When I started implementing sustainable operations in healthcare more than 20 years ago, I was frustrated by leadership’s need for research when I felt a “gut check” was more than enough. I didn’t need a research study to tell me that a safer environment engages workers, that dollars were going out the back door in the waste stream, that red bag reduction saves money, or that eliminating mercury from cantor tubes reduced mercury spills. I knew it because I lived it.

But now, I better understand the deep need for research and science to inform smart, safe, and efficient decision-making, to facilitate faster adoption, and to extend knowledge more broadly across the industry. 

However, often there is a gap between research and implementation. Sometimes, the science is there but the action isn’t. It’s like a seed blowing around in the wind—until it settles on the ground and takes root, it’s not going to change anything. Research alone isn’t enough. 

Case in point: Research on mercury toxicity was first published in 1968 in Minamata Bay, Japan.¹ Medical waste incinerators, as a primary source of mercury in the environment, were identified in the 1997 U.S. Environmental Protection Agency (EPA) report to Congress.² Why are there still hospitals that are using and mismanaging mercury? How can the evidence best be used to inform decision-making and how can it go forward if it doesn’t offer a tangible financial return on investment? How do non-financial outcomes account in decision-making?

Implementers/translators

As implementers—designers, architects, facility managers, educators, and leaders—it’s up to us to grab the “research seed,” plant it, and nurture it. We need to introduce it to soil, water, and sun, in the form of manufacturers, purchasers, contractors, and decision-makers. If we know that a material is toxic to human health and the environment, why would we use it when constructing a healing space? 

Lack of research isn’t the only barrier to positive change. Change is the barrier to change—doing things a new way. This is how I see it: We’re in a rush, running as fast as we can to get to our destination. We’re running quickly because we have limited time, limited resources, limited energy, and a lot to think about. We’re taking the fastest route we know—we’ve traveled on it before, we are familiar with the terrain.

There is another road. Some are on it, but it’s slower. We don’t know the way. It requires reading a map, maybe even asking for directions (oh no!). We could hit a dead end and have to retrace our steps and try again.

It’s natural to consider that path another day, another time, when we aren’t in a rush, and when we feel stronger. It’s like returning to our favorite restaurant. We know there’s a new restaurant, we’ve heard it’s great and it’s on our list of restaurants to go to, but right now we want that comforting meal we know already—we’ve tasted it and we know it’s good. Why mess with that?

What does it take for us to take that unfamiliar step?

Anjali Joseph, PhD, EDAC, director of research at The Center for Health Design, says: “I think the design teams/architecture firms play a crucial role in bridging the gap, especially if they have researchers on their team. These in-house researchers are able to bring the best evidence to the design teams (the architects as well as the client) and translate it in a way that the team can use to inform their decisions and develop innovative strategies. Research provides a good foundation that brings the team on board and helps to build consensus. Further, when it comes to cost-cutting or value engineering, the research evidence helps to demonstrate where the value really is—for the patients, the staff, and the families—and ensures that key features that will impact outcomes stay in the design through the process. Over the last five years or so, most large architecture firms have hired in-house researchers, and these individuals play a key role in educating their teams about the impacts of design on healthcare outcomes and help to spur ideas for innovation based on this research. They also lead research studies on important topics and contribute to the field.

Another important change that is coming about in the industry is that more individuals (designers, architects, hospital administrators, clinicians, and the author of this column) are getting EDAC accredited. This is providing them with baseline knowledge about research and how it can really be used to support their design process and decision-making. As a result, they are becoming more comfortable with discussions around research and more likely to try the new, highly rated but unfamiliar restaurant.”

Whitney Austin Gray, PhD, LEED AP, is the newly appointed director of building science services for the MedStar Institute for Innovation in Washington, D.C. Gray explains, “As part of my role at MedStar, I am interested in how design and operation decisions affect our ROI and our patients, staff, and visitors over the lifecycle of the building—and, in this way, attempt to quantify the holistic impacts of sustainable design.” 

Gray says that often building impacts are considered from the facilities perspective, when there is great potential to quantify the impact on clinical outcomes. Green teams with clinical staff offer one way to help bridge that gap.

Gray explains her role as “translational” and “trans-disciplinary,” meaning she translates the research into interventions and seeks an integrated team with varying perspectives and skills to guide the research and implementation. “Building design and construction affects everyone in the building one way or the other. Engaging with a diverse group of professionals from among the public health, design, and engineering perspective assures that the multitude of potential impacts are studied. And, with the right team, those results may help to revolutionize the way in which we study buildings, introducing innovations within building science,” she says.

While not all hospitals and health systems have a research department dedicated to building science, integrated teams are already in place at most facilities—whether they are the design team, green team, environment of care committee, supply chain team, or quality improvement committee. The beauty of this role, or of any sustainability lead, is the ability to take the 30-foot view, to interact with all departments, make connections, and implement strategies where the positive outcomes ripple throughout the organization and into the community.
 

The seeds

• The Center for Health Design’s Pebble Projectis a research initiative where forward-thinking healthcare organizations engaged in building projects commit to using the best available research during their design process and then conduct research to study the impacts of their design innovation. This is a great example of bridging research and implementation.
• The Center for Health Designis going to focus deeply in the next two years on the development of tools to support the translation of research. This will include the development of checklists, databases (RIPPLE, clinic design), and tools (such as post-occupancy evaluation tools) that will enable teams to easily access and translate research information.
• The RIPPLE databaseof The Center for Health Designwas developed with support from Kaiser Permanente and the U.S. Green Building Council. The database links environmental design strategies with outcomes from healthcare facilities and enables comparison and benchmarking. The case studies and research on RIPPLE will be a prominent resource for healthcare design teams in the years to come.
• Georgia Tech is rolling out a healthcare simulation center, where it will work with leading health systems to create healthcare that is safer, more efficient, and more patient-centered. At the heart of the center is a 4,000-square-foot virtual reality simulation lab that brings together many elements in one setting with a growing toolkit for visualization, value stream mapping, building modeling, acoustic modeling, and spatial analysis. Georgia Tech will work closely in partnership with other thought leaders from healthcare systems, design firms, clinicians, industry, and other academic institutions. The process allows senior executives, clinicians, designers, engineers, and others to jointly analyze problems and design the healthcare environment of the future, supported by staff researchers, simulation tools, and a test bed that allows decision-makers to rapidly prototype innovative ideas, testing their impact on care quality, safety, and cost. This simulation center supports virtual room mock-ups and material, equipment, and people flow to improve efficiency, test out a variety of interventions, and to work out kinks virtually before implementation in the healthcare environment. 

While many of the immediate applications of this currently address equipment locations, room configuration, pharmaceutical, and equipment delivery, there are numerous environmental interventions that also could be virtually tested. Examples include chutes versus elevator transport for recyclables, supply delivery in reusable containers versus disposable containers, and much more. Lorissa MacAllister an architect and a PhD student at Georgia Tech says she sees the opportunity to take research to practice more quickly as a key to success in transforming care delivery with confidence. Using evidence to work across disciplines ensures fully integrated solutions.

• A joint project of Health Care Without Harm and the University of Illinois at Chicago School of Public Health, the Research Collaborativereceived three years of seed funding from the Robert Wood Johnson Foundation to stimulate the development, coordination, and dissemination of research focused on the impact of the healthcare built environment, operations, and organization on patient, worker, and environmental safety and sustainability. The collaborative focuses on the impact of sustainability in healthcare on the intersection of patient, provider, and environmental outcomes—which are often profoundly interrelated—and includes the business case. The Research Collaborative publishes a series of white papers that examine research issues and gaps in cutting-edge areas of healthcare sustainability, including sustainable flooring, pharmaceutical waste, mercury, green cleaning, and ventilation. 

Upcoming white papers include "Creating a Culture of Sustainability," which explores leadership and coordination mechanisms for healthcare sustainability and a study of how healthcare and other industries use benchmarking to measure sustainability success. The Research Collaborative and partners are concluding a study entitled "How Sustainable Hospitals Can Help Bend the Cost Curve" (of which the culture change paper is a part), with funding from the Commonwealth Fund, BD (Becton, Dickinson & Co.), and the Robert Wood Johnson Foundation. The aim of the study is to examine key activities and cost-savings at leading health systems from three sustainability interventions: energy use reduction, waste reduction, and more efficient purchase of operating room supplies. It will extrapolate these cost savings to potential national cost savings if there were broad adoption of these practices nationwide. Check back for the release of these reports. 

• The University of Washington Integrated Design Lab’s research “Targeting 100!” is guided by the hypothesis that it is possible to reach aggressive energy targets, such as those proposed by the 2030 Challenge, for a minimal additional capital cost while still meeting or exceeding code regulations with innovative architectural, building mechanical, and plant strategies. This hypothesis is grounded in the team’s previous work in energy-efficient hospitals, and builds on existing research and evidence indicating that reducing energy and increasing quality in the hospital sector is necessary and possible.
• “Targeting 100!” has a national scope, providing a roadmap for radical energy reductions in hospitals in six of the most diverse and populous climate zones exemplified by six study cities: Los Angeles, Phoenix, Houston, Seattle, Chicago, and New York. The project creates a framework for achieving an energy use intensity of less than 100 kBtu/ft2-year. This energy use intensity would achieve the 2030 Challenge, signifying energy performance in the highest tier of hospitals in the United States. Replicable models for radical energy reduction targets, cost control, and quality interior environments are tested using detailed energy and cost modeling, as well as significant national stakeholder review. As a conceptual framework and decision-making structure for key stakeholders in the design, construction, and operation of hospitals, Targeting 100! provides knowledge that can be implemented today.
• The New York StatePollution Prevention Institute (NYSP2I) and the Golisano Institute for Sustainability (GIS) at the Rochester Institute of Technology (RIT) have been working with the Healthcare Industry on multiple fronts. First,

NYSP2I completed a waste reduction study at Rochester General Hospital (RGH) and, based on the study, has developed and deployed a training program at RGH addressing the benefits of improved waste segregation. This training program has been supported by a grant from the RIT and RGHS Alliance, a collaborative partnership between RIT and the Rochester General Health System (RGHS). NYSP2I is also organizing a roundtable of New York State healthcare institutions in coming months to bring together healthcare industry professionals to discuss best practices, trends, initiatives, and opportunities in relation to sustainability. GIS works with Original Equipment Manufacturers in enabling design and production of sustainable products for the healthcare industry, including using tools such as Life Cycle Assessment.
 

• Practice Greenhealth’s Greening the OR pagecompiles research and articles about surgical services’ environmental footprint.
• Skanska's Green Urban Development reports focus on important trends and developments that will make our society greener. There are three reports: energy, materials, and water.
• Perkins & Will quotes the precautionary principleon its website, where they share their precautionary list and encourage “material health in the built environment.”
• Here’s a peek at upcoming research-related topics to be shared at CleanMedApril 30 through May 3, 2012 in Denver.
• Steven Szydlowski, DHA, MHA, MBA, MHA, program director, assistant professor at the University of Scranton, will be sharing research in “Patient Perspectives on Green Medicine—Does it Matter?
  ” The research provides an in-depth look at consumer buyer behavior as it relates to healthcare decision-making and determining whether green medicine is viewed by patients as value-added healthcare.
• Heather Burpee, research assistant professor, Health Design & Energy Efficiency University of Washington, Department of Architecture, will present “Targeting 100!”
• The Health Care Research Collaborative's Second Annual Research Exchange on Advancing Patient, Worker, and Environmental Safety and Sustainability in the Healthcare Sector will be held as a post-conference to CleanMed on Thursday, May 3, 2012, from 9:00 a.m. to noon. Details can be found on the CleanMed website.

With this research (and countless others) in our hands, we can look to our left to policy-makers, purchasers and manufacturers, and the design team, and look to our right to administrators, clinical leaders, and community liaisons and take that step—together.  

Jennifer DuBose, Research Associate for Georgia Institute of Technology’s HealthyEnvironments Research Group wraps it up: “Sometimes it isn’t enough to know the facts and the facts don’t always inspire people to act. Often times it takes courage to act on the facts that are before us, and it takes leaders with vision to make us all recognize the obvious truths. I am reminded of when Ray Anderson, the CEO of Interface, decided to put a large picture window in the manufacturing floor of a carpet plant. He didn’t rely on research studies on the increase in productivity from natural lighting. He just said, “It’s just the right thing to do.” 

Are you doing research on health care sustainability? Let us know at jbrown@practicegreenhealth.org.

References

1. “Minamata Disease: The History and Measures”, The Ministry of the Environment, (2002). Retrieved January 2, 2012, from http://www.env.go.jp/en/chemi/hs/minamata2002/
2. Office of Air Quality Planning & Standards and Office of Research Development, U.S. EPA Mercury Study Report to Congress, December 1997. Retrieved January 4, 2012, from http://www.epa.gov/hg/report.htm