Methodology to Identify and Prioritise the Sustainability Aspects to Be Considered in the Design of Brazilian Healthcare Buildings

Abstract

The evidence of climate change has increased the necessity for actions to avoid severe consequences for future generations. Recognising the benefits of sustainable and energy-efficient buildings has led to the development of several methods to estimate and rate the performance of building. Healthcare buildings are functional and dynamic structures that support their occupants’ healing processes and comfort. They have a significant role in society and specific goals in merging their strategic planning requirements (cost reduction, regulatory compliance, social responsibility, and performance improvement) with Sustainable Development Goals. Therefore, this paper addresses critical issues regarding the sustainability of the Brazilian healthcare sector by analysing the suitability of the most common international healthcare building sustainability assessment methods to the specific social, economic, and environmental contexts of the Brazilian healthcare sector. The paper analyses the HBSAtool-PT, a sustainability assessment method developed for this type of building, and identifies the possibilities for adapting to the Brazilian context. As a result, this research proposes a framework to assess the sustainability of healthcare buildings in Brazil. In the framework’s definition, a survey was conducted to determine the opinion of building stakeholders regarding the importance of indicators. A weighing system for the proposed sustainability indicators was developed using the AHP method.

1. Introduction

The building industry is one of the largest sectors involving people (services) and materials. It significantly impacts the environment, economy, and society because it consumes large amounts of natural resources [1]. As reported by the World Business Council for Sustainable Development, the building sector accounts for about 40% of total energy use, 30% of greenhouse gas (GHG) emissions, 17% of freshwater consumption, and 25% of harvested wood and is responsible for the production of 45% to 65% of disposed waste in landfills [2].

Consequently, mitigating the environmental impacts of the building sector has become a significant issue, and projections for the future global population and economic growth predict a steady increase in the worldwide energy demand [2]. Energy use in the built environment is the main factor causing climate change. Therefore, promoting energy-efficient buildings is crucial to ensure a more sustainable future [3].

According to Happio and Viietaniemi [4], numerous building sustainability assessment (BSA) methods have been developed over the last decades to evaluate building performance and to analyse the buildings’ life cycle impacts on the environment, economy, public health, and well-being in cities. These methods are based on a list of indicators organised in different sustainability dimensions.

BSA methods are tools for evaluating building performance and supporting sustainable design. Therefore, they are essential to support decision making towards implementing sustainable principles in existing and new buildings. It allows us to obtain a sustainability rate after a detailed report [5] and serves as a management tool or guideline to address sustainability targets during the design, construction, and operation phases. Considering the effect these methods can have in fostering the implementation of sustainable buildings, some governments offer tax incentives for buildings that fulfil certain sustainability rating thresholds [6].

Globally, there are different BSA methods developed by private and public institutions. The approaches share the general aim of promoting sustainable buildings and are based on a similar list of core sustainability indicators. Still, they differ in adjusting to the specific territory’s environmental, economic, and sociocultural contexts [6].

Healthcare buildings are very complex due to the different types of users, the dynamic demand of spaces, the integration of constantly evolving technologies and systems and their social contribution to the community. Incorporating sustainable development criteria in the design strategy is considered the main factor for the success of sustainable hospital projects. Other essential factors are promoting sustainable initiatives, measuring risks and impacts (goals, metrics, monitoring, and evaluation), management programs (water and energy efficiency), low-impact maintenance products, actions towards transparency, educational programs, communication, and response teams.

In Brazil, the healthcare sector is starting to look at sustainability as an opportunity, and efforts are being made to define the sustainability indicators for different healthcare buildings and locations. One of the limitations of developing a method to support the practical implementation of sustainability goals in the Brazilian healthcare sector is the need for comprehensive information about its performance. In addition, the Brazilian territory is very vast. Therefore, diverse economic, environmental, and social goals make it challenging to develop an effective method to be applied nationwide [7]. The analysis and interpretation of the current situation in Brazil are crucial in developing a sustainability assessment framework that fits the market needs and stakeholders’ expectations.

1.1. Challenges for Healthcare Buildings in Brazil

Healthcare is a water- and energy-intensive service, mainly due to the continuous operations that require, among others, light, heat, intensive ventilation, sterilisation, and food preparation. It is responsible for generating significant waste and producing polluting emissions. The built environment accounts for about 40% of all CO₂ emissions, and hospitals alone account for about 4% of the total emissions of the built environment. Therefore, it is necessary that hospitals’ stakeholders feel the urgency to undertake actions to reduce these greenhouse gas emissions. CO₂ emissions are prone to cause respiratory diseases and other illnesses. Thus, hospitals are undermining the communities’ health [8]. Since hospitals provide patient care for people within a community, they can be characterised as inherent to social responsibility by taking care of patients as their core business. In sharp contrast to this, hospitals are among the most significant contributors to climate change [9].

Brazil’s health sector has undergone many changes in the last few years. Concerns regarding sustainability are becoming more evident, mainly because of society’s awareness of the growing environmental issues and how the poor quality of indoor environments affects the health and comfort of patients and employees. Additionally, constant technological changes and the need to incorporate them into hospitals lead to a plurality of design issues that must be considered, such as building flexibility and adaptability.

The need to apply modern concepts in hospital management influences the development of suitable techniques and tools that can support decision making towards integrating sustainability principles that contribute to economic growth, social satisfaction, and the preservation of the natural environment. The design professional can improve the healthcare environment, from being cold, sober, and intimidating to a humanised, ludic, and secure space, increasing the healing ambience of the patient and reducing the hospitalisation period. In addition, designing rest areas enables a better working environment for the employees, resulting in better performance and safety. Besides this set of concerns, merging all specific technical requirements with sustainable development goals is necessary.

1.2. Healthcare Building Sustainability Assessment Methods and Their Application in the Brazilian Context

With regard to implementing the sustainable healthcare building concept, several assessment methods define the criteria that can guide professionals to meet the standards and develop high-performance solutions. Nevertheless, some issues still need to be considered for better accuracy. For example, comprehensive databases that gather life cycle information about buildings and materials are required, as are more and better correlations between construction and operational costs. In the construction sector, traditional and outdated processes lead to multiple construction processes and considerable heterogeneity of the final products [10].

According to Bellen [11], comparing existing methods allows for identifying the main advantages and limitations of the different existing evaluation processes. Comparative analysis will enable groups with various objectives to choose the most appropriate method for achieving their goals. Many countries either have or are developing sustainability assessment methods, which makes the need for coordination increasingly relevant. In Brazil, the assessment tool for healthcare buildings is mainly LEED, but there needs to be a prior adaptation to the country’s specific context.

2. Objectives

Underestimated decisions at the early design stage are often tricky and expensive to remediate during the operation stage. In addition, the environmental impact and cost can be massive for large-scale projects, such as healthcare buildings, if they are not completed well.

This paper aims to identify and analyse the sustainability assessment methods for healthcare buildings, studying their suitability and the need to be adapted to the Brazilian context. This analysis focuses on assessing the potentiality of adaptation of the Portuguese method for healthcare buildings (HSBAtool-PT) to the Brazilian context. The objective is to define a list of sustainability criteria, adapted to the Brazilian environmental, societal, and economic contexts that can support decision making in the design of more sustainable healthcare buildings in Brazilian. Additionally, it will propose a system of weights for the defined list of indicators, based on the opinion of different Brazilian stakeholders of the healthcare sector. The proposed system of weight enables the identification, from the preliminary design stages, of the priorities to consider in the sustainable design of healthcare buildings. In addition, it allows comparing the sustainability priorities of different countries in the context of these type of buildings.

The HBSAtool-PT, LEED v4 for Building Design and Construction, and BREEAM International New Constructions 2016 were the BSA methods analysed to evaluate the potentialities and possibilities for adaptation. The lists of sustainability indicators were studied comparatively, along with the weights and assessment methods used.

A list of indicators was defined based on the abovementioned assessment methods and validated for the Brazilian context, considering the opinion of a group of experts. Afterwards, the sustainability priorities (weighting system) of the proposed list of indicators were outlined using a survey involving the main stakeholders on the design, management, and maintenance of healthcare buildings. This list would define the priorities of a sustainable healthcare building in Brazil.

3. Methodology

This study seeks to analyse different sustainability assessment methods for healthcare buildings to highlight the key similarities and differences and propose a list of sustainability indicators and a system of weights for use in the Brazilian context. Two international methods have been selected to attain these goals: BREEAM International New Constructions 2016 and LEED v4 for Building Design and Construction, the leading systems operated by well-known organisations (BRE and USGBC) with a proven record in the domain of sustainability development. A method developed for a specific country, i.e., HBSAtool-PT, is also considered.

3.1. Comparative Matrix of Healthcare Assessment Methods

The comparative analysis aims at contrasting the selected rating systems for assessing the performance of healthcare buildings. Considering the criteria requirements and guidelines of the different methods used, it is possible to identify, categorise, and standardise the critical building performance [12] criteria that will influence the decision-making process the most.

Analysing the categories of the considered HBSA methods, it is possible to conclude that there are, on one hand, different categories referring to the same sustainability criteria and, on the other, categories with similar denominations that assess completely different criteria. Therefore, thirteen core sustainability criteria were identified, and the categories of the different methods analysed were grouped in this framework. According to this organisation, the categories most commonly assessed within the analysed methods are Energy (21%) and Indoor Environmental Quality (17%). Other important categories are Materials and Resources (13%), followed by Site Quality, Management, Water, Waste, and Transport and Pollution, which are assessed by the majority of the methods. Nevertheless, there are some categories only considered by a few or one of the BSA methods. For example, outdoor quality and the economy are two categories that are only covered by the HBSAtool-PT method.

The HBSAtool-PT method was designed specifically for Portuguese healthcare buildings, considering the national context, European sustainability standards and policies, and other existing and recognised sustainability methods for this type of building [13]. It can evaluate new, existing, and renovated buildings, allowing for future adaptations to new guidelines, standards, or national laws. Thus, it aims to be practical, easily understandable, and flexible to be adapted. This is important to promote sustainable development, construction, operation, and maintenance. The structure of the method is based on 52 indicators, divided into 22 categories, which are integrated into five areas: Environmental; Sociocultural and functional; Economic; Technical; and Site. The sustainability label delivered communicates the performance at the level of each sustainability area and category, allowing a better comparison between different design scenarios.

The proposed research methodology is based on the exact steps of development of the HBSA method for the specific context of Portugal but considers the Brazilian context. The following research steps are considered:

• To define the preliminary list of sustainability indicators based on internationally recognised HBSA methods and international goals for sustainability;
• To pre-validate the preliminary list of indicators through interviews with the most recognised experts and policymakers in the context of the Brazilian healthcare sector;
• To propose the final list of indicators based on a survey (Appendix A) distributed to the main Brazilian healthcare buildings’ stakeholders;
• To develop the system of weights of the proposed list of indicators by applying the Analytical Hierarchy Process (AHP) method.

3.2. Development of the List of Indicators and Questionnaire

The definition of the initial set of sustainable indicators comprehended all criteria identified in existing methods for the healthcare context. It was based on the literature and the analysis of the following data:

• Two most used assessment methods at the international level to assess the sustainability of healthcare buildings, namely: BREEAM International New Constructions 2016 [14] and LEED v4 for Building Design and Construction [15];
• The list of areas, categories, and indicators of the HBSAtool-PT method [16];
• The Global Agenda for Green and Healthy Hospitals objectives [17].

The initial set of indicators included all different environmental, social, economic, technical, and site indicators identified in the BSA methods mentioned before [18,19]. The methodology was similar to the one used by other authors to develop BSA methods for specific contexts [20,21].

Afterwards, three experts (well-known Brazilian academics and practitioners in sustainability and healthcare buildings) were invited to discuss the results and validate the preliminary list of sustainable categories and indicators. These experts include an ex-president from the Brazilian Association for the Development of Hospital Buildings; a member of the International Academy for Design and Health–South American Chapter; and a professional consultant in building sustainability assessment.

The discussions were carried out through online interviews, which allowed the definition of the list of sustainability categories and related indicators. Some were highlighted and considered a priority according to the Brazilian context. Following the experts’ recommendations, one indicator was added to the preliminary list of indicators (

Table 1. Indicators suggested by the experts that were not included in the preliminary list of indicators.

Suggested Indicators	Area	Justification
Corruption avoiding plan	Economy	Considering the Brazilian situation, the Economy area should have sustainable purchase policies in order to prevent extortions.
Olfactory Comfort	Sociocultural and functional	To enhance the comfort of users in hospitals by the minimisation of olfactory discomfort and improvement of indoor air quality.
Contingency Plan	Sociocultural and functional	A very punctual situation caused by emergencies in cases of serious claims (e.g., pandemics, floods).
Universal Design	Technical	Composition of an environment that can be accessed, understood, and used by all people, regardless of their age, size, ability, or disability.
Space flexibility and Space adaptability	Sociocultural and functional	Merge flexibility and adaptability into just one indicator because it makes more sense in this type of building.

).

Experts recommended adding the corruption avoidance plan to the preliminary list of indicators because of its relation to the political context. It is necessary to understand how each healthcare institution implements anti-corruption measures.

On the other hand, the criteria of olfactory comfort are used in the Haute Qualité Environnementale (HQE) and sub-targeted into objectives, such as the provision of efficient ventilation, the minimisation of olfactory discomfort, and the improvement of indoor air quality. These items are already embedded into the User’s health and comfort category. Therefore, they will not be considered as indicators to be added.

The Contingency Plan is another item that would not be interesting to include in the list presented because it is only used in odd circumstances and is challenging to measure. In addition, Brazil has no occurrences of natural disasters (e.g., hurricanes, earthquakes, and tsunamis). The Universal Design was not considered because the research is based on the added value, meaning that only the improvements compared to the standard Brazilian design practices will be considered. Universal Design is already mandatory in the design of healthcare buildings (according to, e.g., ANVISA–RDC 50/2002 [22] and ABNT NBR 9050 [23]).

It was also suggested to merge two items into Space flexibility and Space adaptability. Still, it describes the changes that can happen during the period of a day, using furniture elements, doors, panels, and curtains, while the other describes the adaptive capacity of the room in case of renovation.

As a result of the analysis of the existing assessment methods and the expert’s opinions, the draft list of indicators (

Table 2. List of sustainability areas, categories, and indicators included in the survey.

Areas	Categories	Indicators
A1 Environmental	C1 Environmental life cycle impacts assessment	I1 Assessment of the buildings’ life cycle impacts
	C2 Energy	I2 Primary energy consumption
		I3 Onsite energy production
		I4 Energy Performance
	C3 Soil use and biodiversity	I5 Layout optimisation
		I6 Soil sealing
		I7 Reuse of previously built or contaminated areas
		I8 Ecological protection of the site
		I9 Rehabilitation of the surrounding
		I10 Use of native plants
		I11 Heat Island effect
	C4 Materials and Solid Waste	I12 Construction waste
		I13 Reused and recycled products and materials
		I14 Waste separation and storage
		I15 Responsible sourcing of materials
	C5 Water	I16 Potable water consumption
		I17 Recycling and reuse of effluents
		I18 Treatment of contaminated effluents
		I19 Water efficient equipment
A2 Sociocultural and functional	C6 Occupants’ health and comfort	I20 Natural ventilation
		I21 Toxicity of finishing materials
		I22 Thermal comfort
		I23 Visual comfort
		I24 Acoustic comfort
		I25 Indoor air quality
	C7 Controllability by the user	I26 Ventilation and temperature control
		I27 Natural light adjustment
	C8 Landscaping	I28 Visual link with the surrounding landscape
	C9 Passive design	I29 Layout and orientation
		I30 Passive systems
	C10 Mobility plan	I31 Accessibilities
	C11 Space flexibility and adaptability	I32 Availability and accessibility of social areas
		I33 Space optimisation
		I34 Space flexibility
		I35 Space adaptability
A3 Economy	C12 Life cycle costs	I36 Initial cost
		I37 Operational costs
	C13 Local economy	I38 Hiring local goods and services
	C14 Corruption avoidance plan	I39 Sustainable purchase policies
A4 Technical	C15 Environmental management systems	I40 Commissioning
		I41 Environmental management plan
		I42 Infection control
		I43 Reducing noise pollution
	C16 Technical systems	I44 Efficiency of lighting and air conditioning systems
	C17 Security	I45 Occupants safety
		I46 Responsible construction practices
	C18 Durability	I47 Materials of high strength and durability
		I48 Proper selection of furniture
	C19 Awareness and education for sustainability	I49 Education of occupants
		I50 Education of service providers
		I51 Satisfaction surveys
	C20 Skills in sustainability	I52 Integration in the team of a qualified sustainability expert
A5 Site	C21 Local community	I53 Local community development
	C22 Cultural value	I54 Heritage framework
	C23 Conveniences	I55 Accessibility to public transport
		I56 Low-impact mobility
		I57 Local amenities

) was used to develop the survey to produce the final list of indicators. The draft list presents fifty-seven indicators, organised into twenty-three categories: C1 Environmental life cycle impacts assessment; C2 Energy; C3 Soil use and biodiversity; C4 Materials and Solid Waste; C5 Water; C6 Users’ health and Comfort; C7 Controllability by the user; C8 Landscaping; C9 Passive design; C10 Mobility plan; C11 Space flexibility and adaptability; C12 Life cycle costs; C13 Local economy; C14 Corruption avoidance plan; C15 Environmental management systems; C16 Technical systems; C17 Security; C18 Durability; C19 Awareness and education for sustainability; C20 Skills in sustainability; C21 Local community; C22 Cultural value; and C23 Conveniences. This list was included in the survey (Appendix A) conducted to healthcare buildings stakeholders.

During the survey, a descriptive methodology was used. Descriptive research involves gathering data that describe events which are then organised, recorded, and analysed. The survey consisted of fifty-seven questions, organised into six sections. The first section was a cover letter that explained the research goals and stated the privacy policies of the collected data. The following section allowed for identifying how involved in the life cycle of a healthcare building the stakeholder was, and the remaining sections recognised the relative importance of each indicator according to each stakeholder’s perspective. Respondents were asked to give their opinion regarding the matter of each indicator, using a Likert scale organised into five levels of importance: not at all important (1); slightly important (2); moderately important (3); very important (4); and extremely important (5).

In the final part of the questionnaire, the respondents were asked to provide their opinion on the list of indicators by stating if, according to their experience, it was necessary or not to amend the list of sustainability indicators.

3.3. Sampling Process

The survey was intended for professionals developing a professional activity in the healthcare sector or sustainable development. It included healthcare building designers, managers, and stakeholders with sustainable development experience. To achieve broad participation, an internet-based questionnaire was sent by e-mail to the stakeholders with a cover letter describing the study’s aims and stating the data privacy issues.

The overall sample (

Table 3. Feedback numbers from each field.

Field		Frequency	Percentage
Architect	Less than 5 years of experience	2	3.6%
	More than 5 years of experience	8	14.5%
	Specialists in the hospital sector	12	21.8%
Civil Engineer	Less than 5 years of experience	2	3.6%
	More than 5 years of experience	13	23.6%
	Specialists in the hospital sector	6	10.9%
Sustainable Construction Consultant/Expert		2	3.6%
Hospital Manager	Facilities and Equipment Services	2	3.6%
	Superintendence/Management	4	7.3%
	Others	4	7.3%
Total		55	100%

) consisted of fifty-five respondents, 40% of which were architects, followed by civil engineers (38%), hospital managers (18%), and sustainable construction consultants or experts (4%).

Figure 1 presents the geographic distribution of the Brazilian locations where the stakeholders typically develop their activity. As expected, the majority of people who answered are from the Southeast region of Brazil (59%), where most hospitals are concentrated, followed by the South (15%) and Northeast (11%). A further 9% of the participants develop activities all over the country.

3.4. Development of the Weighting System

Panel weighing is considered the most accurate method for defining the weighting system of a BSA method [24]. The more prominent and representative the panel, the more precise the result is. In this study, the Analytical Hierarchy Process (AHP) panellist’s method was applied to evaluate the relative weight of each indicator. The AHP is an organisational and analytical mathematical method for complex priorities and decisions. It was developed in the 1970s and prioritised human decision making in different fields such as policies, business, project selection, healthcare, and education [25].

The AHP is a simple technique that can translate the decision-makers’ qualitative and quantitative data evaluations into multi-criteria rankings. In addition, the AHP includes a valuable tool for checking the consistency of the decision-makers’ evaluations, thus reducing bias in the decision-making process [26].

The AHP involves the following steps to hierarchise the priorities of a project [25]:

• Modelling the problem as a hierarchy containing the goal decision, alternatives for reaching it, and criteria for evaluating;
• Establishing priorities among the elements of the hierarchy by making a series of judgments based on pairwise comparisons between them;
• Synthesising these judgments to yield a set of overall priorities for the hierarchy;
• Checking consistency;
• Achieve a final decision based on the results of this process.

The professionals were asked to provide their opinion on the importance of the five sustainability areas (environmental, sociocultural, functional, economy, technical, and site) in the overall building sustainability level. Inside each sustainability area, the respondents ranked the importance of each indicator using the five-point Likert scale presented before. Based on the recommendations of the experts interviewed. On the methodology used in other similar studies, e.g., Mateus and Bragança [18], for the practical use of the method under development, the final list of indicators should be as compact as possible while including the most critical indicators. Therefore, the last step was to reduce the list of indicators by removing those that, according to the results, had a shallow contribution to overall sustainability. At this level, it was decided to remove the indicators with a weight lower than 0.2% from the list. The reasoning for this cut-off rule comes from analysing the abovementioned BSA methods. The lowest weight in BREEAM is 0.4%, 0.9% in LEED, and 0.2% in HBSATool-PT.

Therefore, a list considering only the indicators that contributed 0.2% or more to the overall sustainability level was proposed, which meant that the list presented in Table 2 was reduced to 48 indicators. In this process, the following indicators were excluded from the final list: Layout optimisation; Reuse of previously built or contaminated areas; Use of native plants; Heat Island effect; Visual comfort; Commissioning; Proper selection of furniture; Education of occupants; and Satisfaction surveys. Using the AHP method again, the weight of the final list of indicators was calculated.

4. Presentation of Results and Discussion

After removing the indicators with a weight below the cut-off boundary, the weights of the remaining indicators, categories, and sustainability areas were recalculated using the AHP method.

Figure 2 presents the relative importance of the sustainability areas and shows that according to the professionals’ opinion, the Environmental (A1), Sociocultural and Functional (A2), and Technical (A4) areas have similar relative importance. Subsequently, the Economy (A3) area’s importance was 17%, and Site (A5) was appointed as the least relevant, corresponding to a weight of 8%.

Analysing the final weights of the indicators, the “technical systems” and “corruption avoidance plan” were both ranked as the most important ones in the “economic” and “technical” sustainability areas, respectively, accounting for almost about 10% of the total weight in each category. The third most prioritised category in sustainable healthcare buildings was water, with potable water consumption and treatment of contaminated effluents as the most critical indicators.

The “Sociocultural and functional” area was ranked the third most important in healthcare buildings. The most important categories of this area are “mobility plan” and “controllability by the user”, both with a weight of 33% inside the area. Furthermore, the fourth-ranked category was “environmental life cycle impacts assessment”, closely followed by the “life cycle costs” category. The “Operational costs within the life cycle costs” category scored highest. Finally, in the “Sociocultural and functional” area, the less important categories are “landscaping” and “passive design”.

The categories proposed for the “Environmental” area were defined to allow, in a holistic way, the assessment of the most common life-cycle environmental impacts according to national priorities. The “Social and Functional” area presented a list of indicators divided into six categories, including the critical aspects of building occupants’ health and comfort, considering the importance of mobility and space design quality.

The “Economic” area was defined to consider the most relevant building life-cycle costs and the impact on the local economy. On the other hand, the “Technical” area reflected issues about security, durability, management of systems and their efficiency and the occupants’ education and awareness regarding sustainability concerns. In contrast, the “Site” areas’ main issues regarded community and cultural values.

The proposed list of sustainability areas, categories and indicators is presented in

Table 4. The weighing system of the proposed list of sustainability indicators.

Area	Category	Indicator	Weight
			Indicator	Category
A1. Environmental	C1. Environmental life cycle impacts assessment	I1. Assessment of the buildings’ life cycle impacts	100%	24%
	C2. Energy	I2. Primary energy consumption	40%	13%
		I3. Onsite energy production	40%
		I4. Energy Performance	20%
	C3. Soil use and biodiversity	I5. Soil sealing	26%	11%
		I6. Ecological protection of the site	41%
		I7. Rehabilitation of the surrounding	33%
	C4. Materials and solid waste	I8. Construction waste	24%	19%
		I9. Reused and recycled products and materials	19%
		I10. Waste separation and storage	47%
		I11. Responsible sourcing of materials	10%
	C5. Water	I12. Potable water consumption	33%	33%
		I13. Recycling and recovery of effluents	17%
		I14. Treatment of contaminated effluents	33%
		I15. Water efficient equipment	17%
A2. Sociocultural and functional	C6. Occupant’s health and comfort	I16. Natural ventilation	12%	16%
		I17. Toxicity of finishing materials	10%
		I18. Thermal comfort	24%
		I19. Acoustic comfort	11%
		I20. Indoor air quality	42%
	C7. Controllability by the user	I21. Ventilation and temperature control	50%	33%
		I22. Natural light adjustment	50%
	C8. Landscaping	I23. Visual link with the surrounding landscape	100%	3%
	C9. Passive design	I24. Layout and orientation	67%	4%
		I25. Passive systems	33%
	C10. Mobility plan	I26. Accessibilities	100%	33%
	C11. Space flexibility and adaptability	I27. Availability and accessibility of social areas	36%	10%
		I28. Space optimisation	33%
		I29. Space flexibility	15%
		I30. Space adaptability	16%
A3. Economic	C12. Life cycle costs	I31. Initial cost	20%	33%
		I32. Operational costs	80%
	C13. Local economy	I33. Hiring local goods and services	100%	10%
	C14. Corruption avoidance plan	I34. Sustainable purchase policies	100%	57%
A4. Technical	C15. Environmental management systems	I35. Environmental management plan	24%	19%
		I36. Infection control	62%
		I37. Reducing noise pollution	14%
	C16. Technical systems	I38. Efficiency of lighting and air conditioning systems	100%	39%
	C17. Security	I39. Occupants’ safety	75%	18%
		I40. Responsible construction practices	25%
	C18. Durability	I41. Materials of high strength and durability	100%	9%
	C19. Education	I42. Education of service providers	100%	10%
	C20. Skills in sustainability	I43. Integration of a qualified sustainability expert	100%	5%
A5. Site	C21. Local community	I44. Local community development	100%	17%
	C22. Cultural value	I45. Heritage framework	100%	17%
	C23. Conveniences	I46. Accessibility to public transport	69%	67%
		I47. Low impact mobility	24%
		I48. Local amenities	7%

, together with the weights assigned by respondents to each sustainability category and area.

Analysing Table 4, it is essential to highlight that the categories’ weight was equal to that of the indicator in categories with only one indicator. Analysing each category made it possible to understand the most important Indicators according to the respondents’ opinions.

In Category C2 (Energy), the weight of the two first Indicators (I2—Primary energy consumption; I3—Onsite energy production) was the same, whereas Indicator I4 (Minimum energy performance) had the lowest weight. In Category C3 (Soil use and biodiversity), the most important was I6 (Ecological protection of the site), closely followed by I7 (Rehabilitation of the surrounding). In Category C4 (Materials and Solid Waste), I10 (Waste separation and storage) achieved the highest weight, and the other three indicators had a balanced weight. In Category C5 (Water), I12 (Potable water consumption) and I14 (Treatment of contaminated effluents) were the most important.

At Category C6 (User’s health and comfort), I20 (Indoor air quality) was disclosed as a priority, and the other three indicators had a balanced weight. The two indicators had the same weight in Category C7 (Controllability by the user). In Category C9 (Passive design), I24 (Layout and Orientation) was considered more significant than I25 (Passive Systems). In Category C11 (Space flexibility and adaptability), the most important was I27 (Availability and accessibility to social areas), closely followed by I28 (Space optimisation).

Within Category C12 (Life cycle costs), I32 (Operational costs) was considered more important than indicator I31 (Initial cost). In what concerns Category C14 (Corruption avoiding plan), Indicator I34 (Sustainable purchase policies) was proposed by the experts, and the results disclosed it as the most important category within the Economy Area. In Category C15 (Environmental management systems), the most important was I36 (Infection control), and in Category C17 (Security), I39 (Occupants’ safety) was more important than indicator I40 (Responsible construction practices). Finally, the most crucial indicator in Category C23 (Conveniences) was I46 (Accessibility to public transport).

Finally, the weight of each category within the areas is presented in Figure 3. The category with the most significant impact on an area was C23 (Conveniences), representing 67% of the A5 (Site) total. Nevertheless, the importance of the Site area in the overall sustainability level is only 8%. The categories with the lower influence were C8 (Landscaping) and C9 (Passive design), which belong to the “Sociocultural and functional” area, having weights of 3% and 4%, respectively.

From comparing the weights between the proposed assessment framework and other HBSA methods, it is possible to draw some conclusions regarding the differences in the sustainability priorities and the level of the structure of each method.

Analysing the different HBSA methods addressed in this study, it is possible to conclude that they share common core sustainability categories, such as energy use; water efficiency; indoor and outdoor environmental quality; resources and materials; service quality; and site strategies. The proposed framework in this study also considered those priorities. Nevertheless, the weight of each category in the overall assessment varies among the analysed methods, as presented in Figure 4. This difference is because the methods were developed for different locations; therefore, each system of weights reflects specific sustainability properties.

It is important to note that one of the studied methods gives more importance to one core sustainability category than others. The energy-related indicators in LEED BD + C weigh 33% of the global sustainability score. On the other hand, BREEAM International New Construction has a more balanced weighing system between all core criteria.

The “Economic” category was one of the three leading sustainability categories in the proposed framework, and this is not considered in the two most used BSA methods (LEED and BREEAM). Additionally, in the Brazilian context, the importance of the economy category is more suited to the healthcare sector’s role in the Brazilian economy. It also reflects the stakeholders’ opinions gathered in the survey.

Based on these differences, it is possible to conclude that this study is an essential contribution to developing a new HBSA method in the Brazilian context because it sets a more comprehensive list of sustainability priorities suitable for the specific environmental, societal, and economic contexts.

5. Conclusions

Healthcare buildings are complex systems due to specific, higher technical, and functional requirements. The number of health services covered and the population served to mean different types of healthcare buildings. Many initiatives related to environmental sustainability in the healthcare sector present necessary steps for hospitals to deal with the eminent global crisis resulting from excessive consumption of natural resources and production of wastes.

Buildings do not have the inherent capacity for regeneration. However, the built environment can be designed to contribute to and support this goal. It also offers the opportunity to align its ecological profile with the health sector’s core mission—to heal—by providing essential health services while preserving the natural environment.

If decisions are made at the early design stage, using comprehensive and systematic approaches, it is possible to integrate sustainability principles with a greater probability of success and reduced costs. It is also important to highlight that those principles must be aligned with the environmental, societal, and economic contexts of the country/region where the approach will be applied.

This study’s limitations are related to the reduced number of Brazilian experts in the fields of hospital building design, construction, and operation. Sustainable construction applied to this type of building has yet to be made a priority. This situation may cause some need for more understanding by the respondents about what is included in each sustainability category and indicator, thus causing biases in the presented weighting system. An additional limitation may be that it was impossible to involve a more significant number of participants, a situation that is common to other studies that used the same methodology conducted in Brazil.

Healthcare building sustainability assessment methods can support the implementation of sustainability concerns in standard design and building management practices by integrating more comprehensive social and economic aspects and minimizing environmental impacts. These methods will allow identifying the design priorities from the early design stages.

Since there is no common international understanding regarding the weight of each sustainability indicator and it depends overall on the specific context and priorities of the location, the proposed framework was based on the results of a survey involving the main Brazilian healthcare stakeholders. This concept is relevant since it considers the knowledge and experience of different experts in the design process, validates the proposed framework, and evaluates the relative importance of each sustainability area, category, and indicator in the overall sustainability level of a project. This will facilitate priority setting when designing more sustainable healthcare buildings in Brazil.

This kind of initiative brings a significant advantage when seeking improvement towards the performance of healthcare buildings. The assessment method can raise awareness, promote sustainable practices, and decrease consumption rates and costs, thus reducing environmental and economic impacts. Additionally, considering the stakeholders’ opinions in the proposed list of indicators, the weighing system becomes more aligned with their expectations, increasing its potential effectiveness.

As a recommendation, environmental issues and strategies must be the focus. However, considering other vital issues, such as societal needs and requirements and economic and technical aspects, is also essential.

The sustainability framework presented in this study differs from other existing HBSA methods since, in this case, the context of the Brazilian construction and healthcare sector was addressed.

To plan a sustainable healthcare building in Brazil, the designer must focus on the most pertinent sustainability categories disclosed in this study, such as efficiency in technical systems, sustainable purchase practices, and accessibility. Additionally, life cycle impacts and costs must be considered, as well as security, environmental management, and aspects related to the controllability of the indoor environmental quality by the user.