A Few Notes about This Blog

This blog shares my insights on the design, introduction and active management of effective sustainability programs in hospital settings. Unlike the thousands of discussions on sustainability's altruistic, conceptual and technical aspects, though, this blog approaches the discipline from organizational management and development perspectives.

Over the past few years there has been a lot of discussion in the trade media around the American Hospital Association's new "Sustainability Roadmap for Hospitals," which complements the association's excellent work in its recent "Executive Primer on Hospital Environmental Sustainability." (

With the AHA - as well as Practice Greenhealth, Healthcare without Harm and other organizations - staking authoritative claims to the topic, why do I think it necessary to add my two cents? Here's why. The AHA executive primer covers several of the big concepts any good sustainability program should have. Further, its roadmap details many of the high-level steps needed to create and run it. However, neither will be able to adequately explore institution-specific details for successful organizational design, change management and program effectiveness.

That's not a failing of AHA's superlative work; it is simply recognition that when it comes to management programs, such as sustainability, one size does not fit all. Each hospital needs to custom design its own sustainability program to meet its specific needs, including working within its resource limits and opportunities. Helping you and your institution work through the details is where this blog comes in.

The first few blog posts address basic concepts, including the special challenges healthcare delivery organizations face whenever they create new performance capabilities. After that the discussion will shift to the key questions a hospital – or, any other organization for that matter – must answer in creating and running a sustainability program and, by extension, an all-encompassing corporate social responsibility program. Then, the discussions dive into the "how-to-do-it" details with a big emphasis on anticipating and controlling obstructions to success.

Rather than prescribe rigid off-the-shelf methods that may have worked well elsewhere – yet, might not work so well at your hospital – these discussions will pose key questions that must be answered by the best minds at all levels of your institution to create a customized program.

This blog is a serialized body of work. So, if this is your first visit, I highly recommend that you start with the oldest post date and work forward from there. The entries will make a lot more sense that way.

For those of you who work in other industries, substitute the words "hospital" and "healthcare" used throughout the posts with the name of your industry or company. You'll probably find the information in this blog fits your field and organization quite well.

Lastly, if you are a sustainability professional, I would be honored if you sign-up to follow this blog and share it with your colleagues. Also, please feel free to share your views and experiences.

Thank you for stopping by.

Friday, August 27, 2010

Make a Formal Go-Decision to Create the Sustainability Program and Set the Hospital's Green Policies

The next several posts will consider the questions in Question Set 1, Creating the Sustainability Program and Assuring Executive Buy-In. (Refer to August 18, 2010, A Rudimentary Model for a Sustainability Management System.)

The All-Important Go-Decision for a Sustainability Program
In creating any new program that affects the overall performance of a hospital, it is important that senior leadership make a well-reasoned and documented decision to proceed. In other words, it needs to make an unambiguous "go decision." In the case of major initiatives, such as sustainability programs, the board of directors should take the lead through a resolution.

Why all the fuss? Why can't operations- and administrative-level mangers simply be left to do what they think is best?

Formal decisions-to-proceed by the highest levels of leadership are needed because major programs consume valuable resources that are also needed by competing hospital functions and units. Senior leaders are responsible for making sure competing units and functions receive adequate resources to successfully achieve their missions.   It's the essential idea behind The Rolling Stones' lyric:

"You can't always get what you want
But if you try sometimes you might find
You get what you need"

Further, resource consumption must result in specific and adequate returns-on-investment (ROI) if the hospital is to fulfill the "prime directive of finance," the ultimate organizational objective. Of course in sustainability programs, ROI assessments must consider the additional dimensions of social and environmental costs and benefits. Senior leadership also has responsibility for these outcomes.

Money-Grubbing 101
Although the triple-bottom-line concept assigns co-equal status between financial, social and environmental performance, in practical applications the prime directive ekes-out a bit of preeminence on behalf of financial performance over the other two . . . and for good reason.

Let's define that strange Trekkie-sounding term, the prime directive of finance. Every organization must obey it; it's the "No Money, No Mission" concept. The only way this can be done is by balancing all activities within an organization's resource limits and opportunities.

Of course, the no-money, no-mission concept looks a bit different at for-profit, not-for-profit and public hospitals. For example, because of the body of law regulating for-profit corporations – particularly publically traded corporations – their view of the concept is this:

The only reason for-profit organizations exist is to increase the wealth of equity holders.

Yup, it's cold, hard capitalism at its best – or worst – depending on your perspective. Unless a for-profit is financially healthy enough to produce profits – and therefore build-up the balance sheet – it may not survive.

Before those of you at not-for-profit and public hospitals start feeling a bit smug, remember your organizations also have a prime directive of finance:

An organization must secure adequate financial resources to sustain and expand its mission.

In either case without money – i.e., the financial dimension of the triple bottom line – the social and environmental missions are not possible at any organization. Sacrilege? Maybe, maybe not. It's something to ponder, though, isn't it?

Now, Set the Hospital's Sustainability Policy
So, with every hospital facing no money, no mission realities, it behooves senior leadership – i.e., the board of directors and C-level officers – to formally state the high-level policy on environmental sustainability. And, they might as well set this policy in the go-decision's board resolution discussed above.

Guiding principles, programmatic objectives and general requirements must be defined for the whole hospital in the sustainability policy. Also, the policy must state the priority for these mandates relative to the hospital's other declared intentions and requirements. As you're no doubt beginning to realize, these considerations set the extent of sustainability activities, as well as their limits.

For hospitals just now starting to go green there are advantages to be had thanks to all of the existing sustainability programs outside the healthcare industry that are just waiting to be benchmarked. Further, because many of these programs have excellent corporate transparency elements, their policies are readily available via the Internet. So, when it comes to drafting the go-decision and policy statements for a board resolution, don't reinvent the wheel. Simply google the phrase "corporate sustainability policy" and start benchmarking. (Remember how benchmarking was characterized at the end of the August 17th post?)

One thing you may notice with some online policy statements is the addition and comingling of specific objectives, tactics and targets. For the sakes of brevity and subsequent program flexibility, I'd suggest that your hospital resist the urge to include them in your policy statement.  Leave the definition of strategic objectives, tactical goals and specific administrative and operational improvements for later stages in your program's development.

Irrespective of whatever benchmarked and original content is included, write the policy in the context of the green efficiency concept, i.e.:

Achieve the hospital's people, planet and profit objectives with least cost, effort and risk throughout the entire closed-loop lifecycles of its services and products.

Further, just because the green efficiency concept states that objectives must be achieved with least cost, effort and risk, it doesn't mean they can't be set at the highest breakthrough-performance levels.  Of course, they can be set at low levels, too.  But, these considerations must be made by the policy's authors and adopters.     

Which leads to the next question:  Who's going to write the policy?  Drafting the sustainability policy for board approval is a terrific opportunity for the C-level officers to involve individuals at all levels of the hospital organization in a major shared governance activity.  A key advantage of including a wide representation of management and staff is early, broad and continued support for the program.  The importance of this approach cannot be overstated when it comes to effectively managing all of the program's subsequent changes.

IN THE NEXT POST:  The Prelude to Setting the Sustainability Program's Strategic Objectives and Tactical Goals

Saturday, August 21, 2010

A Quick Summation Before Diving into the Details

Before making a "go" decision on creating a sustainability program, the board of directors, the C-level officers and other leaders must thoroughly understand that going green means achieving break-through performance in the:

• Management of sustainability and other CSR risks, including compliance with regulations and industry standards

• Reduction of sustainability- and CSR-related costs

• Creation of new green revenue streams, and

• Leveraging of greenwash-free competitive advantages through transparency.

Breakthrough performance is a tough proposition. It means that the status quo is no longer acceptable; only significant progress toward ideal performance is. As a result, people must stop doing many of the things that make up their professional and emotional comfort zones. Then, they have to start doing new things that are completely outside their skill sets.

That is scary! People work long and hard to figure out how to get through each workday competently with the least hassle. Once they reach their comfort zone, many will fight like wet, cornered cats to prevent anyone from messing-up their work lives. Is there any wonder why so many people react to organization changes as evil incarnate?

So, assuming that all of this talk about change doesn't scare them off, senior leadership must create and effectively run a program that enables all functions and units in the hospital to identify, prioritize and respond effectively to their most-pressing sustainability needs. Further – and this is critical – it must do these things within the context of all of the hospital's other most-pressing needs.

With a little experience running a comprehensive sustainability program, some refinements and good documented outcomes, a hospital could seriously pursue ISO 14000 environmental management system certification. However, don't jump-the-gun to prematurely chase after another plaque for the lobby walls. The certification process consumes large amounts of organizational resources that can be better used initially to make significant sustainability improvements at your hospital.  ISO14000 certification should come much, much later when there is at last a well-functioning program.

The approach described in this blog is a far cry from impetuously forming a few green committees to do ill-defined green things.  Rather, it is a systematic approach that not only achieves important environmental quality goals, but also benefits patients and other stakeholders while financially strengthening the hospital.  As such, you, the leaders and staff may find it worth the effort.

IN THE NEXT POST:  Formally Making the Programmatic Go-Decision and Setting the Hospital's Sustainability Policy

Wednesday, August 18, 2010

A Rudimentary Model for a Sustainability Management System

It sounds fancy and somewhat imposing, doesn't it: a rudimentary model for a sustainability management system? Fact of the matter, though, it has the same basic features of any proper continuous-improvement (CI) management system.

However, rather than overwhelm you with the details of management system design, let's just go through 10 sets of essential questions.   These questions enable a hospital to consider all of the fundamental elements of a sustainability management system.  Further, they allow an institution to scale the level of its activities to fit within its own resource opportunities and limitations.  As such, this approach is a far cry from simply aping another organization's ill-fitted management systemas has been done far too many times when it comes to healthcare performance-improvement initiatives. 

If you look closely, you may notice that these questions cover the big themes in the Malcolm Baldrige National Quality Award criteria and the ISO quality (9000) and environmental (14000) management system standards. It should be no surprise, then, that when the answers to these questions are detailed using the 5W's & 1H + Check format shown in Figure 3 (click on the figure to enlarge), the result should be a custom-designed sustainability program with a fair chance of being effective.

Question Set 1 – Creating the Sustainability Program and Assuring Executive Buy-In

• How will senior leadership - i.e., board members and C-level officers - mandate the definition of the hospital's comprehensive suite of sustainability strategic objectives, tactical goals, hospital policies and standard operating procedures?

• How will senior leadership assure adequate budgetary and other resources to support the mandated objectives, goals, policies and procedures?

• How will these objectives, goals, policies, procedures and budgets be made readily available on a need-to-know basis to internal and external stakeholders?

• Further, who among the board members and C-level officers will be the program champion(s)?

• How will the program's organizational structures be defined, including functions, lines of authority and stakeholder roles?

• How will executive accountabilities for sustainability program success be set and incentivized?

• How will stakeholders be prepared to participate competently, willingly and enthusiastically in the sustainability program?

Question Set 2 – Setting Near-Term Organizational Priorities for Sustainability

• How will senior leadership identify the specific sustainability objectives and goals that need to be achieved during the next fiscal quarter?

Question Set 3 – Sensing Organizational Sustainability Performance

• How will the hospital's decision-support function collect, analyze and sort enterprise- and unit-level poor-performance information into sustainability categories like those shown on Figure 2 in the August 17th post?

Question Set 4 – Creating the Sustainability Program's Shared-Governance Function

• How will senior leadership create a "shared governance" function using "green teams," each of which will be responsible for addressing one or more of the sustainability topics listed on Figure 2?

Question Set 5 – Producing and Distributing Goals-and-Issues Lists to Green Teams

• Each fiscal quarter how will the corporate decision-support function prepare and send a “goals-and- issues” list for each sustainability topic to its responsible “green team”?

Question Set 6 – Prioritizing the Organization's Most Pressing Sustainability Needs and Prescribing Sustainability Project Goals and Accountabilities

• How will each green team prioritize the information it receives each fiscal quarter from the senior leadership and the hospital's decision-support function to create a topical short-list of the hospital's most-pressing sustainability needs?

• How will green teams distinguish "quick-fix" opportunities from larger sustainability initiatives?

• For all of the green teams, how will information on worthy, lower-priority sustainability needs be maintained for future reconsideration?

• How will each green team set specific, measurable triple-bottom-line performance goals for each of its most-pressing sustainability needs?

• Then, how will it identify which profit- or cost-center(s) or cross-functional team(s) should be responsible for achieving the performance goal?

Question Set 7 – Initiating Projects to Achieve Sustainability Goals

• How will senior leadership receive the project proposals from the green teams each fiscal quarter?

• Further, how will leadership:

     o Evaluate the proposals using triple-bottom-line criteria, including returns-on-investment (ROI)?

     o Select projects to be completed in consideration of all of the hospital's other most-pressing needs?

     o Assign and track project design and completion accountabilities?  And,

     o Allocate and commit financial and other resources to enable successful project completion?

• Then, beyond the direct activities of the sustainability program, how will leadership integrate triple-bottom-line concepts into efforts to meet the hospital's other most-pressing needs?

• How will the green teams assist accountable units and cross-function teams in designing capacity-creation and performance improvement sustainability projects?

Question Set 8 –  Completing and Supporting Projects

• How will accountable units and cross-functional teams successfully complete their projects on-time and within budgets?

• How will the green teams oversee and support their respective sustainability projects – including the securing of additional resources, if needed – to assure the accountable units and cross-functional teams provide quality performance on-time and within authorized resource allocations?

Question Set 9 – Assessing Project and Program Progress

• How will senior leadership assess in triple-bottom-line terms the success or failure of sustainability projects at the end of each fiscal quarter?

• How will successes be celebrated?

• How will root causes of failures be determined and corrective actions prescribed consistent with the concept of: "Never punish people for the sins of the work process?"

• How will new capabilities and performance improvements be sustained?

• How will lessons-learned be accessibly archived and shared internally and externally?

• How will the sustainability program's status and progress be reported to stakeholders in a greenwash-free manner using such approaches as the Global Reporting Initiative (GRI)?

Question Set 10 – Sustaining the Program

• How will senior leadership restart the process for the next fiscal quarter, including linking the corrective action prescriptions from Question Set 9 back into Question Set 3, above?


Simple, eh? Not really. Remember, this is a major organizational development effort. Big and nasty change-management demons reside in the details.

Beside the demands placed on the clinical, ancillary and administrative staff, going green will certainly be a transformational challenge for the board of directors, C-level officers, other leaders, and the hospital's organizational-development and performance-improvement professionals. But, it is doable – and sustainable in the business management sense of the word – with their strong, unwavering and hands-on participation.

IN THE NEXT POST:   A Quick Summation Before Diving into the Details

Tuesday, August 17, 2010

Management? We Don't Need No Stinkin' Management! Oops! Yes We Do.

Anyone who has been around healthcare for a while is familiar with one of the favorite adages of Dr. Donald Berwick, the former president and CEO of the Institute for Healthcare Improvement (IHI) and Administrator of the Federal Centers for Medicare & Medicaid Services:

“Every system is perfectly designed to produce the results it gets.”

Underneath this simple proclamation are these essential management concepts:

Organizational structure – or the lack thereof – actively drives or passively enables behaviors. Collective behaviors over time determine – for better or worse – performance quality in the short-term and organizational culture in the long-term. (See Figure 1 - Click on the figure to enlarge)

For sustainability program development to succeed, this means serious planning, organizing, controlling and leading to achieve the institution's green objectives with least effort, cost and risk. Egad! We're talking about real organizational management here.

What does real green management look like? Well, consistent with contemporary management approaches, green management must be systematic. That's going to be hard to do in a lot of healthcare organizations.

Like it or not, the political decision-making model prevails at the expense of the rational decision-making model in far too many institutions. Need proof? Just consider why the positions, concepts and methods promoted by IHI and its cohorts have gotten so much attention.

The All-Important Key Definitions
Before we go on, let's define environmental sustainability in an organizational management sense. Then, let's see how it fits into the larger concept of corporate social responsibility (CSR).

Throughout the entire closed-loop lifecycle of a product or service sustainability is the way an organization creates value by maximizing the positive social, environmental and economic effects of its activities while minimizing their adverse impacts.  This involves:

• Managing risks, including – but not limited to – environmental, health and safety regulatory and industry standards compliance

• Reducing costs by eliminating all waste, especially environmental wastes

• Growing revenues with green-attribute services and products, and

• Building intangible assets, such as competitive advantages, through organizational transparency.

Notice how John Elkington's triple-bottom-line CSR concept is integrated into this definition of sustainability. The triple bottom line is a true-cost-accounting concept that considers the full impact of business decisions in terms of ecological and social values, as well as economic value. It is also known as The Three P's of Corporate Responsibility, i.e., people, planet and profits.

What Does a Hospital Have to Do from a Management Perspective to Become Environmentally Sustainable?
Okay, let's get focused. If you talk to one expert, sustainability is all about facility design. Talk to others and you'll learn its all about energy, product and service lifecycle assessments, waste reduction/reuse/recycling (3R's), greenhouse gases (GHG), green information technology, green procurement, marketing, public relations, and on and on and on. Whew!

Who is right? Collectively, all of them; individually, none of them. So, beware when listening to "experts". Technical specialists tend to view broad disciplines, such as sustainability, in terms of their own narrowly defined professional subsets. There is nothing wrong with that. In fact, we expect specialists to have that kind of laser-like focus.

However, when an organization first starts working on sustainability, it needs to take a S.W.O.T. (pun intended) at determining all – not just a few – of its strengths, weaknesses, opportunities and threats. It can't do that well if it distracts itself by prematurely focusing on only a few specialty aspects of the discipline. The risks are missed opportunities, ineffectual efforts and wasted resources ending in the frustration of program failure.

Yes, there is a lot of specialties that need to be considered in a hospital sustainability program. Many of them are shown in Figure 2 (click on figure to enlarge). So, with all of these sustainability specialties, how does a hospital decide on which ones to work?

With the hospital's rapid-cycle continuous-improvement (CI) management system that links – a.k.a., hardwires – all of its strategic intentions to all of its operational and administrative activities, of course. You know, the one that enables the hospital to systematically:

• Define and prioritize its most pressing needs every fiscal quarter

• Design adequately-resourced projects to meet the highest-priority needs

• Assign and track accountabilities

• Measure project progress and, when necessary, take immediate and effective corrective actions, and

• Celebrate successes.

Uh-oh!  Sorry for bringing that up. Your hospital may not have an effective, highly structured, whole-house CI management system despite a flurry of clinical quality-improvement busy-ness.

In any case, in the next post let's look at what is needed to create a CI management system with a scope limited to sustainability. Who knows? You may end-up providing a good working model that can be expanded in scope to manage the institution in its entirety. That's because the best ideas are always stolen by others and eventually claimed as their own. It's called benchmarking.

IN THE NEXT POST:   A Rudimentary Model for a Sustainability Management System

Monday, August 16, 2010

Introduction to This Blog

It shouldn't be much of a surprise that leaders at your hospital may be thinking about going green. First, there's all of that au courant media coverage. Then, there is the fact that your institution is dedicated to making an altruistic difference in the lives of patients, staff, their families and the community.  It only makes sense for leaders to be thinking:

While we're at it, let's do something nice for ol' Mom Earth!

So goes the reasoning of:

• That shake-up-the-status-quo board member, who recently introduced a new green policy proposal

• The image-conscious executive, who just returned from a conference where s/he learned lots of brand-new green buzzwords, and/or

• The hopelessly quixotic department director, who is always leading the charge for the latest in trendy performance improvements.

Is Your Hospital Really Up for This?
However, somewhere in the recesses of your mind, red flags are a-flying and you are wondering: "Whoa! Haven't I seen these starry-eyed behaviors before?" Why, yes, you have.

Remember how excited everyone at the hospital was when each of those messianic gurus and snake-oil-salesmen promised:

“If you will only believe in my one magic secret-to-success, all your problems will disappear.”

Now, focus on these.

• Harken back to the fun you had during implementation of the electronic medical record system.

• Or, better yet, consider this hot potato: Are you still figuring out how to force-fit continuous-production-flow manufacturing methods into custom-work clinical environments?

Oh! And don't forget the never-ending stream of management-miracles, the flavors-of-the-month.

Ah! You're catching on. Going green involves more than just forming another free-range committee to set out on yet another idealistic journey to do green stuff and perhaps – no, make that probably – waste a lot of scarce resources along the way.

Going green is a major organizational change; it can be as difficult as those other recent whole-house transformation initiatives. Further, if it is truly an important change for your hospital, it can't be dismissed as just another flavor-of-the-month when the going gets tough. Face it now rather than later: The going will get tough!

IN THE NEXT POST: Management? We Don't Need No Stinkin' Management! Oops! Yes We Do.