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Some Thoughts on Healthcare Sustainability, Part II

Posted on May 20th, 2016 in Uncategorized | No Comments »

As promised, I have more to say about the issues facing the soon-to-be UCOP Associate Director of Sustainability (ADS) in their quest to “green the Medical Centers”.  Since the posting of Part I, I’ve learned that our Facilities Planning and Development Director, Joel Swift, will be on the interview panel, vetting ADS candidates.  Very cool.  Joel sits at that intersection of innovative and practical, and will be a good addition to the panel.

In my initial post, I talked about the fight for dollars in the healthcare environment, oversight agencies, student support (or lack thereof), Champions, and Zero Waste.  Let’s see what else we in healthcare, and, by association, the soon-to-be ADS (s-t-b ADS? Nah.), have to deal with.  Note: those who’ve read my older blogs know that I dangle participles at will, and I figure that I’m too old to change now.

Let’s consider sustainable purchasing.  I’ve always found this interesting, as the UC Sustainable Practices Policy seems to treat sustainable purchasing as more like something done at UCOP, like within Strategic Sourcing, rather than amongst the campuses and med centers.  Regardless, this is a tough nut to crack, on a number of levels.  Following are a couple of examples.

First off, a few years ago the UCDMC Linen Efficiency Workgroup conspired to replace most of the single-use surgical linens with reusable items.  We worked with perioperative folks and the vendor to see how good service could be provided at a reasonable cost.  I had to laugh when talking with surgery veterans, who noted that they had reusable linens up to 10 or 12 years ago, when the Med Center was convinced to move to disposables.  So we thought that we had it all sewn up, with the reusable vendor matching the price and product quality of the disposable vendor.  Very cool!  But not to be, for the disposable vendor, Kimberly-Clark, provided a $250K annual incentive payment through our group purchasing body, Novation.  Putting the incentive loss on top of the reusable pricing killed the project.  I find it interesting that Novation paints itself as very green, but its member vendors pull anti-sustainability stunts such as this one.

Second example: sustainable purchasing embraces returnable/reusable packaging, a great waste diversion component.  And lots of pharmaceuticals, being heat sensitive, are shipped in Styrofoam containers.  Well, hey, let’s return those to the vendors!  Not so fast.  The US Food and Drug Administration prohibits the reuse of such containers.  Drat!

Multiply those two examples by a lot, and you’ll see that cost-containment can really knock the wind out of environmentally-preferable purchasing efforts.  As sustainable purchasing efforts scale up, the pursuit of them in healthcare should become more commonplace, but, for now, it’s difficult.

I do want to highlight a recent “win” in the sustainable purchasing arena.  Following UCLA’s lead, UCDMC is finally rolling out reusable isolation gowns to replace disposable gowns.  I say finally because we first started looking at this several years ago when my Grad Student Researcher, Joanne, was still here.  When her term ended, Troy Taylor, a manager in Materiel Mgmt, kept the ball rolling, pushing here and there to get the program trialed.  Troy recently told me that full program roll-out was almost complete.  Sometimes we have victories, and much credit goes to Troy for persevering for this one.

How about alternative transportation?  Many campuses report significant reductions in SOV (single occupant vehicle) use via Alt Trans programs.  Just go over to the Davis campus at 9 AM to get completely swarmed by bicyclists; it’s amazing.  But to get this going in a hospital environment takes a lot of doing.  Consider all of the doctors, nurses and staff involved in direct patient care. It’s 24/7/365, and people are always changing shifts around.  Note also that most acute care nurses work 3-12s.  That doesn’t help carpools and vanpools.  Some units won’t let a staff member tweak their schedule by 30 minutes to accommodate a ridesharing opportunity.  Our Alt Trans coordinator, Sarah Janus, is an outreach all-star, working her keister off to get people into her programs.  It’s a lot of work, and she earns every new participant.

Sometimes it’s just a location issue that sideswipes the alt trans effort.  We have really good transportation within the 140 acre medical center, but it gets flaky once you leave the facility.  Only one bus line serves the (main) west side of the campus, and it’s hourly.  And it’s a shuttle ride or a ½ mile walk to light rail.  So if you can’t ride share, it’s tough to use alt trans.  Much different in San Francisco, where alt trans is almost a residency requirement.

The California drought and water conservation has been in the news a lot over the past several years.  UC has a Water Working Group that, while campus-centric, tries to include the medical centers.  Once again, healthcare looks at water use differently.  Infection prevention and sanitation are huge in the hospital.  Due to infection prevention concerns, aerators can’t be used on faucets, making low-flow a challenge.  However, many of our floor cleaning processes are water-free or use minimal water, so efforts are being made.  Lots of water is used when surgery staff scrubs in, and we can’t readily change that.  However, the larger issue, shared with campuses, is cost. Unless you do retrofits that are associated with a rebate, cost recovery takes many years due to the low cost of water, and funding projects with long ROI terms is not a priority.

We also work at minimizing irrigation use.  Some med centers have little in the way of turf areas; I think we have about 20 acres or so.  We can’t just stop watering the turf, as there is dust generation from dead turf, and that can create an infection prevention problem.  We can take the turf up, but then it has to be replaced with something, and that costs money.  We could have a better irrigation control system, but the cost is prohibitive.  And even tracking/measuring water use is difficult, as many locations are on a loop, with buildings not being individually metered.  Reducing water use is difficult, in some ways due to healthcare issues, and in others due to the challenges facing all UC locations.

I’ll wrap this up with some perspectives on green building and energy efficiency in healthcare.  Current UC policy exempts acute care facilities from the requirement for LEED certification.  However, both UCSFMC and UCSDMC have recently certified new hospital buildings, albeit under older, less stringent LEED certification systems.  LEED for Healthcare v4 is going to be a bear.  At this writing, there are only two Healthcare v4 hospital projects underway nationwide, one in New York, and one in Maryland.  I would imagine that, as with everything else associated with v4, everybody is scrambling to register under v3 before it times out this Halloween.  There are 12 hospitals in California either in progress or certified under New Construction; of these, three are v3 and the remainder LEED 2.2 (a relatively low bar).

Certifying acute care facilities in California is particularly onerous due to one State agency: OSHPD, mentioned in Part I.  We have four LEED projects underway, and all are doing well in Energy and Atmosphere due to 2013 Title 24 requirements.  This wouldn’t be the case with a hospital, as OSHPD isn’t held to Title 24.  LEDs are foreign to them, as are occupancy controls.  One wouldn’t even bother with Savings by Design, as the floor for SBD is 10% better than Title 24.  And that’s just one credit element.  Water Efficiency would be similarly elusive.  For many systems, finding a balance between LEED credits and OSHPD buy-in will be nerve-wracking.  I would certainly suggest that before UCOP sustainability policy requires LEED certification for acute care projects that the counsel of the five med center campus architects be obtained, as OSHPD realities definitely are an impediment to LEED success.

Hmmm.  I said I’d be wrapping it up, but I’ve not addressed Climate Protection Practices.  I’ll keep it brief.  Regarding the UC Carbon Neutrality Initiative to be carbon-neutral by 2025 and its application to medical centers: you’ve got to be kidding.

So, Ms/Mr ADS, there you have it.  And that’s just a “scratching the surface” intro.  There’s more, lots more, starting with the lack of a central focus on healthcare sustainability.  But I digress.

May The Force be with you.

Some Thoughts on Healthcare Sustainability, Part I

Posted on May 5th, 2016 in Uncategorized | No Comments »

Now that I’m coming back to blogging, I find myself inspired to write about overall program issues. This is encouraged by the announcement that UCOP is recruiting an Associate Director of Sustainability (ADS), who will be charged with, among other things, pursuing zero waste, sustainable purchasing, and “greening UC’s medical centers”.  Reality is that the position description contains an intensive laundry list of duties, with these three items among them.  Some iteration of “greening the medical centers” is mentioned several times, but no other detail is offered.  To my mind, greening healthcare is quite a bit different than greening a campus, so following are tips, opinions, guidelines and warning signs for the successful applicant (referred to hereafter as “ADS”).

First, and foremost, if the ADS does not have significant experience in healthcare sustainability, it’ll be a tough road ahead. Healthcare is different, period.  Even if all five UC Med Center Leadership teams loved sustainability, the fight for dollars and support wouldn’t be easy, as there are so many worthy competing interests.  Effective patient care is far and away Job One, and if an initiative doesn’t directly support patient care, one will have to be extremely creative for it to get any traction.  State-of-the-Art imaging equipment or energy-efficient chiller?  Guess which wins.  (And good luck finding an EnergyStar-rated MRI machine)

Patient care has many unindicted co-conspirators associated with reimbursement and regulatory arenas, and none of them have shown any interest in sustainability (well, it’s not their role). Unique to California is the Office of Statewide Health Planning and Development, OSHPD (pronounced OSH-Pod).  In general, acute care buildings are regulated by OSHPD.  OSHPD unintentionally makes energy efficiency very, very challenging.  They don’t mean to, but, for example, if the regulation says “20 air changes per hour”, good luck getting that reduced, regardless of the circumstances.  OSHPD trumps Title 24, so all the cool lighting and energy requirements of that code are irrelevant.

Centers for Medicare & Medicaid Services (CMS) provides reimbursement for healthcare services under those programs, representing a significant revenue stream for most healthcare entities. Periodic evaluations of entities receiving these funds are conducted (typically) by The Joint Commission, which is known for wielding a fine-toothed comb.  I once tried to set up collection areas for discarded medical supplies, such as those from broken kits, for MedShare collection.  The nursing director for the area felt that this would cause a quandary for TJC, so the collection was quashed.  Such examples are not atypical. TJC comes around every three years, and for six months prior to the anticipated (unannounced) inspection period, all other initiatives fall by the wayside in favor of preparation for the visit. Joint Commission accreditation is very important, so, as one might imagine, introducing a sustainability initiative during this time is, at best, counterproductive.

There are other agencies and inspectors unique to the healthcare setting which underscore what I said in the second paragraph: patient care is Job One, and all of these groups are tasked with making sure that we bat close to 1.000 on patient safety. It’s really hard to argue with that, and, at the same time, it’s challenging to promote sustainability unless you can tie it to patient safety or similar pursuits.

Once the ADS accepts these realities, we can talk about good guidelines for healthcare sustainability. While sometimes it seems a little hopeful, Practice Greenhealth is clearly the to-go in this area, with great model programs, historical data, and similar.  A robust awards program recognizes those who are constantly moving forward.  For the UC system, the San Francisco Medical Center gets the brass ring here.  The position description mentions the Healthier Hospitals Initiative (attempted at UCDMC, but faded), which has now been incorporated into Practice Greenhealth.  Practice Greenhealth also promotes the premier healthcare sustainability conference, CleanMed.

Central to the sustainability effort is what the medical centers don’t have: undergrads. I’ve always been of the impression that every September when the campuses get an infusion of new students, at least 20% of them are willing to dumpster dive and similar.  They’ll protest if things aren’t green enough, boycott food service functions that use Styrofoam, lobby for more bike parking.  Sustainability programs can be labor intensive, and students can be had pretty cheaply, particularly if they can get credits, too.

Medical Centers have medical students, dental students, nursing students, all involved in professional studies. They are busy, and can rarely be bought.  Once in a while, they emerge, help out, then fade back into study mode.  A group of med students at UCDMC pushed the Dean to eliminate Styrofoam serveware in the cafeterias, and it worked (it wasn’t cheap then, and it remains expensive now); if not for their effort, we’d likely still be eating off Styrofoam.  But that was a one-trick pony; I’m glad they did it, but haven’t heard any stirrings since.  Could be different at other UC professional schools, but this crowd is working hard to move toward their challenging professions, so there can’t be any ill will towards them.

Since we don’t have many sustainable students, we can look to what I refer to as “Champions”. Champions are staff members who, for whatever reason, are innately Green.  Many will use their personal time to push sustainability initiatives, and I’m grateful for them.  However, as I’ll discuss in a future post, Champions tend not to stay around forever, and, typically, when a Champion retires or transfers, no one steps up to take their place.  It’s hard to keep programs going under these conditions.

There’s a lot to talk about here, so I think I’ll make this a two-parter. I’ll conclude this one with some thoughts on Zero Waste and how it doesn’t apply to healthcare.

I found a waste management blog that I drafted, but didn’t post, a few years ago. Things haven’t changed.  In brief, here’s the deal.  In patient care, infectious waste and product sterility are very important.  For the former, many items associated with infectious waste are disposed of as medical waste; there are rules for what’s med waste and what’s not.  But we want to minimize medical waste, as it costs us 20 cents a pound for disposal, while trash is about 4 cents/pound. So there are two, and only two, choices: expensive medical waste, or cheaper trash (there’s that money thing again), so, when possible, these items go to trash.  The materials in play here are definitely not candidates for recycling.

For product sterility, items use special packaging. Purchased items tend to come in packaging that is not a candidate for recycling.  Reusable items that are sterilized on-site are usually wrapped in “blue wrap”.  Depending on one’s waste hauler and the market for this specific material, blue wrap may or may not be recycled; if not, it goes to trash.  The alternative to blue wrap is to use reusable stainless steel cases, really cool but very expensive (yep, money again), and for many items, S/S containers are not feasible.

So, for these and many other reasons, Zero Waste in healthcare is really, really not in the cards. A few years ago, when I was pursuing Practice Greenhealth awards for UCDMC, I asked PGH leadership what kind of diversion rates they were seeing with top-performing hospitals.  The response: 50% diversion gets a gold star.

Last note on waste diversion. A few years ago, one of my nursing Champions wanted to evaluate several disposable packaging items for recycling.  I provided samples to my Republic Service rep, who provided them to her recycling guru.  Result?  Out of twelve items submitted, only one was suitable for recycling.  The Champion probably wondered why she made the effort.  We were both disappointed.

Welcome to healthcare.

This concludes Part I of ADS guidance. And we’ve not yet touched on alternative transportation, water conservation, sustainable purchasing, and other healthcare-related slippery slopes.  Stay tuned!

What is “Renewable Energy”?

Posted on November 1st, 2013 in Uncategorized | 44 Comments »

I’ve recently seen some posts and articles about “renewable energy” that just didn’t ring true with me.  Give a little thought to what you consider to be truly renewable in the world of energy.  What do you come up with?  Here’s my list:

  • Solar
  • Wind
  • Geothermal
  • Wave/tide action
  • Hydropower

The Natural Resources Defense Council adds “Biomass”, but warns that it must be managed with care, and I concur.  NRDC goes on to state that “Renewable energy comes from natural sources that are constantly and sustainably replenished”.  And that’s where my issue comes in.

The articles and posts of which I spoke suggested that Waste-to-Energy plants provided renewable energy.  Yet another post said that the methane from the local landfill provided good, clean renewable energy.  Think a minute about the renewable aspects of WtE plants and landfill methane.  What’s the base fuel here?  Trash!  No way around it.  For these things to be “renewable”, we humans have to keep on creating trash.  There are a lot of programs out there aiming to reduce landfill waste, so if we happened to get to zero landfill waste (not in my lifetime, but a thought), we’d eventually run out of landfill gas.

When you look at my list of renewable energy sources, do you see any types of environmental pollution associated with them?  Not a bit.  Yes, hydropower impacts fish, but I’m talking about air pollution, water pollution.  These guys yield clean energy.  Waste-to-Energy plants usually involve combustion of the waste, which is in no way clean; with the wide variety of wastes in the fuel stream, air pollution control equipment is pushed to the limit to minimize pollutants out the smokestack.

Now, there are advantages to WtE processes, sorta.  There is potential, emphasize potential, to capture the products of combustion.  If this waste went instead to landfill, much of it would degrade, in the anaerobic conditions in a landfill, to methane gas.  Landfills are required to have methane collection systems, which is fine, but they collect nowhere near all of the methane generated, so it escapes to the atmosphere.  You don’t hear much about methane being a greenhouse gas (carbon dioxide gets most of the press), but it’s several times more potent than see-oh-two.  The only good thing is that its atmospheric residence time is around, I think, 12 years, much less than that of carbon dioxide. But, at the end of the day, we generate trash, and from that we get either atmospheric pollution from the products of combustion or the generation of methane.

So now when you hear the claims of WtE being a renewable energy source, you’ll know better.  And you’ll be able to recognize a form of “greenwashing”, where nice environmental claims are made for a system or process than is not environmentally nice.  Like “Clean Coal”, one of my favorites.

Do something Green today!

 

Arm-wrestling with Climate Change

Posted on June 4th, 2013 in Uncategorized | 19 Comments »

Ad hominem attacks

 

What does it take for people to connect with climate change, or as one researcher puts it, global change? Many people feel that there is a significant disconnect between the scientific community, which tends to keep its collective head down, doing research and publishing papers, and the public at large. The public is much more likely to hear from the skeptic/denier community than the scientific community.

An analysis recently published in the journal Environmental Research Letters (http://bit.ly/14tzcHo) reviewed over 4,000 abstracts of peer-reviewed papers written since 1991 that took a position on human-caused global warming. Of these 4,000 abstracts, 97.1 percent endorsed the consensus that humans are causing global warming. Yet we are more likely, in my view, to hear about the 2.9 percent who don’t support the notion of human-caused climate change. You can read my post on “Merchants of Doubt” to learn more about that.

A local sent a letter in to the editor of the Napa Register a few weeks ago, complaining that Scientific American wasn’t telling the whole truth about climate change, that they were leaving out selected pieces of information that didn’t support his skepticism about the issue. I thought it’d be fun to follow the comments, and I was right.

I was not surprised to see folks jumping in with ad hominem attacks (e.g., a guy boasting of a master’s in political science (really? Poly sci?), so he knows how this works and you don’t), significant broad brushing of human-caused climate change (aka anthropogenic global warming/AGW) being a liberal campaign to throw the free market in disarray, and similar. When folks would bring up specific scientific issues, the denier response would be “that’s wrong” with no evidence to support the claim.

The deeper I went, the more interesting it got. One guy claimed that a Fortune magazine (no conservative bias there) article, which supposedly cited a peer-reviewed paper, established that there has been no warming in the past 10 years, therefore the AGW thing was bunk. I reviewed the Fortune article, which seemed to have the term “alarmist” in every paragraph, then looked at the article that it cited. It was quite a stretch to come to the Fortune conclusion of “no warming” from that article, which largely talked about different forcings and the difficultly of obtaining consistent data. But this commenter thought it was the be-all-end-all, and got rather huffy when I posted a note asking if he had actually read the cited article. He didn’t answer my question, but got huffy regardless.

There was quite a lot of banter about liberal conspiracies in the comments. Every time somebody posted about research findings that supported aspects of AGW, the rantings about liberals undermining the world would come out. And there were many retorts along the lines of “you’re stupid because you disagree with me”. These folks really play nice.

The fun part was when one guy found a piece (on Yahoo search, of course; seems to be the “go-to” for deniers/skeptics with no scientific background) about a recently-published article that claimed that cosmic rays were to blame for global warming, not humans and CO2. He paraded this around quite a bit. Never mind the 97 percent of the papers that support the consensus on AGW: this paper from the three percent shows that they’re all wrong. It took very little time for someone to point out that the paper’s author had brought up this theory before, and it had been thoroughly debunked at that time. Apparently he had new information that encouraged him to try again. I note that the skeptic community frequently claims that editors of peer-reviewed journals will not publish papers that take issue with AGW, but this researcher had the same poorly-received theory published not just once, but twice. Maybe I’ll keep that in my back pocket for the next “they won’t publish contrarian papers” claim. Could be fun.

It’s fine to take issue with global warming. Atmospheric science, oceanography, and similar are tough subjects to get one’s arms around, and it can be frustrating. But that doesn’t mean that you should reject it out of hand. Do some reading, find articles that are based on the literature, whether it’s the 97 percent or the three percent, but try to inform yourself. Send me a note if you are interested in readings aimed at the layperson, as I’ve read several and can make recommendations (a research scientist I am not). Take a position, but do make it an informed position.

MedShare is Coming to UCDHS – Finally

Posted on May 10th, 2013 in Uncategorized | 3 Comments »

In my last post I wrote about the challenge of bringing a new program on board which, as I wrote, doesn’t necessarily color within the lines. MedShare represents a great opportunity to put our surplus medical supplies to great use in 3rd World countries. Stuff that we can’t use, and therefore discard, can save a life in a poor country.

As I concluded in the last post, there was light at the end of the tunnel, with Bob Waste suggesting that we simply change the “donation request” to a “sponsorship”, and have a check cut for such a sponsorship to MedShare. Off we go? Not.

This may be a bit of TMI, but it serves to illustrate some of the intricacies, and, therefore, challenges of our system. Traditionally it has been easy to simply prepare a check request for a sponsorship, which is a good thing since Community Relations sponsors a couple of hundred events and activities a year. I can just imagine what a hassle doing a purchase requisition for each sponsorship would be. Well, guess what happened. Campus Accounting decided that they needed to track sponsorship via the purchase requisition process, and apparently told us that we had to do the same. This slammed the brakes on for a number of sponsorship requests, not just mine. Our purchase req system is not designed for sponsorships, and our Purchasing folks, rightly so, said that purchase req isn’t the right way to do this.

After a bit of back and forth, the two sides got together a few weeks ago, while I was off at the CleanMed conference. The upshot? Campus didn’t know that our Purchase Req system didn’t mirror theirs. They were holding fast because they thought it did. Apparently they agreed to let us handle sponsorship our way, in the check request process. All is now good.

Now MedShare has our sponsorship check in hand, Bill Corbett has processed a purchase order, and we are seconds away from being good to go. My intern, Joanne, and I talked with our MedShare rep, Shannon, the other day to get a handle on logistics and to lay out a plan to put things in motion here.

We have several (30-40) pallets of surplus medical supplies in the warehouse, all of which came back from PHS exchange cart restocking. The warehouse is anxious to get this space back. I just received an e-mail from Shannon, telling me that they have a trucking company that will backhaul these pallets of goods to them, pro bono, so we should get the warehouse freed up next week.

The kick-off meeting is being scheduled for May 20, and the following day we’ll receive shippers which we can fill with accumulated supplies for shipment to the MedShare warehouse. Then we’ll figure where to place the collection barrels, while, at the same time, contractor badges will be processed for the MedShare driver and operations manager.

No small amount of work, and it really did take a village to get this thing going. But, this time, we really are ready to go. Pretty exciting!

Do something GREEN today!
JD

The Challenge of a New Initiative

Posted on April 11th, 2013 in Uncategorized | 2 Comments »

It is interesting to see how a big institution like UCDHS reacts to a new initiative that doesn’t color inside the traditional lines. I made a presentation to the Sustainability Subcommittee earlier this week called “The Trials and Tribulations of a Sustainability Initiative”, which reviewed one such adventure, best characterized as “one step forward, two steps back”. Come along for the ride, and see how the forces of good can overcome the forces of business as usual.

I was at the CleanMed conference last year, cruising the vendor booths during a break in the action (yes, there is action at a sustainability conference!), and came upon the MedShare International booth. MedShare is a really cool non-profit, based in Atlanta with a satellite in the Bay Area. They solicit donations of surplus medical supplies and equipment from hospitals and other health care entities, collect it all up, have volunteers sort it out, and ship the materials to appropriately vetted hospitals in 3rd World countries. What’s not to like? I chatted with the NorCal director, Chuck Haupt, and we agreed to stay in touch.

I was intrigued. Leigh Clary had told me about her process of collecting surplus supplies in the ED, trying to keep them out of the trash. There were rumors that a resident, Dr. Ha, was doing similar in the OR, working with a non-profit that he knew from his Yale med school days. And I had also heard about surplus supplies finding their way from PHS to the warehouse, where they would be sold or donated to non-profits. It really seemed like we had an opportunity to leverage a relationship with MedShare to formalize a donation program, one which would both divert surplus supplies from the landfill, and provide a great community benefit. Let’s do it!

So off I went, figuring out how to make this happen. I talked to Purchasing about how we could have a business relationship with MedShare, and obtained buy-in from the various folks who were working to divert these surplus supplies from the landfill so they could fulfill a better purpose. Distribution’s Troy Taylor was particularly excited, as many pallets of surplus supplies were sucking up valuable space in the warehouse. Finally, COO Vincent Johnson gave his approval to move ahead with the partnership. Off we go!

One potential roadblock was MedShare’s request of a $200/week donation to support the collection and transportation of our materials. Seemed fair to me, as it’s quite a hike to their warehouse in San Leandro, and much time would be spent by their driver going around to our many locations to collect the materials. I received guidance from a few key people on the donation, and it seemed like I had everything going in the right direction. A kick-off meeting with MedShare and UCDHS was set up, and the collection process was just weeks from commencing. Or so I thought.

Purchasing’s Bill Corbett sent me a note, suggesting that we conduct another review of UCD and UCOP policies relevant to the partnership with MedShare. Upon review, Bill thought I might be pushing the envelope a bit on this, and opined that I should get approval from campus Bargain Barn before I went any further. “Why?”, I asked. “This program saves stuff from the trash. What’s the Bargain Barn have to do with it?” Common sense intervened, and I called the Barn’s Katie Jaramillo to get her blessing for the program. A blessing is not what I received, however. Turns out that the Barn had been selling this stuff, not for much money, but selling it nonetheless, and there was a specific process for donating those materials that could not be sold. Unfortunately, the partnership with MedShare did not fit into this process, and I had to back down.

I postponed the kickoff meeting, and started to consider approaches for working around the Barn’s requirements while still keeping peace with the Barn. I was moping about this quandary for the better part of the week, but then, out of the blue, the phone rings. “Hi, John. It’s Katie Jaramillo, and I have good news for you.” Really? Really. Katie had discussed the situation with Janice King, the UCD Director of Materiel Management, and they decided that the little bit of money they received for the surplus supplies really wasn’t worth the Bargain Barn effort, which effectively reduced the value of the supplies to “de minimus”. De minimus (negligible value) provides the flexibility to engage a non-profit for distribution of the goods. The following day, Janice e-mailed a narrow exemption to policy to me, effectively permitting the partnership with MedShare to move forward. Yay, Katie! Katie was immediately gifted with a box of my chocolate chip/oatmeal cookies for her efforts.

Things were suddenly looking really good, but there was still one obstacle to overcome: that pesky $200/week donation for transportation support, which MedShare requested to be paid a year in advance. The donation was already a bit contentious when the project went off the rails. There are essentially two ways to pay for things: via a check request, or via a purchase requisition. It seemed that the check request folks felt that a purchase requisition was necessary, as that’s the way that donations are now handled on campus, and Purchasing said that a purchase requisition didn’t fit into policy regarding donations. Back and forth, back and forth. I’m sure that Bill Corbett got tired of seeing my pathetic face in his doorway. He tried to help, but felt that current policies tied his hands. Ross O’Brien in A/P did a lot of work on his end to assist, but we all ended up stuck in the middle.

As I noted in my presentation, sometimes policies just aren’t geared to take advantage of new opportunities.

I was discussing this with Bob Waste, who’s in charge of government affairs and community relations, and he had a great idea. His group provides sponsorships to a number of efforts that benefit both the community and the Health System, and it appeared that this “donation” was, in fact, a sponsorship of the MedShare partnership. If we reframed it as such, getting a check request approved should go much more smoothly.

Off I went to rework the agreement with MedShare, and the check request is now in the works. There are still a few loose ends to tie up, as I need to register MedShare with the Bargain Barn as a recognized non-profit, and there will be no shortage of logistics to figure out for the collection process. And, of course, submitting a check request is no guarantee of having a check in hand, but I think that most of those bumps have been smoothed out.

It’s been an interesting ride, and quite the learning process. For one, asking for forgiveness instead of permission probably isn’t the best way to go when wrangling with UC policies, for what appears to be wiggle-room can turn out to be the Vulcan Death Grip. However, some really good people came through to save the day, and I’m hopeful that we’ll be in full partnership with MedShare before the summer solstice arrives. It’ll be great to know that those boxes and boxes of surplus medical supplies will be supporting the efforts of a 3rd World hospital instead of filling up a landfill. Sometimes it all works out, in spite of my best efforts to foul things up.  🙂

Check out the MedShare website, and…

Do something Green today!

The Challenge of Climate Change: The Merchants of Doubt

Posted on March 13th, 2013 in Uncategorized | 2 Comments »

I’ve been wondering why people aren’t paying more attention to climate change. One doesn’t have to look far to see the effects of a warming global environment, such as the record heat, drought and fires that have recently plagued Australia. Consider, too, the possibility that the Arctic may be relatively ice-free during the summer sometime soon. And it’s quite likely that Superstorm Sandy (too big to be a mere hurricane, it became a “superstorm”) was the product of our changing climate.

Earthrise

Earthrise

It seems that one of the reasons that we aren’t paying sufficient attention to the global warming issue is that we have a tendency to only regard things from the perspective of how they directly affect us. Temperature goes up a few degrees, we dress for it or turn up the A/C. What’s the big deal? In many ways, it’s the indirect (to us) effects about which we should be concerned. Relatively small changes in average temperature can dictate when plants can be pollinated, where grains can be grown, whether insects are active or dormant. Increasing the average ocean temperature a few degrees can make a day at the beach more comfortable, but it also rapidly increases the rate of melting of Arctic Ocean ice and Antarctic ice sheets, which in turn raise sea level. So, yes, a couple of degrees Centigrade increase in average global temperature is a big deal.

We also tend to dismiss issues that don’t immediately affect us. Ours is a society that tends to want instant gratification, so if it’s not happening within a week, we ignore it. With climate change, many changes happen slowly, over decades, so immediate effects are not seen. The problem here is that once we can really see the overt changes, having ignored the warning sign events such as those mentioned in the opening paragraph, it’s too late for us to change our practices in any meaningful ways. We will have gone well past the tipping point, and our course will be set.

Then the question comes up of “How do we know that it’s us?” It’s a legitimate query. We hear how the sun goes in high and low cycles, that the earth has been substantially warmer in the distant past, that it’s been relatively cooler recently, and similar. Scientists who specialize in climate and earth sciences have looked at all of the known potential causes of the current wave of global warming, and there is substantial consensus that we are the cause, largely through our burning of fossil fuels and the resulting emission of carbon dioxide. The whole chain of events features a large number of variables and “if this, then this, unless this…” scenarios. It’s dense, and tough to understand. We need to trust the scientists who make such investigations their life’s work, and seriously consider the paths that they recommend.

There are a number of people who disagree with the “humans are causing climate change” message. Obvious among them are the fossil fuel companies, particularly coal. Coal is one of the worst players in the climate change game, and, as it has been suggested that the best way to avoid climate catastrophe is to shut down coal-fired power plants, the coal companies are working hard to discredit the climate change message. Much of the business community likes “business as usual”, as it’s how they make money, so they, too, fight against climate change messaging and legislation. There are a number of other big players, with deep pockets and seemingly selfish agendas, who push back hard on the climate change issue.

I recently read a book which describes the way that business works to discredit messages, and messengers, that would negatively impact the bottom line. It’s called “Merchants of Doubt”, the title suggested from an infamous tobacco company memo which stated “Doubt is our product”. The book shows how just a few people, well-placed and well-funded, can work with a goal of discrediting scientists and any others who dare to advocate policies that would be detrimental to business interests.

What I found interesting in “Merchants of Doubt” was the thread that wound through the big “health risk versus business” public policy debates, starting with the link between tobacco use and cancer in the 1960s and continuing to today’s anthropogenic global warming. Four guys from the Cold War era of the 50s were at the core, using their credentials as physicists and knowledge of the system to cast doubt on the tobacco-cancer association. As that died down, they attacked the scientists who suggested a link between CFCs and the hole in the ozone layer. Moving right along, the group went after assertions that second-hand smoke was associated with various diseases, including cancer. It didn’t matter that they weren’t subject-matter experts in any of these areas. They portrayed themselves as concerned scientists who wanted the public to know the “truth”, taking the tiniest grain of perceived scientific inaccuracy and spinning it into a full-blown controversy. These guys reportedly hated government regulation, which they equated with the socialism that the battled in the 50s, and were happy to let the free market trample over the common good. That they eventually lost each battle meant little, as they simply went on to cast doubt in other areas.

The men at the core of this activity are either inactive or no longer with us, but the process remains intact, well-funded by big business interests such as the Koch brothers. The current target is manmade (anthropogenic) climate change, and they are casting doubt with great zeal. Climate change is an easy target for this group, as the numerous and complex variables present great fodder for questioning the science and the scientists. You might have heard of “Climategate”, where the e-mail accounts of many climate scientists were hacked and made public. Some out-of-context comments were heavily publicized as evidence that climate change was simply an antibusiness conspiracy. While several subsequent investigations have shown that such was not the case, the taint of “Climategate” remains. Or consider the outcry against climate scientist Michael Mann’s graph of temperature increases since the 1900’s, the now-infamous “hockey stick”. It was very legitimate science, pilloried by the denialists. Since it’s kinda tough to wade through the science, it’s easier to agree with the doubt-throwers than it is to do our own research…at least that’s what they hope we do.

I encourage you to give some thought to the climate change issue. Take a bit of time to consider whether you are hearing scientific consensus or a simple ad hominem attack on the messenger. Is there more credibility with peer-reviewed scientific evidence, or the cry of “you’ve got it all wrong” without the support of a plausible alternative scenario?

Over the next several weeks I will be posting on climate change issues, including causes, anticipated impacts, and the steps that the University of California and our own Health System will be taking to minimize our impact on the climate. I hope that you take the time to read and comment. To fight climate change, we will have to change our way of life, eschew “business as usual”, and understand that we can’t grow forever. We will have to recognize some new limits. We might not live to see the results from inaction, but life will be very different a couple of generations from now if we do nothing. Should that be our legacy?

Do something GREEN today!
JD

A “Better Mousetrap” for Recycling?

Posted on March 1st, 2013 in Uncategorized | 10 Comments »

Apparently Houston has an annual “great idea” contest, or something similar.  I subscribe to a couple of recycling listservs, and a member posted a link to the contest with a request that we vote for the recycling idea.  I’m always searching for better mousetraps, so I sped over to the Houston site to find out what this next great new thing could be, and was surprised to find that it was a throwback to the days of yore.  It’s called “One Bin For All”, featuring the idea that you could dispense with source separating of recyclables, trash, yard waste and all that, and simply put it all in one bin.  Heck, that’s how we did it when I was a kid, and it all went to the (open) landfill. 

Houston seems to think that it has a better mousetrap with its assumption that Waste Management, Republic Services, or a similar big waste management company will sense the vacuum here and rush in to build a new, beyond state-of-the-art material recovery facility (MRF) that will happily and cheaply sort all this stuff out.  My response to this post was: “One Bin for All. Nice idea, we’d all love to see it happen. But first, show me the MRF.  Sounds like a Dirty MRF to me. We separate trash from recyclables now to reduce contamination. How the proposed MRF handles the pint of pasta sauce spread all over the paper and boxboard will be key. Show me the MRF.” 

Several other responses were along similar lines.  Others pointed out a return to the “easy to throw things away” mentality that we’ve been pushing so hard to change into “Think before you toss”.  With the easy to throw out option, you stop asking manufacturers to make items that can be readily recycled, because everything simply disappears down the same hole.  This process is not going to increase Houston’s waste diversion rate; I’m betting that it will actually decrease it.  The claim that this process will increase diversion to 55% initially, and eventually to 75%, really requires a suspension of disbelief. 

Recycling is a tough business.  After the recyclables (well, we hope they are all recyclable) disappear into the bin and the truck, they do not magically turn into new products.  The MRF is key, with a combination of people and equipment sorting the various plastics, metals, papers, cardboard and such.  A great video of a MRF in action can be seen here. Many MRFs are not as sophisticated as the one shown here, so fewer items are recycled, or additional people power is required for the sort line. 

Recycling won’t work unless there is a market for the materials.  These items are commodities, and value goes up and down.  Once the value of a particular material drops below a certain point, the market disappears, and suddenly the MRF operator is stuck with a bunch of material that can’t be sold.  Additionally, as the video notes, buyers want specific types of items, and they want them free of contaminants that can foul up their manufacturing processes.  That creates two challenges for us. 

Contaminants come in many forms.  One, as mentioned in my comment, above, is foodstuffs, oils and similar contaminating plastics, cardboard and paper products.  Toss a quart of used oil into a bin of paper, and the value of that paper goes to zero: off it goes to the landfill.  Another is the challenge of dissimilar materials in one discarded product.  A good example is the type of disposable “warm-up” jacket used in our ORs.  Made of spun polypropylene, it seems that they’d be an excellent candidate for recycling.  Until you notice that the stretchy cuffs are of a different material, as are the snap closures.  The buyers don’t want these various materials; they’ll take only the polypro without the snaps and cuffs.  As it is impractical to cut out these items, the warm-up jackets are landfilled. 

So is Houston’s “Better Mousetrap” for real, or is it a sham?  I can tell you that our vendor, Allied Waste (part of Republic Services, the second largest waste operation in the US), opened up a new, state-of-the-art MRF in the East Bay several months ago, and they still don’t want contaminants in our recycle bins.  The new MRF does a better, more efficient and more automated job of sorting out the recyclables, but it hasn’t opened the door to more types of recyclables, and it doesn’t want our trash.  We still have to do a good job here. 

Houston, you have a problem.

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Do something Green today!
JD

 

Some Thoughts on Red Bag Waste

Posted on February 21st, 2013 in Uncategorized | 5 Comments »

I figured that, at some point, I’d blog on red bag waste, or, as it’s commonly known, Regulated Medical Waste (RMW), but I thought I’d first spend time on issues that are more obviously associated with sustainability. However, I’ve started a benchmarking project in which I compare UCDHS’ sustainability performance with that of winners of the various Practice Greenhealth (PGH) awards. Among other things, PGH looks at waste diversion practices, and includes RMW among these. So I did a few calculations and extracted some data from our 2013 award application, and compared it to the RMW information in the PGH 2012 Benchmarking Report.

Conclusion: We’re horrible.

Really, our numbers are so bad that we all should be embarrassed. Yes, we can talk our way out of it a bit, as we could take out the RWM generated in research functions, but it’s not that much. The reality is that we tend to use the red bag as a general garbage can, and some people tend to discard items as RMW when they could go to regular trash. In general, many of us are WAY too conservative when determining whether an item should be managed as RMW. Take a look at the numbers that follow, and you, too, will be embarrassed.

Practice Greenhealth has three different award levels. In 2012, we, along with 79 other hospitals, won the Partner for Change (PfC) award. Next level up is PfC with Distinction, which was awarded to 41 applicants, including UCSF. At the very top is the coveted Environmental Leadership Circle (ELC) award, won by 28 hospitals. For evaluating waste generation, Practice Greenhealth uses weight per adjusted patient day. For 2012, the average RMW generation for PfC winners was 3.3 pounds/APD; for PfC w/Distinction, 2.2 pounds/APD; and for ELC, a stingy 1.5 pounds/APD. The weight shown on our 2013 award application is 9.0 pounds/APD. Nine pounds of RMW per Adjusted Patient Day!

We’re horrible. But with “horribility” comes opportunity, as I will illustrate later.

We should be happy that they even let us submit an award application with RMW numbers like that. Don’t think that the folks at PGH don’t notice. This past Saturday I received an e-mail from awards coordinator Lin Hill:

Hi John,
Loved your application. A couple questions.
Your refuse/APD is half what UCSF is and close to some of our other award winning universities, (impressive), but your RMW% of wastestream is almost 3x theirs.
Why do you think it’s so high?
It seems like an opportunity for great cost savings.
Lin
 

Lin, PGH’s Janet Brown, and I discussed RMW last month on a conference call, and they were astounded (“surprised” isn’t strong enough) to learn that we have red bag bins in every patient room. I used to think that this practice was normal, but, when my wife was inpatient at Napa’s Queen of the Valley a few years ago, I learned otherwise. I quickly noticed that there was no red bag bin in her room. Instead there was a roll of small red bags in a drawer, and when a nurse had to dispose of some RMW, she put it in one of the bags, tied it off, and walked it to the soiled utility room. What a concept! It turns out that this same practice is used by UCSF Medical Center and UCLA’s medical centers, where it contributes to their low RMW numbers.

There also seems to be an overabundance of caution when deciding whether or not an item needs to be managed as RMW, which has been noted by many of us in EH&S. We’ve often fielded questions about RMW, particularly from nurses who suggest that colleagues are placing innocuous items in the red bag. This tells me that 1) it’s too easy to “over-redbag” items, and 2) guidance on what constitutes RMW needs to be more accessible.

The general policy on RMW is found in Hospital P&P 2005, with Attachment 1 addressing “Medical Waste Classification”. To me, this information is a bit too dense, making it hard to tell whether or not something should be handled as RMW. Nicole Mahr, RN, an Infection Preventionist with whom I’m working on this issue, says there is a reluctance to get too detailed in a policy, which, in my view, reflects the long turnaround for policy updates which makes timely changes a challenge. We were specifically discussing disposable isolation gowns, which apparently are often red bagged as a matter of practice. Nicole will be preparing a blog for First Tuesday that will address proper handling of used isolation gowns; we’ll see that, in most cases, they should go to trash, not red bag.

This issue of the overuse of red bags needs to be addressed, and Nicole and I will be leading an ad hoc work group to put together, once and for all, accessible red bag waste criteria that we’ll make readily available to all. We’ll address what qualifies an item for the red bag, and will look at common items, like isolation gowns, that all too frequently are handled as RMW.

One last thing that I’d like to mention is cost. Until September 2011, we treated most of our red bag waste in microwave units at the Back Dock. The costs of this process were not documented, and it seemed to create an environment that suggested that there was no cost to treating our red bag waste. However, with our current waste management processes, it costs $0.19 per pound to treat red bag waste. On the other hand, general trash is about $0.04 per pound, making it five times more expensive to throw something in the red bag that doesn’t really belong there.  Some food for thought: we paid over $400,000 in 2012 for management/disposal of RMW.  We should be able to make a significant dent in that if we get our act together.

As you can see, there are a lot of opportunities to improve our RMW management practices that will help us reduce our red bag waste, save money, and move in step with other medical centers in the UC system and elsewhere. Let me know if you’d like to participate in our work group. I’ll bet we can get below 5 pounds RMW/APD in a year. Can you help us achieve this worthy goal?

Do something Green today!

JD

The Paper Use Reduction Act

Posted on February 12th, 2013 in Uncategorized | 33 Comments »

Some of us remember that back when computers first became really popular, there was a lot of chatter on how we would become a “paperless society”. Wonder how that’s working out. Looking around our workplace, it seems like more paper, not less, is used on a regular basis. If the Health System had a Legislature or similar, I’d lobby to get a “Paper Use Reduction Act” enacted. When you understand how much paper we use, it’s really an eye-opener.

Stack of PaperOne of the questions new to this year’s Practice Greenhealth award application is “How many reams of paper do you use in a year?” Hmmm, I never gave that any thought, but I figured that I knew where to get the answer. I sent a note upstairs to Bill Corbett in Purchasing: how many reams of paper did the Med Center use in CY 2012? It turns out that it wasn’t a straight shot, as Bill queried someone in Material Management on campus, who, in turn asked the rep at OfficeMax. They were nice enough to send over a spreadsheet, which was important, as some data was in reams and other in cases (10 reams to a case). Once all the calcs were completed, I had the answer: 128,000 reams of paper. A ream holds 500 sheets, so, when all is said and done, that’s 64 million sheets of paper. Whew!

I was similarly surprised to see that there were over 200 line items on that spreadsheet. Granted, some were the same item, one line for case count and another for purchases by the ream. But I really have to wonder if we really need such a selection of paper. Sure, there are different sizes, and some in color, but I’d wager that 90 percent of our work comes out on 20# 8½ x 11 white copier/printer paper. And all of that should be on paper that is at least 30 percent post-consumer waste content (PCC), which means we’re giving the paper that we recycle a home. Most of our machines work just fine printing on 100 percent PCC paper, and I was heartened to see that quite a bit of the paper used was of this type. While the spreadsheet didn’t provide enough information to do a good drill-down, it looks like well over 75 percent of the paper used was at least 30 percent PCC, a good start!

One of the things that the Act would have us do is to emphasize electronic communication. A nurse recently asked me if I realized that some nurses print out every e-mail that they receive. I wonder why they’d do that. And why don’t the clinics e-mail the appointment reminder to me instead of wasting paper and postage by mailing it? At the conclusion of my appointment last week, I asked to “opt out” of the mailed reminder, and learned that opting out was not an option, as the system is set to automatically waste paper and postage. I also wonder why Training & Development, among others, sends out a ton of flyers for upcoming events instead of doing a mass e-mail. Finally, since I contribute to the Cancer Center, I get a lot of follow-on four-color glossy mailings. This would be a fine thing to receive as a PDF file via e-mail. I’ll bet that this is just the tip of the iceberg as far opportunities for saving paper via electronic communication goes.

The Act would also require all computers/printers to be set up for duplex (double sided) printing. I was complementing the guy at the clinic the other day about double-side handouts, and he said that he had to do those at the copy machine since his printer wasn’t capable of duplexing. Ack! He also noted that (what I assume to be) EMR did not have an option to print documents double-sided. Double-ACK! It’s a shame that conservation processes do not appear to be considered when setting up these complex programs. Discharge orders are similarly crazy. I was inpatient a few years ago, and was amazed to see that my discharge orders were not only printed single side, but the last several pages had only headers, with the page blank, no text (as I had no orders under those headers). Now that is ridiculous. And those are just examples that I have personally witnessed. We have to do better than that.

While I mentioned it under “electronic communication”, above, the Act would explicitly require an “opt-out” option on all processes, with you typically opting-in to receive documents electronically. This could cover appointment reminders, handouts, fundraising follow-ups and similar. It makes sense to me.

Finally, the Act would require us to “think before we print”. We often see this reminder under the signature block of e-mails from our green-thinking colleagues. Does the document need to be printed, or is it just as well saved to your thumb drive? I will admit that I’m old-school about reviewing documents: I prefer to print them out so they can be attacked with highlighter and red pen. Then, of course, I transfer my edits and thoughts to “strikeout and redline” on the electronic document. I’m hard to train, but I do think about it, and try to limit my printing for editing. If I can do it, you have no excuse.

Think about how you can streamline, minimize and otherwise make paper use more efficient in your work area. You’ll save money (paper, toner, postage) while taking some stress off of the environment. Send any good ideas that you come up with to me.

And what if you want to put the “Paper Use Reduction Act?” into play? That’s easy: Vote for me.

Do something Green today!
JD