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Green healthcare, an environmentally sustainable methodology: an investigation of the ecological impacts of the healthcare industry and the role of green initiatives in sustainable medical services

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Green healthcare, an environmentally sustainable methodology: an investigation of the ecological impacts of the healthcare industry and the role of green initiatives in sustainable medical services

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Content Green Healthcare, an Environmentally Sustainable Methodology

GREEN HEALTHCARE

AN ENVIRONMENTALLY SUSTAINABLE METHODOLOGY

AN INVESTIGATION OF THE ECOLOGICAL IMPACTS OF THE HEALTHCARE

INDUSTRY AND THE ROLE OF GREEN INITIATIVES IN SUSTAINABLE

MEDICAL SERVICES

Roya Azizi

A Dissertation Presented to the

FACULTY OF THE USC SOL PRICE SCHOOL OF PUBLIC POLICY
UNIVERSITY OF SOUTHERN CALIFORNIA

In Partial Fulfillment of the
Requirements for the Degree

DOCTOR OF POLICY, PLANNING, AND DEVELOPMENT

Los Angeles, California
December 2016

Roya Azizi 2016
All rights reserved
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EPIGRAPH

“A new type of thinking is essential if mankind is to survive and move toward higher
levels. ”

Albert Einstein

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DEDICATION

To the loving memory of my mom and dad.
The memory of your wisdom, knowledge, and affection always gives me strength.

and,

To my dear husband, Babak, for his love, patience, and kindness.
Thank you for being in my life and inspiring me to be a better person with your love
and care.

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ACKNOWLEDGEMENTS

I would like to express my heartfelt gratitude and appreciation to my committee chair Dr.
Peter Robertson for his valuable guidance throughout the process of conducting this
research. I also want to extend my sincere appreciation to Dr. Robert C. Myrtle and Dr.
Donald Hufford who devoted their ideas and provided constructive feedback to improve
the quality of this study. Many thanks to Sister Suzanne Soppe the lead educator of St.
John’s Hospital. In the most difficult stage of this research (empirical data gathering that
changed my dissertation process), she was one of the few people who agreed to
disclose data about their Green initiatives.
I would like also thank Dr. Frank L. Schwartz in Camden Clark Hospital in West Virginia,
and Dr. Jay Shubrook in Ohio University Hospital for information about the relationship
between environmental toxins and insulin resistance, obesity, and other diseases. I
extend my appreciation to Davide Nardi Cesarini, Christopher M. Gray, Ruben Cosio,
Kris Warner, Steve Michel, Will Crew, Melony Hatchel, Susan Saito, and Roberto Pena
for providing valuable information for this study. Lastly, I thank my husband, Babak, for
his care, compassion, and love. This journey would not be possible without his support.

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Abstract
This study has been conducted to develop theoretically informed practical knowledge
about Green healthcare and to identify how the majority of medical facilities can reduce
their carbon footprint effectively. The healthcare industry, with a very high level of
energy consumption, produces more than 8% of the harmful GHG emissions (Chung &
Meltzer, 2009), disposes 4 billion pounds of waste into landfills (each year), and
purchases more than $106 billion worth of toxic chemicals, annually, with immense
health effects on the public (Roberts, 2002). This is in the situation that the majority of
medical professionals are not aware of the negative impacts of their activities on the
environment, patients, and themselves.
Healthcare organizations lag behind other industries in sustainable operations, and less
than one-fourth of the healthcare facilities are involved in Green activities in different
parts of their services. Also, various studies show that medical staff and healthcare
leadership have a lower level of awareness and concern about Green practices than
individuals in non-healthcare organizations. Therefore, there is an urgent need for more
studies to raise awareness about this dire issue among healthcare professionals. In
addition, there is a need for comprehensive and holistic nationwide guidelines and
requirements for environmentally-friendly operations in the healthcare services
(Hartman, Fok, & Zee, 2009; 2010; 2011).
Although the lack of awareness is not the only reason for the status quo, it plays a
significant role in the situation. One of the main focuses of this research project is to
shed light on existing environmental impacts of medical facilities on public health and
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the need for sustainable healthcare operation in the U.S. It investigates information and
communication technology (ICT), Energy Management and Control System (EMCS),
and Lean and Six Sigma quality improvement methodologies. The aim is to introduce
efficient management, significant energy saving solutions, and explore the results of
integration of these innovative technical and managerial methods. Also, this research,
through a series of interviews with hospitals’ representatives, staff, and physicians,
reviews the best practices and explores the applicable Green initiatives and approach of
different hospitals toward environmentally sustainable operations in Europe and the
U.S. The findings have implications for public policy, local governments, and healthcare
professionals.
For the purposes of this research project, the terms “healthcare organizations” and
“medical facilities”, which include hospitals, are used interchangeably because they
have the same difficulties regarding sustainable operations. However, when it comes to
statistics, the records of medical facilities other than hospitals are unknown. Inevitably,
the vast majority of statistics in this study belong to hospitals.

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TABLE OF CONTENTS

Dedication ii
Acknowledgements iii
Abstract iv
List of Tables xii
List of Figures xiv
Chapter One: Introduction 1
1.1. Background 2
What is Green Healthcare? 4
A Brief History 5
1.2. Problem Statement: Negative Impacts of Healthcare Operations 8
on the Environment, Public Health, and the U.S. Economy

Medical Waste 8
Health Impacts and Social Cost of Greenhouse Gas Emission 11
Harmful Chemicals 13
1.3. Purpose Statement 16
Research Questions 18
1.4. Organization of the Chapters 19
Chapter Two: Literature Review 21
2.1. Introduction 22
2.2. Four Broad Categories of Analysis in the Existing Green Healthcare 27
Literature

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The Role of the Healthcare Industry in Society 27
Cultural Aspects of Sustainable Healthcare Practices 32
Specific Aspects of Sustainable Healthcare Practices 37
Sustainable Initiatives in Existing Green Healthcare Practices 40
2.3. Lean and Six Sigma Efficiency Methodologies 49
Lean Methodology 49
Six Sigma 51
Lean Sigma or Lean Six Sigma 53
Lean and Six Sigma in Healthcare 53
2.4. Summary and Discussion 56
Chapter Three: Methodology 60
3.1. Philosophical Worldview 61
3.2. Strategy of Inquiry 61
3.3. Research Method 62
3.4. Limitations and Delimitations 70
Chapter Four: Different Green Initiatives in Healthcare Settings 73
4.1. Preface 74
4.2. Waste Management 74
Waste Minimization 76
Overstocking Elimination 77
Waste Segregation 78
Medical Waste Incineration 79
Some negative effects of mercury and dioxin on human health 79
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Safe alternatives to medical waste incineration 82
Recycling 82
Paper 83
Plastic 84
Reusable medical supplies 88
Reprocessing 90
Composting to Reduce Food and Landscape Waste 92
4.3. Water Conservation in The Healthcare Industry 97
Indoor Water Use Reduction 101
Outdoor Water Use Reduction 104
Water efficient landscaping 105
Xeriscape 105
Drip irrigation 106
Urban Runoff Prevention and Rainwater Collection 109
4.4. Efficient Lighting 110
The Impact of Natural Light on Patients’ Wellbeing 111
Energy Efficient Light Bulbs 113
LED 113
CFL 114
4.5. Sustainable Food Services in the Healthcare Industry 115
Balanced Menus–Less Meat 117
Better Meat 118
Local Food 118
4.6. Green Buildings 121
LEED 121
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LEED certification 121
LEED critiques 124
LEED and Green healthcare 126
Chapter Five: Experiences of Different Hospitals 131
5.1. St. John’s Regional Medical Center 132
Green Initiatives in St. John’s Hospital 135
Improvement in Sustainable Approaches in St. John's Hospital 137
Sustainability awareness 137
Water conservation 139
Cost-benefit analysis 140
5.2. Kaiser Permanente-Modesto Medical Center in Modesto, California 141
Sustainability Initiatives in Kaiser Permanente-Modesto Medical Center 143
LEED certified building 143
Water Management 144
Ventilation 146
Lighting 146
Flooring 146
Improvement in Environmentally Sustainable Approaches in Kaiser 147
Permanente Healthcare Company

5.3. Santa Barbara Cottage Hospital 148
Highlights Regarding Green Initiatives in Santa Barbara Cottage Hospital 150
Improvement in Environmentally Sustainable Approaches 151
in the Santa Barbara Cottage Hospital

5.4. An Innovative Energy Saving Program in European Hospitals 152
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(Green@Hospital Project)

Project objectives 153
Procedure 155
Four Pilot Hospitals in the Context of Green@Hospital 158
University Hospital-United Hospitals of Ancona, Italy 159
[The Azienda Ospedaliero Univerisitaria Ospedali Riuniti Ancona (AOR)]

Intelligent lighting system 161
Economic Impact of Intelligent Lighting System 165
in the United Hospitals of Ancona

Data center cooling optimization 166
The General Hospital “St. George de Chania” of Chania, Greece 166
Pediatric area fan coil 168
The University Hospital “Virgen de las Nieves” of Granada, Spain 169
Air handling unit (AHU) in surgery theaters and the emergency zone 171
Data Center 172
The Hospital “Fundacio Sanitaria de Mollet” in Mollet, Spain 172
Energy Saving in the Hospital “Fundacio Sanitaria de Mollet” 174
Chapter Six: Discussions, Recommendations, and Conclusions 177
6.1. Preface 178
6.2. Create a Culture of Sustainability in the Medical Organizations 181
6.3. Integration of Green Healthcare Methodology 183
with Other Quality Improvement Strategies

6.4. Customized Approach in Green Healthcare 185
6.5. Focus on Small and Incremental Changes 186
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A List of Practical Green Initiatives that Either Require Low Investments 188
or Have a High ROI

Toxic materials 188
Energy efficiency 189
Water efficiency 190
Waste management 191
Green transportation measures 192
Healthy food 193
6.6. Strengths and Limitations 193
6.7. Concluding Remarks 195
References 197
Appendices 221
Appendix A: Climate Impact on Human Health & GHG Overview 222
Appendix B: Medical Waste 227
Appendix C: Green Initiatives in Different Hospitals 231
Appendix D: Kaiser Modesto Medical Center 234
Appendix E: Four Pilot Hospitals in the context of Green @Hospital 243
Appendix F: Function of Dry Coolers 245

Curriculum Vitae

249

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LIST OF TABLES

Chapter 1

Table 1.1 Electricity Usage of Large Hospitals in 2007 (USA) 4
Table 1.2 Some Notorious Materials that Medical Incinerators Produce 11
Table 1.3 Negative Impacts of Some Widely Used Chemicals in 15

Healthcare Facilities

Chapter 2

Table 2.1 GHG Emissions of the U.S. Healthcare Industry in 2007 29

Chapter 4

Table 4.1 Adverse Health Effects of Mercury Exposure 80
Table 4.2 Different Types of Plastics and Their Usage 87
Table 4.3 Disposable Medical Supplies Demand in the U.S. 89
Table 4.4 Reprocessing of Medical Devises 91
Table 4.5 Potential Losses from Water Leaks 100
Table 4.6 A Practical Experience of Retrofit and Replacement of 103

Medical and Sanitary Equipment in a Hospital
Table 4.7 Typical Efficiencies of Different Irrigation Systems 107
Table 4.8 Light Bulbs Comparison 114
Table 4.9 GHG Emissions Produced by One Kilo of Each Food 120
Table 4.10 Different Levels of LEED Certification for Healthcare 123
Table 4.11 Healthcare LEED Certification Timeline Summary 125
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Table 4.12 Healthcare LEED Certified Buildings vs the Total of LEED 128

Certified Buildings

Chapter 5

Table 5.1 St. John’s Regional Medical Center 134
Table 5.2 Green Initiatives in St. John’s Hospital 136
Table 5.3 Kaiser Permanente-Modesto Medical Center in Modesto 142

Table 5.4 Domestic Average Annual Water Demands for 145

the Kaiser Medical Campus

Table 5.5 Santa Barbara Cottage Hospital 149
Table 5.6 Participating Partners in Green@Hospital Project 154
Table 5.7 University Hospital-United Hospitals of Ancona, Italy 160
Table 5.8 Energy Saving Through Smart Lighting System in the 163

United Hospitals of Ancona, Italy

Table 5.9 The Amount of Saving Through Intelligent Lighting 165

System in the United Hospitals of Ancona

Table 5.10 The General Hospital “St. George de Chania” of Chania 167
Table 5.11 Energy Saving Through Lighting Management in 168

St. George General Hospital of Chania, Greece

Table 5.12 Energy Saving Through Fan Coil Management in 169

St. George General Hospital of Chania, Greece

Table 5.13 The University Hospital “Virgen de las Nieves” of Granada 170
Table 5.14 Energy Savings in the University Hospital 172

“Virgen de las Nieves” of Granada, Spain

Table 5.15 The Hospital “Fundacio Sanitaria de Mollet” of Mollet, Spain 173
Table 5.16 Energy Savings in the Hospital Fundacio Sanitaria de Mollet

175

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Lighting System in the United Hospitals of Ancona, Italy

LIST OF FIGURES

Chapter 1

Figure 1.1

From NEPA to Green Healthcare Movement 7
Figure 1.2

Medical Waste Management and Disposal Costs in the 9

United States

Chapter 2

Figure 2.1

Green Healthcare Literature 26
Figure 2.2

The United States Healthcare Expenditure in Comparison 30

with Other Developed Countries

Chapter 4

Figure 4.1

Hospitals’ Waste 75
Figure 4.2

Nonhazardous Solid Waste in Hospitals (U.S.A.) 83
Figure 4.3

Plastic Waste Disposal in the United States (2008) 84
Figure 4.4

Food Recovery Hierarchy 94
Figure 4.5

Water Consumption in Hospitals 99
Figure 4.6

The Best Eating Choices 117
Figure 4.7

Healthcare Green Buildings vs. Total Green Buildings 127

Chapter 5

Figure 5.1

Standard Energy Audit Procedure 155
Figure 5.2

Energy Consumptions in European Hospitals 158
Figure 5.3

Energy Saving in Different Months of the Year through Smart 164
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CHAPTER ONE: INTRODUCTION

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1.1. Background
The history of healthcare facilities development shows the evolution of hospitals
from simple shelters to super-modern institutions of 21
st
century with highly technical
equipment and comprehensive and complex services. Before the early 20
th
century,
infection in the hospitals was the leading cause of death, and their mortality rate was as
high as 25 percent (Sternberg, 2009). Therefore, patients preferred to avoid hospitals as
much as possible.
However, after the knowledge of germ theory and antiseptic techniques,
minimizing the risk of infection was the major goal of healthcare professionals with a
significant improvement in contagion control. Consequently, healthcare designers tried
to facilitate cleaning and disinfection through selecting the sleek materials and smooth
surfaces. These shiny surfaces reflect and amplify sound and the constant noise of
medical equipment to the point that “hospital noise generally exceeds the recommended
level.” A study of Mayo Clinic in 2004 showed that the noise level in hospitals
sometimes reaches 98 decibels (as loud as a motorcycle) while the recommended level
is 35 decibels (Sternberg, 2009).
On the other hand, the rapid growth of technology enabled hospitals to be
equipped with various high-tech medical equipment with complex specificity and a high
level of energy consumption (Table 1.1). This state of the art equipment dictates the
architecture of the buildings, spatial relationships, and everyday operations and
services. Little by little, the technical complexity and regulatory requirements became
the main determinant of space design in the hospitals. Although these advances
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improved the patients’ condition, the main focus of healthcare facilities’ designers
changed from patient comfort to technical accommodations.
As a result, physical surroundings have changed dramatically, and a hospital
became a stressful place for patients with a large ecological footprint. A cold
environment with noisy equipment, lack of natural light, lack of bright colors, long and
boring corridors, and disconnection with nature became the main characteristics of
medical buildings (Sternberg, 2009). Hospitals became larger, more sophisticated, and
cleaner, but with the price of excessive usage of harmful chemicals, over-consumption
of natural resources (Table 1.1), and enormous waste production (WHO & HCWH,
2009). Instead of being places of hospitality, they became noisy and stressful places,
which release pathogenic toxins into the water, soil, and air.
This trend continued to the point that hospitals became harmful places for the
population again; this time not through the infection of individuals, but through releasing
toxic gasses and hazardous materials by incinerators, soil contamination (landfills), and
surface water pollution, with the result that even avoiding hospitals cannot keep the
population safe anymore. In recent decades, environmental pollution has become a
serious public health problem, and all healthcare facilities, specifically hospitals, play an
important role in this problem.

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Table 1.1: Electricity Usage of Large Hospitals in 2007 (USA)
Number of
Hospitals
Total
Consumption
(billion kWh)
Consumption
Per Building
(kWh)
Expenditures
per 100 kWh
(dollars)
Average
Expenditure of
Each Building

3,040

57

18,727,000

7.76

$1,453,215

Note: “Figures in this table only include hospital buildings with over 200,000 square feet
of floorspace.” Data adapted from Energy Information Administration, Office of Energy
Consumption and Efficiency Statistics, Form EIA-871A and E of the 2007 Commercial
Buildings Energy. Retrieved from
http://www.eia.gov/consumption/commercial/reports/2007/large-hospital.cfm
What is Green Healthcare?
Green healthcare is about the interrelationship between personal health and
environmental sustainability. As knowledge of germ theory revolutionized the healthcare
system of the nineteenth century, awareness of ecological deterioration and the role of
the environment in patient recovery should be the foundation for a twenty-first-century
revolution of healthcare operations. The Green movement is a response to this
necessity. It aims to bring back the main attention of the healthcare industry to patients’
wellbeing (and public health, in general) instead of technical accommodations. This
movement started in the late twentieth century, but the healthcare industry has been
very slow in adapting the Green initiatives (Roberts, 2002).

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A Brief History
In January 1969, one of the largest oil spills in history occurred in Santa Barbara,
California, which spilled about 100,000 barrels of crude oil, polluted the coastline, and
killed 3500 marine animals and sea birds. As a result, it became clear that there was an
urgent need for environmental legislations and standards. On January 1, 1970, the
National Environmental Policy Act (NEPA) was enacted “to assure that all branches of
government give proper consideration to the environment prior to undertaking any major
federal action that significantly affects the environment” (EPA, 2015). Shortly after the
federal government passed NEPA, the California government passed California
Environmental Quality Act (CEQA) with more specific requirements. Nevertheless,
these requirements are not responsive enough to the speed of environmental
degradation caused by human activities.
In March 2000, the United States Green Building Council approved the LEED
(Leadership in Energy and Environmental Design) Green building rating system.
However, LEED is a voluntary program and according to Cassidy (2006), from “2,758
projects registered with the U.S. Green Building Council's Leadership in Energy and
Environmental Design new construction program (LEED-NC), only 73 [projects] - a
measly 2.6% - are in healthcare” (p.26).
In 2010, the state of California adopted a mandatory building regulation
(CALGreen) to improve sustainability. Although CALGreen is the state’s mandatory
regulatory code for sustainable buildings, it has adopted many of the existing state
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requirements for energy efficiency, and its impact is less than the LEED program. Many
public and private buildings are already LEED certified.
In 2010, LEED standards for healthcare were also approved. The LEED for
healthcare rating system is customized for the certain situations of the medical facilities
with a careful focus on all requirements and regulations (USGBC, 2014). Yet, less than
a quarter of the hospitals in the nation voluntarily agreed to follow LEED requirements.
Even organizations such as Kaiser Permanente that have a large amount of research
about Green initiatives, as well as many Green facilities, are not consistent in their
policy (recently Kaiser Permanente has built several medical centers which are not
Green).
The Green movement in the healthcare industry, however, is not all about Green
structures of facilities. It has a broader perspective toward the possibilities for
sustainable activities. A Green building is neither a prerequisite nor the only requirement
for sustainable operations. Green Healthcare has an ultimate goal to bring sustainability
in daily operations of the healthcare industry and the life of employees and patients.
There is not a model for Green healthcare facilities yet, but experiences of different
organizations in various aspects of sustainable operations can be very helpful for
newcomers.
In recent years, rapid advances in technology made this adaptation much easier
and more cost-effective. However, the lack of pervasive awareness of the hidden costs
of environmental degradation (among healthcare employees and top managements),
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upfront costs of changes, and the lack of a nationwide standard can be among the main
obstacles to implementation of Green initiatives in healthcare settings.
Figure: 1.1: From NEPA to Green Healthcare Movement

Source: Data adapted from Aiton (2012), CALGreen. American Institute of Architects,
California Council (AIACC), and EPA (2015). Retrieved from
http://www.aiacc.org/2012/05/30/calcalgreen-a-commentary
https://www.epa.gov/laws-regulations/summary-national-environmental-policy-act

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1.2. Problem Statement: Negative Impacts of Healthcare Operations on the
Environment, Public Health, and the U.S. Economy
This study reviews the lack of efficiency in healthcare facilities and their negative
operational impacts on the environment, patients’ wellbeing (and public health in
general), and the U.S. economy. The main focus is on the urgency of pollution
reduction, waste management, and environmentally friendly medical practices (Green
Healthcare) with particular attention on hospitals’ inefficiency as the largest consumers
of natural resources in this field.
The healthcare industry including hospitals, with 24/7/365 operating schedules
and complex requirements for lighting, air quality, and medical equipment, is a
significant consumer of natural resources and a high volume waste provider (Cassidy,
2010). At the same time, this industry plays a seminal economic role in society. In 2002,
six percent of the total commercial workforce (4.5 million workers) belonged to the
healthcare sector (Roberts, 2002), and the national health expenditure was 13.4% of
the U.S. gross domestic product (GDP). This number with a significant increase
reached 16% of the national GDP in 2009 (Bellestri, 2011). This situation shows the
importance of environmental impacts of the healthcare industry in society.
Medical Waste
The healthcare industry is one of the major contributors to waste production in
the United States. According to the American Hospital Association (AHA), medical
facilities produce about 25 pounds of waste per day per patient with special regulations
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for their disposal and containment. Consequently, waste management expenses of the
U.S. healthcare organizations are very high (Figure 1.2). According to the ‘bcc research’
(a market research company based in the U.S., Europe, China, India, and Brazil), in
2003, the medical waste management expenditure in the U.S. was $1.8 billion and this
number in 2007 reached $2 billion. With expected “compound annual growth rate
(CAGR) of 4.8%”, this number is anticipated to reach $3.2 billion in 2017, which will be a
high burden on the healthcare system and society (bccResearch, 2013).

Figure: 1.2: Medical Waste Management and Disposal Costs in the United States

Resource: Reprinted from bccResearch, 2013, Retrieved from
http://www.bccresearch.com/market-research/environment/ENV005A.html
According to this study, disposal market makes higher revenue than waste containment
and treatment. Therefore, the market leans toward disposing, and containment and
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treatment providers must try very hard to be able to compete with the disposal
companies (bccResearch, 2013).
On the other hand, burning medical waste, through hospitals’ incinerators, leads
to the release of dangerous pollutants, heavy metals, and toxic chemicals such as
dioxin into the environment. Dioxin [C12H4O2Cl4] is a hazardous compound that is
environmentally persistent and can cause cancer, diabetes, learning disabilities, and
liver disease (Table 1.2). In 1997, the U.S. Environmental Protection Agency (EPA)
classified dioxin released from incinerated medical waste as the second largest source
of carcinogens in the United States.
Several studies such as Sukandar, Yasuda, Tanaka, and Aoyama (2006),
Anastasiadou, Christopoulos, Mousios, and Gidarakos (2012) and Harris (2005), show
that incineration cannot eliminate hazardous medical wastes; it can only concentrate
them. In addition to toxic gases, about 30% of the harmful medical waste that goes into
the incinerators remains as ash and needs to be transferred to landfills. In recent years,
public awareness has improved, and there have been more concerns about health
issues related to medical waste burning. However, the report of the United States EPA
(USEPA) shows “incineration of medical wastes remains a prevalent treatment method
in the United States” (Medical Waste Guidelines-EPA, 2012). As an example, in 2008-
2009, a waste management company in North Carolina (Stericycle) burned 26.3 million
pounds of medical waste and released hazardous organics into the air through its
incinerators (BREDL, 2011).

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Table 1.2: Some Notorious Materials that Medical Incinerators Produce

Products

Negative Effects on Human Health
Dioxins & Furans Cancer, liver disease, depression, suppress immune
system., skin rashes, diabetes, learning disabilities
Mercury
Tremors, mood swings, nervousness, excessive shyness,
insomnia, weakness, headache, kidney disease, death
Lead (Pb)
For children can cause learning disabilities, attention deficit
disorder, behavior issues, kidney damage, and speech
impairment. For adults can cause fertility problems, high
blood pressure, joint pain, concentration problems
Cadmium(Cd) Kidney dysfunction, lung cancer, prostate cancer
Nitrogen dioxide
(NO2)
Acute respiratory illness
Sulfur Dioxide
(SO2)
Respiratory illness, aggravation of existing cardiovascular
disease

Source: Data adapted from Health Care Without Harm (2012) and EPA (2014).

Health Impacts and Social Cost of Greenhouse Gas Emission
In regard to greenhouse gas (GHG) emissions, “healthcare ranks as the second-
most-energy-intensive industry [after the food industry] in the United States”
(Ogunseitan, 2011, p.1). The carbon dioxide (CO2) release of medical buildings is three
times that of other commercial office buildings. Hospitals consume 836 trillion BTUs of
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energy annually, and produce almost 10% of the total harmful greenhouse gas
emissions in the United States. This number does not include emissions produced by
visitors, outside services, and food production (Ogunseitan, 2011). This is in the
situation that the average annual growth rate of energy consumption of hospitals in the
U.S. is between one to three percent.
According to the EPA (2010), energy consumption of the healthcare industry in
the U.S. contributes to medical costs of about $600 million per year through increased
asthma and other respiratory diseases associated with air pollution. Also, the American
Lung Association, in its 2004 report, announced that:
According to the California Air Resources Board the annual health impacts of
exceeding state health-based standards for ozone and particulate matter include
[only in California]:
 6,500 premature deaths
 4,000 hospital admissions for respiratory disease
 3,000 hospital admissions for cardiovascular disease
 350,000 asthma attacks
 2,000 asthma-related emergency room visits
 Elevated school absences due to respiratory conditions, including asthma
 Reduced lung function growth rate in children
Sensitive groups, including seniors, people with heart or lung disease, children
and infants are the most vulnerable to the harmful effects of air pollution. Low-
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income communities and communities of color are also especially vulnerable to
pollution-related health impacts due to the multiple pollution sources located in
these communities and their often limited access to health care (American Lung
Association, 2004, p.2).
In addition, the U.S. Energy Information Administration in 2010, estimated that
the social cost of CO2 (SCC) was $21 per metric ton of CO2 emissions with a growth
rate of 2.4% per year. This number was projected to increase to $26.3 per ton of CO2 in
2020, $32.8 per ton of CO2 in 2030, and $44.9 per ton of CO2 in 2050 (in 2007 dollars):
The social cost of carbon (SCC) is an estimate of the monetized damages
associated with an incremental increase in carbon emissions in a given year…
the benefits from reduced (or costs from increased) emissions in any future year
can be estimated by multiplying the change in emissions in that year by the SCC
value appropriate for that year. The net present value of the benefits can then be
calculated by multiplying each of these future benefits by an appropriate discount
factor and summing across all affected years (the U.S. Energy Information
Administration, 2010, p. 2).
Harmful Chemicals
Each year, healthcare facilities purchase more than $106 billion worth of
chemicals (Roberts, 2002), with immense health effects on employees and patients.
Disinfection and contagion control always have been amongst the main concerns of
medical facilities. However, many healthcare cleaning products have been proved to be
harmful to human health. For example, Ethylene Oxide (EtO) and Glutaraldehyde (GA)
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are two widely used products that are used in disinfectants and sterilants in the
healthcare facilities and are detrimental to patients’ and employees’ health (Table 1.3).
Despite the availability of safer alternatives, still many medical institutions
continue to use these destructive materials (Health Care Without Harm, 2002). Although
healthcare facilities face complex regulatory requirements for disinfection and
sterilization, the regular cleaning products are not required by federal law to disclose
their ingredients. Many of these products contain dangerous chemicals. It is estimated
that “35% of conventional cleaning products can cause blindness, severe skin damage,
or damage to organs through the skin... [research] indicates that more than 10% of
confirmed work-related asthma cases may arise from exposure to cleaning products”
(O'Brien, 2007, p.2).
This information shows the role of medical activities on the U.S. economy, public
health, and resource consumption and demonstrates the importance of sustainable
healthcare operations. Although, in recent years, there has been a significant
improvement in understanding the environmental issues and their consequences,
currently, very few healthcare facilities are involved in Green operations in different
parts of their services.

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Table 1.3: Negative Impacts of Some Widely Used Chemicals in Healthcare
Facilities. Data adapted from CDC, 2001 - Health Care Without Harm, 2002 - and
HERC, 2015.
Substances Exposure Possible Health Effects
Glutaraldehyde
(GA)
Disinfectants
asthma, breathing difficulties,
burning eyes, conjunctivitis,
headaches, nosebleed,
sneezing, wheezing, hives,
nausea, rashes, allergic
dermatitis, staining of the
hands, throat and lung irritation
Ethylene oxide
(EtO)
Sterilants
nausea, vomiting, neurological
disorders, burning skin, eyes,
and lungs, damaging the
central nervous system, liver &
kidneys
cataracts
Formaldehyde
(CH2O)
Disinfectants,
Flooring and cabinets,
Vaccines embalming agent,
Dialysis machines disinfection

carcinogenic
destructive to nerve tissue
burning sensations in the eyes,
nose, & throat, coughing,
wheezing
nausea, skin irritation
attention deficit, depression
Triclosan
Cleaning products
Dish soap
Antibacterial hand sanitizers
bioaccumulation, skin irritation,
suspected carcinogen, disrupt
thyroid hormone, alter
development, and impair
important functions at the
cellular level
Xylene
Spot removers,
Floor polishes and
Ironing aids
poisonous to nerve tissue,
memory loss, loss of
consciousness, damage liver,
kidneys, and the developing
fetus

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Note: “Formaldehyde is one of 188 hazardous air pollutants (HAPs) listed by the 1990
Clean Air Act Amendments. In 1982, [it] was banned by the U.S. Consumer Product
Safety Commission; [however] the ban was overturned in the courts” (EPA, 2007). In
healthcare facilities, “formaldehyde is used as a disinfectant and sterilant” with special
regulations for its handling by OSHA (CDC, 2008).

1.3. Purpose Statement
The purpose of this study is to contribute to the general understanding of
the role of sustainable healthcare services in society and their impacts on patients’
wellbeing and public health. The goal is to explore the strengths as well as
shortcomings of healthcare organizations in regard to their ecological impacts, to be
able to create a shared understanding of sustainability in this field, and to find the most
affordable and applicable ways of being Green in a healthcare setting.
One of the main intentions of this study is to raise awareness about the massive
environmental effects of the healthcare industry in the United States, and to explore
major and minor (yet effective) changes that can help medical institutions to minimize
their negative environmental impacts and maximize the quality of their patient care (to
be able to become a model of health, instead of a pollution leader among other
businesses). A special focus will be on smaller scale initiatives and incremental
changes in different aspects of Green operational management. For example, low-cost
initiatives with effective outcomes such as reprocessing of medical devices, considering
bonuses for public transportation users, preferred parking for carpoolers, purchasing
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locally grown food, using efficient light bulbs, and composting can reduce the carbon
footprint of a medical facility considerably with relatively low upfront costs.
Each medical facility has a unique situation, and an environmentally friendly
approach cannot be dictated the same in different socioeconomic, geographical, and
climatic situations. It has to be compatible with the particular situation of the specific
organization. For example, while an efficient landscape irrigation system in hot-arid
regions (i.e. California) has significant impacts on resource consumption, it has slight
effects in cold and rainy areas. Also, for electrical efficiency, solutions of large hospitals
with financial stability are different from small organizations’ provisions. Many large
hospitals are able to install domestic solar systems to save energy, while small or
medium facilities, which are not ready for high upfront costs, can consider other
solutions such as utilizing energy saving lighting fixtures, efficient AC units, and natural
light. The overall aim is to learn from the experiences of existing Green operations of
different medical facilities and their new discoveries in various Green initiatives.
The Green principles hold that any small sustainable effort can make a difference
and is worth learning. Once the main concept of sustainable attitudes is understood by
all employees, then the specificity of each organization can be the best guide to choose
practical Green initiatives for that particular situation. In this regard, with the availability
of enough information, medical facilities would be able to practice Green operations
based on their financial and geographical conditions. This goal cannot be achieved
without discovering the easy and cost-effective ecological initiatives and finding a way to
incentivize sustainable efforts of medical organizations at the national level.
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The findings of this study are based on a review of relevant academic literature,
books published about Green healthcare, secondary data distributed by government
agencies (especially EPA), and publications of nonprofit Green organizations such as
Green Guide for Healthcare (GGHC), Healthcare Without Harm, Center for Health
Design, and Leadership in Energy and Environmental Design (LEED). In addition, a
review of existing Green practices and evaluation of the successes and obstacles of the
forerunners of sustainable operations in healthcare facilities, can help organizations to
identify important factors of sustainability in the healthcare industry. Hence, the
investigator conducted interviews with employees or representatives of the U.S. Energy
and Environmental Design, St. John’s Hospital in Oxnard, California, Cottage Health
System in Santa Barbara, California, Kaiser Permanente-Modesto Medical Center in
Modesto, California, and four European hospitals in Italy, Greece, and Spain to explore
the possibilities of improving medical activities to more efficient and eco-friendly
operations.
Research Questions
This study aims to answer these questions:
1. What are the negative impacts of traditional healthcare operation on the
environment and public health?
2. What is Green Healthcare, and are there any national standards for being Green
in healthcare facilities?
3. What are the different measures of sustainability that can guide medical facilities
change toward healthier practices?
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4. What are the experiences of the Green front-runners in the healthcare industry
(facilitators and barriers)?
5. What are the best practices in Green healthcare operations that can serve as
role models for all medical facilities?
1.4. Organization of the Chapters
The remainder of this study is presented in five chapters. The next chapter
summarizes literature focused on Green healthcare. These studies look at different
facets of sustainability in healthcare operations from socioeconomic, technical, and
cultural points of view. The need for evaluation of existing Green facilities and promotion
of incremental changes is discussed in this chapter. The third chapter describes the
methodology employed in this research to learn about easier and more practical Green
initiatives, which are applicable in the majority of medical facilities. The fourth chapter
reviews different measures of sustainability in detail and evaluates their possibilities and
practicalities in healthcare settings. The fifth chapter discusses the experiences of
different hospitals as they implemented their specific Green initiatives, their difficulties,
obstacles, as well as their attainments in pursuit of a healthy environment. These
hospitals include: Santa Barbara Cottage Hospital in Santa Barbara, California; Kaiser
Modesto Medical Center in Modesto, California; St. John’s Regional Medical Center in
Oxnard, California; Chania General Hospital “St. George Hospital”, in Chania, Greece;
the United Hospitals of Ancona in Ancona, Italy; The Hospital “Fundacio Sanitaria de
Mollet” in Mollet, Spain; and The University Hospital “Virgen de las Nieves” in Granada,
Spain. Finally, the sixth chapter provides a summary and conclusion of this research
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project and offers recommendations and suggestions for creating an environmentally
sustainable healthcare system to protect public health in broader terms.

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CHAPTER TWO: LITERATURE REVIEW

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2.1. Introduction
In the past decades, western industrial societies started to learn about the
limitation of natural resources and their sensitivities to human activities. At first, these
societies were in the phase of ignorance or denial (Elkington, 1994), but later they
accepted the reality, yet, not as a serious matter. In recent years, however, the world
has started to experience the effects of the environmental and natural resources
problems and has realized the importance of sustainable development. Various
organizations have started to educate the general public, and most countries have
taken the responsibility of confronting environmental problems, instead of pushing them
onto future generations (Elkington, 1994).
In 1987, the World Commission on Environment and Development (WCED)
defined sustainability as "development that meets the needs of present generations
without compromising the ability of future generations to meet their own needs"
(Roberts, 2002). In 1992, sustainable development became the central debate at the
UN Conference on Environment and Development (UNCED). The concept of
sustainable development involves every aspect of human activity, such as industrial
development, water accessibility, transportation, agriculture, healthcare, and any activity
that is related to the pollution or consumption of natural resources (Ogunseitan, 2011).
Recently, many industries have been considering various environmentally friendly
practices such as LEED certified buildings, carbon emission reduction programs, waste
management programs, recycling, and promoting public transportation. However, the
healthcare industry is not among forerunners in environmentally sustainable business
practices.
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On the topic of Green Healthcare, academic literature has lagged behind
healthcare practices and non-profit Green organizations in reflecting the significant role
of medical activities on environmental degradation and steps have been taken to
mitigate their adverse effects on patients’ wellbeing and public health. Hence, this
chapter not only presents a review of the relevant academic literature, but it also
reviews publications of governmental agencies and different non-profit Green
organizations. In recent years, several intergovernmental and nongovernmental
organizations such as Environmental Protection Agency (EPA), Healthcare Without
Harm (HCWH), World Health Organization (WHO), and Green Guide for Healthcare
(GGHC) have started to publish several articles in promoting sustainability in healthcare
settings, reporting successful cases of sustainable operations and encouraging all
facilities to follow the same path. These publications have a series of valuable
recommendations for healthcare professionals. Also, several awards and certifications
have been considered to encourage Green activities and sustainable building designs in
this industry.
Nonetheless, there is a gap between these efforts and existing situations of
medical facilities. The vast majority of hospitals still have remained unchanged
(Cassidy, 2006). Also, the investigator visited or contacted by phone many hospitals
that do not even consider starting any changes toward environmentally responsible
business practices. The question is why, and is there any way to expedite the
sustainability trend in the healthcare industry? In the situation that there is no time for
delay, and “climatic changes already are estimated to cause over 150,000 deaths”
every year (WHO, 2014), the healthcare industry is one of the largest contributors to air
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pollution and waste production, and its pace of change towards sustainable operations
is not responsive to the urgent need of reducing the ecological impacts of medical
services.
The aim of the literature review (Figure 2.1) is to identify the role of medical
practices in society to determine the importance of their sustainable activities, learn
about existing Green measures in the healthcare industry, and discover why this field is
slower than other disciplines in the implementation of Green initiatives. This review
shows that there is not enough emphasis on practical and affordable initiatives to
encourage all healthcare facilities to join the Green movement.
Of the 132 studies reviewed, a total of 26 studies were selected. One study
focuses on general impacts of sustainable approaches in all businesses, 21 studies
directly focus on Green initiatives in healthcare settings, and four studies are about
Lean and Six Sigma methods of efficiency to see how environmentally sustainable
approaches can complement efficiency in all areas of a system. In the majority of these
studies, the data only belong to hospitals because the statistics of other medical
facilities’ environmental impacts are mostly unknown (although they cause similar
negative ecological effects on human health).
The selected Green Healthcare literature can be categorized in four broad
groups. Four studies mainly focus on the role of the healthcare industry in society, its
negative environmental impacts on human health, and the necessity of Green
operations in this field. Six studies focus on cultural aspects of sustainability and the
impacts of building designs and operations on healthcare stakeholders. Five studies
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focus on the role of a specific Green initiative (such as plumbing, cleaning materials,
and efficient light bulbs) on sustainable operations. Finally, seven studies (including
governmental publications and different case studies) examine the existing Green
solutions and present successful experiences of different hospitals to show the
practicality of environmentally sustainable operations in medical facilities. In addition to
the selected Green healthcare literature, the author also reviewed four studies related to
Lean and Six Sigma methods of efficiency in medical services to find a common
language between the existing operations and the Green movement.

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Figure 2.1: Green Healthcare Literature

Green Healthcare
The Role of the
Healthcare
Industry
in Society
Cost Benefit Analysis
Elkington (1994)
Serb (2008)
Romano (2004)
Tsai (2009)
Cassidy (2010)
Bellestri (2011)
WHO (2008)
Cultural Aspects
Specific Green
Initiatives
Policy
Recommendations
=
Promote
Sustainability
through
Existing Green
Practices
Hartman et al. (2009)
Hartman et al. (2010)
Hartman et al. (2011)
Sternberg (2010)
Gray (2011)
Kim et al. (2015)
Chung et al. (2009)
USDHHS (2007)
Cassidy (2006)
Arnold (2013)
Kwakye et al. (2010)
Alderson (2008)
O’Brien (2007)
Lemaux et al. (2009)
Rhea (2009)
Efficiency in the
Healthcare Sector
Lean & Six Sigma
Methodologies
=
Graban, et al . (2010)
Martichenko (2008)
Kwak & Anbari (2006)
Smith (2003)
Improving the level of
empirical knowledge
on the topic of
Green Healthcare
&
Affordable/ Practical
Recommendations

Integration with
Existing Efficiency
Models of Lean & Six
Sigma

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As depicted in white boxes of Figure 2.1, there is a need for the following studies:
 Improving the level of empirical knowledge on the topic of Green Healthcare;
 Recommendations for affordable and practical Green initiatives;
 Recommendations for integration of Green healthcare with existing efficiency
models such as Lean and Six Sigma;
 Policy recommendations to local Governments to promote Green approaches in
the healthcare industry; and
 Comprehensive cost-benefit analysis for various Green measures in the
healthcare settings.

2.2. Four Broad Categories of Analysis in the Existing Green Healthcare Literature
The Role of the Healthcare Industry in Society
The first category includes articles that focus on the significant role of the
healthcare industry in society and discuss negative ecological effects of medical
organizations and the necessity of environmentally friendly practices. Chung and
Meltzer (2009), USDHHS (2007), Cassidy (2006), and Arnold et al. (2013) are in this
category.
Chung and Meltzer (2009) and USDHHS (2007) determine the ecological and
economic impacts of medical services in society, respectively. Chung and Meltzer show
the significant amount of carbon footprint of the healthcare industry in the United States
through a quantitative research. They calculated the GHG emissions (carbon dioxide,
methane, nitrous oxide, and chlorofluorocarbons) of this sector based on the 2007 data
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on health expenditures. They considered direct as well as indirect effects (such as
supply- chain effects) of medical activities. This study reveals that in 2007 the health
care organizations contributed an estimated total of 546 million metric tons of carbon
dioxide equivalent (Table 2.1). This amount accounts for 8% of the total GHG emissions
in the United States and shows an urgent need for change in this field. Hospitals and
prescription drug sectors as the largest contributors are responsible for 39% and 14% of
the emissions, respectively (Chung et al., 2009).
Also, the United States Department of Health and Human Services (USDHHS) in
its report of 2007 shows the role of medical expenditures on the U.S. economy. This
article indicates that although the medical costs of wealthier countries, in general, are
much more than of developing countries, the existing healthcare expenditure in the
United States is much higher and not comparable with other developed countries.
As Figure 2.2 shows
Richer countries spend more on health care [but] the United States is a clear
outlier… For example, per capita spending in the U.S. exceeds the level in the
next closest country by more than 50%. Similarly, the share of GDP devoted to
health care in the U.S. surpasses that in other developed nations by a wide
margin” (USDHHS, 2007, p.3,4).
Ecological costs are not included in these calculations.

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Table 2.1: GHG Emissions of the U.S. Healthcare Industry in 2007

Source: Reprinted from Chung and Meltzer (2009). Estimate of the carbon footprint of
the US health care sector. JAMA, 302(18), 1970-1972.
doi: http://dx.doi.org/10.1001/jama.2009.1610
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Figure 2.2: The United States Healthcare Expenditure in Comparison with Other
Developed Countries

Source: Reprinted from the United States Department of Health and Human
Services (USDHHS, 2007). Retrieved from
https://aspe.hhs.gov/pdf-report/effect-health-care-cost-growth-us-economy

These data indicate that the healthcare industry influences a large part of
American society and any inefficiency in its operation can affect the life of the whole
population. Nevertheless, the literature review shows that this industry is not proactive
in eco-friendly operations as expected. In this regard, Cassidy (2006) addresses the
complexity of healthcare regulations and uncertainty of the payback period for capital
investments as two main constraints for Green initiatives in the healthcare industry and
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reasons for its passive approaches to environmentally sustainable activities. He
mentions the scant number of environmentally friendly buildings in the healthcare
industry, and argues that hospitals, based on their responsibilities to patients, should
have leading roles in sustainable practices instead of wasteful characteristics in society.
He offers several practical recommendations such as establishing a sustainability team,
getting “buy-in at the top”, and promoting all benefits of sustainable buildings (such as
economic savings in the long run and patients’ wellbeing), not only the environmental
issues. The main focus of this article is on building designs and LEED certified buildings
in the healthcare industry, not operational management.
In addition to the aforementioned impacts, there are other indirect effects of the
healthcare industry on society and human life such as pharmaceutical contaminations.
Arnold et al. (2013) investigated “the exposure risk and impacts of pharmaceuticals in
the environment on individuals and ecosystems” (p.1). Based on this research,
pharmaceuticals and their biotransformation products have negative impacts on people,
wildlife, and the environment as a whole. (Biotransformation is the conversion or
modification of molecules within a substance by a chemical reaction refers especially to
pharmacologic activities.) In the existing situation, many species are endangered
because of widespread use of over the counter medications and prescription drugs such
as antibiotics and antidepressants. This situation eventually imbalances the ecosystem
drastically and can cause irreversible damage to human life. This research highlights
the need for more research and an integrated approach among academic researchers,
industry risk assessors, and regulators to “assess current and future risks from
pharmaceuticals in the environment” (p.3).
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Cultural Aspects of Sustainable Healthcare Practices
The second category of literature includes studies that focus on cultural aspects
of sustainable healthcare. This category reviews the role of employees’ and
executives’ knowledge of sustainability and their perceptions about the Green
movement. Also, it examines the impacts of healthcare Green initiatives on employees’
and patients’ wellbeing. Hartman, Fok, and Zee (2009), Hartman, Fok, and Zee (2010),
Hartman, Fok, and Zee (2011), Sternberg (2010), Gray, (2011), and Kim, Hwang, Lee,
and Corser (2015) are in this category. Hartman et al. investigate the role of employees
in Green operations through a series of quantitative studies. Their findings “strongly
support that employees’ individual Green orientation affects the organizations’ Green
movement and vice versa” (p.33). They also compare the Green activities in healthcare
vs. non-healthcare organizations and show that the healthcare industry is significantly
different from non-healthcare facilities in regard to their approach (individual and
organizational) to the Green movement. Based on these studies, non-healthcare
employees have more awareness (and willingness to learn) about the negative impacts
of their organizational operations on the environment than those who work in healthcare
facilities (Hartman et al., 2011, p.17-18):
There is widespread support of the premise that healthcare managers and
executives are struggling to cope with environmental challenges in the healthcare
industry (Sieveking & Wood, 1994; Dwore, et al., 1998; Smith, et al., 1998;
Shewchuk, et al., 2005). Zuckerman’s (2000) comments are typical of the
discussion in the literature, in pointing out that it is the dynamic nature of the
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healthcare industry that leads organizations to struggle to survive in turbulent
conditions. Moreover, Zuckerman notes that the management approaches used
by many healthcare organizations continue to lag behind other businesses in
similar industries.
Of special significance to this research, Rundle (2000) has recently suggested
that the healthcare industry is falling behind in issues of management,
particularly with respect to adopting and managing automation and technology.
The implication is that managers and executives in healthcare, compared to their
counterparts in other industries, do not have the business knowledge and skills to
fully utilize the available automation and technology. Mecklenburg (2001) has
recently made similar points when considering the steps healthcare is taking with
respect to preparing to exchange data in ways that will benefit patients. What is
suggested may be that healthcare may be lagging behind at just the time when
turbulence in the industry should be moving them toward the development of
sophisticated sustainability systems. Is it possible that differences in the factors
we have discussed could be underlying causes of any differences between
healthcare and non-healthcare?

In their study, in the comparison between healthcare and non-healthcare
organizations, the focus was on staff’s perceptions (mainly nursing staff). Future studies
with a focus on patients’ wellbeing and other outcomes would be helpful for a
multilateral evaluation of the differences.
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Two other studies in this category belong to Sternberg (2010) and a doctoral
dissertation about LEED (Leadership in Energy and Environmental Design) from Johns
Hopkins University (Gray, 2011). Dr. Sternberg, in her book Healing Spaces, reviews
the “science of place and well-being” and claims that existing settings of hospitals are
stressful for patients. Since stress is harmful to health and affects the immune system,
hospital environments make patients susceptible to “more severe and more frequent
infection.” She does not directly talk about environmentally sustainable operations;
however, her emphases on intimacy with nature, use of natural light, non-hazardous
cleaning materials, healthy food, and a tranquil environment for patients in hospitals can
be attained with a sustainable design and operation of a healthcare facility.
According to Sternberg (2010, p.3):
[Roger Ulrich] had examined the hospital records of patients who had undergone
gall bladder surgery in a suburban Pennsylvania hospital during the period 1972-
1981. He’d chosen forty-six patients, thirty women and sixteen men, whose beds
were near windows that overlooked either a grove of trees or a brick wall.
Twenty-three beds had views of nature and twenty-three did not. …He’d found
that patients whose beds were located beside windows with views of a small
stand of trees left the hospital almost a full day sooner than those with views of a
brick wall. Not only that, but the patients with nature views required fewer doses
of moderate and strong pain medication. The results were dramatic and
statistically significant.
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This study demonstrates the role of sustainable design of hospitals on patients’
rate of recovery. Therefore, the use of natural light not only contributes to carbon
footprint reduction, but provides a connection with nature for patients that can improve
their well-being.
Gray (2011), in a mixed-method qualitative and quantitative study, investigated
the relationship between physical work environment (PWE) and health and safety of the
occupants with a focus on healthcare facilities. Her research findings show “significant
improvement in workers' perceptions of safety and building satisfaction after moving into
a LEED” certified building. The sample size in this study is small, and there is a need for
more research before any generalizations can be made.
The last study in this category is the research of Kim, Hwang, Lee, and Corser
(2015). This quantitative study determined the environmental factors that affect
occupants’ comfort in LEED certified hospitals:
This study investigated staff’s perceived comfort and satisfaction through
questionnaire surveys that determined such environmental factors. To
examine staff’s comfort and satisfaction in green hospitals and
conventional ones, a comparative study was conducted… the research
team categorized selected environmental features into indoor
environmental quality elements and design elements…
There were seven questions to evaluate the occupant satisfaction…The
mean for each question was calculated and compared for different
building types using mean difference tests. Because the staff satisfaction
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toward the working environment in two building groups could have been
influenced by factors other than the existence or absence of green
building attributes such as workload, type of work, and interpersonal
relationship, these questions could help identifying the satisfaction related
to building types from those which are not. Then the responses for those
satisfaction questions showing clear difference between green and non-
green hospitals were summed and averaged to result in a new overall
satisfaction parameter labeled as “overall satisfaction.” The purpose of this
test was to determine if the overall perceived satisfaction was
associated with two groups (green vs. conventional building occupants)
(p.156-157, 162).
This study confirms Gray’s findings and shows that there is a significant
difference between LEED certified hospitals and traditional hospitals in regard to
employees’ happiness. Employees who are working in LEED-certified hospitals feel
more comfortable and are more satisfied with their working environments.
Although Green buildings play a substantial role in Green operations, it is clear
that sustainability in the healthcare industry cannot be achieved only by LEED certified
buildings. Sustainable operational management, eco-conscious employees, and Green
measures in all routine duties are the keys for Green healthcare operations. The review
of this category of literature shows that there is a need for more studies on the impacts
of smaller scale Green initiatives (not only building design) on public health, as well as
patients’ and staff’s welfare.
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Specific Aspects of Sustainable Healthcare Practices
In the third category, there are studies that focus on a specific aspect of
sustainable healthcare practices, such as building structure or design, plumbing, food
chain, Green cleaning products, and lighting fixtures. Kwakye, Provost, and Makary
(2010), Alderson (2008), O'Brien (2007), Lemaux and van Eenennaam (2009), and
Rhea (2009) are in this group. Kwakye et al. (2010) focus on medical equipment
reprocessing and its role in waste reduction in hospitals. They believe recycling and
reproducing the medical equipment, and packaging is crucial in the healthcare industry.
Reprocessing of medical equipment in hospitals not only reduces their waste
production, but it can also save millions of dollars annually across medical disciplines.
Towards the goal of reducing tons of disposable waste generated annually, this
study found that over 20% of the hospitals in the United States are using medical
equipment reproducing. Nevertheless, patients’ safety concerns and misunderstandings
about the reproducing methods have prevented acceptance of the procedure among the
majority of medical practices. Kwakye et al. review the process of reproducing,
its financial and environmental benefits, and evidence regarding its safety. In terms of
validating the safety of reprocessing, this study divides medical devices into three
classes of safety. Class I includes those devices whose reprocessing or reproducing is
a low risk for patients and which are exempt from premarket submission requirements.
Elastic bandages, pressure infuser bags, tourniquet cuffs, and general-use surgical
scissors are in this class. Class II includes devices whose reprocessing has a medium
risk for patients and which require submission of a premarket notification report to show
their safety and efficacy in order to obtain FDA premarket approval. This class includes
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65% to 75% of the reprocessed single use devices (SUD). Pulse oximeters, sensors,
ultrasound catheters, drills, compression sleeves, and most laparoscopic equipment are
in this group. Finally, Class III includes medical devices whose reprocessing is high risk
and can be dangerous for patients. Balloon angioplasty catheters, percutaneous tissue
ablation electrodes, and implanted infusion pumps are in this class of safety.
Reprocessing of medical devices in this group is not recommended.
Kwakye et al. (2010, p.23) advocate that medical equipment reproduction “has
a reliable safety record of excellence identical to that of new equipment [as long as it
has FDA approval]”, reduces tons of waste, and saves millions of dollars for medical
practices. This study found that in 2008, $138,142,000 was saved through medical
equipment reprocessing nationwide. Also, Banner Health in Phoenix Arizona was able
to save $1,494,050 in 12 months from reprocessing. No calculation was provided in this
article (The amount of savings reported from Ascent Reports - Ascent Healthcare
Solutions. Hospitals Benefit from Sustainability Initiatives…, Mon Jan 12, 2009).

Alderson (2008) focused on Green plumbing opportunities for healthcare facilities
and suggested that more durable plumbing fixtures with a longer lifecycle can reduce
waste and save water. Also, she provided practical suggestions for improving plumbing
in healthcare facilities. O'Brien (2007) examined the role of housekeeping activities and
focused on cleaning products in the healthcare industry. Operation and maintenance
play a significant role in environmentally sustainable healthcare facilities. Green
cleaning products can provide a healthy indoor environment, as well as prevent surface
and ground water contamination.
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Lemaux et al. (2009) and Rhea (2009) addressed the problems with genetically
modified organisms (GMOs) and cloned-animal meat and dairy products. GMOs are
organisms whose DNA has been altered “through the introduction of a gene from a
different organism” (WHO, 2013). There is a concern that these altered genes can be
transferred to other non-targeted species and cause biodiversity decay, superweeds
(weeds that are resistant to herbicide), and environmental imbalance. In addition,
allergies, cancers, and resistance of human bodies to antibiotics are among the
potential health effects associated with GMOs. Since protecting public health and
patients’ well-being are among the primary goals of the Green movement in the
healthcare industry, using GMOs in patients’ food is a subject of concern. Yet, there is
not enough scientific research and consensus about these products, and insufficient
evidence to accept or reject any argument. Nevertheless, the secrecy concerning the
existence of GMO in foods prevents comprehensive research about the impacts of
GMOs on the human body.
GMOs are banned in many European countries and labeling is required in 64
countries, but in the United States and Canada they are legal, and the Food and Drug
Administration (FDA) does not require labeling of genetically engineered plants and
cloned-animal products. Therefore, it is extremely hard (if not impossible) to distinguish
them from non-engineered products. There is a social debate on the requirement of
GMO labeling on all food packaging in the United States and the right of consumers to
know what is in their food. With this requirement, there will be more opportunities for
researchers to investigate the quality of food for the public. So far, Vermont is the only
state in the nation that has passed a law (in 2014) requiring GMO disclosure for the
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food industry. In this regard, although some hospitals have started to purchase non-
GMO food for their patients, without further research and national legal support to
identify these products, this initiative cannot be promoted as an active measure in
Green healthcare organizations.
The findings of the literature in this category show the important role of every
single Green measure in sustainable operations of the healthcare industry. While the
cooperation of all departments plays an important role in the ultimate success of an
efficient operation in any organization, a Green initiative can be started in one
department or one area of practice independently. Starting any small Green initiative in
one area of operation can educate managers and employees of other departments and
motivate them to join the movement with small steps and less upfront cost.

Sustainable Initiatives in Existing Green Healthcare Practices
Finally, the fourth category includes studies that examine the existing Green
healthcare organizations through different case studies, introduce successful practices,
and provide suggestions based on the experiences of different hospitals and medical
centers. The focus of this category is to promote Green healthcare through positive
experiences and show the practicality of sustainable operations in medical facilities.
Serb (2008), Romano (2004), Tsai (2009), Elkington (1994), Cassidy (2010), Bellestri
(2011), and WHO (2009) are in this group.
Serb (2008) promotes sustainability through success stories of different
hospitals. He believes that the shift from conventional operations toward
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environmentally-friendly approaches is very cost-effective, as well as popular among the
public and environmentalists, and gives “the facilities competitive advantages." He
states that the high price of energy and the need to replace older facilities in many
hospitals, as well as public health concerns and environmental awareness about
hospitals’ incinerators, can be the main facilitators of change in healthcare practices.
However, he does not provide any evidence to support his statements. In contrast, a
review of the Green healthcare literature shows that one of the main reasons for the
hesitation of the healthcare industry about adapting Green activities is the upfront costs
and uncertainty of return on investment (ROI).
This article reviews the situation of three hospitals and their success stories
about going Green:
 Branson Methodist Hospital in Kalamazoo, Michigan closed down its
incinerator, improved recycling up to 80% of the materials and built a
LEED certified building. This hospital saved a half million dollars per year
through the incinerator shut down.
 Providence Newberg Medical Center in Oregon received Gold LEED
certification for its building. Also, it uses natural light in the buildings, and
gets its electricity through renewable energy (wind, geothermal and
hydroelectric power).
 New York-Presbyterian Hospital, in Manhattan New York, has achieved $2
million in annual savings through energy-efficient equipment and light
bulbs, and “proper maintenance and improved heating controls”. Also, to
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spread the culture of efficiency, the hospital administration provided
hundreds of energy-efficient light bulbs to all employees.
In this study, there is no discussion about the obstacles and barriers faced by the
hospitals. Also, it is not clear if Branson Methodist Hospital transfers its medical waste
to incinerators in other places (that would have the same result) or uses non-
incineration technologies.
Romano (2004) with the topic of “Turning Green” tries to demonstrate healthcare
institutions’ improvements in terms of Green activities. He suggests “hospitals must shift
gears to focus on long-term benefits _ not short-term costs” (p. 31). He presents several
medical centers such as Children Medical Center of Texas (the project before
construction), Boulder Community Foothills Hospital in Colorado, Metropolitan Hospital
in Grand Rapids, Michigan, and Children's Hospital of Pittsburgh in Pennsylvania. He
also introduces several Green organizations which have been formed to help the
healthcare industry catch up with the rapid pace of “environmentally sensitive design” in
other industries. American Society of Healthcare Engineering, Green Guidelines for
Healthcare, and Hospitals for a Healthy Environment (H2E) are among these groups
(H2E is a result of a coalition between the American Hospital Association and EPA in
1998).
The main focus of Romano (2004) is on the Green design of the hospitals’
buildings, not operations and maintenance. Based on this study, it is anticipated that
environmentally sustainable design and construction will add about 3.5% to the total
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cost of building a hospital, and a period of five years is enough to pay back the extra
cost. No calculation is provided for this prediction.
Tsai (2009) reviews Green initiatives in three medical institutions to show the
growth of sustainable approaches among healthcare providers. She introduces the
experiences of the Stony Brook University Hospital in Stony Brook, New York, the East
Carolina Heart Institute in North Carolina, and Kaiser Permanente's Modesto Medical
Center in Modesto, California. Based on this paper, the Stony Brook University Hospital
with different Green measures increased its recycling by about 420 tons, the East
Carolina Heart Institute reduced its power expenses by 33%, and Kaiser Permanente
saved $400,000 in construction costs. Tsai quotes from an EPA representative that
Green initiatives can save money in the long run.
Elkington (1994) supports sustainability in general and provides bright ideas for
environmentally-friendly businesses. He offers a definition of sustainability as
“integration of environmental thinking into every aspect of social, political, and economic
activity” (p. 90). Also, he sees sustainable development as a win-win-win situation
between companies, customers, and societies. He suggests that people’s desire for
using organic materials is increasing, and this is an excellent opportunity for businesses
to move toward Green practices and be more competitive in the market. This situation is
more critical for medical institutions because their activities have a direct impact on
public health and patients’ well-being. However, the experience of the last decade
shows the lack of enough knowledge about sustainability among people and the lack of
enough environmental concerns among businesses. Twenty years after the date of this
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article there is still a major debate amongst government officials and people’s
representatives as to whether sustainable growth is a necessity or ecological issues are
fictions! Thus far, there is little or no demand by people for serious sustainable action in
society (or if there is, it is not responsive to the speed of environmental degradation).
Cassidy (2010) with the topic of “America’s Greenest Hospital” talks about the
building design and construction of the Dell Children's Medical Center of Texas as the
first hospital that could achieve LEED Platinum certification in the United States. This
hospital is the subject of review in Romano (2004) and WHO (2009) as well. Cassidy
(2010) explains the Green measures of the project such as recycling, water
conservation, and saving energy:

To provide power to the new facility, the local utility, Austin Energy, built an $18
million combined cooling/heating power (CCHP) plant. This increased the energy
efficiency of the primary fuel conversion for the project from roughly 29% in a
conventional power service model, to 75% efficiency.
The CCHP also saved $6.8 million in capital costs that would have gone to
boilers, emergency generators, cooling towers, chillers, and the space necessary
to house them. The bulk of the savings, $5.8 million, was plowed back into
energy-conservation measures and other LEED initiatives (p.49).
He claims that this project was able to reuse 47,000 tons of runway pavement,
divert 92% of construction and demolition (C&D) debris from landfills, and save water
through low-flow plumbing fixtures and decreased water usage for landscaping. He
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also, talks about the practical problem that occurred after using motion sensors in the
“on-call room”. The lights turned on anytime the physicians moved in their sleep.
Therefore, they had to remove the sensors from this room immediately. No other
experience of planning or mechanical problems has been reported in this study. The
main focus of the article is on Green buildings and construction, not operations and
maintenance.
Sage Knowledge (a social science digital library) has published a series of
articles about Green Health, and Bellestri (2011) is one of these articles.
Bellestri (2011) introduces Green movement supporting organizations such as Hospital
Energy Alliance (a coalition of national healthcare sector leaders and the Department of
Energy [DOE]), Premiere Healthcare Alliance, Practice Greenhealth, and WHO.
These organizations provide valuable information to help medical facilities reduce
their carbon footprint. She also presents tools for measuring carbon footprint and
describes the experiences of the University of Chicago Medical Center, the
Harris Methodist Fort Worth Hospital (HMFW) in Texas, and Saint Francis Care (SFC)
in Connecticut. It would be more helpful if the experiences of these hospitals
demonstrate obstacles as well as opportunities for and the practicality of Green
initiatives in healthcare settings. However, the main focus of the article is on introducing
success stories, and there is almost no discussion about any obstacles.
Bellestri argues that environmentally sustainable measures not only conserve
natural resources, but can also reduce the cost of operation of the facilities in the long
run. According to this paper, the University of Chicago Medical Center established a
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plastic recycling program that diverts about 500 pounds of waste from landfills each
day. Also, 90% of its cleaning supplies are environmentally sustainable products.
Harris Methodist Fort Worth Hospital (HMFW) of Texas, in 2005, created a Green team
and was successful in reducing solid waste and decreasing energy consumption in the
hospital. Also, Saint Francis Care (SFC) was the first hospital in Connecticut that
installed its own fuel cell and reduced its CO2 emissions significantly. This hospital
saved energy by recovering the heat produced by the fuel cell for its hot water.
Moreover, the improvement in efficiency of heating and cooling systems and
laundry facilities could save a substantial amount of money in operating costs. However,
no cost-benefit analysis has provided. Based on this study, the Green Design Institute
at Carnegie-Mellon University developed a tool to measure carbon footprint named
Environmental Input-Output Life Cycle Assessment model (EIOLCA). This tool has been
used in a study by Chung et al. (2009). Furthermore, Stericycle launched an online
Carbon Footprint Estimator to help hospitals calculate their carbon footprint induced by
their plastics and cardboard usage. This program is free of charge and has helpful
suggestions for healthcare organizations to reduce their negative ecological impacts
(Bellestri, 2011).
This situation illustrates a noticeable paradox in the United States’ healthcare
industry. Stericycle has numerous incinerators in North Carolina and is one of the major
polluters in the nation. At the same time, this company is a pioneer in providing a
Carbon Footprint Estimator in the health sector! What is missing here? A lack of laws
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and regulations and serious policy decisions on environmental management is one of
the major shortfalls in society.
The last paper in this category is a publication by the World Health Organization
(WHO) in 2008 that was prepared in collaboration with Health Care Without Harm
(HCWH) to address unsustainability in the healthcare industry across the globe, and
offer recommendations in this regard. In the first part, this article provides information
about the severity of climate change and its impacts on human health, as well as the
role of healthcare activities in ecological degradation (the topic of the first category of
this literature review). It then gives different suggestions for “climate-friendly” hospitals
and identifies different examples of Green healthcare organizations and their specific
actions to be the international models for all medical institutions. Only four of these
facilities are located in the United States:
 Dell Children’s Medical Center in Austin, Texas;
 York Hospital in York, Maine;
 Pitt County Memorial Hospital in Greenville, North Carolina; and
 St. Luke’s Hospital in Duluth, Minnesota.

These hospitals were able to reduce their carbon footprint through Green building
design, use of renewable energy instead of fossil fuel, different arrangements for
transportation (such as energy-efficient vehicles, promoting carpooling, and public
transportation), and waste management.

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The aim of the review of this category of literature was to learn about the steps
that have been taken by different healthcare organizations, their successes, and
obstacles to their endeavors. However, in the majority of these studies the main focus is
on success stories, and rarely is there any emphasis on difficulties and problem-solving
(e.g., the malfunction of lighting sensors was mentioned above). This issue can have
two possible reasons. First, the academic literature has lagged behind Green healthcare
practices, and there is little academic research and few comprehensive analyses about
Green healthcare. Second, the healthcare industry is lagging behind many other
industries in environmentally sustainable operations. Apparently, this situation motivates
Green movement advocates to focus on propaganda and advertisement more than they
attend to obstacles and their solutions.
Although this approach is understandable from an advertising point of view,
seeing only the positive points and ignoring the practical implementation problems is
neither realistic nor helpful for promoting sustainable practices. In contrast, it can cause
regular medical organizations to distance themselves from the Green movement and
assume that they need to wait for the perfect moment to do the job without any mistakes
or deficiencies.
The literature review shows that, for advancing the practice of Green Healthcare,
there is a need for more studies to examine all aspects of Green operations in
healthcare settings and reflect the problems and their solutions, not only achievements
and successes. The point is not that the path of sustainability in the healthcare industry
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is easy and tranquil without any cost, obstacles, and difficulties. The point is that it is
necessary to find a way to fundamentally change the existing situation of healthcare
facilities given the extreme demands on the nation’s natural and economic resources.
Without this essential change, future problems will be disastrous and costly for society
and the industry.
2.3. Lean and Six Sigma Efficiency Methodologies
In addition to the selected Green healthcare literature, this paper presents a
review of the relevant literature on Lean and Six Sigma Efficiency Methodologies. These
methods in recent years have become very popular among healthcare leaders because
they can save a significant amount of money in different organizations. The aim of this
review is to introduce the Lean and Six Sigma quality improvement strategies and
explore the viewpoints of these efficiency methods towards the ecological inefficiency of
the healthcare industry.
Lean Methodology
Lean management is a philosophy that focuses on efficiency and elimination of
waste in a system, and the main idea is to create more value with fewer resources. The
Lean philosophy has been borrowed from the Toyota Production System (created by
Taiichi Ohno in the mid-20th century), which helped Toyota improve its production
system faster than its competitors.
This philosophy identifies seven (and in some documents eight) different
categories of waste (Muda in the Japanese language), which have to be eliminated in a
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process of production or rendering services (Graban & Prachand, 2010). These
categories are as follows:
 defects;
 overproduction;
 inventories;
 over-processing;
 motion (workflow);
 transportation;
 waiting; and
 wasting human talent.
A few years later, by seeing the success of the Toyota Production System, the
General Motors Company (GM) tried to implement this system in the whole
organization, but the cultural gap was the first and most important obstacle to
implementation of this methodology. GM tried to implement the Lean tools, not its
philosophy. Thereafter, several manufacturing companies have adopted this method
and enhanced the efficiency of their systems.
Martichenko (2008) in his book, Everything I Know About Lean I Learned in First
Grade, mentions that the Lean philosophy is “a way of thinking,” not a set of tools, and
focusing on Lean tools without understanding its key principles cannot help
organizations. According to the book, this philosophy is based on teamwork and quality
checks at the source vs. quality control at the end. “[T]here is a big difference between a
mistake and a defect” (p.6) - mistakes happen, and there is no way to prevent errors
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100 percent of the time. However, they can be corrected at the source, instead of being
handed off to the end customer or the quality control department at the end of the
production process.
The Lean approach needs strong harmony and teamwork among all employees
including supervisors and top management. However, in many cases (such as the GM
experience), this culture does not match completely with the individualism and
competition culture in the West. In this methodology, the goal is to find the “system
related elements of waste”, not blame or punishment of an individual. Administrators
encourage everybody to discover why the mistake happens and what the best way is to
prevent it the next time. Also, management encourages and rewards employees who
offer their suggestions to speed up the line of production. In Toyota’s manufacturing
system, there are myriad changes in the production line based on the suggestions of
regular employees who had firsthand experience with the system (Martichenko, 2008).
In recent years, many healthcare organizations adopted this methodology to
improve efficiency in their system and decrease their overhead expenses. However,
there is no concern about environmental inefficiency and excessive use of natural
resources in their Lean models. Ecological costs are not included in any calculations of
Lean and Six Sigma methodologies.
Six Sigma
Six Sigma is a quality measurement method that began in 1986 in Motorola Inc.
in the United States. This “method is a project-driven management approach to improve
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the organization’s products, services, and processes by continually reducing defects in
the organization. It is a business strategy that focuses on improving customer
requirements understanding, business, systems, productivity and financial performance”
(Kwak & Anbari,2006, p. 708). Sigma is the symbol of a standard deviation, and Six
Sigma quality equates to 3.4 defects per one million opportunities (DPMO). Over time,
this method has evolved into a comprehensive performance improvement system,
which no longer focuses only on DPMO. Today, the focus of this model is on the
DMAICT model, which is an acronym for:
D - Define opportunity
M - Measure performance
A - Analyze opportunity
I - Improve performance
C - Control performance, and optionally
T - Transfer best practice to spread the learning to other areas of the organization
The Six Sigma methodology has helped various organizations such as local
governments, banks, and hospitals. However, it has a strong emphasis on statistical
analysis and is not easy to understand for everybody. As Smith (2003) states, “Six
Sigma programs are popular, focused and effective, but projects often take months to
finish, and the program creates elite Black Belts (BBs) who are frequently disconnected
from the shop floor [and regular employees]” (Smith, 2003, p.37).

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Lean Sigma or Lean Six Sigma
The combination of the Lean and Six Sigma methodologies has the best result
for an efficient management approach. Hence, in 2008, Motorola integrated Lean and
Six Sigma methodologies and launched the Lean Six Sigma training and certificate
program. This new program can be used for the improvement of efficiency in a variety of
businesses such as banks, government agencies, and healthcare organizations.
According to Smith (2003):
 Lean brings action and intuition to the table, quickly attacking low hanging
fruit with kaizen events. (kaizen is a Japanese business philosophy of
continuous improvement of working practices and personal efficiency).
 Six Sigma uses statistical tools to uncover root causes and provide
metrics as mile markers.
 A combination of both provides the tools to create ongoing business
improvement (p.37).
The Lean Sigma management system became very popular, and its
implementation improved efficiency and saved a vast amount of money for many
organizations.

Lean and Six Sigma in Healthcare
The financial distress of recent years and the necessity of quality improvement in
the healthcare industry motivated many organizations in this field to look for a possibility
to increase efficiency and reduce overhead expenses. In this regard, many medical
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facilities have joined the group and adopted Lean, Six Sigma, or Lean Sigma
methodologies to eliminate waste and improve the quality of services in their operations.
In an article about Lean Leaders for Hospitals, Graban and Prachand (2010)
analyze “value” vs. “waste” in Lean methodology and propose how hospitals can benefit
from this method. In a traditional management approach, cost reduction inevitably is
accompanied by lower quality of services. However, in Lean methodology, both cost
reduction and quality improvement can be achieved simultaneously through teamwork,
respect for those who perform the actual work, and engaging all employees in problem-
solving and waste reduction. According to Graban and Prachand (2010):
A classical Lean definition of value requires three criteria to be met.
 First, the customer (patient) must be willing to pay for the given activity,
directly or indirectly. When a hospitalist initiates care in the Emergency
Department by placing admitting orders for a patient, the patient would
view this activity as a value because it progressed the care of the patient.
However, if the patient is forced to wait 5 hours in the Emergency Room
for an available inpatient bed while receiving minimal care, the patient may
likely view that time as waste;
 Second, the activity must move the process forward toward the desired
outcome in a meaningful way. Testing and exam activity that leads to a
diagnosis would meet this criterion, while unnecessary CT scans might
not;
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 Third, the activity must be done properly the first time so as to minimize
any rework …to free up more time to deliver value... When hospitalists
must take time to locate a colleague or a piece of information, that
‘‘hunting and gathering’’ time is waste (p.317).

In this article, the authors argue that reducing waste cannot be dictated as a
general rule. It needs systematic changes and continuous improvement with trials and
errors to find the best approach for the specific situation of the facility. “Motion (walking
and searching) is a common form of waste in healthcare.” For example, several studies
show that nurses spend only 30-35% of their time in patients’ rooms.
In 1922 Henry Ford wrote, ‘‘[i]n the ordinary hospital the nurses must make
useless steps. More of their time is spent in walking than in caring for the patient.” This
problem has not been addressed in many modern facilities yet. In many cases,
hospitals have old structures or, even in new buildings, they follow the old procedures.
In addition to inefficient workflow and wrong location of equipment, nursing units, and
medication storage, there are various wastes such as unnecessary tests, patient wait
times, uncoordinated care between members of the care team, and excessive
medication inventory in many hospitals. All these types of waste can be reduced
through the application of Lean methodology (Graban & Prachand, 2010).
The main focus of these articles is on the internal framework of the system
isolated from society and the environment in which the organization is located. In the
Lean and Six Sigma literature, there is no consideration about inefficiency in natural
resource consumption. The central attention is on cost reduction and money saving
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without seeing the organization as a part of a society and the environment. For
example, if medical waste incineration is less expensive than waste treatment for a
facility, then it would be considered as an efficient choice without bearing in mind the
negative impacts on the environment.
2.4. Summary and Discussion
Overall, the literature review suggests that the healthcare industry has significant
impacts on the U.S. economy, as well as on ecological degradation and human health.
Therefore, sustainable operation of medical services is a crucial issue which influences
the welfare of the entire society. Nevertheless, this field lags behind other industries in
sustainable development. A study of employees’ perceptions of and organizational
commitment to the Green movement indicates that “individuals in the non-healthcare
organizations are perceived to have a higher level of Green awareness than those in
the healthcare organizations” (Hartman, 2010, p.32). Scholars suggest that complexity
of rules and regulations in the healthcare system and the lack of business knowledge
and skills of managers and executives “to fully utilize the available automation and
technology” are among the fundamental causes of this situation (Hartman, 2011, p.17).
On efficiency and performance of Green initiatives in sustainable healthcare
organizations, the academic literature has not done much. However, different
intergovernmental and nongovernmental organizations have published a great number
of articles, reports, and case studies to introduce sustainable hospitals and their
successful experiences.
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Despite the efforts of these organizations and improvement of the operation of
some hospitals, it seems there is still a large gap between existing medical practices
and these exertions. The vast majority of hospitals do not consider any changes toward
sustainable operations. An interview with a representative of the Leadership in Energy
and Environmental Design revealed that in 2014, the total number of LEED certified
healthcare projects was only 98 buildings (Christopher M. Gray, LEED Media and
Communications Specialist, Feb. 2015). In 2010, hospitals spent about $20 billion for
constructions (Gray, 2011). If this amount had been used in eco-friendly buildings, it
could have benefited patients, society, and the environment for several years (hospital
buildings are usually used for more than 50-100 years, and their sustainable design and
construction could have a long term benefit for society).
For advancing the practice of Green Healthcare operations, it appears that there
is still a need for raising awareness among healthcare professionals about the negative
impacts of their practices on the environment. Also, there is a need for practical and
easy to understand descriptions of different Green initiatives. The focus should be on
low cost and smaller-scale measures, to expedite the sustainability trend in the
healthcare industry, and to encourage more facilities to start Green practices on any
scale that is feasible in their operations. It is very important that an increasing number of
medical centers join the Green movement as soon as possible. Results from this paper
provide more accessible, applicable, and understandable information about Green
initiatives in the healthcare industry for all stakeholders, specifically regular employees,
to educate all levels of medical employees about eco-friendly practices.
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Furthermore, since the core ideas of the Lean philosophy are very close to the
goals of the Green movement (improving productivity through eliminating waste), there
is a need for research on the feasibility of integration of environmental impacts of the
healthcare industry to the existing Lean and Six Sigma efficiency methods in this field.
Results of this literature review suggest that the next steps for advancing the
practice of sustainable healthcare activities are to:
1. Raise awareness about the massive environmental effects of the healthcare
industry amongst medical professionals at every level, with a special focus on
regular employees (not only managers and supervisors);
2. Identify the fastest, easiest, most practical, and affordable ways of reducing the
carbon footprint of medical organizations;
3. Expand the meaning of efficiency in Lean and Six Sigma management
methodologies to include environmental impacts of the medical services in their
analyses;
4. Develop comprehensive cost-benefit analyses of different Green initiatives in
medical practices; and
5. Create a cohesive policy recommendation for municipalities and local
governments to incentivize Green operations in healthcare facilities.
In general, healthcare workers have a very demanding and stressful work
environment. Therefore, if they do not fully understand the positive impacts of
sustainable practices on their health and workplace, adding Green requirements can
give them the feeling of adding more demands on their existing occupational stress.
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This study reviews different aspects of environmentally sustainable healthcare
operations to identify the most applicable Green initiatives in the healthcare industry. It
then explores the experiences of seven hospitals in various geographic locations to
learn about their hands-on experiences, successes, and limitations. Based on this
information, in the last chapter, the investigator provides a list of Green initiatives with
relatively low upfront costs, so that many small and medium-sized hospitals and medical
centers can start their Green activities as soon as possible. Environmentally sustainable
operations in the healthcare industry are an urgent necessity for public health. Medical
facilities cannot wait for the perfect moment to start, and scholars can pave the path
through more information and awareness.

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CHAPTER THREE: METHODOLOGY

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3.1. Philosophical Worldview
The philosophical worldview proposed in this study is pragmatism. This
philosophy “instead of focusing on methods, emphasizes the research problem and
uses all available approaches to understand the problem” (Creswell, 2009). This
philosophy is based on practical rather than theoretical deliberations. A pragmatic
researcher is open to explore and understand the problem and looks to the ‘what’ and
‘how’ rather than ‘why’, which indicates a cause-and-effect form of approach (Creswell,
2009).
3.2. Strategy of Inquiry
This study is a qualitative research project that is devoted to the scrutiny of
definitions, specifications, and performance of different aspects of Green healthcare
operations. The main focus is to investigate the most applicable Green initiatives in
healthcare settings and help to develop a foundation for a practical approach to
sustainability in the healthcare industry. Published academic literature, government
agencies’ publications, existing Green journals, conference proceedings, and internet
web pages are the primary sources of information in this study.
In addition, the experiences of several hospitals regarding their innovative
projects and Green initiatives have been reviewed to demonstrate the feasibility and
constraints on sustainable development in the healthcare industry. Green healthcare is
a relatively new subject, and academic literature on this topic is less abundant than
such subjects as LEED and Green buildings. Nonetheless, several healthcare practices
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and private hospitals in the U.S. have valuable experiences in this matter. Therefore,
their practical knowledge can be a reliable source of information for understanding the
opportunities, difficulties, or both in Green medical activities. Furthermore, a sustainable
operation is an ongoing activity for which maintenance is as important as (and
sometimes more difficult than) the initial implementation. Hence, these examples can
demonstrate the difficulties and opportunities in sustainable maintenance through years
of experiences.
3.3. Research Method
This study is intended to be informative and increase environmental
consciousness among healthcare professionals (in every level) through the most current
research findings regarding sustainable healthcare services, as well as experiences of
existing Green medical organizations. Data was obtained by conducting a literature
search on several sources using tools including Google Scholar, MEDLINE (National
Library of Medicine), ProQuest, and publications of the Environmental Protection
Agency (EPA), Practice Greenhealth, Environmental Excellence, Johns
Hopkins University, Green Guide for Healthcare (GGHC), Healthcare Without Harm,
Center for Health Design, Leadership in Energy and Environmental Design (LEED), and
WHO.
An initial literature scan (132 studies) revealed that a large number of Green
Healthcare studies have been written by non-healthcare professionals and are focused
on building designs, not the daily operations. Although changing some building
materials is necessary to provide a healthy environment for patients and staff, the
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Green movement is not only about Green structures of facilities. A Green building
makes sustainable operations much easier and more meaningful, but it is not enough
and cannot replace Green operations. Also, a Green structure should not be a
prerequisite for Green healthcare organizations because this approach can exclude
many medical facilities which cannot change or improve their buildings. There is a
significant body of literature on “Green design” and “LEED certification” while adequate
attention has not been paid to promoting sustainable daily operations of the healthcare
industry. Therefore, the focus of this research is on applying Green methods in medical
operations, not on construction and building design from an architectural viewpoint.
Furthermore, the literature scan determined that articles on the topics of
“sustainable healthcare operation” or “efficient healthcare operation” mostly concentrate
on financial savings and efficiency as a means of minimizing cost of the systems without
any concern about environmental impacts of healthcare practices. Thus, the keyword of
‘’sustainable healthcare” had to be changed to “Green healthcare” to be able to find the
relevant studies for review. Also, in order to make a bridge between traditional
approaches of healthcare operations with Green healthcare operations, some of the
studies on efficiency in healthcare facilities (not related to environmental issues) were
reviewed. The purpose was to find a faster way to convey the Green principles to
healthcare managements, decision makers, and employees, and encourage more
medical organizations to move toward ecofriendly practices.
After the literature scan, the next step was data validation. The validity of
information was confirmed by checking the source of data. The literature selected only
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from peer-reviewed journals or reliable governmental and nongovernmental agencies
such as EPA and WHO. The next step was scrutinizing and summarizing the studies to
be able to categorize the existing research on Green Healthcare operations. After this
step, all data (descriptive data as well as outcome and findings) relevant to the research
questions were extracted and categorized in five different groups that became the
foundation for this research. Four broad categories are directly related to different
aspects of Green healthcare, and one category is about the existing efficiency
methodologies in healthcare settings (not related to environmental issues).
In addition to published literature, to explore hands-on experiences and all
possibilities of transforming the healthcare industry to a more efficient discipline, the
investigator used multiple sources of data. Semi-structured interviews of people in
different levels of operation (management, staff, technical experts, physicians), and an
extensive documentary examination and analysis were the data gathering methods of
this part of the study (chapter 4 and 5). The investigator studied the Green
achievements of a total of 25 medical organizations, and conducted interviews with
employees and sustainability officers of seven hospitals in the United States and
Europe. These hospitals include Kaiser Permanente-Modesto Medical Center in
Modesto, California; St. John Hospital in Oxnard, California; Cottage Health System in
Santa Barbara, California; University Hospital Ospedali Riuniti "Umberto I - G. Salesi.
G.M. in Lancisi, Italy; General Hospital “St. George de Chania” of Chania, Greece; the
University Hospital “Virgen de las Nieves” of Granada, Spain; and the Hospital
“Fundacio Sanitaria de Mollet” of Mollet, Spain. The interviews and discussions took
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place between September 2012 and December 2015 and were conducted either on site
or via Skype, phone conference call, or email.
In spring 2012 the investigator conducted an online search to identify existing
Green healthcare facilities; and based on the obtained information made a contact with
the representatives of the Kaiser Permanente Health Care Company. Through a series
of conversations, Modesto Kaiser Permanente Medical Center agreed to be the subject
of a case study with a focus on Green measures in their operations. Over a period of
several months, the investigator reviewed the Environmental Impact Report (EIR) of the
building construction of the hospital. She also phone interviewed Mr. Steve Michel,
Senior Planner of the City of Modesto, Mr. Will Crew, chief building official of the City of
Modesto, Ms. Melony Hatchel, environmental coordinator of Kaiser Permanente, and
Ms. Susan Saito, public relations officer for Kaiser Permanente. However, after
preliminary agreements, due to confidentiality issues, the idea of a case study was
refused by Kaiser, but valuable information about their Green initiatives was delivered.
Therefore, information about the Modesto Medical Center in this paper was obtained
through phone interviews as well as Kaiser’s web pages.
In February 2013, the investigator approached Sister Suzanne Soppe, the lead
educator of St. John’s Hospital in Oxnard, California that was in the process of applying
for the Environmental Excellence Awards of the Practice Greenhealth. Sister Suzanne
welcomed the idea of a case study and provided invaluable information about Green
activities of the facility. The investigator had site interviews, phone interviews, and email
communications with Sr. Soppe, Mr. George West, Vice President of Mission
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Integration, and Ms. Amanda Tamburro, a staff member of the Health Education
Department. Through these sessions, they provided helpful information about the
existing situation of the hospital and their future plans. However, following these
communications, either the recorded data about their Green initiatives was not
available, or Mr. West (the decision maker) was not comfortable disclosing further
information. For example, the sustainability officers believed that one of their surgery
theaters had higher water consumption rate compared with another surgery room (with
the same operational capacity) and they wanted to investigate it. However, they had
only one water bill, and it was not possible to confirm or reject this assumption. Another
example was about their recycling performance. In recent years, they improved their
recycling program, increasing recycling and decreasing waste. Nevertheless, no
document was disclosed regarding this assertion. Therefore, the missing data was
obtained through their website insofar as possible.
In 2014, the investigator received information about Green measures in Cottage
Health System in Santa Barbara, California. She conducted data gathering through
Practice Greenhealth (studied the publications of the Practice Greenhealth about the
Cottage Hospital) as well as the hospital’s websites. She also had email and phone
interviews with Mr. Ruben Cosio, director of hospitality services and chair of the
Environmental Sustainability Committee, and Ms. Kris Warner, administrative assistant
of the Cottage Health System in Santa Barbara. These interviews provided information
about some of their Green initiatives, but there were no recorded data about the
benefits or costs of their Green measures in the hospital because they do not have any
fulltime employees for the sustainability committee and both environmental officers have
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fulltime jobs in other departments of the hospital and help this committee as part-time
volunteers. Information regarding this hospital was obtained through the interviews,
email communications, and the website of the organization.
The situation was getting harder and harder. Many hospitals either were not
Green or refused to share their information or both. Nonetheless, the search for hands-
on experiences using Green measures in medical facilities continued and the
investigator contacted the U.S. Green Building Council. She had several emails and
web communications with Mr. Christopher M. Gray (Media and Communications
Specialist of the U.S. Green Building Council) and obtained invaluable data (some are
not published on the website yet). This information determined the number of healthcare
LEED certified buildings and their ratio to the total number of Green buildings in the last
decade (Table 4.11)
The final data gathering was in 2015 and focused on an energy saving program
for four hospitals in Europe. A Skype interview and several email communications were
conducted with Mr. Davide Nardi Cesarini (in Angeli di Rosora, Italy) who is the project
coordinator of an innovative energy saving program of four European hospitals in Italy,
Spain, and Greece. These hospitals include University Hospital Ospedali Riuniti
"Umberto I - G. Salesi - G.M. in Lancisi, Italy, General Hospital “St. George de Chania”
of Chania in Greece, University Hospital “Virgen de las Nieves” of Granada, Spain and
the Hospital “Fundacio Sanitaria de Mollet” of Mollet in Spain. This program that goes
by the name of Green@ hospital, was started in 2012, and is an IT solution for energy
integration in public buildings, which can reduce the energy consumption of hospitals by
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15%. The experiences of these four hospitals can be a good guide for interested
hospitals in the United States and other countries.
The interviews with the representatives of the above hospitals, although not
providing a complete set of data for a case study of any particular hospital, offered first-
hand data about existing Green initiatives in those medical facilities, and confirmed and
augmented the previously obtained information about sustainability indicators in the
healthcare industry. The interviewees of the hospitals in this study include:
 Steve Michel, Senior Planner of the City of Modesto;
 Will Crew, chief building official of the City of Modesto;
 Melony Hatchel, environmental coordinator of Kaiser Permanente;
 Susan Saito, public relations officer for Kaiser Permanente;
 Sister Suzanne Soppe, the lead educator of St. John’s Hospital in Oxnard;
 George West, Vice President of Mission Integration, St. John’s Hospital;
 Amanda Tamburro, a staff member of the Health Education Department, St.
John’s Hospital in Oxnard, California;
 Ruben Cosio, director of hospitality services and chair of the Environmental
Sustainability Committee, Cottage Health System in Santa Barbara;
 Kris Warner, administrative assistant of the Cottage Health System in Santa
Barbara;
 Christopher M. Gray, Media and Communications Specialist of the U.S. Green
Building Council;
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 Davide Nardi Cesarini, the project coordinator of the Green@Hospital research
program of four European hospitals in Italy, Spain, and Greece;
 Roberto Pena, Azienda Ospedaliero Universitaria Ospedali Riuniti Umberto I –
G.M. Lancisi – G. Salesi in Italy; and
 Abelardo Ruiz, Kaiser Permanente / National Facilities Services, Oakland,
California
As mentioned before, after choosing the studies through reliable databases such
as MEDLINE, ProQuest, and Science Direct, the next step was data validation. After the
validation process, the investigator summarized the selected literature and extracted the
main findings of the studies. These summaries were classified into different categories,
based on the key points and main findings, to generate a conclusion in important
aspects of Green healthcare operations.
In general, the trustworthy literature (studies published in scholarly journals,
reliable governmental agencies’, or dependable nonprofit Green organizations’
publications) supported each other’s findings. However, on some issues such as PVC
and other plastic materials, there were many controversies on their adverse health
effects. In these cases, further research was warranted. Therefore, the investigator
studied and scrutinized more literature related to this specific issue, compared and
combined findings (with a focus on more reliable sources) to generate a precise
conclusion.
In addition, whenever possible, the outcomes were confirmed through the hands-
on experiences of the hospitals inspected in this study. In this regard, through several
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interviews, the investigator obtained information about the specific Green initiatives of
the aforementioned hospitals, initiations, implementation process, obstacles, and finally
the outcomes. Several times, the investigator requested more interviews for detailed
information. Nevertheless, there were missing data especially about the documented
financial impacts of the Green provisions on the operations and cost-benefit analysis of
each initiative. Inevitably, this information was completed through the hospitals’
websites insofar as possible.
In the next step, the investigator categorized the data and placed them in
different group subjects and different tables for each hospital to be able to compare the
outcomes of the organizations’ Green activities with each other, as well as to verify the
results with the main findings of the reviewed literature. This analysis helped to
determine the most applicable Green initiatives in healthcare settings. It also revealed
that the main focus of the reviewed literature was promoting sustainability in the
healthcare industry in general, not necessarily the time and cost involved with the
activity (the issues that were among the main concerns of the interviewed hospitals).
3.4. Limitations and Delimitations
Accessibility and business confidentiality were among the most important factors
that affected the time, design, and quality of this research. The initial plan of this
research was to conduct an exploratory case study of the Kaiser Permanente Medical
Center in the City of Modesto in the County of Stanislaus, California. However, data
accessibility was problematic and after initial interviews, the agreement was canceled.
No other Kaiser locations agreed to provide data about their Green initiatives more than
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their website’s information. Some of the medical facilities of Kaiser Permanente are
pioneers in developing and implementing environmentally sustainable practices in the
U.S. Hence, their experiences in Green practices can be very helpful for other facilities
nationwide. However, they did not agree to provide any data about the barriers or cost-
benefit analysis of different aspects of their Green operations. St. John’s Hospital in
Oxnard, Cottage Health System in Santa Barbara, and three Kaiser medical centers in
California were among facilities that the investigator approached to conduct a case
study of their Green initiatives. Nonetheless, these facilities either did not have any
records about the internal and external impacts of their Green measures or were not
willing to disclose those records for a case study. All facilities kindly agreed to disclose
general information about their practices, but not detailed data for a case study.
Therefore, the information about these facilities in this study is a combination of
materials that have been gathered through interviews as well as their websites’ data.
This situation created a basic challenge for obtaining accurate information about the
strengths or shortcomings of the Green healthcare experiences. It also forced the
author to change the plan, and instead of doing a case study of a specific facility, she
conducted a broader investigation of different Green initiatives in the industry to be able
to introduce various possibilities of ecofriendly approaches in medical services.
In addition, although Green buildings have great impacts on Green operations,
to be able to have an in-depth analysis of the issue, the main focus of this research is
on administrative procedures, not building design and structure. There is an extensive
literature regarding LEED constructions and sustainable structural planning from an
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architectural viewpoint that provides invaluable information. However, there is an
urgent need for research on sustainable daily operations of healthcare facilities, not only
buildings and building materials. Green structure is important, but it is not sufficient for a
Green medical facility.

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CHAPTER FOUR:

DIFFERENT GREEN INITIATIVES IN HEALTHCARE SETTINGS

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4.1. Preface
In an effort to develop theoretically informed practical knowledge about Green
healthcare, this chapter reviews different Green initiatives and evaluates the possibilities
and practicalities in healthcare settings. The aim is to understand the necessity of
environmentally friendly operations and find affordable and applicable ways of being
Green in the healthcare industry. The special focus is on basic and practical steps and
incremental changes in the field.
There is a common misunderstanding about Green healthcare that it is too
expensive. However, there are numerous sustainable measures that can be started
without a high upfront cost. As a matter of fact, some small and basic solutions such as
using energy efficient light bulbs, composting, recycling, and purchasing locally grown
food do not require a high budget while they have a massive impact on the environment
and public health. Experiences of different organizations show that any small effort can
help to understand the main concept of sustainability and change the culture of natural
resources consumption. The review of these Green initiatives can help medical
professionals choose the best solutions for the problems of unsustainable practices,
based on their own specific situations.
4.2. Waste Management
In recent years, waste management has become a dilemma faced in every field.
However, in the healthcare industry, this problem is multifarious and complex because it
deals with infectious and hazardous materials. Consequently, waste regulation in
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healthcare institutions is among the most important activities that affect the health of
people and the environment. In this regard, fully understanding the details of the “overall
waste stream” of a medical facility and integration of diverse approaches for solutions
are the main keys to efficient waste management (AHA, 2011). This chapter introduces
different solutions for diverting healthcare waste away from landfills and incinerators. It
also briefly reviews the harmful effects of waste burning to show the necessity of
minimizing medical waste incineration.
Every day, the U.S. healthcare sector generates about 7000 tons of waste, with
disposal costs reaching more than $10 billion per year (AHA, 2011). Only 10 to 15
percent of this medical waste is infectious and, with a correct approach, the rest can be
recycled, composted, or treated without burning (Figure 4.1.).
Figure 4.1: Hospitals’ Waste

80% to 85% of hospitals’ waste is not infectious or hazardous, and about 60%
80-85%
10-15%
5%
Hospitals' General Waste
Regulated Medical Waste
Hazardous Waste
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of it can be recycled or composted. Data adapted from American Hospital
Association (2011). Retrieved from
http://www.sustainabilityroadmap.org/topics/waste.shtml#overview

Waste Minimization
Waste minimization can be the first step of waste management in the healthcare
industry. Waste management, in general, is labor intensive, but it can reduce costly
medical waste disposal, material purchasing, and environmental damages, and
increase patients’ safety.
Based on the recommendations of the Practice Greenhealth organization (PGH),
developing a quantitative waste baseline can be a good step to initiate a waste
reduction program in hospitals and other medical facilities (Practice Greenhealth, 2014).
For this baseline, all divisions of a healthcare organization need to know the quantity
and types of waste they produce to be able to succeed in the waste reduction program.
In this regard, EPA has convened several workgroups to help hospitals and other
medical facilities to minimize their waste. These workshops include “baseline data
collection, model mercury virtual elimination plan, model comprehensive waste
reduction plan, education seminars, awards program, and clearinghouse of best
practices and service providers” (EPA, 2012). Reducing the waste created should
always be the first step in waste management. Reusing and recycling have second and
third priority.

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Overstocking Elimination
Purchase reduction of medical supplies and medications plays an important role
in medical waste minimization. In healthcare organizations, there is a tendency to over-
order materials “to be on the safe side” and prevent supply shortage. Nonetheless, all
the extra orders can end up being trash due to expiration. In this regard, the negative
environmental impacts of disposal of outdated medications (that is inevitable in an
overstock inventory), is severe. Several studies show that pharmaceuticals which enter
the environment through sewage, water, and animals’ bodies have significant impacts
on a wide variety of species and the food chain and eventually can cause ecosystem
imbalance. For example, extinction of Asian vultures is the result of exposure to
diclofenac drug (Arnold et al., 2013). Diclofenac (C14H11Cl2NO2) is a non-steroidal
anti-inflammatory drug that is used for pain management.
In addition, the high amount of annual expenditures of hospitals for medications
shows the necessity of reducing drug waste due to expiration. As an example, in 2009,
the hospitals in the United States spent $27.7 billion for medications (Gebicki et al.,
2014). For minimizing waste in medication and medical supplies purchases, the
hospitals can use the “Consignment Inventory” method, having their inventory at a
minimum level and keeping the vendors responsible for providing the supplies on a daily
basis:
Consignment Inventory is inventory that is in the possession of the customer, but
is still owned by the supplier. In other words, the supplier places some of his
inventory in his customer’s possession (in their store or warehouse) and allows
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them to sell or consume directly from his stock. The customer purchases the
inventory only after he has resold or consumed it (Piasecki,2000, para.1).
Some hospitals have started this approach using various methodologies such as
inventory elimination through Lean and Six Sigma methods, and digital supply
management including automated dispensing systems and “scanners and bar codes to
track supply use and notify central inventory of what is needed” in each department
(Dunn, 2009, para. 14).
Waste Segregation
Waste segregation is the next important step in waste management. This approach
can reduce medical and regular wastes significantly. As Figure 4.1 shows, waste in
hospitals and other medical institutions can be divided into two major categories; general
waste and medical waste. General waste does not need any special treatment if there is
no contact with contaminated waste or patients. Medical waste, however, needs special
handling based on the waste category. If for any reason, the separation between these
two groups is not done properly, then the entire volume of waste should be considered
infectious and hazardous (Practice Greenhealth, 2014).
Therefore, it is essential to have waste segregation from the starting point in
each department. Each unit can start with small changes and build upon the successes
based on the types of waste and specific situation of that department. For example, with
a thorough waste separation program, kitchens of hospitals are able to reduce their
waste close to zero. A high percentage of their waste can be composted, food
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packaging can be recycled, and the rest (that should be close to zero) does not need
any special treatment. In a better scenario, hospitals can order food and raw materials
through vendors with reusable packaging (see recycling section). This approach needs
careful management, and it is labor intensive. However, it has a high return on
investment because it reduces the costly medical waste disposal, and healthcare
organizations can save significant amounts of money. In addition, this method has a
positive impact on the environment and ultimately patients’ health that is the main
mission of the healthcare industry.
Medical Waste Incineration
Incineration has been a traditional way of treatment and disinfection of medical
waste for more than a century. Unfortunately, incinerators produce greenhouse gases
(GHG), dioxin, and mercury and other heavy metals that are among the most
dangerous environmental toxins. “Incineration of municipal, medical, or hazardous
wastes is the major source of dioxin and the fourth leading source of mercury
emissions” (EPA, 1999, p.2).
Some negative effects of mercury and dioxin on human health
Mercury (Hg). Mercury is one of the byproducts of burning medical and
municipal wastes. It exists in three chemical forms:
 Methylmercury;
 Elemental mercury; and
 Organic and inorganic mercury.
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Each chemical form has different adverse health effects on the human body
(Tables 1.2, and 4.1). Methylmercury can cause impaired neurological development for
fetuses, infants, and children. Elemental or metallic mercury can cause tremors, mood
swings, nervousness, excessive shyness, insomnia, weakness, and headaches. Higher
exposures can cause death. Organic and inorganic mercury cause similar problems and
damage kidneys and the nervous system (EPA, 2014).
Table 4.1: Adverse Health Effects of Mercury Exposure

Chemical Forms of Mercury Negative Effects on Human Health
Methylmercury
 Loss of peripheral vision
 Lack of coordination of movements
 Impairment of speech, hearing, walking
 Impaired neurological development for
fetuses
Elemental Mercury

 Damage to lungs causing cough, sore
throat, shortness of breath, and chest
pain
 Neurological damage causing tremors,
mood swings, nervousness, excessive
shyness, insomnia, weakness, and
headaches

Organic and Inorganic Mercury
 Damage kidney and nervous system
 Skin rashes and dermatitis
 Mood swings
 Memory loss
Source: Data adapted from EPA (2014) and USEPA, Agency for Toxic Substances
and Disease Registry (ATSDR). Retrieved from
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https://www.epa.gov/mercury/health-effects-exposures-mercury#methyl
http://www.atsdr.cdc.gov/mercury/docs/healtheffectsmercury.pdf
The healthcare industry is a significant source of mercury pollution. In medical
facilities mercury can be released from blood pressure devices, thermometers, and
gastrointestinal products. “At room temperature significant amounts of liquid elemental
mercury transform to a gas, exposing workers or patients in the area to potentially
highly toxic levels” (Healthcare Without Harm, n.d., para.3). Also, “medical waste
incinerators (MWI) contribute 13% (the fourth-largest source) of the anthropogenic
mercury emissions to the environment. Additionally, hospitals contribute 4 to 5% of the
total wastewater mercury load in some communities” (EPA, 2002, p.1). Furthermore,
many cleaners, preservatives, and lab chemicals such as sodium hypochlorite, urine
analysis reagents, wash solutions, fixatives, antiserums, and antigens contain mercury
which can contaminate the environment (Health Care Without Harm, 2001). Hence, the
use of non-mercury devices in hospitals is recommended. This provision can improve
public health and reduce compliance costs for the organization.
Dioxin. “Dioxin is the common name for a group of toxic chemicals that are often
made as unwanted byproducts of burning” organic material, such as paper products, in
the presence of chlorine (EPA, 1999). This hazardous chemical compound is
environmentally persistent, and its exposure can cause cancer, liver disease,
depression, weak immune system, skin rashes, diabetes, and learning disabilities.
Incinerators produce dioxin through burning polyvinyl chloride or PVC (#3 or V plastics).
In hospitals, IV bags, IV tubing, blood bags, specimen bags, anesthesia masks,
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examination gloves, catheters, feeding tubes, dialysis tubing, sharp containers, bed
pans, and other supplies contain PVC (Harris, 2005).
Safe alternatives to medical waste incineration. The US Environmental
Protection Agency has introduced several alternatives to incineration of medical waste
such as thermal treatment (i.e. microwave technologies), biological processes, steam
sterilization (i.e. autoclaving), electropyrolysis, and chemical mechanical systems (EPA,
2012). Most of the non-incineration medical waste treatment technologies can be
installed on-site at a hospital or medical facility. Using these technologies provides an
opportunity to minimize medical waste incineration and its negative impacts on public
health.
Recycling
Recycling is not the first choice for minimizing waste production in the healthcare
industry; instead, using reusable materials (i.e., equipment, supplies, and packaging) is
the best approach. However, in situations when utilizing reusable or returnable supplies
is not possible, recycling can be useful (Practice Greenhealth, 2014). Establishing a
recycling program in a medical institution requires careful planning and continuous
education. It needs full-time staffing to create incentive programs and teamwork among
employees. Recyclable materials including paper and paper products, packaging,
plastics, glasses, metals, and wood should be collected carefully in separate clearly
signed bins, and recycled separately (EPA, 2002).
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Paper. In the United States, about 30% of all wastes and more than 50% of all
recyclable materials are paper or made from paper (EPA, 2010).
Figure 4.2.: Nonhazardous Solid Waste in Hospitals, U.S.A.

Source: Data adapted from Environmental Protection Agency (2002). Retrieved from
https://www3.epa.gov/region9/waste/p2/projects/hospital/totes.pdf
As Figure 4.2. shows, about half of the nonhazardous solid waste in hospitals is
paper or paper products such as cardboard that mostly belongs to packaging and
administration divisions. This number shows the importance of paper recycling in the
healthcare industry. With a correct segregation and contamination prevention program,
more than 60% of nonhazardous solid waste can be reused or recycled (CalRecycle,
2009). Unfortunately, some incinerators use paper for heating up their furnaces, while
“more than 5,000 products including masking tape, bandages, dust masks, and hospital
gowns can be made from recycled paper” (EPA,2014).
3%
7%
15%
10%
45%
10%
10%
Wood 3%
Glass 7%
Plastic 15%
Metal 10%
Paper-Paper products 45%
Other 10%
Food 10%
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Plastic. The next noticeable item for recycling, in hospital waste, is plastic that is
used in almost all departments of hospitals and medical institutions from diagnostics
and treatments to admissions and administration divisions. However, not all kinds of
plastics are recyclable. As Table 4.1. shows, there are different kinds of plastics with
various characteristics and recycling possibilities (not all plastics are recyclable).
Unfortunately, the overall recycling rate of plastics in the U.S. is very low (Figure 4.3). In
2008, the recycling rate for plastics was only 6% and in 2012 was 9% (EPA, 2014). Not
only does “making plastic from recycled materials needs less energy than making new
plastics”, but recycling also produces less waste for landfills and incinerators (National
Recycling Coalition , 2014).
Figure 4.3: Plastic Waste Disposal in the United States (2008)

Source: Reprinted from North, E. J., & Halden, R. U. (2013). Retrieved from
http://journalistsresource.org/studies/environment/pollution-environment/plastics-
environmental-health-literature-review
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According to the U.S. Environmental Protection Agency, Office of Resource
Conservation and Recovery (2009), plastic waste generation in the United States from
1960 to 2008 increased exponentially. In 1960, plastic waste generated in the U.S. was
390 thousand tons or “less than 1% of the waste stream” (p.41). By 2008, this number
increased 76 fold and became 30 million tons or 12% of the waste stream.
Unfortunately, degradation of plastics takes a long time (e.g., PE has a half-life of
48 years). According to Woods End Laboratories (2011), oceans contain one hundred
million tons of non-degraded plastic trash and this amount is increasing rapidly. Hence,
it is essential to maximize recycling and minimize the usage of non-recyclable materials
such as plastic bags and white foam cups and containers.
As mentioned above, establishing any recycling program in medical facilities
needs careful planning and a leading team to implement the program in a correct way.
Sustainability is a lifestyle and needs to be adopted based on the specific situation of
each organization. The job of the recycling team and leaders is to find the most
environmentally friendly approach in different circumstances. For example, shipment of
recyclable resources involves GHG emission and long distance transportation of
materials is not efficient (EPA, 2002). Therefore, before any planning, it is necessary to
coordinate with regional recyclers and waste reduction services and make arrangement
to prevent long distance deliveries. Also, it is important to educate staff and
management about the risks of ignoring environmental protection and dangers that can
be threatening to their health and their patients’ safety.
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In 2002, the United States Environmental Protection Agency prepared a case
study report about recycling of blue sterile wrap and plastic film in Dominican Hospital
(Catholic Healthcare West) in Santa Cruz, California and the Legacy Health System
(LHS) in Portland, Oregon. “Blue wrap is made from polypropylene [or number 5 plastic
that] is used for wrapping surgical instruments for sterilization [in surgical rooms]. Sterile
[and] uncontaminated blue wrap can be collected for recycling” (CalRecycle, 2009).
According to this report, “blue sterile wrap represents about 19% of all surgical
service waste.” By adopting this recycling program, LHS was able to divert away 3.5
tons of plastic from landfills each month and the diversion rate for the Catholic
Healthcare West was 8 tons of plastic in one year. Unfortunately, the financial benefits
of these recycling programs are not substantial because polypropylene (# 5 plastic) is
inexpensive.
As these numbers show, different organizations using different quantities and
types of plastic and have different results. There is no single formula for success in
recycling initiatives in all medical facilities.

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Table 4.2: Different Types of Plastics and Their Usage
Plastics
Type of Resin
Content
Resin
ID
code
Common
Recycling
Common
Usage
Major Concern
Reported
PET, PE

or PETE
polyethylene
terephthalate
1 yes
beverage
bottles

Antimony (a toxic
chemical) leaching
when plastic is in heat

HDPE
high-density
polyethylene
2 yes

food storage
detergent
bottles

_
PVC

or V
polyvinyl
chloride
3 no
plastic based
medical
devices

DEHP commonly found
in PVC –
can be carcinogenic -
dioxin formation in
incinerators

LDPE
low density
polyethylene
4 yes plastic bags _
PP polypropylene 5 yes

blue sterile
wrap in
hospitals

_
PS polystyrene 6 yes
food service
containers

styrene exposure can
cause headache,
fatigue, and depression

O
BPA
Bisphenol a
Mixed Plastics
7 no

food
packaging
plastic
containers

release of chemicals
that act like the sex
hormone estrogen

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Note: “PETE plastic should not be reused because cleaning detergents and high
temperatures can cause chemicals to leach out of the plastic. Plastic #1 is only intended
for one-time use.” DEHP “is a manufactured chemical that is commonly added to
plastics to make them flexible… EPA has determined that DEHP is a probable human
carcinogen.” Data adapted from DEPARTMENT of HEALTH AND HUMAN SERVICES,
Public Health Service Agency for Toxic Substances and Disease Registry (2002), and
BABY green thumb (2011). Retrieved from
http://www.atsdr.cdc.gov/phs/phs.asp?id=376&tid=65
http://www.atsdr.cdc.gov/ToxProfiles/tp9-c1-b.pdf.
http://www.babygreenthumb.com/p-122-safe-plastic-numbers-guide.aspx

Reusable medical supplies. Healthcare facilities pay billions of dollars for
disposable medical supplies each year in the United States (Lee, 2012). As Table 4.3.
shows, the demand for disposable medical supplies (in four categories of drug delivery
products, wound management products, nonwoven medical disposables, and other
disposable healthcare materials) will increase 4.3 percent annually to $57 billion in 2021.
Although not all medical supplies can be reusable or returnable (e.g., blood
glucose test strips), the use of reusable items such as surgical textiles, isolation gowns,
and surgical packs (sterile or non-sterile) can bring millions of dollars savings for medical
facilities and divert tons of waste from landfills and incinerators. For sanitation concerns,
the laundry providers should be accredited by the Healthcare Laundry Accreditation
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Council (HLAC). As an example, fifteen years ago, the University of Maryland Medical
Center decided to go with reusable textiles and, therefore, utilized a vendor to provide
sterilized surgical textiles. The analysis of this practice in 2010 showed the diversion of
138,748 pounds of waste from landfills, $38,849 savings in waste disposal costs, and
$39,000 in ROI (Practice Greenhealth, 2011).

Table 4.3: Disposable Medical Supplies Demand in the U.S.
Items
Million Dollars/Year
2006 2011 2016 2021
Drug Delivery Products 7200 9480 12230 15600
Wound Management
Products
7210 8550 10120 12000
Nonwoven Medical
Disposables
4030 5060 6240 7600
Other Disposable Medical
Supplies
11570 14660 18110 21800
Total (Million Dollars) 30010 37750 46700 57000

Source: Data adapted from Lee (2012). Growing demand seen for disposable medical
supplies. Retrieved from
http://www.modernhealthcare.com/article/20120404/NEWS/304049984

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Reprocessing
Reprocessing of medical equipment is one of the most profitable Green initiatives
for medical facilities because it can reduce the cost of medical equipment by 50% or
more. At the same time, this practice reduces medical waste substantially. According to
the Practice Greenhealth (2011) “More than 70% of hospitals nationwide now reprocess
some or all of their FDA-eligible medical devices.” However, patient safety is the main
concern for acceptance of medical equipment reprocessing in many healthcare
facilities. In this regard, the Food and Drug Administration assigned medical devices
into three regulatory classes with different levels of control and safety requirements
based on the risk involved for patients (Table 4.4). A comprehensive regulatory policy
and “detailed quality-control standards to recalibrate, clean, sterilize, and remanufacture
medical equipment” can assure healthcare facilities about the safety of their patients
(Practice Greenhealth, 2011).
In 2002, the government required that all reprocessed single-use devices need to
have identifications and labels that show their certifications. In 2008, the U.S.
Government Accountability Office (GAO) released a report that showed “reprocessed
SUDs do not present an increased health risk when compared with new, non-
reprocessed devices. Of the 434 adverse events reported to the FDA between 2003
and 2006 in which reprocessed SUDs were identified, only 65 actually did involve a
reprocessed device, and all adverse events were similar to those reported for new
devices” (Kwakye et al., 2010).

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Table 4.4: Reprocessing of Medical Devises
Class of Safety Class I Class II Class III
Safety Measure
of
Reprocessing
Low Risk Medium Risk High Risk
Requirement

Exempt from
premarket
notification report

Submission of a
premarket notification
report is required

Reprocessing is not
recommended
Medical
Devices

Elastic bandages

Pulse oximeter

Balloon angioplasty
catheters

Pressure infuser
bags

Sensors

Percutaneous tissue
ablation electrodes

Tourniquet cuffs

Ultrasound catheters

Implanted infusion
pumps
General-use surgical
scissors

Drills

Compression sleeves

Most laparoscopic
equipment

Source: Data adapted from Kwakye et al. (2010). A Call to Go Green in Health Care by
Reprocessing Medical Equipment. Academic Medicine, 85(3), 18-23. Retrieved
from http://search.proquest.com/docview/210945963?accountid=14749

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Composting to Reduce Food and Landscape Waste
Composting is another Green initiative that is very helpful for waste minimization
in both large and small healthcare organizations. However, in the food recovery
framework, it is the last preferred choice before landfill disposal. The first choice always
is the principle of “source reduction” that works for all natural resource consumption
(Figure 4.4). The strategy of food waste reduction should always start before food is
prepared. This approach not only helps to save many resources associated with food
production (such as water, energy, fertilizers, and pesticides), but it also reduces the
amount of greenhouse gas (GHG) emissions induced by growing, manufacturing,
transporting, and disposing of food. According to EPA (2009), GHG emission of food
preparation and delivery is very high, and 13% of the total GHG emissions in the U.S.
are the result of creation and transportation of food. Also, “food waste is the single
largest component of the US municipal solid waste (MSW) that enters landfills and
incinerators.” (USAPHC,2013, p.1). In 2010, 14% of the MSW generated in the U.S.
was food waste of which only 3% was recycled and the rest (97%) was disposed. Food
waste is “a significant source of methane (a potent greenhouse gas with 21 times the
global warming potential of carbon dioxide)” in landfills (EPA, 2014).
Minimizing food waste in a hospital can be started by improving food preparation
process through a careful assessment of all details that contribute to excess food
preparation. These details are not the same in different organizations; therefore,
planning cannot be the same. For example, a study of the U.S. Army Public Health
Command (USAPHC) showed that “having a choice of meals [for patients] results in
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less waste, cold food is more likely to be wasted” (USAPHC, 2013, p.4)., and women
prefer smaller portions. Consequently, they have more leftovers. Also, this study found
that long staying in the hospital increases the possibility of wasted food. These
experiences show that waste management needs careful planning, and the specificity of
each hospital should dictate its waste minimization policy and program. Furthermore,
understanding the amount and type of food waste, as well as cost analysis of the
current disposal method, is the next step for having a realistic evaluation of the existing
situation and finding the best solution to improve the status quo. In this regard, EPA
has provided several techniques and software for waste measurement to help
organizations improve their waste management and protect the environment (USAPHC,
2013).
After hospitals optimize their food preparation and obtain detailed information
about their food residuals and cost of disposal, then the waste management team
should coordinate with different organizations such as shelters and food banks to
donate their extra food to hungry people. Based on the EPA suggestion, the next step
should be reaching out to licensed farmers and zoos and donating the excess food to
them to feed their animals. Finally, the last alternative before composting is offering food
residuals for industrial usage. According to EPA (2013):
Liquid fats and solid meat products are materials that should not be sent to
landfills or disposed of in the sanitary sewer system. Fats, oils, and grease
(FOG) can clog pipes and pumps both in the public sewer lines as well as in
wastewater treatment facilities… FOG should be sent to the rendering industry to
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be made into another product, converted to biofuels, or sent to an anaerobic
digester [to generate electricity] (para.3).
Once these provisions for the reduction of prepared food and residuals in
hospitals have been done, then the next step can be composting (Figure 4.4). “The
main objective of composting is to transform organic materials into a stable usable
product” (Epstein, 1996). Composting is a biological oxidation, and can be done onsite
or offsite (through other organizations) in various methods. Conditions such as space
availability, quantity and type of food waste, and the budget that has been designated
should be considered before establishing a composting program.

Figure 4.4: Food Recovery Hierarchy

Source: Reprinted from EPA (2013). Retrieved from https://www.epa.gov/sustainable-
management-food/industrial-uses-wasted-food
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Onsite composting needs a “well-designed system” to function properly. “If the
biological system is violated, conditions will not be optimized for composting, and
problems such as odor generation, insufficient aeration or moisture, or a combination of
these conditions may result” (Epstein, 1996). The result of the recent survey by the U.S.
Army Public Health Command of several hospitals showed that the majority of them
were able to save money by composting or, at least, break even while conserving the
environment. The hospitals stated different motives for composting as follows:

 A good start. The facility had a point person for sustainability, a
justification for composting that focused on waste, efficiency, and saving
money more than on being “green,” the food service personnel led the
project design (it’s their workspace and labor after all), and upgrades such
as including biodegradable to-go-ware were phased in slowly.
 Composting as implemented did save money or at least broke even when
compared to waste disposal.
 Availability of offsite composting facilities and food waste transporters.
 If composting on-site, partnering with grounds maintenance or operations
and maintenance staff to maintain composting equipment [this partnership
reduces labor costs, therefore, it is more reasonable for the hospitals to
continue composting].
 Composting only pre-consumer food waste and no free liquids [free liquids
are the materials that drip from the waste and require specific treatments;
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regulations prohibit the landfilling of free liquids]. Post-consumer food
residuals were contaminated with paper and too time-consuming to
separate; free liquids led to spills in storage. [In some hospitals reviewed
in this study, the reason that they continued composting was that they
compost only pre-consumer food and do not need to deal with all the rules
and regulations of composting.]
 Staff quickly adjusted to separating compostable food residuals from
trash, and the separation did not cause additional labor.
 The facility had enough space and the right containers or equipment to
store or process food residuals without causing odors or attracting pests
or vectors [vectors are organisms that transmit disease to humans]. For
offsite composting, this included a pickup frequency that prevented odors
or pests.
 As an unexpected benefit, weighing all food waste before disposal raised
the kitchen staff’s awareness of wasteful practices and reduced food
waste significantly (U.S. Army Public Health Command, 2013, p. 8).

The hospitals stated the following reasons for discontinuing their composting
activities:
 Offsite composting facilities or transporters went out of business or
stopped accepting food residuals.
 Onsite composting equipment broke down, the manufacturer was no
longer in business, and no one on site could repair it.
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 Staff turnover resulted in failure to separate compostable food residual
from waste.
 Poorly designed storage containers or composting equipment allowed
odors and attracted vectors and pests (U.S. Army Public Health
Command, 2013, p. 9).

4.3. Water Conservation in The Healthcare Industry
Global water scarcity is one of the most challenging problems of the 21
st
century.
In the last decades “intensifying competition for water resources by agricultural,
industrial, and domestic users has led to a sharp increase in stress on aquatic and
wetland ecosystems” (Jury, 2005, para. 3). In this situation, new water management
approaches indicate that conservation measures can be extremely effective. Increasing
water use efficiency, recycling used water, and reclaiming polluted water can all
significantly reduce water consumption.
In the healthcare industry, water conservation can benefit the environment by
minimizing water consumption as well as decreasing wastewater discharges. In
addition, water use reduction can improve energy saving significantly because water
treatment and delivery consume a considerable amount of energy. For example, five
minutes running a lavatory faucet uses as much energy as a 60-watt light bulb in 22
hours (EPA-WaterSense, 2012). Therefore, saving water benefits the environment in
numerous ways.
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According to the USEPA (2012), the healthcare industry is responsible for about
7% of the total water consumption of all commercial facilities. Domestic (hospitals’
inpatient washing and bathing facilities) and restroom and cooling and heating systems
have the highest level of water consumption. Therefore, adding efficient plumbing
fixtures and improving HVAC (heating, ventilation, and air conditioning) efficiency can
reduce water consumption significantly. The other water-intensive areas in healthcare
facilities include medical equipment, landscaping, kitchen, and laundry facility (Figure
4.5).
A detailed water management system is an important key to water conservation
in the healthcare industry. The U.S. Environmental Protection Agency suggests the
following system for effective water-efficient practices in medical buildings:
 Develop a water management plan;
 Assess your water use to identify opportunities for savings and track results;
 Check regularly for leaks and, when found, repair them promptly;
 Consider replacing bathroom fixtures with more efficient models;
 Consider retrofitting or replacing medical equipment to more efficient models;
 Eliminate single pass cooling by recirculating cooling water or moving to air-
cooled systems.
 Evaluate equipment in cafeterias and laundry for potential water savings; [and]
 Review WaterSense at Work for information on these practices and more (EPA-
WaterSense, 2012, para.2).

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Figure 4.5: Water Consumption in Hospitals

Source: Data adapted from (EPA, 2012). “Created by analyzing data from:
New Mexico Office of the State Engineer, American Water Works
Association (AWWA), AWWA Research Foundation, and East Bay
Municipal Utility District.” Retrieved from
https://www3.epa.gov/watersense/commercial/types.html#tabs-hospitals
Water efficiency can be achieved through outdoor as well as indoor water use
reduction. Experiences of different hospitals indicate that, with careful management,
many water-efficient measures are feasible without a high upfront cost because small
changes can have large impacts on water conservation. According to EPA (2012), more
than 6% of the water consumption in medical facilities is from malfunction and plumbing
fixtures’ leaking that can be prevented with careful supervision. Even small leaks can
waste a significant amount of water (Table 4.5).
0
5
10
15
20
25
30
35
20
15
7
9
7 7
35
Water Consumption in Hospitals %
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Table 4.5: Potential Losses from Water Leaks
Malfunction
Leaking Flow
Rate
(gallons/minute)
Water Loss
gallons/month
Estimated Cost of
Water Loss
Leaking Toilet 0.5 21,600 $2,100 per year
Drip Irrigation Malfunction 1.0 43,200 $4,300 per year
Unattended Water Hose
at Night
10.0 5,400 $16,000 per year
Tempering water line on a
Steam Sterilizer Stuck in the
On Position*
2.0 86,400 $8,600 per year
Stuck Float Valve in a
Cooling Tower
5.0 216,000 $21,000 per year

Note*: “Steam Sterilization is a simple yet very effective decontamination method.
Sterilization is achieved by exposing products to saturated steam at high temperatures
(121°C to 134°C). Product(s) are placed in a device called the autoclave and heated
through pressurized steam to kill all microorganisms including spores.” Reprinted from
EPA (2012). Retrieved from
https://www3.epa.gov/watersense/commercial/managing_water.html#tabs-leaks
http://www.lso-inc.com/sterilization-validation-services/iso17665-steam-sterilization.html

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Indoor Water Use Reduction
To reduce indoor water consumption, the U.S. Environmental Agency, LEED,
and CALGreen suggest utilizing efficient plumbing fixtures for the buildings as well as
water-efficient medical, heating, and cooling equipment. However, promoting
sustainability culture and passion and commitment to water conservation, among
medical professionals and regular healthcare employees, is as important as (if not more
than) the technical efficiencies. Therefore, educating the employees should be the first
step of water-efficient practices. The employees need to be a part of the program and
understand the details of the planning, implementation, and equipment improvement of
the facility. They must be encouraged to share their ideas and report any malfunctions
of the new equipment as soon as they notice them. Without well-informed and
committed employees, long-term maintenance of a water- efficient program would not
be possible.
In this regard, there is no one set of actions appropriate for all facilities’ efficiency
practices. Rather, different organizations can utilize different water-saving initiatives
based on their particular situations. After a careful planning for education,
implementation, and maintenance strategies for water-efficient activities, utilizing low-
water plumbing fixtures and medical, heating, and cooling equipment can improve water
reduction efforts in the organization. These improvements can be started by small
changes with low upfront costs and gradually extended to greater changes with higher
impacts. For indoor water consumption, medical facilities have room for water-efficient
practices in many areas such as sterilizing, vacuum systems, image processing for x-
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rays, air-conditioning and boilers, hygiene practices, food preparation, and plumbing
fixtures.
Although upgrading plumbing fixtures can save a significant amount of water
(Table 4.5), the upfront cost is one of the main obstacles in healthcare settings. Also,
some studies (e.g., Hartman et al., 2009; 2011) revealed that employees’ knowledge
about environmental issues has a direct effect on their behavior regarding natural
resources (including water) conservation. Therefore, financial capabilities and
managements’ and employees’ knowledge are among the main factors that affect the
decisions about water conservation. In addition, recent technical advancements have
allowed remarkable efficiency improvements in medical and mechanical equipment and
plumbing fixtures. They provide substantial water and energy saving and their payback
time is much less than before. Increasing the price of energy and decreasing payback
years of improvements should encourage healthcare stakeholders to make more
environmentally sustainable decisions. According to EPA- WaterSense Program (2012),
water-efficiency measures, on average, can reduce water consumption by 15%, energy
consumption by 10%, and operating costs by 11%. Upgrading regular lavatory faucets
(2 gallons per minute [gpm]) to laminar spray flow faucets (0.5 gpm), and regular
shower heads (2.5 gpm) to efficient shower heads of (1.5 gpm) can save a significant
amount of water. Also, water-efficient toilets use 1.28 gallons per flush (gpf) vs. 6 gpf of
old toilets and 3.5 and 1.6 gpf in newer toilets.

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Table 4.6: A Practical Experience of Retrofit and Replacement of Medical and Sanitary
Equipment in a Hospital
Project
Water
Savings
(gallons/year)
Estimated
Payback
(years)
Medical Equipment Retrofits and Replacements
Steam Sterilizer Pump Replacement and
Condensate Collection
1,600,000 1.9
Replacement of Non-Water-Using Medical Air
Compressors (reciprocating system)
790,000 5.0
Waste Anesthesia Gas Pump Replacement 530,000 5.7
Mechanical System Replacements
Replacement of Single-Pass Cooling Ice
Machines, Air Conditioning, and Refrigeration
Equipment
more than
330,000
1.1
Sanitary Retrofits and Replacements
Retrofit of Flushometer-Valve Toilets With Dual-
Flush Valves and Handles
2,300 4.8
Installation of 1-Pint Urinals 10,000 3.4
Installation of Some Dual-Flush Flushometer-
Valve Toilets
9,800 6.8
Installation of 1.5 GPM (gallons per minute)
Showerheads
3,700 2.1
Installation of Reduced Flow Rate Faucets 1,500 4.5
Commercial Kitchen Replacements
Installation of a More Efficient Tunnel
Dishwasher
660,000 18.0
Installation of a Food Separator and Garbage
Composting System
1,000,000 Not available
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Project
Water
Savings
(gallons/year)
Estimated
Payback
(years)
Outdoor Replacements
Installation of a Weather-Based Irrigation
Controller
1,000,000 Not available
Total
Approximately
5,900,000

Note: with today’s more advanced equipment, there are more opportunities to save
water and energy through efficient practices. Data reprinted from EPA-WaterSense
(2014). Retrieved from
https://www3.epa.gov/watersense/commercial/tools.html#two
https://www3.epa.gov/watersense/docs/ci_casestudy_provstpeterhospital_508.pdf
In an effort to demonstrate a practical experience (and as a role model), the
USEPA- WaterSense Program (2014) presented a case study of Providence St. Peter
Hospital in Olympia, Washington, which started its water-efficient practice more than 10
years ago. The results indicate that this hospital was able to save a significant amount
of water through various water reduction measures (Table 4.6).
Outdoor Water Use Reduction
Outdoor water use reduction can be achieved through measures such as water-
efficient irrigation systems, landscaping with native plants, urban run-off prevention
through drainage and permeable asphalt, rainwater collection, more frequent landscape
maintenance, and pulling weeds to decrease competition for water.
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Water efficient landscaping. Landscape irrigation is one of the important
freshwater expenditures that is often overlooked as an area for water conservation.
Outdoor water consumption can be reduced significantly by using efficient methods,
such as drip irrigation, Xeriscape, and native plants, without any detriment to the water
system. In all types of irrigation systems, installation of a weather-based irrigation
controller is essential.
Xeriscape. According to the U.S. Environmental Protection Agency (2002):
Xeriscape landscaping is defined as ‘quality landscaping that conserves water
and protects the environment.’ The word “Xeriscape” was coined and copyrighted
by the Denver Water Department in 1981 to help make water conserving
landscaping an easily recognized concept. The word is a combination of the
Greek word “xeros,” which means “dry,” and “landscape.” … EPA is using this
term with permission from Denver Water.
The seven principles upon which Xeriscape landscaping is based are:
• Proper planning and design
• Soil analysis and improvement
• Appropriate plant selection
• Practical turf areas
• Efficient irrigation
• Use of mulches
• Appropriate maintenance (USEPA, 2002, p.2)
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In Xeriscape, the goal is to use dry tolerant plants, not necessarily all native
plants. Also, the Xeriscape landscaping is low maintenance; however, appropriate
design and planning is important to have a beautiful garden. Many people do not like
Xeriscape and prefer to have flowers with bold colors. In these circumstances, drip
irrigation systems are good alternatives. These systems can save about 50% water
compared with regular sprinkler irrigation systems.
In this research, in the interviews with representatives of three hospitals in
California, the investigator asked about their plan for efficient landscaping. All
answered, “we need to have a beautiful garden for our patients.” This answer shows the
common misconceptions about efficient landscaping.
Drip irrigation. Drip irrigation systems are considered the most efficient
automated irrigation methods (Table 4.7). However, it is important to have enough
knowledge about the system, its benefits and disadvantages, and all requirements
before any action is taken to install drip irrigation. In this method, emitters apply low-
pressure water (at 0.5 to 2.0 gallons per hour) precisely on to the plant's root zone. So
no water is wasted on non-growth areas, and the root zone is maintained at its ideal
moisture level. A drip irrigation system maximizes water use efficiency by reducing
water runoff, evaporation, or deep percolation, and can be used for plants with high or
low water demands. Therefore, if for any reason Xeriscape is not desirable, using
efficient irrigation systems such as drip irrigation is a good alternative.
In any situation, it is strongly recommended to remove grass turf from
landscaping in arid and semi-arid regions such as California. There is a misconception
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among people that beautiful gardens are only possible through having grass turf, but
grass turf requires 30-50% more water than other groundcovers. As a general rule, if
having grass needs irrigation, it means grass turf is not appropriate for that climate.
Table 4.7: Typical Efficiencies of Different Irrigation Systems
Types of Irrigation Systems Percentage of Efficiency
Micro-irrigation (drip) 80 - 95
Center Pivots 70 - 85
Overhead Agricultural Sprinkler 40 - 60
Landscape spray systems 40 - 65
Landscape rotor systems 50 – 75

Source: Data adapted from Irrigation Association (2007). Drip design in the
landscape. Virginia: The Irrigation Association. Retrieved from
http://www.cuwcc.org/Research-Portal/Drip-and-micro-irrigation-systems
Drip irrigation advantages. Drip irrigation systems prevent the following water
waste possibilities that are common in different irrigation systems:
 Evaporation from open water surfaces;
 Evaporation from the soil surface (common in overhead sprinklers);
 Evaporation from wet leaves (common in overhead sprinklers);
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 Evaporation of water misting in the air (common in overhead spray);
 Runoff from the soil surface (high possibility in clay soils);
 Deep percolation (high possibility in sandy soils); and
 Tail-water (water running to the end of the furrow in flood/ furrow irrigation).
Drip irrigation disadvantages. In spite of the efficiency of a drip irrigation, this
system is not suitable for all situations. For example, lawn areas cannot be irrigated with
drip irrigation. In addition, this system in areas with low water quality can cause frequent
clogging in emitters, which decreases the efficiency of the system. The following issues
are the disadvantages associated with drip irrigation systems; however, many of the
items mostly are important for very large fields such as agricultural areas and do not
cause too much problem in landscape irrigation:
 Blockage of the emitters; filtration can reduce clogging, but cannot entirely
eliminate the problem;
 The audit of the system is harder than with overhead sprays;
 Soft tubing of drip irrigation systems can be susceptible to insect and rodent
damage;
 All drip irrigation tubing and laterals are on the surface and can be damaged;
 There is no protection against cooling and frosting; and
 Drip irrigation requires low-rate water pressure throughout the system, therefore,
needs pressure regulation.
Drip irrigation systems for landscaping on average save about 50% water
consumption compared with regular sprinklers. This system is one of the best
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alternatives to sprinklers especially in arid and semi-arid regions due to water scarcity
and the lack of dominant cooling and frosting problems. Also, auditing of landscape
irrigations is much easier than agriculture irrigations. Therefore, this system is a
practical option for efficient landscape irrigations of hospitals.
Urban Runoff Prevention and Rainwater Collection
Urban runoff is the second most frequent source of surface water pollution in the
nation. Landscape irrigation runoffs usually add to urban runoffs and dry-weather flows
of creeks especially in arid and semi-arid regions. Dry-weather flows
refers to flows through a storm drain system that are not from a storm event. Dry-
weather flows can include lawn irrigation runoff, washwater from cars and
industrial sites, or pretreated industrial wastewater… Just like stormwater flows,
dry-weather flows can mobilize pollutants on impervious surfaces (Wenzlick,
2007, para. 3).
As a result, some rivers become biologically dead and toxic and extremely
harmful to public health. Therefore, runoff prevention is essential for the health of the
residents. Adopting water efficient irrigation systems for landscaping in hospitals not
only saves water, but it can also reduce water and fertilizer runoff associated with over-
head sprays and sprinklers, and help cities maintain their water quality. Rainwater
collection can also reduce urban runoff and provide water for different non-drinking
purposes such as irrigation, especially in dry climates. This Green initiative, which
provides water efficiency in landscaping and reduces surface water pollution, has a low
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upfront cost but needs careful management. Rainwater is suitable for plant and
landscape irrigation because it is sodium-free and its pH is almost seven (neutral).
Furthermore, using permeable asphalts in parking lots is another effective measure to
prevent urban runoff. Permeable asphalt is one of the cost-effective solutions for urban-
runoff reduction that can also reduce light reflection, water splash, and local heat island
effect in hot seasons (Cahill, Adams, & Marm, 2004).
A typical porous pavement has an open-graded surface over an underlying stone
recharge bed. The water drains through the porous asphalt and into the stone
bed, then, slowly, infiltrates into the soil. Many contaminants are removed as the
storm water passes through the porous asphalt, stone recharge bed, and soils
through filtration and microbial action (NAPA, n.d., p.1).
4.4. Efficient Lighting
Hospitals are amongst the most intensive energy users and produce about 10%
of the greenhouse gas emissions in the United States (Health Care Without Harm,
2010). The expenditure by hospitals and other medical facilities for energy is about $5
billion per year (Meer, 2015) and lighting is one of the major sources of energy
consumption that plays a significant role in the carbon footprint of healthcare facilities.
To change the status quo, it is necessary to have a comprehensive plan and utilize both
small and major changes to reduce energy usage. Nonetheless, when organizations are
not ready to make major improvements in their buildings and equipment, small
adjustments such as using natural light, energy efficient lightbulbs, and delamping
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(decreasing the number of lamps in the areas that need less light) are helpful for energy
saving as well as for cost reduction.
The strategies for of energy saving (through lighting) in new and old buildings are
different. In new medical buildings, with sustainable designs, incorporating natural light
is necessary and the main areas should have full windows. However, in old buildings,
where remodeling is not possible or desired, maximizing the use of natural light through
existing windows and minimizing energy consumption through measures such as
occupancy sensors, delamping, motion detectors for outside lighting, and efficient
lighting fixtures can benefit patients, reduce costs, and save the environment.
The Impact of Natural Light on Patients’ Wellbeing
Many medical facilities are lit mostly by artificial light, but several studies show
that artificial and natural light have different impacts on human health. “Sunlight
provides a balanced spectrum of colors with elements in all parts of the visible
wavelength range” (Joseph, 2006, p. 2) and has a positive impact on the
regulation of human circadian rhythms, but artificial light is concentrated only on limited
areas of the visible light spectrum such as yellow to red or orange to red.
Utilizing natural light not only helps patients’ recovery, but it also benefits energy
conservation in the organization. However, in some hospitals, even when their rooms
have access to natural light, thick curtains have covered the windows and artificial light
is the main source of illumination. This situation shows that there is a need for educating
healthcare employees and managers about the positive impact of natural light on
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patients’ and employees’ wellbeing as well as the negative impact of artificial lighting on
the environment.
The following examples (from a publication of the Center for Health Design in
August 2006) illustrate the positive impacts of natural light on patients’ wellbeing:
Benedetti and colleagues (2001) found that bipolar depressed inpatients in east-
facing rooms (exposed to bright light in the morning) stayed an average of 3.67
days less in the hospital compared with similar patients who stayed in west-
facing rooms…[Also] a retrospective study of myocardial infarction [heart attack]
patients in a cardiac intensive-care unit treated in either sunny rooms or dull
rooms found that female patients stayed a shorter time in sunny rooms (2.3 days
in sunny rooms, 3.3 days in dull rooms) (Beauchemin & Hays, 1998). Mortality in
both sexes was consistently higher in dull rooms (39/335 dull, 21/293 sunny) ...
[According to Walch et al., 2005] patients undergoing elective cervical and
lumbar spinal surgeries were admitted to the bright or the dim side of the same
hospital unit postoperatively. The outcomes measured included the standard
morphine equivalent of all opioid medication used postoperatively by patients and
their subsequent pharmacy cost. Patients staying on the bright side of the
hospital unit were exposed to 46% higher-intensity sunlight on average. This
study found that patients exposed to an increased intensity of sunlight
experienced less perceived stress, marginally less pain, took 22% less analgesic
medication per hour, and had 21% less pain medication costs (Joseph, 2006,
p.5-6).
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It is important to understand that “biological lighting needs of humans are
different from visual lighting needs” (Begemann, van den Beld, & Tenner,1997, p.231).
For visual needs, artificial lights can well meet the requirements. However, for biological
necessities, the human body needs a certain amount of natural light per day. In this
regard, there are some full-spectrum fluorescent lights in the market; however, they are
six times more expensive than regular lights and most organizations do not use them.
Plus, there is no research on their impacts on the human body yet (Boyce, Hunter, &
Howlett, 2003).
Energy Efficient Light Bulbs
LED. The blue light-emitting diode (LED) is an environmentally friendly long
lasting light bulb that earned a Nobel Prize for its inventors (Isamu Akasaki, Hiroshi
Amano, and Shuji Nakamura) in 2014. The Nobel newsletter named this invention as
the “greatest benefit to mankind.” This efficient light source produces 300 lm/W
“luminous flux (measured in lumen) per unit electrical input power (measured in watt)”
compared with regular incandescent lights with 16 lm/W and fluorescent lamps with 70
lm/W. Also, LEDs have a lifespan of up to 100,000 hours while regular lights work 1,000
hours, and fluorescent lights work for 10,000 hours (Nobel Media AB, 2014). The only
drawback of LEDs is their price which is several times more expensive than other light
bulbs. However, their long life can justify the purchase for commercial lighting (Table
4.8). In general, for large organizations, the upfront cost is not too high and, on average,
within two years the energy saving will be more than the cost of the fixtures.
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CFL. The CFL (compact fluorescent lamp) is another energy efficient lamp that
comes in different models to replace traditional incandescent light bulbs. Its energy
usage is about ¼ of the incandescent light bulbs with a lifespan of 6000 to 15000 hours
(FDA, 2014). Also, its price is much less than LEDs. Nonetheless, there are some
controversies about their usage. Unfortunately, CFLs contain hazardous mercury, and
their disposal needs special handling (Table 4.8). Opponents of CFLs are concerned
about the spread of mercury-containing lamps among people with no real control over
their correct disposal. There is hope that, with the advancement of technology, LED
prices go down, and there would be no need for CFL usage.
Table 4.8: Light Bulbs Comparison
Bulbs Lifespan
Hours
Efficiency
lm/W*
Disadvantages
UV
Radiation
LED up to 100,000 300
More expensive than
other light bulbs
No
CFL 6000 to 15000 100 Contains Mercury Yes**
Regular ***
Incandescent
1,000 16 Inefficient Yes

Note: Numbers are for comparison only; they vary in different kinds of lights
*Quantity of light measured in LPW (Lumens per Watt)
** At typical use distances, UV levels from CFLs fall below the level of general
concern for normal, healthy individuals (FDA, 2014)
***The traditional incandescent light bulbs can no longer be manufactured in the
United States. The old bulbs can be purchased until the supplies run out (FDA,2014).
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Data adapted from (FDA,2014 & Hovey, 2011). Retrieved from
http://www.hoveyelectric.com/hovey-electric-power-blog/?BBPage=6
http://www.fda.gov/Radiation-
EmittingProducts/RadiationEmittingProductsandProcedures/HomeBusinessandE
ntertainment/ucm116400.htm#2
4.5. Sustainable Food Services in the Healthcare Industry
Sustainable food service “seeks to reduce wasted food and its associated
environmental impacts over the entire life cycle, starting with extraction of natural
resources and manufacturing, sales and consumption and ending with decisions on
recycling or final disposal” (EPA, 2013, para.1). It also utilizes reusable food packaging
and reusable or degradable utensils to minimize waste in all steps of preparation,
delivery, and serving food.
In recent years, awareness about the role of human activities on ecological
deterioration and the impact of a healthy environment on human wellbeing has changed
the meaning of healthy food. If the traditional evaluation of food had a focus only on the
biochemical components of food (such as amount of calories, vitamins, and fiber),
today’s holistic and scientific methods have a broader view for evaluating healthy food
because “[h]uman well-being depends on healthy, resilient ecosystems to nourish and
sustain all life” (Health Care Without Harm, 2014, p. 3).
The new approach has added more factors such as if the food was “grown with
harmful pesticides or synthetic fertilizers? What labor standards were used? Were toxic
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chemicals used in packaging?” Was the food grown locally or transferred from long
distances with a high amount of preservatives to keep it fresh for a long time and a high
carbon footprint resulting from the transportation?
The current industrial food system in the U.S. has significant impacts on human
health, climate change, air and water pollution, and the viability of future
agricultural production. The United States spends billions of dollars annually to
treat diet-related, chronic diseases—$147 billion to treat obesity alone—another
$116 billion to treat diabetes, and hundreds of billions to treat cardiovascular
disease and cancer (Practice Greenhealth, 2014, p.8).
Nevertheless, the healthcare industry has the ability to change this trend and
create a new market for healthier food and lead society toward more sustainable diets
because it has high purchasing power. In the United States, this industry spends $12
billion on food and food services every year. Therefore, adopting Green initiatives in
food services in healthcare facilities (even small changes) can influence the market and
encourage vendors to provide and offer healthier and more sustainable food. According
to Practice Greenhealth (2014), the following provisions can help to offer healthier
meals to patients and society as a whole.

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Balanced Menus–Less Meat
The Harvard T. H. Chan School of Public Health (2014) suggests that the best
eating choice is to limit red meat and dairy products and focus on vegetables and fruits
(Figure 4. 6). They recommend ½ vegetables and fruits (potatoes and French fries are
not included), ¼ whole grain, and ¼ protein including nuts, beans, fish, chicken, and
limited use of red meat (Harvard School of Public Health, 2014). Fruits and vegetables
not only are healthier for the human body, but they have also much lower carbon
footprints compared with meat (dairy products and meat are responsible for 18% of the
world’s GHG emissions that are hazardous to human health). Hence, many Green
hospitals have started to reduce meat and poultry in their food. Some Green hospitals
do not offer any meat in their menus once or twice a week (Practice Greenhealth,
2014).
Figure 4.6: The Best Eating Choices

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Source: Reprinted from Harvard T.H. Chan School of Public Health (2014).
Retrieved from
http://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/
Better Meat
According to Practice Greenhealth (2014):
Eighty percent of the antibiotics used in the U.S. are given routinely in low doses
to animals to both promote growth and prevent infections, compensating for
overcrowded, unsanitary and unhealthy living conditions in factory farms known
as concentrated animal feeding operations (CAFOs). According to the Centers
for Disease Control and Prevention, antibiotic resistance costs the U.S. $20
billion a year in direct health care expenses and $35 billion a year in lost
productivity (p.9).
In this regard, Green hospitals not only reduce meat and poultry procurement,
but they also buy meat and poultry raised without antibiotics or organic meat. So far “23
hospitals have met the goal of decreasing their meat purchasing by 20 percent [and]
[f]ifty-four hospitals have decreased their lbs. of meat per meal in 2014” (Practice
Greenhealth,2014, p.9). These numbers demonstrate that there is a long way to go to
have a pervasive Green approach in the healthcare industry.
Local Food
In Green healthcare, priority is always with purchasing sustainable and locally
grown products to provide fresh food with no preservative chemicals and to prevent
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extra greenhouse gas emission for transportation. Unfortunately, there is not a single
definition for locally grown food yet. Some define “local” as 100 miles from production to
consumption. In some definitions, 250 miles is considered local, and for some products,
500 miles is measured as local, depending on the availability of the products or the
possibility of replacing them. However, the main concept does not change. The aim is to
offer fresh food to patients with maximum nutritional value and minimum carbon
footprint.

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Table 4.9: GHG Emissions Produced by One Kilo of Each Food
Rank Food
CO2 Kilos
Equivalent
Car Miles Equivalent
1 Lamb 39.2 91
2 Beef 27 63
3 Cheese 13.5 31
4 Pork 12.1 28
5 Turkey 10.9 25
6 Chicken 6.9 16
7 Tuna 6.1 14
8 Eggs 4.8 11
9 Potatoes 2.9 7
10 Rice 2.7 6
11 Nuts 2.3 5
12 Beans/tofu 2 4.5
13 Vegetables 2 4.5
14 Milk 1.9 4
15 Fruit 1.1 2.5
16 Lentils 0.9 2

Source: Data adapted from EPA (2013) and Hamerschlag, K. & Venkat, K. (2011).
Reprinted from
http://static.ewg.org/reports/2011/meateaters/pdf/methodology_ewg_meat_eaters_guid
e_to_health_and_climate_2011.pdf
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https://www.epa.gov/sustainable-management-food/sustainable-management-food-
basics
http://www.greeneatz.com/foods-carbon-footprint.html
If more hospitals join this movement, there will be a stronger market for sustainable
food, and medical facilities can lead the whole society toward a healthier lifestyle. Table
4.9 shows the carbon footprint of one kilo of various foods and the car miles equivalent
(e.g., eating one kilogram of lamb produces the same emissions as driving 91 miles).
4.6. Green Buildings
Although designing a Green building is not a guarantee for having a Green
facility, sustainable and energy efficient buildings are very helpful for Green operations
in the healthcare industry. The main focus of this research is on applying Green
methods in healthcare operations, not on construction and structural planning from an
architectural viewpoint. Nevertheless, due to the great impact of the physical work
environment (PWE) on patients’ and staff’s wellbeing and sustainability of organizations,
this section has a brief overview of Green buildings and the main principles of LEED
(Leadership in Energy and Environmental Design) certification.
LEED
LEED certification. LEED is a Green building certification program that
provides standards for measuring building sustainability. In March 2000, the U.S.
Green Building Council (USGBC) released the LEED certification program for
“commercial, institutional and residential projects” that became the most popular Green
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building rating in the world (USGBC, 2012). However, due to complex safety
requirements of healthcare facilities, this sustainability rating system was not
correspondent to the needs of medical services. Hence, in November 2010, “LEED for
healthcare new construction and major renovations” was approved by the United States
Green Building Council. LEED for Healthcare aims to meet the unique needs of medical
activities in hospitals and other healthcare organizations.
There are 110 credits available in LEED for healthcare including 100 base points,
6 “Possible Innovation in Design” points, and 4 “Regional Priority” points. The base
points are divided into five categories of:
 Sustainable sites;
 Materials and resources;
 Water efficiency;
 Energy efficiency; and
 Indoor environmental quality.
The category of Possible Innovation in Design (with 6 points) addresses any areas that
are not covered by the main five categories. Also, the category of Regional Priority
earns 4 points for sustainability in specific local conditions and design of each project.
The LEED certification can be awarded in four rating levels of Certified, Silver,
Gold, and Platinum, based on the number of points the project earns (Table 4.10). Of
the 110 total core points in LEED for healthcare, 16 points are directly related to the
health and well-being of occupants with the five major areas of attention on:
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1. Indoor air quality (IAQ);
2. Thermal quality;
3. Lighting;
4. Acoustics; and
5. Access to nature.
In addition to the LEED certification program, the Center for Health Design (a
non-profit organization) offers a set of principles for Green hospitals called Evidence
Based Design (EBD) guidelines and Eco-effective design (EED) (Shepley, Baum,
Ginsberg, & Rostenberg, 2009). The viewpoints of these courses of action and
healthcare architecture philosophies are similar to LEED; however, they do not have a
rating system. LEED, EBD, and EED have a focus on sustainability and the role of the
PWE on the health and well-being of buildings’ occupants.
Table 4.10: Different Levels of LEED Certification for Healthcare
LEED for Healthcare
Certification Points
Platinum 80 & above
Gold 60–79
Silver 50–59
Certified 40–49

Source: Data adapted from U.S. Green Building Council (USGBC, 2012).
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Retrieved from http://www.usgbc.org/leed
LEED critiques. Although the LEED certification system, in general, is popular
among Green activists, there are some critiques of this program from different points of
view. Some LEED critics argue that the focus of this program is on energy saving
instead of the health and comfort of occupants. Some building materials such as
adhesives, solvents, flame retardants, sealants and plastics include toxic substances,
and the LEED award system does not pay attention to their usage in LEED certified
buildings. Also, only about 14% of the credits (16 points out of 110 points) are directly
related to human health. These critics believe that this certification program needs to
pay more attention to the occupants’ conditions and set clear requirements for the
protection of human health from hazardous chemicals. Furthermore, there are some
complaints about the cost of these requirements (Wargo, 2010). In general, the major
critiques of the LEED system are:
1. LEED costs too much;
2. The main goal of the designers and construction team is gaining points instead of
focusing on the best sustainable buildings;
3. LEED does not have enough emphasis on the indoor air in the built environment;
4. The main focus of LEED is on energy saving instead of human health;
5. There is no evaluation system to determine the impact of LEED features on
occupants’ health;
6. There is no LEED police, and it is not clear what the maintenance requirements
for a LEED certified building are.
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For these reasons and the other considerations mentioned above, the Green
movement believes that Green Healthcare is not all about the LEED certification, and an
eco-friendly building is not enough for having a sustainable operation. However, despite
the shortcomings, a Green building is very helpful for efficient operations.
Table 4.11: Healthcare LEED Certification Timeline Summary
Date Certified Number of Projects Gross Square Footage
2003 1 153,773
2004 1 27,000
2005 2 41,081
2006 8 735,775
2007 18 1,866,520
2008 17 2,448,578
2009 60 4,518,924
2010 98 13,743,977
2011 114 11,990,169
2012 147 17,238,367
2013 157 15,986,529
2014 120 18,423,527
2015* 7 734,056

Note*: The numbers are from February 2015; therefore, the total Green buildings of the
healthcare facilities in 2015 are not yet determined. Data were obtained through an
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interview with the U.S. Green Building Council's representative (Christopher M. Gray) in
February 2015.
LEED and Green healthcare. Being in a Green building is not a prerequisite for
Green healthcare. Yet, changing some building materials is necessary for providing a
healthy environment for patients and staff. Nonetheless, applying for LEED certification,
especially in new constructions, can show the stakeholders’ commitment to
sustainability and their approach to the necessity of minimizing environmental impacts
of their activities. Statistics indicate that, in recent years, there has been a growing trend
in applying for LEED certification in healthcare organizations (Table 4.11). However, it is
very slow and not responsive to the urgent need for environmental degradation
prevention. Currently, fewer than a quarter of the hospitals in the nation are LEED
certified (Table 4.12).
In 2010, hospitals spent about $20 billion in building new facilities or repairing
existing structures (American Hospital Association, 2010). Nevertheless, many of these
buildings are not energy-efficient and Green (Table 4.11). Since hospitals consume 3
times more energy than regular commercial buildings and usually work for 50 to 100
years (on average), building energy-efficient hospitals is very crucial for the environment
and public health. Unfortunately, after building traditional energy-intensive structures (as
with the majority of old and new hospitals), it is much more expensive to improve their
energy efficiency.

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Figure 4.7: Healthcare Green Buildings vs. Total Green Buildings

Source: Data adapted from the interview with the U.S. Green Building Council's
representative (Christopher M. Gray), February 2015.
Note*: The numbers are from February 2015; therefore, the total Green buildings of the
healthcare facilities in 2015 are not yet determined.

0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
Healthcare vs. Green Buildings
Number of Green Projects (USA) Number of Green Healthcare Projects (USA)
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Table 4.12: Healthcare LEED Certified Buildings vs the Total of LEED Certified
Buildings
Year
Total Number of Green
Projects
Number of Green Healthcare
Projects
2000 3 0
2001 6 0
2002 21 0
2003 46 1
2004 117 1
2005 201 2
2006 321 8
2007 541 18
2008 963 17
2009 2303 60
2010 3154 98
2011 3657 114
2012 4215 147
2013 4677 157
2014 4502 120
2015* 7

Source: Data adapted from the interview with the U.S. Green Building Council's
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representative (Christopher M. Gray), February 2015.
Note*: The numbers are from February 2015; therefore, the total Green buildings of the
healthcare facilities in 2015 are not yet determined.
The review of the above Green initiatives has illustrated some examples of
wastefulness in existing medical activities and the necessity of sustainable approaches
in the healthcare industry. It has also revealed that efficient operations have different
facets, and there are no one-size-fits-all methods to achieve environmental
sustainability. There are various solutions that different medical organizations can
choose from, based on their financial capabilities and employees’ preparedness and
knowledge. Not all sustainable initiatives in healthcare operations need high upfront
costs or complicated preparations. Many Green activities (such as using energy efficient
light bulbs, reprocessing, donating extra food to local charities, efficient irrigation
systems, recycling, and ordering locally grown food) can be started immediately, without
high upfront costs, if management and employees have enough knowledge about the
importance of these activities and their positive impacts on patients’ wellbeing and
human health.
This chapter can be a convenient source to inform medical professionals about
the negative impacts of their activities on the environment and public health, and
encourage them to stop the existing trend by starting small and practical efficient
solutions as explained. It can also work as a crash course about possibilities and
practicalities of different Green initiatives in healthcare settings. The point is to
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encourage the healthcare industry to start using more efficient approaches as soon as
possible (as it lags behind other industries such as construction and architecture).
However, making informed decisions is the key to success because sustainability
is a lifestyle and does not necessarily work with command and control systems. In the
past, many leaders started large and expensive Green measures before being
financially ready and culturally preparing and educating their employees. The result was
not satisfactory. Employees did not know why they were following a new system, and
operating expenses did not match the results. Hence, the organizations stopped the
Green initiatives before seeing real outcomes. Therefore, education and raising
awareness among employees at all levels, about the necessity of sustainable activities,
is one of the main keys to the success of Green healthcare operations.

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CHAPTER FIVE: EXPERIENCES OF DIFFERENT HOSPITALS

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After demonstrating the necessity of Green approaches in the healthcare
industry, this chapter reviews the experiences of different hospitals in regards to their
Green initiatives to show the possibility and practicality of these activities and learn from
their successes, as well as mistakes and errors. The information of this chapter is
mostly based on different interviews with leaders, employees, and representatives of
seven hospitals in the U.S. and Europe. These medical organizations include:
 St. John’s Regional Medical Center in Oxnard, California
 Kaiser Permanente-Modesto Medical Center in Modesto, California
 Santa Barbara Cottage Hospital, California
 University Hospital-United Hospitals of Ancona, Italy [The Azienda Ospedaliero
Universitaria Ospedali Riuniti Ancona (AOR)]
 General Hospital “St. George de Chania” in Chania, Greece
 University Hospital “Virgen de las Nieves” in Granada, Spain, and
 The Hospital “Fundacio Sanitaria de Mollet” in Mollet, Spain
5.1. St. John’s Regional Medical Center
St. John’s Regional Medical Center is in the city of Oxnard in Ventura County
located on the Central Coast of California north of Los Angeles. This hospital was
founded in 1913 by the Sister of Mercy. In 1993, this hospital merged with Pleasant
Valley Hospital in Camarillo, and in 1997, the two hospitals joined Catholic Healthcare
West. In 2012, Catholic Healthcare West became Dignity Health. Dignity Health is a not
for profit healthcare system headquartered in San Francisco, California with 39 facilities
serving communities in California, Arizona, and Nevada. The primary service areas of
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St. John’s Regional Medical Center are the cities of Oxnard, Port Hueneme, and
Camarillo. This 265-bed hospital provides medical services to about 187,000 patients
per year. About 62% of the patients are residents of Oxnard or Port Hueneme and
23.5% from Camarillo (St. John’s Regional Medical Center-Implementation Plan, 2013).
St. John’s Hospital offers comprehensive services and programs, including:
 24-hour Emergency Services
 Cancer Care and Support
 Diabetes Program
 Diagnostic Imaging Procedures
 Health and Wellness Programs
 Heart Care
 Intensive Care
 Inpatient and Outpatient Surgical Services
 Maternity and Birth Services
 Neonatal Intensive Care
 Orthopedic Care
 Palliative Care
 Patient and Family Education
 Rehabilitation Services
 Spiritual Care
 Weight Loss Surgery
 Women’s Services

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Table 5.1: St. John’s Regional Medical Center
Healthcare Organization St. John’s Regional Medical Center
Address 1600 N Rose Ave, Oxnard, CA 93030
Phone # (805) 988-2500, (877) 753 - 6248
Patients 187,000 patients per year
Number of Beds (including a 23-
bed acute rehabilitation center)
265
Number of Operating Rooms 8
Number of Operating Room
Procedures per Year
3877
Service Area Oxnard, Port Hueneme, Camarillo
Employees 1094
Contracted Employees 50
Sustainability Officers and Leaders 1 Full-time and 1 Part-time
Green Team/Sustainability
Committee
Ecology Committee to implement &
monitor Green initiatives

Source: Data adapted from St. John’s Regional Medical Center-Implementation Plan
(2013), and interviews with the hospital’s representatives in 2014.

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Green Initiatives in St. John’s Hospital
St. John’s Hospital of Oxnard as a part of the Dignity Health organization is
committed to reducing its carbon footprint through different Green initiatives. The goal is
to “increase the use of reusable products, reduce the use of hazardous chemicals…,
and promote food systems that are ecologically sound, economically viable and socially
responsible” (Dignity Health, Sustaining Our Healing Ministry, 2013, p.43). In this
hospital, from 2005 to 2013, reprocessing of medical devices, recycling, and
replacement of disposable products with reusable materials have helped to minimize
solid wastes and divert 82.38 tons of waste each year from landfills and incinerators,
and saved money for the facility. In the same period of time, Dignity Health (the parent
company of St. John’s Hospital of Oxnard) was able to reduce the solid waste in all its
hospitals by 271,000 pounds and saved $8 million as a result.
In addition, a new chemical treatment system for cooling towers was installed to
reduce the use of hazardous chemicals. According to Mr. West (Vice President of
Mission Integration at St. John’s), this system not only reduced the usage of harmful
chemicals, but it also saved a significant amount of water. The usage of ozone for water
treatment in cooling towers is a good alternative to traditional chemical treatments. This
new system uses fewer chemicals (toxic and non-toxic) and decreases the
concentration level of water and chemical build-up. As a result, the need for water
replacement or “blow down” in the system can be reduced. The general policy of this
hospital is based on the three essential components of environmentally-responsible
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activities (R3: reduce, reuse, recycle) (Dignity Health, Sustaining Our Healing Ministry,
2013).
Table 5.2: Green Initiatives in St. John’s Hospital
Green Initiatives Outcomes
Healthier Hospitals Initiative (HHI)
Challenges
Waste minimization - Safe Chemicals -
Healthier Food - Smart Purchasing
Solid Waste Reduction 82.38 Tons (total from 2005 to 2013)
Solid Waste Reduction 13.47 lbs. per adjusted patient day
Regulated Medical Waste (RMW)
reduction
Reduced from 66.44 Tons to 62.72 Tons:
(3.72 Tons reduction)
Reduction of Chemicals drainage
Installed new chemical Treatment for cooling
towers
Paper Reduction
Reduced network printers - Reduced number
of automatically printed reports - Implemented
EMR/HER system
Paper Reduction
Switch to online newsletters, forms, and
policies instead of hard copies
Composting Food waste collection contract for composting
Recycling (Plastics)
Clinical/Medical Plastics such as:
Trays - Rigid inserts - Blue wrap - Basins -
Urinals/Bedpans
Recycling (Metal)
Copper & Silver from piping & fixtures - Metals
from furniture & equipment - Computers

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Table 5.2: Green Initiatives in St. John’s Hospital (continue)
Green Initiatives Outcomes
Recycling
Recycling improved from 247 Tons to
279.93 Tons: 32.93 Tons
Reusing Materials
Furniture - Office supplies - Shipping
containers - RMW shipping
containers - Pharmacy waste
containers - Red sharp containers -
Replacement of Paper Products -
Switch to reusable gowns, wraps,
reusable plates, bowls and cups
Water Conservation
Installation of a new chemical
treatment system for cooling towers
reduced water consumption
significantly
Smoke Free Facility
The hospital is a tobacco free facility
to reduce toxins in air

Source: Data adapted from St. John’s Regional Medical Center-Implementation Plan
(2013), Dignity Health, Sustaining Our Healing Ministry, (2013), and interviews with the
hospital’s representatives in 2014.
Improvement in Environmentally Sustainable Approaches in St. John’s
Hospital
Sustainability awareness. St. John’s Hospital has made significant
achievements in many Green initiatives, and in 2014 received the Environmental
Excellence Award from the Practice Greenhealth organization. However, interviews with
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several employees of the hospital showed that they are not aware of this achievement
and do not know its importance. Hence, the environmental sustainability awareness
among employees needs improvement. The first suggestion for improving sustainability
measures in St. John’s Hospital is to work on cultural aspects of Green healthcare and
educate employees about eco-friendly medical services.
Sustainability is a lifestyle and does not work in a “one-man show” system. To
have a successful sustainability plan in an organization, there is a need for innovative
ideas from all employees at all levels of the organization. Usually, the best practical
suggestions come from employees that have hands-on experience with the daily tasks
of that specific department, not from leaders and administrators with old systems of
orders and commands.
In 2014, while St. John’s Hospital was applying for the Environmental Excellence
award from the Practice Greenhealth organization, and in many respects was qualified,
interviews with employees and physicians demonstrated that, in many cases, they did
not have any knowledge about the Green objectives of the hospital or even its
achievements. Interviews with physicians and staff of the organization confirmed the
results found by Hartman et al. (2010 & 2011) regarding healthcare employees’ lack of
awareness about the negative impacts of their organizational operations on the
environment. Therefore, the sustainability committee or Green team of the hospital
should have a clear awareness program for education and involvement of all employees
at different levels of the organization. This program can include:
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 Publishing different pamphlets about environmental stewardship of the
organization;
 Adding sustainability measures into performance evaluations of the leadership
staff;
 Adding environmental commitment to the employees’ job descriptions;
 Adding environmental concerns in employees’ satisfaction survey;
 Publishing a periodic sustainability newsletter to report successes and obstacles
of different Green measures in each department;
 Scheduling periodic workshops about different Green initiatives for employees in
each department; these workshops need to be directly related to the specific
responsibilities and exposures of employees in those departments.
Water conservation. St. John’s Hospital can improve its water savings through
changes in its surgical theaters and irrigation systems. The sustainability officers have
some evidence about high water consumption in one surgery theater in the hospital,
without a clear explanation. To be able to resolve this problem and improve water
management in general, as the first step, the hospital needs to apply for a separate
water bill for each water-intensive unit (currently, there are no clear data on water usage
by the surgical department). A detailed analysis of water consumption in each area
should be the next step in water management. Fixing plumbing fixtures’ malfunctions,
repairing leaks, and purchasing water-efficient equipment are among the solutions that
can improve indoor water conservation in the hospital.
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In addition, there is an important opportunity for outdoor water saving through
efficient landscaping and the adoption of effective alternatives for the existing irrigation
system (i.e., drip irrigation, Xeriscape landscaping, dry tolerant vegetation, and native
plants). This issue, especially, is crucial for the new facility that they have a plan to
build.
Starting a new efficient irrigation system is much more cost-effective than
changing the existing one. In this regard, the investigator was not able to obtain any
data about water consumption of the landscape irrigation of this hospital because she
was informed that there is only one water bill for the whole hospital. Nevertheless,
statistics show that landscaping consumes a high percentage of potable water usage in
California.
There is a misconception about sustainable landscaping in California that it is
equal to Xeriscape or the lack of vegetation. Therefore, this idea usually faces great
resistance (as happened in an interview with the Vice President of Mission Integration of
this hospital). However, there are different alternatives for efficient and beautiful
landscaping other than Xeriscape that were mentioned in Chapter Four.
Cost-benefit analysis. As mentioned in previous chapters, a comprehensive cost-
benefit analysis is necessary for a successful sustainability plan. In this regard, the
investigator was informed that there is a ROI report for purchasing new equipment for
cooling towers. According to sustainability officers of the hospital, the ROI analyses
justify the purchase (no numbers were disclosed). In addition, this new equipment has a
stronger air purification system and improved indoor air quality (IAQ) (less need for
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ventilation), reduces usage of harmful chemicals (less need for cooling tower water
replacement), and saves a significant amount of water. All these subsidiary results can
improve the ROI. Preparing a cost-benefit analysis for each Green initiative can help the
decision makers to measure the achievements and alter the tactics to get better results.
Nevertheless, no information regarding sustainability program budget analysis was
disclosed whatsoever.
5.2. Kaiser Permanente-Modesto Medical Center in Modesto, California
Kaiser Foundation Hospital-Modesto, as one of the 38 medical centers of the
Kaiser Permanente healthcare company, was founded in October 2008. This 670,000
square-foot hospital is surrounded by farmland located on the northwest corner of the
city of Modesto in Stanislaus County, California. This hospital is within walking distance
to residential areas and provides medical services to 210,000 citizens in the area. The
total licensed beds of this hospital are 152, but currently, it works with 140 active beds.
It means there is room for expansion in this medical center.
This hospital is considered as one of the Greenest hospitals in the nation.
The construction of this medical center started with an environmentally friendly
philosophy. According to Kaiser’s representatives, more than 80% of construction waste
was recycled. Although this number seems too high and no document supports this
statement, there are many other innovative Green initiatives that make this facility one
of the Greenest hospitals in the nation. Some of these measures are unique even for
the Kaiser company that has several Green facilities.
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Table 5.3: Kaiser Permanente-Modesto Medical Center in Modesto, California
Healthcare Organization Kaiser Permanente-Modesto Medical Center
Address 4601 Dale Rd. Modesto, California 95356
Phone (209) 735-5000
Location California, U.S.A.
Medical Campus 1,425,000 gross square feet
Built/Restored Year 2008
Beds 140
Total Licensed Beds 152
Provide Service to 210,000 citizens

Source: Data adapted from (Kaiser Permanente, 2014), and (OSHPD, 2010).
Retrieved from
http://www.kaiserpermanentejobs.org/location-details.aspx?id=10

http://gis.oshpd.ca.gov/atlas/places/facility/106504042

http://www.ccwaonline.org/Module/PortfolioModule/ProjectDetail?id=10

http://www.modestogov.com/ced/projects/kaiser.asp

A review of the Environmental Impact Report (EIR) of Kaiser Permanente Project
in Modesto shows that this project had significant impacts on the environment, hence,
based on California Environmental Quality Act (CEQA) guidelines, there was a need for
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“feasible alternatives” or “feasible mitigation” measures. In many areas, such as
disturbing wildlife or regional water consumption, there were no feasible alternatives.
Therefore, Kaiser Hospital agreed to defray the cost of mitigation. Municipal records
show that, in this project, Kaiser Permanente not only complied with all environmental
requirements, but it also went beyond the scope of requirements of the Mitigation
Monitoring Program. It went Green!
Sustainability Initiatives in Kaiser Permanente-Modesto Medical Center
A combination of ecofriendly policy, planning, design, materials, and
maintenance helped this organization to be sustainable and maintain the quality through
time. If Kaiser Permanente would be able to continue this policy in all its centers, it
could become a model for Green medical services in the nation.
LEED certified building. The building of the Kaiser Permanente-Modesto
Medical Center has been awarded a Gold LEED certification. However, as mentioned
before, a LEED certified building is not enough for being a Green healthcare
organization. The Modesto Medical Center not only has a LEED certified building, but it
also established a positive environment for Green philosophy for all employees and
their decision makings. In this hospital, employees and management were successful in
maintaining the LEED features in the building and a Green approach in purchases and
daily operations and thus protecting the sustainability of their facility.

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Water Management. According to the Environmental Impact Report (EIR) of the
project, the estimated water demand of the Kaiser Medical Campus at build-out in 2028
is 586,075 gallons per day (Table 5.4). This report asserts that the existing water
supplies in the region are able to provide about 95% of the demand. Also, Kaiser is
responsible for designing, installing and dedicating a new water well and connecting the
Well to the City’s water system (Kaiser EIR-Chapter 3.0: Environmental Analysis, 2004).
Due to the drought in California and the condition that the existing groundwater
bed can provide only 95% of the demand of the hospital in its full capacity (there is 5%
water shortage), water conservation is a top priority in this project. This hospital has 140
active beds, but its full capacity is 250 beds, and water demand should be calculated
based on its full capacity.
One of the water saving provisions in this hospital is the use of condensate for
cooling tower makeup water. Cooling towers lose water through evaporation, drift
(splash out or blow down), and recirculation (bleed). Make up water is the water that
needs to be replaced:
Condensate is an inherent byproduct of building HVAC systems. Since
condensate is formed from moisture in the air, it is [“free” and] relatively
high-quality water… The most effective use of condensate water collected
from commercial or industrial buildings is for makeup water in cooling
towers” (Glawe, 2013, p. iv & 2).

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Table 5.4: Domestic Average Annual Water Demands for the Kaiser Medical Campus

Phase (Est. completion)
Floor Space
(sf)
Beds
Estimated Water
Demands (GPD)
Phase 1 (2005) 400,000 200,000
Phase 2 (2007) 435,000 250 191,050
Phase 3 (2013-2020) 200,000 125 95,525
Phase 4 (2014-2020) 120,000 49,750
Phase 5 (2028) 120,000 49,750
Total: 1,141,000 375 586,075
Source: Data adapted from (Kaiser EIR-Chapter 3.0: Environmental Analysis, 2004).
Also, other provisions such as using native plants for landscaping, utilizing low-
flow toilets, utilizing low-flow faucets, replacing traditional x-ray machines with digital x-
ray, and permeable asphalt in the parking lot helped Kaiser Permanente to reduce its
water consumption considerably and prevent urban runoff. Permeable asphalt can
also reduce light reflection and local heat island around buildings in summers.
However, a correct structure, open-graded stone bed, and careful installation are
imperative, otherwise it can lose its permeability over time (Cahill, Adams, & Marm,
2004), as has happened in this hospital. In an interview with a representative of the
City of Modesto, the investigator was informed that the parking lot asphalt (in the
Kaiser Hospital) lost its porousness after two years and does not prevent runoffs as
before. In permeable pavements, usually when the design and installation techniques
are not quite right, it needs constant and costly maintenance.
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Ventilation. A new ventilation system (currently used in many European and
Canadian hospitals) is one of the areas of energy saving in this hospital. In this system,
supply air, with a temperature a little lower than the room temperature, is slowly
introduced to the space near the floor level. This cooler air constantly replaces the
warmer room air and creates a zone of cool fresh air at the occupied level. Experience
suggests that this ventilation system can save about 66% of heating and cooling energy
consumption. In addition, a clean-air filtration method that continually enters fresh air
into the system, with no re-circulation, limits airborne bacteria and provides
healthy indoor air quality. Also, this facility has reflective roofing material that helps to
prevent heat passing through the roof in the hot summers of Modesto (110+ degree).
Lighting. Kaiser Permanente-Medical Center in Modesto is not an energy self-
sufficient facility; however, its roof-top solar panels generate electricity (enough to
power at least 15 homes). All rooms are designed with full windows to be able to utilize
natural light during the day and minimize the use of artificial light whenever possible. At
night and in the middle areas where utilization of natural light is not possible, all light
bulbs are LED that can save up to 75% of the usage of incandescent light bulbs. Also,
all lighting fixtures are equipped with sensors, motion detectors, and timers to minimize
energy consumption at different times of the day in full-time-occupied, part-time-
occupied, or non-occupied areas.
Flooring. In this hospital, rubber flooring replaced vinyl flooring because vinyl
contains hazardous phthalates chemicals that have harmful effects on human health
(phthalates exposure can cause asthma, ADHD, breast cancer, obesity, diabetes and
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low IQ). Rubber flooring is more durable, absorbs sound better, and has easy-to-clean
surface. In addition, all carpeting of the facility is PVC free. This new carpeting uses
fewer VOCs (volatile organic compounds) that are harmful to patients. This custom-
made carpeting was developed by Collins & Aikman Corporation to become a standard
for all Kaiser Permanente facilities.
Improvement in Environmentally Sustainable Approaches in Kaiser Permanente
Healthcare Company
The Kaiser Permanente-Modesto Medical Center is one of the Greenest
healthcare organizations in the nation. However, many new medical centers in Kaiser
are not Green and do not implement the same measures during their construction,
operation, and maintenance. Even their buildings are not LEED certified. There are no
official documents to show any obstacles Kaiser has faced for maintenance of the
Green measures or any reasons for this policy change. However, some informal
communications indicated that many Kaiser facilities have independent administrations
with dissimilar management philosophies. Different leadership, prolonged procedure of
approvals for LEED certified buildings, repair and maintenance costs (i.e., permeable
asphalt mentioned above), and low ROI are among the main factors limiting the use of
Green initiatives.
The only suggestion for the Kaiser Permanente-Modesto Medical Center is
greater attention to maintenance and continuation of its Green activities. Furthermore,
Kaiser Permanente, as the parent company, should follow its own Green path instead of
returning to the inefficiency of traditional constructions and operations. Policy makers
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and local governments should also provide incentives for Green constructions and
operations in medical organizations, instead of prolonging the approval process and
adding to upfront costs. For the benefit of society and public health, there should be
policies to expedite the process of getting permissions and obtaining licenses for Green
buildings to encourage and promote sustainability in society, especially for hospital
buildings that usually have a lifespan of 50-100 years.
5.3. Santa Barbara Cottage Hospital
Santa Barbara Cottage Hospital is located in the City of Santa Barbara,
California. This hospital is a 483-bed acute care teaching hospital and the only level II
trauma center between Los Angeles in the south and San Francisco in northern
California. Its annual admissions are 20,000 patients, and its emergency department
has about 73,000 visits per year. This hospital practices several Green initiatives to
reduce its negative impacts on the environment. It is especially successful in waste
minimization and recycling.
In the Santa Barbara area, the Tajiguas Landfill that is owned and operated by
the county will be at its full capacity by 2020. Therefore, all businesses in this area
(especially medical organizations that have one of the highest rates of waste
production) need to be serious about their waste minimization. According to the chair of
the Environmental Sustainability Committee of the Cottage Hospital (Ruben Cosio),
Santa Barbara Cottage Hospital had great achievements in their Green initiatives.

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Table 5.5: Santa Barbara Cottage Hospital

Healthcare Organization Santa Barbara Cottage Hospital
Address
400 West Pueblo St.,
Santa Barbara, CA 93105
Phone # 805.682.7111
Patients Admitted 19,898 patients in 2012
Employees 2,892 (fulltime equivalents)
Volunteers 1,184
Volunteer hours 131,792
Medical staff physicians 673
Physicians in residency programs 55
Sustainable full-time Employees 0
Sustainability Officers and Leaders 2 Part-time Volunteers
Composting 9000 pounds in 2014
Recycling 1 million pounds in 2014

Source: Data obtained through interviews with the chair of the Environmental
Sustainability Committee and Administrative Assistant of Nutrition Department of the
Santa Barbara Cottage Hospital in 2014, and the hospital’s website retrieved from
http://www.cottagehealth.org/locations/locations-profile/?id=2&searchId=6f52d059-
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Highlights Regarding Green Initiatives in Santa Barbara Cottage Hospital
 The Santa Barbara Cottage Hospital has met the American Hospital Association
(AHA) goal of reducing 50% of hospital waste by 2010.
 This hospital is ahead of schedule for waste reduction. All packaging (food and
supplies) and cardboard boxes are separated from the waste stream for
recycling. In 2009, only 35% of the waste was sent to the landfills.
 Recycling at the Cottage Hospital increased by tenfold over the last decade. In
2000, the volume of recycled materials in this center was 82,000 pounds. This
amount increased to 1 million pounds in 2014.
 Composting is another way of waste reduction in this hospital. The Cottage
Hospital composted about 90,000 pounds of food waste in 2014. This initiative
reduced the amount of greenhouse gas of methane from the air “equivalent of 24
cars being taken off the road.”
 This hospital was an award winner of the California Recycle Waste Reduction
Award Program (WRAP) in 2010 and 2011 and is one of only 20 health services
in California that received this honor. It has also been recognized the City of
Santa Barbara for its recycling efforts.
 The Santa Barbara Cottage Hospital is in the process of building a new hospital
that was the recipient of the Santa Barbara Beautiful President’s Award for its
healing environment and architectural design.

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Improvement in Environmentally Sustainable Approaches in the Santa Barbara
Cottage Hospital
According to Ruben Cosio, this facility had a great achievement in waste
reduction. However, there is more room for improvement in their Green approaches.
This hospital is in the process of building a new facility. While the sustainability officers
of this hospital are aware of the importance of environmental protection, the new
building is not LEED certified. The reason is that the application for LEED certified
buildings takes two months more than regular buildings, and the organization is not able
to extend the process of planning and approval. This situation shows the policy
obstacles for Green initiatives in the City of Santa Barbara. The City, instead of making
this process easier and offering incentives for eco-friendly approaches in different
businesses, makes more obstacles and discourages those who care about the
environment and public health. Apparently, sometimes public administrators mix their
role with business administrators!
In addition, there is no specific plan for sustainable irrigation systems in this
organization. The sustainability officers believe “this issue is not a priority at this point.”
This is in the situation that Southern California has been suffering from a dreadful
drought for more than seven years. The landscape irrigation in this facility uses potable
water. There is no information available about the percentage of water usage for
irrigation in this hospital. However, numbers regarding the average usage in California
demonstrate the importance of water consumption reduction in all areas of all facilities.
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Furthermore, in this hospital, only two part-time volunteers are involved in
planning and implementing Green initiatives (of the total of 4076 fulltime and volunteer
employees). This situation indicates that involvement of all employees to achieve
sustainability is not a common culture in this organization. No calculation or cost-benefit
analysis regarding Green initiatives in this hospital was available (or was not disclosed).
Therefore, ROI of the sustainable activities is unknown.
5.4. An Innovative Energy Saving Program in European Hospitals
(Green@Hospital Project)
On the journey of finding practical solutions for the negative environmental
impacts of the healthcare industry, the investigator learned about an innovative energy
saving program in Europe that could reduce energy consumption in hospitals by 15%.
This program (Green@Hospital) is a “web based energy management system for
optimization of the energy consumption in hospitals” and other public buildings through
a modern ICT (information and communication technology) system. This system
monitors, controls, and integrates multiple buildings’ energy consumption and develops
a model for energy saving and algorithms for consumption optimization. It is helpful for
new Green buildings with efficient operation and low energy consumption, as well as for
the old building structures of European hospitals (many hospitals in Europe have old
buildings). The focus of this project is on intelligent management of energy use, and it
can be replicated in other hospitals and medical organizations (Penna, 2014).
The funder of the project is the European Union, the producer and supplier of
electrical and mechanical materials and software is Schneider Electric from Italy, and
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the project coordinator is Loccioni Italian Technology. Other technology partners for this
project include DEERNS Raadgevende Ingenieurs BV (Netherlands), IF Technology BV
(Netherlands), and DALKIA Catalunya (Spain). Also, the IREC Fundacio Institut De
Recerca De L’Energia De Catalunya in Spain, and the Technical University of Crete in
Greece are the research partners of this project. The total budget of the project is
€2,869,956, and the requested European Union contribution is €1,434,978.
Project objectives
1. Develop a standard benchmarking model for energy consumption in hospitals
2. Develop a web-based Energy Management and Control System (EMCS)
3. Develop advanced holistic control algorithms for energy consumption
optimization
4. Implement and validate the system through pilot hospitals
5. Develop a system for maintenance of the energy saving program
6. Educate the stakeholders about socioeconomic impacts of the system
“The main output of the project is a Web-based Energy Management and Control
System (Web-EMCS) which integrates model based energy saving algorithms” (Davide
Nardi Cesarini, 2014).

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Table 5.6. Participating Partners in Green@Hospital Project

Organization Role Country
1 AEA Srl – Loccioni Group
Coordinator &
Technology Partner
Italy
2 Deerns Raadgevende Ingenieurs BV Technology Partner The Netherlands
3 IF Technology BV Technology Partner The Netherlands
4 Schneider Electric SPA Technology Partner Italy
5 Dalkia Catalunya Technology Partner Spain
6 Technical University of Crete Research Center Greece
7
Fundacio Institut de Recerca de
L’Energia de Catalunya
Research Center Spain
8
Azienda Ospedaliero Universitaria
Ospedali Riuniti Umberto I – G.M.
Lancisi – G. Salesi
Pilot Hospital Ancona - Italy
9 General Hospital Chania Saint George Pilot Hospital Chania- Greece
10
Hospital Virgen de las Nieves of the
Servicio Andaluz de Salud
Pilot Hospital Granada- Spain
11 Fundacio Sanitaria de Mollet Pilot Hospital Mollet-Spain

Source: Data adapted from Digital Agenda for Europe, 201, retrieved from
http://ec.europa.eu/digital-agenda/en/content/greenhospital-making-hospitals-healthier-
and-greener
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Procedure. First, four hospitals in three European countries were chosen to be
pilot sites for this energy saving research. Then, each hospital made specific areas
available for the research and assigned a team to work with researchers for model
creation and algorithm development and a comprehensive energy audit. Next, through
a comprehensive energy audit, the potential areas of energy saving for each hospital
were identified. With the help of the models and software simulations, possible savings
were calculated, and energy saving strategies have been implemented. The main focus
of this research project is on the practicality of the solutions. Therefore, the solutions
adopted in the different hospitals were not the same. They were based on the particular
energy consumption patterns and the ability of each hospital to change (Figure 5.1).

Figure 5.1: Standard Energy Audit Procedure

Audit team appointment
Model Creation
Algorithm

Energy Audit

energy use
& bills

lighting HVAC
ICT data
collection
energy audit
level III **
building *
envelope

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Source: Reprinted from Green@hospital Project Overview, Davide Nardi Cesarini,
2014.
* “Building envelope is the physical separator between the interior and exterior of
a building. Components of the envelope are typically: walls, floors, roofs, fenestrations
and doors. Fenestrations are any opening in the structure: windows, skylights,
clerestories…” (AUTODESK Education Community,2015, para.1,2)
**Energy Audit Levels:
Level 1
 Rapid assessment of building energy systems
 Building energy benchmark
 High-level definition of energy system optimization opportunities Outline
applicable incentive programs
Level 2
 Detailed building survey of systems and operations
 Breakdown of energy source and end use
 Identification of Energy Efficiency Measures (EEMs) for each energy
system
 Range of savings and costs for the EEMs
 Spotlight on operational discrepancies
 Outline of priorities for limited resources, next steps, and identification of
EEMs requiring more thorough data collection and analysis …
Level 3
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 Longer term data collection and analysis
 Whole-building computer simulation calibrated with field data
 Accurate modeling of EEMs and power/energy response
 Bid-level construction cost estimation
 Investment-grade, decision-making support (Hudgens, 2010)

Based on initial research, and as depicted in Figure 5.2, the highest rate of
energy consumption of hospitals in European countries belongs to space heating (38%)
and the second one is for water heating (19%). These numbers are followed by lighting
(16%), ventilation (8%), cooling (7%), cooking (2%), office equipment (2%), refrigeration
(1%) and others (7%). In this study, the main focus is on the highest energy
consumption areas and the feasibility of modification in each hospital. Heating and
cooling, water heating, lighting, and ventilation are the main areas of focus for energy
saving in this research.

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Figure 5.2: Energy Consumption in European Hospitals

Data adapted from: Brett C. Singer, Jennifer L. Coughlin and Paul A. Mathew,
Environmental Energy Technologies Division, Lawrence Berkeley National
Laboratory. Summary of Information and Resources Related to Energy Use in
Healthcare Facilities – Version 1. October 2009.

Four Pilot Hospitals in the Context of Green@Hospital
This section first briefly reviews the situation of each hospital to show the volume
of their services and necessity and, at the same time, the complication of energy saving
in each unit, and then introduces the saving program and the amount of savings.
Energy Consumption in Hospitals (Europe)
space heating 38%
water heating 19%
lighting 16%
ventilation 8%
cooling 7%
cooking 2%
office equipment 2%
refrigeration 1%
other 7%
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University Hospital-United Hospitals of Ancona, Italy [The Azienda
Ospedaliero Universitaria Ospedali Riuniti Ancona (AOR)].
In June 2003, three hospitals of Umberto 1, G.M. Lancisi, and G. Salesi in Italy
merged and formed the Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona
(AOR), also known as the University Hospital or United Hospitals for short. The first
hospital (Umberto 1) was founded in 1911. The number of patients of this hospital in
1922 was 237 adults with 106 employees in service. This hospital was later extended
and became a university hospital in 1972. In the year 2000, it was the largest hospital in
the Marche (one of 20 regions of Italy) with about eighty departments and 2000
employees. Today, Umberto 1 serves about 40,000 patients and performs 12,400
surgeries per year (AOR website, 2014).
The second hospital (G.M. Lancisi) is the “only example of Hospital Specialist in
Cardiology” in Italy. It was founded in 1965 and was renovated in 1968 to accommodate
the focus on high specialization Cardiology (Hemodynamics, Cardioradiology, Cardiac
Surgery, Anesthesia, and Emergency Relief Cardiology). Finally, the third hospital (G.
Salesi) had its official opening in December 1900 with six beds and two patient rooms.
During the past century, this hospital changed significantly with new constructions and
the expansion of different departments such as Pediatrics, Otolaryngology,
Ophthalmology, and Orthopedics. In 1995, it became a hospital specializing in pediatric
and gynecology-obstetrics. In 2003, the G. Salesi as a highly specialized hospital
merged with G.M. Lancisi and Umberto 1 hospitals and formed the United Hospitals of
Ancona.
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Table 5.7: University Hospital-United Hospitals of Ancona, Italy [The Azienda
Ospedaliero Universitaria Ospedali Riuniti Ancona (AOR)]
University Hospital-United Hospitals of Ancona, Italy (AOR)
Address
Via Conca 71- Torrette, Ancona, Italy
Phone Number
071 5961
Location
Ancona, Italy
Surface
120,000 m2
Built/Restored
1970/2003
Beds
756
Employees
3100
University professors
120
Surgical rooms
18

Source: Data adapted from University Hospital-United Hospitals of Ancona website.
Retrieved from
http://www.ospedaliriuniti.marche.it/portale/pagina20_relazioni-con-il-pubblico.html
This new hospital is a part of the National Health Service and Marche Region
Health, and provides clinical activities, research, and teaching and training in many
complex and sophisticated healthcare services. The operation of this organization
focuses on the integration of similar activities among all three joint hospitals
(Dipartimenti ad Attività Integrata [D.A.I.]) and establishment of the Regional
Department of Transfusion Medicine. The goal is to have a more efficient operation with
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minimum waste. However, this efficiency does not yet exist in energy consumption of
the hospital. The cooling, heating, data center, and lighting systems work separately
using energy intensive equipment. An organized and integrated system to calculate the
real need and identify the unnecessary energy usage could improve efficiency, reduce
cost, and protect the environment. Therefore, in 2013, this hospital decided to be a part
of a pilot program for research on sustainability in public buildings in the context of
Green@Hospital to establish an integrated management system for energy
conservation and carbon footprint reduction. Through this program, the United Hospitals
of Ancona was able to achieve good progress toward energy efficiency goals in different
areas of activities.
Intelligent lighting system. In the first step, a comprehensive energy audit and
data analysis revealed that some departments such as Oncology, Hematology,
Oncohematology, and Oncology Pharmacy had excessive energy consumption and
showed inefficiency in their operations. Also, the data showed that some of the highest
energy usage was due to the lighting system of the hospital. This information indicated
that, for the best result, special attention needed to be on oncology care with a focus on
lighting. Therefore, an intelligent lighting system was established based on the following
variables:
 Occupancy rate of the rooms;
 Optimal brightness that is needed, based on the functions being performed;
 Power consumption (time schedule based control);
 Behavior of the occupants.
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The aim was to identify energy conservation factors that could result in standardized
solutions and to make them applicable to different buildings. Based on these variables
the following provisions were applied.
 Replacement of high energy consumption devices with energy smart equipment;
 Refurbishment of lighting equipment when replacement is not cost effective;
 Natural light utilization whenever feasible;
 Luminance level optimization based on occupancy time, scale, and function of
the room;
 Busbar installation (which conducts electricity within a switchboard) to reduce
power loss and corona effects (partial discharge of electrical energy);
 Sensors and motion detectors installation;
 Timers and actuators installation and time schedule based control;
 Replacement of all inefficient light bulbs with LED lights.
These solutions were gradually tested in all four pilot hospitals to fix the errors. The
results were significant, as indicated in Table 5.8.

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Table 5.8: Energy Saving Through Smart Lighting System in the United Hospitals of
Ancona, Italy (Azienda Ospedaliero Universitaria Ospedali Riuniti of Ancona)
Department Room Savings
Oncology Visitors waiting room - corridor 83%
Oncology Patients waiting room 93%
Oncology Nurse offices 43%
Oncology Doctor offices 61%
Oncology Archives – no window 43%
Oncology Archives - window 92%
Laboratory Waiting room 76%
Laboratory Hematology lab window side 85%
Laboratory Hematology lab corridor side 80%
Hematology Warehouse *
Hematology Nurse offices *
Hematology Doctor offices 88%

Source: Reprinted from Loccioni Group, 2014.
The results show that the higher savings were in rooms
 With a window
 Where occupancy is discontinuous
 Where lights used to be always on
and lower savings were in the areas where luminance level was increased (i.e.
Oncology nurse office)

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Figure 5.3: Energy Saving in Different Months of the Year through Smart Lighting
System in the United Hospitals of Ancona, Italy

Source: Reprinted from Loccioni Group, 2014
As Table 5.8 and Figure 5.3 show, the energy savings from this new method of
integrated energy management is meaningful and confirms the validity of the program.
Also, the data demonstrate that the rate of saving in winter is higher than summer. The
reason can be related to the utilization of natural light in this new program. The short
days of winter lead to the longer use of artificial lighting compared with long days of
summers.

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Economic Impact of Intelligent Lighting System in the United Hospitals of
Ancona. As illustrated in Table 5.9, different rooms in this department had
different savings resulting from the new program. The highest savings belonged to the
laboratory and technical areas with € 487,587 and the lowest savings were in the
waiting room with € 4,186. The overall energy saving was 75% and the total amount
saved through this program was € 830,105.

Table 5.9: The Amount of Saving Through Intelligent Lighting System in the
United Hospitals of Ancona
Room Saving (%) Saving (kWh) Saving (€)
Laboratory and
technical areas
70% 3,250,583 487,587
Warehouse 97% 1,049,431 157,415
Corridor 77% 908,236 136,235
Archives and WC 87% 154,237 23,136
Nurse and other offices 56% 113,546 17,032
Ambulatory 52% 30,090 4,514
Waiting room 76% 27,905 4,186
Total 75% 5,534,028 830,105

Source: Data adapted from Green@Hospital Final Report,2015.

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In general, the retrofit costs of intelligent lighting were high because it required the
renewal of the lighting infrastructure. However, the results were promising and showed
75% average saving.
Data center cooling optimization. The amount of energy needed for cooling the
data center of the hospital is immense, and this need has been increasing continuously
due to technological advances, digital medical equipment, and data management
activities. Therefore, the data center cooling optimization was the next step for reducing
the carbon footprint of this program. In the data center, energy consumption was
reduced through regulating dry coolers and pump speed based on “predicting external
air temperature” and the use of a free cooling system. “Free cooling reduces
refrigeration energy consumption by using evaporative cooling equipment to produce
chilled water in cool weather. Free cooling can be designed into new chilled water
systems or retrofitted into existing systems” (Vallabhaneni, 2006, p.41). According to
Vallabhaneni (2006), this system is about 75% more efficient than standard air
conditioning systems.
The General Hospital “St. George de Chania” of Chania, Greece
The St. George General Hospital of Chania with 1150 employees and a capacity
of 460 beds is the main healthcare center of the City of Chania on the Crete Island in
Greece (Crete with a population of 600,000 people is the most populous island in
Greece and Chania is one of the four regional units of Crete). St. George Hospital was
founded in the year 2000, and provides healthcare services to the citizens of the City of
Chania as well as the Chania region with a total population of 156,585 inhabitants. This
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Hospital provides its services through six different departments of Nephrology,
Neurosurgery, Oncology, Children, Heart, and Obstetrics-Gynecology, as well as an
autonomous 24-hour Emergency Department.
Table 5.10: The General Hospital “St. George de Chania” of Chania, Greece

The General Hospital “St. George de Chania” of Chania, Greece
Address Moyrnies Chania, Crete TK 73300, Greece
Phone Number +30 28210 22000
Location Chania, Greece
Surface 51,000 m2
Built/Restored - Year 2000
Number of Beds 460
Employees 1150
Surgical Rooms 17

Source: Data adapted from Chania General Hospital “St. George” (2015), retrieved
from: http://www.chaniahospital.gr/en_index.jsp and
http://www.chaniahospital.gr/el_tep.jsp
In 2013, this hospital agreed to be a part of a pilot program helping to determine
the validity of the Green initiatives of the Green@Hospital research. Each hospital in this
pilot program makes specific areas available to test the developed technologies “while
normalization factors are identified and monitored in order to predict the benefits of the
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same solutions in other operating conditions. The solutions will be standardized to be
replicated in other hospitals or different public buildings” (Green@Hospital, 2014, para.5).
The initial data analysis in the General Hospital of Chania showed high energy
consumption in the pediatric clinic and the lighting system. Therefore, energy savings
started with fan coil management and artificial lighting management in this department.
Tables (5.11) and (5.12) show the energy savings through lighting management and fan
coil management in this clinic respectively.

Table 5.11.: Energy Saving Through Lighting Management in St. George General
Hospital of Chania, Greece
Department Room Savings
Pediatric Doctors’ restroom 4%
Pediatric Doctor’s room 15%
Pediatric Patient’s restroom 38%

Source: Reprinted from (Cesarini, 2014)

Pediatric area fan coil. To optimize the performance of the fan coils in the
pediatric department, new controllers and sensors were added to regulate the start and
stop time, based on temperature prediction and occupancy. Temperature, relative
humidity, and CO2 measurement determined the comfort conditions.
The aim was to enhance patients’ and staff’s comfort and decrease energy
consumption. The results showed energy saving in three areas (see Table 5.12).
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Nevertheless, in the doctor’s room the automatic system had a slow response and a
manual control was activated. Therefore, the saving in this room was less than
expected.
Table 5.12: Energy Saving Through Fan Coil Management in St. George General
Hospital of Chania, Greece
Department Room Savings
Pediatric Doctors’ restroom 26%
Pediatric Doctor’s room 18%
Pediatric Patient’s restroom 22%

Source: Reprinted from (Cesarini, 2014)

The University Hospital “Virgen de las Nieves” of Granada, Spain
The University Hospital Virgen de las Nieves with 915 beds, 41 surgical rooms,
and 4521 employees is the second largest hospital in Spain serving more than 439,035
citizens. This hospital was founded 57 years ago as Sanitary Ruiz de Alda Health
Center. Then, in the 1970s, 1980s, and 1990s, it had major changes and merged with
other healthcare facilities to form the existing modern Virgen de las Nieves University
Hospital, which is equipped with state-of-the-art diagnostic equipment and has a patent
for a new method for the diagnosis of SLOS (Smith-Lemli-Opitz Syndrome). Eco-friendly
approaches have a history in the Virgen de las Nieves University Hospital. In 2005, this
hospital registered under EMAS and environmental management has become a core
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business issue for this organization. EMAS stands for Eco-Management and Audit
Scheme, a voluntary initiative established by European Regulation 1836/93 to improve
companies’ environmental performance. Environmental initiatives practiced by this
hospital include:
 Participation in the Campaign “Stay Healthy Stop Mercury”
 Better knowledge among the staff of best environmental practices through edition
of a newspaper, environmental ideas competition, and surveys
 Promotion of the Environmental Management National Symposium in Sanitary
Centers
 Inclusion of environmental clauses in suppliers’ contracts (EMAS, 2014)
Table 5.13: The University Hospital “Virgen de las Nieves” of Granada, Spain

Address
Avenue of the Armed Forces, 2., 18014,
Granada, Spain
Phone Number
958,020,009
Location
Granada, Spain
Surface
133,600 m2
Built/Restored
1953/1984 (11 buildings)
Number of Beds
915
Employees
4521
Surgical Rooms
41

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Source: Data adapted from Cambil Hernández, María de la Encarnación. The
University Hospital Virgen de las Nieves. Editorial ATRIUM. Granada: Editorial
Atrium, 2011. ISBN 978-84- 96101-95-1. Retrieved from:
http://www.hvn.es/comp_hospitalario/historia/index.php
http://www.hvn.es/comp_hospitalario/contactar/index.php
In addition, in 2013, this hospital agreed to become a part of the Green@Hospital
research to focus more on energy consumption minimization and carbon footprint
reduction. The initial energy audit and data analysis, in this hospital, directed attention
towards the emergency zone’s air handling unit, the surgery theaters’ air unit control,
and the data center.
Air handling unit (AHU) in surgery theaters and the emergency zone. In the
University Hospital Virgen de las Nieves, the AHU of the surgery theaters provides
heating, cooling, and ventilation for four surgery rooms. However, its manual operation
was inefficient with a low level of comfort for occupants. Therefore, the manual
operation of the AHU was changed to an automatic control system through the
installation of sensors and actuators and constant monitoring of the temperature and
ventilation. In addition, air handling units feeding the emergency area of the Maternity
Hospital were not equipped with modern and efficient control technologies. To improve
efficiency, sensors, meters, and a new controller were added to the AHU of this area.
Also, excessive ventilation was reduced and the use of the existing free-cooling system
was increased. As a result, occupants’ comfort increased while energy consumption
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decreased. The results show a significant reduction in energy consumption in the
emergency zone’s AHU and surgery theaters’ AHU (65% and 38% respectively).
Data center. Synchronizing the existing three chillers in the data center was the
solution for improving efficiency in cold water production for the cooling system of the
data center. Also, electrical and thermal meters were installed to monitor the
performance of the system on a daily basis. Also, cooling system optimization of the
data center decreased energy consumption by 6.5% (Table 5.14).
Table 5.14: Energy Savings in the University Hospital “Virgen de las Nieves” of
Granada, Spain

Energy Saving Solution

Average Energy Saving

Emergency Zone Air Handling Unit Control 65%
Surgery Theaters Air Handling Unit Control 38%
Data center cold water production management 6.5%

Source: Data adapted from Overview of the Green@Hosptial project, Roberto Pena,
2014.
The Hospital “Fundacio Sanitaria de Mollet” in Mollet, Spain
The Fundacio Sanitaria de Mollet Hospital with 160 beds and 700 employees
was built in 2010 in the city of Barcelona, Spain. This hospital has 42 consulting and six
operating rooms and provides healthcare services to 150,000 citizens. The specialty of
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the hospital is on kidney disease, fibromyalgia, and chronic fatigue. This hospital is
considered “a pioneer public hospital in environmental responsibility and energy
efficiency”, and is one of the four pilot hospitals of the Green@Hospital project for
energy saving innovation (Fundacio Sanitaria de Mollet Hospital, 2014).
Table 5.15: The Hospital “Fundacio Sanitaria de Mollet” of Mollet, Spain
The Hospital “Fundacio Sanitaria de Mollet” of Mollet, Spain
Address San Lorenzo 39-41, 08100 Mollet del
Vallès, Barcelona, Spain
Phone 34 935 63 61 00
Location Mollet, Spain
Surface 26,645 m2
Built/Restored - Year 2010
Number of Beds 160
Employees 700
Surgical Rooms 6
Consulting Rooms 42
Provides Service to 150,000 citizens

Source: Data adapted from (Fundacio Sanitaria de Mollet Hospital, 2014).
Retrieved from:
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http://www.consorci.org/associats/directori/fundacio-privada-hospital-de-mollet-del-
valles

Energy Saving in the Hospital “Fundacio Sanitaria de Mollet” of Mollet,
Spain. In 2013, a management team was created to work with the
Green@Hospital research program to establish and maintain modern and efficient
mechanical and lighting systems. In this new system, heating and cooling are provided
through a geothermal system and an innovative radiant ceiling. According to the U.S.
Department of Energy:
Radiant heating systems supply heat directly to the floor or to panels in the wall
or ceiling … [The systems are based on] the delivery of heat directly from the hot
surface to the people and objects in the room via infrared radiation…Radiant
heating is more efficient than…forced-air heating because it eliminates duct
losses (ENERGY.GOV, n.d., para. 1, 2)
At the same time, there is a 24-hour monitoring system to identify the area of
highest consumption in the organization for future improvement. In this hospital, initial
evaluations showed high energy consumption for heating and cooling, as well as in
surgery rooms’ ventilation systems. Based on this analysis, a new system for heating
and cooling generation has been installed, and as an experimental approach, meters
were installed to assess the efficiency of the new system of geothermal heat pumps vs.
the traditional system of gas boilers and chillers that work simultaneously in this area.
The goal was to learn about the best result at different times of the day and in different
seasons to identify the most efficient alternatives for this area. The initial analysis
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showed that, in different situations, different systems are more efficient
(Green@Hospital, 2014).
In addition, there are six surgery rooms in this hospital that require very high
ventilation rates with “strict environmental conditions.” Therefore, they are among the
most energy intensive areas. The existing ventilation system was oversized with an
unnecessarily high flow rate. To improve efficiency, the ventilation rate of the surgery
rooms was reduced to the required flow rate. Also, a particle detector was added to the
system to minimize the concentration of biological particles and to improve air quality.
The final result shows a reduction of the energy consumption for the hospital’s
heating and cooling system, improvement of air quality of the surgery rooms, and
operating cost reduction.

Table 5.16: Energy Savings in the Hospital “Fundacio Sanitaria de Mollet”

Energy Saving
Solution
Average Energy
Saving
Economic saving
(in 6 months)
Expected yearly
savings
(6 surgery rooms)
Heating and cooling
generation
26% €14,000 _
Surgery Rooms
Ventilation
10%
(for one surgery
room)
€1,100 €13,200
Overall Hospital
Consumption
Reduction
8.50% _ _

Source: Data adapted from (Green@Hospital, 2014)

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In general, the results of the Green@Hospital research program demonstrate
that there are significant savings in energy consumption in the hospitals and their
different departments through improved lighting, heating and cooling, ventilation, data
center, and surgery theatre ventilations. This research showed that a holistic strategy
and synergies among equipment can improve efficiency and reduce consumption
significantly (especially in larger organizations). Although the amount of savings in each
unit is different and depends on the amount of optimization in the particular section, the
total energy consumption reduction is substantial. The algorithms for consumption
optimization in this ICT program are replicable in other hospitals, and can help
sustainable operations in different healthcare facilities.

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CHAPTER SIX: DISCUSSIONS, RECOMMENDATIONS, AND CONCLUSIONS

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6.1. Preface
Some of the main goals of this study were to explore the socioeconomic and
environmental impacts of the healthcare industry in society, create a shared
understanding of sustainability in the medical activities, improve the level of empirical
knowledge on the topic of Green Healthcare, raise awareness, and present the most
affordable and applicable Green initiatives in medical practices. The aim was to find the
main barriers to adoption of sustainable practices in the healthcare industry and
determine the best ways to encourage more facilities to join the Green movement. The
literature review and the experiences of different hospitals in this study showed that two
major obstacles to Green operations are the lack of employees’ and leaders’ awareness
about the negative environmental impacts of their activities as well as the upfront costs
of improvements. For example, in 2011, the Johns Hopkins Hospital assigned a budget
to start some Green initiatives. In this experiment, the main resistance came from the
surgeons, then other employees followed these “superior” professionals and resisted
any changes in the status quo. Hence, the office of sustainability had to change its
implementation methods and started to educate the personnel and facilitate dialogues
among employees in this matter. Although it was time-consuming, the new method was
successful to the point that this hospital was able to become a member of Practice
Greenhealth in 2014. Today, this hospital has one of the top 10 Greenest ORs across
the nation (Johns Hopkins University, 2015.).
In many small activities such as separating wastes, if the employees do not
understand the importance of their actions, there is no way to force them to be diligent
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in their task. Without enough knowledge, a new order or policy can be considered as an
extra duty on top of all the existing complicated healthcare rules and regulations. The
best way to encourage employees (including physicians) to do the small and, at the
same time, important activities toward sustainable operations is to educate them about
the necessity of these practices. Employees need to own these changes; otherwise, the
results will would not be effective.
The literature review findings revealed that despite the hard work and sincere
efforts of different Green organizations, still, the majority of the healthcare facilities have
not adopted Green operations as their main management philosophy (see chapter 2).
According to the reviewed literature, in summary, the next steps for advancing the
practice of sustainable healthcare activities are to:
1. Raise awareness about the negative environmental impacts of medical activities
among medical professionals, with a focus on all healthcare workforce members
not only managers and leaders;
2. Expand the meaning of efficiency in Lean and Six Sigma management
methodologies to include environmental impacts of the medical services in their
analyses;
3. Identify the most practical and affordable Green initiatives in the healthcare
industry;
4. Develop comprehensive cost-benefit analyses of different Green initiatives in
medical practices; and
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5. Create a cohesive policy recommendation for municipalities and local
governments to incentivize Green operations in healthcare facilities.
This study was able to undertake the first three steps. It contributed to the
general understanding of sustainable healthcare services in society and determined the
environmental factors that affect patients’ wellbeing and public health. It offered a more
comprehensive meaning of efficiency and identified the most practical and affordable
Green initiatives in the healthcare industry. However, there is a need for more research
on steps four and five to break the barrier of the business confidentiality of hospitals,
and develop a comprehensive cost-benefit analysis for each Green initiative in
healthcare settings. In addition, there is an urgent need for research on the mutual
relationship between medical facilities and different municipalities to create a cohesive
policy recommendation for local governments to be able to incentivize Green operations
in all businesses, especially in hospitals, and provide mutual benefit for medical
organizations and society.
This chapter first summarizes the recommendations regarding raising awareness
among healthcare employees (at all levels of employment) to make them ready for
meaningful changes toward sustainable operations, and then presents some of the
most practical and affordable Green initiatives based on the literature review findings
and the experiences of different hospitals. These suggestions are to inform all
employees, not only the leaders (as was done in the majority of existing studies)
because sustainability is a lifestyle and does not work with the old systems of command
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and control. In other words, environmentally sustainable operations are not effective in
rigid and “mechanistic” systems of management.
Based on the findings of the study, this chapter provides practical
recommendations in four sections of creating a culture of sustainability in the system,
integration of Green healthcare philosophy with Lean and Six Sigma methodologies,
customized approach in Green healthcare, and focus on small and incremental
changes. Lastly, a list of practical Green initiatives that either require low investments or
have a high ROI, is presented to be useful for medical facilities in different size of
operations. In the end, strengths and limitations of the research and concluding remarks
will be discussed.
6.2. Create a Culture of Sustainability in the Medical Organizations
The results of the interviews with some employees of different hospitals, in this
study, confirmed the findings of the studies of Hartman, Fok, and Zee (2009; 2010;
2011) regarding the lack of pervasive awareness by healthcare professionals about the
negative environmental impacts of their medical activities. Even in a hospital which was
rewarded for its Green initiatives, physicians and regular employees were not aware of
the requirements, the hospital’s achievement, and the necessity of their Green activities.
Educating all employees and creating a culture of sustainability in the body of a
healthcare organization is one of the main factors for having Green operations in the
healthcare industry. A sustainability approach cannot be isolated amongst two or three
employees or leaders as sustainability officers. Sustainable operations need
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understanding and cooperation of all employees. Although from the start there is a need
for full-time staffing, they should be the leaders not the only performers. Otherwise,
adding more requirements to the already heavily regulated industry will be considered
as more burden on the workforce and nobody will follow the path. Employees need to
be the main initiators of the creation of new policy and planning in Green operations. To
create this culture among employees, medical organizations should engage in the
following activities:
 Put priority on Green approaches in the process of all administrative tasks;
 Assign a sustainability officer, or if it is possible, a sustainability group for each
department to work with the general sustainability plan of the organization and
lead the employees based on the plan;
 Hold periodic lectures about the negative environmental impacts of medical
activities for employees;
 Give recognition and value to any small Green initiatives;
 Print flyers about Green healthcare;
 Distribute monthly and weekly brochures about small and effective Green
initiatives;
 Determine awards for best Green practices in each department;
 Determine awards for the new and innovative suggestions for saving natural
resources;
 Provide incentives for undertaking activities which save natural resources such
as carpooling;
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 Hold annual meetings for employees and their families to celebrate their Green
endeavors
6.3. Integration of Green Healthcare Methodology with Other Quality Improvement
Strategies
In recent years all healthcare facilities, more than any other time, have been
looking for ways of saving and reducing costs, and quality improvement strategies such
as Lean and Six Sigma have become very popular amongst different hospitals. Their
main focus is on efficiency improvement and cost reduction through waste minimization
(in its general meaning) in hospitals’ service providing cycles. As mentioned in the
literature review chapter, these methods are ingenious and can save a considerable
amount of money for different organizations.
However, the definition of efficiency in Lean and Six Sigma quality improvement
methodologies is limited to the internal framework of the system isolated from the
society and the environment in which the organization is located. These methods, in
their analyses, perceive a system (or an organization) as separate and independent
from its social and environmental contexts without interactive effects between them.
Despite the fact that environmental efficiency in the healthcare industry plays an
important role in public health and patients’ wellbeing, there is no consideration of these
issues in the Lean and Six Sigma analyses and assessments. Moreover, the meaning
of efficiency that was defined three decades ago (only monetary efficiency and
overhead reduction) cannot address the needs of today’s organizations. Efficiency
cannot be only an improvement in an organization without considering the
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environmental impacts of each activity, and the short-term economic benefits cannot
justify the long-term degradation of the environment. In today’s societies, all
organizations eventually will pay the social cost of environmental degradation.
A comparison of the core ideas of the Lean (or Lean-Sigma) philosophy and the
Green methodology shows many similarities in these two approaches. In both, the main
point is to “create more value with fewer resources.” Therefore, these two methods can
complement each other, and their integration can improve the economic and
environmental sustainability of an organization at the same time. A general review of
these methodologies shows that, with a Green perspective, the seven categories of
waste in a healthcare facility can be defined as follows:
1. Defects: (anything that requires re-work): Such as unlabeled medication,
unlabeled specimen, poor legibility of physicians’ handwriting, lack of recycling,
lack of composting;
2. Overproduction: Unnecessary tests, excessively prescribed medication,
unnecessary re-admission, extra use of energy and water;
3. Inventories: Overstocked medicines, overstocked inventory for medical supplies
and medical equipment;
4. Over processing: Such as redundant paperwork, different computer systems in
different parts of the organization without a direct connection;
5. Motion: Unnecessary motion of employees due to improper planning and design
of spaces, wrong placement of medication cabinets in a healthcare setting;
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6. Transport and handling: Unnecessary goods and supplies transport due to the
lack of management, purchasing food and supplies from companies which
require long-distance transportation, lack of ridesharing policies for employees;
7. Waiting: Any waiting that can be prevented in the system, such as patients’
waiting to do the test, doctors’ waiting for the test result, and technician waiting
for patients’ preparation.
Further research is needed for a comprehensive analysis of the compatibility of
these methodologies and any implementation. Nevertheless, it seems that adding
environmental notions into the Lean & Six Sigma methodologies can have mutual
benefits for both philosophies. This integration not only can improve inclusiveness of the
Lean-Sigma methodology and eliminate disconnection between a system with its
environment, but it can also empower the Green movement in the healthcare industry
and make it acceptable for a greater number of facilities.
6.4. Customized Approach in Green Healthcare
Adopting Green strategies in healthcare settings requires solutions that address
patients’ wellbeing and cost reduction, and decrease negative environmental impacts of
medical activities. The leaders and employees of medical facilities need to assess their
current conditions and use a careful analysis to develop systematic planning and
determine the best and the most practical Green measures in their organizations. The
plan should be based on patients’ safety in the particular context of each facility. It
cannot work as a one-size-fits-all policy. One perfect solution in a big hospital may not
be the best choice for small or medium sized medical centers. The size of the institution,
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its financial resources, climate and geography of the area, and the knowledge of the
managers and employees about environmental issues are among the most important
factors influencing the Green strategies of each organization.
In many Green hospitals, recycling, elimination of mercury, and energy efficient
equipment are among the main Green initiatives. Nevertheless, none of the measures
has priority over others. The main point is to help organizations adopt Green provisions
as soon as possible and catch up on sustainable operations in any scale and any area
that is feasible for them. There are a large variety of Green provisions, the application of
which depends on the specific settings of each facility. Large hospitals, with greater
financial reserves, can start with major efficiency improvements such as adopting
renewable energy (solar system, wind power, and thermal power plants) and LEED
certified buildings along with other small initiatives. However, companies that have more
concerns about upfront costs can start with smaller scale measures such as recycling,
composting, food management, efficient lighting fixtures, efficient landscape irrigation
systems, and reduction of toxic materials. With this approach, there will be no excuse
for delay on adopting Green methodologies in any medical facility. In all organizations,
however, educating the employees should be among the first steps on this path.
6.5. Focus on Small and Incremental Changes
The experiences of many medical facilities show that, in normal situations, the
best approach is to start with smaller initiatives with lower upfront costs and short
payback periods and little by little build upon the successes in different parts of the
organizations. In the past, many Green activities in the healthcare industry were not
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effective because the leaders started with large and expensive measures before being
financially ready and culturally preparing their employees. Therefore, results did not
match the operating expenses, and the organizations stopped the measures before
seeing the real outcomes.
In this regard, careful management is one of the key factors for the success of
Green initiatives in each facility, especially small and incremental changes. Conscious
leadership is crucial for advancing sustainability objectives in the healthcare industry,
but not the old forms of leadership and management based on order and command.
Rather, leaders need to lead the employees toward sustainable operations based on
cooperation and teamwork and understanding the main concepts and goals of eco-
friendly activities.
In this study, a variety of eco-friendly activities and their advantages and
practicalities in the healthcare industry were scrutinized. Since upfront costs are among
the main barriers to undertaking sustainability efforts in many organizations, this section
offers a list of some practical suggestions that either require relatively low investments
(such as efficient irrigation systems) or have a high ROI (such as reprocessing the
medical devices). Nonetheless, sustainability knowledge among leaders and employees
and careful planning are necessary for both groups of Green activities. A
comprehensive education and training program for employees about environmental
issues should be the first step (with a top priority) in all medical facilities.
Focusing on even one Green initiative can have a significant impact on the
environment, and combining several initiatives would have substantial positive results in
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favor of the environment. Also, experiences of the forerunners in Green operations of
healthcare facilities indicate that this combination can reduce operating costs in the long
run.
A List of Practical Green Initiatives that Either Require Low Investments or
Have a High ROI
The following measures are appropriate to help medical organizations accelerate
their rate of change toward environmentally sustainable practices. As mentioned
previously, none of the measures has priority over others. Leaders and employees can
choose the desired activities based on the potential and actual capabilities of their
particular healthcare organization. They can start small and expand their Green
activities and build upon their successes to add to the existing measures whenever it is
feasible in each department. Each facility needs to assess the feasibility of various
Green provisions based on its geographical location and particular financial status.
Although none of the initiatives has priority over others, measurement of the
effectiveness of the program and relevant education and training for employees is
crucial in all sustainable activities.
Toxic materials
 Use non-mercury alternatives for medical devices such as thermometers, blood
pressure devices, and gastrointestinal devices, and for medical products such as
fixatives, preservatives, lab chemicals, and cleaners
 Use nontoxic sterilizing materials
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 Use nontoxic cleaning products
 Start PVC phase out in the organization and stop dioxin exposure (dioxin is one
of the most dangerous chemical compounds on the planet)
 Purchase PVC-free flooring and carpets
Energy efficiency
 Utilize natural light when it is possible
 Use LED light bulbs, improve sustainability and save money. For example,
replacement of the exit signs’ bulbs to LED in a typical 600-bed hospital with 300
exit signs would cost $17,100 and save $14,755 a year on energy costs,
resulting in a payback period of 1.15 years (U.S. Department of Energy, 2011).
 Use light sensors and motion detectors
 Use ENERGY STAR computers and other office equipment
 Use CRT monitors instead of LCD monitors. CRT flat-screen monitors use 50% -
70% less energy (Doris, 2009)
 Replace desktop computers with laptops. Laptops usually use 50 watts, but
desktops can have up to 200 watts of energy consumption (Cornell University
Facilities Services, 2005)
 Use energy efficient power strips to reduce phantom loads. Energy efficient
power strips can be used with any nonmedical equipment and some medical
equipment that can be powered down (phantom loads or standby power is the
electricity consumed by equipment even when turned off, which can be 5-10
percent of an electrical plug load)
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 Use only EnergyStar or EPEAT registered products
EPEAT [ or Electronic Product Environmental Assessment Tool] is the
definitive global rating system for greener electronics. It is an easy-to-use
resource for purchasers, manufacturers, resellers and others to identify
environmentally preferable devices. “EnergyStar is a voluntary program
established by USEPA to identify and promote energy-efficient products and
buildings” (Omelchuck, Katz, Salazar, Elwood, & Rifer, 2006, p.101)
 Use networked power management systems for the whole organization
 Purchase dryers with automatic shutoff sensors (if the hospital has a laundry
facility) that automatically turn the dryers off when clothes are dry, and save
energy
 Use sensor-based vending machine controls, which can save up to 50% on
energy costs
 Insulate hot water system equipment and piping
Water efficiency
 Request separate water meters for major water usage areas such as irrigation
systems or surgery rooms
 Upgrade regular lavatory faucets (2 gpm) to laminar spray flow faucets (0.5 gpm)
 Upgrade regular shower heads (2.5 gpm) to efficient shower heads (1.5 gpm)
 Upgrade old toilets (6 gpf) to water-efficient toilets (1.28 gpf)
 Provide water fountains for employees and visitors in the facility
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 Consider landscaping with native plants
 If native plants are not desired, utilize drip irrigation systems instead of regular
overhead spray systems for landscape irrigation
 Xeriscape landscaping is another good alternative to minimize landscape water
expenditure
 Use permeable asphalt instead of conventional asphalt in the open areas and
parking lots to help urban run-off reduction
 Collect rain water to use for different non-drinking purposes
If the hospital has a laundry facility:
 Use front-load washers rather than top-load washers. Front-load washers
automatically adjust the amount of water required based on the size of a load of
laundry
 Use ENERGY STAR labeled washers. They consume 37% less energy and 50%
less water (U.S. Department of Energy, 2011)
Waste management
 Eliminate incineration and use other alternatives such as autoclaving and
electropyrolysis when it is possible
 Provide color-coded trash cans in all areas (including patients’ rooms) to make
the waste-sorting easier
 Request reusable packaging and containers for food and medical supplies from
vendors and suppliers
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 Use consignment inventory for medications in hospitals, to prevent
pharmaceutical waste and save money
 Separate the medical waste from the kitchen and office waste
 Prevent food waste through a careful meal plan based on patients’ demographics
and their requests
 Provide composting areas for food and landscape waste. There should be
different composting systems for food scraps and yard waste (including food
waste in the yard waste can attract rodents)
 Separate PVC from the waste stream
 Provide an effective recycling system for papers and plastics
 Make a contract with certified reprocessing companies and reprocess medical
devices when it is safe for the patients (it can reduce waste and save money
significantly)
Green transportation measures
 Provide incentives to employees for carpooling, and to those who use public
transportation (incentives such as free parking, preferred parking, reward
programs, food coupons, monthly paid-time-off (PTO), and more)
 Increase monthly and daily parking fees
 Offer employees’ shuttle, when it is possible
Employers can benefit from Green transportation measures through tax savings and
reduction of parking structures.
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Healthy food
 Purchase locally-grown food
 Reduce meat in the patients’ weekly food schedule. The result is healthier diet for
patients, less carbon footprint, and operation cost reduction for the company
 Order seasonal produce as much as possible
 Purchase organically grown foods whenever possible, especially foods that are
heavily contaminated with pesticides such as apples, celery, strawberries,
spinach, kale/collard greens, potatoes, peaches, nectarines, grapes, sweet bell
peppers, blueberries, and lettuce
 Buy non-GMO food whenever possible
Note: “Buying 100% Organic, Certified Organic, and USDA Organic-labeled products is
usually the easiest way to identify and avoid genetically modified ingredients. The
United States and Canadian governments do NOT allow companies to label products
‘100% / Certified Organic’ if they contain genetically modified foods” (GMO-
Awareness.com, 2011, para.1). Buying organic food is more expensive; however, in
combination with other healthy food programs such as meat reduction, the food costs
would not increase significantly.
6.6. Strengths and Limitations
This study explored different aspects of environmentally sustainable healthcare
operations and examined the findings through multiple case studies to provide more
accessible, applicable, and understandable information about Green initiatives in the
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healthcare industry and educate all levels of medical employees about eco-friendly
practices. It created a shared understanding of sustainability in medical activities and
offered a customized approach to Green Healthcare to encourage all medical facilities
to join the Green movement as soon as possible without any limitations (as this mission
is already past due for several years). This study also identified two widespread quality
improvement strategies of Lean and Six Sigma and offered improvement in their
meaning of efficiency and integration of environmental impacts of the healthcare
industry to their existing methodologies.
The majority of previous studies have documented the efforts and successes of
Green hospitals with an emphasis on convincing healthcare leaders to adopt Green
practices. This study, however, focused on the practicality and understandability of
Green initiatives for all employees without any prerequisite for medical facilities to start
any Green activity. The discussed Green initiatives can be started in any department of
a hospital, mostly with minimal upfront costs.
Nevertheless, inability to gain access to the financial information of the reviewed
hospitals resulted in the lack of enough data for comprehensive cost-benefit analyses of
their sustainable activities. These analyses could have helped the stakeholders to better
understand the role of Green activities in their operations and could have helped to
scrutinize and eventually overcome one of the major obstacles (financial efficiency) to
Green healthcare. Another limitation of this study is the lack of enough information
about the role of each medical facility in the city in which it is located to show the
benefits of Green medical facilities for public health.
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Future studies can focus on collaboration between medical facilities and local
governments to provide cohesive policy recommendations for different municipalities to
expedite the approval processes for Green facilities instead of adding more obstacles
and prolonging the process of obtaining building permits. In addition, although Green
buildings play an important role in Green operations in healthcare settings, the main
focus of this research is on operations, not the building design and structures. There is
a significant body of literature on Green buildings, but there is not enough attention on
sustainable daily operations and the connection between these two. After clarifying the
importance of Green medical operations, the role of Green buildings in facilitating Green
operations is a valuable topic for future studies.

6.7. Concluding Remarks
"Do not wait for extraordinary circumstances to do good action; try to use ordinary
situations."
Jean Paul Richter, German Novelist

In the existing situation that the environmental degradation and public health
impairment caused by medical services is much faster than the adoption of Green
initiatives in the healthcare industry (WHO, 2009), there is no time to wait for eliminating
the main obstacles in this matter. According to the literature review findings that were
confirmed by the experiences of different hospitals in this study, two major obstacles to
Green operations are cultural and financial preparations of the medical facilities. This
study aimed to raise awareness regarding the massive negative environmental impacts
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of the healthcare industry among medical professionals and recommended several
provisions in this regard. It also introduced the most affordable and applicable Green
initiatives with relatively low upfront costs to encourage more organizations to join the
Green movement.
Results from this dissertation show that the main focus should not be on a
specific Green activity, but it should be on correct implementations, transparency, and
measurement of the effectiveness of any initiatives that medical facilities choose to
practice (based on their financial and geographical status and the feasibility of their
activities). For example, although recycling is one of the most important sustainable
measures in the medical field, if a facility is located in a city without an active recycling
program, then this activity is not recommended as a top priority. In this situation,
recycling would require long-distance transportation that increases the carbon footprint
of the facility instead of helping the environment and public health. Another example is
the installation of a water efficient irrigation system that has a high priority in arid and
semi-arid regions such as California, but does not have priority in rainy regions such as
Athens, Ohio. Therefore, there is no general priority whatsoever in the order of
implementation of the suggested Green measures. The focus should be on encouraging
more practices in order to join the movement as soon as possible in any way that is
feasible for them, not on any specific Green activity.

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APPENDICES

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Appendix A:

Climate Impact on Human Health & Greenhouse Gases Overview
(Source: EPA, 2011)
Human Health
 A warmer climate is expected to both increase the risk of heat-related
illnesses and death, and worsens conditions for air quality.
 Climate change will likely increase the frequency and strength of extreme
events (such as floods, droughts, and storms) that threaten human safety
and health.
 Climate changes may allow some diseases to spread more easily.
Greenhouse Gases
Gases that trap heat in the atmosphere are called greenhouse gases. The main
greenhouse gases are:
 Carbon dioxide (CO2)
 Methane (CH4)
 Nitrous oxide (N2O)
 Fluorinated gases
Carbon dioxide enters the atmosphere through burning fossil fuels (coal, natural
gas and oil), solid waste, trees and wood products, and also as a result of certain
chemical reactions, such as manufacture of cement.
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Methane is emitted during the production and transport of coal, natural gas, and oil.
Methane emissions also result from livestock and other agricultural practices and
by the decay of organic waste in municipal solid waste landfills.

Nitrous oxide is emitted during agricultural and industrial activities, as well as
during combustion of fossil fuels and solid waste.
Hydrofluorocarbons, perfluorocarbons, and sulfur hexafluoride are synthetic,
powerful greenhouse gases that are emitted from a variety of industrial processes.
Fluorinated gases are sometimes used as substitutes for stratospheric ozone-
depleting substances (e.g., chlorofluorocarbons, hydrochlorofluorocarbons, and
halons). These gases are typically emitted in smaller quantities, but because they
are potent greenhouse gases, they are sometimes referred to as High Global
Warming Potential gases ("High GWP gases").

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U.S. Greenhouse Gas Emissions (2010)

Total Emissions in 2010 = 6,822 Million Metric Tons of CO2 equivalent

Source: EPA (2012)
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The number of 100-degree days per year is projected to increase

Source: USGCRP (2009)
The "urban heat island" refers to the fact that the local temperature in urban
areas is a few degrees higher than the surrounding area.
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Source: USGCRP (2009)

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Appendix B:

Medical Waste

What do we do with Medical Wastes?
• Incinerators:

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Incineration is a traditional way of treatment and disinfection of medical waste for more
than a century.

Incineration cannot eliminate hazardous medical wastes, it can only concentrate
about 30% of the harmful medical waste that goes into the incinerators remains as ash
Burning medical waste leads to the release of dangerous pollutants, heavy metals, and
toxic chemicals such as dioxin into the environment.

 Landfills

• Soil contamination
• Surface water pollution
• Methane
• Return to food chain

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Dioxin is one of the most toxic medical wastes, and hospital waste incinerators are the
largest Dioxin sources in industrial countries.
Dioxin is a Carcinogenic compound that is environmentally persistent.
Dioxin (C12H4O2Cl4)

Dioxin Health Effects:

• Cancer
• Diabetes
• Learning disabilities
• Liver disease
• Immune system suppression
• Skin disorder
• Birth defect
e.g., :

Mr. Yushchenko (former president of Ukraine) suffered disfigurement after ingestion of
dioxin during the presidential election of 2004.
Waste minimization
Healthcare waste is divided into two parts:
1. Healthcare General Waste (HCGW=75-85%)
2. Healthcare Risk Waste (HCRW= 15-25%)
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Estimated number of jobs per one million tons of waste processed:
Type of waste disposal/Number of jobs:
• Landfill - 40-60
• Incinerators - 100-290
• Mixed waste composting - 200-300
• Recycling - 400-590
Recycling is helpful, but it is not the best solution for waste reduction. Switching to
reusable, returnable, and repairable equipment and packaging can reduce the volume
of recyclable waste.
Reprocessing
According to the American Society for Healthcare Central Service Professionals,
“reprocessing is any process which renders a used, reusable, or single-use device
(SUD) to be patient-ready or which allows an unused product that has been opened to
be made patient-ready”. In recent years, European hospitals are increasingly reducing
the amount of their waste by switching to reusable medical equipment which can be
sterilized.

An auto-reprocessing machine
Reprocessing can reduce 50% of cost in medical device purchasing.

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Appendix C:
Green Initiatives in Different Hospitals

Hospitals
Green Measures
Stony Brook
Univ. Hospital
E. Carolina
Heart Inst.
Kaiser Modesto
Medical Cent.
Nontoxic paint

Captured stormwater

Eliminate disposable
wrapping materials

Energy efficient air
conditioning chillers,

Energy efficient utility
plant.

Environmentally friendly
products

Ergonomic equipment

Natural light

Paper reduction

Permeable pavement

Purchasing local produce

Recycling

Reprocessing

Reusable containers

Rubber flooring instead of
vinyl

Sensors

Solar panels

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Green Initiatives in Different Hospitals (continue)

Hospitals
Green Measures
Dell Children
Medical Ctr.-
TX
Boulder
Community
Foothills
Hosp.-CO
Metropolitan
Hospital-MI
Children's
Hospital of
Pittsburgh-PA
Efficient
Landscape

Energy efficient
chillers

Energy efficient
utility plant.

Energy-efficient
Equipment

Energy-efficient
light bulbs

LEED Certified
Building

Low-flow plumbing
fixtures

Natural light

Purchasing local
produce

Recycling

Renewable energy
source

Reuse pavements

Sensors

Solar panels

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Green Initiatives in Different Hospitals (continue)

Hospitals
Green Measures
Branson
Methodist Hosp.
Providence
Newberg Med. Ctr.
New York-
Presbyterian Hosp.
Energy efficient air
conditioning chillers,

Energy efficient utility
plant.

Improved Heating
Controls

Incinerator closure

LED Light Bulbs

LEED Certified
Building

Natural Light
Utilization

Recycling

Renewable Energy

Reusable containers
Spread the Culture of
Efficiency

Source: Data adapted from: Romano (2004), Cassidy (2010), Serb (2008), and WHO
(2008)

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Appendix D:

Kaiser Modesto Medical Center

A 1,427,000 square feet medical center campus will be constructed in three phases in
Modesto, California. The total cost of construction will be 430 million dollars.
Phase A:
400,000 sqf hospital with 250 bed, 260,000 sqf hospital support wing, 140,000 sqf
medical services building, and 30,000 central utility plan
Phase B:
Add a 200,000 sqf expansion of the Hospital and a 46,000 sqf (515 stall) parking garage
(2013-2016)
Phase C:
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Addition of two 120,000 sqf (3 stories) medical services buildings, a 65,000 sqf (920
stall) parking garage, and 46,000 sqf (750 stall) parking garage (2025-2028)

Based on the CEQA’s (California Environmental Quality Act) guidelines and
the EIR (Environmental Impact Report) assessment, this project has significant impacts
on the environment, and there is a need for feasible alternatives or feasible mitigation
measures in the following categories.
• Aesthetic/Visual, Agricultural Land
• Air Quality, Drainage/Absorption, Flood Plain/ Flooding
• Noise, Population/ Housing Balance, Public Services,
• Cumulative Effects Growth: land use, sewer capacity, soil erosion
• Solid waste, toxic/ hazardous,
• Traffic/circulation,
• Vegetation
• Water supply, water quality
• Wildlife

The review of the final Environmental Impact Report (FEIR) of this project in 80
files and 3,520 pages demonstrated that there were no feasible alternatives in many
categories, and Kaiser Permanente Medical Center had to comply with the
environmental requirements through mitigation measures. In a Development
Agreement, Kaiser agreed to contribute to the costs of public facilities and services as
required to mitigate impacts on the community arising from the development of the
Green Healthcare, an Environmentally Sustainable Methodology

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project site. The FEIR states “mitigation measures in this Agreement may be more
comprehensive than those measures which are set forth in the Mitigation Monitoring
Program”.
The Modesto Kaiser Medical Center as a Green facility, not only complied with
the CEQA’s requirements, but voluntarily executed a higher level of environmentally
friendly approaches for its building design and operation.
Environmental Impact Report (EIR) Screenshot
80 files of final EIR (FEIR), approximately 3,520 pages

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Green Healthcare, an Environmentally Sustainable Methodology

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Kaiser Modesto hospital, Modesto, California

The use of natural light in the Green hospitals not only saves energy, but improves
patients’ recovery rates

Water Management
Water (accessibility and management), as one of the most important issues in this
region, was the first concern in this project.
Water Supply Assessment Process
 The Kaiser Permanente Modesto Medical Center (Project) Water Supply
Assessment (WSA) is prepared in compliance with Senate Bill 610. SB 610
 The proposed project meets the criteria of a “Project”, by employing more than
1,000 persons and having more than 500,000 square feet of floor space, and
therefore triggers an SB 610 WSA.
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 The format of this WSA follows the format specified in the “Draft Guidebook for
Implementation of Senate Bill 610 and Senate Bill 221 of 2001” prepared by the
California Department of Water Resources
 The project was outside the City limits originally, but the City of Modesto had
annexed the project and became the project’s water provider

Annual Potable Water Supply Sources
1. Groundwater Tuolumne Basin: Up to 45,625 (Acre Feet/yr.)
2. Groundwater Turlock Basin: Up to 4,587 (Acre Feet/yr.)
3. MID Treated Surface Water: 33,602 (Acre Feet/yr.)
Estimated Domestic Average Annual Water Demands for the Kaiser Medical
Campus
Phase (Est. completion)
Floor Space
(sf)
Beds
Estimated Water
Demands (gpd)
Phase 1 (2005) 400,000 200,000
Phase 2 (2007) 435,000 250 191,050
Phase 3 (2013-2020) 200,000 125 95,525
Phase 4 (2014-2020) 120,000 49,750
Phase 5 (2028) 120,000 49,750
Total: 1,141,000 375 586,075
Green Healthcare, an Environmentally Sustainable Methodology

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Source: Data adapted from Capital Engineering Consultant Memo, February 19, 2003
and revised building descriptions from the Kaiser Permanente Project EIR dated July
10, 2003.

Based on the above information, the estimated water demands of the project, at build-
out in 2028 is approximately 586,100 gallons per day

Estimated Domestic Average Annual Water Demands for the Cornerstone
Business Park (the total project)
Cornerstone
Business Park
Area
Water Use
Factor,
gallons/acre/day
Estimated Water
Demands (gpd)
Business Park 39 acres 1,785 69,740
Landscaping 3.9 acres 3,570 13,923
Total: 83,663

Source: Data adapted from Capital Engineering Consultant Memo, February 19,
2003 and revised building descriptions from the Kaiser Permanente Project EIR
dated July 10, 2003.
 The total average annual water demands for the entire Kaiser Permanente
Modesto Medical Center, including both the Medical Campus and Business Park
is estimated to be approximately 670,000 gallons per day (750 af/yr)
Green Healthcare, an Environmentally Sustainable Methodology

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 It is estimated by the State Department of Finance that there is a reduced
population growth from 2003 to 2006, resulting in a lowering of projected demand
by 381,500 gpd.

Water Supply vs. Water Demand for the Project
Total anticipated water supply for the Project:
381,500 Plus the 251,014 gpd attributed to the 88-acre project site by the 2000 UWMP
≈ 632,500 gpd.
Water Supply vs. Water Demand for the Kaiser Medical Campus Project in
Modesto

Source: Data adapted from Capital Engineering Consultant Memo, February 19, 2003
and revised building descriptions from the Kaiser Permanente Project EIR dated July
10, 2003.

Water supply (gpd)
Difference (gpd)
Green Healthcare, an Environmentally Sustainable Methodology

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This is nearly 95% of the detailed demand calculated for the project and is well
within the accuracy expected for a planning level estimate (Figure 5.1). After the
environmental feasibility analysis, the next step is water conservation measures to
minimize water consumption.

Green Healthcare, an Environmentally Sustainable Methodology

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Appendix E:
Four Pilot Hospitals in the context of Green @Hospital
University Hospital in Italy, General Hospital Chania, University Hospital in Granada, &
Hospital de Mollet, Spain

University Hospital-United Hospitals of Ancona, Italy(AOR)
Azienda Ospedaliero Universitaria Ospedali Riuniti Umberto I- G.M. Lancisi – G. Salesi
Beds: 756
Employees: 3100

General Hospital Chania Saint George (SGH)
The Chania General Hospital St. George, Chania, Greece
Beds: 460
Employees: 1150
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Hospital Virgen de las Nieves of the Servicio Andaluz de Salud (HVN)
The University Hospital “Virgen de las Nieves” of Granada, Spain
Beds: 915
Employees: 4,521

Hospital de Mollet (HML)
The Hospital “Fundacio Sanitaria de Mollet” of Mollet, Spain
Beds: 160
Employees: 700

Green Healthcare, an Environmentally Sustainable Methodology

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Appendix F:
Function of Dry Coolers
Retrieved from:
http://www.thehotaisle.com/2008/07/14/architectural-aesthetics-can-minimize-cooling-
efficiency/ -- Jul 14, 2008 –

Dry coolers are used in many air cooled refrigeration systems. ... External air is used to
cool the liquid being pumped around the CRAC units in data centers without resorting to
a refrigeration process. In simple terms the hot liquid from the CRAC units is pumped
through the dry ...

Architectural Aesthetics Can Minimize Cooling Efficiency
Published by Steve O'Donnell on Monday 14th July 2008, 19:18 | Related | Filed Under

Dry coolers are used in many air cooled refrigeration systems. In case of low
outdoor temperatures, outdoor air can be applied for cooling applications. In dry coolers,
Green Healthcare, an Environmentally Sustainable Methodology

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large fans create a forced airflow along air-to-water heat exchangers. Subsequently, the
water circuit can be used for cooling of data centers, office buildings and industrial
processes.

Dry coolers play an important role in Data Center refrigeration systems. External
air is used to cool the liquid being pumped around the CRAC units in data centers
without resorting to a refrigeration process. In simple terms the hot liquid from the
CRAC units is pumped through the dry coolers into cooling vanes, electric fans blow air
at ambient temperature over these. We still use energy to pump the liquid and power
the fans but much less than if we need to refrigerate the liquid.
By raising the return air set point on our CRAC units we can make use of dry coolers for
more of the year, not just winter months. As an example raising the return air set point
to 28 °C can increase the efficiency of a cooling system from 16% (free air cooling with
return set point at 22 °C) to 26%.
Green Healthcare, an Environmentally Sustainable Methodology

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From an aesthetic point of view, dry coolers are not the crowning glory of the
architect’s work. Therefore, dry coolers are often hidden from sight by extended façades
or higher parts of the building. Unfortunately, in many cases this will result in a short-
circuit in the air flow. A short-circuit in the air flow leads to a significant reduction of the
cooling capacity of the dry coolers.
For a guaranteed cooling capacity of the dry coolers, the temperature of the
forced airflow must be as low as possible. It is often assumed that the air temperature at
the inlet of the dry cooler corresponds to the free field outdoor temperature

User manuals of dry cooler systems give only rough guidelines to achieve this:
1. A sufficient free area at the air inlet, where the free space around the dry cooler
must be at least 1 meter.
2. The exhaust air side must be free of obstructions.
3. No short-circuits in the air circulation.
Green Healthcare, an Environmentally Sustainable Methodology

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Practical experience has shown that following the first two guidelines is not
sufficient. The question is how the third guideline can be guaranteed. Apart from
temperature measurements and smoke tests afterwards, Computational Fluid Dynamics
(CFD) can be used to analyse the performance of dry cooler systems.
Practical advice is avoid locating dry coolers behind walls where airflow can be diverted
from the output back into the input airflow. Even where the first two installation rules are
followed, temperature increases of up to 1.7 °C have been observed when units are
installed adjacent to walls or other airflow obstructions.

Green Healthcare, an Environmentally Sustainable Methodology

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CURRICULUM VITAE

Green Healthcare, an Environmentally Sustainable Methodology

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ROYA AZIZI
---------------------------------------------------------------------------------------------------------------------
tel: 818-519-4110
818-880-0595
fax:818-473-4920
email:roya91302@gmail.com - razizi@csudh.edu - mazizi@usc.edu
---------------------------------------------------------------------------------------------------------------------

Education & Training:

Doctoral Candidate: Policy, Planning, and Development, Sol Price School of Public
Policy, University of Southern California (USC) - Advisor: Dr. Peter Robertson,
Research focus: Green Healthcare - GPA: 3.62

M.S.: Master of Regional Planning: University of California Irvine, School of Social
Ecology, Department of Planning, Policy and Design - Advisor: Dr. Luis Suarez Villa, -
GPA: 3.79

B.S.: Bachelor of Architectural Engineering (B.A.E.): National University of Iran- School
of Architecture and Urban Planning - Advisor: Dr. Vaziri - GPA: 3.05

License & Certification:
 Course Design for Universities Certificate - UCI
 Medical Management Certificate
 Medical Assistant Certificate
 Medical Insurance Billing Certificate
 Sustainable Cities Graduate Certificate- USC
 2012 Academic Professional Development Certificate - USC
 Building Inspection Certificate - WVOC
 Different computer programs: Moodle (a Learning Management System),
BlackBoard LMS, Adobe connect distance learning, Apex, Microsoft Office:
Word, Excel, and PowerPoint
Green Healthcare, an Environmentally Sustainable Methodology

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Research:
 Green Healthcare - sustainable healthcare operation
 Clinical Trials Operations Improvement Report at Keck School of Medicine of
USC (collaboration between USC Industrial Systems Engineering Department
and USC Norris Comprehensive Cancer Center).
 Rural Health Clinics in Haiti and Zimbabwe and their water Accessibility
 CT Scan (Computed Tomography scan/Computer Axial Tomography) Overuse in
the U.S.
 Health effects of Transportation Emissions in Built Environments Surrounding
Major Arterials (research assistant)
 Healthcare and accessibility issues in South Los Angeles - research within the
‘Future of South LA Conference’ (Under supervision of Commissioner Shaw -
Board of Public Works-City of Los Angeles)
 Trans-Alaska Pipeline Environmental Impact Statement Review
 Environmental Impact Report of Chamran Freeway in Tehran, Iran
 An experimental research on water saving in a sustainable project, which has
demonstrated more than 50% savings in water consumption(2012 UC Davis
Presentation- 2010 USC Presentation- 2009 UCI Presentation- 2009 City of
Calabasas Presentation )

Experience:
Teaching: 2006 - Present
 Fundamentals of Public Administration – California State University Dominguez
Hills
 Administration of Local Government- Teacher Assistant-University of Southern
California (USC)
 Medical administration teaching and training of new managers for 16 different
Green Healthcare, an Environmentally Sustainable Methodology

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facilities
 Pre-Algebra - teacher assistant
 Geometry - teacher assistant
 Algebra - tutor
 Environment and Regulatory Compliance- USC School of Engineering

Healthcare Management Consulting: 2006 - Present
Encino Medical Clinic: Encino, California
Ali Azizi MD Inc.: Encino, California
Babak Bokaie MD Inc.: Oxnard, California
Responsibilities:
 Organizational development and training
 Strategic Management
 Contract Management
 Efficient Space Planning in the healthcare settings

Healthcare Administration: Sina Imaging Center: 2003-2006
Responsibilities:
Director of operation of two medical offices in Huntington Beach and Irvine, California,
including:
 Strategic planning
 Professional training systems for new managers
 Supervision of contracting, equipment and software purchasing, marketing,
billing, and collection, credentialing, recruitment and placement
 Negotiation and settlement with attorneys and physicians for W.C. and Personal
Injury (PI) cases

Green Healthcare, an Environmentally Sustainable Methodology

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Performance:
Enhanced efficiency and business productivity by more than 85% each year and
improved the annual revenue to $5,000,000.

Awards & Recognition:
 Recognition of excellent demonstration: ECO Innovators - Spring Green Expo,
2013
 Certificate of Recognition: City of Los Angeles, Board of Public Works, 2011
 Recognition of excellent performance: Environmental Commission of the City of
Calabasas, 2009
 Recognition of Achievement in Graduate Level Education: Association of
Professors and Scholars of Iranian Heritage (APSIH), 2009
Conference Scholarship & Presentation
 Project presentation at ECO Innovators Showcase at Metropolitan Water
District’s 6
th
Annual Spring Green Expo, 2013
 Poster presentation at Environmental Sustainability Research Workshop, USC,
2013
 Research presentation at the California Higher Education Sustainability
Conference, University of California Davis, 2012
 Project presentation at the City of Calabasas City Hall, 2009
 Project presentation at the City of Fountain Valley City Hall, 2008

Volunteer Experience:
 Teaching:
o Environment and Regulatory Compliance- USC School of Engineering –
2013
Green Healthcare, an Environmentally Sustainable Methodology

Page | 254

o Energy saving instructor: USC CALPIRG - 2012
o Algebra 1 – 2008
 Project evaluator: Center for Civic Education - 2012
 Researcher: Future of South LA Conference - 2011
 Evaluator: Global E-Governance Survey - 2010

Affiliation:
 Association of Environmental Professionals (AEP)
 American Planning Association (APA)
 Women's Transportation Seminar (WTS)

Language:
Fluent speaking and writing in Persian
Personal Data:
Excellent health, Stamina and Energy
Married
Avid reader and nature enthusiast, interests include: poetry and literature, music, skiing,
and hiking

Abstract (if available)

Abstract This study has been conducted to develop theoretically informed practical knowledge about Green healthcare and to identify how the majority of medical facilities can reduce their carbon footprint effectively. The healthcare industry, with a very high level of energy consumption, produces more than 8% of the harmful GHG emissions (Chung & Meltzer, 2009), disposes 4 billion pounds of waste into landfills (each year), and purchases more than $106 billion worth of toxic chemicals, annually, with immense health effects on the public (Roberts, 2002). This is in the situation that the majority of medical professionals are not aware of the negative impacts of their activities on the environment, patients, and themselves. ❧ Healthcare organizations lag behind other industries in sustainable operations, and less than one-fourth of the healthcare facilities are involved in Green activities in different parts of their services. Also, various studies show that medical staff and healthcare leadership have a lower level of awareness and concern about Green practices than individuals in non-healthcare organizations. Therefore, there is an urgent need for more studies to raise awareness about this dire issue among healthcare professionals. In addition, there is a need for comprehensive and holistic nationwide guidelines and requirements for environmentally-friendly operations in the healthcare services (Hartman, Fok, & Zee, 2009

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Asset Metadata

Creator Azizi, Roya (author)

Core Title Green healthcare, an environmentally sustainable methodology: an investigation of the ecological impacts of the healthcare industry and the role of green initiatives in sustainable medical services

School School of Policy, Planning and Development

Degree Doctor of Policy, Planning & Development

Degree Program Policy, Planning, and Development

Publication Date 09/26/2016

Defense Date 08/23/2016

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag green healthcare,methodology,OAI-PMH Harvest,sustainability,sustainable medical services

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Robertson, Peter (committee chair), Hufford, Donald (committee member), Myrtle, Robert C. (committee member)

Creator Email mazizi@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-306594

Unique identifier UC11280650

Identifier etd-AziziRoya-4813.pdf (filename),usctheses-c40-306594 (legacy record id)

Legacy Identifier etd-AziziRoya-4813.pdf

Dmrecord 306594

Document Type Dissertation

Format application/pdf (imt)

Rights Azizi, Roya

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA