Achieving sustainability in healthcare: Trends and practices (YEL2022)

Date:  18 October 2022

Achieving sustainability in healthcare: Trends and practices (YEL2022)

Authors: Alyeah Ramjit (USA), Akolade Oni (Nigeria), Pierre-Marc Legris (Canada), Jean Stoefs (Belgium).

Reviewers (YEL Alumni): Fatma Al Jahwari, Melinda Bemis.

Background

The effects of global warming have become increasingly visible as weather patterns have changed causing an increase in hurricanes, heatwaves resulting in extensive drought, thunderstorms and monsoon storms which lead to extensive flooding. To help combat this, many industries have embarked on the journey of becoming “net-zero” with a goal of achieving this in the coming decade. As Young Executive Leaders, it is our belief the environment, and more broadly, sustainability, will be the challenge of our generation.

The healthcare industry is responsible for 4.4% of global CO2 emissions, but sustainability is not only about global warming and environment. Sustainable development has been defined by the United Nations as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs. For sustainable development to be achieved, it is crucial to harmonize three core elements: economic growth, social inclusion, and environmental protection.” [1]

To better understand healthcare’s role in sustainable development, we chose to survey a group of executives[2] from all over the world to identify the level of preparation as well as best practices that have begun to appear. Given our small sample, we used the survey to identify key trends and best practices that are highlighted in this paper.

Based on the survey, it appears the social inclusion dimension is clearly rooted in the DNA of our organizations. For 90.4% of respondents, the social inclusion dimension is explicitly part of their organizations’ missions and values. As a second priority, 33.3% of respondents work in organizations which have committed to the environment in their missions and values, but only 90.5% state it as a priority. Finally, economic growth is also part of 28.6% of our hospital’s strategic priorities.

In the group surveyed, 84% of respondents confirmed that environment is an overall concern, for 20% a daily concern and for 64%, a concern often overpassed by daily priorities. In addition, respondents identified having a lack of education on this topic: 20% of respondents feel “not equipped at all” while the majority thinks they have the basic tools (55%) or “equipped”, but with a need for additional support/training” (36%). Lack of time, education/knowledge and governance are mentioned as what prevents action.

Finally, the group was surveyed to identify areas they see as levers to reduce a hospital’s footprint. Infrastructure improvements was ranked number one, while changes to the way care is delivered was ranked the most challenging lever.

In this article, we thus wanted to explore four focused areas:

(1) What could our organizations do in terms of communication, to increase awareness?

(2) What governance should be put in place to drive change?

(3) What concrete actions could be put in place, in terms of infrastructure and

(4) What best practices could be put in place, in terms of clinical care?

Before diving into these questions, it’s worth clarifying the terms: achieving “carbon neutrality” is different from achieving “net zero CO2 emissions”. Carbon neutrality is about balancing out CO2 emissions, while net zero means no emissions were emitted by design (e.g., using renewable sources for energy production). It is also important to mention if it’s COcarbon neutrality vs. emissions net-zero that is targeted: “emissions” cover all greenhouse gas emissions. Websites like noharm.org provide great resources to better understand the “basics”.

Focused areas

Communication

Young Executive Leaders were surveyed to identify if their organization/hospital was actively communicating about climate change to (1) patients, (2) staff and (3) the public.

The survey results showed few hospitals communicate to patients and the public about their mission and values associated with sustainability. In addition, less than 5% of hospitals have a structured program to communicate about climate change. Interestingly though, more than 50% include a “sustainability” component in their annual report. In terms of communicating with staff (internal communication), the results are different: 56.5% of surveyed leaders report that their hospital communicates actively about its sustainability initiatives.

To make their work visible, some hospitals opt for a “certification”, such as the Green Star Building label (a certification for sustainable building) or promote initiatives such as “Health Care without Harm”. Some others are working towards B-Corp certification. Based on our survey, visibility is mainly targeted towards staff rather than the public at this stage. This could be explained by the fact that, as an employer, being active on the climate change front is also a way to attract and retain top talents. Some hospitals also calculate their “carbon footprint” to break down emissions and identify the levers to work on (some might be in staff’s hands, such as transportation).

Governance

Corporate governance describes the processes, structures, and mechanisms that influence the control and direction of corporations. In terms of sustainability, it is how organizations are set up to meet sustainability targets and track progress.

The overall goals healthcare organizations are chasing is to create processes, structures and systems that can decarbonize healthcare delivery, decarbonize healthcare’s supply chain, and accelerate decarbonization in the wider economy and society.

Tone at the Top – To achieve these goals, governance needs to start from the top, with the Board and Executive Management setting the right tone. The Board and Executive Management need to have a sustainability agenda, this must be inculcated into the missions and values of the hospital, and ensure it gets to all employees.

While the Board and Executive Management play a key role, most of the day-to-day management is in the hands of Senior Management. In addition,  sustainability should also be part of the portfolio of a senior member of the team. In our survey 32% of respondents confirmed a member of the Board or Executive team is specifically in charge of leading sustainability efforts, acting as the ‘face of sustainability’.

Measurement – Once hospital level goals are set, and a leader is assigned with this portfolio, it will be important to measure current emission levels as an organization and agree on the metrics to be tracked across

1) healthcare delivery – clinical practices, waste management, supply chain – e.g the choice of our vendors and the targets we set for them

2) public or societal impact through advocacy or communication

3) governance and internal structures

Sustainability practices can be further enhanced by embedding related Key Performance Indicators into the performance review of employees. Only 24% of survey respondents confirmed sustainability related KPIs are embedded into annual metrics and appraisals.

Processes – Examples of these could be the inclusion of sustainability metrics in supply chain vendor/contractor selection – as part of the contracting process. New services and products can also be made to go through net-zero assessments to ensure they do not tip the carbon balance further down.

Reporting and Public Transparency – A good idea is to have a section of annual reports dedicated to sustainability and public transparency on climate and net-zero initiatives. 52% affirmed their organizations include some form of sustainability reporting in annual reports.

Infrastructure – Energy

More than half of healthcare’s footprint comes from energy use, not only from emissions from healthcare facilities but also from indirect emissions from purchased electricity, steam, cooling, and heating.  A large part of this energy footprint also comes from the healthcare supply chain (production, transport, use and disposal of goods and products). In the survey, energy consumption was voted as number one feasible lever to improve hospitals’ environmental footprint. It’s also the first lever recommended by Health Care Without Harm. In the US, Kaiser Permanente became the first health system to achieve carbon neutrality (for scope 1 and 2, i.e. for direct emissions and emissions from electricity consumption). It’s only a first step as scope 3 emissions usually accounts for ~80% of CO2 emissions, but it’s a bold move worth mentioning.

It is obvious energy consumption must be a priority for the leaders of today and tomorrow, but also for health organizations and governments. Indeed, it is possible to observe, without great surprise, the countries that generate the most pollution are the same countries whose health sector pollutes the most. The involvement of governments is therefore crucial to complete a sustainable energy transition and to provide health care establishments and the population with renewable energy sources. In addition, the support of governments is essential in the granting of subsidies for organizations and hospitals that modernize their existing installations to create efficiency in consumption or implement in-situ renewable energy sources, such as, solar energy and geothermal energy.  An example is Royal Wolverhampton NHS Trust moving towards 85% renewable energy supply from a solar panel farm. Some governmental bodies also set standards: the European Investment Bank (the investment body of the European Union) has defined high environmental and social criteria that must be met by any project supported. The world bank is also promoting “climate-smart healthcare”.

The optimization of consumption, waste management and energy recovery are essential steps in the march towards net zero. Health systems must therefore establish design criteria for new health facilities that promote energy efficiency and renewable energy sources. It is essential to consider in the design of buildings natural ventilation, rainwater recovery, thermal accumulation, intelligent management of energy demand, energy recovery loops, solar panels, etc. The EDGE Buildings Standards are a useful and affordable tool. Several of these measures can also be implemented in an existing building as part of modernization or renovation work. It is recommended to begin an energy improvement process in an existing building, to set certain bases such as measuring and monitoring consumption for each energy source, producing an assessment of the existing situation, setting objectives and monitoring the evolution of the situation.

As mentioned above, an important part of the health care’s footprint is the supply chain, so leaders must question the supplier selection process and within the limitations of the regulations in force and when possible, favor suppliers that produce the least emissions.

Clinical care redesign

As healthcare continues to progress and efforts towards sustainability increase, healthcare leaders need to be mindful of the way in which quality care is delivered to patients. It is known clinical care is a large utilizer of healthcare resources and waste. One of the first steps to address the educational gap identified in the survey and create engagement is to begin partnering with safety and quality organizations, such as the Institute of Healthcare Improvement (IHI), the National Patient Safety Foundation (NPSF) and others to advance the overall work. Working towards preventing adverse events in the care setting also contributes to sustainable efforts. As mentioned above, supply chain management is a key component in this work and management of use from a waste-sparing practice aligns with adverse event management.

Within clinical care, patients require the use of equipment, devices for implantation, pharmaceuticals, durable medical equipment, and one-time use products. Equipment and device design, in many cases, can be designed in a more efficient manner. As an example, an EKG machine has a larger carbon footprint than an implantable device. Certain pharmaceuticals cost more to produce and have a shorter half-life (e.g.: infusion drugs) thereby utilizing a high level of resource making the overall process less sustainable. A possible recommendation to review the use of equipment, pharmaceuticals, and devices to create an inventory database which can be used to study the way items are selected, ordered, procured, and delivered.

A final key point to consider is the need to refocus on creating preventative care aligned with overall clinical care goals. Early detection and screening tools, activation of primary care, creation of enhanced clinical access points, funding to address social determinants of health and public health goals as well as partnership with social and economic organizations will provide a long-term strategic plan to support healthcare’s focus on working towards sustainability.

Conclusion

Achieving sustainability in health care is a huge challenge. Across the three core elements (social, environment, economics), our survey shows that environment is the biggest concern of respondents. Even if run on a small sample, executives surveyed confirm that climate change is an important topic for them and their organization, and are willing to act, but need support and training. This news is reassuring but also shows the difficulty of the challenge ahead. It’s the challenge of a generation, our generation. We believe international organizations, like IHF and others, have a role to play to facilitate exchange of best practices and speed up transformation across the globe. 

References

  1. Global Road Map for Health Care Decarbonization – Health Care Without Harm – Annex C (https://healthcareclimateaction.org/sites/default/files/2021-06/Health%20Care%20Without%20Harm%20Road%20Map%20for%20Health%20Care%20Decarbonization%20Annex%20C_final.pdf)
  2. The first carbon neutral health system in the U.S. – Kaiser Permanente https://about.kaiserpermanente.org/community-health/news/first-carbon-neutral-health-system-in-us
  3. Climate Smart Health Care – World bankhttps://openknowledge.worldbank.org/handle/10986/27809
  4. European Investment Bank Environmental and Social Standards (https://www.eib.org/en/publications/eib-environmental-and-social-standards)
  5. Global Road Map for Health Care Decarbonization – Health Care Without Harm – Annex C (https://healthcareclimateaction.org/sites/default/files/2021-06/Health%20Care%20Without%20Harm%20Road%20Map%20for%20Health%20Care%20Decarbonization%20Annex%20C_final.pdf)
  6. Healthcare’s Climate Footprint Report (https://noharm-global.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf)

Appendix: Survey questions

1) Sustainability is usually described as having 3 pillars:

1. Environment (reduce environmental footprint)
2. Social (enhance quality of life and access to care) and
3. Economic (choose cost-effective solutions, considered over their life cycle).

How is your organization prioritizing these different topics? (for each pillar)

  • Yes, it’s explicitly part of our Mission, Values and Strategic plan
  • Yes, it is explicitly part of our strategic plan (but not in Mission or Values)
  • Yes, but it is not explicitly part of our strategic plan. It is an important topic
  • It’s an important topic, but among others
  • It’s not a priority for our organization

2) Focusing on climate change, does your organization actively communicate about it?
(0 = 0 not at all, 3 = somehow, but not in a structured fashion; 4 yes, through a structured program)

3) As a healthcare leader, would you say that…

  • Environment is a daily concern in strategic and operational choices you make
  • Environment is a concern, but often overpassed by operational concerns/constraints
  • Environment is not (yet) on your priority list
  • Environment is not a priority

4) As a healthcare leader, do you feel equipped to drive change towards environmental impact reduction?

  • Not at all
  • I have basic tools but need additional support/training
  • Equipped, but need additional support/training for some areas
  • Fully equipped

5) What prevents you from acting? (multipleanswers possible)

  • Time (it’s not a priority, you have other tasks to accomplish first)
  • Knowledge/education (you would like to know more to identify how to act)
  • Governance (you don’t see how your initiatives could fit in the overall picture of your organization)
  • Motivation (you don’t really see the value of working on these topics)

6) Please rank the following levers to improve your hospital environmental footprint, by feasibility:

  • Energy:Energy consumption control/reduction
  • Mobility: increase of “green” mobility across your employee population (biking, public transport, …)
  • Mobility: offer teleconsultation/telehealth
  • Procurement:increase the share of “green”suppliers
  • Waste:increase sorting and recycling
  • Waste: increase use of re-usable devices
  • Water: reduce water usage and water pollution
  • Equipment: greener ambulances, low energy equipment, …
  • Clinical care: shift in anesthetic gazes, low carbon inhalers, …
  • Infrastructure:design new facilities to achieve net zero, adapt existing facilities

7) Do you think of any other lever that could be used?

8) Do you have “best practices” to share to the group? Any initiatives done by your hospital on its way to reduce its impact?

9) Is there a senior member of your organization at the Executive Management or Board Level that is specifically in charge of Sustainability or Net Zero.

10) Are Net Zero and Sustainability goals embedded in your KPIs and/or that of other senior members of your organization.

11) Do you include a Sustainability report componentin your annual report or any other specific report for this purpose.

12) How well do your sustainability activities help you in winning customers and growing your business on a scale of 1 to 10 (1 – Not at all and 10 for impossible to win business without it)

13) How well do your sustainability activities help you in winning investors and investments on a scale of 1 to 10 or N/A (1 – Not at all; 10 for impossible to get investors without it, No Answer is We do not raise funding externally)

 

[1] https://www.un.org/sustainabledevelopment/development-agenda/

[2] We surveyed the « Young Executive Leaders 2022” of IHF, a group of 40 health care executives from all over the globe. 25 full answers have been received and analyzed.

Written by:

Katherine Bennett

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