green@work : Magazine : Back Issues : Jan/Feb 2004 : Cover Story

Cover Story

Putting the Healthy Back Into Healthcare
Kaiser Permanente prescribes the need for healthcare that protects and enhances the environment and the health of patients, employees and communities. The long-term prognosis: a transformed healthcare industry.

Environmental activism at the Oakland, CA-based Kaiser Permanente (KP) began decades ago when the organization found itself mired in controversy when it invited Rachel Carson, considered to be a radical writer at the time, to deliver the keynote address to a KP symposium of 1,500 physicians, scientists, students and news media. Opening the program, which examined pesticides, cigarettes, radiation and drugs as “potential weapons for self-destruction,” Dr. Clifford H. Keene, then a KP vice president and general manager, said its purpose was “to examine the propensity and the ability of man to harm man on a grand scale.” Carson’s keynote address, titled “The Pollution of Our Environment,” was her last public appearance before her death.

This 1963 symposium signaled Kaiser Permanente’s early concern with environmental issues that continues today. As the largest non-profit healthcare organization in the United States, it has at its core a commitment to provide healthcare services in a manner that protects and enhances the environment and health of its patients, employees and the communities in which they do business now and for future generations. Chairman and CEO George Halvorson, in his recently-published book Epidemic of Care, issues a call for safer, better and more accountable healthcare.

“Unless the healthcare delivery system goes through an extensive reengineering to take full and consistent advantage of science-based, outcomes-focused, computer-supported medical best practices, we will continue to see an epidemic of dysfunctional care and care outcomes that fall far below what we deserve and what we are paying for. “In other words,” he writes, “we are on the verge of a whole new era of healthcare politics. It’s time to face reality and recognize that we are moving into a major healthcare crisis in this country, driven by the way we deliver, receive and pay for care.” The book, co-authored with Dr. George Isham, recommends practical strategies to improve the quality and economics of care, based on their mutual experiences at Minnesota’s HealthPartners and more recently at Halvorson’s tenure at Kaiser Permanente.

With all the bad news coming out of the healthcare industry recently—hospital infections now listed as the fourth leading cause of death in the U.S., escalating insurance premiums and drug prices, doctors and their patients swamped under the burden of paperwork and politicians acting irresponsibly—it is encouraging to find a growing movement among some healthcare providers, spearheaded by Kaiser Permanente, that is aggressively subscribing to long-term environmental stewardship.

What KP is doing is providing the leadership that will eventually transform the healthcare marketplace—in the products and materials it purchases, the buildings it constructs and its operational practices. “Kaiser Permanente has played a seminal role both internally and in the healthcare industry in moving the industry toward a stronger sense of environmental stewardship,” states Michael Lerner, a founder of the advocacy group Healthcare Without Harm. “They’ve extended ‘do not harm’ from patient care to doing no harm to the web of life.”

Support from and partnerships with groups such as Healthcare Without Harm, the Healthy Building Network, the Center for Environmental Health and Catholic Healthcare West have propelled KP’s concern for the environment. Collectively they’ve brought together healthcare decision-makers to set strategic agendas for environmental stewardship and to tap into the brains of all the people grappling with the same issues. For example, the California Sustainable Hospitals Forum, convened in June 2003, assembled architects, designers, engineers, owners and contactors to discuss how best to incorporate environmentally sustainable practices into healthcare facilities. The timing of the forum coincided with the tremendous hospital building boom in California, driven by seismic safety codes that require adherence to more stringent standards. KP and its partners seized this opportunity to study and proliferate ecologically superior building designs throughout the industry. The forum published the findings of its meetings at the Center for Environmental Health Web site (www.cehca.org/hcwh.htm) and the participants have worked together to implement the strategies that had been agreed upon.

Modern-day environmental attentiveness at Kaiser, widely respected for its leadership, began gradually as a grassroots effort. Local green teams formed and some key executives—the heads of facilities, purchasing and environmental health and safety—became personally interested in supporting a national program. Kathy Gerwig, director of environmental stewardship and national environmental health and safety for KP, remembers that there had been pockets of sustainability since the beginning, but it was very decentralized and informal. The tipping point occurred in 1997 when KP experienced a coming together of a variety of opportunities: a grassroots interest by members of KP’s green teams, heightened interest in improving environmental performance by several national KP leaders, and increased public scrutiny around environmental issues associated with healthcare (e.g., concerns with needles washing up on beaches). Gerwig’s position was created to help pull all these parts together and provide a national perspective, and to help build awareness at the top of the organization while supporting people at the local level so that each one didn’t have to reinvent the wheel every single time. “We had the executive support, we had the grassroots support, we had external organizations saying this is the right thing to do and you’re obligated to do it,” she states. “That’s when Kaiser formally created a national environmental stewardship program.”

In 2001 The Environmental Stewardship Council was formed, and in less than a year it has achieved or surpassed most of its initial goals, not because the goals weren’t big enough, but because some of the barriers that were thought to exist disappeared when various pockets of resistance didn’t materialize. Instead the council has had great support and innovation, and its successes are tangible, ranging from recycling practices to disposal avoidance to energy efficiency to air pollution prevention and the discontinued use of mercury and polyvinyl chloride (PVC) in its facilities and in the medical products industry. (See “First-year Successes” on page 21.)

In fact, KP’s decision in early 1999 to begin to phase out the use of PVC is highly commendable, but also controversial. PVC is ubiquitous in our lives, used to make many common, everyday materials and is a key component of medical products such as IV bags and tubing, but there’s also demonstrated evidence that it’s a pretty nasty substance. According to the Healthy Building Network, dioxin (the most potent carcinogen known), ethylene dichloride, hydrochloric acid and vinyl chloride are unavoidably created in the production of PVC and can cause severe health problems, including cancer, birth defects and other serious health hazards. Gerwig believes that KP has taken a precautionary approach, meaning that where there is credible evidence that a material it is using may result in environmental harm, it should strive to replace that material with safer alternatives. There is enough evidence about the hazards of vinyl, she thinks, that the responsible course of action for a healthcare organization is to replace it with healthier, commercially available alternatives that are equal or superior in performance, especially in the design and construction of their buildings.

Approximately 75 percent of all PVC manufactured is used in construction materials such as flooring, window frames and piping. With its nationwide network of 30 hospitals and 431 medical office buildings, KP is in a position to affect change in the marketplace for PVC; an early success is reflected in the story of the award of a national carpeting purchasing contract. The process began in the summer of 2002 when the facilities group added environmental considerations to its product selection process. Carol Antle, director of capital projects for KP’s National Facilities Services, queried manufacturers about the environmental performance of their products.

“Our questionnaires are very rigorous and include issues about manufacturing, production and use,” Antle said. “The questions go deep into chemistry and deep into the issues of the content of the carpet fiber and the backings as well as worker safety, recycled content, emissions, energy, waste disposal and end-of-life disposition. One of our carpet vendors, with whom we had had a long relationship, didn’t take our environmental query seriously either in the questionnaire or in the follow-up interview process, and so we changed providers and awarded our contract to a more responsive vendor. They weren’t happy about it, but the process reinforced that there was a total disconnect between where we were going versus where they thought we were going.”

Kaiser Permanente has played an important leadership role in working to eliminate mercury and PVC and other problematic materials out of the medical product world. It has switched from PVC gloves to an alternative that has proved to be price competitive. Tom Lent, a healthcare projects coordinator with the Healthy Building Network, credits KP with a lot of forward-thinking and risk-taking, especially in its engagement with manufacturers to shape the market in important ways.

“They came to the table quite convinced on their own that PVC was to be eliminated, but not sure exactly how to do it in buildings materials, particularly in healthcare with its demanding specification requirements. Frankly, in many ways when they started doing this, the market wasn’t really ready for them. One of the very exciting things about working with Kaiser is that they’re not at all daunted by that prospect, but instead have been engaging very actively to move the market where they needed it to be to meet their mission, goals and performance requirements.”

Lent is also impressed with KP’s resilience, clarity of purpose and resistance to intimidation from the trade associations. “It’s been a very important gift that they have given to the world of sustainability, to the rest of the industry and one for which they themselves are going to get great payback,” Lent continues. “They’re going to be able to get products that really meet their sustainability goals, morally and socially and economically, while the rest of the industry is going to gain tremendously. I’m thinking particularly about their engagement with the carpet industry and how they’ve established some different, more open models for collaboration between industry and buyers that can help speed up the transition to more truly sustainable products in the marketplace.”

The incorporation of environmentally responsible practices permeates every level of KP’s management. CEO George Halvorson, although he’s been with the organization just a little over a year, fully supports environmental stewardship for his organization. “As a long-time member of Greenpeace and the Nature Conservancy, as well as an outdoorsman who’s enjoyed kayaking and being out in nature during my time in Minnesota, this is a personal conviction of mine. It’s a sense of comfort and pleasure to me that the company has made this commitment, and I’m grateful to the people who lead it internally. It lets me sleep at night.”

Among those responsible for Halvorson’s restful slumber is Tom Heller, vice president of Kaiser’s National Facility Services as well as the co-chair of the Environmental Stewardship Council. Directly responsible for all facility development activities, including design, construction and maintenance, he is extremely cost conscious of what it does as an organization. He is quick to dispute the widely-held notion that green buildings and other sustainably-directed initiatives cost more.

“The first question that I am asked is how much more are you willing to pay to be green? I don’t think you need to accept as a foregone conclusion that it’s going to cost more,” Heller says. “Many of the things that we do would make good business sense, regardless of the green application. Some of them reduce our utility and maintenance costs. In some cases, we’ve elected to pilot particular applications to see if they work for us, rather than to just move forward very quickly with decisions that, ultimately, may be the wrong direction. We look at the things that we feel strongly about, that are effective and that we can make work within the budgets that we have. It’s a very thoughtful approach.”

Kaiser’s approach is indeed thoughtful, and comprehensive within three primary categories of environmental stewardship—environmentally responsible purchasing, sustainable operations and green buildings. The purchasing committee has, for example, identified alternatives for items used in neonatal intensive care that contained DEPH—a plasticizer that is added to vinyl as a softener and is listed by the National Toxicology Program as a probable human carcinogen and endocrine disruptor. It has also conducted a survey to identify environmentally responsible product options and have worked with KP’s purchasing contractor on purchasing priorities.

The sustainable operations committee has recommended voluntary energy conservation policies and practices that have resulted in decreased electrical consumption and savings of millions of dollars. They’ve also reduced waste, including medical waste, and are working with the IT department to develop new standards for disposing of electronic equipment.

However, it’s the green building group, under the direction of Carol Antle, which is perhaps the most fully developed. “With such a huge capital plan it seemed logical to develop green building strategies,” she says. “The other piece of it is how well it fit the corporate mission: healthy buildings supporting healthcare seemed like a no-brainer. We’re here because the work that we do has social value. We’re not building casinos or office buildings, but healthcare facilities—and that resonates.”

A very small, 20,000-square-foot remodeling of a clinic space in Southern California served as a pilot project to test KP’s evolving strategies. As the general contractor, it has partnered with the capital projects group to investigate things it could do differently to be more sustainable. Everyone expected that the project was going to cost more and take longer. Instead, with a little up-front planning and sourcing in areas such as demolition and waste management, they brought it in on time and within budget. Antle describes it as “the most influential 20,000-square-feet” that KP ever built.

In 2001 the Green Buildings Committee was formed with Antle as its chair. Committee members include architects, engineers, planners, designers and other experts. Its purpose is to incorporate sustainable measures into KP’s building standards, which it has done, in large part, through the development of the Eco-Toolkit design and construction resource guide. Intended primarily for internal use by KP staff and others directly involved in the design and construction of Kaiser’s healthcare facilities, Antle sees it as a tool that all can use to compare standards and to present a clear set of choices. Each section of the toolkit contains a concise set of goals developed by the American Society of Healthcare Engineering that identify improvements to the environment, or reduced impacts, that could be achieved. It has forced the committee, Antle states, to pay attention to some things it hadn’t considered, such as site planning and the disposition of demolition debris. Designed to encourage creative thinking, the toolkit also serves as a reminder that there is a great deal more that can be done to reduce the environmental impact of buildings.

In April 2003, 18 Kaiser facilities were singled out for exemplary accomplishments by Hospitals for a Healthy Environment. KP also received multiple awards from the California Integrated Waste Management Board and an award from the Healthy Building Network. While it’s not surprising that Kaiser is being recognized with these awards, it must be pointed out that it has not sought nor received much attention from the press or the public for its environmental initiatives and achievements.

Halvorson believes that it would be beneficial and reassuring for KP’s members to have a better sense of the organization and so he has spent some time developing a brand position that links Kaiser to three important aspects of their mission: people, understanding and health. Simply put, according to Halvorson, “the people part refers to the people of Kaiser Permanente. Understanding means we understand health and we understand best practice and we understand medical science. And, health is that we improve and restore people’s health. All of this is extremely compatible with environmental protection and will play a part in our branding efforts.”

In her 1963 keynote address, Rachel Carson said, “We begin to feel an uneasy certainty that man is becoming too ingenious for his own good. We’ve had the scientific knowledge to anticipate this destructive chain reaction. Why haven’t users and responsible bodies of government acted on this knowledge?”

Halvorson, proud of the creativity and passion of the thousands of people at Kaiser Permanente who see the possibilities for change, and then own that change, should be fairly confident that Carson would be pleased.