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." (
http://www.hospitalsustainability.org/)

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.

Sunday, September 25, 2011

LIFECYCLE ASSESSMENT FOR HEALTHCARE ORGANIZATIONS – PART B

In the last post – which was the first of three on lifecycle assessments (LCA) in healthcare organizations – we examined basic concepts, applications and precautions.   Now, in this second post, we'll explore the initial steps for actually doing one by outlining processes to define the:
·     LCA project's scope, and
·     Product or service's lifecycle.

In the third LCA post we'll continue on to explore methods for:

·     Assessing the lifecycle's significant environmental impacts

·     Prescribing obviation and mitigation measures, and

·     Applying the LCA's findings and prescriptions through the environmental sustainability program's management system.

Are these methods the only way to do an LCA?  Of course not!  But, they are highly simplified processes well suited to first-timers who already have a bit of experience in solving complex organizational problems in clinical settings.  As mentioned in the last post, you'll be able to substitute more sophisticated methods for achieving more exacting results – if you ever need to – when you gain some experience. 

As you plod through these steps, you are going realize:
·     This is a lot of work
·     That's going to take a lot of time, and
·     Require the involvement of a lot of people. 

Is it really worth the bother?  It can be if you stick to examining your hospital's most inefficient value systems.  You know, those activities that produce its most significant and costly waste streams, like:

·     Facilities operation and maintenance, as well as environmental services in the janitorial sense of the phrase

·     Food service

·     Controlled-substances and other hazardous-materials management, and even

·     Clinical service lines, such as surgery.

If your hospital is on the bleeding-edge of sustainability, it can and probably will go it alone in conducting relatively simple LCA's.  Of course it will do this only when it really needs information to eliminate costs, efforts and risks to achieve specific strategic people-planet-and-profit objectives. 

But, think about this: 

Your hospital isn't unique in its conduct of basic clinical and administration activities.

Just about every other institution does the same things.  So, there must be essential process commonalities that just beg the question: 

"Aren't there better ways to share the load in creating the LCA information that eventually will become common industry knowledge leading to new best practices?"

Of course there are better ways to lighten the load – albeit long-term ones – that involve:

·     Teaming up with like-minded hospitals and other organizations in your region

·     Creating healthcare-system-wide LCA working groups

·     Becoming actively involved in purchasing-group sustainability programs like Premier's GreenLink® to lobby for and actively participate in the production of generic LCA's, and

·     Lobbying and materially supporting industry organizations such as Practice Greenhealth and Healthcare without Harm – perhaps in association with the Institute for Healthcare Improvement – to produce a series of generic LCA's.   

However, in the short term don't hold your breath.  Change in healthcare occurs on a glacial timeline, especially when yet another healthcare-system or industry-wide committee is formed.  By the time all the big-ego'd formin', stormin', normin' and performin' issues get resolved, your hospital can become an industry leader by going ahead and completing a few LCA's in-house. 

So, resign yourself to the fact that you'll be doing your own LCA's – or maybe even contracting them out – for a while.  Despite the required effort and expense, there is a huge advantage in going-it-alone.  Your hospital will be providing the industry's LCA benchmarks.  Nice, eh?

That said, there's no time like the present.  Let's get started . . .


STEP ONE:  DEFINE THE LCA PROJECT'S SCOPE
Before starting any organizational-management project, like an LCA, it is critical that the work scope be formally defined to set clear boundaries around the effort.  Internal and external stakeholders need to know what will be included and excluded in the assessment effort by:

·     Clearly defining the focus, range and boundaries of work efforts

·     Fostering realistic expectations for such things as levels-of-effort and utility of assessment results, and

·     Creating a means to avoid resource-wasting project-scope-creep. 

As you read the project-scope topics listed below you'll likely realize they are really just a bunch of fill-in-the-blanks items.  Therefore, they are well suited to a standardized form, like the one shown on Figure 10.  (Click on figure to enlarge or download the original document at:  https://docs.google.com/leaf?id=0B-43ksRRuoFQMjA2OTU2MjgtZmVkOC00YzY5LWI2ZTUtZmRkYTMxZjk2NzBm&hl=en_US ) 

When completed, such a form should be no more than two pages in length to keep things simple.  If you use small fonts, you might even be able to squeeze everything down to one page.  
FIGURE 10
TEMPLATE FOR A LIFECYCLE ASSESSMENT PROJECT PLAN COVER SHEET


The first parts of the form present the project in its most basic terms:

·     Project title, including identification of the specific product or service to be assessed

·     The names of the responsible executive, project manager and project team members

·     A problem statement – preferably based on a formal root-cause analysis, like an Ishikawa diagram  – that provides the rationale for doing this particular LCA as an important step in:
o    Creating an important new organizational capability or
o    Resolving a significant performance issue

·     A clear statement of LCA goals and other success criteria to resolve the problem statement 

·     A brief explanation of the consequences to the organization if the LCA is not completed successfully – (Note:  Project success is defined in terms of the triple constraints of performance quality, schedule and budget. So, what does it mean to the organization if the LCA goals are not met, the project's performance-quality standards are not observed, the schedule is overrun, or the budget is blown?)  

·     A temporal list of major progress-evaluation requirements, including the LCA completion date, and

·     A list of any related past, current or future projects because you don't want to be reinventing the wheel and you don't want anyone else wasting their time either. 

The rest of the form adds analytical detail to the LCA work scope by:

·     Listing the major lifecycle phases for the product's or service's value system that will be assessed in this LCA – (Note:  This is an important consideration.  When you see just how complex a LCA can be in the next post, limiting the lifecycle phases at first might be a useful project-scoping tactic.)

·     Identifying the specific internal and external stakeholders in each lifecycle phase, and

·     Mandating the required degree of analytical specificity, i.e., broad in a management planning sense or highly detailed in a scientific or engineering sense.


STEP TWO:  DEFINE THE PRODUCT OR SERVICE'S LIFECYCLE
The lifecycle for a particular product or service is defined in this step by producing a value-system flowchart and populating it with appropriate work-process information on inputs, input-transforming-work, and outputs and/or outcomes for each lifecycle phase.
 

Step 2-A:  Produce a Basic LCA Flowchart for the Targeted Value System
As with all kinds of contemporary work-process assessment techniques based on continuous-improvement methods – such as TQM, Japanese Union of Scientists and Engineers (J.U.S.E.), Toyota Lean and six sigma – LCA requires the graphic definition of a proposed or actual work process.  That is, a lifecycle needs to be illustrated in a format such as a process diagram, decision tree or flowchart.   What makes LCA diagrams unique is the addition of two new dimensions:
·     A closed-loop view of an entire value system and
·     Inclusion of all phases of that value system's lifecycle(s).  

Using the phases shown in the previous post on Figure 9, Figure 11 provides a template for defining a closed-loop value system's lifecycle.  (Click on figure to enlarge or download the original document at:  https://docs.google.com/leaf?id=0B-43ksRRuoFQNGQ5MjYzZjAtY2RlMy00MmNlLWE2YzktZDUwNjRlNDMzODc5&hl=en_US )  Note that each lifecycle phase has, as does any work process:
·     Inputs
·     Input-transforming work activities, and
·     Outputs or outcomes, including waste production.

FIGURE 11
TEMPLATE FOR
A CLOSED-LOOP LIFECYCLE ASSESSMENT OF A VALUE SYSTEM


Then, notice that the outputs or outcomes from each lifecycle phase serve as inputs to the next phase.  Because each phase also produces various kinds of waste, note the how wastes are controlled by closing the value-system loop. 

Some products and services may have different lifecycle phases than those shown on Figure 11.  Therefore, this template may require modification through additions, deletions and relabeling to fit your particular situation.  Also, as you can see from this basic template, even a simple LCA is structurally complex.  Therefore, as you amend the template, you need to carefully to apply the KISS principle.


Step 2-B:  Populate the LCA Flowchart with Product or Service-Related Operations Information
With the LCA flowchart template intact or amended, specific information on the targeted product or service needs to be added in preparation for the subsequent impact assessment steps.  This information will be used to identify and analyze those factors that have the potential to adversely affect or be affected by various environmental conditions. 

Please note that although the LCA flowchart template is sequential, you will probably not want to start filling-in information in the first phase and working down from there.  Why?  Because you're not that familiar with the first lifecycle phase.  So, start with the phase you are most familiar, Ongoing Production and/or Service Delivery with Associated Logistics.  Then, move upstream and downstream to complete the other value system phases with which you are most familiar.  You'll make faster progress this way.

Okay, let's take a look at the kinds information needed to populate the flowchart template.

·     Inputs – Essential inputs to a work process phase may include:
o        Labor
o        Information
o        Equipment, materials and supplies, including energy and water
o        Vendor services, and
o        Space.

Simply list the types, quantities and costs of each LCA phase's inputs in the appropriate "inputs" boxes.  It shouldn't be too difficult to figure out, though, that this much information may not fit in the available space.  So, provide adequate cross-references to supporting documentation when necessary. 

·     Input-Transforming Work Activities – As Philip Crosby was fond of preaching, "all work is a process".  Not surprising, the information listed on this part of the flowchart is the work-process steps each stakeholder organization takes to complete its particular phase of the value system. 

These steps come directly from the standard operating procedure (SOP) documentation an organization uses define and control its production and service delivery processes.  Armed with this information, you simply list a high-level summary of the work-process steps in the appropriate "work activities" boxes for each LCA phase.

This can be fairly easy for upstream suppliers in a hospital value system because they tend to be the producers of equipment and supplies.  These producers have long been adept at thoroughly documenting their work processes for quality-control and regulatory-compliance purposes. 

However, in many healthcare delivery organizations there is a potential for difficulty in providing such work-process information.  The difficulty is this: 

Far too few routine service delivery processes are documented with sufficient clarity and detail to be useful in LCA's.

Therefore, a bit of extra effort may be needed to adequately define the sequence of activities in a hospital's service-delivery processes.  This won't be a wasted effort, however.  Such information is also useful in clinical and administration performance-improvement efforts. 

·     Outputs and Outcomes to the Input-Transforming Work Activities – Outputs and outcomes to input-transforming work activities for the various LCA phases typically consist of: 
o    Products
o    Successfully provided services, and
o    Wastes, including financial, solid, hazardous, gaseous, aqueous and energy wastes.

To define the outputs and outcomes for each lifecycle phase simply identify, characterize and quantify each product, service and waste resulting from the work activities.

Now, let's take a look at a LCA flowchart that has been populated with such information.  Figure 12 shows two phases from an actual LCA flowchart for mobile field hospital structures used by militaries and emergency-response agencies around the world.  (Click on figure to enlarge or download the original document at:  https://docs.google.com/leaf?id=0B-43ksRRuoFQYWE5Y2JjN2QtZGM2NC00YjEwLWJiMjItNjY1ZWU5Y2JkYTg3&hl=en_US )   It is important to point out that the names of the lifecycle phases in the figure have been modified to fit the particular activities associated with the manufacture, transport, use and end-of-design-life for this product.  (Note:  The LCA for which the Figure 12 flowchart was developed following Canadian Department of National Defense guidelines.)

Also, notice how the descriptions on the flowchart are extremely general consistent with the KISS principle.  Later, when we explore impact assessment and management methods you'll see where the voluminous details are finally considered.
 

FIGURE 12
EXAMPLES OF PHASED WORK-PROCESS ACTIVITIES FROM
AN ACTUAL LIFECYCLE FLOWCHART


oOo

CONCLUSION
In this post we've used both environmental sustainability and industrial engineering's continuous-improvement (CI) concepts and methods to:
·     Scope an LCA project, and
·     Define and illustrate the activities in a value system's closed-loop lifecycle.

IN THE NEXT POST:   ASSESSING, OBVIATING AND MITIGATING LCA IMPACTS
We'll build on this work in the next post to identify, assess and obviate or mitigate adverse changes in defined lifecycles.  Then, we'll conclude the discussion with an exploration of ways to use the LCA's actionable information to make sound management decisions via a hospital's overall CI-based environmental sustainability program.

Wednesday, August 17, 2011

LIFECYCLE ASSESSMENT FOR HEALTHCARE ORGANIZATIONS: PART A

The last 10 posts addressed the design, implementation and operation of a systematic environmental sustainability program for healthcare and other organizations.  However, this post – while continuing to emphasize systematic approaches – shifts the blog's focus to advanced needs-assessment and problem-solving methods starting with the critically important environmental sustainability concept of lifecycle assessment (LCA). 

Basic LCA concepts and applications are discussed in this post.  In the next two posts, rudimentary step-by-step methods will be described so that readers will actually be able to start using this invaluable analytical tool.    

Among the various environmental sustainability needs-assessment and problem-solving techniques, LCA is one of the more thorough methods for identifying opportunities-for-improvement (OFI – pronounced "oh-fee").   Even though it relies to a degree on technical analyses, its ultimate goal is to drive all wastes – financial, social and environmental – out of an organization's activities.  As such in a business context, LCA is primarily an organizational management tool that helps:

  • Increase operational and administrative efficiencies, thereby reducing costs, efforts and risks, and

  • Incorporate green and social-benefit attributes into existing and new products and services, thereby enhancing customer loyalty and attracting new customers in support of revenue growth. 


WHAT IS LIFECYCLE ASSESSMENT AND HOW DOES IT FIT INTO CONVENTIONAL MANAGEMENT CONCEPTS?
Why is LCA important?  Think of it as the conceptual cradle-to-cradle – i.e., closed-loop – framework for all environmental sustainability efforts.  At its simplest:

LCA identifies all of the possible adverse environmental impacts of resource inputs, work activities, and outcomes or outputs at every step in a product or service's value chain.

With this information, an organization can then obviate or mitigate adverse environmental impacts to reduce its operating and administrative inefficiencies in terms of costs, efforts and risks. 

The LCA concept grows in importance for an organization over time.  Here's why:  when an environmental sustainability program is first started, it's easy to just work on those activities touted by the various green-advocacy organizations, like:
  • Energy conservation improvements and greenhouse-gas (GHG) reduction tracking
  • Better controls on solid and hazardous waste management, and
  • The greening of the procurement process. 

However, once these "low-hanging-fruit" issues are under control, it may be difficult for an organization like a hospital to identify its own unique OFI's.  This is where various needs-assessment methods, especially LCA, become increasingly important in finding less-than-obvious opportunities.   


LCA's Hybrid OriginsWhere did the LCA idea come from?  Although it has engineering and scientific features arising out of the environmental impact assessment disciplines, it is equally rooted in basic business management and industrial engineering concepts starting with supply-chain and value-system management. 

Let's look at its origins by defining a basic business and logistics management idea, supply chains.  A supply chain involves:

The movement and storage of raw materials, work-in-process inventory and finished goods from point of origin to point of consumption.

Did you notice how this definition of supply chain stops at the point of consumption?  That's not very sustainable, is it?  You're right!  It's missing the reverse-logistics element!

(Definition:  Reverse logistics is the discipline of planning, implementing, and controlling the efficient flow of materials, production inventory, finished goods and related information from the point of consumption to the point of origin for the purpose of recapturing value or proper disposal.)

Well, as you might imagine, such conceptual limitations have inspired others to expand the supply chain idea.  For example, Harvard professor Michael Porter expanded it in these paraphrased terms by introducing the idea of value systems: 

A value system includes all of the supply chains of an organization's suppliers, the organization itself, the organization's distribution channels, and the organization's downstream buyers and so on until the product or service has reached the end of its useful life.

As products – as well as services – pass through all sourcing, production and distribution activities in order, they should gain some value.

Further, it's through this idea of value systems that value-engineering methods arose.  Value engineering is a body of operations management and industrial engineering techniques that identifies and removes unnecessary expenditures, thereby increasing value for producers and their customers.  The basic idea of value engineering is this:

For every dollar put into production and/or service delivery, the organization should have more product and/or service capacity to sell by eliminating waste.

It's not too hard, then, to understand that each activity in a value system presents significant risks to the desired achievement of value gain.  In standard value engineering terms, the risks that diminish or prevent value gains include: 
·     Delays
·     Mistakes
·     Defects
·     Waste, including financial, solid, hazardous, gaseous, aqueous and energy wastes
·     Work-arounds and rework, which are two rather insidious forms of waste in healthcare settings
·     Accidents, and
·     Negligence.

For readers who have been exposed to continuous-improvement problem solving – including Deming, Japanese Union of Scientists and Engineers (JUSE), Toyota Lean, and six-sigma methods – these risk factors should sound familiar.  At their hearts, these interrelated methods strive to get this kind of "junk" out of all work processes.  In regard to value systems, just think of them as big complex work processes that collect a lot of junk over time.   


What LCA Adds to Supply Chain and Value-System ConceptsFor the purposes of environmental sustainability, though, the LCA concept enhances the value system concept with these three additional dimensions:

·     The first dimension, as noted above, is the explicit inclusion of solid, hazardous, gaseous, aqueous and energy wastes on the list of junk to be eradicated.  These wastes are significant because they are the primary casual agents of many adverse environmental impacts.   

·     The second dimension is a clear focus on the upstream, current and downstream lifecycle phases like those shown on Figure 9.  (Click on figure to enlarge.)  Effective management of lifecycle phases generally offers several environmental advantages.  Here are two of the primary ones.
 
  • By influencing upstream suppliers to become more sustainable, an organization may create specific opportunities for lower production and service-delivery costs.

  • Likewise, specific opportunities may arise by influencing downstream product and service users and end-of-design-life reverse-logistics agents to reduce corporate risks and their associated costs. 

·     And, the third dimension is recognition that all value-chains must be closed-looped through effective use of the 3-R concepts to manage wastes in every lifecycle phase by reducing, reusing, and recycling.
  



So, as you can see, LCA may be regarded as the most fully evolved set of considerations in value system management.  As such, LCA provides a core organizational management incentive for environmental sustainability program development, i.e.: 

LCA provides the closed-loop production and service-delivery framework spanning a product or service's entire lifecycle within which an organization may achieve its objectives with least cost, effort and risk.


SIMPLICITY IS A VIRTUE WITH LCA
If you haven't figured it out, yet, the field of environmental sustainability is in its "Wild West" developmental stage and this is not an exclusive issue in healthcare.  There are nearly as many approaches to the field's needs-assessment and problem-solving methods as there are buzzwords, starry-eyed acolytes and starving consultants.  As you might imagine, some approaches are right-on-the-mark while others are . . . well, you get the idea. 

It's amazing how complicated LCA can become even in its simplest forms, if you let it.   So, be forewarned.  It's really easy with LCA to fall into that old healthcare trap of paralysis-by-analysis.  Remember, the KISS principle is critical to your success and sanity when first starting to do LCA's.  Please, for your own sake and the sake of your coworkers, keep it simple, stupid!   

To help you keep things simple, explanations of LCA methods in this blog eschew highly advanced industrial engineering approaches, such as one described in ISO 14040:2006 and 14044:2006.  Rather than decode these ISO standards, we'll just focus on LCA's most elementary concepts and processes. 

This, of course, is important for those of you who are new to the sustainability game.  Later, when you've got several LCA's to your credit, you can get fancy . . .  if you ever need to. 

Keep in mind that you may never need to employ some of the more complex, highly quantified methods.  Here's why:  what you are trying to produce with an LCA is merely actionable decision-making information.  This information is used to:

·     Support the organization's sustainability and other policies
 
·     Provide a rational basis for operational and administrative sustainability initiatives, and

·     Improve organizational performance from a sustainability perspective.

Simple LCA methods, like the ones that will be described in the next post, produce such information quite well, especially in healthcare-delivery organizations.  Here's why this is important.  Unlike manufacturing organizations where rigidly defined and controlled production activities are repeated with predictable precision thousands of times a day, healthcare delivery organizations are quite different. 

Granted, hospitals have numerous well defined and controlled work processes, especially in the ancillary services such as laboratory services and pharmacies.  However, bedside clinicians frequently use complex – and often poorly defined and communicated – decision-tree methods that are based as much on science as experiential preference – and, dare I suggest it, informed intuition – to provide custom-designed care plans for their patients. 

So, to demand industrial engineering precision in the application of LCA methods on loosely defined and controlled work processes in clinical environments may not always be a desirable or even realistic expectation.


IN THE NEXT POST:   A SANDBOX APPROACH TO LCA METHODS
In the next two posts we'll delve into the rudimentary methods of LCA.  In the first of these posts we'll examine on a step-by-step basis:
·     Scoping an LCA, and 
·     Defining a product or service lifecycle

Then, in the second post we'll explore:

·     Impact assessment methods

·     Obviation and mitigation prescriptions, and

·     LCA findings and prescriptions as inputs to the environmental sustainability program's management system.




Sunday, March 20, 2011

THE SECOND LINKAGE STEP: A SUSTAINABILITY PROGRAM MANAGEMENT PROCESS

I would love to say this is the wittiest, most lively post to date.  But, I can't.  As a process description, this post has as much liveliness as an engineering specification.  That said, though, like any well done engineering spec, it is indispensable.  So, suck-it-up and just wade on in.  Some of the most important ideas for creating a hospital sustainability program are lurking in here. 

oOo

In the last post we examined the details of a possible organization-structure template for a hospital sustainability program.  Now, let's look at how all of the policies, plans, people and projects discussed so far might fit together in a fast-track, continuous-improvement (CI) management process. 

I say "might" because even though I have successfully applied the process illustrated in Figure 8 – including the design and implementation of the United States Marine Corps Base Camp Pendleton's first benchmark environmental management system – each healthcare institution needs to custom-design its own program management process.  (Click on the figure to enlarge.)  Remember, what makes perfect sense at one institution may not at another.

FIGURE 8
A RUDIMENTARY SUSTAINABILITY PROGRAM
MANAGEMENT PROCESS


LINKING STRATEGIC INTENTIONS TO ADMINISTRATIVE AND OPERATIONAL ACTIVITIES:  PART 2
The October 20, 2010 post discussed the first step in linking strategic intentions to administrative and operational activities.  That step is the definition of the hospital's sustainability tactics.  As noted in that post, there is a second complementary linkage step:  the design and successful completion of capacity-creation and performance-improvement projects by specific administrative and operating units, as well as cross-functional teams.  This post describes one of many possible systematic approaches to the second linkage step.  
   

OVERVIEW OF A STRAWMAN PROGRAM MANAGEMENT PROCESS 
As with so many of the suggestions in this blog, Figure 8 is offered only as a strawman that can be disassembled and rebuilt to meet the specific needs of individual organizations.  So, after answering the 10 sets of rudimentary sustainability management system questions from the August 18, 2010 post, a hospital needs to modify Figure 8 through additions, deletions and resequencing.

In case you are wondering how this post differs from the August 18th one – i.e., A Rudimentary Model for a Sustainability Management System – that post posed essential design questions for a sustainability program.  Whereas, this post shows how some organizations have answered such questions to define their programs' management work processes. 

Figure 8 illustrates answers – at least partially – to the 10 sets of design questions in a flow diagram format.  In this layout it is fairly easy to see the work process's underlying four-part structure.

           Inputs – Elements 1 through 7 provide the process's inputs

           Input-Transforming Work – Element 8 is the work that creates new sustainability capabilities and/or resolves performance issues

           Outcomes/Outputs – Element 9 reviews the efficacy of the work-activities, and

           Process Restart – Element 10 restarts the iterative process in consideration of work outcomes and outputs, as well as lessons-learned. 

O.K., it's quiz time.  Where have you seen a four-part work process like this before?  That's right!  It's Shewhart's Plan/Do/Check/Act (PDCA) Cycle expressed in slightly different old-school industrial engineering terms!  

Because it is anchored in the PDCA concept, this CI sustainability management process model is fully compatible with any total quality management (TQM), Lean or six-sigma methods your institution is currently using.  Isn't that a relief?  Rather than replace anything you are currently doing, this process model complements and builds on your institution's more progressive management methods. 


PROCESS ELEMENT FUNCTIONS  
Using the PDCA-based structure discussed above, let's consider how each of the 10 elements in Figure 8 function to provide a fast-track, closed-loop sustainability program management process.  Please note that the references below to "Elements" pertain to the activities shown on Figure 8, whereas the references to "Question Sets" pertain to the 10 sets of rudimentary sustainability management system questions in the August 18, 2010 post.


Inputs 
As the PDCA-cycle Plan Steps, the first seven process elements shown on Figure 8 are critical for creating the overall program and defining an institution's most-pressing sustainability needs.  They also provide the means to design capacity-creation and performance-improvement projects, as well as assign accountabilities for successfully completing those projects.  While some of the elements focus on longer-term strategic and tactical tasks, others deal with shorter-term – i.e., quarterly – activities to assure rapid-cycle responses to an institution's most-pressing needs. 

           Element 1:  Creating the Sustainability Program and Assuring Executive Buy-In (See Question Set 1) Senior leadership – i.e., the Board of Directors and the Chief Executive Officer – mandate the definition of the sustainability program's strategic objectives, tactical goals, corporate policies and standard operating procedures. 

           Element 2:  Setting Near-Term Organizational Priorities for Sustainability (See Question Set 2) The Sustainability Program Oversight Group identifies the sustainability strategic objectives and tactical goals that need to be implemented during the next fiscal quarter.  Refer to the December 31, 2010 post for details on the oversight group's composition and activities. 

           Element 3:  Sensing Organizational Sustainability Performance (See Question Set 3) The corporate decision-support function collects and analyzes enterprise and unit-level poor sustainability performance data and information for each of the sustainability topics shown both on Figure 2 in the August 17, 2010 post and Figure 8, above. 

           Element 4:  Creating the Sustainability Program's Shared-Governance Function (See Question Set 4) The Sustainability Program Oversight Group creates and staffs a green team for each sustainability topic shown on both Figure 2 in the August 17, 2010 post and Figure 8, above.  Refer to the December 31, 2010 post for details on green team composition and activities. 

           Element 5:  Producing and Distributing Goals-and-Issues Lists to Green Teams (See Question Set 5) Each fiscal quarter the corporate decision support function sends a “goals-and-issues” list for each sustainability topic to its responsible green team.

           Element 6:  Prioritizing the Organization's Most Pressing Sustainability Needs and Prescribing Sustainability Project Goals and Accountabilities (See Question Set 6) Each green team produces a short-list of the institution's most-pressing needs for its particular sustainability topic.  Then, for each of these needs it sets a measurable performance goal and project completion date.   Lastly, it identifies the best-suited administrative or operating units or cross-function team to achieve the goal.

           Element 7:  Initiating Projects to Achieve Sustainability Goals (See Question Set 7) Each green team forwards its project proposals to the Sustainability Program Oversight Group for final selection and formal assignment of project design and completion accountabilities for the next fiscal quarter.  Then, the responsible green team provides project design and oversight support to the accountable operating or administrative unit or cross-function team.   Under the green team's guidance, the accountable unit or team designs its capacity-creation or performance-improvement project.


Input-Transforming Work As the PDCA-cycle Do Step, Element 8 in Figure 8 is where projects are completed to achieve the sustainability project goals set in Element 6.  
 
           Element 8:  Completing and Supporting Projects (Question Set 8)  The project work is undertaken, actively managed and completed by the accountable unit or team in accordance with the project plan.

Outcomes/Outputs As parts of both the PDCA Check and Act Steps, Element 9 is a key function in actively managing sustainability project performance.  It is the process's primary programmatic monitoring activity wherein variances and non-conformances to project plans are detected and effective corrective actions are implemented to assure achievement of project goals. 

           Element 9:  Assessing Project and Program Progress (Question Set 9) At the end of each fiscal quarter the Sustainability Program Oversight Group assesses the success or failure of each project.  That is the Check part of the element.  Then, moving on to the Act part, successes are celebrated.  However, in the case of project failures, the root causes are determined and corrective actions are defined and mandated.  Lessons-learned are shared with internal and external stakeholders, as are other other transparency concerns.


Process Restart Element 10 completes the PDCA Act Step.
  
           Element 10:  Sustaining the Program (Question Set 10) Once Element 9's activities are completed, the information on project successes, failures, corrective-action mandates and lessons-learned are linked through Element 10 to the corporate decision support function's activities in Element 3.  The project failures, corrective-action mandates and adverse lessons-learned are then included in the decision support function's activities to identify new sustainability needs.  Also, although not shown on Figure 8, Element 9 periodically links back through Element 10 to Element 1 to assist in future sustainability strategy and tactics planning activities.

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With this post, the basic approach to creating a hospital sustainability program is complete.  The next several posts will examine the details of an essential sustainability program analytical technique, lifecycle assessment (LCA).

 
In the Next Post:  Lifecycle Assessment for Healthcare Organizations