Greener medical homes

Why should this matter to us?

As an influential group involved in both health consumption and health education, we have health, environmental, and business reasons for “greening” our clinics; but we also have a growing and most compelling rationale for pursuing environmentally friendly practices: a multigenerational responsibility and ethical imperative to deliver health care with solid efforts to mitigate the environmental impact.³

Ecological footprint is a concept that provides a “method for assessing the overall impact of an activity, facility, community or nation in terms of the amount of land required to produce the resources that are consumed or absorb the wastes that are produced.”³ Dr Susan Germaine assessed the ecological footprint of Lions Gate Hospital in North Vancouver, BC; she found that the hospital had an ecological footprint of about 2841 hectares, which is 739 times its actual size.^2,3 If health facilities and clinics were to calculate their ecological effect or footprint, would the results be as staggering as those found by Germaine? In 2000 Ontario’s Ministry of the Environment estimated that Ontario hospitals produced 150 000 tonnes of solid waste annually.³ We are repeatedly advised that the effect of human activities on the globe is being and will be felt most directly by the world’s most vulnerable populations, and as providers of health care, this might be the most motivational knowledge we have.⁸

There was support for green health care at a 2006 workshop held by the Institute of Medicine Roundtable on Environmental Health Sciences, Research, and Medicine: Thus a hospital with a successful triple bottom line would boast positive impacts on the health and well-being of its patients, staff, and visitors; efficient use of energy and natural resources, with minimal waste and pollution generated; and healthy financial performance. Many private firms recognize that this approach not only advances their goals but also positions them well on the market, enhancing their image and earning customer loyalty. These rationales apply directly to green health care.⁹

Financial benefits, waste reduction, and resource conservation are benefits of a resource-reduced approach to clinic management. Being better global and local citizens is considered another benefit in a milieu of increasing concern about climate change and its relationship to consumption and health effects. In Table 1¹⁰ we offer a checklist that can assist in starting a green family medicine clinic.

Where do we go from here?

As leaders in family medicine, we must ensure that family medicine educational settings commit to the environment in their everyday work, ensuring family physicians of the future learn ways to make the environment part of quality improvement routines and an ethical foundation of their academic and clinical practice. Such a movement would be consistent with commitments to environmental sustainability in higher education already made by many universities in Canada such as the Sustainability Tracking, Assessment and Rating System of the Association for the Advancement of Sustainability in Higher Education, the Talloires Declaration, and the University and College Presidents’ Climate Change Statement of Action for Canada.

Some hospitals have already started along this path. The Cleveland Clinic in Ohio was the first US health care provider to commit to the United Nations Global Compact initiative, which included human rights, labour, and environmental and anticorruption standards.¹¹ Hospitals, with their considerable ecological footprints, are increasingly using environmental measures as quality indicators.^9,12 Government funding has encouraged this activity and subsequent publishing of the outcomes of green initiatives. Hospital sector initiatives include the Green Hospital Scorecard Initiative and the Green Hospital Champion Fund Implementation Program of the Ontario Hospital Association, as well as the adoption of the ISO 14001 environmental management system standards (Hospital for Sick Children in Toronto, Ont, and Lions Gate Hospital among others). The UK National Health Service is another example of a comprehensive system-wide program. Many non–health care organizations are making similar progress using frameworks such as Triple Bottom Line,¹³ Leadership in Energy and Environmental Design,¹⁴ B Corp Best for the World,¹⁵ and the Global Reporting Initiative.¹⁶

Have we kept pace in our family practices?

It is apparent that businesses, universities, and hospitals have been making progress in environmental sustainability and social responsibility while continuing to focus on financial efficiency and care provision. However, there is little outcomes-based literature available detailing implemented environmental sustainability measures in our family medicine clinics and academic settings. The Quality Book of Tools, a peer-reviewed family practice quality improvement tool by Levitt and Hilts, has extensive quality indicators but lacks a specific section on environmental considerations because its family physician–participant-driven Delphi method did not validate the “commitment to an eco-efficient or green office” as a quality improvement criterion.^17,18 The Lean system, a familiar quality improvement tool used in health care settings, and the College of Family Physicians of Canada’s Patient’s Medical Home practice and education document address practice efficiency but do not indicate resource rationing or environmental concern as a collective value in either the training of residents or the care of patients.^19,20 Some family medicine teaching settings in Canada have taken steps to incorporate environmentally sound and greener approaches in their practices. Such sites include McMaster University’s Stonechurch and David Braley family health centres in Hamilton, Ont, and the Centre for Family Medicine in Kitchener-Waterloo, Ont.^21–23 Additionally there are many articles detailing practical approaches to reducing use of resources in medical outpatient settings. However, we were unable to find published evidence of the adoption of this ethos in family medicine educational settings along with implementation outcomes.

Next steps to lighter footprints

Residents are looking for quality assurance projects that will make a difference when they have completed their programs. We suggest they consider how they might contribute to local and global environmental health during their quality assurance or research time. In fact, funding exists from the Ontario College of Family Physicians’ Environmental Health Committee to encourage this type of research, and similar opportunities likely exist elsewhere. Residents and students can be our greatest asset in making responsible decisions about the use of resources and, vitally, disseminating new experience and knowledge. The application of new environment-inclined practice changes will need outcomes to be monitored and shared to build an evidence-informed body of literature to support and guide change.

Family medicine clinics and teaching clinics’ waste generation and energy and resource use are all compelling reasons to understand our ecological footprints and employ direct and immediate action to mitigate our collective contribution to climate change. The potential now and in the future is considerable; it is urgent that we join the world and reduce the effects of health care on our environment and the very people for whom we provide care.

Getting started

Whether using the Quality Book of Tools,^17,18 the Lean system,¹⁹ or some other means to address continuous quality improvement, consider environmental practices as a stated value.

With the recognition of responsibility for consumption and its effect locally and globally, clinicians and administrators can identify a leader and put together a team. Bring together all team members appropriate in your setting. Consider including learners and family practice patients who will have either expertise or interest in this area. The suggestions in Table 1¹⁰ can help you get started. Approaches to greener health care must also be an iterative process that includes publishing findings with the goal of identifying best practices in management of resources in family medicine outpatient health care provision and medical education.