AAMC Reporter: October 2007

Going Green

Health care institutions help the planet, their patients, and the bottom line

A worker stocks the stands at Greenmarket, which Mount Sinai School of Medicine helped establish in New York City's Harlem neighborhood.

A plate and frame heat exchanger is a pretty complex piece of machinery. A maze of metal pipes and plates weighing in at several tons, the exchanger acts as an adjunct to the cooling component of a building's ventilation system by using chilled water to siphon heat out of a facility.

And then, on the other hand, there is the earthworm. It does not get much simpler than what essentially amounts to a few modest inches of dirt-eating tube.

What is the connection between the two, or for that matter, to a medical school or a teaching hospital? It lies in a trend unfolding across the country: companies, organizations, and institutions of all stripes that are "going green" by factoring the environment more heavily into their decision making. And the health care industry, including academic medicine, is beginning to enter the green fold, by taking actions large and small, simple and complex, obvious and not so obvious.

By now, it is widely known that most scientists view climate change and other environmental matters as real threats. As public opinion snowballs on the issue, many sectors of society are trying to alter their impact on the environment by reducing waste and resource consumption. An increasing number of proponents claim that greener thinking in health care means happier patients and workers, and helps institutions save dollars—that other kind of green—as well.

"This is a moment in history where we as a nation and a society are talking about this, and health care is not exempt from that," said Howard Frumkin, M.D., Dr.P.H., director of the National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry at the Centers for Disease Control and Prevention (CDC) and a member of the Institute of Medicine's (IOM) Roundtable on Environmental Health Sciences, Research, and Medicine. "We have evidence that environmentally friendly buildings lead to healthier patients and are more pleasant to work in. And green medical centers can save money."

Some might claim that getting an institution as large and intricate as a medical school or teaching hospital to change its environmental practices is something akin to turning around an aircraft carrier. But according to members of the IOM's environmental roundtable, now may be the time to literally build new environmental policies into health care institutions. Health-care-related construction in the United States is booming at an estimated 100 million square feet per year, partly because facilities built in the last boom—which took place in the 1940s following the Hospital Survey and Construction Act, commonly known as the Hill-Burton Act—are beginning to show their age.

"The health care industry is expected to continue to grow, and there is a bit of a movement out there in terms of building green," said the IOM's Christine M. Coussens, Ph.D., who co-directed the workshop. "There's a lot of talk about replacing the Hill-Burton hospitals, so the timing is right as people look to rebuild."

Several academic medical centers are part of this movement. The Cleveland Clinic, Emory School of Medicine, Rush University Medical Center,Vanderbilt University Medical Center, and Yale-New Haven Hospital are among those creating new and greener facilities. There are many means of becoming more environmentally sound: adding windows to increase natural light and reduce electricity use, improving efficiency with new practices or equipment such as plate and frame heat exchangers, or simply buying more environmentally friendly versions of everyday products.

"If all other things are equal, and we can buy something that is more friendly to the environment, we do it," said Barry Hilts, vice president of support services for Cambridge Health Alliance (CHA), a Massachusetts health system that has received several environmental awards from Hospitals for a Healthy Environment, a group co-founded by the American Hospital Association and the Environmental Protection Agency. "Sometimes, people end up doing what they have always done, and it's just a matter of taking a step back and looking at that."

A first stop for any environmentally minded construction project is the U.S. Green Building Council, whose Leadership in Energy and Environmental Design (LEED) program provides best practice standards for everything from site selection to building materials, and offers four levels of certification—Certified, Silver, Gold, and Platinum. (Currently, only about 2 percent of 1,800 LEED-registered projects are health care institutions.)

For hospitals, greener buildings can mean happier employees—and clients. In 2004, a comprehensive green health care facility analysis led by Roger S. Ulrich, Ph.D., director of Texas A&M University's center for health systems and design, found evidence of reduced staff stress and improved patient safety and health outcomes. A 2005 study sponsored by the University of Pittsburgh Medical Center revealed that patients exposed to more sunlight required 22 percent less pain medication.

Even with purported benefits to people and planet, for many the bottom line is still the bottom line. And green policies can exert positive influence on that all-important place on the institutional balance sheet. A 2003 study from clean energy consulting firm Capital E reported that while construction costs were $3 to $5 per foot higher for green buildings, there was an average net return of $50 to $65 per square foot over a 20-year period. Hilts said CHA's energy-efficiency investments have paid off to the tune of $1 million in savings.

"We're focused on how we can reduce our consumption on the demand side, and mitigate the effects of energy market fluctuations on our costs," he said. "We have made a large investment in energy efficiency, and we closely monitor that investment. You always have to be upgrading your mechanical infrastructure, so as you do so, why not build in more efficiency?"

Green buildings are on the rise nationwide, but some measures are exclusive to the health care sector. Mercury reduction or elimination programs are key components of many institutions' environmental and public health plans. And with hospitals tossing out approximately 6,500 tons of waste each day, recycling programs have emerged as a cornerstone of many environmental campaigns.

Some medical centers recycle more than just paper, plastic, and glass, however. Histopathology labs at the University of Texas Medical Branch at Galveston are able to reuse certain solvents, thanks to state-of-the-art distillation units that annually conserve five to seven tons of chemicals and save up to $19,000. The center also runs an internal Web site where employees of more than 900 laboratories can exchange chemicals and other materials. Call it a chemical Craigslist.

"A lot of times, research will change and there will be unused chemicals as a result," said Jack Tarpley, the branch's institutional safety officer. "If something is still usable, we take it back."

According to Frumkin, academic medical research centers could be a key factor in the greening of America. "We need to collect data to see how much various environmental initiatives affect health," he said, citing as an example the need to study whether greener cleaning products are less toxic to humans. "Creating and acting on this kind of data will be a crucial role for health care institutions to play."

Some academic medical centers are already at the forefront of green technology. At University of Washington Medical Center (UWMC), some surgical instruments are sterilized with a special machine that employs hydrogen peroxide gas plasma, rather than more common and hazardous options like ethylene oxide. UWMC also uses an innovative recycled water system in its laundry service.

"We feel like we should be a leader, and not only in gall bladder surgery or cancer," said Gary Butrymowicz, UWMC's director of environmental services and waste management. "We want to go out and take risks." Elsewhere, schools are taking more low-tech, but perhaps no less effective steps to spread environmental awareness. Mount Sinai School of Medicine co-developed Greenmarket, which sells organic produce in New York's Harlem neighborhood.

"The food is all locally grown, so there is less energy involved in transporting it," said David Thomas, M.D., a Mount Sinai physician involved with Greenmarket. "And we're educating people in a community where there isn't a lot of this kind of thing. We're teaching them what it means to go green."

Hundreds of pounds of earthworms help break down waste at the Medical University of South Carolina.

On the other end of the food chain, so to speak, there are earthworms. At the Medical University of South Carolina, food waste and other flotsam means dinner for more than 200 pounds of hungry worms as part of the university's "vermicomposting" program.

"You have to have a sense of humor about it," conceded Christine Von Kolnitz, the university's recycling coordinator. "But you try to educate people, too. You tell them that in the long run, it's saving money for the university, and it's serving a purpose."

Von Kolnitz, who noted that if done correctly the system pays for itself by around the seventh year, said the nutrient-dense digested waste is harvested and used as fertilizer.

"Our groundskeepers thought the plants looked better than ever."

The complexity of academic medical centers can present challenges to going green, but with so many areas to consider come many opportunities for exploration, and improvement.

"There are times when commendable goals collide with each other," Frumkin said. "A good health care facility wants to reduce medical errors, cut costs, retain staff, and be more environmentally conscious."

—By Scott Harris

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