On a recent tour of a high-profile green hospital, I noticed something odd—no recycling bins; not in the nurses’ stations, not next to the copier, not anywhere.

This raises an important concern and is a key reason that Hospitals for a Healthy Environment (H2E) is a partner in the launch of Clean Design and Operations magazine. Creating a truly green and healthy building doesn’t stop at the design phase but must include a wide range of ongoing environmental considerations.

H2E is a leading provider of tools and resources to help hospitals green their operations—from the materials they purchase at the front end to how they handle waste at the back end. The most successful green buildings will, from the start, create an infrastructure that is conducive to ongoing green operations.

The building boom in healthcare today is astonishing. Almost every healthcare campus is working on a major renovation or has a building project under way, and many are designing “greener” buildings that use less energy and water and incorporate less-toxic materials. This is great news, but crucial design and planning elements that may affect ongoing operations are sometimes overlooked. For example, stories abound about “green” flooring materials that weren’t installed or maintained properly, of energy-saving equipment that is not meeting performance standards because it’s not being optimized, and of native plants ripped out and replaced with grass because the landscaper was not included in the decision-making process.

You can purchase less-toxic building interiors but still use toxic cleaning chemicals. You can buy water-saving devices and energy-efficient equipment but not save money if staff is not properly trained. You can design a beautiful new healing garden but still use hazardous fertilizers and pesticides. You can also design green buildings but not integrate sound waste management and minimization operations, raising the question: Is the facility really green?

Integrating design with operations and maintenance considerations must start early in the process to ensure buy-in from a wide range of individuals and departments that will ultimately be charged with maintaining your new green building after the architects and contractors are long gone. Nurses, housekeeping staff, waste management staff, and food service professionals should be at the table from the start, giving input on the design and use of spaces. Plans for ongoing operations should include continuous quality performance measures to ensure that these new spaces meet environmental performance standards throughout their life.

Purchasing is key not only to the design process, but also to integrated operations. Through early involvement, purchasing staff have the opportunity to better understand material-specification criteria, so that the same criteria will be used beyond the construction process.

If waste is a measure of inefficiency, then the first place to look for opportunities for improvement is the back door, where the trash itself is the evidence of design and material choices. Designing spaces for efficient waste management requires an understanding of how hospitals generate waste, which waste is avoidable, and what kinds of spaces are needed throughout the facility for optimal waste management. Even without a renovation or building project, hospitals can optimize waste management by implementing practical waste reduction and recycling programs, and by reducing waste “upstream”—that is, by purchasing recyclable materials, less-toxic products, and products using the least amount of packaging.

Few would argue that the two million tons (and counting) of waste generated every year by healthcare is an environmental and financial problem, but we can design spaces conducive to waste minimization. For example, operating room nurses routinely dispose of huge volumes of waste, including unused sterile devices and materials from OR kits, as well as large amounts of clean sterile packaging and blue wrap, which can account for up to 20% of total waste. How can integrated design better accommodate the handling and storage of these materials and blue wrap?

Tons of cardboard boxes are unpacked and thrown out every day as new products arrive. Are cardboard compactors routinely included in the design of receiving dock spaces? Do the patient areas have space for packaging and paper recycling? Kitchens are also huge producers of waste, and kitchen spaces should be designed to accommodate composting processes and recycling of tin, glass, and plastics. And what about redesigning spaces to allow the food service to go back to processing reusable dishware?

Nurses’ stations, copy rooms, and administrative areas need recycling bins strategically placed in spaces designed for them, not sticking out and in the way. Utility rooms need space for segregation of reusables and recyclables. Trash docks need space for waste segregation, treatment, and storage.

That brings up other operational considerations to think about during the design phase—for example: Where are hazardous chemicals used, and are spaces designed to be well ventilated and to include other occupational health and safety considerations? How and where are hazardous chemical wastes stored? Are there opportunities to use less-toxic chemicals, thereby reducing liability and risks to workers, patients, and environmental health?

Designing for efficient, environmentally friendly, worker-friendly spaces up front will save hospitals money, increase efficiency, increase compliance, reduce occupational injuries, and give true meaning to the claims of green building.

There is no such thing as a perfectly green facility, but the prognosis for improvement is excellent since practical, cost-effective solutions exist. The H2E-sponsored Green Guide for Health Care (http://www.gghc.org) is a self-certifying tool kit to help steer users through greener design, construction, and operations in the healthcare sector. This tool doesn’t stop after construction but continues to integrate greener operations throughout the life of the building–from mercury reduction to greener cleaners to recycling.

H2E’s contribution to Clean Design and Operations is to help readers stretch limited resources by sharing stories about what works and what hasn’t worked so well—to highlight the successes of hospitals that are taking the lead in prioritizing human and environmental health. We hope these stories will engage the broader community of healthcare practitioners in the work of building not only safer, healthier green hospitals, but also a safer and healthier society.