Sustainability for healthcare executives: Getting the language right and getting started

By Stephen Ashkin

If an architect recommended that the patient room be “green” most would assume that they were speaking to the color and not the room’s size. And while clarification as to the shade of “green” might be requested, most would know that the color was that of grass or maybe limes, but not the color of snow or chocolate. This is because of language convention where there is agreement and understanding of the word “green”.

But when "green" is applied to buildings or products, there is still a lack of clarity and as a result one may not get what they are expecting because we have not yet defined a meaning that everyone accepts.  And when the term "sustainability" is used there is even a further lack of agreement and understanding.

Sustainability has the potential to drive improvements in health services and increase profitability by identifying inefficiencies and eliminating wastes, as well as reducing impacts on the environment.  However without developing the appropriate "language" to define sustainability, even a well-intended but poorly articulated or implemented sustainability program can wreck havoc on the institution.

The issue of language of sustainability and how it is defined, measured and reported is critical for success.  Some of the questions that highlight the issues surrounding the language of sustainability include:

• Is sustainability limited to just protecting health and the environment?
• When speaking of health, is it referring only to the definition of health as would be appropriate for patients or should it include the impacts on nursing staff, environmental services workers and others?
• Does the definition address other issues affecting people such as their wages, benefits, working conditions, training, antidiscrimination and other human rights issues?
• Are the issues addressing sustainability confined within the property line of the institution or should it consider the affect on the community where the institution exists?
• If sustainability extends beyond the property line does it also include the impacts of suppliers, and if so to what degree and how should the institution appropriately address their supplier chain?
• And if sustainability addresses all of these larger issues, how is it done while meeting the institution's financial needs?

The Language of Sustainability: Defining Terms

Green has become a commonly used term and in some areas widely adopted.  But far too frequently, green and sustainable are being used interchangeable, which is a mistake and this clarification is important.

The most widely accepted definition of green comes from Presidential Executive Order 13423[1] which defines green and environmentally preferable (two terms that can be used interchangeably) as "products or services that have a lesser or reduced effect on human health and the environment when compared with competing products or services that serve the same purpose. This comparison may consider raw materials acquisition, product, manufacturing, packaging, distribution, reuse, operation, maintenance, or disposal of the product or service."

Whereas, the generally accepted definition of sustainability comes from United Nation's Brundtland Commission[2] which in 1987 defined it as "development which meets the needs of the present without compromising the ability of future generations to meet their own needs."  And frequently associated with this is the Triple-Bottom Line[3], which suggests that for an enterprise to be sustainable it must simultaneously address three issues or the 3 P's for people, profits and planet.

Practically speaking, green focuses on products and services such as green buildings, energy efficient and green cleaning products that reduce the health and environmental impacts.  And while for example a green cleaning program will consider the impacts on worker health as well as environmental impacts, "green" typically does not dive deeper into other issues affecting people.  Green is a narrow focus on the product, while sustainability is much more.

As a result, the recommended way for healthcare executives to think about sustainability is to think of sustainability as a focus on the activities of the organization itself.  How the organization delivers health care services.  How the organization operates its buildings.  How the organization operates its vehicles.  How the organization treats its people.  How the organization buys products and manages waste.  Sustainability focuses on the "how" the organization itself does things, while green focuses on specific details or the "what" the organization is using or doing.

Thus when a healthcare organization talks about sustainability it is speaking about its journey and how it is improving the delivery of health services including its impacts on people, profits and planet in a way that does not compromise the ability of future generations to meet their needs.

Practical Application of Sustainability

Now that the difference between green and sustainable has been addressed, it is important to address some of the key areas and "low hanging fruit" that healthcare can and should address.

Developing a Team

The first practical step for any healthcare organization is to build a team to investigate and ultimately take ownership of the effort.  While in many cases it is best to assign the challenge to an existing "green team", health & safety team or other similar group already in place.  But irrespective of the origins of the team, it is important that the team include representatives from across functional units including administration, doctors, nursing staff, infection control, environmental services, facilities, waste management, purchasing, human resources, IT, community relations and others as it is inevitable that each will uniquely be responsible for specific pieces of information.  And one often overlooked, but of enormous value is to include vendors who can contribute expertise, time and other resources and are often very motivated to help with these types of programs.

Choosing a Sustainability Frameworks

Sustainability and sustainability reporting are becoming increasingly visible and scrutinized.  Thus it is important for healthcare institutions to adopt one of the existing reporting frameworks which will avoid overlooking areas that should be addressed, giving more credibility to the program, prioritizing activities, and with communicating results with the outside world. 

Selecting a framework can be challenging, but while there are a handful of recognized programs it is recommended that healthcare organizations become familiar with the Global Reporting Initiative[4] and their Sustainability Reporting Framework[5] and Sustainability Reporting Guidelines[6].  These can help identify the issues that might be considered and takes a global perspective on the growing understanding of good reporting on key sustainability indicators.  And it is important to point out that the organization may choose to address only a handful of issues in the beginning of its journey, but excluding elements should be an informed decision and not something that was simply overlooked.

Healthcare Specific Roadmaps

Green buildings have become very popular, but the issues are actually very complex when it is applied to a healthcare facility, especially when considering all of the options such as the selection of materials for construction or renovation, energy and water efficient products, lighting, plumbing, flooring products, furnishings, roofing, landscaping, parking, information technologies, safety & security, and more.  And not only are there synergies between these areas, but there are often trade-offs as well.

Thus again, it is important to utilize an existing framework or in this case a specific "roadmap" to help guide the process and insure that all of the complimentary and competing areas within the organization are being integrated into an efficient process that maximizes the outcomes and return-on-investment.  In this regard there are two important frameworks to consider.  These are the US Green Building Council's LEED®[7] Rating Systems[8] and the Green Guide for Health Care[9] which is a project of the non-profit organizations Health Care Without Harm[10] and Center for Maximum Potential Building Systems[11].

It is important to clarify that the Green Guide for Health Care is not a LEED rating system and is not a product of the U.S. Green Building Council. The Green Guide has a history of collaboration with the U.S. Green Building Council, beginning with an agreement in 2002 to borrow the organizational structure from the USGBC's LEED Green Building Rating System.

But what is most crucial for healthcare executives to understand is that becoming a more sustainable institution is not dependent upon becoming LEED "certified" of otherwise recognized.  Rather the real value of both LEED and the Green Guide to Health Care is that they will help inform decisions whether it is constructing a new building or making repairs and upgrades or "greening" operations and maintenance.  Thus put aside concerns about the cost of certification and think if these tools as a roadmap to help navigate the journey.

Easy 1^st Steps: Green Purchasing Policies, Waste Management & Green Cleaning

Sustainability is a journey and not a destination, and as such it is critically important to get started.  So once the overall sustainability framework has been selected (i.e. Global Reporting Initiative) along with a health care specific roadmap (i.e. LEED for Healthcare or Green Guide for Health Care) it is important to demonstrate some early progress and success.

Three easy first steps include instituting green purchasing policies which can cover medical devices to building materials to waste management to implementing a green cleaning program.  Both roadmaps provide significant details to make these relatively easy.  And in addition to these 1^st steps being reasonably easy, they can also help the institution reduce costs!

Just keep in mind that sustainability is never an "all or nothing" proposition, so for example when "greening" cleaning some healthcare facilities may find it harder to change disinfectants or floor care products, and start in other areas such as enhancing their hand hygiene program which can also improve infection control or upgrading vacuum cleaners.

Just remember that sustainability looks holistically at the entire process and not just the product itself.  So when using the example of improving a hand hygiene program, if using the LEED roadmap the healthcare facility would rely on third-party product certifications such as Green Seal's GS-41 for hand soaps and EcoLogo's CCD-170 for hand sanitizers.  These third-party certifications allow purchasers to buy with confidence because the health, environmental, packaging, labeling, performance and other issues can be extremely complicated and are handled by the eco-labeler.  As a result of using these roadmaps and their recommended third-party standards, it makes purchasing EASY!

This example helps illustrate the difference between just a green cleaning program where meeting these requirements would be sufficient, while a sustainability program would also request more specific information from the manufacturer such as their commitment to sustainability and what they are doing to measure, track and report their use of resources such as energy and water, as well as waste production and other information including the source of their raw materials and other issues related to the product and impacts during raw material acquisition and manufacturing.  Furthermore, questions should be asked to identify how the vendor would help with training of environmental service workers, nurses, administrative and other staff members, and even visitors to help maximize the opportunity to holistically address the needs of people, planet and the institutions profitability.

[1]The definition of green used interchangeably with the term environmentally preferable is found in Executive Order 13423.  http://www.whitehouse.gov/omb/assets/procurement_green/eo13423_instructions.pdf, page 36.  While this Executive Order was signed into affect on March 29, 2007 it was originally included in Executive Order 12873 signed on October 20, 1993.

[2] The Report of the Brundtland Commission, Our Common Future was published by Oxford University Press in 1987.   http://www.un-documents.net/ocf-02.htm#I

[3] The Triple Bottom Line was first coined by John Elkington in 1994 in his article "Towards the sustainable corporation: Win-win-win business strategies for sustainable development." California Management Review 36, no. 2: 90-100.

[4] General information on the Global Reporting initiative (GRI) can be found at http://www.globalreporting.org/Home

[5] GRI's Sustainability Reporting Framework can be found at http://www.globalreporting.org/ReportingFramework/

[6] GRI's Sustainability Reporting Guidelines can be found at   http://www.globalreporting.org/ReportingFramework/G3Online/

[7] LEED or Leadership in Energy and Environmental Design is a registered trademark of the US Green Building Council.

[8] Information on the US Green Building Council's LEED for Healthcare Rating System can be found at http://www.usgbc.org/DisplayPage.aspx?CMSPageID=1765

[9] Information on the Green Guide for Health Care can be found at http://gghc.org/

[10] Information on Health Care Without Harm can be found at http://www.noharm.org/

[11] Information on the Center for Maximum Potential Building Systems can be found at http://www.cmpbs.org/cmpbs.html