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.

Sunday, September 25, 2011


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 . . .

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.  

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.

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.


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.



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.

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.