sustainable healthcare change … journey to a sustainable healthcare environment involves a...

Cork University Hospital

SUSTAINABLE HEALTHCARE CHANGE PROGRAMME

2016–2017


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Overview of Cork University Hospital

Cork University Hospital (CUH) with over 40 different medical and surgical specialties on site is the largest university teaching hospital in Ireland and the only Level 1 Trauma centre in the country.

It is the tertiary referral centre for the HSE Southern area, and the supra regional area ofLimerick, Clare, Tipperary, Waterford and Kilkenny. Cork University Hospital functions as a regional centre for secondary and tertiary care for the catchment population of 550,000 served by the HSE Southern area and a supra-regional centre for a total a population of 1.1 million.

In 2015 there were 66,000 ED presentations, 208,000 out-patient attendances 46,000 inpatient discharges and 88,000 day cases while the maternity service had 8,300 births and 89,000 outpatient attendances.

The Hospital has 800 beds and this will increase further on completion of the transfer of additional services to the campus.

The hospital currently employs 4,000 staff (3,555 WTE) of multiple professions and is the primary teaching hospital for the Faculty of Health and Science in University College Cork.

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Sustainable Healthcare – The Change Programme 2016–2017

Contents

Forward 4

Introduction to Sustainable Healthcare 5

HSE Sustainability Programme 6

Sustainability and Change Management at CUH 7

Leadership and Governance 8

Environmental Review 9

Key Deliverables and Actions 11

On-going Monitoring and Evaluation 12

Informing and Involving the Campus and Wider Community 15

Links to Learning on Campus 16

Development of a Green Charter 17

Looking to the Future 18

Conclusion 18


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Forward

In 2014, CUH Campus became the first healthcare facility in the world to be awarded Green Flag status by An Taisce and the Foundation for Environmental Education (FEE) for its work in environmental management and sustainable healthcare. This award is in recognition of the commitment of the Executive Management Board in developing CUH as a healthcare facility that delivers high quality care and improved public health and wellbeing without exhausting natural resources or causing ecological damage. A challenge for the modern day health service is in actively changing the current approach to healthcare in order to stay within these limits.

Much progress has been made in the areas of reducing energy consumption, water consumption, clinical waste generation and increasing the level of recycling. The challenge now is to maintain these achievements and work towards implementing further changes to maintain Cork University Hospital’s Green Flag Status. In doing so we must acknowledge the support of the CUH staff for their continuing commitment and endeavours in this area.

J. A. McNamara,Chief Executive Officer.

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Introduction to Sustainable Healthcare

Sustainability in healthcare revolves around delivering high quality care and improved public health and wellbeing without exhausting natural resources or causing ecological damage. In theory, a sustainable healthcare system can go on forever within the limits of financial, social and environmental resources. The challenge for the modern day health service is in actively changing the current approach to healthcare in order to stay within these limits.

The journey to a Sustainable Healthcare environment involves a cultural change in the perception of healthcare delivery and the ‘Route Map for Sustainable Health’ outlines a number of transformational shifts required for a more sustainable health and care system:

FIGURE 1: ROUTE MAP FOR SUSTAINABLE HEALTH

From healthcare as an institution led service To health and social care as part of the community

From curative and fixing medical care To early intervention and preventative care

From sickness To health and wellbeing

From professional To personal

From isolated and segregated To integrated and in partnership

From buildings To healing environments

From decision making based on today’s finances To an integrated value of the future which accounts for the impacts on society and nature

From single indicators and out of date measurements To multiple score card information

and in real time

From sustainability as an add on To integration in culture, practice and training

From waste and over use of all resources To a balanced use of resources where waste becomes a resource

From nobody’s business To everybody’s business

Topics such as energy efficiency or waste management are often at the forefront when thinking about environmental health issues, but good everyday work practices and the behaviour of staff and patients also have an influence on the environmental performance of hospitals.


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HSE Sustainability Programme

In 2013 the HSE established the National Health Sustainability Office (NHSO) in order to develop and build staff, patient and public awareness of sustainability related issues within the Irish health system and to deliver a healthier environment while at the same time keeping costs low. The areas of focus include energy efficiency, waste reduction water conservation, and at a minimum the provision of sustainable transport along with issues of sustainability arising in relation to health and wellbeing. The NHSO encourages the development of sustainable facilities and buildings in both design and operation and promotes sustainability in the procurement process in order to reduce current and future costs and minimise environmental impact.

FIGURE 2: ELEMENTS OF A SUSTAINABLE HEALTH AND CARE SYSTEM

Social

Economic

Environment

Sustainable Health & Care System

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1. Leadership

and Governance

2. Environmental

Review

3. Identify Key Deliverables and Idnetify Action Plan

4. Monitoring and

Evaluation

5. Links to Learning on

Campus

6. Informing and Involving

7. Green Charter

Sustainability and Change Management at CUH

The Green Campus Programme, run in Ireland by An Taisce, is traditionally an environmental management system for use in tertiary educational facilities. At the 2010 FEE General Assembly in China it was deemed that once a hospital is affiliated with a University it can be considered a third level teaching environment and therefore eligible to participate in the Green Campus Programme.

The CUH approach to environmental change management was based on the steps set out in the An Taisce Green Campus Application. In 2010 CUH approached the Green Campus Office with a view to beginning the process of gaining Green Flag accreditation. The process required to achieve accreditation is set out in Figure 4 hereunder and forms the basis of the change management process.

FIGURE 4 – ACCREDITATION PROCESS


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Leadership and Governance

The CUH Sustainable Healthcare Steering Group was established in April 2013 in order to advise and oversee the direction, coordination and implementation of the 2013 to 2017 HSE Sustainability Management Strategies on the hospital campus.

Group members were carefully chosen for their knowledge and skills and also the ability to represent and influence their relevant interested departments and staff groups. The committee is chaired by the CUH Chief Executive Officer and contains representatives from a variety of disciplines including nursing, medicine, finance, maintenance and engineering, estates, biomedical engineering and security.

Importantly, the committee is representative of the organisation as a whole. Partnerships were also developed with external organisations which have the expertise to inform the Steering Group on environmental issues. The governance structure is set out in Figure 5 hereunder.

FIGURE 5 – GOVERNANCE STRUCTURE

PartnershipsSEAI Training & Support

Power of One Program

EPA/CIT Clean Technology Centre(Green Healthcare Programme)

National Transport Authority(Smarter Travel Work Places)

An Taisce(Green Campus Programme)

Healthcare without Harm

Global Network for Green Hospitals

University College Cork

St Catherine’s National School, Cork

Mount Mercy College, Cork

Ward/DepartmentGreen Advocates & Green Teams

Line Management

Patients

Students

Members of the Public

PartnershipsSEAI:

Energy Map TrainingOn-site Mentoring (AMA)

Energy Efficiency Design Review

Power of One Program

Energy Cork

Horizon 2020

Communication Line

CEO

ExecutiveManagement Board

SeniorManagement Team

Sustainable HealthcareEnvironmental Steering Group

SustainableEnvironment Officer

AssistantNational Director,

HSE EstatesSouth

RegionalEstate Manager

EnergyChampion,HSE Estates

South

Reporting Line

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Environmental Review

Environmental review is the process of examining the campus’ environmental impacts in order to identify targets for improvement. Within CUH environmental reviews were undertaken in respect of energy, waste, water and transport. On a basic level this involves analysing bills and contractor data in order to build a baseline profile of how the hospital consumes energy, water and generates waste. Year 2012 was chosen as the baseline year to measure future improvements and the charts below demonstrate the baseline data for electricity, gas and waste respectively.

1,380,000

1,400,000

1,420,000

1,440,000

1,460,000

1,480,000

1,500,000

1,520,000

1,540,000

1,560,000

1,580,000

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Un

its (

kW

hr)

2012

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000


Units (

kW

hr)

2012

HCRW Special WasteMunicipal WasteFood WasteRecycling 596.81 15.205 858.626 70.476 295.964

0

100

200

300

400

500

600

700

800

900

1000

HCRW Special Waste Municipal Waste Food Waste Recycling


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In certain cases, the installation of metering devices will be required in order to undertake departmental specific measurements in relation to energy and water consumption. Such measurements will help to better understand the processes involved and opportunities for continuous improvement.

Similarly, the rates of patient activity, patient numbers and occupancy rate of the hospital can be collected from the relevant hospital office. This data is used by the Sustainable Healthcare Steering Group to calculate Key Performance Indicators (KPIs) for each material and supply. The KPIs can then be monitored on a monthly or quarterly basis.

Following the collection of baseline data, a material and energy flow analysis was carried out. This provides a detailed description of process steps, quantities, material and energy consumption, identifies specific sources of waste and emissions and describes the amount of each raw and waste material.

Without understanding the culture in relation to the ‘green agenda’ it is difficult to make meaningful changes in a large organisation. Baseline attitudinal surveys were carried out with the organisations staff to determine what they perceived as being important and what immediate change could be made within their own respective departments or clinical areas.

CUH staff were asked to identify where changes could be made in energy efficiency. The results are displayed in Figure 6 hereunder.

FIGURE 6: CHANGE INITIATIVES

Turn Off Lights 34Turn Off/Reduce Heating 17Lighting Controls 6Turn Off Water Taps 2Energy Efficient Lighting 2Turn Off Applicances 24Local Heating Controls 5Eliminate Draughts 2Turn Off Air Con 2Others 6

34, 34%

17, 17% 6, 6%

2, 2% 2, 2%

24, 24%

5, 5%

2, 2% 2, 2%

6, 6% Turn Off Lights

Turn Off/Reduce Heating

Lighting Controls

Turn Off Water Taps

Energy Efficient Lighting

Turn Off Applicances

Local Heating Controls

Eliminate Draughts

Turn Off Air Con

Others

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Key Deliverables and Actions

Information gained from the environmental review is utilised to identify priority areas and create an Action Plan. Action planning involves setting achievable and realistic targets and deadlines to improve environmental performance on specific issues. This is achieved by listing a number of agreed environmental objectives, target completion dates for each objective, deadlines and clearly allocated responsibilities for each step.

Actions and targets were developed in relation to;• Reducing energy consumption • Reducing water consumption and increasing leak detection • Reducing clinical waste generation • Increasing the recycling rate across the hospital • Reducing food waste• Establishing registers of opportunities for energy and waste• Developing, launching and maintaining a large scale staff awareness and engagement

campaign• Carrying out staff energy and waste awareness surveys• Participating in the EPA Green Healthcare Programme• Improving existing healthcare buildings to make them more sustainable and efficient• Reviewing travel and transport on campus and participating in the NTA Smarter

Travel Workplaces initiative • Exploring greener procurement options• Establishing emissions to air and putting mitigation measures in place• Developing a plan for landscaping and gardening on the campus

One of the major targets for CUH is to reduce energy consumption by 33% by 2020 in line with the national public service commitment. This will have significant cost benefits for the hospital as outlined in Figure 7 hereunder.

FIGURE 7: GLIDE MAP

-

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

Tota

l P

rim

ary

Energ

y C

onsum

ption (

kW

hr)

Glidepath

Actual


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In order to achieve meaningful reductions in energy consumption, significant investment has to be made in infrastructure within the hospital. The initial projects that were completed relating to energy systems included:

• Energy efficient lighting upgrade works• Timer controls for split A/C units• AHU controls• Variable speed control of pumps• Lagging jackets for valve and pump sets in plant rooms• Boiler optimisation

On-going Monitoring and Evaluation

Monitoring and evaluation are used to assess progress made towards achieving targets identified in the action plan and to identify areas that require further attention or modified actions. Energy and water consumption and waste generation trends are monitored monthly and compared with the baseline and other years. These trends are followed up monthly at the Sustainability Steering Group meetings and interventions are decided upon. The following charts below demonstrate trends for energy and waste for the period of 2012 – 2014 when the initial action plan was in the process of being implemented.

FIGURE 11: ELECTRICITY CONSUMPTION 2012 - 2016

Hospital Campus - Electricity Consumption

1,300,000

1,350,000

1,400,000

1,450,000

1,500,000

1,550,000

1,600,000

1,650,000


Un

its (

kW

hr) 2012

2013

2014

2015

2016

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FIGURE 12: GAS CONSUMPTION 2012 - 2016

FIGURE 13: WASTE GENERATION 2012 - 2015

Key performance indicators such as energy/water consumption and waste generation are assessed and benchmarked based on hospital activity metrics such as total patient contacts or inpatient bed days. In this way it is possible for CUH to compare itself with other acute hospitals when assessing our overall environmental performance.

Hospital Campus - Gas Consumption

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000


Units (

kW

hr) 2012

2013

2014

2015

2016

HCRW Special WasteMunicipal WasteFood WasteRecycling 2012 597 15 859 70 2962013 589 15 724 67 3402014 576 17 653 74 3732015 582 17 700 74 252

0

100

200

300

400

500

600

700

800

900

1000

HCRW Special Waste Municipal Waste Food Waste Recycling

2012

2013

2014

2015


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FIGURE 14: CUH KPI DASHBOARD

Total Unit Change 2020 Target Unit Change

62.19kWhr / patient

contact-8.56%

466 kWhr / m2

1.28%

14,038 2012 14,308 t CO2 1.9% -33% 21.65kg / patient

contact -7.88%

58.32kWhr / patient

contact-14.17%

437 kWhr / m2 -5.03%

14,038 2012 13,255 t CO2 -5.6% -33% 21.57kg / patient

contact -8.22%

Water Total Water Use 188,195 2012 178,537 m3 -5% < 530 729

l / patient bed

day -15.8%

Mixed Recyclables 225.66 2012 298.01 t 24% 0.90 1.22kg / patient

bed day17%

Health Care Risk 596.79 2012 575.87 t -4% 1.90 2.35kg / patient

bed day-14%

Food 70.46 2012 74.43 t 5% 0.70 0.85kg / patient

bed day-4%

General Landfill 920.54 2012 652.89 t -41% 4.20 2.67kg / patient

bed day-55%

Total 1813.45 2012 1618.57 t -12% 7.70 6.54kg / patient

bed day-24%

% Waste Recovered /

Recycled12 2012 19 % 35% - - n/a -

On target to meet target or improved performance

Some progress but not on track to meet target

Worsening performance

* Adjusted to take account of increased energy consumption arising from area

change of use and additional heating capacity, above baseline data. (Calculated)

Baseline

YearTheme Indicator Baseline

-33%

1.3%

Energy & Carbon

Management

Waste

Total energy (Actual)

Total energy (Adjusted) *

40,585,925 2012

201240,585,925

Per Patient Contact - 2014

38,543,520

41,106,196 kWhr

kWhr

How are we doing overall - 2014

-33%

-5.0%

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Informing and Involving the Campus and Wider Community

Engagement and involvement of staff on campus are vital to the success of any environmental programmes. In CUH we have engaged in two ways;

• Information provision and exchange – letting people know what is going on within CUH and considering their views and opinions.

• Consultation – approaching the wider hospital community to be involved in decision making.

The Green Advocate Network was established in 2013/2014 as a means of engaging and consulting with staff around the sustainability programme at CUH.

A Patient Advocate is somebody who will act on the patient’s or the patient’s family’s behalf when dealing with the hospital or healthcare service. CUH campus have adapted this concept and applied it to sustainable environment/ green champions who will act on behalf of the environment, hence Green Advocates.

The aim is to have a designated Green Advocate(s) within each ward / department who will play a key role in the Cork University Hospital Group achieving a sustainable campus. Green Advocacy is a voluntary role and staff either volunteer or are nominated by the Ward/ Department Manager/ peers. Recruitment of Green Advocates is ongoing. Approximately 130 Green Advocates have been identified to date.

The role of the Green Advocate is centred on actively promoting CUH Sustainable Healthcare initiatives to staff they work with and to keep their colleagues informed about environmental issues around the hospital campus and;

• Acting as a communication channel between staff/ students and the Steering Group and Sustainable Environment Officer so that we can develop initiatives and resolve concerns

• Raising staff/ student awareness about the impact of their workplace on the environment by reducing our carbon foot print, our energy consumption and associated costs, conserving water and managing our waste correctly

• Providing staff/ students with the tools to improve and minimize their environmental impact

• Facilitating and supporting staff in creating their own Sustainable Healthcare Environment opportunities for improvement and initiatives.


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A CUH campus Green Advocate Training Programme has been developed to provide staff / students with the skills and knowledge needed to embed and advocate Sustainability practices in their workplace. The course outlines the initiatives that CUH and the HSE has undertaken towards Sustainable Healthcare and provides Green Advocates with practical sustainability applications that can be taken back to their respective departments. This training is currently available 3 times a year and is provided by the CUH Sustainable Environment Officer and a HSE Estates Project Engineer.

In order to increase staff awareness and engagement the staff, the Sustainability Steering Group produces and coordinates;

• Monthly sustainability newsletters• Email communication with all staff• Green Advocate training module available to all staff• Green Advocate drop in forums • Energy and Waste awareness days • Live Green Notice Board • Sustainable Healthcare and Living pages on CUH website• Best practice guidance for wards, laboratories and offices available to all staff • Sustainability checklists for staff to use locally• Local energy and waste audits • Public broadcasts and environmental messages on hospital radio CUH FM• Information on Public Information Screens.

In order to make the Sustainability Programme instantly recognisable to the staff, a unique brand was developed for the awareness campaign in partnership with BA Visual Communications at CIT. The SEECO brand mark that emerged is based on the concept that sustainable healthcare and living requires three vital individual elements, which are social, environmental and economic. The SEECO brand mark which is displayed below is printed on all the literature and guidance documents that are produced for use on the hospital campus.

Links to Learning on Campus

CUH is the major teaching hospital of University College Cork and therefore plays a central role in the education of students from the UCC faculty of Health and Science. Furthermore, one of the two undergraduate teaching schools for dental students is located on the grounds of CUH. At any given time, there can be upwards of 400 clinical students learning and working on the CUH campus.

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All students are inducted as if they were members of staff and must undergo formal induction and orientation where information on the CUH sustainability programme is disseminated. Students are encouraged to get involved with the Green Advocate network. All new medical and nursing staff are required to attend the Prevention and Control of Hospital Acquired Infections training programme which includes a detailed module on healthcare waste management and segregation.

The student population is also represented on the Sustainability Steering Group in the form of the elected class rep for Medicine and Health in any given term. This provides a direct link between the Steering Group and the College of Medicine and Health.

Development of a Green Charter

The Green Charter is a “this is how we do things here” guide to environmental management on site. Most organisations have a substantial Environmental Policy with specific policy statements related to waste, energy, water and other environmental issues. The differences between an environmental policy and the green charter are the former is an expression of what the campus intends to do and provides assistance at the strategic/management level; the latter is the means by which the campus community can achieve the aims through specific advice and information. The Green Charter may contain an environmental policy but essentially it is a guidance document on how environmental issues are handled on campus. The CUH Green Charter was compiled after the initial action plan had been implemented and the monitoring and evaluation steps had been carried out. The Green Charter is available to be viewed on the CUH website.


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Looking to the Future

Cork University Hospital is proud of its achievements in environmental management to date but realises that there is much more to be done. In 2016 the CUH expanded its sustainability brief substantially and in Quarter 4 with the help of our many partners will explore;

• Water Management Systems• Water Benchmarks for Acute Hospitals • Staff Garden Groups • Local Organic Food Procurement• Mobility Management • Further Metering and Technical Projects

This work will form the basis of the Green Agenda for year 2017.

Conclusion

Cork University Hospital would like to extend its gratitude to all of the organisations and individuals who have helped us along on this journey; HSE Estates Department, The National Health Sustainability Office, The Environmental Education Unit - An Taisce; EPA Green Healthcare Programme; Clean Technology Centre Cork, Sustainable Energy Authority of Ireland; University College Cork; Cork Institute of Technology and the National Transport Authority.

We looking forward to working with all agencies in further developing the CUH Sustainable Healthcare Environment.


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