If hospitals are to improve efficiency and quality while cutting costs, sustainability programs will have to be part of the solution. The Healthy Hospitals Initiative (HHI), founded by Gary Cohen, is helping health systems to meet all of these objectives. He assesses progress and remaining challenges in this field.

Why should hospitals engage in sustainability?

They will save money, improve patient care and better serve the communities in which they're operating.

How is HHI encouraging hospitals to become more sustainable?

Our approach is to embed sustainability as a core business strategy in the health care system and HHI is a vehicle to make that happen. With a coalition of 11 sponsoring health care systems that represent about 500 hospitals, we launched in April 2012. Nearly another 300 hospitals have enrolled, so that's a significant success.

We have an increasing number of state hospital associations that are becoming supporting organizations, so we can interact with their networks to recruit more enrollees. State hospital associations in California, New Hampshire, Michigan, Wyoming and Ohio are about to become supporting organizations.

The Greening America's Hospitals conference at the White House last summer was supportive in validating the initiative. The Commonwealth Fund report released last year stated if hospitals undertake sustainable innovations they would save money. That's a game-changer because health care is so desperate to save money wherever it can be done.

All those things are going to drive enrollment in the initiative and, over three years, we will be able to embed these kinds of strategies in health care.

What are HHI's goals and what will it take to reach them?

We want at least 2,000 U.S. hospitals to implement at least some of the sustainability strategies outlined in HHI (www.healthierhospitals.org). We want to have some kind of incentives set up by the government either through Medicare or other parts of the federal government that would incentivize hospitals to become sustainable. Now that the election is over, we're just starting those discussions with the federal government.

What would be a game-changer in my mind is implementing a healthy food and beverage strategy in institutions. Hospitals need to reduce some of the dangerous health indicators of both their employees and their patients who contribute toward obesity and diabetes.

We know that implementing greener cleaners has a direct and positive impact on asthma rates among nurses. By implementing sustainable flooring, we can also reduce slips and falls, which are big issues.

This intersection between sustainability, patient safety and worker health, that's the sweet spot that we're hoping to reach.

What's causing the change in attitudes among facilities to embrace sustainability?

I don't think there's a lot of opposition any more to sustainability. Once you make the economic argument, it's smart business practice to adopt measures that are going to save money. Then there are the collateral health benefits.

The impediment that we still face is there are so many other pressures hospital CEOs face around changes in care delivery that it's an issue of prioritizing.

There's a huge initiative on the part of the Centers for Medicare & Medicaid Services and Health & Human Services to look at how to reduce waste in the system. And when you say waste, in their minds it means bad clinical practice, wasteful practices that make patient care more expensive. They're not thinking of waste the way I think of waste. We need to connect the dots there.

So even starting from a narrower definition of waste, some consultants say that if you're not doing medical instrument reprocessing, you're wasting enormous amounts of money. That's showing up in mainstream conversations. It's just a matter of a little bit more time and a little bit more uptake and we will achieve this objective.

How should hospitals initiate a sustainability program?

One of the HHI objectives is to have C-suite executives talk with their peers. Health care is a very peer-driven system. CEOs want to hear from other CEOs. Nurses want to hear from other nurses, doctors want to hear from other doctors, architects want to hear from other architects and so on.

Having certain CEOs play leadership roles in HHI has had a big impact. Blair L. Sadler, who was a highly respected president and CEO of Rady Children's Hospital in San Diego for 26 years, is talking with his peers. CEOs from Gundersen Lutheran Inc., La Crosse, Wis.; Partners HealthCare, Boston; Kaiser Permanente, Oakland, Calif.; Dignity Health, San Francisco, are talking with their peers, saying, 'This is important, you need to pay attention to this.'

The other convincing factor is if someone who's not part of the C-suite but participates in Practice Greenhealth tells executives how much they're saving through this initiative, CEOs will pay attention.

Another condition is that under the Affordable Care Act, for the first time, nonprofit hospitals are mandated to perform community needs assessments and to begin to align their community benefits programs with these needs.

That's important because now hospitals are looking beyond their four walls and are asking about the conditions of the community in which they operate that are contributing to obesity, asthma and cancer. It forces leaders to address the social and environmental determinants of health, which is important.

What's the future of sustainability in health care systems and facilities?

Our expectation is that sustainability in health care will become mainstream and it will be a key catalyst as a preventive approach. We'll also see the health care supply chain leading the economy toward a low-carbon, toxic-free future.

Many companies recognize that they need a strategy to reduce their greenhouse gas emissions. They realize they need to get toxic chemicals out of their supply chain. Very large health care organizations are doing this. So the ripple effect of having hospitals lead by creating demand for safer chemicals, cleaner energy and healthier food is influencing the marketplace through group purchasing organizations and suppliers.

We've been at it for 17 years and we've seen enormous changes. Another decade of this work will help to mainstream this whole strategy. We are helping hospitals to move from being providers of chronic disease management to being anchors for sustainability and community health.

Sidebar - The Cohen File

CV: Gary Cohen is co-founder, president and executive director of Health Care Without Harm. He is founder of the Healthier Hospitals Initiative and president of Practice Greenhealth. He is executive director of the Environmental Health Fund and co-founder of Green Harvest Technologies. He graduated from Clark University, Worcester, Mass., with a bachelor's degree in philosophy.

Achievements: Health Care Without Harm worked to eliminate the use of mercury at Beth Israel Medical Center in Boston, which expanded to near-elimination of mercury in U.S. health care.

Health Care Without Harm worked to reduce the number of U.S. medical-waste incinerators from 5,000 in 1996 to 83 by 2006.

Helped raise awareness for hospitals and health care facilities to serve patients and staff healthier food and beverages and for health care to maintain a role in preventing obesity and diabetes.

Accolades: Awarded the global Skoll Award for Social Entrepreneurship in 2006 and the Frank Hatch Award for Enlightened Public Service in 2007.