The Hippocratic Oath has served as the foundation of ethical medical practice since the fourth century B.C. Today, one of the oath’s core principles—the promise to do no harm—is guiding more than just bedside care. It is the cornerstone of the green movement in healthcare, a rapidly growing effort to help the profession evolve from one that simply cares for the sick to one that serves as a broader force for healing in society.
Some experts note the medical industry has been slow to understand the effects of its practices on public health. Barely a decade ago, U.S. Environmental Protection Agency (EPA) reports revealed staggering statistics: Medical waste incinerators were the leading producer of airborne carcinogenic dioxins, asthma rates for healthcare workers were among the highest of any profession, and healthcare waste was responsible for 10% of mercury air emissions.1
The incredible irony produced “a teachable moment,” says Gary Cohen, co-executive director of Health Care Without Harm in Arlington, Va., an international coalition established in 1996 to help make the industry more ecologically sustainable. Since then, hospitals have eliminated mercury from many of their supplies, including blood-pressure cuffs and thermometers. Additionally, the efforts to transform buying practices and lessen reliance on fossil fuels have gained considerable traction. And the number of medical waste incinerators in the U.S. has dropped from 5,000 to less than 100.
—ALICE ST. CLAIR / METRO HEALTH
“The healthcare sector began to understand the links between the environment and disease. They realized they were both addressing the collateral damage of a poisoned environment, and they were contributing to it,” Cohen says.
Now, even those who are critical of the profession’s past practices are lauding industry leaders’ efforts to build more efficient facilities, reduce waste, and modify day-to-day practices to lessen their environmental footprint.
“Hospitals have been so focused, rightly so, on patient safety,” Cohen says. “Now we’re at the point where we’re talking about patient safety, worker safety, and environmental safety. It’s changing the architecture of how things are done, and it is becoming much more accepted as a mainstream concern.”
Concern should stretch beyond the C-suite to those on the front lines, says Don Williams, MD, a pediatric hospitalist at Dell Children’s Medical Center in Austin, Texas, and a board member of Austin Physicians for Social Responsibility. “Although it is rare for us to see the direct effects of green choices on the health of individual patients, I think it is important to recognize that less air pollution and less global warming leads to less illness,” says Dr. Williams, who works in the only platinum-rated Leadership in Environmental Energy and Design certified hospital in the U.S. The certification, through the U.S. Green Building Council (www.usgbc.org), means the hospital meets the highest of standards in sustainable site development, water savings, energy efficiency, materials selection, and indoor environmental quality.
Hospitalists should be engaged in environmental stewardship because they often are seen as role models for hospital staff, residents, students, patients, and families, Dr. Williams says. “We are also frequently in positions of influence when it comes to instituting hospital policy,” he adds. “Hospital administration officials usually like to keep a friendly relationship with us, and are therefore typically open to our thoughts and concerns on everything from recycling programs to new hospital design.”
New Ways to Build
The most visible sign of American hospitals’ commitment to environmental responsibility is evident in construction. About 81% of hospital building projects last year included environmentally friendly materials, according to a survey by the American Society for Healthcare Engineering. That’s up from 55% in 2006.
Kaiser Permanente, an integrated managed-care organization that operates 37 medical centers in nine Western states, is among the industry leaders in green construction. Its Modesto (Calif.) Medical Center, which opened in October 2008, has received national recognition as one of the greenest healthcare facilities in North America. How green? Permeable pavement in the parking area allows rainwater to filter into the ground, and solar panels generate enough electricity to power up to 20 homes. Building materials were selected with an eye toward patient and employee health. Kaiser worked with a carpet manufacturer to create a product free of potentially harmful polyvinyl chloride. It installed cabinetry made from medium-density fiberboard that did not contain formaldehyde, and it chose paints low in volatile organic compounds.
“People would walk into the hospital and say, ‘This place doesn’t smell new,’ ” says project director Jeffrey Deane. “That’s because people are used to smelling new carpet and new paint, because those materials are outgassing huge quantities of nauseous gases.”
Deane acknowledges it is difficult to create a truly green hospital, given the presence of chemicals and pharmaceuticals, and the way the facility must be cleaned to fight infectious bacteria. But the effort to make the environment within the building less harmful didn’t break the bank. The paint and essentially toxin-free fabrics cost the same or less than traditional materials, and a two-duct air system—which draws air solely from the outside, eliminating recirculation—is easier to maintain and costs less to operate.
“One of the biggest hurdles is getting people past the idea that it’s going to cost too much money,” Deane says. “We have a tendency to value-engineer things because they are cheaper up front. Even in cases when they aren’t, there are ramifications down the road that are pretty significant. For every dollar you spend upgrading your system to be more efficient and environmentally friendly, you’ll get paid back several times over.”
Although new construction provides a clean slate for hospitals to go green, administrations at existing facilities have identified several ways to lessen their environmental footprint. One of the quickest—and most cost-effective—is to improve energy efficiency.
Hospitals are the second-most energy-intensive type of structure in the U.S. behind food service, according to the U.S. Department of Energy.1 That consumption costs inpatient healthcare facilities about $5.3 billion annually—about 3% of the average hospital’s operating budget—and results in about 30 pounds of carbon dioxide emissions per square foot, more than double the emissions of standard commercial office buildings, the department estimates.
Energy savings provide an immediate boost to the bottom line, says Clark Reed, director of the Healthcare Facilities Division at the EPA’s Energy Star program. Based on average profit margins, every dollar a nonprofit hospital saves on its energy costs is equivalent to generating $20 in new revenue, Reed says.
“Because of the dollars involved, energy management is getting C-suite attention,” says Nick DeDominicis of Arlington, Va.-based Practice Greenhealth, a networking organization for healthcare institutions that have committed to eco-friendly practices. “We see an increasing number of hospitals thinking about developing strategic master energy plans, looking at facility management in much the same way they’d look at asset management at the boardroom level.”
That’s why Practice Greenhealth created its Healthcare Clean Energy Exchange, an electronic marketplace in which more than 250 suppliers compete to meet healthcare facilities’ energy needs. The program debuted in 2008 and is operated in a reverse-auction format, with suppliers bidding downward to compete for contracts. It is designed to help healthcare entities lock in stable pricing and increase their percentage of green or renewable energy purchases. The auctions carry no upfront fees, and if a healthcare entity doesn’t like the results, it is not forced to sign a contract.
Ingalls Health System in Harvey, Ill., explored the exchange program after energy prices skyrocketed last summer. Before participating in the exchange, Ingalls used 100% “brown”—or conventionally produced—electricity. During the auction, it sought bids for varying mixes of conventional and renewable power. “I actually was very skeptical we would be able to get green energy at a lower cost,” says chief financial officer Vince Pryor. “Frankly, I was hoping to break even.”
The results surpassed expectations. Ingalls signed a three-year contract for electricity, 5% of which now comes from renewable sources. It’s a small step, one the health system believes is in the right direction, as they expect to save $375,000 over the contract period and cut carbon dioxide emissions by 3,433 tons. “I think we would have been happy if we had kept costs neutral and gotten a bit of a green footprint,” Pryor says. “But the process worked out far better than that. It’s obviously a win-win for us.”
—Paul Rosenau, MD, pediatric hospitalist, Fletcher Allen Health Care, Burlington, Vt.
U.S. hospitals generate approximately 6,600 tons of waste per day, and they pay more than $106 million each year to dispose of it, Practice Greenhealth reports. About 80% of waste generated in hospitals is nonhazardous solid material (i.e., paper, cardboard, food, and plastics), according to the Green Guide for Health Care, which offers recommendations for sustainable construction, operations, and maintenance of healthcare facilities (www.gghc.org).
Some health systems are putting pressure on vendors to reduce the amount of packaging materials they use. Others are finding alternative homes for items that ordinarily would go straight into dumpsters.
During construction of Kaiser’s Modesto hospital, Deane and his colleagues found one firm that turns Styrofoam into crown molding. They identified another company that recycles bubble wrap and foam, and a third that pays for certain nonrecyclable products. Their efforts prevented about 40 tons of waste from entering the landfill.
“It’s tough for some organizations to get past the culture of doing things the way they’ve always been done,” Deane says. “There’s a lot of opportunity if people just push their comfort level.”
The same holds true for hospital departments. Diane Imrie, director of nutrition services at Fletcher Allen Health Care in Burlington, Vt., led efforts to replace foam and plastic dishware with products that fully degrade when composted. A shift to reusable catering trays saved $1,000 a year.
“The key is to think about what would make a positive impact within your department,” Imrie says. “If there’s something that irritates you or you don’t feel comfortable doing because you know it’s not great for the environment, start there. If you don’t like it, your staff probably doesn’t like it, either.”
Some hospitals are creating sustainability councils or “green teams” that involve many specialties rather than hiring one sustainability coordinator. The groups usually meet monthly or quarterly. Conversations range from how to reduce waste and promote alternative transportation, to how to utilize alternative energy sources, conserve water, and purchase environmentally friendly products. Such panels provide an excellent opportunity for hospitalists to take an active role in the greening of their facilities, says Paul Rosenau, MD, a pediatric hospitalist at Vermont Children’s Hospital at Fletcher Allen Health Care in Burlington. Dr. Rosenau has served on Fletcher Allen’s sustainability council since its inception more than a year ago.
As the only physician on the roughly 15-person panel, Dr. Rosenau represents what he calls “the clinical interface” with what otherwise would be operational issues. Consequently, when Fletcher Allen recently launched a program to begin collecting recyclables in patient rooms, physicians did not view the initiative simply as a directive coming down from the top. Instead, they embraced the effort, helping to legitimize the program and make it more efficient.
“We will counsel families about how to use these bins,” Dr. Rosenau says. “We identify areas where it isn’t working. We know where waste streams are getting mixed. We know where they are a hindrance and not a help because we’re in there day in and day out.”
Hospitalists who work at facilities where sustainability councils don’t exist still can play their part in the green movement. They can start by following the same rules they teach their children, such as turning out the lights when they leave the room.
“Hospitals use an incredible amount of equipment,” says Louis Dinneen, director of facilities management for Fletcher Allen Health Care, which reduced energy consumption at its main campus by 8% last year. “The next big drive is to improve awareness of the staff. … Developing a sense of ownership is a big part of it, especially in a large organization. We’re asking ourselves, ‘What equipment do we have on all the time?’ If it isn’t necessary to leave it on, make sure it gets turned off.”
Hospitalists also can look at program operations and QI projects with an eye toward environmental responsibility. Dr. Rosenau outlines several strategies:
- Begin with something that enables early success. “It really enforces the idea that this is a multidisciplinary effort,” he says. “It makes people feel like they are part of a team working to make the place better. It’s not this external, foreign idea that, ‘We’re going to green things.’ ”
- Be prepared to establish new relationships. For example, get to know the person who does the purchasing in your group if you are concerned about the environmental lifecycle of certain products. “We aren’t experts in these areas, and it’s important that we not take on a completely new activity. We need to be cognizant of the realities of time, burnout, and quality of care,” Dr. Rosenau says. “But having a dialogue with administrators or other key people who can help assess the environmental impact of healthcare delivery is part of the QI role we play. Some of these things probably are not going to change if the initial interest does not come from a clinician who says, ‘I’m concerned about X.’ ”
- Don’t reinvent the wheel. Take advantage of the growing number of resources (e.g., Practice Greenhealth and Health Care Without Harm) that explore the relationship between healthcare and the environment (see “Help Your Hospital Get Green,” p. 25).
The Next Step
Thanks to a shift in attitudes and practices among those in healthcare, including HM, the industry has taken significant steps to reduce its environmental footprint. The future, experts say, is to make sure physicians have the tools they need to improve the relationship between care delivery and the environment.
“We have a lot of growing to do on the physician side,” Dr. Rosenau says. “That’s not to say we need to have a PhD in ecotoxicology, but we do need to learn some. … We’re in this to be healers. We say ‘Do no harm.’ We try to avoid adverse drug effects. We also have to avoid adverse environmental impacts.”
Cohen, Health Care Without Harm’s co-executive director, agrees. “Doctors get four hours in four years of environmental education, and most of that is about things like smoking,” he says. “If someone comes to a physician and says, ‘My child has asthma,’ most doctors have no idea to ask, ‘Do you apply pesticides at your home? Do you use toxic cleaners? Are you living down the street from a diesel truck route or incinerator?’ ”
The bottom line: Sustainable medicine goes beyond changing light bulbs or implementing recycling programs.
“We’re at a tipping point, and we feel these issues will become mainstream,” Cohen says. The business case has been made for a number of these initiatives, and I think the rapidly rising costs of healthcare and the epidemic of chronic disease is pushing the sector to realize it needs to move upstream and focus on prevention a little bit more.” TH
Mark Leiser is a freelance writer based in New Jersey.
- Principal Building Activities in the Commercial Buildings Energy Consumption Survey. Energy Information Administration Web site. Available at: www.eia.doe.gov/emeu/consumptionbriefs/cbecs/pbawebsite/contents.htm. Accessed Sept. 10, 2009.