… and what could make hospitals
Dr. Jean-Jacques BERNATAS ADB, July 2013 1
… and why it should be so.
More than just showcasing, health sector is supposed to be a leader and to
bring onboard the other sectors.
A hospital is usually one of the main employers in a community and has a
high economic impact on it.
A hospital has a corporate social responsibilities.
The hospitals are dealing with highly toxic substances.
The hospitals are among the heaviest energy consumers.
The hospitals produce a huge amount of regular and hazardous waste.
• Not a marketing-driven initiative.
• Shared interest between the medical service providers and the users, about a
“development that must allow current generations to satisfy their needs,without
prevening future generations from doing the same”. 2
The context of SD in HCF
• toxic substances
• energy and water
• carbon footprint
• nosocomial infections,
• accidental deaths and
• work accident and
Immediate profitability vs. Sustainable
Lowest cost vs.
Back to fundamental: The
Better health (patients,
Adverse events (patients,
visitors), work accident
(staff), and negative
Conceptual framework of SD in
events and negative
From quality grass-roots:
• Structure/process/outcome Donabedian’s framework and its further
improvements, for evaluation and quality improvement
• Non-quality as a factor of increased costs of healthcare,
• P-D-C-A and continuous quality improvement in health.
to sustainable management:
• Motivate: motivation is the cornerstone
• Link: network of hospitals sharing experience on SD
• Train: knowledge is power; on-site, hands-on and continuous is better
• Validate: certification (ISO14001, LEED, EMAS, …)(*)
• Communicate: creation of SD commissions, sharing experience with a
larger audience, and to convince people on the relevance of SD.
(*): ISO: International Standard Organizatio; LEED (US Green building Council): Leadership in Energy & Environmental
Design; EMAS: European Eco-Management and Audit Scheme. 6
•Usually a higher immediate investment for a mid-
even long-term profitability « only ».
•Refers to specific labelling such as LEED, BREAM,
ISO 14001, …
•Starts with a decision-making, then a choice of a
site, and a participative multidisciplinary approach.
•Environmental impact studies to be conducted.
•Energy performance, choice of materials, noise
reduction, choice of light, … among others.
Saving energy and water
• A hospital energy consumtion in France is around 350 kWh/m2/year
(energy efficiency index) where the new low energy building standard
for healthcare buildings in France is now 50 kWh/m2/year.
• Hospitals energy consumption represents an average 11% of energy
consumption of tertiary sector in Western countries.
• A German study evaluated one hospital bed to consume as much
electricity and heating as two households.
• Energy performance assessment applies to hospitals. Benchmarking is
• Water is a finite resource: the estimated average consumption of a
medico-surgical hospital is 300 to 750 liters/bed per day:
• Using less « thirsty » autoclaves, recycling water from hemodialysis
for flushing systems, using bio-digestive membranes 8
Preserving the atmosphere
• Carbon footprint: the University Hospital of Geneva (HUG) has evaluated
that it consumes yearly as much energy as a European city of 16,000
inhabitants, and producing 10 tons CO2
• HUG carried out a « life-cycle analysis » showing that 40% of carbon
emission comes from materials and incoming products (mainly from drugs
and textile objects); energy consumption of the buildings counts for 25%;
transport makes 25% of total carbon emission, and infrastructure and
traetment of waste counts for 10%:
Reducing the impact of transport on CO2 production:
• Hospital better connected to the city
• Green mobility: hybrid engine ambulances, carsharing for
ambulances, staff mobility (car pooling, bicycle, …)
Improving the hospital functionning in reducing CO2 production:
• Promotion of green spaces
• Shortening of the supply chain
• Energy saving policy 9
• Appropriate purchase is of utmost importance to:
• Getting rid of toxic substances
• Reducing waste and energy consumption
• Decreasing greenhouse gas production
• About toxic substances:
• endocrine disrupters (transgenerational effect of Distilbene; BPA and
feeding bottels; DEHP and nutrition pockets, tube, transfusion packs)
• Nanoparticulated titanium in wall paints (production of titanium dioxide
under UV exposure with antibacterial effects, but nanoTiO2 has possible
adverse effects on membrane blood-brain barrier)
• Ethylene oxide sterilization, including bottle teats: listed as carcinogen to
man, but still in use to sterilize enteral feeding devices.
• Responsible and professionalized purchase based on transparent
information made available, traceability of the products to face the
fragmentation of internal and external purchases, purchasing centrals,
pooled purchases ...
• Substitution of toxic/carcinogenetic substances (Karolinska Hospital in
Huddinge, Sweden: list of 100 substances to be abolished).
Sorting, recycling and re-using
• Chemical releases
• REACH regulation (European Community Regulation on chemicals and
their safe use): guidelines for identification and substitution of
• Effects of low concentration persistant residues in discharged water:
drugs, radioactive substances, antibiotics,
• Possible bioaccumulation in aquatic organisms.
• Reduction of drugs in effluents requires better prescription (less
/appropriate prescription of antibiotics), specialized treatment plants,
separate sewage network for hospital.
• Substitution of reagents (cyanide for blood count),
• Issues in disinfection/sterilization: place of incineration? Substitution to
autoclaves for some mediacal waste (grinding and chlorine dioxide
• Sorting channels and recycling: up to 30 channels in some hospitals, with a
specific lifecycle for each type.
• Chasing any unnecessary packaging.
Waste reduction and recovery policy in
Sustainable health (1)
• Taking care of employees:
• Occupational health improvement, based on prevention: back pain
prevention, tobaco-free environment/smoking cessation support, ...
• Psychological stress, specific issue of HCW: counseling, adapted innovative
management (decentralized management unit providing more autonomy
for nursing staff). Experience of « magnetic hospital » keeping low attrition
rate among workers in providing better conditions at work – ARIQ label in
Canada (attractiveness of a hospital/ ability to keep staff/ involvement of
nurses/ quality of care)
• For patients
• The International Declaration on Diseases due to Chemical Pollution, known
as the Paris Appeal, launched at the Paris conference on Cancer,
Environment and Society on 7 May 2004: an agenda to deal with
• Implementation of environmental medicine services in hospitals: multiple
sensitivity, low fertility due to endocrine disrupters, ...
Sustainable health (2)
• Prevention is the cornerstone of sustainable health, but:
• Can hospitals shift to prevention+care, when they primarily exist for care
only and when the competition is based on the scope of services and
cutting-edge technology access? For private sector: Is prevention a good
• Another reason to rethink care more globally and to revisit the primary health
care concept = PHC as the grassroots of sustainable health in all development
setting (LIC/MIC/HIC) = essential health care based on 8 components through a
transversal and intersectoral approach.
• Was considered as cheap basic – and then affordable - quality medical services
• Now comes back on our radar, brushed up (see Jim Yong Kim’s Speech at World
Health Assembly: Poverty, Health and the Human Future, May 2013)
• Addresses not only Health for All (in 2000 …) but quality of care and universal
• Is a strong rationale to bring hospitals on board of SD
• The diagonal approach: sustainable development of hospitals will support health
WHY the poor must benefit from such
When it comes to saving money, the poor
are the first to be affected:
• Similar to double-burden of nutrition: the poorest
are more often sick and will have only access to the
cheapset care, which includes the use of the
The poor are more exposed to
• This includes risks generated by the hospitals in the
neighborhood: unsafe waste management,
incinerator producing dioxines production, for
HOW the poor must benefit from such
Environment regulations to be reinforced
• and to apply to all healthcare facilities, including
public and decentralized.
Adequate financing and existing agenda.
Promotion of projects or projects components
adressing this issue:
• just to incorporate the hospital in the picture and see
what can support its sustainable development.
An assessment is necessary in public healthcare facilities. Possibility to start
with a version of an autodiagnostic tool, implemented already in more than
1,200 hospitals in Europe, now in Canada with the support of C2DS.
• No way to escape
• Asian/South-East Asian countries are more
exposed to the environmental risks and
should take up the lead in developing
sustainable healthcare facilities.
• Olivier TOMA, C2DS (www.c2ds.eu )
• Health Community of Practice, Asian
Development Bank, Manila.