Building a Climate-Smart Healthcare System for California

Climate change remains a serious threat to human health, and healthcare organizations in California, across the U.S., and globally can be catalysts in creating a climate-smart future.


The Bay Area Council Economic Institute would like to thank its partners and co-authors on this project, Health Care Without Harm and the California Clean Energy Fund.

Patrick Kallerman, Research Director at the Bay Area Council Economic Institute and Jessica Wolff, MBA, MSN, U.S. Director of Climate and Health at Health Care Without Harm co-authored this report. Robert Knop, intern at the Economic Institute, Eric Lerner, former Climate Director at Health Care Without Harm, and Ben Bartlett, former Director of Strategic Partnerships at the California Clean Energy Fund also made significant contributions to the report.

The authors would like to thank the following individuals for thevaluable insight and expertise they shared during
the drafting process:

• Ramé Hemstreet, Travis English, Seth Baruch, Hilary Costa, Kathy Gerwig — Kaiser Permanente

• Sister Mary Ellen Leciejewski, Rachelle Wenger, David Jones — Dignity Health

• Gail Lee, Christopher McCracken — UC Health

• Andy Wunder, Kirsten James — Ceres

• Paul Lipke, Robin Guenther, Julie Moyle, Beth Eckl, Lucia Sayre, Courtney Crenshaw, Stacia Clinton, Janet Howard, Hermine Levey Weston — Health Care Without Harm and Practice Greenhealth

This report was made possible in part with support from the Kresge Foundation, the MacArthur Foundation, and the Wallace Global Fund.

Executive Summary

California’s widely varying weather, coastal location, and large population mean the state is feeling the effects of climate change sooner and more severely than other regions. Severe heat waves, prolonged drought, uncontrollable wildfires, increased flooding, poor air quality, invasive species, and increased disease have already begun to impact every aspect of life in the state. The California wildfires of 2017 were the deadliest and costliest in the state’s history, claiming forty-two lives, destroying or damaging 32,000 homes, and costing nearly $12 billion.

California has set extremely ambitious greenhouse gas (GHG) emission reduction targets. The state has goals to reduce greenhouse gas emissions
to 1990 levels by 2020, and to 80 percent below 1990 levels by 2050, but despite recent progress, current simulations show the state’s emissions increasing around the year 2030, and continuing up from there. In order to reduce the health impacts of climate change, every business sector must take responsibility, but the massive size and mission-driven nature of the healthcare sector provide even greater impetus for action.

There is an increasingly wide range of proven climate-smart technologies and interventions that can be employed to mitigate emissions in hospitals. A number of California hospitals have established themselves as national leaders in their efforts to reduce their carbon footprints to improve the safety and well-being of their communities. If all hospitals in California adopted the climate-smart strategies being implemented by these leading institutions, the sector would be a key contributor to meeting the state’s GHG emission reduction goals, protecting the health of California communities, and supporting the transition to a low-carbon economy.

The chart above demonstrates the total contribution the healthcare sector could make in the race to meet California’s goals. To help sector leaders and policymakers with their efforts to combat climate change, this report examines why the healthcare sector must act, what the extent of the sectors emissions are, and how investing in climate-smart strategies can provide health and often financial benefits. The report showcases some of the major steps that California hospitals have already taken to redesign their facilities and implement practices to address climate change. It then concludes with a list of recommendations for concerted private and public-sector action.

In order for hospitals to make the dramatic changes needed to build a climate-smart healthcare system, state policies and regulations must support climate-smart healthcare strategies. Even in California, a national leader in environmental policy, there are policies and regulations that limit the healthcare sector’s ability to act. Policymakers and regulatory bodies need to understand how healthcare’s needs and regulations uniquely impact their ability to implement climatesmart interventions, and healthcare executives need to advocate for the integration of healthcare into climate and energy policy and climate considerations into health policy. With the right the healthcare sector can become a considerable positive force to help the state meet and exceed its climate goals, direct billions of dollars into the low carbon economy, and serve as a model to be replicated in other states and subnational entities around the world.

To help sector leaders and policymakers with their efforts to combat climate change, the analysis in this report makes the case to invest in climatesmart health systems and details ways to achieve that goal.

Sector and Policy Recommendations

The list of recommendations below was developed with the intention of guiding concerted private and public-sector action. To make the healthcare sector more sustainable, it will require significant coordination between the healthcare sector, its upstream and downstream suppliers, and policymakers on a local, state, and national level.

Sector Recommendations

Perform energy audits of facilities and implement a continuous commissioning program to reduce energy consumption. Operating buildings as designed and immediately addressing suboptimal conditions and settings presents an opportunity to reduce GHG emissions while positively impacting the bottom line. A continuous commissioning capability that combines real-time fault detection with algorithms that identify high payback actions will quickly resolve operating problems, improve comfort, and optimize energy use.

Invest in renewable energy. The combustion of fossil fuels leads to significant adverse health impacts and hospitals have the responsibility to protect public health. Renewable energy sources are becoming cost competitive with fossil fuels and eliminate the risks of energy cost volatility. California has strong policy support and incentives for on-site and off-site investments in renewable energy.

Advance the transition to a low-carbon transportation system for cleaner air and healthier communities. Hospitals should follow a four-pronged approach:
A. Incentivize alternative transportation modes for employees.
B. Convert fleet vehicles to low/zero emission fuels.
C. Provide electric vehicle (EV) charging infrastructure.
D. Address supply chain impacts through adopting idle-reduction practices,consolidating deliveries, and incorporating EPA SmartWay criteria in vendor selection.

Purchase local and sustainably-grown and produced food to reduce climate impacts from industrial agriculture and transportation, and to support the regional food economy. As large-volume buyers, hospitals can make purchasing commitments to local producers that allow them to expand operations and invest in new processing equipment. Hospitals should instruct their GPOs to source local food and ensure it is clearly labeled as such in catalogs and ordering forms.

Focus on waste reduction as the key strategy to reduce environmental impact and associated costs. Look for opportunities to switch from disposable to reusable options across the system—sharps containers, sterilization cases, totes, isolation gowns. Reduce preand post-consumer food waste for savings on food purchases and significant GHG emissions reduction. Regular staff training on waste segregation is critical for success.

Implement an environmentally preferable purchasing policy and embed environmental attribute considerations in purchasing standards, specifications, decisions, contracting, and requests for proposal (RFP) to prioritize environmentally preferable, low-carbon products and services.

Conserve water and save money on water and sewer bills. Start with a water audit to analyze the facility for leaks and identify opportunities to:
A. Save water in facilities (e.g. maintain boiler steam traps, capture condensate on cooling towers).
B. Install water-efficient equipment (e.g. low-flow, sensor-activated faucets).
C. Reduce water use for irrigation (e.g. xeriscape landscaping, rainwater collection).

Advocate for climate-smart public policies. Use healthcare’s trusted voice to educate policymakers and the public that strong climate mitigation and resilience policies are good for both public health and the control of health care costs.

Policy Recommendations

Adopt energy-saving opportunities from national standards into California code. For some years, California requirements for healthcare infrastructure—largely set by the Office of Statewide Health Planning and Development (OSHPD)—have been substantially more restrictive than national and other state standards. National standards contain a number of opportunities for energy savings, which should be adopted into California codes and that should be considered.

— Develop a leadership position in energy conscious health care ventilation through pilot projects and research. Hospital ventilation standards present a significant opportunity for energy and carbon reduction and current California standards exceed national requirements The California Energy Commission (CEC) has begun an advanced HVAC demonstration project, and should expand this opportunity, taking a role of national leadership in introducing new technology into the national standards paradigm.

Design streamlined approval processes for proven technologies that have demonstrated significant energy-savings. The time and money imposed by permitting is significant and makes it difficult for hospitals, especially smaller hospitals, to do even simple energy-saving upgrades like LED retrofitting. Streamlined approvals processes should be implemented for projects such as LED retrofitting, the conversion of exhaust fans to low voltage units, the replacement of inefficient motors with efficient ones, and the replacement of water savings devices.

Create an advocate in the Attorney General’s Office for enforcement of the Solar Rights Act (Code 658). The Solar Rights Act is largely ignored by municipalities and many health systems have had significant pushback when trying to install solar projects. Health systems are unlikely to complain to a municipality for fear of repercussions. A Solar Rights Act Advocate to whom developers and customers could file complaints could facilitate the installation of additional solar at an increased pace.

Maintain and scale state support for the SelfGeneration Incentive Program (SGIP). This program makes it economically viable for health systems to install battery storage, and these rebates should be maintained until large-scale battery storage becomes more competitive.

Continue state funding to support the transition to electric vehicles and renewable fuels, particularly for development of needed infrastructure. Include social equity measures to promote access to alternative transportation and vocational opportunities related to new transit technologies.

Create policy incentives to support shifts toward reduced meat and dairy production and consumption. Examples include: increasing research and support for transitioning animal agriculture farms to integrated systems or to the production of nitrogen-fixing protein alternatives such as organic legumes, or implementing carbon tax policies that account for livestock emissions.

Adopt farmland conservation efforts that include access and affordability strategies, to not only protect farmland, but to protect the benefits that the state’s small-scale, sustainable farmers provide and to ensure their livelihoods.

Examine ways to encourage municipalities—especially medium and small municipalities—to commit to Zero Waste Principles. The majority of hospital waste is non-regulated and is therefore handled by municipal providers just like residential waste. Several major California cities, including San Francisco and Los Angeles, have committed to Zero Waste Principles in cooperation with refuse and recycling service providers. Structures to encourage and even incentivize smaller municipalities to commit to Zero Waste could go a long way in reducing a hospital’s footprint.

Support a sustainable water supply through conservation, efficiency, and infrastructure maintenance. Ensure full implementation of the Sustainable Groundwater Management Act. Provide adequate funding for smart water management projects and programs, including funds to provide safe and affordable drinking water to all Californians.