By Arjun Mehta, Contributing Writer

Key Takeaways:

• Hospitals consume energy at an outsized rate, making reliable and efficient infrastructure essential not only for controlling costs but also for protecting continuous patient care.
• Deferring maintenance on critical systems such as HVAC, boilers and switchgear can turn manageable capital projects into costly emergencies that create operational disruption and clinical risk.
• Phased efficiency projects — combining equipment upgrades, controls optimization and energy-savings-based financing — can reduce utility costs, fund subsequent improvements and preserve capital for patient-care priorities.

Hospitals operate continuously, and every mechanical system in them must operate around the clock because patients’ lives depend on it. That demand makes hospitals some of the most energy-intensive buildings in the country. 

Hospitals and other healthcare buildings account for just 4 percent of U.S. commercial building floorspace but roughly 9 percent of commercial building energy consumption, according to the U.S. Energy Information Administration. They use about 2.75 times the energy per square foot of a typical commercial building. 

An Energy Star benchmarking of 5,000 hospitals found a striking disparity in energy performance: The most energy-intensive 5 percent of hospitals used more than three times as much energy as the most efficient 5 percent. 

For many healthcare facilities managers, it is not difficult to identify the opportunity. They generally understand where their buildings fall on the efficiency spectrum, and the engineering strategies needed to improve performance are well established. 

The more persistent challenge is finding a practical way to fund those improvements while competing with capital priorities that continue to place pressure on limited budgets. When a CFO weighs a new MRI suite against a chiller replacement, the chiller project is deferred. 

What happens when it breaks 

That reactive approach carries a significant cost. When critical equipment such as a boiler or chiller fails unexpectedly, managers often are forced to absorb premium expenses for emergency procurement, expedited labor, temporary equipment and accelerated installation. Years earlier, the facilities team identified and planned for an infrastructure replacement but could not secure funding to address it, so the problem ultimately becomes far more expensive when deferred maintenance turns into an operational emergency. The result is not simply a higher replacement cost but avoidable disruption and additional pressure on already constrained operating and capital budgets. 

Then there is the issue of what happens to patients when infrastructure fails. Behind every ICU bed, procedure area and laboratory are electrical, plumbing, thermal and HVAC systems that must perform reliably to support demanding clinical requirements that drive successful patient outcomes. 

Hospital staff are understandably focused on the patient and the care delivered in the room, while the mechanical systems that maintain critical temperature, humidity and air-change requirements operate largely out of sight. When those components go down unexpectedly for repairs or emergency replacement, clinical consequences follow. 

Managers and their teams understand both the infrastructure and what is at stake when it fails. But they often are tasked with making the case for upgrades to leadership teams that seek to balance competing priorities and view infrastructure investments as distinct from the delivery of patient care. 

The conversation changes when energy engineers focus on operational consequences: What happens if the HVAC system fails? What happens if aging switchgear no longer can reliably support the required load? 

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Those questions reframe the discussion from whether the hospital can afford to invest in its infrastructure to whether it can afford to continue deferring that investment, as well as the financial, operational and patient-care risks that come with doing so. 

Phasing the work so savings fund the next round 

The capital challenge looks different when energy savings become part of the funding strategy. Rather than competing for a large, upfront capital allocation, facilities managers can phase infrastructure improvements so savings generated by earlier measures help support subsequent investments. 

When structured appropriately, this approach can enable critical upgrades without an upfront capital commitment or the addition of traditional debt to the balance sheet, allowing hospitals to modernize infrastructure while preserving capital for other priorities. 

For example, Constitution Health Plaza — a five-building, 400,000-plus-square-foot medical campus in South Philadelphia — executed a retrofit over three phases, with a total upgrade value of $5.4 million. The project now generates $620,000 in annual savings, which is a 52 percent reduction in total energy costs. The campus went from spending roughly $1 million a year on utilities to around $300,000. 

Part of what made those numbers possible was aligning the campus’ building systems with its current mix of healthcare and commercial use. Constitution Health Plaza once operated as a full-service hospital. As the property evolved into a multipurpose medical campus, an evaluation of the way energy was distributed and consumed across the five buildings identified significant opportunities to modernize the central utility plant and improve campus-wide efficiency. 

The resulting improvements included: converting the campus from steam to hot water; installing high-efficiency heating equipment and chillers; consolidating nine air handling units into six; and implementing a campuswide building automation system. Together, these upgrades reduced energy consumption while improving comfort, system reliability and long-term maintainability. 

HVAC systems account for 52 percent of a hospital’s total energy consumption, according to BSA Design, and they experienced energy waste from controls that were never sequenced properly. 

At Rothman Orthopaedic Specialty Hospital in Bensalem, Pennsylvania, optimizing controls cut energy use by 21 percent as observed over a 12-month rolling period. This energy savings was realized by a $598,857 investment with a 4.7-year payback. The hospital’s opportunities were identified and executed upon to better align HVAC systems operation with actual space requirements and changing building loads. 

Improvements included BAS-integrated occupancy control in select areas, advanced airside control sequences and coordinated optimization of the chiller, boiler and associated pumping systems. This project design demonstrates  

The way controls optimization and retrocommissioning can produce meaningful savings without relying solely on major equipment replacement. The strongest results often are achieved when equipment improvements and controls strategies are evaluated together. 

Getting work done with no shutdown 

Executing infrastructure upgrades in an active hospital requires a level of flexibility and coordination that extends well beyond the technical work itself. Systems that support patient care cannot simply be taken offline on a conventional construction schedule. Work that might take days in an unoccupied facility can extend over months as upgrades are carefully sequenced around clinical operations. 

For example, work in inpatient areas might need to proceed room by room as beds become available, with each phase coordinated around infection-control protocols, ventilation requirements and the hospital’s broader operational needs. 

Targeting equipment that serves specific areas of a campus rather than overhauling the central plant means work can proceed in one section while the rest of the facility runs normally. Shoulder seasons in October and April — when ambient conditions reduce the need for mechanical cooling and heating — create opportunities for overnight work during free-cooling hours. Temporary HVAC and air systems can bridge gaps during equipment changeovers. 

None of this work is fast, but all of it is manageable when the project is scoped to the facility’s operating reality rather than an engineering timeline. 

Patient care should always be a hospital’s primary mission, but the savings generated by phased energy upgrades can preserve hospital capital for clinical investments. Most healthcare systems still treat infrastructure upgrades and optimization as a cost to be deferred rather than a source of savings. Shifting that perspective requires a different approach to financing and a willingness to begin with targeted, smaller, scoped projects that can demonstrate measurable savings and create pathways for broader infrastructure investments. 

Arjun Mehta is vice president of operations and service at Ecosave, an energy-as-a-service provider specializing in energy and water efficiency, clean energy generation and building automation for commercial facilities.