Metrics today, metrics tomorrow
Based on a sustainable building session, “Trends in Greening-Where Does Your Facility Fall in the Greening Spectrum?” presented at the HEALTHCARE DESIGN.10 Conference, November 13-16, 2010, in Las Vegas.
Medical waste incinerators are a major source of mercury in the environment1; newborn babies are born with more than 200 industrial chemicals in their bodies2; the President's Cancer Panel reported this year that environmentally caused cancers are “grossly underestimated” and “needlessly devastate American lives”3; and the World Health Organization reports that climate change will be the defining issue in the 21st century4.
Caring for people requires caring for the planet. Healthcare sustainability leaders are strategically positioning environmental improvement activities into their short-, medium-, and long-term goals. In memory of John Lennon's 70th birthday this year, imagine how it could be.
When we scratch the surface and allow ourselves to feel the undeniable connection between planetary and human health and explore the concept of healthcare “environments,” we exchange the current sustainability icon (the blue bin by the photocopier) with an icon more central to public health-people-the immunocompromised, the developing fetus, the healer.
If we don't move beyond green arrows and blue bins, then we'll be satisfied with garden-variety greening activities, like toner cartridge recycling and cloth bags, when we need to move towards energy independence, safer materials in both building materials and medical devices, community education, leadership in preventive medicine, and healing environments for staff and patients. How can we promote wellness and have a fast food operation in the hospital lobby? How can we treat asthma while using asthma-inducing cleaners?
The “environment” covers a variety of critical spaces. It extends beyond the bedside into the basement, the board room, the back door, front door, community, home, womb, breast milk, and the global environment, including the manufacturing plant where medical devices are made and the landfill or treatment plant where they are trashed, the water we drink, foods we consume, and air we breathe.
Connecting sustainability and mission
Practice Greenhealth Environmental Leadership Award Winner Gundersen Lutheran in La Crosse, Wisconsin, connects sustainability initiatives to its commitment to patients and has set a target of energy independence by 2014. Tom Thompson, Gundersen Lutheran's sustainability coordinator, explains, “The rising cost of healthcare dominates the national agenda. Gundersen Lutheran believes part of the answer lies in finding solutions to our rapidly rising energy costs. When we reduce energy and waste management costs, we save money for our patients and preserve the valuable resources of our community. At Gundersen Lutheran, our promise is to deliver exceptional care in an environmentally and economically sustainable system.”
Gundersen Lutheran's Envision Program aims for energy independence by 2014.
With the understanding of the critical role sustainability plays in climate change prevention, health, and wellness, how is success measured? What are the sustainability metrics in use now and what should they be?
Sustainability metrics are as varied as the activities that define “going green” in healthcare. Healthcare organizations conduct both qualitative and quantitative sustainability assessments, measuring baseline data that can be tracked over time (energy, waste, water, greenhouse gases) and identifying specific activities (energy conservation, recycling, xeriscaping) that help meet measurement targets. Tracking both qualitatively and quantitatively enables facilities to track their performance yet capture the accompanying narrative and sustainability sign posts-the specific activities that demonstrate commitment, mission, and values that don't come across in numbers alone. Tracking data without capturing the accompanying narrative is like a stale cracker-boring and tasteless.
Practice Greenhealth sustainability benchmark report
Practice Greenhealth released its second sustainability benchmark report in October, based on data from more than 140 hospitals applying for the Partner for Change Award and from 24 hospitals that achieved top honors. The report attempts to provide a snapshot of what sustainability in healthcare looks like, smells like, and tastes like today, sharing data complemented by detailed greening activities.
Comparing hospitals on a level playing field is challenging, considering varying patient populations, complexity of illnesses and treatments, and geographical location. A variety of attempts made include benchmarking by staffed bed, licensed bed, and adjusted patient day, to name a few. If you wonder how many Practice Greenhealth Partner for Change Award winners are Energy Star partners (57%), the average recycling rate (24%), or number that have signed the Health Care without Harm Healthy Food Pledge (47%), then this report would be of interest to you. Additionally, Practice Greenhealth pulled out the same data from the top 24 performers (Energy Star partners-75%, recycling rate -36%, and those that signed the Healthy Food Pledge-54%) to show how top performers match up. These percentages are not static and will change as programs mature.
Other metric resources
The Green Guide for Health Care, a voluntary self-certifying (and free) green building toolkit customized for the healthcare sector, steers facilities through greener design, construction, and operations through specific credits that measure performance related to site, water, energy, materials, environmental quality, facilities management, environmental purchasing, and more, all based on metrics. The U.S. Green Building Council's LEED for Healthcare, scheduled to be released in the near future, is a voluntary, third-party-certified green building rating system that verifies performance through building design and construction and spans a range of metrics, including energy, water, carbon dioxide emissions, indoor environmental quality, and resource stewardship.
Measuring community and staff engagement
Sustainability in healthcare and the associated metrics are in their infancy. Employee engagement and community activities could be measured by the number of staff participating in community events like farmers markets, the number of pharmaceuticals collected in a pharmaceutical take-back program, or the number of Earth Day activity participants. Toxicity reduction could be measured by inventory of supplies and progress in the transition to less-toxic materials. Internal surveys measure sustainability's role in attracting and retaining new physicians, nurses, and staff, in general.
Planetree, a membership-based nonprofit organization, works with hospitals, continuing care, and health systems to assist them in creating facilities and organizations that personalize, humanize, and demystify healthcare experiences. As part of its work, Planetree has developed designation criteria aimed at helping healthcare affiliates meet specific goals to become recognized as a “Planetree Designated Hospital.” With 50 criteria, these hospitals are then recognized by the Joint Commission as part of their quality check. In addition, Planetree has focused its efforts, along with affiliates, on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys and tracks how a patient-centered hospital compares to the national averages in all 10 domains, as noted on the Hospital Compare Web site.
Planetree's Kimberly Nelson Montague, director, design consultation services, explains, “The HCAHPS surveys only measure two areas of the physical environment in a healthcare facility: quiet at night and cleanliness in and around the patient room. With the increased acknowledgement of healthcare's impact on human health and the environment, we believe more focus on additional measures in the HCAHPS questionnaire will further capture the patient's value on their healthcare facility's efforts in creating healing environments, that is, improved safety, reduced stress, and contribution to ecological health.”
“CLIMATE CHANGE WILL BE THE DEFINING ISSUE FOR HEALTH SYSTEMS IN THE 21ST CENTURY. HEALTH PROFESSIONALS HAVE THE KNOWLEDGE, CULTURAL AUTHORITY, AND RESPONSIBILITY TO PROTECT HEALTH FROM CLIMATE CHANGE.”
-World Health Organization
External sustainability reporting
While a few hospitals are reporting their social, economic, and environmental performance based on frameworks such as those established by the Global Reporting Initiative and the United Nations (UN) Global Compact, and a few hospitals are reporting greenhouse gas emissions through programs like the Climate Registry and the Environmental Protection Agency's Greenhouse Gas Reporting Program, sustainability reporting is destined to become more commonplace in the healthcare sector.
Greenhouse gas inventories can capture the big picture and help prioritize climate action initiatives through identification of tiered contributions to an organization's carbon footprint. Greenhouse gas sources are categorized based on an organization's sphere of control, but include on-site fuel use, fleet emissions, and purchased electricity. The third tier includes emissions from less-direct sources, like supply chain, employee transportation, waste, pharmaceuticals, and waste anesthetic gases. While these inventories report out on the big picture, they don't describe the action around environmental, social, or human rights impacts. The measurement complemented by the narrative is critical for capturing culture, mission, and the personal aspect of an organization's journey.
Catholic Healthcare West and Kaiser Permanente are two health systems that measure and report greenhouse gas emissions and other sustainability priorities; both systems connect their work to organizational mission and community benefit; and both publish detailed summaries of their programs on their Web sites in the form of either a sustainability report (Catholic Healthcare West) or a community benefit report (Kaiser Permanente).
In 2008, Cleveland Clinic became a signatory to the United Nations Global Compact. The compact brings business together with UN agencies, civil society, and governments to advance 10 universal principles in the areas of human rights, labor, environment, and anticorruption. Cleveland Clinic's Global Compact Report can be found on its Web site.
A first step by some hospitals towards transparent sustainability reporting is inclusion of sustainability activities as part of a community benefit report. This positions environmental stewardship as a key component of a hospital's mission to improve the health of the communities it serves. It can also highlight the important role that strong communities play in both improving our natural environment and adapting to environmental changes in healthy, resilient ways. Hospitals are also reporting their sustainability efforts on a greening Web page or intranet page. Conversely, some hospitals are putting in the effort, but not communicating the activities to staff, patients, or the community-a big disconnect and opportunity for improvement. If the measurement and activities aren't captured, they can't be adequately communicated or celebrated.
Management use of metrics
Big-picture measures can effectively connect activities to leadership reporting and more action-specific metrics at the departmental level. Hospital or system-wide initiatives can be developed, implemented, and measured at the Green Team, Safety or Joint Commission (or other accreditation structure) level.
When individual departments tackle an environmental improvement activity within their area of expertise, they have ownership and ensure its success. Facilities management develops a green design standard; laboratories eliminate mercury from lab chemicals; dentistry puts in amalgam traps; food services increases the percentage of locally sourced produce and eliminates water bottles for meetings; and nursing, environmental services, and infection control can be part of a team looking at greener cleaners. “Poster sharing” on Earth Day where departments share their success stories can capture specific activities, and a press release to the community celebrates the departmental leadership and cumulative impact on the environment and worker and patient safety. The departmental metrics can be shared at the corporate oversight committee, and the case studies may be included in community reporting and documented for the organization's sustainability narrative.
New York-Presbyterian Hospital (NYP) engages staff through departmental volunteers called “Green Champions.” Clinical and nonclinical Green Champions attend campus green team meetings, where they receive new information, discuss goals and challenges, and build a collaborative support network with each other. In turn, they educate their colleagues about how to “green” their daily activities by providing guidelines on how to properly recycle, conserve energy, and minimize waste they create. Success is benchmarked through a four-level “green workspace” certification program, which was shared by Harvard University's sustainability office. The Harvard Green Leaf Program empowers individual departments to improve environmental performance at the departmental level. Jessica Prata, NYP's sustainability officer, shares, “Green Champions are a constant source of new ideas, and their grassroots enthusiasm is key to increasing awareness around sustainability at our organization.”
On Oct. 12, NYP held a sustainability event, “Going Green-An Emerging Mission in Healthcare,” where Skanska presented its corporate metric to advance beyond code-compliant “vanilla” to “deep green.” This commitment was reflected in completed and new projects underway to pursue third-party certification, such as LEED. Results were presented for the Living Building Financial Study, making the financial case for zero-net hospitals. Noel Morrin, senior vice president, sustainability and green construction, for Skanska AB, says, “The only way to deep green is [through] time, measurement, and commitment. We have the technology to get to deep green today; what we lack are enlightened investors and owners.” HCD
The Green Guide for Health Care-www.gghc.org
Global Reporting Initiative-http://www.globalreporting.org/Home
UN Global Compact-http://www.unglobalcompact.org/
Harvard University's Green Leaf Program-http://green.harvard.edu/green-office
Living Building Institute and Living Building Financial Study-http://ilbi.org/
Gundersen Lutheran's Envision Program- http://www.gundluth.org/green/
Kaiser Permanente Community Benefit Report-http://info.kp.org/communitybenefit/html/about_us/global/annualreport_09/index.html
Catholic Healthcare West Social Responsibility Report-http://www.chwhealth.org/Who_We_Are/Environment/index.htm
Cleveland Clinic Global Compact Report-http://my.clevelandclinic.org/about/overview/global-compact-report.aspx?utm_campaign=2010uncompactreport-url&utm_medium=offline&utm_source=redirect
Janet Brown is the director of sustainable operations and green building at Practice Greenhealth. She can be reached at
- Office of Air Quality Planning & Standards and Office of Research Development, US EPA Mercury Study Report to Congress, December 1997.Retrieved October 13, 2010, from http://www.epa.gov/hg/report.htm
- Environmental Working Group, Body Burden - The Pollution in Newborns, July 14, 2005.Retrieved October 13, 2010, from http://www.ewg.org/reports/bodyburden2/execsumm.php
- Presidential Cancer Panel, Reducing Environmental Cancer Risk, May 6, 2010. Retrieved October 13, 2010, from http://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf
- World Health Organization, Protecting Health from Climate Change, 2009.Retrieved October 13, 2010, from http://www.who.int/globalchange/publications/factsheets/WHD2008_health_prof_2.pdf, and full report http://www.who.int/globalchange/publications/reports/9789241598880/en/index.html
Healthcare Design 2011 January;11(1):14-18