Exploring the Medical/Surgical Unit as a Complex System

Design Dilemma: S u s t a i n a b i l i t y

Claudia Mei & Jaclyn Popkin

DEA 4530

Planning & Managing the Workplace: Evidence Based Design & the Organizational Ecology of Healthcare Fall 2010

Table of Contents

I. Introduction & Executive Summary

II. The Issue

III. The De�nition

IV. The Stakeholders

V. The Dilemma

VI. Existing Solutions: Case Studies

VII. The Innovations

VIII. References: Bibliography

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Introduction/Executive Summary

A “design dilemma” is a critical design decision for which there is no clear, obvious solution. This project focuses on accessing, organizing, interpreting, and applying information to form and create complex decisions and innovations. This has been accomplished by drawing on research literature examining present designs and their associated issues. As a class, we identi�ed a wide range of systems, sub-systems and issues that must be considered in planning, designing, and managing a Med/Surge medical unit. This report will focus on the incorporation and challenges that encompass sustainable design within Hospitals. After a thorough evaluation of the key elements, measures and issues of sustainability, the discussion will converge towards detailed examples and design innovations that we believe would prove successful.

To begin, we will describe the underlying issues of sustainability, what it entails and how it can be broken down. The stakeholders will be identi�ed, followed by three examples of design dilemmas falling under the issue of sustainability and conservation versus infection and cleanliness. Next, we focus on three di�erent examples of case studies o�ering unique sustainable solutions. Finally our project will �xate on the operating room, o�ering design solutions and innovations for maximum impact in crucial areas.

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The Issue

Hospitals play a pivotal role in protecting health. However, they can also inadvertently contribute to illness and pollution by exposing patients and sta� to a variety of toxins from building materials, medical waste, hospital supplies and cleaning products. For example, inadequate ventilation and generally high-energy consumption have contributed to poor air quality and pollution, with e�ects ranging from longer patient recovery times to more sick days for sta�. Every year, the health care industry produces 2 million tons of waste that pose occupational and environmental threats. (Ananth 2008) “We will not have healthy individuals, families and communities until we have clean air, clean water and healthy soil.” (Lloyd Dean, CEO of Catholic Healthcare West)

One challenging issue of sustainability itself is the numbers attached: “The long-term return on evidence-based design and incorporating energy e�ciency and some of the things that are included in green design are enormous, and they pay for the cost of the hospital 10 times over or sometimes even 30 times over. But the initial thinking that ‘okay, we have to get $210 million instead of $200 million’ is a real hard challenge for some people to face. But that’s what the Center is all about -- educating people about why they should care about EBD and providing the data to support those decisions.” (Sara Marberry, COO of Concord, California-based Center for Health Design)

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De�nition

Sustainable: a) of, relating to, or being a method of harvesting or using a resource so that the resource is not depleted or permanently damaged b) of or relating to a lifestyle involving the use of sustainable methods

It is a term used to describe the triple bottom line: People, Planet, and Pro�t. Sustainability in healthcare thrives to reach the goals of establishing a socially just, environmentally sound and economically viable development. Hospitals stand at the center of sustainable development because of their signi�cant contribution to human well-being. “As the healthcare industry’s environmental foot print negatively a�ects the environment, these environmental impacts may in turn a�ect human health, and human health issues further increase the need for healthcare services. This is the center of the sustainability challenge. Improved environmental performance may contribute to an improved community health status.” (Roberts & Guenther 2006)

The well-being and safety of patients and sta� members is the number one priority in any hospital. However, it is also in the interest of hospitals to reduce their environmental load and contribute to a cleaner environment. These three �elds are part of cyclic underlying interaction.

A cleaner environment equals more healthy human beings.

PLANET PROFIT

PEOPLE

Bearable Equitable

Viable

Sustainability

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Organization

To better help understand Sustainability’s implications on Healthcare design; it can be broken down into di�erent topics.

Architecture, Green design and Transport

Green design is much more than healthy material choices and energy e�cient formation of buildings. It also gives consideration to the provision of well functioning and pleasant working and healing environments that optimize the health outcomes. Sustainable and e�cient transport and travel should be a key consideration for all large organizations. Measures can yield considerable bene�ts, for both the hospital and its sta�, as well as for the patients.

Environmental Management, Chemical and Pharmaceutical Policies

All employees have the responsibility to contribute to a safe and healthy workplace and a reduced environmental impact. Routines and management plans need to be developed and e�ectively communicated to all levels of sta� in order to secure well functioning environmental, health and safety practices. Green procurement and chemical and pharmaceutical policies are some of the speci�c areas where specialist consultation is often necessary.

Medical Equipment and Smart Application of Technology: Information & Communication

Innovative medical technology is a prerequisite for e�ective healthcare but can also contribute to a healthier environment. One good example is the successful replacement of conventional �lm & chemical-based X-ray technology with digital X-ray in hospitals. E�ective information and communication technology (ICT) solutions can eliminate duplicate administrative tasks, redundant medical examinations, needless prescriptions o�er new training channels and replace transport with electronic transference.

Sustainable System Solutions: Energy, waste, water, and emissions control

With today’s increasing prices for energy, investing in energy and resource e�cient solutions for heating, cooling and ventilation, lighting, and water provision is no longer just an environmentally but also an economically motivated action. Professional handling of chemical and medical waste, and laundry, are also important considerations for hospitals, not only due to environmental and health risks but also because of the costs involved.

(Sustainable Health Care, www.sustainablehospitals.se)

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The Stakeholders

It is vital to involve and address the needs of all key stakeholders in designing and implementing a sustainable program. “Often, additional organizational social bene�t is achieved through an integrated design process that engages a wide group of stakeholders, where the building design is viewed as only on component of an institution wide environmental improvement initiative that involves everyone.” (Roberts & Guenther 2006) The well-being and safety of patients and sta� members is the number one priority in any hospital. The links between buildings and health, and “the irony of healthcare system that may contribute to environmental illness, and the strong connection to healthcare’s fundamental mission to “�rst, do no harm” make sustainable building an important goal that is impossible to ignore.” (Roberts & Guenther 2006) The stakeholders include patients, the medical sta�, hospital administration and management and various environmental services.

Patients

Medical Sta�

Hospital Administration

Environmental Services

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The Stakeholders

• Patients: To ensure the well-being of patients, sustainable healthcare construction will enhance the community and medical reputations. For example: The connection of natural lighting is an example supported by both evidence-based design research and sustainable building practice. Biochemical and hormonal body rhythms can be in�uenced by the amount of light exposure, as can the synthesis of certain vitamins. (Ulrich 1993) Patients will want to come to the spaces if there are proven bene�ts for themselves as individuals. It is also important to measure patient satisfaction. When evaluating patient satisfaction with the sustainable design features.

• Medical Sta�: A sustainable program can provide a signi�cant service to physicians at the hospital. For example, employees with views of a natural landscape report greater job satisfaction, less stress and fewer illnesses. (Clay 2001) As such, it can be helpful to involve the medical sta� in the design, implementation, and review of the program. A “Sustainability Committee” may be a useful vehicle for addressing these issues. A program may want to implement satisfaction surveys, to determine how the sta� perceives the actions taken. “There is no actual nursing shortage. There is a shortage of places that nurses want to work.” (Roberts & Guenther 2006) Sustainable healthcare will establish a place that enhances medical reputation, thus improving sta� recruitment and retention, and increasing marketing share, philanthropy and research grants. The bene�ts of the program are mutual with all stakeholders involved.

• Hospital Administration: Hospital administrators often de�ne the goals and provide the �nancial sup¬port for hospital programs. By de�nition, they will play a key role in designing and monitoring the sustainable program as a whole, and it is really in their hands that the sustainable design implementations are followed and maintained appropriately. Perhaps a new position such as a “Sustainability Operational Manager” would be necessary to appropriately supervise the new system.

• Environmental Services and Infection Control and Prevention also have important roles to play. It is important to involve the right mix of voices to ensure a comprehensive review of the di�erent greening strategies and determine critical synergies with quality, safety and infection control and prevention disciplines.

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The Dilemma

Hospitals are vast consumers of resources. They tend to be massive buildings, and also happen to operate 24 hours, 7 days a week. Consequently, hospitals actually rank as some of the most energy and resource-intensive building structures in the country.

General Overview

• Healthcare facilities are the second most energy-intensive commercial building type (the food service industry ranks �rst). (Johnson 2010)• The healthcare sector is responsible for at least 80% of the country's emissions (Johnson 2010).• U.S. hospitals use more than 2.5 times the energy of commercial office buildings, and emit 2.5 times the amount of carbon dioxide (Johnson 2010).

Some statistics:

Also significant is the fact that a hospital's biggest priority is often cleanliness and infection control. Hospitals are constantly striving to eliminate healthcare-associated infections (HAIs), which can rapidly spread serious illnesses to hospital sta� and patients. In 2002, HAIs in U.S. hospitals were associated with nearly 99,000 deaths (Markkanen et. al. 2009). This means that nearly 1 out of every 22 hospitalized patients acquired an infection (Ulrich et. al. 2008). Outbreaks such as the SARs pandemic, as well as other multi-drug-resistant organisms (MDROs), have only served to exacerbate such fears. Not to mention that the cost of treating HAIs are estimated to be around $5 billion a year (Ulrich et. al. 2008). Therefore, many aspects of the hospital, such as ventilation, use of building materials, disposal techniques, and laundry facilities, are carefully designed with infection control as a major consideration. With such paramount emphasis on disease prevention, concerns about excessive energy or resource consumption may go unnoticed, or seem to be directly contradictory.

Next, we will discuss the dilemma of Sustainability and Conservation vs. Infection/Cleanliness according to 3 types of resource management in hospitals:

Waste management

Water Management

Air Quality Management

Sustainability and Conservation vs. Infection/Cleanliness

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The Dilemma

The term hospital waste refers to all waste generated from a hospital facility (Bernstein et. al. 2009). The term medical waste refers to “that portion of hospital waste that includes wastes from patient diagnosis or treatment, or vaccination of humans or animals” (Bernstein et. al. 2009). Medical waste, which can contain hazardous materials such as human matter, dangerous pathogens and toxic chemicals, is heavily regulated. To prevent contamination, disposal of hazardous medical waste is usually incinerated, either onsite or o�site. The incineration process releases toxic chemicals into the air, presenting a direct environmental issue.

Why do hospitals generate so much waste? Studies have revealed that the answer lies within traditional hospital practices and waste management.

The �rst major problem is due to the fact that the majority of medical tools, devices, and materials are disposable. Disposable medical tools are popular in hospitals because they present an easy solution to keeping treatments sterile. In terms of sustainability, switching from disposable tools and devices to reusable items is the obvious solution. However, from the eyes of key stakeholders such as management or caretakers, the idea of recycling equipment is a contentious and risky one. Even the tiniest fraction of improperly decontaminated products could end up causing an infectious disaster, and hospitals are undoubtedly hesitant to incorporate a change that even remotely compromises patient health. Another fear is that cleaning and re-sterilization might erode the less durable components of a medical device, leading to malfunction (Chen 2010).

In a similar vein, a second major problem stems from the fact that a signi�cant portion of hospital garbage is actually made up of unused disposable medical devices, such as surgical instruments, gauze, and excess syringes. The reason for this stems from standard hospital practices. For example, during surgery procedures, it is standard for doctors to use sterilized disposable surgical kits. At the end of the surgical procedure, all of the medical equipment within the surgical kit is disposed, even if it was never used, for reasons related to sterility (Chen 2010).

• Sustainable Waste Management

Some statistics:

Annually, U.S. hospitals generate more than 2 million tons of waste, containing everything from plastic bandages to single-use hospital robes (Johnson 2010). Much of this is considered "contaminated medical waste" that subsequently ends up being incinerated. The rest of the garbage from hospital facilities ends up in the land�ll.

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The Dilemma

• Sustainable Water ManagementAn important component of environmental sustainability concerns water use and conservation. It is a vital topic to consider in hospitals, as healthcare facilities are incredibly water-intensive buildings.

Hospital water conservation is an area that drastically calls for improvement, but many barriers stand in the way of a solution. The �rst barrier is the fear that re-treated water could contribute to infection. Extensive scienti�c literature research has actually concluded that Type I reclaimed water poses zero increased risk of infection (Vittori 2008), but even beyond this, a second major barrier exists: local policy. Municipal water systems within the United States must comply with extremely strict requirements, so hospitals have a lot of di�culty implementing reclaimed water systems that comply with the rules (Vittori 2008).

Challenges are not limited to implementing solutions related to reusing and recycling water; there are challenges inherent in the idea of water conservation as well. One of the main reasons why hospitals consume so much water is because it is vital for cleaning. A major problem, as strategist Tyler Krehlik states, is: “How do you �nd a balance between conserving as much water as possible, but encouraging everyone to wash their hands as much as possible?” (Hutchinson 2010). When sustainability e�orts and infection/cleanliness e�orts seem to clash, �nding innovative solutions can be much more di�cult.

Some statistics:

• U.S. hospitals typically use 80-150 gallons of water per bed per day (Roberts & Guenther 2006)

• A typical healthcare facility uses an average of 139,214 gallons of water a day (Vittori 2008)

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The Dilemma

Quality of the indoor environment is a top priority for healthcare facilities, so air quality is of paramount concern for hospitals, especially since extensive research has shown that indoor air can be as much as 10 times more polluted than outside air (Carpenter 2010).Intense concern for air quality means that hospitals consume massive amounts of energy to meet ventilation/heating/cooling needs. It's hard to focus on reducing energy use because hospitals place such high priority on maximizing patient comfort and minimizing HAIs. When dealing with air quality, there are complex trade-o�s between energy e�ciency, patient/sta� comfort, and patient/sta� health.

• Sustainable Air Quality Management

Features of Evidence-Based Design that increase patient/sta� comfort and health, but are energy intensive:

• Improved air quality from increased ventilation. Research has shown that just a 10% increase in ventilation rates equates to an increase of 33% in energy consumption (Roberts & Guenther 2006).

• Increased 'comfort' cooling in patient bedrooms. 'Comfort' cooling also have the added bene�t of o�setting the dangerous e�ects of heat waves (Short & Al-Maiyah, 2009).

• Increased percentage of single-occupancy bedrooms. An in�uential study by Ulrich et. al. stated that single-occupancy patient bedrooms could help reduce infection rates (2008).

However, although minimizing airborne infections has been implicated in a lot of the aforementioned features, it is important to note that the concept of airborne infection control is actually quite hazy and di�cult to study or operationalize. Tracing infections to the cause of airborne pathogens is actually very di�cult, as people who acquire infections could have acquired them for a multitude of possible reasons. There is actually minimal evidence-based research that even demonstrates that airborne infection is a signi�cant problem (Short & Al-Maiyah 2009). Regardless, the fear of airborne infections continues to drive a great deal of hospital design decisions.

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Existing Solutions: Case StudyThe Green Lighthouse, Denmark

• 75% of the energy reductions achieved are said to be a direct consequence of architectural design (Meinhold 2009).• Designed to use the least possible amount of energy for heating and ventilation and to produce electricity on its own for lighting. In order to reach these goals, solar cells, sun collectors, natural ventilation and shading strategies were developed to reduce the need for cooling. • Daylight and natural ventilation are provided by carefully placed skylights and windows• The building itself is oriented to maximize its solar resources, while windows and doors are recessed and covered with automatic solar shades to minimize direct solar heat gain inside the building. (Winston 2009) • Solar-thermal panels are on the slanted roof that produce surplus heat during the summer, which is stored in heat pumps in the ground for use during the winter. • Throughout the year, a computer system monitors the energy consumption and turns off rooms that are not being used. • The building is cooled through the use of the natural ventilation and concrete floors that absorb heat. Additionally, a geothermal heat pump and district heating system help heat and cool the building. • To optimally use energy, the walls have been filled with 400mm of insulation, which is double the normal size. Phase change material consisting of tiny pieces of wax fused in plaster was used to improve the structure’s ability to absorb and release energy. (Taekker & Schmeichel, 2008) The material absorbs heat when the room temperature is high and releases it again when the temperature falls. With this technology, energy consumption for heating and cooling is reduced.

The Green Lighthouse, Denmark’s �rst carbon-neutral building, is located on the North Campus of the University of Copenhagen and serves as the student services center for the campus.

Some of the important sustainable measures the Green Lighthouse uses:

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Existing Solutions: Case StudyOregon Health and Science University

• A "right-size" HVAC system. To ensure comfort, many traditional buildings contain oversize HVAC systems that are designed to handle even the hottest or coldest days. OHSU's HVAC system is much smaller, but aspects of human comfort are covered in other design aspects, such as energy-e�cient windows, extra wall insulation, ground level radiant heating and overhead radiant chilled beams to create a solid building envelope.• Variety of sensors and controls ensure that ventilation systems, lights, and fans turn o� when spaces are not being used.• Overhanging sunshades to limit building heat gain from summer sun.• Implementation of a "Thermal Flywheel" Concept: Cooling energy generated during off-peak hours when power is cheaper is stored temporarily in the building's mass and used throughout the day, especially during peak hours, in radiant cooling slabs.• Displacement ventilation in exam rooms drops cool air from above. Since cool air is denser than warm air, less air�ow into the room is needed to maintain comfort and less energy is used. Fan energy is reduced by two-thirds, and reheating of incoming air is eliminated.• An on-site bioreactor that treats 100% of sewage in the building and recycles wastewater for toilet and urinal �ushing.

The Center for Health & Healing at OHSU Teaching Hospital is a 400,000 sq. ft., 16-story mixed-use facility for medical research, clinics, and surgery and includes classrooms, o�ces, a �tness center, and ground-�oor retail. (Frichtl & Yudelson 2006)

Some of the important sustainable measures OHSU undertook included:

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Existing Solutions: Case StudyLexington Medical Center, South Carolina

Lexington Medical Center, one of the �rst hospitals to achieve LEED certi�cation, champions not only a vision of sustainability but also represents one of the hospitals at the forefront of the "healthy hospital movement." According to InsiderHealth Magazine, the healthy hospital movement is spearheaded by healthcare organizations "striving to create environments that are more conducive to healing, while also working to eliminate barriers to patient safety and environmental risks" (Dunlop 2009). As a showcase of the intersection of values between evidence-based design and sustainability, Lexington Medical Center represents an exemplary case study.

• Over 75% of the construction waste generated by the project was recycled.• Building materials with high recycled content, and provided from regional manufacturers, were used. • An existing retention pond that captures runoff from the new building reduces the impact of the building’s stormwater runo� . The retention pond allows suspended solids in the stormwater to settle in the pond, so they were not discharged to rivers or streams.• Bicycle storage racks and showers in the building were provided to encourage workers in the building to bicycle to work. A shuttle system operated by Lexington Medical Center also encourages use of public transportation.• A 30% savings in energy usage was accomplished by using energy-efficient white roo�ng to re�ect the sun, improved building insulation, and energy-e�cient windows to reduce the amount of heating and air conditioning needed.• The building’s air conditioning equipment was selected to use refrigerants that are less damaging to the earth’s ozone layer.• Paint, carpet, adhesives and sealants, and composite wood products were selected to minimize the amount of harmful chemicals these products emit into the building.

Some of the important measures Lexington Medical Center undertook in the development of its new environmentally and people-friendly medical o�ce building included:

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Existing Solutions: Case Study

Spectrum Health Hospital Recycling Program

• Administrators at Spectrum Health implemented "green teams" at all Spectrum Health hospitals to involve employees directly in the recycling initiative. The teams of 10-15 are formed from many di�erent departments in the organization, such as facility management, environmental services (cleaning and waste removal) and construction services. These small groups are encouraged to start and implement speci�c sustainable projects of their own choosing.• Spectrum Health hospitals employ the concept of "single-stream recycling," where each unit on every �oor contains designated containers for all di�erent types of recyclable materials.• Containers of recycled materials are collected every other day to take to a centralized compactor.• Previously, hazardous waste containers were used once and incinerated with their toxic contents. Spectrum changed the process so that hazardous medical waste containers were re-sterilized and reused to �ll with more hazardous waste. (No infection or contamination problems are implicated, as the containers are only used for holding waste matter). • The Recycling Program has a business partnership with Rapid Shred, who takes all of the shredded paper waste from sensitive hospital documents to develop products such as "blue wrap," a sterile fabric used for surgical situations.• A Water storage tank below the parking garage collects rainwater runoff for irrigating the grounds.

Some of the important sustainable measures Spectrum undertook included:

• Spectrum's Butterworth and Blodgett hospitals recycle about 70 tons of waste material (cardboard, paper, plastics, metal, glass) each month.• By 2009, Butterworth was recycling 19% of its total waste stream• From 2007-2009, Butterworth Hospital recycled 1,515 tons of materials, saving roughly $120,000 in incinerator/land�ll fees.

Spectrum Health hospitals boast Recycling Programs with impressive statistics:

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Innovation

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2Inspire Organizational Change

Greening the O.R.

Design Recommendations

Engage and Encourage Participation

Our proposal for innovation consists of 4 steps:

Overview

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Innovation

Before any sort of innovative sustainable hospital design initiative can even occur, it is imperative that key stakeholders value and believe in sustainability enough to motivate change. After all, it's not as if there are key stakeholders who are strongly opposed to initiatives that bene�t the earth. The main reason why top management and administrators might not incorporate a sustainable model is not because they are opposed to sustainability, but simply because it not a priority. As American Society for Healthcare Environmental Services (ASHES) director Patti Costello states, "Finding balance between cost and competing priorities is the bigger challenge" (Carpenter 2010).

Additionally, research from Bilec et. al. (2009) demonstrated that LEED-certi�ed hospital projects were more successful in implementing sustainable strategies when the hospital management and owner were "green champions" from the get-go, and had other aligned project goals, such as designing an indoor environment conducive to patient recovery, than LEED-certi�ed projects where sustainable practices were treated as an additional hospital feature and not an overall design vision.

Inspire Organizational Change1

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Innovation

Without a doubt, the �rst step to getting key stakeholders to believe in and prioritize sustainability is knowledge. Dale Woodin, the executive director of ASHE, posited that a major barrier to not only sustainable hospital initiatives but also hospital management in general was the fact that a startling percentage of hospital management was not aware of performance metrics in their hospitals to begin with (see �gure below). A waste management audit conducted by Bernstein et. al. (2009) revealed that only 15% of U.S. institutions use online tools for documenting waste tracking.

It goes without saying that energy and water use and waste generation cannot start to be conserved until a hospital is aware of how much they generate. Therefore, conducting environmental audits or implementing data visualization systems of resource consumption can be extremely helpful in increasing management awareness of the impact of their facilities.

Inspire Organizational Change1Educate/Create Awareness

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Innovation1Barriers to incorporating sustainability can come from common misconceptions, the top concern being economic viability/return on investment. According to an article in Health Facilities Management: "Cost savings was the No. 1 factor cited by the 960 American Society for Healthcare Environmental Services (ASHES) members who participated in the survey, in terms of in�uencing whether their facility opts for environmentally sustainable operations" (Carpenter 2010). The common misconception is that sustainable facilities are signi�cantly much more expensive to design and construct. In fact, 71% of contractors and 83% of care providers at the Greening Healthcare Facilities Roundtable in Pittsburgh named "higher design and construction costs" as the greatest barrier to the delivery of green healthcare facilities (Phelps et. al. 2006).

Inspire Organizational Change1Educating Common Misconceptions: Economic Viability/Return on Investment

In reality, countless examples from scienti�c research literature demonstrate that sustainable healthcare facilities can actual save money, or even pay for themselves over the long-term. "These are not do-gooder projects; each brings real savings," states Tom Thompson, the sustainability coordinator at the LEED-Certi�ed Gundersen Lutheran Health System in Wisconsin. "You can be economically viable, you can make money and save money by doing the right thing" (Carpenter 2010).

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(Phelps et. al. 2006)

Some statistics/�gures:

A "green linen" program that streamlined linen management at the Nebraska Medical Center has resulted in $600,000 a year in savings (Carpenter 2010).

Kaiser Permanente commited to using and recycling low-power computers. Between 2006-2007, the EPA calculated that their e-waste program helped achieve savings of over $4.7 million in energy savings (Johnson 2010).

Innovation

For a sustainable hospital to be successful, not only the top management needs to be on board – hospital sta� and care providers, such as doctors, nurses, and allied health professionals, need to share the same values as well. “Success or failure of the recycling/waste management process is all on the employees,” states Josh Miller, sustainability coordinator at Spectrum Health (Daly 2010).

Plus, resistance to change, which can be common in any organizational change initiative, can be overcome by involving the participation of hospital employees. "Problem identi�cation, ownership and action begin in and remain with the [hospital] community," states strategists Pascale & Sternin (2005). For example, at Spectrum Health hospitals (see CASE STUDY), small, multi-departmental teams were formed and encouraged to initiate their own environmental e�orts in projects.

When forming green teams, encouraging the involvement of positive deviants, who are stakeholders already passionate about the cause, is important (Pascale & Sternin, 2005). For example, the recycling program at William Beaumont Hospital in Royal Oak, Michigan, gained traction when administrative director of patient and support services Mark Mason formed a "Green Team" where any employee or colleague who called about recycling was invited to join the team and help plan a systemwide recycling program (DePaul 2010).

Lastly, it's a wise decision to involve key stakeholders, as sustainable hospital programs require education/training of the sta� for the program to be successful. If key stakeholders are already intrinsically motivated to value sustainability, education/training is much more likely to be successful.

Engage and Encourage Participation2

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Innovation2 Design Recommendations3• Keep track of patient supplies through the use of bar code tags, tracking the supplies used per patient. Successful implementation can be accomplished through persistent follow-up and education to reduce the amount of waste per patient.• Recycle solid waste such as paper, cardboard, plastic, glass. An extensive recycling program can go a long ways. Often materials go to waste that can otherwise be recycled. This includes everything from bulbs and furnishings, to mercury and X-ray �lm.• Require that products use less packaging, recycled content, and end-of-life recycling services. The products supply is dependent on the demands of hospitals. If hospitals require companies to pay attention to their methods of production and impact on the environment, there is potential for a domino e�ect of action/reaction

Sustainable Waste Management

• Limit the amount of linen to what is needed and avoiding excess linen washed because it is contaminated once it is taken to patient rooms. Similar to new hospitality regulations taken to help reduce the amount of wasted water to clean linens, limit the linen taken into patient rooms.• Water conservation methods for irrigation systems, such as moisture sensors, help lessen the need for watering. • Collect rainwater through the use of green roofs.• Incorporate waterless urinals and dual flush toilets.• Use microfiber mops and cleaning clothes to reduce water and chemical use.

Sustainable Water Management

• Use cleaning equipment that do not negatively impact indoor air quality.• Use the least possible amount of energy for heating and ventilation. Incorporate a natural ventilation system that works automatically, reacting to the present interior air quality, state and temperature. • Use recessed windows and doors covered with automatic solar shades to minimize direct solar heat gain inside the building.• Ensure building materials and indoor materials contain no harmful odors, particles or volatile organic compounds (VOCs).

Sustainable Air Quality Management

Health Facilities Magazine 2009

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Innovation

Greening the O.R.4The Operating Room (OR) is the epicenter of today’s hospital, generating 42% of the hospital’s revenue. A primary source of hospital admission, the OR also drives signi�cant costs related to equipment, supplies and personal. A recent study estimated supply costs at 56% of the total budget of the operating room dwarfing salary costs at 35%. The OR also generates huge volumes of waste, producing 20-30% of a hospitals total waste volume, despite its small spatial footprint. (Practice Greenhealth 2010).

Thus, it makes sense to focus on the departments encompassing the highest costs and greatest ine�ciencies and most waste, making the OR a key target for greening e�orts. Potentially, millions of dollars could be saved, once sustainable interventions are adopted. In greening the OR, sustainable interventions should focus on the reduction of environmental impact, cost, increased e�ciency, and improved worker or patient safety.

• Regulated medical waste reduction and segregation• Fluid management systems• Water-saving scrub wash - surgical tap redesign• Single-use device reprocessing• OR kit reformulation• Reusable surgical gowns and basins• LED lighting and power booms• Displacement ventilation• Waste anesthetic gas (WAG) capture and reclamation• Medical plastics recycling• Paper recycling into surgical gauze• Reusable hard cases for surgical instruments

Potential Sustainable Interventions

The following are examples of possible design innovations speci�cally relating to hospital operating rooms.:

The bolded ideas, which are innovations that could potentially yield the largest impacts, yet are the least likely be challenged by barriers or resistance, will be described in further detail on the following page.

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Innovation4

An innovative solution to dealing with surgical supply management was one inspired by Spectrum Health hospitals (see CASE STUDY), which was partnered with a company that turned recycled hospital documents into surgical "blue wrap." This innovative idea has the potential to be turned into a common closed-loop system within any hospital, detailed as such:1. Hospital recycles shredded sensitive hospital documents.2. Recycling plant turns shredded paper into surgical "blue wrap" and redistributes to hospital.3. Hospital distributes "blue wrap" to surgical units.In this way, not only do hospitals recycle a resource, they also end up reusing the resource in a completely novel way.

For this idea to work, it is recommended that hospitals partner up with nearby recycling plants or paper shredding facilities.

Recycle + Reuse of Surgical Supplies

Greening the O.R.4Much of the surgical profession spends a signi�cant proportion of their day performing the surgical scrub. Therefore, the process of scrubbing actually constitutes a signi�cant percentage of potable water usage within hospitals.

A recent study in Glasgow showed signi�cant savings in water use between di�erent types of tap ware in surgical scrub bays. (Jones 2009). The study demonstrated that changing the design of the tap type had widely varying e�ects on total volume of water used in scrubbing. As shown in the table below, taps controlled by foot pedals (which seemed to be the most controllable and precise) resulted in doctors using nearly 28% less water than an elbow lever control (Jones 2009).

This research demonstrates that, just by redesigning the tap type in the OR to be operable by footpedels, a hospital can gain signi�cant water savings with very little e�ort.

Redesigning the Tap for Surgical Scrub Procedures

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(Jones 2009

Innovation

The OR generates a great deal of waste, yet many are hesitant to implement a waste-sorting recycling program. The reasoning for this, states RN Geraldine Falacy, is: “The OR is very time sensitive, and anything that can potentially negatively a�ect turnover time is a problem.” However, after conducting research, Falacy found that recycling did not a�ect OR turnover times in any way (DeJohn 2010). Therefore, many ORs would bene�t from a waste-sorting recycling program.

Additionally, in a study conducted at a Melbourne hospital, it was found that anesthesia waste was about one quarter of the total operating room waste (McGain 2009). 40% of total anesthesia waste and 60% of general anesthesia waste was potentially recyclable. (This excludes infectious waste, which is not acceptable for recycling.) Of this 7% of general waste was infectious while 16% of the waste in the infectious bags did not fulfill the infectious criteria. 30% of operating room wastes are plastics and 30% are cardboard/paper.

With the implementation of education programs for sta� to properly learn how to sort infectious waste versus recyclable material, this sort of recycling program can have a major impact due to the high proportion of waste produced in operating rooms. The manufacturing process of recycled plastics uses 25% of the energy compared to a primary plastic production process.

To foster this recycling education program, types of waste and recycling can be clearly identi�ed in the rooms to remind sta� of correct procedures. In addition, the items themselves, such as di�erent pieces of equipment, can be color coded to correctly dispose of the items in coordination with the bins or bags.

Innovative Procedures for Reduction and Segregation of Regulated Medical Waste

Greening the O.R.4

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Green Resources

For those interested in learning more about sustainable healthcare design, below are some valuable and reputable guides and organizations that serve as great resources.

Healthcare Without Harm. “Together with our partners around the world, Health Care Without Harm shares a vision of a health care sector that does no harm, and instead promotes the health of people and the environment.” http://www.noharm.org/

Practice Greenhealth. “Practice Greenhealth is the nation’s leading membership and networking organization for institutions in the healthcare community that have made a commitment to sustainable, eco-friendly practices. Members include hospitals, healthcare systems, businesses and other stakeholders engaged in the greening of healthcare to improve the health of patients, sta� and the environment.” http://www.practicegreenhealth.org/

Green Guide for Healthcare. “Through our volunteer committees, we develop and distribute healthcare speci�c and health focused tools, technical guidance and educational resources to support, reinforce and accelerate the creation, operation and maintenance of high performance healing environments.” http://gghc.org/

Environmental Protection Agency. Hospital Pollution Prevention Guide. http://www.epa.gov/region9/waste/p2/hospart.html

U.S. Green Building Council: LEED for Healthcare. “The LEED for Healthcare Green Building Rating System was developed to meet the unique needs of the healthcare market, including inpatient and outpatient care facilities and licensed long term care facilities. LEED for Healthcare may also be used for medical o�ces, assisted living facilities and medical education & research centers. ” http://www.usgbc.org/DisplayPage.aspx?CMSPageID=1765

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Bibliography

Ananth, Sita. (March 25, 2008). “Healthy Environment, Healthy Patient.” Hospitals & Health Networks Magazine. Accessed 10/31/2010.<http://www.hhnmag.com>

Arie�, Allison. (December 13, 2009)“A Breath of Fresh Air for Health Care.” The New York Times. Accessed 11/1/2010.<http://opinionator.blogs.nytimes.com>

Bernstein, D.; Haug, R.; Ottenfeld, M.; Witte, C. (2009). Hospital Waste Management: An Informational Assessment. AHCMJ, 5(2), 97-112.

Bilec, M.; Ries, R.; Needy, K.; Gokhan, M.; Phelps, A.; Enache-Pommer, E.; Horman, M; Little, S.; Powes, T.; McGregor, E.; Sheane, C. (2009). Analysis of the design process of green children's hospitals: focus on process modeling and lessons learned. Journal of Green Building, 4(1), 121-134.

Carpenter, D. (2010). Green + Greener: Hospitals embrace environmentally sustainable practices, though laggards remain. Health Facilities Management Magazine, July, 15-21.

Chen, I. (2010, July 5). In a World of Throwaways, Making a Dent in Medical Waste. The New York Times, pp D1.

Daly, P. (2010). Green teams form at Spectrum Health. Grand Rapids Business Journal, 8-11.

DeJohn, P. (2010) Reducing OR Refuse. Materials Management in Health Care, March.

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Johnson, S. (2010). Summarizing Green Practices in U.S. Hospitals. Hospital Topics, 88(3), 75-81.

Jones, E. (2009). Water use in the surgical scrub: surgeons can reduce their environmental footprint. ANZ Journal of Surgery.

Landro, Laura. (Octover 4, 2006).“The Informed Patient: Hospitals Go 'Green' To Cut Toxins, Improve Patient Environment.” The Wall Street Journal. Accessed 10/30/2010. <http://online.wsj.com/article/SB115991894763881827.html>

McGain, F.; Hendel, S.; Story, D. (2009). An audit of potentially recyclable waste from anaesthetic practice. Anaesthetic Intensive Care, 37, 820-823.

Meinhold, Bridgette. “Green Lighthouse: Denmark’s First Public Carbon Neutral Building Completed.” Inhabitat. (Oct. 27, 2009) <http://www.inhabitat.com>

Pascale, R., and Sternin, J. (2005). Your company's secret change agents. Harvard Business Review, 5, 72-85.

Phelps, H. (2006). Greening Healthcare Facilities Roundtable: Bridging the Physics of Building with the Physiology of Healthcare.

Practice Greenhealth. "Greening the Operating Room." http://www.practicegreenhealth.org/educate/greening/greening-the-or/ Accessed 11/6/10.

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Bibliography

Roberts, G., and Guenther, R. (2006). Chapter 5: Environmentally Responsible Hospitals. Improving Healthcare with Better Building Design. ACHE Management Series, Health Administration Press.

Short, C., and Al-Maiyah, S. (2009). Design strategy for low-energy ventilation and cooling of hospitals. Building Research & Information, 37(3), 264-292.

Sustainable Health Care, Sustainable Hospitals. Accessed 10/20/2010.<http://www.sustainablehospitals.se/companies.php>

Taekker, C, and Schmeichel. “Green Lighthouse: a beacon for low-energy buildings.” Consultancy within Engineering, Environmental Science and Economics. (Aug. 29, 2008) <http://www.cowi.com>

Ulrich, R.; Zimring, C.; Zhu, X.; DuBose, J.; Seo, H.; Choit, Y.; Quan, Z. (2008). A review of the research literature on evidence-based healthcare design. Health Environments Research & Design Journal, 1(3), 61-121.

Vittori, G. (2008). Research agenda for sustainable healthcare: A work in progress. Health Environments Research and Design Journal, 1(2), 49-53.

Winston, Anna. “Carbon Neutral Building Ready for Copenhagen Summit.” The Architects’ Website. (Nov. 18, 2009) http://www.bdonline.co.uk>

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