October 2, 2008

The Challenge of Sustainable Hospital Building

By Hamilton, D Kirk

FEW TOPICS ARE as timely as discussions of our shared sustainable future, and there are few settings more difficult to design for sustainability than hospitals with their critical functions, continuous operation, constant energy consumption, huge demand for water, and enormous generation of waste. It is almost a cartoon caricature to say that the gargantuan volume of dangerous and toxic wastes constantly spewed out of our hospitals is making the communities and environments around them sick, and so to wonder about the irony that to some degree they are probably creating their future clientele. BOULDER COMMUNITY HOSPITAL, BOULDER, COLORADO

David Gehant lets us know early in his piece on Boulder Community Hospital that grassroots activity by environmentally conscientious employees spurred the hospital's involvement and commitment to environmental principles. These are folks from a progressive college community in Colorado with an activist history. Management's decision to develop a volunteer "green team" and the actions that followed began to align the goals of the organization with the goals of its employees. The decision to hire a full-time sustainability coordinator to develop and maintain environmental initiatives strikes me as forward thinking and relatively rare in the industry. Following the decision to support the bottom-up initiatives of the staff, board approval of the Statement of Principles of the Environment completed the process of endorsement at every level of the organization and allowed the environmental attitude to permeate the culture. This strikes me as an important lesson for organizations wishing to emulate Boulder Community Hospital's success.

Its Statement of Principles of the Environment deals with waste reduction, waste disposal, recycling, nonrenewable resources, toxic emissions, alternative transportation, purchase of recyclable and reusable products, water conservation, and commitment to disclosure of incidents of environmental harm. While the list is impressive and laudable, I wondered why energy consumption didn't appear. By the conclusion of Gehant's paper, it is obvious that attention to energy use became important to the organization and that it received significant results in that area.

Gehant's documentation of the system's results is extraordinary. It is recycling 500,000 pounds per year, saving more than $2000,000 per year in surgical instrument wraps and instrument reprocessing, and generating more than 100 kilowatts from solar panels. In 2004 it was able to document saving more than 1.5 million gallons of water, nearly a million kilowatt-hours of energy, 1,779 cubic yards of landfill, and 13,500 pounds of air pollutants for which it won the Eco-cycle Award.

Boulder Community Hospital makes a strong business case for enlightened healthcare organizations. The numbers and resulting savings from its decision to "go green" would seem to tickle the fancy of any chief financial officer at any hospital. I would have liked some additional comments from the author about what kind of effort is required to gather this sort of data. While hospitals are awash with more data than any reasonable manager might need, and under regulatory obligation to report practically everything associated with the services they provide, few healthcare organizations have a system in place to capture the kinds of data that Boulder Community Hospital has collected to document its sustainability performance. It is said that one can't manage anything that is not measured; if so, healthcare organizations must learn to measure new indicators of stewardship, such as gallons used in irrigation, amounts of disposables, pounds of red bag waste, or tons of landfill.

Boulder Community Hospital is a system of facilities, one of which is the new and well-documented Boulder Community Foothills Hospital, which earned LEED Silver Certification. Another is the older main Boulder Community Hospital in Boulder. It would be interesting to be able to see a breakdown of the numbers provided at the different sites in the system. Are virtually all the initiatives and savings at the new site? Do each of the sites recycle a similar percentage of materials used in the hospital? Are there significant differences in the waste reductions at the different sites? What portion of the energy use and energy savings occur at the different sites? Can one achieve dramatic results in existing buildings that match the kinds of results gained in a new building? My naive assumption is that it is harder to obtain spectacular savings in older buildings. If there are differences, it would be instructive to know what the system is doing to spread the positive behaviors and positive results to other sites.

Gehant's success story is exciting and encouraging to all of us who hope to experience a more sustainable future for healthcare organizations. I am, however, left with a few questions. I wonder what the system found to be the simplest and most effective quick wins, and which were the most difficult to achieve. It might have been especially useful to learn what barriers at existing facilities were most difficult to overcome, as compared to what was possible in a new building constructed with the intent to be more sustainable. I am impressed with the spectacular results from Boulder Community Hospital, and would have enjoyed more explicit advice that could have given me a deeper understanding of the hard work required to make it a reality. After all, what is really important here is whether this can be accomplished elsewhere. I feel certain that other healthcare organizations that share Boulder's commitment to environmental stewardship and are prepared for the demanding work required can achieve similarly dramatic results.


Jim Coller and Annette Grunseth tell another story of environmental success that springs from the stewardship obligations of the Hospital Sisters Health System and the teachings of Christ, St. Francis, and St. Clare, who believed in "reverence for the earth" and all living creatures. The Hospital Sisters required every hospital in its system to integrate environmental standards into its facilities and communities. St. Mary's already had a history of brainstorming concepts and trying new ideas. With the support of the local board, its Environmental Statement for St. Mary's Hospital Medical Center declared its reverence for the earth and recognition that protecting the environment "is critical to our community's long- term health." It states its commitment to the environment and implementing new initiatives annually.

Environmental activity at St. Mary's began more than two decades ago with employee- initiated projects to clean up the river and bay, begin recycling at a local museum, and make donations to food pantries. A "Green Team" formed in 1996 began to address issues related to the hospital property, which led to a nationally recognized storm water management system. A new director of environmental services led efforts to recycle, reduce waste, and conserve energy.

Coller and Grunseth share a litany of successful results. I found myself incredulous at the report of an overall recycling rate of 31.5 percent by 2006, which had grown to 40 percent in 2007. The authors contend that a typical hospital is doing well to recycle 25 percent, according to Hospitals for a Healthy Environment (H2E). They explain that in 2007 St. Mary's recycled more than 163 tons of waste material. Its innovative programs, like recycling medical waste suction canisters, to name only one example, are superb models for others to emulate, and the authors openly share the lessons they have learned.

One of the biggest lessons from St. Mary's seems to be its decision to partner with anyone who was willing, and to make especially fruitful use of gifts and programs such as the Focus on Energy grants to help purchase energy-saving equipment. Its community program to exchange digital thermometers for mercury thermometers must have paid off in goodwill while it protected the community.

The authors provide a helpful set of suggestions for others who intend to follow the environmental path they have pioneered: engage the ownership, partner with community leaders, find more partners, tell the story, start with small steps, and conduct environmental audits. The issue of audits seems to be a bit too quickly glossed over in the sense that understanding where the organization stands is vital to the decisions that must be made to take the organization to a new and better place. I would imagine that most organizations starting this activity would need considerable coaching to perform the types of environmental audits needed to guide their subsequent actions. Bills from utility companies tell the organization how much water, electricity, natural gas, and heating oil is used, but auditing where and how they are used in order to reduce consumption requires another level of analysis. Every hospital will have a community relations staff able to manage and promote public campaigns, but few will have the skills and expertise on staff to assess the organization's environmental impact and confidently lead the change initiatives. A common thread in these stories might be the need for the organization and its champions to educate themselves about what can be done. CONCLUSION

Together these articles make a strong case for more aggressive environmental action on behalf of hospitals and healthcare organizations. I sincerely applaud them both for their role as exemplars for the industry and hope their stories will spread widely. Both have obtained notable results in recycling, reduction of waste, protection from toxic chemicals, conservation of energy, conservation of water, and considerations of sustainability associated with construction of their facilities. Each used a wide array of programs to achieve its overall impact. Their investment in environmental initiatives has resulted in positive financial returns. I am especially pleased to note the numbers and frequency of tours they conduct to share with others what they have accomplished and learned.

These two organizations have exhibited the courage to try something before others had shown it to be possible, each indicating in some fashion that it chose to do it because it was "the right thing to do." It is interesting to contrast Boulder's activist employee beginnings to St. Mary's requirement from the system's faith-based sponsors. A commitment to the environment can begin at the grassroots or the governance level, but for environmental initiatives to become a success, the commitment must spread to the entire organization and infuse the culture. Each organization adopted a statement, although quite different, that helped spread a shared understanding of the goal to the members of the larger organization. Each organization had an energetic champion-the sustainability coordinator at Boulder and the director of environmental services at St. Mary's. Both examples feature a guiding coalition in the form of green teams. Each began with smaller steps and over time moved to larger and more comprehensive initiatives. Both proudly tell their stories publicly in a way that helps consolidate their gains, embed the culture of sustainable practice, and build momentum for the next initiative. I believe it is fair to observe that neither accomplished it all at once, and both would tell us they are not through improving.

As the early adopters show us the way, I sincerely hope the mainstream of the healthcare industry will rapidly grasp that organizational self-interest will be served by a genuine commitment to conservation, environmental impact, and sustainability principles. Commitment to the community's environmental health and stewardship of valuable resources seems to fit comfortably within the mission of every healthcare organization. Thanks to Gehant, Coller, and Grunseth, we have evidence that "doing the right thing" can work to the benefit of the organization, the community, and this precious green and blue planet we share.

Boulder Community Hospital makes a strong business case for enlightened healthcare organizations.

Commitment to the community's environmental health and stewardship of valuable resources seems to fit comfortably within the mission of every healthcare organization.

D. Kirk Hamilton, FAIA, FACHA, is an associate professor of architecture at Texas A&M University.

Copyright Health Administration Press Fall 2008

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