Editor’s note: This article is the first in a series on the impacts of climate change and climate events on health care facilities and the planning, preparedness and response efforts of health care organizations.

Gundersen Health System's Tomah Clinic is fitted with 175kw ground and 240kw rooftop solar arrays. The renewable energy supports Gundersen's site-based energy independence goal.

Image by John Kerrigan from Gundersen Medical Media

The urgency to address climate change has only increased as the impacts become more apparent, including more frequent and extreme weather events, threats to the resiliency of communities and growing public health inequities. The link between climate change and greenhouse gas emissions is clear. The health care sector contributes almost 9% of total emissions in the United States, and hospitals, therefore, need to be at the forefront of decarbonization efforts.

In June, the Department of Health and Human Services together with the White House launched the Health Sector Climate Pledge. More than 650 hospitals have committed to reduce greenhouse gas emissions by 50% by 2030 and to net zero by 2050, inventory supply chain emissions and develop climate resilience plans for their facilities and communities.

“We know sea levels are on the rise and the planet is warming,” says Richie Stever, CHFM, CLSS-HC, LEED AP, vice president of real estate and property management at the University of Maryland Medical System. “If health care organizations reduce pollution through decarbonization, then we can hopefully stop or reverse the effects of climate change and the negative effects we’ve had on the environment. This pollution has a direct impact on our communities and their need to access health care.”

Goals and vision

In the health care sector, the focus on emissions reductions has mainly been on Scope 1 direct emissions from facilities and Scope 2 indirect emissions that result from the production of energy by utility providers. Identifying emissions sources, both within a facility and outside of it, is an important first step in a developing a decarbonization plan.

“How you define decarbonization goals is really important because carbon exists in many different aspects of the health care industry,” says Peter Dahl, Ph.D., a strategic sustainability specialist with define sustainability LLC. “Do we want to be net-zero energy on-site or for the whole organization? Or are we thinking about zero emissions? Those are very different goals, and this can’t be just a C-suite or director of sustainability decision. It has to engage key stakeholder groups within the organization to understand the likely implications, what we’re working with and, ultimately, how to make it better.”

A clear commitment to decarbonization at the organizational level can help foster that needed engagement. It also makes sustainability a priority across departments and with the support of the leadership.

“The compelling reason to make these decarbonization changes is that they really become part of a much wider mission-driven argument for the organization,” says Kim Shinn, PE, LEED Fellow, BEMP, principal at TLC Engineering Solutions. “If the organization thinks that it’s part of its mission to reduce the operations impact on the climate, then that becomes part of what facilities managers do. If the mission is to improve the population health of the community that we serve, then part of that is decreasing carbon emissions.”

Growing body of strategies

For many health care organizations, decarbonization starts with improving the energy efficiency of facilities, benchmarking and tracking progress, and setting goals to lower consumption and emissions. The Energy to Care Dashboard tool from the American Society for Health Care Engineering (ASHE) helps facilities managers collect and maintain data, identify energy savings opportunities and share results.

“A lot of our hospital utility systems are highly efficient, but they’re not focused on minimizing carbon emissions,” says Jason D’Antona, PE, LEED AP, director of engineering and utilities at Mass General Brigham, Sommerville, Mass. “For example, high-efficiency hot water systems are ubiquitous, but those systems are centered around fossil fuels, usually steam or natural gas. We’re realizing now that because we’re using combustion to create that high temperature water, there’s an emissions profile associated with it. 

D’Antona says that newer applications of existing technologies are an effective way to reduce carbon emissions. In the case of hot water systems, for example, lower temperature hot water coupled with heat pumps is a more sustainable system because it is extremely efficient and reduces site emissions. 

Dahl also encourages facilities managers to think about sources of emissions in buildings other than the burning of fossil fuels and how they fit into broader plans to develop sustainable systems.

“Decarbonization is not limited to energy consumption,” he says. “For example, facilities often have systems that use refrigerants, and those refrigerants can leak over time as Scope 1 emissions, which can be much more potent than just carbon dioxide. Keeping strong documentation of those systems can help to justify the repair or replacement of that refrigeration system.”

The shift away from fossil fuel use to renewable energy is another important facet of decarbonization. Many health care organizations have started using alternative energy sources, often as part of energy efficiency efforts (see sidebar, below).

“At the University of Maryland Medical System, we’re interested in more opportunities for energy capacity, particularly as we focus on resiliency and reliability,” Stever says. “We already have a solar farm that produces 2% of the energy for our whole hospital system. We’re looking at other ways to diversify our portfolio, including partnering with a hydro company to generate another 12% of our capacity from water and a community solar program.”

An evolving area of decarbonization involves electrification mandates, an approach that addresses the emissions issue and encourages the use of renewable energy. The majority of this legislation is happening at the local level, in cities such as New York City, Seattle and San Francisco, where natural gas is banned in new construction.

Statewide efforts to ban the use of natural gas in buildings are also underway across the country. In Maryland, Senate Bill 528, the Climate Solutions Now Act, was enacted earlier this year and sets greenhouse gas reduction and net zero goals for the state. The legislation also includes the development of codes requiring electrification in new and existing buildings.

Stever and his team anticipated this development and started planning before the legislation was finalized. “I do not think this topic is going away anytime soon,” he says. “So we’ve already had internal conversations about how we can prepare ourselves for decarbonization and electrification in both retrofit projects and new construction.”

Kai Abelkis, sustainability manager at the University of Maryland Medical Center, Baltimore, says that many of the buildings in his organization are old and based on older technologies. “To retrofit a hospital that’s been there for hundreds of years is a challenge. For new builds, we’ve already built one facility that’s all electric and we’re learning from that. So going forward, we’re going to have to adhere to these plans, and we want to go in the direction of eliminating carbon-polluting energy in our facilities.”

However, the future of electrification mandates and their impacts on health care facilities are unclear. Twenty states have laws in place that prevent municipalities from banning natural gas. As a result, which health care facilities will be required to retrofit existing facilities or design new ones remains uncertain.

“Some hospitals will have the weight of this on top of them, in addition to operating their facilities and trying to make good long-term decisions,” says Michael Sheerin, PE, LEED AP, chief executive officer at TLC Engineering Solutions. “However, other hospitals won’t have the burden of that unless the leadership says that they have an obligation to do this as a steward of the environment. Some health care systems voluntarily have sought to go net-zero carbon, looking forward to a future where they know that this is an important impact that they make in their communities.”

Electrification, however, could be reframed as a chance to make great strides in decarbonization regardless of where a facility is located and whether the move away from natural gas is required. 

“Facilities managers are likely to be anxious about someone else mandating decarbonization for them,” Dahl says. “But, if they look at it from the big picture perspective, climate change is already affecting the daily operations [of] health care facilities with extreme weather events. If we’re investing in systems and strategies that promote resiliency and sustainability, that’s the big opportunity here. 

Other emissions reductions

Scope 3 emissions, the indirect emissions that result from upstream and downstream activities in the supply chain, are another facet of decarbonization that health care facilities managers can address through their work.

“If you build something new, then there is embodied carbon from upstream because the materials that you need have consequences,” Sheerin says. “Then ultimately operating that building becomes another Scope 1 emission in the future. So, making smart decisions when you need to build something, advocating for and encouraging reuse, and considering the Scope 3 impacts are all pieces of that calculation. 

Dahl says that health care organizations can start asking questions to better understand how suppliers can reduce emissions associated with their products and equipment. 

“We’ve seen that work outside of the health care industry with, for example, the LEED rating system that has been hugely successful in creating a new vocabulary for sustainable design and construction,” he says. “That simply started by asking designers and contractors to document the percentage of products that are meeting certain sustainability criteria, and now it’s ballooned beyond that to have much bigger impacts. The same thing can happen within health care procurement and reducing emissions associated with the supply chain.”

The Long Road

“Our energy conservation program [at Mass General Brigham] goes back to 2008 when we implemented a strategic energy master plan centered around reducing consumption,” D’Antona says. “We have a new lens now to evaluate our systems and path forward, and we have decided to implement a decarbonization master plan. Our previous efforts to reduce consumption have already jumpstarted things. I would suspect a lot of other health care institutions, because of efforts to reduce operating costs and energy consumption, are also ahead of the curve in terms of decarbonization.”

Still, decarbonization is a huge endeavor and a major shift in approach, Shinn says. For health care organizations, it is a transformation that will occur over time and one that will require looking at the carbon implications of every decision and the opportunities for increased sustainability.

“It is basically taking what we’ve been doing for the last 150 years and changing it fundamentally,” he says. “If you're planning on renovating your emergency department five years from now, you can tell the design team that they need to reduce the carbon emissions associated with that renovation by at least 50% over what they would have done last year. If you have to replace a boiler, instead of putting in another natural gas-fired boiler, change over to hot water heating systems and put in heat pumps. In stages and bite-sized chunks, you can actually get your hospital converted over." 

Any decarbonization endeavor will ideally involve a team within the organization as well as outside experts — energy modelers, engineers, architects, designers — who can provide the right insights and analyses. Abelkis notes that health care organizations also benefit greatly from having a staff person driving the decarbonization program. 

“Every health care institution needs to hire a full-time sustainability professional to address the issues related to the environmental impact of their operations,” Abelkis says. “The organizations that are struggling don’t have that direction. The organizations that are succeeding do have that direction because there is an individual whose sole focus is equating human health and sustainability. That moral compass is critically important.”

Meaningful actions

Stever urges health care facilities managers to take a broad view on decarbonization and to acknowledge and embrace the important role they play. 

“We have the authority to make decisions that are fiscally responsible as well as socially responsible,” he says. “And small actions have a large impact over time. I don’t think we as facilities managers fully appreciate how our decisions today are impacting future generations.” 

Shinn agrees that every action, big or small, helps. He also points out that health care facilities should not expect to get to net zero tomorrow; instead, the commitment should be long-term.

“Everything that you do to reduce your carbon emissions and improve the resilience of your facility matters,” Shinn says. “Don’t do things that would have been automatic in the past, and don’t get overwhelmed by the size of this challenge.”

Gundersen Health System’s Goal of Energy Independence

 In 2008, Gundersen Health System, based in La Crosse, Wisc., set out to achieve 100% energy independence, where the system would produce more energy than it consumed. It reached this ambitious goal in 2014 by focusing on reducing energy consumption and using clean energy.

"More recently we’ve shifted to a goal of site-based energy independence,” says Tim Wilson, facilities operations manager at Gundersen Health System. “We’re really focusing on behind-the-meter work right now, including the efficient design of new buildings, to reduce consumption.”

Gundersen’s portfolio of projects includes solar panels, geothermal energy systems, wind turbines, recycling programs, and pharmaceutical and hazardous waste reduction initiatives at its facilities in Wisconsin, Minnesota and Iowa. In addition, two biogas programs are using landfill waste and manure to generate renewable energy.

“We have a biomass boiler facility, and we actually burn waste wood products from lumber facilities,” Wilson says. “We burn the chips to generate steam, and it offsets the majority of the gas that we normally would have purchased. This is by far the biggest energy offset we have at Gundersen in terms of reducing the consumption of fossil fuels.”

Wilson says that Gundersen benchmarks its existing facilities against the national averages for similar sites and then aims to cut the energy consumption level to 50% of the average. The approach for new facilities has been to set even more aggressive energy targets through facility design and then boost efficiency through a variety of sustainability projects.

“At one of our pilot sites in Elroy [in Wisconsin], we’re trying to do 100% offset,” he says. “We’ve designed the building for 27,000 BTUs per square foot, which is a really efficient design target. And then we’re offsetting with rooftop solar and geothermal heating and cooling.”

Gundersen’s sustainability improvements have brought over $3 million in annual savings. Wilson says the financial benefits, however, are just one aspect of an effort with community health and environmental impacts that extend far beyond the facilities themselves. “Obviously, there are health concerns with burning fossil fuels and pollution,” he says. “We’re a health care organization and we don’t want to contribute to that.”