PRESENTATION: Primum non nocere, deinde curare » also applies to hospitals

8/16/2019 PRESENTATION: Primum non nocere, deinde curare » also applies to hospitals

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« Primum non nocere,deinde curare » alsoapplies to hospitals.

1Dr. Jean-Jacques BERNATAS ADB, May 2016

Disclaimer: The views expressed in this paper/presentation are the views of the author and donot necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Boardof Governors, or the governments they represent. ADB does not guarantee the accuracy of thedata included in this paper and accepts no responsibility for any consequence of their use.Terminology used may not necessarily be consistent with ADB official terms.


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Negative global public healthimpact of HCF

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•Uncontrolled development for immediate profitability in health carefacilities causes collateral damages”:

Direct: malpractice, higher rate of unavoidable side-effects oftreatments;

Indirect:

To the patient: stress, disruption at work/family life; exposure tohazardous components (air pollutants, utilization of potentiallyharmful device or material - IV lines/phtalates/newborn …), riskof hospital-acquired infection including with resistant bacterias

To the visitors: same as for patients, except care-associated risk

To the community: spread of communicable diseases, outbreaksof emerging diseases (SARS, EBOV, CCHF, …); environmentalimpact (water, energy, effluants, carbon footprint).


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The context of SD inHCF

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Input(equipment,

supply,

consummables,…)

$ (investment,capital,income)

People (staff,patients,visitors)

Strategy

Management

Process (SOP)

curativepreventive HEALTH

Adverse publichealth impact:•

toxic substances• energy and waterconsumption• carbon footprint

Individual adverseevents:• nosocomial infections,• accidental deaths anddisabilities• work accident andoccupational diseases

Immediate profitability vs.Sustainable development

Lowest cost vs.

Sustainableinput


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Back to fundamental: TheHippocratic Oath

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Better health (patients,community, country)

Adverse events (patients),exposure to hazard (staff,visitors), work accident(staff), and negative

environmental impact(indoor/outdoor)


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Conceptual framework of SD inhealthcare sector

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Improvingoutcomes

Mitigating adverseevents andnegative

environmentalimpact

Sustainablemanagement

Ecoconstruction

Saving energyand water

Preserving the

air quality

Sustainable procurement

Sorting,recycling and

re-using

Sustainablehealth


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Sustainable management

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From quality management basics:

•Structure (=ingredients)/process (=recipe)/outcome (… the cake!)Donabedian’s framework and its further improvements, for evaluation and qualityimprovement

•Non-quality as a factor of increased costs of healthcare,

•P-D-C-A and continuous quality improvement in health.

… to sustainable quality management:

•Motivation: embracing this vision relies on real understanding of its rationale. Well-informed staff makes a positive choice. Patient’s motivation++

•Cooperation: network of hospitals sharing experience on SD

•Training: part of the remediation process; on-site, hands-on and continuous education• Validation/good practice: certification (ISO14001, LEED, EMAS, …)(*)

•Communication: creation of SD commissions, sharing experience with a largeraudience, and to convince people on the relevance of SD.

(*): ISO : International Standard Organizatio; LEED (US Green building Council): Leadership in Energy &

Environmental Design; EMAS : European Eco-Management and Audit Scheme.


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Ecoconstruction

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• Usually higher immediate investment for a mid- evenlong-term apparent profitability « only ».

• Refers to specific labelling such as LEED, BREAM,

ISO 14001, … • Starts with a decision-making, then a choice of asite, and a participative multidisciplinary approach(ex. /Location).

• Requires multiple kinds of specific expertise.

• Energy performance, choice of materials, noisereduction, choice of light, … among others.


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Saving energy and water inhospitals has a global impact

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• A hospital energy consumption in France is 350 kWh/m2/year(energy efficiency index) where the new low energy buildingstandard for healthcare buildings in France is now 50kWh/m2 /year: long way to go …

• Hospitals energy consumption represents an average 11% ofenergy consumption of tertiary sector in Western countries.

• A German study evaluated one hospital bed to consume asmuch electricity and heating as two households.

• Water is a finite resource: the estimated average consumptionof a medico-surgical hospital is 300 to 750 liters/bed per day:


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Saving energy in hospitals :solutions (1)

1. Carrying out energetic assessment: heating/AC (up to 62%of energy costs, in Canadian hospitals; energy consumed byhospital represents 50% of ecological footprint of healthcare facilities)

2. Certification: BUND certificate (“ EnergiesparendesKrankenhaus”, Germany); Energy Star program; ecologyfootprint calculation; ISO 50001:2011; ISO 14001:2015

3. Green light program (European Commission) (in 2009, Virgen de la Arrixaca University hospital, Spain, saved70,000 kWH)


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Saving energy in hospitals :

solutions (2)Renewable energies:

• recovering heat generated by air conditioning systemsdecreased the fuel consumption from 1200l to 500l a

month (La Colina Hospital Tenerife, Spain);

• steam boiler (Newberg Hospital, Oregon),

• geothermal (St Jerome Regional Hospital, Canada:75 geothermal wells saving 500,000 USD a year on

heating),• photovoltaic panels (Portland OHSU, Oregon -

http://www.ohsu.edu/xd/about/initiatives/green.cfm

http://www.ohsu.edu/xd/about/initiatives/green.cfmhttp://www.ohsu.edu/xd/about/initiatives/green.cfm


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Saving water in hospitals:

solutions

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1. Using less « thirsty » autoclaves for sterilization units (newautoclaves will use 120l per cycle instead of 250l previously),

2. recycling water from hemodialysis for flushing systemsafter osmosis treatment (USP Hospital in Santa Cruz,Tenerife, Spain); recycling water for laundry in using wastewater to heat tap water (CHRU Tours, France: 5.5 l/kginstead of 12l/kg linen before)halves effluent discharge

40,000 € saving;

3. use bio-digestive membranes for filtering water = cleanfiltering system


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Impact on air quality

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• Carbon footprint: the University Hospital of Geneva (HUG) hasevaluated that it consumes yearly as much energy as a Europeancity of 16,000 inhabitants, and producing 10 tons CO2

•

HUG carried out a « life-cycle analysis »: 40% of carbon emission come from materials and

incoming products (mainly from drugs and textile objects

25% come from the buildings;

25% from transports (patients, visitors, staff)

10% from and infrastructure and waste management


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Solutions to preserve air

quality

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• Reducing the impact of transport on CO2 production:

Hospital better connected to the city

Green mobility: hybrid engine ambulances, carpooling for

ambulances, staff mobility (car pooling, bicycle, …) • Improving the hospital functionning in reducing CO2

production:

• Promotion of green spaces

•

Shortening of the supply chain• Energy saving policy


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• Shorter/local supply chain: to reduce environmental impactand carbon emission; to contribute to positive economic impacton local communities

•

Responsible and professionalized purchase based ontransparent and evidence-based information made available,traceability of the products to face the fragmentation ofinternal and external purchases, purchasing centrals, pooledpurchases ...

•

Substitution of toxic/carcinogenetic substances (KarolinskaHospital in Huddinge, Sweden: list of 100 substances to beabolished).

Sustainable purchase for safe andsustainable products -1. Principles


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Sustainable purchase for safe andsustainable products – 2. example

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• Chasing hidden dangerous substances, for example:

endocrine disrupters (BPA http://www.niehs.nih.gov/health/topics/agents/sya-bpa/ ; DEHP banned in UE ( European Directive 2005/84/EC ) for all children’s toys and

childcare articles/ http://www.cirs-reach.com/Testing/Phthalates_Testing.html)

Engineered nanomaterials (ENMs), and nanoparticulated titaniumin wall paints (antibacterial properties under UV, but may affect theblood-brain barreer.

Ethylene oxide sterilization, including bottle teats: listed ascarcinogen to man , but still in use to sterilize enteral feeding devices.

VOCs (Volatil Organic Compounds): organic gases found inambient air, issued from detergents, cleaning fluids, ….

http://www.niehs.nih.gov/health/topics/agents/sya-bpa/http://www.greenfacts.org/glossary/def/directive-phthalate-containing-toys-childcare-articles.htmhttp://www.cirs-reach.com/Testing/Phthalates_Testing.htmlhttp://www.cirs-reach.com/Testing/Phthalates_Testing.htmlhttp://www.cirs-reach.com/Testing/Phthalates_Testing.htmlhttp://www.cirs-reach.com/Testing/Phthalates_Testing.htmlhttp://www.cirs-reach.com/Testing/Phthalates_Testing.htmlhttp://www.cirs-reach.com/Testing/Phthalates_Testing.htmlhttp://www.greenfacts.org/glossary/def/directive-phthalate-containing-toys-childcare-articles.htmhttp://www.greenfacts.org/glossary/def/directive-phthalate-containing-toys-childcare-articles.htmhttp://www.greenfacts.org/glossary/def/directive-phthalate-containing-toys-childcare-articles.htmhttp://www.niehs.nih.gov/health/topics/agents/sya-bpa/http://www.niehs.nih.gov/health/topics/agents/sya-bpa/http://www.niehs.nih.gov/health/topics/agents/sya-bpa/http://www.niehs.nih.gov/health/topics/agents/sya-bpa/http://www.niehs.nih.gov/health/topics/agents/sya-bpa/


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Sorting, recycling and re-using

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• Chemical releases

• Compliance to existing regulation or necessity to improve it.

• REACH regulation (European Community Regulation on chemicalsand their safe use): guidelines for identification and substitution

of chemicals

• Effluents:

Effects of low concentration persistant residues in dischargedwater: drugs, radioactive substances, antibiotics,

Possible bioaccumulation in aquatic organisms.

Reduction of drugs in effluents requires better prescription (less /appropriate prescription of antibiotics), specialized treatmentplants, separate sewage network for hospital.

Substitution of reagents (cyanide for blood count),


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• Techniques for disinfection/sterilization: place ofincineration? Substitution to autoclaves for some medicalwaste (grinding and chlorine dioxide treatment)

•

Sorting channels and recycling: up to 30 channels in somehospitals, with a specific lifecycle for each type.

• Chasing any unnecessary packaging.

• Waste reduction and recovery policy in place.

• Improvement/Enforcement of national regulations, globalbut also specific to hospitals.

• Major concern about antibiotic microbialresistance: hospitals must take the lead and set an

example.

Using less, using better …


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Sustainable healthcare servicesdelivery Broadening the scope of

beneficiaries.

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• Taking care of employees:• Occupational health improvement, based on prevention: back

pain prevention, tobaco-free environment/smoking cessation support,...• Psychological stress, specific issue of HCW: counseling, adapted

innovative management (decentralized management unit providingmore autonomy for nursing staff). Experience of « magnetichospital » keeping low attrition rate among workers in providing

better conditions at work – ARIQ label in Canada (attractiveness of ahospital/ ability to keep staff/ involvement of nurses/ quality of care)

• Visitors are actors and vectors


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Sustainable healthcare servicesdelivery: Broadening the spectrum

of Heath benefits for the patients.

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• The International Declaration on Diseases due to ChemicalPollution, known as the Paris Appeal, launched at the Paris

conference on Cancer, Environment and Society on 7 May2004: an agenda to deal with environmental health.

• Implementation of environmental medicine services inhospitals: multiple sensitivity, low fertility due to endocrinedisrupters, ...


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Sustainable healthcare servicesdelivery figuring out the impact

on the community

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1. Positive1. Providing individual better health

2. generating income and employment to the local community

2. Negative:1. Pollution (air, water)2. Exporting diseases: AMR, emerging/re-emerging diseases

…


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Sustainable healthcare servicesdelivery: is it marketable?

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• Integration of preventive medicine in hospitals services in a contextof biased competition (marketing services with high and immediatereturn on investment)? For private sector: Is prevention a goodbusiness?

• There are many return of experience from hospitals havingimplemented a SD approach, but few global comprehensivebusiness case studies.

• (http://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdf ): « Environmental sustainability is also good

business, as it helps lower operational costs and allowshospitals to direct more resources to patient care» . (HealthResearch & Educational Trust. (2014, May). Environmentalsustainability in hospitals: The value of efficiency . Chicago, IL:Health Research & Educational Trust. ( Accessed at www.hpoe.org , American

Society for Healthcare Engineering)

http://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/http://www.hpoe.org/http://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdfhttp://www.hpoe.org/Reports-HPOE/ashe-sustainability-report-FINAL.pdf


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The poor are more exposed to pooroutcomes of unsustainable care

consequences

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When it comes to saving money, the poor are the first to beaffected:

• Non sustainable options for immediate profit may also offer health services atlower cost – and higher financial accessibility - but of lower quality and mayexpose the poorest users to higher incidental health risks.

• Similar to double-burden of nutrition: the poorest are more often sick andwill have only access to the cheapest care, which includes the use of the

cheapest materials and cheapest care that may harm them worse in return …

The poor are more exposed to environmental risks.

• This includes risks generated by the hospitals in the neighborhood: unsafewaste management, incinerator producing dioxines production, for exemple.


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HOW the poor must benefit fromsustainable development in

health care?

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Environmental regulations to be extendedand reinforced,

• and to apply to all healthcare facilities, including publicand decentralized.

Set up an adequate financing agenda.

Raise awareness,

• and make decision-makers bear in mind that sustainabledevelopment for hospitals is an integral part of fightagainst poverty, and of climate change management.


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• Sustainable development= “primum non nocere”, whichis an action in itself

• Asian/South-East Asian countries are more exposed to

the environmental risks and should take up the lead indeveloping sustainable healthcare facilities.

• Climate change is a driver for change in a sustainablemanner for hospitals since many determinants of CC are

also factors of negative health outcomes from healthcare providers

• What is expected to apply under COP21 to all industrialsectors applies also to health sector.

Finally …

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Health and SDGs: leveragingSDG3 will optimize the

outcome and minimize the risk

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Acknowledgements

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• Olivier TOMA, C2DS (www.c2ds.eu )• Health Sector Group, ADB.
http://www.c2ds.eu/http://www.c2ds.eu/

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PRESENTATION: Primum non nocere, deinde curare » also applies to hospitals