Enhancing environmental sustainability at Dubai Community Health Center

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Enhancing environmental sustainability at Dubai Community Health Center
One definition of sustainability is a system’s ability to continue doing what it is doing over time (HERT, 2014). Scientists, politicians and sociologists, among other people, are increasingly advocating for global sustainability for prosperity and posterity. Currently, nations are appending their signatures in agreement to adherence of the Paris Climate Accord of 2016 that holds nations responsible and accountable for environmental sustainability. The comity of nations is committed to fiscal and moral support of these green initiatives.
To optimize the savings and benefits accrued from environmental sustainability, the efforts must be multi-pronged so as to fully utilize available opportunities. In a health facility setting, the efforts must combine various strategies that target energy efficiency, water conservation, supply chain management and waste management with the aim of reducing costs, improving efficiency and enhancing the patient’s healthcare.  Commitment to sustainability by embedding it to a health facility’s vision, strategy and processes will ensure short- and long-term benefits to the health facility, the local community and to a country’s overall healthcare system.
Embracing environmental sustainability ensures a health facility is able to lower operational costs with concomitant saved resources being channeled to better care for patients. It also builds rapport with the community who consequently view the institution as a responsible corporate citizen. The local community benefits by having more available resources (e.g. water and electricity) due to reduced usage by the hospital as well as improved communal health due to less pollution (American Hospital Association, 2011).  A country benefits from a hospital’s environmental sustainability efforts by reduced healthcare costs for the populace and having a healthier, more productive populace.
As international healthcare shifts to a value-based system, there is increasing financial and regulatory pressure for hospitals and national healthcare systems to make the necessary changes. Various organizations, such as the American Hospital Association, have consequently come up with strategy outlines for future success of healthcare institutions in a value-based environment. These strategy outlines ensure adoption of viable sustainability measures.
This study will look at how some of these sustainability strategies can be adopted by Dubai Community Health Center (DCHC) for the benefit of the center, its local community and the UAE nation.
A private health organization, DCHC was started in 1996 so as “to meet the emotional and developmental needs of the Dubai community” (DCHC, undated). It caters to people of all ages and offers psychiatry, psychology therapy, counseling, learning support, speech and language therapy, and occupational therapy services.
Its mission statement to “Help People To Help Themselves” targets enabling successful patient access to mental health and special needs, but also renders itself to effective embedding of environmental sustainability by the hospital getting involved in community initiatives and programs that not only address its stipulated health support area, but also environmental issues. This is especially because the mission is supported by a commitment to values enshrined in its Quality Management System of international standards (DCHC, undated). Thus the health center is well-placed to embrace sustainability strategies in line with the international shift from volume-based healthcare to value-based healthcare. 
DCHC is located on the first floor of Faisal Al-Gurg building in Oud Metha, Dubai; in close proximity to other health facilities such as the American Hospital, Dubai Healthcare City and Rashid Hospital. This makes it easy for DCHC to collaborate with leading health institutions in the country. However, the effectiveness of a health center in the heart of the city center in developing and implementing a sustainability strategy is debatable with this paper suggesting eventual commissioning of the health center’s premises outside the city center.
It is recommended that DCHC develops a sustainability statement stipulating the environmental principles guiding the health center anchored on healthcare improvement, caring for the environment and cost reduction (Sustainability Roadmap for Hospitals, 2010). The center will practice innovative existing and new ways of conserving, recycling, reusing and reducing use of scarce resources. In doing this, DCHC will collaborate with other hospitals and institutions of a similar inclination nationally and internationally. The statement will guide the various strategies employed by DCHC towards enhanced sustainability. The sustainability statement will form part of DCHC’s overall strategic plan so as to ensure commitment from the hospital’s top management.
In a nutshell, the sustainability statement will answer the following questions:
·         Why sustainability for DCHC?
·         What sustainability efforts has DCHC undertaken already?
·         What choices will DCHC make and why?
·         What are the benefits of adopting sustainability strategies at DCHC?
·         What impediments does DCHC face in implementation of the sustainability strategies?
·         What resources will DCHC require to effectively implement the sustainability strategies?
·         Who will be involved in DCHC’s sustainability efforts?
·         How can sustainability be embedded into DCHC’s corporate culture?
Notably, this paper offers a guideline that addresses most of the issues raised in the above questions.

It is important that all the staff members at DCHC are involved in developing and implementing the sustainability statement and strategies. This will involve training programs on environment, health and safety to ensure that everybody at the health center is aware of the sustainability direction of DCHC. This cannot be overemphasized as evident from the unawareness of staff at Memorial Hermann Health System, where, despite having two similar hospitals, one was more energy efficient than the other (HERT, 2014). Upon investigation, some of the causes attributed to the discrepancy were lack of training and poor use of energy-smart technology. Training of staff rectified this anomaly. As such, it will be crucial for DCHC staff to be trained from the start on how to implement the sustainability strategies. DCHC will use new and existing training and education programs (e.g. Lean training).
To further improve performance of staff in executing the sustainability strategies, a reward system will be put in place. The best annual performers in each of the four strategies – energy efficiency, water conservation, supply chain management and waste management – will be rewarded either by promotion or cash awards. The Baldridge award criteria that align to sustainability efforts can also be used to determine who, how and when to reward the staff (LBNL, 2014). A reward scheme for good implementation of the sustainability strategies will ensure the staff strives to meet set targets, ensuring DCHC eventually implements all the sustainability strategies.


Suggested sustainability strategies for DCHC
1)      Energy efficiency
One of the major sustainability strategies for a hospital to reduce costs and to minimize use of resources is energy efficiency. Hospitals usually use a lot of energy, with most of them operating 24/7. Some of the areas that hospitals use a lot of energy include running equipment in surgery and emergency rooms, laundry, catering and data centers. For example, “large hospitals make up just 2 percent of commercial floor space in the United States but use about 5.5 percent of energy delivered to the commercial sector” (HERT, 2014).
Comparing energy consumption for various areas in a health facility can be the basis to determine which sections to prioritize on reducing energy use. Sections that usually consume the most energy include reheating and heating, lighting, fans, and chiller plants (Sustainability Roadmap for Hospitals, 2010). Energy use in these sections can be reduced by using new meters, having energy audits and or upgrading equipment.
That DCHC is a non-clinical health facility means its energy use is not that intensive compared to many clinical health facilities. However, with twenty consultancy rooms, an indoor children play room and underground parking, the health center still uses a lot of energy (DCHC, undated). A proposed sustainability guideline for DCHC is to reduce its energy consumption by about 10%. Reducing energy costs by 10% adds about two pennies for every share of a private hospital (HERT, 2014). A HERT report notes that “every $1 a nonprofit hospital or care system saves on energy is equivalent to generating $20 in new hospital revenues”. Though it may require DCHC to invest finances and time to implement energy efficiency, the sustainability strategy would reflect healthier return on ROI, with the opportunity to plough back this into better healthcare.
Implementing the energy efficiency strategy would involve establishing an energy use baseline. This would involve laying out guidelines on energy use at the hospital; stipulating the rules and procedures for procurement, operation and maintenance of energy-intensive systems; and setting up a committee to oversee development and successful implementation of the strategy (HERT, 2014).
Guidelines from the committee would stipulate the most efficient lighting for DCHC. This could involve retro-commissioning to have low-wattage lighting and motion sensors to control the lighting usage. The committee can also decide to retro-commission air conditioning such that fans have sensors. While the former may require substantial investment in terms of time and finances, programming when to heat or cool a place according to needs requires little time and financial investment yet the benefits accrued are huge.
Establishing energy use baseline does not directly contribute to ROI but it lays the necessary groundwork for implementation of the energy efficiency sustainability strategy.
It would also be important to schedule maintenance of the various machinery, tools and equipment, maybe every quarterly. This is because these will be in heavy use so they are likely to wear and tear quickly. So to maximize the output and lifespan of the machines, tools and equipment at DCHC, these need to be serviced regularly.
Some of the equipment and machinery may need retro-commissioning so that DCHC has modern equipment with inbuilt controls to reduce energy usage. The hospital can buy equipment and machinery that transition quickly between various operational modes, being cognizance of the fact that the patient’s healthcare is always the first priority. Being aware of this fact will ensure that, despite the machines and equipment minimizing energy use, DCHC can quickly utilize the machines and equipment for fast response and in emergency situations (LBNL, 2014).
As earlier mentioned, a long-term energy efficiency goal would be to relocate the hospital to its own green premises on the outskirts of Dubai. Here, the compound would be serene and more conducive for the healthcare services offered by the institution. There would be adequate open parking, ensuring that DCHC saves on the energy used to run the underground parking. Children would have a playground, minimizing on the energy used on an indoor play area.
When DCHC moves to its premises, it would install solar panels on the building to capture renewable energy so as to lessen its carbon footprint. This technology is quite affordable and manageable in the desert setting of Dubai, yet the positive impacts on ROI are huge.
The energy efficiency sustainability strategy at DCHC would be geared towards attaining international accreditation. The hospital would pursue such accreditation as the Leadership in Energy & Environmental Design (LEED) and ENERGY STAR (Sustainability Roadmap for Hospitals, 2010).

2)      Water
Availability of good, clean water is crucial to the operations of a hospital in ensuring effective delivery of health services. However, it is important to conserve water through proper use as it leads to major cost savings in water, sewer and energy bills as well as to reduced impact on the environment (HERT, 2014). Conserving water also helps the local community and the nation by reducing pressure on the water and sewer systems. In putting in place a water use efficiency sustainability strategy, DCHC should not compromise on the quality of its services, but rather it should enhance the hospital’s healthcare provision.
DCHC can reduce water consumption by increasing water conservation awareness among staff, patients and visitors (Alliance for Water Efficiency, undated). In DCHC’s sustainability strategy committee, there will be members responsible for ensuring reduction of water use in the health center. These people will continuously monitor the plumbing fixtures (e.g. steam traps) to ensure there are no faults to the water system. They will also train and sensitize other employees and the entire hospital community on ways to reduce water use at DCHC. For example, operators of dishwashers and laundry will be encouraged to wash full loads only. These washing machines will also be reprogrammed to remove additional rinse cycles, as long as this adheres to relevant legislation. There will be putting up of signage at suitable places throughout DCHC instructing employees, patients and visitors on how to conserve water e.g. signage instructing people to turn off taps will be placed near sinks and in restrooms.
Another way of conserving water is through maintenance, repair and modification of water equipment including pipes and pumps. Any drips and leaks in bathrooms, kitchen and laundry will be promptly fixed. Aerators and flow reducers will be retro-fitted on plumbing fixtures to control the water reaching sinks and showers (Healthcare Environmental Resource Center, 2015).
Modern technology will be used in sterilizing the hospital’s equipment so as to reduce water use. For example, steam condensate temping systems will be installed on the sterilizers. The sterilizers will also have electric pumps rather than use water (Healthcare Environmental Resource Center, 2015). The condensates from refrigerators, freezers and sterilizers will be reused on boilers.
When DCHC commissions new premises, water fixtures can be aimed at reducing water consumption. The taps, shower heads and toilets installed in the new building will aim at minimizing water use. Ways to do this include having low-flow flushes for the toilets or by fitting flushometer toilets with water-saving diaphragms. Automatic valves to shut off taps and showers as well as faucets activated by motion sensors will also be installed (Alliance for Water Efficiency, undated).
Water equipment and piping in the new building would use new eco-efficient technology. Water treatment will be onsite so that water is recycled to enrich DCHC’s nosocomial environment. Hence water from laundry and sewer systems will be recycled to irrigate plants within the compound and for a fountain to supplement cooling towers.  Water used to irrigate the plants will be controlled by having adjustable sprinklers and soil moisture controllers. 
If the new premises have a radiology section, flow control equipment will be used on the film processors. Water dispensed by equipment and processes performed at the hospital, e.g. reverse osmosis and heat exchangers, will be reused in the building’s cooling tower (HERT, 2014). Any excessive blowdown in the cooling tower will be reduced, ensuring that it operates close to the manufacturer’s recommended level. The cooling tower will be treated using ozone.
3)      Supply chain management
Trends in supply chain management encourage close collaboration between suppliers, purchasers and users. This collaboration between supply chain partners is enabling organizations to lower costs, reduce inventories, decrease obsolescence, quickly adapt to market changes and have more user satisfaction. One way this is being accomplished is by having digital systems that automatically replenish stocks.
DCHC can improve healthcare by collaborating more closely with suppliers, distributors and patients to ensure that purchases are delivered in optimal quantities at the right time. In so doing, the health center needs to consider the environmental impact of their decisions and actions. This is by:
·         Minimizing wastage and obsolescence through better sourcing and inventory management
·         Determining and reducing losses and environmental costs
·         Minimizing use and cost of hazardous materials
·         Repairing, reusing and recycling
(Sustainability Roadmap for Hospitals, 2010)
The health center needs to embrace environmental accounting practices so as to reduce the costs of the supply chain. This is by determining and recording the costs and benefits of specific environmental issues such as training, legislation and waste disposal (HERT, 2014). This cost-benefit analysis will enable DCHC to make informed decisions, taking appropriate action to reduce the costs and impinge more positively on the environment. The health center needs to take a sustainability strategic approach to improve its ROI and environmental profile.
In its supply chain management, DCHC would be encouraged to consider a lean and green approach that promotes good healthcare, reduces the hospital’s expenses and has little or no impact on the environment. This holistic procurement approach would include considering the maintenance and disposal costs; financially, environmentally and to the patient.
By streamlining its purchasing and inventory practices, DCHC can reduce expenses and wastage. This includes identifying a few suppliers or distributors with whom to form partnerships with; giving them the mandate to track DCHC’s inventory and to restock when necessary as well as committing them to take back extra or obsolete stock (LBNL, 2014).
Most suppliers give good discounts when items are purchased in bulk and DCHC can take advantage of this by sourcing its various purchases from a few distributors. For example, pharmaceuticals, gauzes, syringes, and tissue and sharp containers can all be sourced from one distributor. All these need to be stored in one specific place for better monitoring of the center’s inventory.
DCHC can reprocess certain medical devices designed for single use (American Hospital Association, 2011). These include tissue containers and laundry. In the reprocessing, the health center should adhere to national and international health and safety laws.
Before replacing an item, DCHC will ensure that it is not repairable. It would be harmful to the environment and expensive to the hospital to replace items that are not condemned. As such, together with scheduled maintenance to ensure longevity of an item, DCHC will aim to repair and reuse items with a view to extending their lifespans. Only when an item is no longer serviceable or repairable will it be condemned and replaced. And even then, the health center should try to reuse the item (or its parts) for other purposes or recycle it altogether.
DCHC is encouraged to purchase items made from recyclable material. These items can then be recycled to make other items that will help the institution achieve its healthcare goals. For example stationery and laundry can be recycled to make craft items that can help children in learning.
It is noteworthy that supply chain management may meet some resistance from certain staff members, especially those who have got used to plenty of supplies. It is therefore important to loop all staff and the entire nosocomial community into the sustainability strategy through training. The team spearheading the lean and green supply chain management need to be from all the departments since the environmental concerns will affect everyone at the health facility (HERT, 2014). Looping in senior management is also important so as get moral and financial support towards achieving the required supply chain efficiency.
The efficacy of the strategy needs to be continuously benchmarked against supply chain management best-practice nationally and internationally. This will help minimize risks and costs, leading to a quick turnaround in achieving the set targets. Benchmarking will also ensure that DCHC always strives even more, finding new ways to make the strategy even more sustainable.
To improve and maximize the benefits associated with supply chain efficiency, DCHC needs to institutionalize the practices as well as constantly review and evaluate the various processes and information coming from its information collection systems using TQM tools (Sustainability Roadmap for Hospitals, 2010). In so doing, the health center will be able to reduce its financial and environmental costs as well as deliver better healthcare.
Implementation of a good supply chain management sustainability strategy will impinge positively on all the other sustainability strategies: energy efficiency, water conservation as well as waste management. It will also have an impact on the society by encouraging suppliers to stock sustainable products.

4)      Waste management
Most hospital supplies eventually become waste. While most of it is unregulated general waste, there is a portion that is regulated waste which includes hazardous waste. It is important for a health facility, such as DCHC, to separate and have signage for the various wastes it generates for efficient and safe waste collection, treatment and disposal.
To implement best practices in the field, DCHC can contract out its waste management (World Health Organization, 2011). This would include outlining performance specifications for the contractor. The specifications should be based on existing arrangements at DCHC and should include the requirements of the health facility, standards to adhere to and Key Performance Indicators. The performance specifications for waste management contracting should also stipulate the following:
·         Period of the specified contract
·         The terms and conditions of the contract
·         The nature of the services i.e. collection, treatment and disposal
·         Value addition of the contract
·         Ownership of the waste containers
·         Schedule of the various waste management services
·         Onsite and offsite treatment and disposal
(HERT, 2014)
To ensure DCHC meets its waste management sustainability strategy, waste reporting needs to be inculcated in its operations so as to track performance and evaluate as necessary (World Health Organization, 2011).  There should be reports from the waste contractor and from DCHC staff, with all reports been availed to the senior management. This is important in tracking progress in achieving the waste management sustainability strategy and in determining its impact on financial, environmental and healthcare performance.  The reports will also help DCHC identify waste management trends in the health facility, administer the waste management contract and also track risk and contamination. These reports offer a platform for supervision, assessment and evaluation.
DCHC can reduce handling and disposal expenses, benefit the environment and enhance nosocomial safety by reducing the amount of waste it generates. One way to do this is embracing lean and green supply chain management. For example, by having recyclable purchases, the hospital would reduce condemned items and be eco-efficient. Reuse, recycle and repair would greatly impact on waste management at the hospital.
As it is, DCHC does no produce a lot of regulated medical waste due to the nature of the medical conditions it treats and prevents. These conditions are more psychological in nature rather than clinical ensuring that not many medical samples (e.g. blood and stool samples) are required. However, the health center can further reduce the little amount of regulated medical waste it produces. Because of the nature of its services, treatment regimens at the health facility can be made greener e.g. by reducing the number of pharmaceuticals used so as to reduce hazardous waste.
All staff at DCHC needs to be involved in waste management practices at the health facility. This is because they are variously involved in waste generation and collection. Concomitantly, the staff needs to be trained on various aspects of effective waste management including waste separation, individual responsibilities in waste management process, and health and safety in waste management. Relevant staff members, especially those responsible for the entire process, need to be trained on importance of waste management, best practices and legal requirements (World Health Organization, 2011).
5)      Commissioning
As mentioned earlier in this paper, one of the long-term sustainability strategies for DCHC would be to relocate to the outskirts of Dubai. This would ensure a serene nosocomial environment conducive to the healthcare offered at the health center.
Commissioning of hospital facilities requires special consideration because of the equipment and machinery located in the facilities. DCHC will ensure it considers all the important factors in hospital commissioning by adhering to the outlines and instructions described in the books The Health Facility Commissioning Guidelines and The Health Facility Commissioning Handbook (HERT, 2014).
Special consideration would be given to plumbing, cooling and lighting so as to optimize patient healthcare, benefit the local community and reduce use of scarce resources (Sustainability Roadmap for Hospitals, 2010). The commissioning would involve analysis of current premises in terms of the design and its functionality with a view to improving on these. The new building and embedded equipment and medical systems would consequently be constructed and fitted to address any noted pitfalls hence enhancing efficacy and efficiency of healthcare at the hospital.

Conclusion
Meeting sustainability strategies at DCHC will be an on-going process. Led by the committee set up to spearhead design and implementation of the stated strategies, DCHC will continuously monitor and evaluate the progress in achieving the sustainability strategies.
Successful implementation of all the sustainability strategies laid out in this paper will ensure DCHC becomes more effective and efficient in healthcare provision as well as a better corporate citizen beneficial to the local community and the environment. Savings from the sustainability initiatives can be channeled towards optimizing healthcare for its patients.
The benefits DCHC will accrue from successful development and implementation of the sustainability strategies include:
·         More efficient operations
·         Improved ROI
·         Enhanced company image and reputation through demonstrated corporate social responsibility
·         Better employee motivation and job satisfaction
·         Enhanced talent scouting and retention
·         Better compliance to national and international rules and regulations
·         Improved risk management
·         Pursuance of performance excellence
References
 Alliance for Water Efficiency. (undated). Water Savings in the Medical and Health Care Sector. http://www.allianceforwaterefficiency.org/Medical_and_Health_Care_Systems_Introduction.aspx. Accessed on 9 July 2016.
American Hospital Association. (2011). Hospitals and Care Systems of the Future. http://www.aha.org/about/org/hospitals-care-systems-future.shtml. Accessed on 9 July 2016.
DCHC. (undated). Dubai Community Health Center. http://www.dubaicommunityhc.com. Accessed on 7 July 2016.
Health Research & Educational Trust (HERT). (2014). Environmental Sustainability in Hospitals: The value of efficiency. http://www.hpoe.org. Accessed on 9 July 2016.
Healthcare Environmental Resource Center. (2015). Facilities Management: Water Conservation. http://www.hercenter.org/facilitiesandgrounds/waterconserve.cfm. Accessed on 12 July 2016.
LBNL. (2014). Benchmarking: Healthcare facilities. http://hightech.lbl.gov/benchmarking-hcf.html. Accessed on 10 July 2016.
Sustainability Roadmap for Hospitals. (2010). Drivers and Motivators for Sustainability. http://www.sustainabilityroadmap.org/drivers/index.shtml. Accessed on 11 July 2016.
World Health Organization. (2011). Waste from Healthcare Activities. http://www.who.int/mediacentre/factsheets/fs253/en/. Accessed on 10 July 2016.





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