The Workshop on Environmental Sustainability in Clinical Care

The Workshop on Environmental Sustainability in Clinical Care, held at Yale University in New Haven, Connecticut, USA, April 6-8, 2018, co-hosted with New York University, brought together experts in engineering, sustainability science, clinical care and health systems management to tackle the issue of resource consumption and environmental emissions associated with medicine and health care services. This Workshop was supported by grant 1818038 from the National Science Foundation, the Yale University School of Medicine, New York University Green Grants Fund, Yale University School of Public Health, Yale University School of Nursing, and the Yale University Office of Sustainability.

Workshop Topics:

• State of the Research in Clinical Sustainability
• Critical Approaches and Research Directions to Address Knowledge Gaps
• Quality, Safety and Value: Waste Reduction and Pollution Prevention Metrics that Matter
• Collaborations Across Medicine, Engineering, and Allied Fields for Innovation and Implementation
• Materials, Devices, and Drugs: Design to Minimize Environmental Impacts in Clinical Care
• Implementation Science: Translating Environmental Assessments into Change

Key Findings:

• Pollution and climate change are contributing to a global health crisis.
• Pollution itself is a patient safety issue, and pollution prevention should be included in efforts and metrics to improve health care quality.
• Clinical activities are the major driver of resource utilization and waste in healthcare and provide a fundamental opportunity for engaging health professionals in pollution prevention efforts.

Health Care Emissions Research

• Strategic areas of investigation include: basic materials management, pharmaceuticals and medical device design, environmentally preferable clinical care pathways, hospital/health systems and provider-level performance metrics with international benchmarks.
• A new life cycle inventory database containing whole medical products (pharmaceuticals and medical devices) is needed, to facilitate the study of clinical best practices and enable global benchmarking of best practices. Such a tool should be integrated into electronic health records and procurement information management systems, to support environmentally preferable practices and benchmarking.
• Translational science must include application of existing metrics that measure environmental performance. Such metrics should then be embedded into existing quality and safety reporting frameworks, including remuneration models.
• The study of clinical best practices should be expanded to include optimization of resource efficiency and pollution prevention, in addition to patient outcomes.
• Reporting guidelines for healthcare sustainability research also need to be developed. This can be achieved through the creation of guidelines consistent with the reporting guidelines developed by the Enhancing the Quality and Transparency of Health Research (EQUATOR) network for other types of translational research. (​130​)

Implementation, Benchmarking and Accountability

• Partnership is called for between healthcare sustainability experts and patient safety experts. Safety and quality organizations such as the Institute of Healthcare Improvement (IHI), the National Patient Safety Foundation (NPSF), the Anesthesia Patient Safety Foundation (APSF), and others should work to advance the synergistic agenda around resource stewardship.
• Excessive infection control standards without sufficient evidence are viewed as a major driver of avoidable pollution and waste generation in healthcare. Engagement of accrediting agencies and regulatory bodies is essential to minimize unintended adverse environmental effects as a result of care that offers no proven patient benefit.
• The evidence-based, best practices identified by initiatives like Choosing Wisely, GIRFT, and Wise List must include environmentally preferable, in addition to waste-sparing, practices. Partnerships with these organizations are recommended to mainstream environmental stewardship into the health care quality discourse.
• Integrating environmental sustainability into value-based healthcare reform, and communicating with clinicians and policy makers in the language of these paradigms, can help to achieve rapid uptake and success of healthcare sustainability initiatives.

Research Funding for Sustainable Clinical Care

• Government funding agencies, e.g. the National Science Foundation and the National Academies of Science, Engineering and Medicine (NASEM), and philanthropic foundations, should create funding mechanisms that bridge environmental sustainability science with health services research to translate knowledge into sustainable clinical practices.
• Formation of a Global Commission on the Advancement of Environmental Sustainability in Healthcare is called for, to further research efforts that inform policy and practice, and urgently focus leadership on the pollution public health crisis.

For Full Publication Results:

1. Sherman JD, MacNeill A, Thiel, C. Reducing Pollution from the Health Care Industry. JAMA, Published online August 2, 2019. doi:10.1001/jama.2019.10823
2. Sherman JD, Thiel C, MacNeill A, Eckelman MJ, Dubrow R, Hopf H, Lagasse R, Bialowitz J, Costello A, Forbes M, Stancliffe R, Anastas P, Anderko L, Baratz M, Barna S, Bhatnagar U, Burnham J, Cai Y, Cassels-Brown A, Cimprich AFP, Cole H, Coronado-Garcia L, Duane B, Grisotti G, Hartwell A, Kumar V, Kurth A, Leapman M, Morris DS, Overcash M, ParvatkerAG, Pencheon D, Pollard A, Robaire B, Rockne K, Sadler BL, Schenk B, Sethi T, Sussman LS, Thompson J, Twomey JM, Vermund SH, Vukelich D, Wasim N, Wilson D, Young SB, Zimmerman J, Bilec MM.The Green Print: Advancement of Environmental Sustainability in Healthcare. Resources, Conservation & Recycling (in production)”

Location:

Dates:

Workshop Aims:

• Facilitate a critical review of existing information and tools, and identify research gaps.
• Develop a strategic action plan for the development of support tools and data to aid clinical and health administration decision-makers.
• Produce a White Paper and a peer-reviewed publication that summarize the outcomes of the workshop.

Workshop Participants:

Invitation only, select group of around 40 experts in medicine, sustainability engineering, health administration, and quality-safety-value experts.

Workshop Format:

To facilitate professional networking, attendees are asked to talk about their own research interests in 5-minute “lightning presentations,” and lunch, dinner and social time will be provided. Panel sessions and breakout discussions around specific topics form the framework for setting the future directions of sustainability in clinical services. These discussions will be summarized in a workshop white paper.

Workshop Hosts:

Yale University Schools of Medicine and Public Health and New York University School of Medicine and NYU Wagner School of Graduate Public Service

Advisory Board:

• Jodi Sherman, MD, Associate Professor, Director of Sustainability, Department of Anesthesiology, Yale School of Medicine
• Cassie Thiel, PhD, Assistant Professor, NYU School of Medicine, NYU Robert F. Wagner Graduate School of Public Service, and Tandon School of Engineering
• Robert Dubrow, MD, PhD, Professor of Epidemiology (Environmental Health), Faculty Director of the Climate Change and Health Initiative, Yale School of Public Health
• Melissa Bilec, PhD, Associate Professor of Civil & Environmental Engineering, University of Pittsburgh, Swanson School of Engineering
• Harriet Hopf, MD, Professor and Vice Chair of Anesthesiology, School of Medicine, Associate Dean of Faculty Development, University of Utah
• Matt Eckelman, PhD, Assistant Professor of Civil & Environmental Engineering, Northeastern University
• Bob Lagasse, MD, Professor and Vice Chair for Quality and Safety Improvement, Department of Anesthesiology, Yale School of Medicine

Welcome!

The Institute of Medicine (IOM) 2013 Public Health Linkages with Sustainability Workshop Summary suggests “the health sector should lead by example by greening itself and reducing its ecological footprint…to improve global health and the health of the planet”. The IOM described specific aims for building quality as a health systems property: avoiding injuries to patients from care that is intended to help them, improving efficiency, and avoiding waste. Pollution from healthcare services, therefore, is a patient safety issue, and pollution prevention ought to be included in efforts to improve healthcare quality.

Pollution is a leading cause of morbidity and mortality, globally responsible for 9 million premature deaths annually. Climate change resulting from greenhouse gas emissions has been named the number one public health issue of the 21st century. Health professional leadership is essential to draw attention to the disease burden stemming from pollution, and to help identify and prioritize mitigation strategies.

Ironically, the health care sector, itself, is a major emitter of environmental pollutants that adversely affect human health. Clinicians, health administrators, and other healthcare professionals have called for efforts to quantify environmental impacts to aid decision-making. We seek to improve the performance of health services and to target waste and pollution reduction measures that prevent ecosystem damage and adverse public health outcomes.

This workshop brings together international experts in engineering, sustainability science, clinical care, and health systems management to tackle the issue of resource consumption and environmental emissions associated with medicine and health care services. The workshop aims to foster collaboration, critically review existing information and tools, identify research gaps, develop a strategic research agenda to aid decision-makers, and disseminate results for maximum impact.

Together, we hope to create a lasting platform and community that makes healthcare healthy.

Sincerely,
Jodi and Cassie
Co-hosts
#ClinicallySustainable

Agenda

Friday, April 6

Breakfast, Check-in, Orientation (8:00-8:45 AM)

Opening Remarks (8:45-9:00 AM)

Plenary Speakers (9:00-10:15 AM)

• Anthony Costello, FMedSci, “The Lancet Countdown to 2030: Health Care’s Role” @globalhlthtwit
• David Pencheon, MD, “Sustainability in Safety, Quality and Value in the NHS” @pencheon1

Lightning Round 1 (10:15-10:30 AM)

• Cassandra Thiel, PhD, “Introduction to Lightning Presentations (and clinical sustainability)!” @CassandraLThiel
• Michael Overcash, PhD, “Environmental Impacts of Medical Equipment (Radiology example)”
• Laura Anderko, RN, PhD, “Nursing perspective on opportunities for sustainability in clinical care” @dranderko

Coffee Break (10:30-10:45 AM)

Sten Vermund, MD, PhD (10:45-10:50 AM) Importance for Advancing Health Care Sustainability and Public Health

Lightning Round 2 (10:50-11:00 AM)

• Brett Duane, DDS, PhD, MPH “Dentistry and Sustainability Science” @brettduane2
• Alex Cimprich, MES “Literature on Sustainability in the Healthcare Sector”

Panel Speakers (11:00 AM–12:00 PM) Topic #1: The State of Research in Clinical Sustainability

• Forbes McGain, MBBS, PhD, “Clinical sustainability studies- from the ground up”
• Matt Eckelman, PhD, “National Health Sector Benchmarking-A Unified Top Down Approach”
• Joe Bialowitz, MS, “Health Systems Benchmarking from the Perspective of Kaiser Permanente”
• Moderator: Jodi Sherman, MD

Lunch Breakout Discussion #1 The Vision of Sustainable Clinical Care (12:00-1:30 PM)

Report-Back #1 (1:30-2:30 PM)

Panel Speakers (2:30-3:30 PM) Topic #2: Critical approaches to addressing knowledge gaps

• Melissa Bilec, PhD, “Knowledge gaps within LCA frameworks (when conducting clinical / healthcare assessments)” @Pitt_SGD
• Steven Young, PhD, “An industrial ecology framework for sustainable healthcare” @stvnyng
• Andrea MacNeill, MD, “Clinician driven study design: what do we want to learn from sustainability metrics?” @ecosurgeon
• Moderator: Cassandra Thiel, PhD

Break (3:30-4:00 PM)

Lightning Round 3 (4:00-4:15 PM)

• Debbie Wilson, RN, DHSc, “Life Cycle Assessment of medical services in New Zealand” @Envir_Health
• Gabriella Grisotti, MD, “Concerns of a Surgery Resident and Lab Scientist”
• Stefi Barna, MPH, “Sustainability in medical education - how clinical care research can help inform the curriculum development”

Breakout Discussion #2 The Tools for Sustainable Clinical Care (4:15-5:00 PM)

Report-Back #2 (5:00-5:45 PM)

Dinner at Miya’s Sushi (7:30 PM)

Saturday, April 7

Breakfast (8:00-8:45 AM)

Opening Remarks and Day 1 Review (8:45-9:00 AM)

Panel Speakers (9:00-10:15 AM) Topic #3: Quality, Safety and Value: Waste Reduction and Pollution Prevention Metrics that Matter

• Jeff Thompson, MD, “Pairing clinical outcomes and sustainability: the hospital CEO perspective” @jeffthompsonMD
• Blair Sadler, JD, “Moving Beyond Silos: Taking Good Ideas to Scale”
• Harriet Hopf, MD, “Balancing Sustainability and Infection Control” @HarrietHopfMD
• Scott Sussman, MD, “Health Care Administration Approach to Safety, Quality, and Value Analytics for Clinical Re-design” @LScottSussmanMD
• Moderator: Harriet Hopf, MD

Coffee Break (10:15-10:30 AM)

Lightning Round 4 (10:30-10:50 AM)

• Beth Schenk, RN, PhD, MHI, “Nursing perspective on opportunities for sustainability in clinical care”
• Adam Pollard, PhD, “Life Cycle Assessment and Critical Care Health Services”
• Janet Twomey, PhD, “Collaborating to assess environmental impacts from radiology”

Karl Rockne, PhD, Program Officer for NSF CBET (10:50-11:15 AM) Interdisciplinary Funding Opportunities @docrockorg

• Moderator: Cassie Thiel, PhD

Panel Speakers (11:15 AM-12:30 PM) Topic #4: Collaborations across medicine, environmental engineering, and allied fields

• Dan Morris, MBChB, “Collaborating to improve sustainability of ophthalmology in the UK”
• Cassandra Thiel, PhD, “Clinical Sustainability Research: Global sampler of interdisciplinary projects in operating rooms” @CassandraLThiel
• Rachel Stancliff, MSc, “Interdisciplinary research models from the Center for Sustainable Healthcare” @SusHealthcare
• Ann Kurth, RN, PhD, “The Nursing Perspective on Opportunities for Clinical Sustainability”
• Moderator: David Pencheon, MD

Lunch Breakout Discussion #3 The Partnerships for Sustainable Clinical Care (12:30-2:00 PM)

Report-Back #3 (2:00-2:45 PM)

Lightning Round 5 (2:45-3:00 PM)

• Mark Baratz, MD, “Orthopedics, waste, surgery process/delivery”
• Heidi Cole, “Industry approaches to aid clinical sustainability- device design and SUD reprocessing”
• Arthy Hartwell, MSc, “Ethical Procurement: How do we measure it?”

Coffee Break (3:00-3:30 PM)

Lightning Round 6 (3:30-3:50 PM)

• Michael Leapman, MD, “Urology: the environmental footprint of excessive prostate biopsies” @mleapman
• Jason Burnham, MD, “Infectious Disease Issues for Clinical Sustainability Science” @JasonPBurnhamMD
• Daniel Vukelich, Esq, CAE, “Reprocessing medical devices: opportunity for sustainability research and metrics” @DVukelich
• Abhijeet Parvatker, MSc, “Life Cycle Inventory of Pharmaceuticals”

Panel Speakers (3:50-5:00 PM) Topic #5: Materials, Devices, and Drugs: Design to Minimize Environmental Impacts in Clinical Care

• Bernard Robaire, PhD, “Medical Plastics: can they be made safer for human & planetary health?”
• Julie Zimmerman, PhD, “Healthcare: Creating Future Patients”
• Paul Anastas, PhD, “Achieving superior outcomes while preventing undesirable consequences through first principles”
• Jodi Sherman, MD, “Critical Medical Supply Shortages and Perceived Excess in a Throw-Away Culture: How Do We Stop the Madness?” @greeningdoc
• Moderator: Anthony Costello, FMedSci

Social Hour and Dinner at The Heirloom (7:00 PM)

Sunday, April 8

Breakfast (8:00-8:45 AM)

Opening Remarks and Workshop Review (8:45-9:00 AM)

Panel Speakers (9:00-10:15 AM) Topic #6: Implementation Science: Translating Environmental Assessments into Change

• Robert Lagasse, MD, “Sustainability and Value Metrics for Clinical Performance”
• Lorea Coronado-Garcia, MSc, “UNDP: sustainable procurement for the health sector” @Lorea_CG
• Andy Cassels-Brown, MB BS, FRCOphth, “Ophthalmology: translating environmental assessments into change”
• Moderator: Jodi Sherman, MD

Coffee Break (10:15-10:30 AM)

Breakout Discussion #4: The Steps Toward Sustainable Care (10:30-11:30 AM)

Report-Back #4 (11:30 AM-12:00 PM)

Summary and Adjournment (12:00-12:15 PM)

Working Lunch: Steering Committee, Discussion Leaders, and Scribes (12:30 PM-2:00 PM)

Participants:

• Paul Anastas, MA, PhD, Director of the Yale Center for Green Chemistry and Green Engineering, Professor, Schools of Engineering, Public Health, and Forestry and Environmental Studies, Yale University, USA
• Laura Anderko, PhD, RN, Professor, and Chair of Values Based Healthcare, Georgetown University, USA
• Mark Baratz, MD, Hand and Upper Extremity Specialist, Orthopaedic Surgery, University of Pittsburgh Medical Center, USA
• Stefi Barna, MPH, Professor, Azim Premji University, India
• Urvashi Bhatnagar, DPT, MBA Candidate, Yale School of Management, USA
• Joe Bialowitz, MS, MSc, National Environmental Program Leader, Kaiser – Permanente, USA
• Melissa Bilec, PhD, Associate Professor, Civil & Environmental Engineering, University of Pittsburgh, USA
• Jason Burnham, MD, Instructor in Medicine, Infectious Disease, Washington University School of Medicine in St. Louis, USA
• Grace Cai, MBA Candidate, Stern School of Business, New York University, USA
• Andy Cassels-Brown, MB BS, FRCOphth, Consultant, Ophthalmology, National Health Services, UK
• Alexander Cimprich, MES, PhD Candidate, University of Waterloo, Canada
• Heidi Cole, MS, Senior Innovation Manager, Research & Development, Stryker Sustainability Solutions, USA
• Lorea Coronado-Garcia, MSc, Sustainability Consultant, United Nations Development Programme, Turkey
• Anthony Costello, FMedSci, Co-Chair, Lancet Countdown: Tracking Progress on Health and Climate, UK
• Brett Duane, DDS, PhD, MPH, Associate Professor, Public Dental Health, Dublin Dental University Hospital, Ireland
• Robert Dubrow, MD, PhD, Professor of Epidemiology (Environmental Health Sciences), Faculty Director, Yale Climate Change Health Initiative, Yale School of Public Health, USA
• Matthew Eckelman, MS, PhD, Assistant Professor, Civil & Environmental Engineering, Northeastern University, USA
• Gabriella Grisotti, MD, PhD, Surgery Resident, Department of General Surgery, Yale University School of Medicine, USA
• Arthy Hartwell, MSc, Head, International & Immigration, British Medical Association, UK
• Harriet Hopf, MD, Professor and Vice Chair, Anesthesiology and Interim Vice President for Faculty, University of Utah, USA
• Varshini Kumar, MBA Candidate, Stern School of Business, New York University, USA
• Ann Kurth, PhD, CNM, MPH, FAAN, Dean of the Yale School of Nursing and Linda Koch Lorimer Professor of Nursing, Yale School of Nursing, USA
• Robert Lagasse, MD, Professor and Vice Chair for Quality and Safety Improvement, Anesthesiology, Office of Cooperative Research, Yale University, USA
• Michael Leapman, MD, Assistant Professor, Urology, Yale University, USA
• Andrea MacNeill, MD, FRSC, Assistant Professor, University of British Columbia, Canada
• Forbes, McGain, MBBS, PhD, Anaesthetist, Western Health, Honorary Associate Professor, School of Medicine, University of Sydney, Australia
• Dan Morris, MBChB, FRCSEd, Consultant, Ophthalmology, National Health Services, UK
• Michael Overcash, PhD, Sam Bloomfield Distinguished Chair and Professor, Sustainable Materials and Energy Systems, Wichita State University, USA -
• Abhijeet Parvatker, MSc, PhD Candidate, Northeastern University, USA
• David Pencheon, MD, Founding Director, Sustainable Development Unit, UK
• Adam Pollard, PhD, Research Director, Numeration Systems, Ltd, Honorary Senior Research Fellow, University of Exeter Medical School, UK
• Bernard Robaire, PhD, James McGill Professor, Pharmacology and Therapeutics and Obstetrics and Gynecology, McGill University, Canada
• Karl Rockne, MS, PhD, Professor, University of Illinois at Chicago, Program Director, National Science Foundation-Chemical, Bioengineering, Environmental and Transport Systems, USA
• Blair Sadler, JD, Senior Fellow, Institute of Healthcare Improvement, Associate Professor at the University of California at San Diego School of Medicine, Former President and CEO, Rady Children’s Hospital, USA
• Beth Schenk, PhD, MHI, RN-BC, Nurse Scientist and Sustainability Coordinator, St. Patrick Hospital, Assistant Research Professor, Washington State University, USA
• Jodi Sherman, MD, Associate Professor of Anesthesiology, and of Epidemiology in Environmental Health Sciences, Yale Schools of Medicine and Public Health, Director of Sustainability, Department of Anesthesiology, USA
• Rachel Stancliffe, MSc, Director and Founder, The Centre for Sustainable Healthcare, UK
• Scott Sussman, MD, Assistant Clinical Professor, Yale School of Medicine, Senior Medical Director of Clinical Operations, Yale New Haven Health System, USA
• Cassie Thiel, PhD, Assistant Professor, Population Health and Ophthalmology, New York University Langone Health, New York University Wagner School of Public Service, New York University Tandon School of Engineering, USA
• Jeff Thompson, MD, Executive Adviser and CEO Emeritus, Gundersen Health System -
  Neonatal Intensive Care and Pediatric Critical Care, USA
• Janet Twomey, PhD, Associate Dean, Graduate Education, Research, and Faculty Success, Wichita State University, USA
• Sten Vermund, MD, PhD , Dean of the Yale School of Public Health, Anna M.R. Lauder Professor of Public Health, Professor of Epidemiology, Yale School of Public Health, USA
• Daniel Vukelich, Esq. CAE, President/CEO, Association of Medical Device Reprocessors (AMDR), USA
• Natasha Wasim, MPH Candidate, Yale School of Public Health - Environmental Sciences, Yale Office of Sustainability Researcher, USA
• Debbie Wilson, RN, DHSc, Sustainability Officer, Middlemore Hospital, Counties Manukau Health, New Zealand
• Steven Young, PhD MASc, Associate Professor, School of Environment, Enterprise and Development, University of Waterloo, Canada
• Julie Zimmerman, PhD, Senior Associate Dean of Academic Affairs, Professor of Chemical and Environmental Engineering and Forestry and Environmental Studies, Assistant Director for Research at the Center for Green Chemistry and Green Engineering, Yale University, US

• Yale School of Medicine
• NYU Langone Health
• NYU Wagner Graduate School of Public Service
• Yale School of Public Health

• National Science Foundation
• NYU Green Fund
• Yale School of Medicine
• Yale School of Public Health
• Yale School of Nursing
• Yale Office of Sustainability

• Jodi Sherman, MD
• Cassandra Thiel, PhD