While greening healthcare has finally hit the mainstream and the number of engaged facilities has increased substantially, “getting started” is often a challenge, even when there is interest in the topic. Where facilities fall on the greening spectrum and how they compare with other facilities are common questions. It’s easy to get paralyzed by the process, with difficulty prioritizing activities and assessing which programs have the largest payback. I suppose it might be easier if we could take a cookie-cutter approach and just list the order of activities that hospitals could follow, but we know that varying regions, size of facility, opportunity for grants, and existing program areas can impact these decisions and return on investment.

What we can do, though, is identify a menu of options that can be broken down, in some cases, by department, in other cases, by topic area. These activities can be implemented incrementally over time, bundling cost-saving opportunities with environmental priorities and balancing cost savings with mission demonstration. While we recognize the critical importance of reducing costs and can identify numerous cost-saving environmental activities, we can’t dilute the call to action by only addressing cost-saving initiatives. We can’t just go for the “Green” that saves green, and fully realize the connection between human and environmental health and the imperative for action.

Environmental improvement structure
While greening is the goal, of equal importance is understanding the process for creating that culture of excellence. The greening process could be approached with the same ingredients that have led to success in the past, including strong leadership commitment, a structure that supports the change, a tracking and reporting mechanism, identification of a lead for the project, saturation of the message, and an employee engagement strategy. Single- or multi-facility systems can address environmental activities through a site-specific green team or existing committees such as the environment of care or healing environment team. A system-wide advisory council can drive corporate mission, develop policy language, and provide tools and resources to support the site-specific activities and communicate site-specific and system-wide accomplishments. (Get the greening organizational charts for two Practice Greenhealth Members: New York Presbyterian and the Cleveland Clinic.)

Implementing greener strategies is too often carried on one or two individual’s overburdened shoulders. Greening a facility goes way beyond implementing a recycling program or eliminating mercury and has the potential to extend into every department, purchasing decision, investment portfolio, job description, and community project. Instilling the work activity into the structure and operations of the organization requires a diverse team approach and policy development. Leadership’s involvement is critical, and without it, the programs will be challenged to move beyond departmental and grassroots initiatives. If there is lack of buy-in from senior leadership, a

Sidebar 1
Imperative for action The evidence is in: In the process of providing care, hospitals are negatively impacting public health. Medical waste incinerators are major sources of both mercury and dioxin in the environment (Keating, M. H., K. R. Mahaffey, et al. 1997).
Six percent of women of child bearing age are at risk of permanent impact to their unborn child through fish consumption (CDC 2004). Consumers have been advised to avoid certain fish because of mercury levels (FDA 2004).

The evidence is in: Babies are born with more than 200 toxic chemicals in their cord blood (Environmental Working Group 2005). Hospitals can avoid certain chemicals, identify safer alternatives, and legally manage those they can’t avoid to reduce negative environmental impact.

The evidence is in: Warming of the planet is unequivocal (Intergovernmental Panel on Climate Change 2008).
Hospitals use more than double the energy per square foot than commercial office buildings (Department of Energy 2008) and need to take advantage of greener energy suppliers and actively implement methods to conserve energy and water. The combination of conservation and cost savings makes this a win-win strategy.

The evidence is in: Workers and patients deserve and expect a safe and respectful environment. General medical and surgical hospitals reported more injuries and illnesses than any other private sector industry in 2007. This industry alone accounted for more than 6% of all nonfatal injury and illness cases reported among private industry workplaces (Bureau of Labor Statistics 2007).

The evidence is in: Responsibility extends beyond the walls of the facility. Electronics are the fastest growing waste stream. Heavy metal laden U.S. electronics waste has been found in third world countries where it ended up in open fire pits, turning communities into super fund sites (60 Minutes Report 2008).

The evidence is in: Asthma rates are on the rise. Childhood asthma more than doubled from 1980 to the mid-1990s and remains at historically high levels (Akinbami, L. J. 2007). Why is still a mystery, but we know that certain cleaning chemicals and high-level disinfectants, like glutaraldehyde, can induce asthma and impact indoor air quality.

The evidence is in: Pharmaceuticals are in our drinking water, generating from flushing, pouring, and otherwise emitting them into the environment (Daughton, C. G. 2003). Through prevention, education, research, and best management approaches, hospitals play a role in identifying opportunities to reassess medication use and responsible management.

The evidence is in: Workers and patients care about environmental sustainability. Corporate social responsibility (CSR) and responsible employers will attract and retain quality employees. Eighty-three percent of corporate employees in G7 countries (Canada, Italy, Germany, United States, France, Japan, and England) say company’s positive CSR reputation increases their loyalty and motivation (GlobeScan 2006).

The evidence is in: The IRS requires reporting on community benefit for nonprofits. Environmental improvement activity is a demonstration of community benefit. On the new IRS Form 990, Schedule H, healthcare facilities are now able to report environmental initiatives under Community Building activities in Part 1 (Internal Revenue Service, 2008).

presentation can often help, offering examples of

cost-saving opportunities and scientific documentation, as well as linking healthcare and negative impact on human health and the environment (sidebar 1). Through identification of key champions, a team approach can successfully inform leadership on the imperative for environmental leadership. Folding environmental sustainability into the visioning process and strategic planning process will ensure it takes root in day-to-day operations and withstands the test of time.

All too often, we hear of utter frustration because a key individual is not on board. If critical department heads are not engaged, the program can really suffer, even before it starts. New hires should be checked for their interest in improving environmental performance. This is very different from a skill set. The resources and technical information can be accessed on the job, but the personal interest and commitment to positive change cannot be infused. This must be identified up front. If an existing key player lacks the “eco-energy,” leadership can help either with a mandate or a change of staffing to get the right person on board. It’s hard to believe that we could have a director of environmental services who would remove a recycling bin from his office or not see the value in greener cleaners, but this is still the case in too many facilities. The groundswell of interest cannot be deterred by those holdovers who choose to resist their role in a facility’s environmental sustainability initiatives. Instituting change is challenging enough without adding a less-than–motivated key individual.

As my boss Tony used to say, “The only thing constant in healthcare is change.” Staffers have to adjust and continuously seek educational opportunities and flexibility to meet the changing demands in the healthcare environment. No interest in greening is a prescription for failure. Take care when hiring new staff—especially in key positions like environmental services, food services, support services, infection control, purchasing, and chief financial officers—to ensure they have the interest and passion for positive change and not just managing things “the way they always have.” The wrong people in critical positions can severely challenge a facility’s chance at environmental success.

Large hospitals and health systems are recognizing the value of the emerging position of the sustainability coordinator or the environmental coordinator, whose salary is justified through cost savings, reduced workplace exposures, improved community relations, and positive recognition. Identifying a lead on sustainability initiatives enables faster implementation of various programs and offers a more cohesive approach and long-term success. Successful integration of programming, associated policy development, and training programs can help communicate and educate patients, staff, and the community of specific environmental improvement activities. (Get sample educational posters, brochures, and presentations.)

Instilling practices into policy, structure, reporting, and training will help keep programs alive, even as key staffers change. Those systems and facilities that have identified sustainability leaders are recognizing the amount of work required and the necessity to identify a coordinator of ongoing activities. Smaller facilities may not have this option, but the leadership role should be appointed to an existing employee or team. As facilities break into the lead on sustainability, integrating green building, energy and water conservation, and community engagement strategies, they will get the deserved recognition for quickening the pace on the number of programs that are needed to really make an impact. (For a list of leaders in this area, check out Practice Greenhealth’s top award winners and members of the Circle of Excellence.)

Recognizing environmental excellence as going hand-in-hand with worker and patient safety and staff morale helps identify activities that address several priority areas. Tying environmental sustainability to creating a healing environment pulls together the direct patient-care activity, the activity behind the scenes, and all workers, linking all activities to patient care quality.

The integration of green building and operational environmental-improvement strategies completes the picture. The

Green Guide for Health Care, a self-certifying tool kit that steers facilities through greener design, construction, and operations, helps us explore the activities taking place within the facility and the connection between what we buy, how we use it, and how we manage it at the back door. It addresses the types and amounts of energy and water we use to run the operations and takes a long view of creating and maintaining healing environments. With an increase in the number of credits from 75 in the earlier version to 121 points in the 2009 revision, the Operations Section offers digestible bites of sustainable operational credits to help select goals for further operational greening activity. The

Green Guide also offers a health statement for each of the activities, tying its pertinence back into the mission of the organization and the imperative to act. The sections now include: Integrated Operations & Education, Sustainable Sites Management, Transportation Operations, Facilities Management, Chemical Management, Waste Management, Environmental Services, Food Service, Environmentally Preferable Purchasing, and Innovation in Operation. Any hospital can use the operations section, regardless of renovation or construction activity. The document includes a checklist to help track

Green Guide goal achievement. (Get a free

Webinar overview of the Operations Section.)

Part II of this article will appear on March 11, 2009.

Janet Brown is Director of Sustainable Operations at Practice Greenhealth and is a member of the Green Guide Steering Committee and the Planetree Design Advisory Council. For more information contact her at