Susan Gamble, M.D., a third-year internal medicine resident at Yale, is job hunting. She’s looking at many factors as she decides where to practice, but at first glance, the greenness of a practice or facility isn’t necessarily one of them.
That’s not to say she isn’t concerned about the environment.
"I want to be somewhere where I can control it (environmental responsibility) in my own life," she says. "At work, I haven’t thought about it."
But after talking about environmental consciousness and health care, Gamble is more inclined to consider it as a criterion.
After all, it’s a good sign the practice is paying attention to other things, as well.
"It’s impressive, because you think someone who is able to take a green initiative for their office probably has it all together so they’re able to focus on the environment," Gamble says.
Green practices may sound like code for solar panels and recycling bins, or perhaps waste management. Environmentally responsible initiatives in medical practices and hospitals go far beyond stereotypical "green" projects, however.
Take Denver Health, for example. When the health care organization built the new Park Hill Family Health Center, which opened in 2009, they designed it to reduce heat and energy consumption, according to spokesperson Chris Poisson. But they didn’t stop there.
Together with Simpler Consulting, Denver Health was determined to improve the facility’s access and efficiency. In Park Hill’s building design, patients benefit from minimized distance from registration to check-in to exam room, and from a more confidential registration space. Physicians and other staff members benefit from initiatives that encourage commuting alternatives, including on-site bicycle racks and showers.
Going "green and lean" affects every area of health care, and includes promoting a healthy environment for you, your staff, and your patients as well as improving the financial well-being of the organization.
What should you look for when searching for a green medical practice?
New medical facilities are often designed with energy efficiency in mind. If you find a clinic or hospital with a LEED certification (an internationally recognized green building certification), you know it’s designed for energy efficiency.
Many organizations take green measures in building their facilities without acquiring the LEED certification. For example, the Park Hill center was built with occupancy sensors in rooms to reduce electricity costs, a rooftop daylight system that funnels sunlight into the building, and a white roof, among other things.
In older buildings, generally speaking, it’s more of a challenge to provide a comfortable level of care for patients and staff while saving energy than it is in a new one.
Organizations like Fletcher Allen Health Care in Vermont that have many older facilities are gradually making improvements, however. "The organization is also committed to energy reduction," says Dawn LeBaron, vice president for hospital services at Fletcher Allen. "We’ve done a lot of improvements in that world. We’re trying to do everything we can to not waste."
Why it matters: The organization saves energy costs, and patients and staff enjoy natural lighting and increased comfort.
Remember when we all got computers and stopped buying paper? Neither do we. The promise of less paper usage with computerization has yet to be realized. In fact, EMRs can make it easier for staff to print and reprint more paper than ever.
Gamble works at two hospitals; one uses EMRs and the other doesn’t. Gamble says, "People print out reams of paper that are supposed to go in charts, and then they don’t use them."
Gamble thinks every medical facility should have EMRs. "I think they’re so fantastic," she says. "You can’t read anyone’s handwriting at the other hospital (the one without EMRs). I’m constantly calling people saying, ’It looks like you wrote what?’ And they have to explain their note."
And over time, it’s possible physicians can go entirely paperless. "They can eliminate all the paper in their office," says Helen Phung, media relations specialist for Practice Fusion, a free online provider of EMRs. That doesn’t stop people from printing, but eventually as more documents, including X-rays, are stored online and are interoperable (accessible from everywhere), the need to print should decrease.
Delbe Meelhuysen, M.D., from Fort Worth, Texas, points out that although EMRs don’t reduce paper consumption, they have other advantages. "It does improve communication, improve quality of care, reduce errors in care and in medication adverse events," she says. "EMR does help with correctly coding, billing and optimizing collections. It helps promote patient privacy in that the electronic footprint is permanent - someone can’t just wander by and pick up a chart and peek at it and set it down and no one know. In order to access anyone’s record, you have to pass security, and whatever you do and wherever you go is monitored. Various health care providers have different levels of security and can only access what is pertinent to their job."
One challenge to electronic medical records systems currently in place is getting access to records in one system from another system. "EMRs work well within a system," says Greg Saunders, M.D., of Coquille, Ore. "But if we refer a person to Eugene or Coos Bay and then try to get into that record system, it’s not that easy. It has the potential to facilitate care if we can make people’s different systems talk to each other."
"Everybody’s worried about privacy, but restricting that information makes it harder to take care of the patient," says Saunders.
Why it matters: EMRs can save time and improve accuracy, accessibility and readability of records to help improve patient care and help protect privacy. Practices can potentially save money on paper and printing if their system becomes totally electronic. And the practice may receive higher reimbursements and incentives from insurance companies. Phung says, "Physicians can be more connected than they were in the past. And it actually saves lives."
Your first impression of a green practice may be the on-site bicycle racks and showers, like the ones at Denver’s Park Hill Family Health Center. They make it much easier to stay out of your car when the weather’s nice. Some hospitals, like Castle Medical Center in Kailua, Hawaii, even provide bike lockers. "You don’t want to chain a $2,000 bike to a rack," says Kevin Roberts, FACHE, Castle’s president and CEO.
Don’t write off a practice too quickly if they give you a blank look when you talk about bike racks and lockers, however. In some areas like Coquille, Ore., they don’t need them. Saunders parks his bike outside his office door. "I don’t lock it. This is a community where theft is unusual. Things are pretty safe," he says. "I like to bike to work when it’s not pouring down rain. In the summertime, I usually bike."
Gamble looked at a place where she’d have to commute a long distance, a "concrete jungle sprawling mass of suburbia" where you can’t walk or bike anywhere. That, combined with a perceived lack of local interest in caring for the environment, makes that city not her top choice. (The uncovered trash bin at the beach that allows litter to blow out was one clue.) "It seemed so different," she says. "The biggest thing for us is how much we feel like we can be outdoors. When I lived in Seattle, sometimes I walked to the hospital." She hopes to be able to live close to where she works.
Not everyone can live in a small town, but they can still avoid driving solo long distances to work. Staff at Fletcher Allen Health Care facilities are encouraged to find ways to get to work other than by driving single occupant vehicles. In addition to subsidized passes for public transportation, employees can get coupons for perks if they promise to walk or bike to work a number of days per week. "People really take advantage of that," says LeBaron. "They know they’re helping the environment, but they’re also saving money."
Why it matters: Besides saving energy and money, avoiding long solo commutes in snarled traffic is one sure way to improve your everyday quality of life.
It’s easy to spot the practice that isn’t using water wisely. In arid parts of the country, they look like an oasis. Lush, non-native landscaping is watered by sprinklers in mid-day. Some of the water may be running down the sidewalk. Inside, the break room offers bottled water and no waterless hand sanitizers are available. (Like so many green issues, the use of hand sanitizers has pros and cons, and is not preferable for or accepted by every practice despite their water-saving advantage.)
Less obviously, medical facilities can use significant amounts of water for cleaning, sterilizing and cooling. For example, X-ray film processing sends water down the drain unless a device is installed to recycle the processing water or the practice switches to digital imaging. The same is true for equipment cooling systems and cooling towers - with closed loop cooling systems, they can use far less water.
Why it matters: Every gallon of water saved can potentially save money by cutting the water bill, the expense of heating or cooling water, and the sewer bill.
We expect to see recycling bins at every work station in health centers nowadays. However, recyclable paper is only a small portion of the tons of food waste, cleaning supplies, patient supplies and more that medical facilities deal with every day.
One issue is disposable vs. reusable instruments and supplies. Most people would be surprised at how many things, from patient gowns to physician tools, are used once and thrown away.
Saunders prefers reusable instruments whenever possible. "(In Coquille, Ore.,) we have reusable laparoscopic instruments vs. disposables," says Saunders. When Saunders worked in Africa, he was accustomed to using instruments, gloves and even sponges over again. There wasn’t much choice. "We washed them out with soap and resterilized them in the autoclave. We even mended the holes in the operating room drapes in Africa and kept using them."
"In America, they’re all disposable," he says. Saunders acknowledges that reusing instruments and linens takes resources, too. "Some people say by the time you use soap and energy on the surgical drapes and gowns, you’re better off getting new ones. I don’t know the answer."
One success story for reducing waste is with food composting. At Fletcher Allen Health Care, all food waste is sent to the community compost program at the Intervale Center in Burlington. According to LeBaron, they even brought compost back to the hospital’s rooftop garden.
Safe disposal of chemicals is a major issue in the health industry. The chemical industry, hospitals and the government have abundant resources to help hospital and private practice staff learn how to dispose of chemicals safely. An office that disposes of chemicals, including drugs, safely has information posted on the wall or available in a brochure to teach safe disposal practices to both patients and staff. They may also have "do not flush" signs beside toilets warning users that disposing of medicines in the sewer contaminates natural water sources.
Why it matters: When feasible, reusing tools and supplies and reducing hospital waste can save money and therefore improve the facility’s bottom line. Some non-disposable tools may be of higher quality than those meant to be used once.
Health care facilities that are interested in sustainability and other green initiatives may find it difficult to make changes in cleaning procedures and chemicals used if their housekeeping is contracted out to a separate company. The contracts may span years, making change slow even if an attempt is made to make housekeeping more green.
When facilities do have direct control of housekeeping, they can drastically reduce the non-green chemicals they use. LeBaron says, "Our housekeeping department uses green clean chemicals. There’s a certification on them. We used 11 different kinds of cleaning products, now reduced to five. Only one of the remaining is non-green and that’s for certain disinfection. It’s the only thing that is effective on that."
Why it matters: Fewer non-green chemicals means a healthier environment, with less fumes and chemicals in contact with patients and staff.
Gamble says she would be impressed by a workplace with better food choices as she looks for a position. In particular, she’d like to see less meat, more food that’s grown locally, and less pre-packaged food. "I think it’s ridiculous that in some hospital cafeterias, you go downstairs and it’s like three-cheese casseroles and then burgers and a creamy soup, and a soda bar. And then a really small salad bar. It would be so great if we had fresh food that was locally grown, and people could feel good about what they’re eating."
"You should find the healthiest food there (in the hospital)," Gamble says.
She might appreciate Fletcher Allen Health Care’s food program. Like more than 300 facilities across America, Fletcher Allen signed the Healthy Food in Health Care Pledge, which demonstrates a commitment to "treating food and its production and distribution as preventive medicine that protects the health of patients, staff and communities." As part of that commitment, Fletcher Allen has a sustainable food program. "The food offerings there are wonderful. We have arrangements with local farmers, so almost everything we provide is local, with the exception of fish some times of the year," says LeBaron.
The results dispel any old impressions of hospital food. "We have food cooked to order," she says. "They call to a catering service and get food within 45 minutes. If patients want a grilled chicken breast, that gets cooked for them and taken upstairs." The physicians can take advantage of eating that food when they’re working here, but at the same time they know that it’s contributing to their health. We don’t even have a deep fryer. And it’s delicious. People are happy with it. For some people it’s a destination dining facility because the prices are reasonable but the food is great."
You can find health care facilities that have signed the Healthy Food in Health Care Pledge online, or check out the cafeteria and break room on a site visit and judge for yourself.
Why it matters: You and your patients will feel better and be healthier as you enjoy higher quality food. As a surgeon, Saunders says, "80 percent of the diseases I care for are related to the American lifestyle and diet."
Lean and green initiatives sound great, but not everything works. A skeptic may wonder if some of it is window dressing, while business goes on as usual. Other times, not everyone agrees on what is the most environmentally friendly solution.
For example, at Fletcher Allen, brainstorming and "crazy ideas" for saving energy are encouraged. "People are interested in burning alternate fuels," says LeBaron. "We do burn natural gas. It’s our primary fuel. It’s a clean fuel." It doesn’t please everyone, however. "We’ve had a lot of people interested in us using wood pellets, but for here, it just does not work with the volume we would have to burn and the equipment conversion cost." Also, "Gas comes to us through a pipeline, so we’re not trucking it over the roads."
"Everything we’ve done here and tried has worked. There are downsides to everything you do. Low-flow faucets and showers in certain areas of a health care facility are not my favorite. We’re Vermonters. We question everything."
When looking for a job, questioning everything isn’t a bad idea. After all, if you do the asking at the start, you’re going to be happier with the outcome at the end.
Sally Herigstad is author of Help! I Can’t Pay My Bills: Surviving a Financial Crisis (St. Martin’s Griffin).