Green Healthcare Sally Hunter University of Idaho

Hunter Introduction For hundreds of years, societies have sought out learned individuals to administer their healthcare needs. Over time, these healers have grown from individuals with a shingle hanging by their door to multi-building campuses with the ability to treat hundreds of patients at a time. Society has gone from medieval medicine to the most advanced medical care available. From being bled regularly to relieve ones humors to laser assisted laparoscopic surgeries that barely leave a scar. From not understanding the importance of sterility to the most complex, heat assisted chemical sterilization process ever known. Over several generations, hospitals have begun to develop into miniature cities, sometimes employing their own waste facilities and wastewater treatment plants. As these facilities grow to meet the ever-increasing demands of civilization, they must also learn to do it while lessening their impact for future generations. Hospitals are where many citizens of the Western world begin and end their lives. They depend on hospitals to heal them, help them, and hopefully teach them to live a better life. These lessons dont need to end with simple health. Hospitals have a responsibility to be a role model and a leader in their communities. These days, that extends to being a sustainable business. LEED the Hospital Due to the nature of hospital size and function, facilities management can easily make the biggest impact on whether a hospital is green or not. Hospitals are open 24 hours a day, 7 days a week and close for no man. They are huge users of energy and water and are caring for some of the most vulnerable members of the community. There are several ways a hospital can go green, either during the design and build process or as a retrofit to an existing property.

Hunter If a health system is considering building a new facility, they would be wise to consider the implications of going green and doing it early in the design process. In 2007, the U.S. Green Building Council (USGBC), the certifying body for LEED and the Green Guide for Healthcare (GGHC) partnered together and updated their programs to make it a little easier for hospitals to see the benefits of LEED or even just being a little more sustainable (LEED, 2012). USGBC would remain the LEED certifiers but the GGHC program would help the hospital design team with the building requirements and provide the necessary tools to be as environmentally friendly as they could afford. Make no mistake, going green does cost extra, but as the years go by, the costs are declining. Today, on average, designing a sustainable healthcare facility is a 2% premium over a conventional build. That 2% premium will reap 10x the rewards. Restated, to green up a $5M facility, it would cost an extra $100,000. Over the life of the building, these improvements would save the hospital $1M, paying for themselves ten times over (Kats, Alevenatis, Berman, Mills, & Perlman, 2003)). Earlier intervention in the design process can even bring the green premium down to nothing! Currently, there are only 36 healthcare facilities that are LEED certified, though several hundred more have applied. This is less than 2% of all LEED building. Healthcare has a long way to catch up in this sector. Energy Savings Building a new healthcare facility isnt always an option for health system. When its not, management can still make huge changes to gain the rewards of a sustainable facility. The statistics are astounding: hospitals are the second most energy intensive commercial buildings, trailing only the food industry (Johnson, 2010). American hospitals use double

Hunter the amount of energy as a comparably sized American office building and twice as much energy per square foot as European hospitals (Healthy Food, [n.d.]). Reducing energy use in a healthcare facility is, surprisingly, fairly easy and straightforward. There are several systems one can start with: lighting, mechanical systems, and air handling systems are just a few. All of these systems use copious amounts of energy and maintaining them to be as efficient as possible can produce large savings. There are two main ways to improve a facilities energy usage: demand side reduction and supply side greening (Energy, 2012)). Demand side reduction involves reducing a facilities need for energy or improving the efficiency of energy end users. Supply side greening involves changing the source of energy a facility employs. To begin a demand side reduction, the facility needs to conduct an audit to find the biggest energy users. Practice Greenhealth and the Energy Star Program suggest the following steps. Retrocommissioning of equipment is the first step after the audit. This involves testing, repairing, and maintaining equipment to make it as energy efficient as possible. A poorly working boiler, for example, would likely waste energy trying to continually heat the water. The next largest area for energy efficiency is lighting. As previously mentioned, hospitals are on 24 hours a day. Staff needs sufficient light to complete their tasks and care for patients. Lighting uses as much as 35% of a facilitys total energy (Energy, 2012). While the hospital is always open, there are areas that arent always occupied; administrative offices are often empty at night and on weekends and holidays. Installing motion sensors and lighting timers is one way to eliminate the light in these areas when not in use. Switching lighting from halogen to LED lights is another way to reduce energy use. LED bulbs have a lower wattage and therefore use less energy overall. In addition, LED

Hunter lighting doesnt put out as much as a halogen bulb. This can be a difference of several degrees in a confined space, like an operating suite. This heat reduction affects the need for air cooling, thereby reducing energy. Several European hospitals have begun using daylighting in appropriate areas, even the OR. By adjusting the intensity of the light to augment the natural daylight, the facility can reduce their energy use. An added side benefit is that staff is happier in day lit facilities, providing a morale boost in a demanding atmosphere (Pradinuk, 2009). Dell Childrens Medical Center in Austin, Texas designed their new Platinum LEED facility to include six courtyards and natural light shafts so that 80% of the 500,000 square foot facility can be daylit. Most of their interior spaces are with 32 feet of a window and even their underground dining room is lit with lighting shafts to allow natural light [Johnson, 2010]. Additionally, the Boulder Community Foothills Hospital installed windows in their operating recovery room and found the daylight helped patients wake up and orient to their surrounding faster, reducing the length of their hospital stay (Trossman, 2007). Once a facilitys lighting has been taken care of, the next step is to take a look at the supplemental load sources, i.e. people, computers, equipment, the building itself. Facilities can either reduce equipment use, like turning off equipment when not in use, or upgrade to a more energy efficient model. If considering an upgrade, the facility should conduct a thorough energy consumption evaluation of multiple models before choosing one (Scheeres, 2012). In addition to equipment, the building itself can be an energy sink. Facilities should consider upgrading their insulation, roofing, and fenestration. These improvements will have an overall impact on the heating and cooling systems of the hospital.

Hunter The last major sources of energy use in the hospital are the air handling systems. Since patients and staff are confined to an indoor area for the length of their stay, it is extremely important to have a high air quality. Fans that move conditioned air around the facility are responsible for as much as 8% of total energy usage and are often not sized for the job. Facilitys can downsize their fans to the right size for the area and can also adjust the ventilation rate to account for both occupant loads and building codes. The heating and cooling systems can account for another 25% of the facilitys energy use and again, are often not of the right size for the job (Energy, 2012). Energy saving controls can retrofitted to most systems to allow for fine temperature and ventilation adjustment to make the system even more efficient. While a facility is repairing and maintaining their building and equipment, they should take it a step further and search out renewable energy sources. This is the process of greening the supply side. Renewable energy sources are typically non-polluting, clean, and proved the greatest environmental benefit. Renewable energy sources include: hydroelectric, wind, solar, geothermal and biomass (Energy, 2012). Several of these methods are simply way to secondarily produce electricity. Wind turbines move a generator to produce electricity. Geothermal and biomass burning both utilize heat generation to produce steam which in turn powers the generator which makes the electricity. Even hydroelectric uses water to turn the turbines to power the generator. Providence Newburg Medical Center in Newburg, Oregon uses only green electricity for their energy needs. They report that 100% of their electricity comes from renewable energy sources such as wind, solar, and hydroelectric (Serb, 2008).

Hunter Solar power is unique in that it directly transforms light into electricity. Another version of solar power is to use a solar thermal collector to heat water to produce steam to power a generator. This method is used at large solar power plants using acres and acres of solar arrays. The major challenge behind solar power, for a hospital, is that, again, the hospital is open 24 hours a day and there are considerably less hours in the day of usable sun. This can be rectified by installing solar panels on the hospital itself and buying renewable energy from a reputable power source. When choosing a power source, hospitals can often enter into a solar power purchase agreement with a willing utility company. This agreement can make most hospitals up to 50% solar powered and keeps the price increase rate lower than a conventional energy source (Does Green, 2009). Water Conservation Water is another big contributor to a healthcare facilitys footprint. It is used in everything from sinks and toilets to landscaping to instrument processing. Water is usually not very high on the list of changes a facility may consider, but it should be. Water is a finite resource and in most cases, cant be reused without extensive treatment. Water is also still relatively cheap and therefore doesnt promise the extensive savings that an energy reduction program can (Carpenter, 2010). Even so, healthcare facilities use as much as 51 gallons per square foot, accounting for both domestic and processing uses. In contrast, award winning green facilities use only 44 gallons per staffed bed per day (Water, 2012). Domestic use accounts for roughly one quarter of the total water usage, while processing uses make up the rest. Domestic water use includes sinks, showers, and toilets, while processing uses encompass everything else. Facilities must use water in food production, laundry, vacuum systems, cooling units, boilers, image processing, sterilizers,

Hunter and hygiene practices. Not only do these processes use considerable amounts of water, processing the water to be used is extremely energy intensive. Water conservation programs center around reduction and reuse. First a water audit should be conducted, much like the energy audit. Priorities are established and the easiest fixes tackled first. Repairing leaks and drip are the quickest reduction fix. Water use can then be reduced by installing flow controls and low flow fixtures. Aerators can also be installed to mix air with the water and produce a higher water pressure without using as much water. Down in the kitchen and the laundry room, simple measures such as turning off continuous flow draining systems and reprograming the washing machines to eliminate the extra rinse cycles can dramatically reduce water usage. Just like in any home, the washing machines and dishwasher should only be run with full loads and reduced water levels. Outside, facilities should incorporate xeriscaping into their grounds maintenance and minimize irrigation. Successful reduction programs can provide a 25-40% return on investment. On the processing side of things, equipment can be upgraded to air-cooled models rather than water cooled ones. Condensate recovery is another highly effective way to reuse water. Steam condensate can be recovered and used to heat incoming water in boilers and sterilizers. Facilities can also recover the condensate from fridges, freezers and ice machines for further reuse. Some systems are far more involved but are quite inventive. Water can be taken from the reject side of the equipment used in radiation therapy and pumped to the cooling towers to be reused in evaporative cooling. Reject water can also be reused for miscellaneous non-potable uses. The University of Washington Medical Center retrofitted 50 sterilizers and autoclaves with water saving kits to eliminate the need to

Hunter temper the incoming water. They have saved over 2.5 million gallons per year and roughly $250,000 in associated water and sewer costs (Carpenter, 2010) Green Cleaning Not only can building a green facility help with a health systems energy and water use, but also if done properly, builders can reduce cleaning chemicals use. By installing an easily cleaned flooring surface, for example, chemical use can be reduced (Markkanen, Quinn, Galligan, Bello, 2009). Kaiser Permanente in California installed rubber flooring in their facilities, and although the initial cost was high, the floors proved easier to clean and sterilize (Serb, 2008). A better entry system such as high efficiency mats can capture, trap and retain soil, reducing the need for cleaning. Conversely, since all air in a hospital is either treated and re-circulated or continuously pumped in anew, a correctly sized and installed air handling system can actually help control humidity and airborne pathogens. Also, vacuums with a true HEPA filter can reduce air particulates. Besides airborne pathogens, hospitals are constantly contending with droplet and contact precautions as well. Contact and droplet precautions govern the proper precautions one should take when dealing with pathogens that are either communicated through direct contact with an infected surface or communicated through wet droplets (think cough or sneeze spray). These precautions are to protect both the staff and the highly vulnerable patients in the facility. Because of these precautions, cleaning the hospital is long and dirty task. Every surface in a healthcare facility must be kept in clean and working order. Some area must be kept more than clean; they must be sterile. Environmental Services is responsible for teasing out the difference between the areas and applying the appropriate

Hunter cleaning chemicals. Sterile OR suites, for example, have a higher need for disinfection than, say, the administrative offices, where a patient is rarely present. The Environmental Services team can take a number of steps to best apply pollution prevention tactics while maintaining the integrity of the hospital. Surprisingly, one of the biggest advancements in chemical reduction and replacement came about with the replacement of cotton string mops with reusable microfiber mops. These newer mops are considerably more effective at removing microbes from a surface (95% effective vs. 65% effectiveness of cotton string) even when only a detergent is used (Markkanen, et al., 2009). Detergents are different from disinfectants. Chemicals labeled as disinfectants have the capacity to kill microbes. As such, they can never be labeled as green or organic. Detergents, on the other hand, are less hazardous and can be labeled green or organic. The UC-Davis Medical Center found a 60% lifetime cost savings by switching to microfiber mops and also realized a 95% reduction in chemicals costs. These switches also led to a 20% labor savings per day (Markkanen, et al., 2009). Disinfectants should be saved for the most sterile areas of the facility and green detergents should be used in replacement in the remainder of the facility, i.e. offices, desks, waiting areas, outpatient therapy clinics. Green detergents are third party certified and there are several certification programs to choose from when picking a detergent: GreenSeal, EcoLogo (Canada), Cradle to Cradle, EcoLabel (EU), Blue Angel (Germany) and Nordic Swan. Health Care Without Harm lists several other ways to help determine how green a cleaner is. In addition to checking for third party certification, they suggest using unscented cleaners (fragrance can mask unsafe chemicals), rejecting chemicals with nonyl- and octyl-phenols, using only cleaners that list 100% of the

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Hunter ingredients, and to stay away from any chemical labeled Danger or Warning. These chemical types could be fatal or toxic, respectively (Ten Ways, [n.d.]). Not only are disinfectants more difficult to dispose of, due to hazardous materials disposal regulations, they are dangerous for the staff using them. Much of the safety concern surrounding disinfectant chemicals is due to poor handling procedures and policies. Chemical splash back is a very real threat when diluting chemicals for use or when transferring the chemical to the surface to be cleaned. One way to combat this is to use the above mentioned microfiber cloths pre-soaked in pre-diluted cleaners. Workers can then simply retrieve a cloth for each room or area to be cleaned and remove and replace them as they move about the facility. Not only do these mops last longer and can be laundered (which is in itself a bonus the high heat from the washing machines and dryers will kill microbes without using toxic disinfectants), but they are safe and easy for the Environmental Services worker. Hospitals are huge consumers of products that must be cleaned and sterilized before reuse. The standard has been to use very toxic chemicals like ethylene oxide (EtO) and glutaraldehyde in combination with high heat to sterilize expensive equipment for use on multiple patients. One of the EPAs major initiatives has been to reduce the use of these two chemicals in healthcare facilities (Partnership, 2011). EtO is a probable teratogen and may pose reproductive hazards. Inhaling it can lead to nausea, vomiting, and neurological disorders. It also is highly dangerous without proper supervision. It is so flammable that even static electricity can ignite it. While there isnt yet an alternative that can completely replace EtO, there is a small selection of hydrogen peroxide- and paracetic acid-based

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Hunter sterilizers that can replace EtO for many of its applications. These alternatives are both cheaper and safer to use. Glutaraldehyde is used during as a cold sterilizer for instruments and equipment that are too sensitive to heat. It can also be used as a tissue fixative in histology and pathology labs and as a hardening agent for x-rays. While glutaraldehyde is not classified as a carcinogen, it has been shown to cause asthma, headaches, nosebleeds, and throat and lung irritation. Glutaraldehyde can also often be replaced with hydrogen peroxide- and paracetic acid- based solutions but these are more expensive than the glutaraldehyde and therefore rarely replaced. Cleaning a healthcare facility is large task and is very intricate. Ensuring it is done responsibly and in an environmentally friendly way needs to be systems approach. There should be standardized operations, uniform dispensing techniques, proper protection equipment, competency training, chemical use reduction and clearly written policies and protocols describing the various levels of cleaning and sterilization needed throughout the hospital environment. Big Hospital, Big Waste Stream Hospitals are like miniature cities, often employing hundreds of people per day, while also housing another several hundred patients. People, in their home, trying to be responsible, can produce tremendous amounts of waste. People, in a hospital, using single use items, produce considerably more. Large hospital waste streams are especially complex due to the nature and variety of items being wasted. There is regulated medical or red bag waste, municipal or black bag waste, hazardous waste, pharmaceutical waste, food waste, universal waste, construction waste, and recycling! Hospitals across the nation are

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Hunter producing more than 5.9 million metric tons of waste every day (and many consider that a conservative estimate) (Waste, 2012). Depending on the type of waste, this can cost anywhere from $44-$68 per ton for disposal (Riedel, 2011). Solid municipal waste, consisting of the type of trash one might find anywhere and requiring no treatment, is the third cheapest waste to dispose of at $.03-.08/lb. on average. As the waste becomes more hazardous, the disposal costs skyrocket. Regulated medical waste costs between $0.20-0.50/lb. and hazardous waste can cost up to $2/lb. (Waste, 2012). Hazardous waste includes hazardous pharmaceutical waste, bulk chemotherapeutic agents, mercury, xylene, solvents, paints and aerosols. Pharmaceutical waste disposal costs are harder to pin down due to the variety of pharmaceuticals and varying chemical ingredients among manufacturers. Universal waste, which includes batteries, pesticides, light bulbs, and mercury containing equipment, costs somewhere in the middle of all these waste categories at around $1/lb. By contrast, recyclable disposal is charged at a rate that averages $.01/lb. and composting can be free if the compost produced is used at the facility for landscaping uses. Clearly this is an area that can provide major savings for a healthcare facility. Combine the costs of landfilling with the sheer volume of waste produced and one can see how much a facility stands to save by implementing reduction and recycling measures. In fact, recycling is one of the first actions recommended to start greening up a healthcare facility. It is fast and easy to implement and produces measurable results. Facilities can do this by implementing co-mingled recycling that prevents the consumer from having to sort the material before pickup thereby increasing the likelihood of recycling. A more advanced, costlier option is to switch the hospitals patient records system to an electronic medical

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Hunter record system, thereby eliminating tons of paper products. Traditionally, hospitals kept a patients medical record in paper format at an off-site warehouse for several years. By eliminating paper records, a facility can both reduce paper waste and eliminate the need for off-site storage facilities, which in turn use energy. Not only is recycling a cost benefit to the hospital, it is also a cost incentive for the community. Recycling creates six times more jobs than landfilling does. Nationally, recycling facilities employ over a million people and gross over $230 billion in annual revenue (Riedel, 2011). Not all hospital waste can be recycled or even landfilled without processing and treating the waste first. These methods can be costly and produce harmful greenhouse gases and dioxin release. One method to reduce this type of treatment is to implement a strict educational campaign directed at staff that are responsible for disposing of their waste. Often a busy staff pays no mind to which container they are placing their waste and non-hazardous or non-medical hazardous waste are needlessly treated and disposed of in harmful, costly methods. Another way is to reduce chemical use by switching to greener chemicals or by implementing policies aimed at taking only what you need and encouraging staff to come back for more of the necessary chemical, pharmaceutical, or cleaner when needed, rather than stocking up and having to waste it at the end of the shift. Reduction of waste is by far the most environmentally friendly approach and Practice Greenhealth does a fantastic job of helping facilities do this. They provide resources to their member hospitals to find reusable items rather than rely on single use products. They also can direct a hospital towards a manufacturer that uses more environmentally friendly packaging and production materials (Environmentally, 2012). As

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Hunter much as 20-30% of a single hospitals waste comes from the operating room and these supplies account for over half of their budget, far more than the salaries of those staffing the OR. It makes sense to pursue items that can be used, sterilized, reprocessed and reused to both reduce waste and cost. The Practice Greenhealth Environmentally Preferred Purchasing program can help a member hospital develop questions to ask manufacturers and help a facility identify products that are superior in their packaging, manufacture, use and end of life wasting. EPP can even be considered a preventive medicine technique as it reduces the environmental impact of the hospital while also reducing costs and making healthier environment for vulnerable patients and the staff that cares for them daily (Environmentally, 2012). Traditional products have been shown to produce a poor indoor air quality and some are even made of carcinogenic materials. Even the impact from a relatively small healthcare facility is worth noting. A 148 bed facility in Cincinnati, Ohio introduced mixed recycling in 2008 and saved themselves $4700 in waste disposal costs in one year. Their paper and cardboard recycling was akin to removing 19 cars from the road (Riedel, 2011). Legacy Health in Oregon, a large connected system of facilities, has their own recycling center and treats their medical waste to make it municipal waste and has saved themselves $1 million. Local Patients, Local Food Perhaps the most overlooked aspect of creating a sustainable hospital system is the production and distribution of food to patients and staff. Cafeterias and patient meals are huge producers of food waste and municipal waste. Food waste is as much as 10% of the hospitals waste stream (Health Food, [n.d.]). Much of this is due to the transient nature of the customers. Patients and their families are in a hurry and often need to take their meal

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Hunter to go. They are given overly large portion sizes that are wasted alongside the container they were served in. Additionally, the food often used for cafeterias is cheap and not likely to be of a sustainable source. This is a shame because hospitals are responsible for helping the community make responsible choices and this should extend to their nutrition. Where possible, food purchasers for the hospital should source hormone and antibiotic free meat, milk produced without rBGH, locally grown, organic produce and should limit fast food and vending machines. They should provide nutrient dense whole foods to their staff and patients. Often patients and staff that work long hours are eating all of their daily meals from the hospital cafeteria. These people should have the healthiest food choices made available. For the staff, reusable containers should be made available to reduce container waste and smaller portions should be served to reduce overall food waste. Food waste that is produced should be composted on campus and used for landscaping. Its not the biggest moneymaker for the hospital but being a good role model and helping their patients make health choices should be a priority just as energy, water and waste reduction are. St. Alphonsus Medical Center, Boise, Idaho The Sister of the Holy Cross founded St. Alphonsus in 1894. Over the last century they have grown from the first hospital in the area to a sprawling campus that includes a 381 bed hospital, several outpatient clinics and even more independent physician offices. In 2007 they began a new remodel and expansion project, as well as started a Green Team. The Green Team is comprised of several hospital employees who volunteer their time to monthly meetings to guide the hospital to a sustainable future. They have no budget and spend countless hours of their own time researching ideas and devising plans to

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Hunter present to various departments within the hospital. They are tasked both with finding better alternative to make their employer more sustainable and with convincing these same executives of the financial and social benefits of implementing their plans. In just over five years, they have made tremendous strides in making St. Alphonsus a sustainable healthcare facility. In the area of facilities management, St. Alphonsus has implemented several drastic changes. During their 2007-2010 expansion, they supported the construction of LEED certified building on their Boise campus. They installed occupancy sensors in several offices and rooms throughout the hospital so that the lights shut off when the space is unoccupied. They have switched to energy efficient lighting throughout the hospital, retrofitting lights to T8 lights and reducing the wattage of the parking lot lights by 43% (1000W to 575W), as well as switching lighting in the visitor parking area from halogen to LED. In several other areas, including the OR, they have also exchanged halogen lights for newer LED lighting. Not only has this improved energy savings in the lights themselves, but it has also allowed them to turn down the air-cooling in the operating rooms. The halogen lights produced so much heat that the air temperature had been adjusted to compensate. They have also installed a programmable reset schedule to their air system that monitors each space individually and adjusts the temperature based on occupancy. Before this program, all air in the hospital was cooled to one temperature at all times. The have also added a feature to their industrial supply fans to run at variable speeds rather than at a constant 100% power rate. They have also added dampers to some areas that allow them to reduce the airflow to unoccupied areas on nights and weekends while still meeting code

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Hunter requirements. When these dampers are closed, air pressure builds up and sends a signal to the fan to slow down, reducing the rate of power needed. The have changed the way they flush and refill their boilers. When the boiler is emptied, fresh water is added through a heat exchange system with the water being flushed. In this way, the water entering the boiler enters at a higher temperature, reducing the energy needed to heat it to functioning levels. They have also begun to reuse the water in their medical air compressors through a closed loop system for 1/3 of the year. They hope to reduce their water usage by at least 2.3 million gallons this year. The last two facilities management tasks they have upgraded are creating a rooftop garden in their new expansion and placing sensors on the vending machines so that they sleep when not in use. The St. Alphonsus Green Team has also done some great work reducing their waste stream. They have implemented recycling programs, began using more reusables and started buying products with less packaging. After implementing co-mingled recycling, they were able to divert 1,480,212 lbs. of recyclable material from being landfilled- 28% of their total waste stream. They also recycle all of the shrink-wrap, filmy plastics, and packaging materials that come through their supply department. The Green Team supports an office supply swap program to promote supply reuse rather than buying new and saves packing boxes for employee to collect and reuse when needed. In the supply sector, they have begun to sterilize and reprocess several FDA approved items that once were bought as one-time use items. In the last year, they have diverted 78,224 units totaling 31,000 lbs. from being landfilled. They have also switched to a reusable sharps container program something traditionally only available as a

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Hunter disposable item. A company called Daniels Sharps sends a representative to the hospital to exchange all the sharps containers periodically. The containers are sent to a sterilization plant and then cycled back into use. They have diverted another 22,463 lbs. from the landfill through this program. They have also converted all their high use solutions (saline, LR, etc.) to a specialized IV bag that was formulated to withstand shipping and storage without the outer wrapper on other bags. This effectively eliminated double bag waste on their IV bags. They have implemented a volume reduction strategy through their print shop and moved all paper subscriptions to electronic documents. In their cafeteria, they have implemented a Green to Go program. Rather than only supplying disposable food containers, the customer has a choice. They can either pay a one-time fee to gain access to a reusable to-go container that can be swapped at each visit or they can use the provided china in the dining room. For those customers that are one-time users of the cafeteria (patients, patient visitors), they can pay a slightly higher price to use a disposable to-go container that doesnt need to be returned. This program passes the disposal cost directly to the consumer while encouraging them to use a more sustainable food container. The St. Alphonsus Green Team was unable to provide any data on their cleaning methods but they did give a list of tasks they hope to implement in the near future. These tasks include: reducing linen waste, xeriscaping, installing a pulper and dehydrator to compost scraps on site, hosting a farmers market on site, replacing an existing air handling system with a more energy efficient fan system and finding a more energy efficient air handling unit for the upcoming Emergency Department expansion.

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Hunter Its clear that the St. Alphonsus Green Team has done a fantastic job of deploying several industry standard green objectives over the course of their life. In only five short years they have hit on almost every major strategy that industry experts suggest. They are a leader in the Treasure Valley for their innovation and commitment to a sustainable future. Combined with their extensive community outreach programs, St. Alphonsus is making a difference in the way healthcare does sustainability. Acknowledgements Thanks to Niky Dryden, Green Team Leader, at St. Alphonsus Medical Center for providing all the information regarding the extensive work done at St. Alphonsus.

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Hunter Resources Carpenter, Dave. (2010). GREEN + GREENER. (cover story). Health Facilities Management, 23(7), 15. Does Green Really Pay Off? Ideas from Hospitals That Say 'Yes!'. (2009). hfm (Healthcare Financial Management), 63(5), 3. Energy. (2012). Practice Greenhealth. Retrieved from http://practicegreenhealth.org/topics/energy-water-and-climate/energy Environmentally Preferable Purchasing. (2012). Practice Greenhealth. Retrieved from http://practicegreenhealth.org/topics/epp Health Food in Health Care (n.d.) Health Care Without Harm. Retrieved from http://www.healthyfoodinhealthcare.org/index.php Johnson, Sherryl W. (2010). Summarizing Green Practices in U.S. Hospitals. Hospital Topics, 88(3), 75-81. Kats, G., Alevantis, L., Berman, A., Mills, E., & Perlman, J. (October 2003). The Costs and Financial Benefits of Green Building. Retrieved from http://www.noharm.org/lib/downloads/building/Building_Green_Costs_Benefits.pdf LEED for Healthcare. (January 1, 2012). U.S. Green Building Council. Retrieved from http://www.usgbc.org/DisplayPage.aspx?CMSPageID=1765 Markkanen, P., Quinn, M., Galligan, C., Bello, A. (April 2009). Cleaning in Healthcare Facilities: Reducing human health effects and environmental impacts. Retrieved from http://www.sustainableproduction.org/downloads/CleaninginHealthcareFacilities.pdf Partnership for Sustainable Healthcare. (June 6, 2011). U.S. Environmental Protection Agency. Retrieved from http://www.epa.gov/p2/pubs/psh.htm Pradinuk, Ray. (2009). Incentivizing the Daylit Hospital: The Green Guide for Health Care Approach. Health Environments Research & Design Journal (HERD), 2(4), 92-112. Riedel, Lisa M. (2011). Environmental and Financial Impact of a Hospital Recycling Program. AANA Journal, 79(4), S8-S14. Scheeres, D. Junell. (2012). Facilities planning for greener hospitals. Industrial Engineer: IE, 44(3), 24-24. Serb, Chris. (2008). THINK GREEN. (cover story). H&HN: Hospitals & Health Networks, 82(8), 22.

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Hunter Sustainable Food. (2012). Practice Greenhealth. Retrieved from http://practicegreenhealth.org/topics/sustainable-food "Ten Ways to Find Safer, Greener Cleaners." (n.d.) Health Care Without Harm. Retrieved from http://www.noharm.org/lib/downloads/cleaners/10_Ways_Safer_Cleaners.pdf Trossman, Susan. (2007). Who says it's not easy being green? Nurses and health care leaders promote healing, environmentally friendly facilities. (Cover story). American Nurse, 39(2), 1-9. Water. (2012). Practice Greenhealth. Retrieved fromhttp://practicegreenhealth.org/topics/energy-water-and-climate/water Waste. (2012). Practice Greenhealth. Retrieved from http://practicegreenhealth.org/topics/waste

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