Contemporary hospitals in Scandinavia, with climates similar to Seattle or Vancouver, operate on a third or a quarter of the energy used by most new Pacific Northwest hospitals. Another hospital will open in Stockholm next year, in a climate more like Juneau’s, projected to run on a fifth of the total energy of our code compliant hospitals. These hospitals typically provide plentiful daylight and operable windows in virtually all of their spaces, ventilation rates that meet or exceed US codes, and construction costs that closely align with local hospital projects. In this presentation we will consider the factors that contribute to this remarkable difference in energy use, and the changes that would be required in our own practice to approach this level of performance.