).
Healthcare Facility Classification
A classification for healthcare facilities is dic-
tated, to an extent, by the field of enquiry and the
purpose of the conducted research.
Type of Care Provided
One of the most common healthcare classifica-
tions is according to the type of care. The follow-
ing are the three main types of care provided in
healthcare facilities: acute care, subacute care,
and long-term care. Acute care is provided in
hospitals, in facilities that provide at least a min-
imal medical, surgical, and diagnostic services
for patients as well as providing qualified nur-
sing and requiring at least an overnight stay
(Hargreaves, Grayson, & Titulaer, 2002). Some
acute care patients can be treated on a day basis
in day hospitals (ABS, 2010).
Subacute care is a post-acute type of care that
lies between acute medical care and long-term
Health Environments Research & Design Journal 8(4)
rehabilitation and is usually provided at a skilled
nursing home. This kind of care does not require
intensive diagnostic or invasive procedures as
required in acute care. However, it requires
highly qualified nurses and at least 3–4 hr
follow-up weekly or daily by a physician, which
is not delivered in an ordinary nursing home.
The U.S. Department of Health and Human Ser-
vices (1994) states that many patients who could
be treated in subacute care are treated in acute
care facilities due to the absence of this type of
care in the health system. They are considered
a cost-effective alternative to acute hospitals due
to the high cost of inpatient beds. Subacute care
includes, for instance, rehabilitation, palliative,
and psychogeriatric care (Calder et al., 2000).
Miller et al. (2012) reported that the average
length of stay for rehabilitation in a subacute care
facility is between 2 and 3 weeks. They add that
before the existence of diagnostic-related groups,
skilled nursing facilities were responsible for
patients with chronic illnesses, while subacute
patients were the specialty of acute care hospitals.
Long-term care is usually used to describe resi-
dential features. The expression could encompass
a range of services provided such as rehabilitation
and maintenance care. This care type is meant for
patients who cannot look after themselves for a
prolonged period of time, for example, those suf-
fering from disabilities or chronic illness. The age
of the patient is not predetermined in this classi-
fication; however, it is usually associated with
older people. The extended service could be
either provided at home or at a nursing home.
Aged care is an alternative term used in Austra-
lia, where the main focus is residential and com-
munity care for aging people and does not refer
to other post-acute care services for different
ages. The average length of stay for patients in
a long-term care facility ranges from 1 to 2 years
(Miller et al., 2012).
Management and Ownership
Healthcare facilities can also be classified accord-
ing to their management and ownership, either
public or private healthcare facilities. Public
healthcare facilities are run, funded, and/or admi-
nistered by governments, whereas private
Ahmed et al.
facilities are usually administered and managed
by private entities. A healthcare facility might
operate on a for-profit or nonprofit basis. Most
profit-based facilities are privately owned,
whereas the nonprofit hospitals are found in the
public sector. The nonprofit health service is
provided by governments, municipalities, reli-
gious, or voluntary organizations. For a particu-
lar type of facilities being available under the
public or private sectors does not determine the
types of healthcare facilities included in each
sector (Tulchinsky & Varavikova, 2009). How-
ever, the types of facilities covered by each sec-
tor, private or public, depend on the trends in the
healthcare system provision within a country.
Size of Healthcare Facility
Another classification that is widely used is the
size of the facility. This classification is often
associated with hospital buildings. Tradition-
ally, the size of hospitals is determined by the
number of beds (Cowan, 1963). Hospital size
varies considerably and the number of beds
might give a good indicator for the hospital size.
As this classification is bed based, it is only
applicable for healthcare facilities with inpatient
accommodation. The number of beds taken into
account are only those prepared and staffed for
the care of inpatients (Tulchinsky & Varavi-
kova, 2009). In terms of size, hospitals can typi-
cally be divided into the following three main
categories: large, medium, and small. Loux,
Payne, and Knott (2005) referred to small rural
hospitals as those with less than 50 beds,
medium size from 50 to 99 beds, and large hos-
pitals as those with 100 or more beds. Reuters
(2011) in ranking the top 100 hospitals defined
small-size community hospitals as those with
between 50 and 99 beds, medium size between
99 and 149, and large size from 150 to 249 beds.
Heidenreich, Zhao, Hernandez, Yancy, and
Fonarow (2012) noted that small-size hospitals
are those with less than 200 beds, medium size
range from 200 to 500 beds, and large size have
more than 500. Likewise, Bujak (2010), in a
study performed on University Hospital in
Bydgoszcz, Poland, considered that large hospi-
tals are those with more than 600 beds.
147
Hargreaves, Grayson, and Titulaer (2002)
grouped public hospitals into broadly similar
groups, with large hospitals having an average
of 144 beds and medium hospitals an average
of 63 beds, while both small-size rural and
remote area hospitals have a similar range with
an average of 23 beds. Gupta et al. (2007) recog-
nized hospitals that contain less than 100 beds as
small hospitals, whereas medium hospitals range
from 100 to 300 beds and large hospitals include
more than 300 beds. Similar research by Aiken,
Clarke, Cheung, Sloane, and Silber (2003) quan-
tified bed numbers into three categories as
follows: <100 beds, 101–250 beds, and 251
beds without relating these numbers to a partic-
ular size such as small, medium, or large ones.
Other healthcare facilities that are not inpatient
based such as ambulatory surgery and medical
centers, clinics, and dentists are considered to
be small healthcare facilities (American Society
of Heating, Refrigerating and Air-Conditioning
Engineers [ASHRAE], American Institute of
Architects, Illuminating Engineering Society,
U.S. Green Building Council, & U.S. Depart-
ment of Energy, 2009). In the United States, this
classification differs according to the region. For
example, large tertiary hospitals are classified as
those with 325 beds in the western region and
with 425 beds in the southern region.
In the energy assessment and management
field, the size of healthcare buildings (area) is one
of the crucial indicators in assessing whole build-
ing energy performance. The gross floor area and
the type of healthcare building are important
criteria in judging building energy performance.
In this regard, the energy use intensity, that is,
energy use per unit of area, is a widely accepted
indicator for evaluating the energy consumption
of healthcare buildings. However, energy use
per bed is also recognized as an indicator in
acute care facilities with inpatient beds (Kappor
& Kumar, 2011). There is a direct correlation
between the number of beds or building users
and the building size and its energy consump-
tion. Typically, large buildings consume more
energy than small ones. Although the bed num-
bers are important in classifying hospital sizes,
it is not a reliable indicator on its own. For exam-
ple, some of the healthcare facilities are on an
148
outpatient basis or have beds that are not used
for long periods of time such as day hospitals,
however, they are big in size. Similarly, for
building energy consumption, it depends on the
type of the healthcare facility, number of users,
number of beds, and the building size.
Location of Healthcare Facility
Another possible classification is the location
of the facility. According to Fraze, Elixhauser,
Holmquist, and Johann (2010) as identified by the
National Center for Health Statistics and American
Hospitals Association that ‘‘hospital is in a large
central metropolitan area (‘urban’), a fringe county
of a large metropolitan area (‘suburban’), a small-
to medium-sized metropolitan area (‘micropoli-
tan’), or nonmetropolitan area (‘rural’)’’ (p. 1).
Health Services Provided
Finally, healthcare facilities can be classified
according to the health services covered and pro-
vided by the hospital. In this context, they can be
classified as general and specialty hospitals.
General hospitals offer a wide range of acute
healthcare services, such as obstetrics and gyne-
cology, orthopedic and pediatric surgery, and
deal with many diseases and injuries (Sheth,
2011). In addition, most of the diagnostic and
laboratories are also found within the same
building. On the other hand, in a specialty hospi-
tal, the focus is generally on a specific kind of
care or age-group, such as children hospitals,
cancer hospitals, rehabilitation, and psychiatric
hospitals (Sheth, 2011). A specialty hospital
works the same as an outpatient surgery center
but with one specialty. One possible major dif-
ference between specialty and general hospitals
is that specialty hospitals provide an emergency
service and offer hospitalization for complex
surgeries. The AIHW (2014) developed a new
classification for public hospitals using peer
groups. The report states that the classification
is intended to be released later in 2014. It reflects
the need to compare different hospitals when
evaluating performance and reporting statistics.
The groups have been defined by the type and
the service provided. Hospitals have been
Health Environments Research & Design Journal 8(4)
classified into two groups, namely, acute public
hospitals and specialist hospitals. The acute hos-
pital group comprise the following five sub-
groups: principal referral hospitals, large acute
hospitals, medium acute hospitals, small acute
hospitals, and very small hospitals. On the other
hand, the specialist hospital groups encompass
nine groups as follows: women’s and children’s
hospitals, early parenting centers, drug and alco-
hol hospitals, psychiatric hospitals, day hospi-
tals, other acute specialized hospitals, subacute
and non-acute hospitals, outpatient hospitals,
and un-peered hospitals. Role delineation for
healthcare facilities according to the health ser-
vice level has been proposed (New South Wales
Health Department, 2002). The services are
divided into two types, namely, core services and
clinical support services. The health service level
assigned is based on the responsibilities and func-
tion of a particular healthcare facility. Six levels of
service 1–6, defining the complexity level, have
been proposed. In addition, the following six
core service categories, comprising 53 major
specialities, have been identified: emergency,
medical, surgical, maternal and child, integrated
community and hospital services, and community-
based health services. Eight essential clinical
support services, that is, pathology, pharmacy,
diagnostic imaging, nuclear medicine, anes-
thetic, intensive care, coronary care, and operat-
ing suites have been recognized.
In the previous sections, different healthcare
types, classifications, and purposes have been
examined. The main classification categories
found in the literature were the size, manage-
ment and ownership, care provided, and service
covered. Table 2 presents a proposed classifica-
tion for healthcare facilities and aspects of cate-
gorization. As discussed earlier, due to the wide
range of facilities, an assessment method or tool
that encompasses the different types of healthcare
buildings is not yet available. In the next section,
energy use and environmental assessment tools
within healthcare facilities are examined.
Energy Use in Healthcare Facilities
In order to improve the energy efficiency in
healthcare facilities, a proper assessment for the
 Table 2. Classification of Healthcare Facilities.
Patient Facility Size (Bed
Type Healthcare Facility Type Service Provided Care Level Management Ownership Number) Service Covered (Specialty) Location

T1 Hospital Inpatient Acute care Secondary care Public Nonprofit Small General Urban
Outpatient Tertiary care Private For profit Medium Specialty Suburban
Quaternary Large Micro-politan
care rural

T2 Ambulatory/day surgery or Outpatient Secondary care Public Nonprofit Number of operating Multispecialty Urban Suburban
procedure center Private (mostly) For profit theaters and TFA Specialty(mostly)

T3 Medical healthcare/centers Outpatient Primary care Private (mostly) Nonprofit TFA General Urban
For profit Specialty (mostly) Suburban
Micropolitan
Rural

T4 Clinics Outpatient Primary care Public For profit TFA General Urban
Private Specialty Suburban
Micropolitan
Rural

T5 GP and specialist Outpatient Primary care Private (most) For profit TFA General Urban
Suburban
Micropolitan
Rural

T6 Rehabilitation palliative care Inpatient Subacute care Public Nonprofit TFA General Urban Suburban
Private For profit Specialty Micropolitan

T7 Aged care/nursing homes Inpatient Non-acute care Public Nonprofit TFA General Urban
Private (most) For profit Suburban

Note. TFA ¼ total floor area; GP ¼ general practitioner.

149
150
Figure 6. Energy breakdown in healthcare facilities in Canada.
buildings should be conducted to identify the cur-
rent performance and potential energy savings.
The scope of healthcare facilities is too wide
to follow a specific pattern in terms of energy
consumption. Accordingly, the energy break-
down from an end-use perspective varies signif-
icantly. The classification provided in Table 2
can now be used to categorize the facilities.
Large Healthcare Facilities
Several studies address the energy performance
of acute care hospitals. Hu, Chen, and Chuah
(2004) estimated the energy consumption in a
large acute hospital (T1) in Taiwan. It was found
that air-conditioning is a major electricity end
use, comprising more than 50% of the total
energy used. The highest energy load was found
in the operating theaters. Natural Resources
Canada (2003), discussing acute and extended
care facilities (T1 and T7), noted that energy use
is dominated by heating, lighting, and ventila-
tion. The energy used for heating in acute care
facilities was found to be more than 56% fol-
lowed by lighting (Figure 6). The study devel-
oped benchmarks based on a survey of 222
acute and extended care facilities. Kappor and
Kumar (2011) noted that HVAC has the highest
energy consumption in hospitals (T1), followed
by lighting, with a range of 36–65% and 30–40%,
respectively. The Department of Health (2012) in
Australia conducted a study via sub-metering on
a metropolitan hospital (T1). The study revealed
that HVAC has the highest energy consumption,
where heating has the highest contribution.
Health Environments Research & Design Journal 8(4)
In the United Kingdom, one of the recent
leading studies in the healthcare field has been
undertaken by Short et al. (2012). The project
aimed to understand the potential resilience of
existing hospitals (T1) in the United Kingdom,
within the NHS carbon target, in terms of indoor
environmental quality, energy, and CO2 emis-
sions in relation to future climate change.
Furthermore, it evaluates various scenarios for
low energy refurbishment and adaptive strate-
gies through a series of case studies on hospital
wards in acute hospitals using 2,030, 2,050, and
2,080 scenarios. The research used a hybrid
assessment method of dynamic simulation and
on-site measurements. The study focused on a
functional area, that is, ward areas in acute care
hospitals. Results of the research have been
discussed in a series of articles (Lomas & Girid-
haran, 2012; Lomas, Giridharan, Short, & Fair,
2012; Short & Al-Maiyah, 2009; Short, Cook,
Cropper, & Al-Maiyah, 2010; Short, Lomas,
Giridharan, and Fair, 2012). Smith, Lowndes,
and Wei (2010), aiming to evaluate the energy
performance in large hospitals (T1), used
dynamic simulation modeling for a metropolitan
hospital built in compliance with the Building
Code of Australia (2009, 2010) in 10 different
climate zones in Australia. The HVAC had the
highest energy consumption. The study indi-
cated that a 15% improvement could be achieved
by reducing the average annual energy consump-
tion from 1.35 down to 1.15 GJ/m2. This could
be used as a benchmark for designing new hospi-
tals with similar requirements. It also adds a break-
down of the energy consumption for functional
Ahmed et al.
areas in the hospital. The average highest energy
consumption was the ward area followed by oper-
ations. Sheth, Price, and Glass (2010) on the
refurbishment of existing healthcare facilities
concluded that there is a need for a framework
to integrate modeling, simulation, and assess-
ment tools through the whole process to improve
the energy efficiency. Department of Climate
Change and Energy Efficiency (2012) analyzed
the energy consumption pattern in Australian
hospitals stock, major and regional hospitals
(T1). Bed numbers were used to define hospitals
space when data were not available. The average
energy consumption estimates in 2005 and 2011
were 1.49 and 1.56 GJ/m2, respectively, with
49% of the total energy use for electricity and
47% for gas. A forecast for hospital floor space
and energy consumption to the year 2020 was
presented. The uncertainty about the definition
of hospitals and the need to construct modules
to represent energy performance for small health-
care facilities was noted.
Small Healthcare Facilities
Murray, Pahl, and Burek (2008) established an
energy benchmark target for smaller healthcare
buildings (T2), named C5 buildings, based on the
NHS Scotland classification, using data collected
from 180 buildings in Scotland through statistical
analysis. The statistics revealed a poor correlation
between heating energy consumption and other
parameters, such as age and physical location.
The study confirmed the scarcity of research on
this size of healthcare buildings. The average
energy consumption across the sample was 0.45
GJ/m3. The study did not consider the best prac-
tice as a benchmark due to the poor performance
of the top buildings. Therefore, it suggests that a
realistic benchmark based on the good practice of
small office buildings be adopted, that is, 0.16 GJ/
m3, as they resemble the C5 buildings in their pat-
terns of energy use. This figure is adjusted to 0.20
GJ/m3, due to the unique indoor environmental
quality in healthcare facilities of, for example,
higher temperature for patients’ comfort is
required. In an attempt to improve the energy
efficiency in small healthcare facilities of area
less than 3,680 m2 (T2, T3, and T4), ASHRAE
151
issued the advanced energy design guide for
small hospitals and healthcare facilities. The
guide devised measures and recommendations
that could be adopted in different climatic zones
across the United States to improve the energy
efficiency in small healthcare buildings. Using
a dynamic simulation, two prototypes were
developed, that is, a baseline model for newly
constructed surgery centers and community hos-
pitals, and a low energy model. Energy savings
of 30% could be achieved over the Energy Stan-
dard 90.1-1999 and up to 30% in some areas
compared to 90.1-2004 (ASHRAE et al., 2009).
Another study evaluated the impact of number
of users on the energy efficiency of 70 health cen-
ters (T3 and T4) in Extremadura, Spain. A strong
correlation was found between the number of
users, energy consumption, and the building size.
The study devised a mathematical formulation
that predicts the optimal size of health centers,
with respect to the energy efficiency, based on the
number of building users. The average energy
consumption across the sample is 86 kWh/m2
(Garcı́a Sanz-Calcedo, Cuadros Blázquez, López
Rodrı́guez, & Ruiz-Celma, 2011; Garcı́a-Sanz-
Calcedo, López-Rodrı́guez, & Cuadros, 2014).
Rajagopalan and Elkadi (2014) evaluated the
environmental performance of three small health-
care centers in Victoria (T3). The energy use
intensity ranged from 0.57 to 1.1 GJ/m2. The
study also noted a poor correlation between the
energy consumption and building fabric and that
a single benchmark is not suitable for different
locations. The electricity and gas energy con-
sumption ranges between 55–85% and 45%–
15%, respectively.
Energy Assessment Tools for
Healthcare Facilities
Energy and environmental assessments, rating,
labeling, and benchmarking tools have been
discussed extensively (Pérez-Lombard et al.,
2009; Rajagopalan & Leung, 2012; Wang
et al., 2012). Generally, there are three cate-
gories embraced by all assessment methods and
tools, namely, calculation-based, measurement-
based, and hybrid methods (Wang et al.,
2012). Table 3 illustrates the range of healthcare
152
Table 3. Energy Assessment Tools for Healthcare Buildings.
Assessment Criteria
Assessment Tool Scope of Healthcare Facilities Conditions Method Type and Output

Energy Star (portfolio Hospitals 50% Of the gross floor area should be used for general or surgical Measurement based Energy use intensity
manager) General service; 50% of the beds should be for acute care. Energy consumption
Surgical prediction
Specialty Energy star rating and
e.g., rehabilitation center certificate
cancer center

LEED Inpatient and outpatient
facilities
GGHC Institutional occupancies,
such as acute care
hospitals, medical office
buildings, clinics, and other
buildings where the main
function is healthcare
Green Star Healthcare facilities in
Australia
BREEAM Teaching/specialty hospital,
General acute hospitals,
Community and mental
health hospitals, GP
surgeries, Health centers,
and clinics in the United
Kingdom
Eco-bench Hospitals 24 hr operation in Limited to multispecialty hospitals
India
Energy reduction 10% over a self-referenced baseline building Measurement based LEED certificate and rating
according to ASHRAE standard 90.1-2007 ENERGY STAR rating in (new construction) score
2
the case of an acute hospital with small facilities, less than 8,360 m , Calculation based
the building should be fully compliant with AEDG for small hospitals (existing building)
and healthcare facilities requirements for the climate zone. Comply
with the green guide for healthcare GGHC for energy improvement
in hospitals and this works for facilities over 8,360 m2.
Adopted many of the credits in the LEED system, modified some, and Measurement based Self-certifying guide based on
added new credits to suit the healthcare facilities. Energy star rating. (new construction) best practice rating score
EUI of 19% above industry average in KBtu/ft2/year Calculation based
(Existing building)
Points achieved are based on the reduction percentage in CO2 Green Star calculator Green star certificate CO2
emissions relative to the reference building measurement based emissions
Specific requirements for Healthcare assessment scheme (feature Measurement and BREEAM certificate rating
specific) calculation based score
Measurement based Energy performance index

Note. GP ¼ general practitioner; EUI ¼ energy use intensity; LEED ¼ Leadership in Energy and Environmental Design; AEDG ¼ advanced energy design guide; GGHC ¼ Green Guide for
Healthcare; BREEAM ¼ Building Research Establishment Environmental Assessment Method.
Ahmed et al.
buildings within energy assessment and rating
tools. The absence of a clear classification of
healthcare buildings encompassed within each
tool and an energy benchmark model for each
building type is evident. Energy assessment
tools were compared in terms of the types of
healthcare encompassed within each tool, con-
ditions that should be applied for the building
to be assessed, method of assessment, and
finally the expected output from the tool and its
relative importance are explored (Table 3).
Discussion
Hospitals are the major and most complex type
of healthcare facility. The classification of
healthcare facilities is a complicated process. It
is noted that the importance of any classification
adopted is mainly dependent on its purpose and
the field of enquiry, for example, medical, archi-
tectural, and/or energy analysis to provide a
meaningful indicator. In conducting energy per-
formance assessments, it is of great importance
to understand the category and characteristics
of the healthcare building typology under inves-
tigation for proper assessment and benchmark-
ing. The patient type (inpatient or outpatient)
and the care type (acute care, subactue, or non-
acute) have a great impact on the energy use pat-
tern in a facility. For example, acute care facility
with inpatient beds consumes significantly more
energy than an outpatient non-acute care facility.
The facility’s energy consumption per unit of
area is not a highly reliable indicator for energy
performance on its own. However, some studies
have shown a correlation between building size
and energy consumption. Small acute care hos-
pitals, for example, consume higher energy than
healthcare centers of a comparable size. In addi-
tion, a definition or classification of hospital size
based on the number of beds varies significantly
based on the specialty and the community they
are serving. The use of the term large, medium,
or small, without defining the number of beds or
the service level, varies with users and is there-
fore misleading. There is no absolute classifica-
tion regarding the size of hospitals, and the size
also depends on the geographical area, whether
it be metropolitan, regional, or a remote area.
153
For example, a small hospital in one area could
be classified as a medium hospital in another
area. The number of users in health centers has
shown a good correlation with the facility size
and energy consumption. Therefore, for a proper
sizing of a healthcare facility, a combination of
number of beds and users and service level needs
to be considered simultaneously.
With respect to energy studies, it is noted that
most of the previous studies have focused on
two main aspects. First, at a building level,
acute care hospitals were the most frequently
evaluated, with a focus on inpatient wards. Sec-
ond, energy-efficiency measures and energy
improvements of HVAC systems were mostly
investigated. There are two main reasons behind
this trend. First, most of the studies agreed that
HVAC is the major end-use energy consump-
tion. In addition, ward areas are critical areas
with the highest energy consumption among
functional areas as patients spend long periods
of time there after operations. The second rea-
son is the complexity of healthcare buildings.
To develop a model to predict energy perfor-
mance for an entire acute care building or to do
on-site measurements for the entire facility is time
consuming and requires significant effort/exper-
tize and cost. This explains why most of the
research focuses on either a functional area or a
subsystem. In addition, current assessment meth-
ods and tools are limited to a great extent. It is
contextual and/or limited to a particular type of
healthcare building. Research also revealed that
limited attention has been placed on small health-
care buildings and day procedure/surgery centers
in particular. However, a significant shift has
occurred worldwide in healthcare service delivery
from inpatient to more outpatient services. This is
because of the long waiting lists in hospitals and
also up to 80% of operations that used to require
hospitalization are now done on day surgery basis.
Day surgery is growing fast to cover the long
waiting period in acute care hospitals. They differ
from other healthcare and community centers,
although they sometimes are similar in size. It has
been noticed that operating theaters, which are a
major component of day surgery, consume a high
amount of energy compared to other functional
areas. The number of operating theaters ranges
154
from one to six based on the operations and pro-
cedures provided by the center, that is, uni or
multispecialty.
Conclusions
This article has presented classifications for dif-
ferent typologies of healthcare facilities. Health-
care facilities have been classified into seven
types, T1–T7. Seven main aspects for the cla-
ssification have been identified: patient type,
service provided, care level, management and
ownership, facility size, service covered, and
location. Healthcare service is provided over
four levels of care, namely, primary, secondary,
tertiary, and quaternary. This study revealed
the lack of a comprehensive tool to assess and
quantify the energy performance of healthcare
facilities. Literatures on the assessment of day
procedure/surgery centers were lowest in num-
bers even though they are considered as having
the highest energy consumption among the
healthcare facilities. There is still a need to focus
on the energy performance of small healthcare
facilities and understand their usage patterns and
factors influencing energy consumption, which
are quite different from large-size acute hospi-
tals. Future work will be undertaken to develop
suitable models for day facilities through objec-
tive measurements, using building performance
simulation tools and statistical analysis in order
to set benchmarks and recommend achievable
energy targets for this typology.
Implications for Practice
Healthcare sector comprises a wide range of facil-
ities and they consume a considerable amount of
energy. In order to improve the energy efficiency
in this sector without compromising the indoor
environmental quality, a target should be set for
particular type. Therefore, a proper classifica-
tion of healthcare facilities is an essential step
toward benchmarking their energy performance.
Identifying the type of healthcare facility will
help to provide an accurate analysis for the
energy consumption, thus facilitating the appro-
priate energy-efficiency measures and strategies.
The detailed classification helps in positing the day
Health Environments Research & Design Journal 8(4)
surgery/procedures centers in the broader context
of healthcare facilities to evaluate their energy
performance.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The author(s) disclosed receipt of the following
financial support for the research, authorship,
and/or publication of this article: This article is
a part of ongoing PhD research funded by the
Cultural Affairs & Missions Sector, Ministry of
Higher Education in Egypt and Deakin Univer-
sity in Australia.
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