Green Healthcare Institutions: Health, Environment, and Economics: Workshop Summary (2007)

Future historians of the late 20th and early 21st centuries may well mark the growth of environmentalism as one of the epochal transformations of the time. Governments, industries, and the public have come to understand the importance of sustainability and of environmental protection, and the necessary science, technology, and policy have evolved rapidly. The healthcare sector, which accounts for one-sixth of the U.S. economy, has come relatively late to environmental thinking, but the rise of “green health care” signals a major step forward.

Green health care—the incorporation of environmentally friendly practices into healthcare delivery—appeals to health professionals and institutions for many reasons. It offers the potential to safeguard the environment, an increasingly compelling challenge. It allows healthcare institutions to demonstrate leadership in their communities. It can be a platform for educating students and members of the public. It can save money. Each of these rationales was acknowledged at the workshop on green health care held by the Institute of Medicine (IOM) Roundtable on Environmental Health Sciences, Research, and Medicine on January 10–11, 2006. However, for health professionals like those represented at the workshop, green health care is likely to be most compelling because of its potential to protect and promote health, both directly and indirectly.

These health benefits may operate on at least three scales: local, community, and global. On the local scale, within the walls of a hospital, research facility, or clinic, green construction and operation can protect patients, workers, and visi-

tors. For example, choosing safe cleaning agents or limiting the use of pesticides can reduce the potential for toxicity among those exposed. On the community scale, reducing the ecological footprint of a hospital reduces environmental hazards and protects natural resources. For example, linking a hospital to its community with pedestrian infrastructure and mass transit can reduce motor vehicle traffic and help achieve clean air. Reducing packaging in the hospital cafeteria or adopting biodegradable cutlery and plates can reduce the volume of waste sent to landfills. On the global scale, green practices help steward scarce resources and reduce environmental degradation. For example, a hospital that purchases food or supplies from local sources reduces the need for long-distance transport of goods, thereby reducing the associated greenhouse gas emissions that contribute to climate change. A hospital that installs flooring made from sustainably harvested wood helps slow deforestation, which in turn preserves biodiversity and the livelihoods of faraway rural populations.

Green building can be defined in many ways. According to the Office of the Federal Environmental Executive, “green or sustainable building is the practice of designing, constructing, operating, maintaining, and removing buildings in ways that conserve natural resources and reduce pollution” (OFEE, 2003). This definition is fully applicable to healthcare facilities at all stages of design, construction, and operation. The Green Guide for Healthcare (2006) identifies opportunities to enhance environmental performance in the following domains: site selection, water conservation, energy efficiency, recycled and renewable materials, low-emitting materials, alternative transportation, daylighting (the use of natural light in a space to reduce electric lighting and energy costs), reduced waste generation, local and organic food use, and green cleaning materials. Some decisions, such as site selection, occur during the planning and construction phases; other decisions, such as food sourcing and cleaning practices, are primarily questions of operation after a building is completed. Commitments to energy conservation, renewable resource use, and similar principles must be made and reinforced throughout the life cycle of a facility, from building conception through operation and replacement.

At the IOM roundtable workshop, an even broader perspective emerged. Participants discussed “natural” features of buildings, such as daylighting, gardens, and nature views, some of which may offer health benefits. They discussed functional aspects of hospital design, such as legibility, coherence, and way-finding cues, which are used to orient oneself within the built environment and may ease and humanize the experience of being a visitor or patient. They discussed health-promoting design features and messages, such as attractive staircases that lure people from using elevators. Characteristics such as these, taken together

with green principles, offer a positive vision of sustainable, health-promoting healthcare settings.

In fact, in creating a vision that resonates with health professionals and leaders, “framing” the concept of healthcare facility design for public and environmental well-being is critical. Characteristics of such framing include:

• Aspirational: Green healthcare facilities aim not only to avoid harm, but also to enhance well-being and to restore the environment.

• Economical: Green healthcare facilities provide value and save money.

• Prudent: Green health care reduces future risks, such as those related to energy price shocks, building-related health problems, and building obsolescence.

• Long-term: Some benefits of green buildings emerge over years, or even over the entire life span of a building.

• Contextual: Green buildings yield benefits not only within their own walls, but also in the context of the community or even the national or global arena.

A constant theme of the workshop was complexity. Designing, constructing, and operating buildings require careful balancing of a vast array of variables. Careful analysis using systems thinking is essential. Craig Zimring of the Georgia Institute of Technology, during his presentation, warned of the “fallacy of generalized goodness”; not all green decisions are all good. For example, although wide hallways, large rooms, and oversize windows that provide natural daylighting may create pleasant environments for staff and patients, they may also increase energy demand and costs. The presence of plants may pose challenges for infection control. Thoughtful analysis, supported by empirical data and a culture of continuous improvement, is necessary.

Green healthcare principles can be implemented on many scales, from physicians’ offices, clinics, and community hospitals to vast medical centers that occupy several city blocks. At the workshop, most discussion focused on large hospitals and academic medical centers, not only because these are the venues in which many Institute of Medicine (IOM) members work, but also because data are most plentiful from such settings. Moreover, large institutions offer strategic advantages: health science students are trained there, so effective green healthcare principles can be modeled and disseminated. Also, many large institutions are currently undertaking building programs, offering opportunities for far-reaching impact. Even so, participants noted that there is an important role for environmentally friendly practices at every level of the healthcare system.

In both the public sector and the private sector, the concept of the “triple bottom line” has become well established in recent years (Elkington, 1998; Esty and Winston, 2006; Savitz and Weber, 2006; Willard, 2002). This concept, sometimes summarized as “people, planet, and profit,” holds that the best performance for a firm, agency, or institution is one that optimizes social, environmental, and economic outcomes. For healthcare institutions, the social dimension includes health impacts. Thus a hospital with a successful triple bottom line would boast positive impacts on the health and well-being of its patients, staff, and visitors; efficient use of energy and natural resources, with minimal waste and pollution generated; and healthy financial performance. Many private firms recognize that this approach not only advances their goals but also positions them well on the market, enhancing their image and earning customer loyalty. These rationales apply directly to green health care.

There are also ethical reasons for pursuing green health care. Biomedical ethics are usually based on four principles: autonomy, beneficence, nonmaleficence, and justice (Beauchamp, 2001; Engelhardt, 1995). The provision of green health care is especially consistent with beneficence, as it provides benefits to patients and staff (and, in a larger sense, to communities near and far and to unborn generations), and with nonmaleficence, as it avoids harms (including distant downstream harms) that could result from certain conventional practices. Public health ethics have been linked to three traditions—utilitarianism, liberalism, and communitarianism (Roberts and Reich, 2002)—and these also offer a compelling rationale for green health care. Utilitarians would point out that the net sum of human well-being—considering patients, staff, visitors, community members, and others—is likely to increase if healthcare institutions are green. Liberal analysts, following Kant, would argue that the right to a healthy environment is infringed by policies and practices that permit dangerous exposures. And communitarians would argue that the necessary conditions for “good society” are enhanced by green health care. The Principles of the Ethical Practice of Public Health begins with a statement that, prima facie, supports green health care: “Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.” (Thomas et al., 2002). Thus, green health care falls squarely in the traditions of both biomedical and public health ethics.

What one does in health care—the medications administered, the surgical procedures performed, the health behaviors that are recommended to the public, the systems that are fashioned to deliver services—ought to be safe and effective, and these attributes ought to be established by evidence. In the case of therapies,

the gold standard of evidence is the randomized clinical trial (Chow and Liu, 2004; Friedman et al., 1999; Katz, 2006). In the case of systems, performance-based measurement provides evidence that supports continuous improvement (Gawande, 2007; IOM, 2000; Smith, 2005) . With respect to economic outcomes, careful analysis of costs and benefits can provide the evidence base for wise decisions (Brent, 2003; Donaldson et al., 2002 ; Drummond et al., 1997).

Similarly, the move to green health care should be supported by evidence. Simply claiming that something is green, without demonstrating empirical benefits for human health and well-being, the environment, and economics,

is not enough. Although anecdotal accounts of success and case studies are useful in advancing green health care, a robust evidentiary base for the practice is needed. Many endpoints might be studied—patient health outcomes, staff turnover, the psychological comfort of visitors, the magnitude of the waste stream, the use of water, and the cost of energy, to name a few. An important goal of the workshop was to discuss some of the lines of research that, if carried out, could help guide the transition toward green health care.

Healthcare institutions, like any complex systems, do not change easily or quickly. Many factors drive change, including the evolution of new external demands, the emergence of new data, the reframing of questions about a healthcare institution’s operation, the influence of visionary leadership, and the reconciliation of competing interests within the institution. In the case of green health care, each of these may play a role; indeed each may be indispensable. Advocates of green health care need to understand the institutional dynamics, including the strengths and weaknesses of particular institutions and the opportunities and threats both at the institutional level and in the larger operating environment. Green healthcare success stories are useful in illuminating what works and what can go wrong.