Pediatric Intensivist and Neonatologist, Gundersen Health System, US.
At Gundersen Health System, we define health of the populations we serve to include physical and mental health, social well-being, and the fiscal health of our communities. We are so convinced that this should be a part of responsible healthcare, and thus been embedded in our strategic plan and is a measured, integral part of how we accomplish our goals. That is, we pursue a broader purpose than just taking care of sick people who show up at the door. The purpose of the organisation expects us—indeed demands of us—that we see beyond our walls and look at our effect on the general health and well-being of our communities.
Furthermore, healthcare facilities, as a rule, are some of the most energy-intensive buildings in the commercial sector in the United States. According to the United States Department of Energy, hospitals are 2.5 times more energy-intensive than other commercial buildings.
The fact that we are more energy intensive and that the energy costs will continue to escalate, increases the urgency—if we are to hold down our costs—to address these issues.
Just as a reference, our organisation is a healthcare delivery system made up of five hospitals, 61 clinics, 7000 employees, 500 doctors, and 300 nurse practitioners and PAs. We teach, we conduct research, and we work with many partners to improve the health of the communities. We serve across 19 counties in three states.
Gundersen Health System didn’t set out to be the greenest health system in the country when we embarked on our plans to reduce our energy spending and improve our impact on the communities through, both, better health and improving the local economy. However, in October last year, when we reached energy independence, we became the first in the country to reach that goal. To achieve success, we started by measuring our impact on regional environment. We found in 2008 that we were putting 48 million kilograms of carbon dioxide into the atmosphere, 1 kilogram of mercury and 197,000 kilograms of particulate matter.
For a healthcare organisation, we felt we could not continue on the same path. We had to be better for our patients and the communities we serve.
So how did we do it? We took a two-sided green approach to our efforts—green as in good for the environment and green as in financially sustainable—not programmes that would detract the financial performance of the organisation. We did not want to take any more money out of the community to pay for this activity. And we had to be conscious about not passing any unnecessary waste off on our patients through higher healthcare costs. Our goal, therefore, was to decrease our costs, decrease our negative impact on the environment and work to find ways to reduce our reliance on energy from outside our region. More specifically, since all of our energy comes from outside our region (coal from Wyoming for electricity and natural gas from Texas for heat), we felt developing local resources would improve that profile. Our approach was multi-pronged and looked to decrease waste in every part of the organisation with the same principles of decreasing pollution, improving the organisation’s finances, and improving the regional economy.
One of our earliest gains was to focus on recycling. We rapidly pushed our recycling rate above 35 per cent and held it there for five years. This gave us a financial start as we received payment for recycling plastics, cardboard and paper, bringing in tens of thousands of dollars. We also focused on food waste. In fact, over a five-year period, we reduced our food waste by 80 per cent. It kept 18 tons of food from going to the landfill each year and resulted in donations of thousands of meals through the Salvation Army. This saved money and served a community good at the same instance.
Other activities that resulted in substantial savings include remanufacturing of single-use devices—supplies from surgery, oxygen sensors from the intensive care units, and toner cartridges from printers across the organisation. All could be remanufactured and purchased back at remarkably low costs. This recycling of equipment saved US$400,000 – US$500,000 every year. The combined savings of recycling and reusing and remanufacturing of waste and equipment consistently, year over year, averaged savings in the US$500,000 per year range and easily paid for a coordinator and many of the projects we started. Other areas of significant waste occurred around bio-hazardous (blood-stained or body-fluid contaminated waste) and pharmaceutical waste. Disposal of contaminated and pharmaceutical waste has been historically expensive. A focused approach to carefully examine what exactly was in this waste and how to mitigate it had substantial savings. This was not easy work. It meant taking red bags of waste, carefully putting them out on large tables, sorting through them, and asking ourselves what is regarded as waste and what can be recycled. Then it meant going back and revising systems and using the LEAN methodology of careful examination, developing a plan, and re-working the flow. Bio-hazardous waste per patient visit has dropped by over 25 per cent and pharmaceutical waste has dropped by over 60 per cent and is saving us hundreds of thousands of dollars.
Not only did the pharmaceutical waste reduction save all this money, it markedly increased the efficiency of our staff by now having to deal with only one barrel a month of pharmaceutical waste, rather than 17. We not only saved hundreds of thousands, we saved a great deal more in staff time.
A great advantage in focusing on waste has been addressing the issue of medication waste in the public. In the United States, the most common pathway to heroin addiction is the abuse of prescription opioids. Once that is no longer available or is too expensive, patients then turn to heroin. As a public service, in the first six months of 2015, Gundersen Health System placed public drop boxes in several clinics. We collected 3,000 pounds of medication that otherwise would have gone into the sewer system or into landfills. By collecting these medications and disposing of them in an appropriate fashion, we kept all those chemicals out of the landfill. A little known effect is that many medications, antibiotics, and hormones, when put through the sewer system, are not altered and end up in our water and food supply unchanged. Of the 1500 kilograms of medication that we collected in the public drop boxes, we believed that 10-20 per cent was narcotics. We kept them off the street and out of the hands of persons who may become addicted.
In addition to managing waste, at Gundersen Health System we made a huge effort to address our energy needs. In 2008, we set a goal to become the first healthcare system heated, powered and cooled, by local renewable energy. As you can see from the chart our goal was to start out with a very heavy dose of conservation, add in wind, landfill bio-gas activity, a bio-mass boiler using local hardwood chips, a geo-thermal system, bio-gas from dairy farms, and more conservation. This aggressive plan could not have happened without a dedicated Board willing to take on this plan. You might ask – why would a strong Board allow this plan? The Board felt that it was the best use of a small portion of its savings, that the overall program had a good return on investments (7.7 years), the investment was safer than the stock or bond market, and that it was a great local investment that raised our status in the community as a business partner. At that time, there were certain grants and interested partners available that helped us accomplish our goal. And as important, we had early successes with very hard measures that showed we could improve our environmental footprint and save money for the organisation.
To be a disciplined organisation, we had to carefully measure all these activities. Where were our biggest payoffs? The biggest financial successes were in conservation. Our initial US$2 million spent on conservation saved us US$1.2 million every year thereafter. That is a tremendous return on investment. Our wind farms vary depending on the rate that the utilities are willing to pay us–and for the most part are a strong financial success. The land fill bio-gas and the dairy bio-mass boiler are also very strong. Solar hot water is a little less of success but still has a reasonable return on investment that helps pre-heat the water for our dialysis unit. However, in full disclosure, not every item we worked on was a success:
• Early on we put up some solar panels that were a bit expensive and so the payback on them was a little longer than we anticipated
• We tried a bio-gas project with a local brewery, but with high sulphur content it became unattainable and hard on our engines
• The solar hot water project for the Gundersen daycare is wildly popular with the kids at the school who point out every day that they are washing their hands heated by the sun, however, financially; it is not a big win.
As you look through the options, where do you start? Energy should be your first fuel. As I mentioned, our US$2 million dollar investment in conservation had a significant savings the first year and every year thereafter. We lowered our fixed operating costs, which was essential for the long-term financial health of the organisation.
Our landfill gas project was a partnership with our county government who had a solid waste landfill site where the methane was just being burned off into the atmosphere. We collected that methane, it was piped to our campus, and our campus is now heated, cooled and powered all with this previously wasted methane. The county receives US$250,000 every year that they never had before. The system saved several hundred thousand dollars over the cost of previous fossil fuels, and the staff was very proud that they were in the first campus in the country that was completely heated, powered, cooled, and saved a lot of money from renewables. That outpatient campus, in Onalaska, Wisconsin, has 1,200 staff members.
The inpatient and large speciality campus, in La Crosse, Wisconsin, has several thousand staff, and a large tertiary hospital, which has its heat and electricity augmented by a large bio-mass boiler. This boiler, powered by locally sourced hardwood chips, produces a majority of the steam to heat that campus, as well as a high pressure steam turbine providing electricity. This saves the organisation US$600,000 a year, produces almost no greenhouse gasses, and when coupled with a large geo-thermal field, is able to produce remarkably clean, safe, and cost-effective energy for that campus.
Another piece of our energy portfolio was to examine all facilities and see if they could be replaced. An inpatient Behavioral Health hospital (psychiatric hospital) was replaced with a newer facility. Not only was the newer facility one-third as expensive per square foot to heat and cool, the patients had a remarkably faster healing time, required less medications, and less restraint because of the better design of the facility. In addition, a brand new 250-bed hospital had cut down the energy use from 253 in the United States, to 120kgb per square foot. These facility designs work great on the large scale, but also work equally well on smaller clinics or smaller hospitals. Our energy experts have worked not only in our central campus, but also in regional clinics that are 3,700-5,000 square yards, whose energy costs range from US$70,000-90,000 per year. With careful identification, a good energy audit, and implementation of recommendations, energy savings of 35-50 per cent is common, and the payback of investments are averaging one to two years. Small 10-20-bed hospitals also can see similar savings with energy costs decreasing by 15-20 per cent with short one to two-year payback periods.
This may seem daunting to start out on such a journey, but there are many opportunities to help you along the way. The Global Green and Healthy Hospital Initiative is an international program with many great ideas that are available on the web. At Gundersen we are talking what we have learned and now teaching and consulting. We are always looking to help others1.
Equally important, beyond all these issues, is the impact on your staff. The rise in staff pride around an organisation who said “we will lead on being environmentally sound and take care of the health of our community, and we will do it in a way that saves money and improves the health of the economy” has raised the interest and engagement of the staff across our organisation. Another thing that is absolutely critical that I mentioned earlier, is the tying together of the mission of the organisation. When you look at sustainability in this light, it affects the patient’s care experience, it lowers the per-capita costs and it will improve the health of the population. Sustainability is a central core to the Triple-Aim that the Institute for Healthcare Improvement has been pressing and mentioning for some time. A disciplined organisation should be able to spread the culture of discipline across the whole organisation. Because of that, Gundersen has felt it is inappropriate to continue investing in fossil fuels. So, from our savings as of January 1, 2015, the managrs of many of our investments will not purchase any bonds issued by companies listed on the Carbon Underground 200. We do not feel it is appropriate for healthcare to invest in fossil fuel generation when those fossil fuels are clearly linked to making people ill.
So what’s the total impact of this programme? For the organisation, the total costs savings will be US$3-4 million per year. For our contribution to greenhouse gasses, our carbon dioxide production is on track to be 83 per cent less than it was in 2008. Our particulate matter is over 75 per cent less than in 2008. Our local energy production includes wind, wood, geo-thermal, dairy bio-gas, landfill gas, as well as solar hot water. Our overall cost savings to the organisation will be US$3-4 million dollars a year at a minimum. Our food waste, as mentioned before, is down 80 per cent, and to help decrease the overall impact of our food energy footprint, we have developed a regional food co-operative that will help us increase the percentage of local bulk buying of regionally grown foods. Although our educational impact has been from grade schools, technical schools, universities, and world-wide visitors, inspiration beyond our staff has extended to patients, our patient families, community partners, job applicants and our competitors.
If you want to set out to be recognised as one of the most environmentally sound organisations to truly approach the Triple Aim of improving the health of the population, the experience of care, and lowering per-capita costs, there are many important factors. First, you must commit to significant goals that may seem difficult, but are certainly possible to achieve. Develop a programme that connects a broad group of your staff that includes recycling, conversation, and food-waste reduction. Front-line staff can become actively involved in all of these areas. Along with your high-goal setting, measure clearly what your baseline is and what your impact is; it will help you build momentum. Report these initial small gains to your staff, help them understand that you truly are improving the well-being of the patients, the organisation’s economy, and the economy of your region. Prove the outcomes to communities so that the schools, businesses and government become partners and help you not only in improving your environmental impact, but that of your whole region.
There are also great resources available. Look to other regional, national and international examples to glean the best practices. The World Health Organisation, Global Green and Healthy Hospital Initiative, the CleanMed Conference held every year in the United States, are great sources of information and inspiration.
As set out by the National Health Service, we need to move from more than just a consideration of pollution, to broader awareness of the health and well-being of our communities. We have to move from thinking just about carbon reduction to the reduction of oil, greenhouse gasses and our overall impact on air and water. We need to move from just doing a few things better to doing better things consistently. We need to not only start new projects; we have to stop many of the old things that we have been doing. We need to, of course, measure some process and activity, but we need to move to measure outcomes. We need to look at sustainability, not as a problem to be solved, but as a solution and an opportunity to improve the health and well-being of our communities and distinguish ourselves as organisations. We need to move from sustainability being done in isolation to seeing it as the responsibility and a great opportunity for an integrated system of care.
Jeffrey E Thompson, MD is a pediatric intensivist and neonatologist at Gundersen Health System in La Crosse, Wis, US. During Dr. Thompson’s 14 years as chief executive officer, Gundersen received international recognition for its high-quality patient care and innovative clinical, population health and business initiatives.
1. More information can be found on our website: http://www.gundersenenvision.org/.