First Do No Harm: Channeling healthcare dollars into health-promoting innovations

The Health Care Without Harm campaign has permanently transformed the market for medical products and services. By helping hospitals to develop purchasing criteria that consider the ultimate health impacts of products as well as their cost, our visionary yet practical approach has given rise to new manufacturing lines, new industry trends, and less illness among the patients, neighbors, and health care providers who are most impacted by hospital pollution.

The innovations that we have promoted include mercury-free medical devices, safer health care waste treatment technologies, healthy hospital food programs, multi-disciplinary “green teams” for facility construction, PVC-free IV bags, and training/mentorship workshops for nurse-leaders in the environmental health movement, among many other creative initiatives for health care leadership.

All of these innovations require breaking with traditional hospital policy in order to develop alternatives to toxic emissions. Yet when “business as usual” is disrupted at facilities that have become complacent to the health hazards they create, not only patients benefit, but also nurses, doctors, waste handlers, and the many people living near hospitals. And as environmental health practices improve, so do patient outcomes and the overall cost of care.

Our movement is unique – no matter how commonsense it may appear, the concept of “healthy hospitals” was only rarely on the agenda prior to the formation of Health Care Without Harm (HCWH) and Hospitals for a Healthy Environment (H2E). However, today this message is being picked up by health market leaders from Kaiser Permanente to the American Nurses Association to Premier, with an estimated 1,400 hospital partners taking an active stand in favor of better public and environmental health.

About You

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n/a

Your idea

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Focus of activity

Policy/institutional change

Year the initiative began (yyyy)

1996

Positioning of your initiative on the mosaic diagram

Which of these barriers is the primary focus of your work?

Complex, expensive medicine

Which of the principles is the primary focus of your work?

Center consumers in business model

If you believe some other barrier or principle should be included in the mosaic, please describe it and how it would affect the positioning of your initiative in the mosaic:

On principle, hospitals should be leaders in the movement for health-promoting business practices. Their oncology wards should be free of carcinogens, their cafeterias should model good nutrition, their neonatal intensive care units should use non-toxic life support equipment, and their waste should be treated in ways that does not create health problems.

Yet this is not just a question of principles – medical services will ultimately cost society less and bring greater rewards if we can avoid dangerous pollution. We ask health care systems to be responsible consumers and use their significant purchasing power to drive disruptive innovations in the marketplace – thus leading to safer products and institutions that place a higher premium on human health.

Name Your Project

First Do No Harm: Channeling healthcare dollars into health-promoting innovations

Describe Your Idea

The Health Care Without Harm campaign has permanently transformed the market for medical products and services. By helping hospitals to develop purchasing criteria that consider the ultimate health impacts of products as well as their cost, our visionary yet practical approach has given rise to new manufacturing lines, new industry trends, and less illness among the patients, neighbors, and health care providers who are most impacted by hospital pollution.
The innovations that we have promoted include mercury-free medical devices, safer health care waste treatment technologies, healthy hospital food programs, multi-disciplinary “green teams” for facility construction, PVC-free IV bags, and training/mentorship workshops for nurse-leaders in the environmental health movement, among many other creative initiatives for health care leadership.
All of these innovations require breaking with traditional hospital policy in order to develop alternatives to toxic emissions. Yet when “business as usual” is disrupted at facilities that have become complacent to the health hazards they create, not only patients benefit, but also nurses, doctors, waste handlers, and the many people living near hospitals. And as environmental health practices improve, so do patient outcomes and the overall cost of care.
Our movement is unique – no matter how commonsense it may appear, the concept of “healthy hospitals” was only rarely on the agenda prior to the formation of Health Care Without Harm (HCWH) and Hospitals for a Healthy Environment (H2E). However, today this message is being picked up by health market leaders from Kaiser Permanente to the American Nurses Association to Premier, with an estimated 1,400 hospital partners taking an active stand in favor of better public and environmental health.

Innovation

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Define the innovation

The Health Care Without Harm campaign has permanently transformed the market for medical products and services. By helping hospitals to develop purchasing criteria that consider the ultimate health impacts of products as well as their cost, our visionary yet practical approach has given rise to new manufacturing lines, new industry trends, and less illness among the patients, neighbors, and health care providers who are most impacted by hospital pollution.

The innovations that we have promoted include mercury-free medical devices, safer health care waste treatment technologies, healthy hospital food programs, multi-disciplinary “green teams” for facility construction, PVC-free IV bags, and training/mentorship workshops for nurse-leaders in the environmental health movement, among many other creative initiatives for health care leadership.

All of these innovations require breaking with traditional hospital policy in order to develop alternatives to toxic emissions. Yet when “business as usual” is disrupted at facilities that have become complacent to the health hazards they create, not only patients benefit, but also nurses, doctors, waste handlers, and the many people living near hospitals. And as environmental health practices improve, so do patient outcomes and the overall cost of care.

Our movement is unique – no matter how commonsense it may appear, the concept of “healthy hospitals” was only rarely on the agenda prior to the formation of Health Care Without Harm (HCWH) and Hospitals for a Healthy Environment (H2E). However, today this message is being picked up by health market leaders from Kaiser Permanente to the American Nurses Association to Premier, with an estimated 1,400 hospital partners taking an active stand in favor of better public and environmental health.

Context for Disruption:

Since our efforts began 11 years ago:

- 98% of medical waste incinerators have been shut down, opening the door for cleaner and cheaper technologies.

- Expanded recycling has saved hospitals millions of dollars. At one small facility in Florida, the switch to reusable mammography gowns alone reduced costs by $11,000/year. In New York, Beth Israel Medical Center reduced fees by over $1 million/year as a result of improved waste segregation and reusable sharps containers. And in Poland, a county hospital cut 70% of its waste management costs by recycling 35,000 tons of materials.

- All of the country’s major pharmacy chains now offer cost-competitive digital thermometers, which are affordable to low-income families and safer for developing children. The three largest healthcare purchasing organizations in the U.S. have also taken mercury “off-contract,” and the European Union just passed a mercury thermometer ban that is being replicated at facilities in the Philippines, India, Argentina, & Brazil.

- Nurses across the country are helping patients lay the groundwork for better lifelong health by educating them about environmental health hazards. In one major Pittsburg hospital, nurses now teach new parents not only about breastfeeding, but also about how to avoid mercury, pesticides, and toxic cleaning products in the home.

- More than 113 hospitals, representing 30 million sq. ft. of construction and renovation, are implementing sustainable design criteria from the Green Guide for Health Care. The GGHC is the first ever green building resource to integrate public health criteria into its guidelines.

- The movement for sustainable and healthy food is reaching hospital cafeterias, with facilities in 17 states supporting the Healthy Food in Health Care pledge. Kaiser Permanente is hosting farmers’ markets in California and Hawaii, while Fletcher Allen in Vermont allows patients to be in control of their own menu choices – offering organic, local food.

Delivery Model

HCWH’s delivery model is unique in its breadth & organizing approach:

- We successfully link purchasers with industry giants in pursuit of a shared goal – to grow the market for a sustainable health care system. For example, our partnership with Catholic Healthcare West was a guiding force in building early demand for PVC-free medical products, which are now being used nationwide.

- Our network joins together more than 450 public and private sector organizations in 55 countries, including doctors, nurses, and patients as well as environmentalists and scientists. In the United States we also work with group purchasing organizations representing $70 billion in procurement power, as well as many other partners.

- The support, guidance, and training that we provide to health facilities is eminently practical. For example, we not only call on hospitals to switch to safer and cleaner products, we also provide directories of manufacturers. We have demonstrated that basic supply and demand principles will bring prices down for healthier products, and often work with big purchasers in order to create momentum that can be enjoyed by all.

- We have developed an “open source” model of organizing, and create tools which allow people to intervene in the healthcare system at multiple entry points. Hospitals and health care facilities can choose from a menu of options, and individuals can participate in our many initiatives through engagement with HCWH Workgroups, H2E teleconferences, and gatherings such as CleanMed Conferences.

Beyond all else, we strive to link people around a common purpose, and support innovation on multiple levels. Rather than building a monolithic organization, we have devised structures that encourage inclusion and accountability.

Our market penetration is measured in practical victories, such as the dollars invested in safer products, waste volumes reduced and recycled, piloting green building practices, toxic products eliminated, etc.

Key Operational Partnerships

Health Care without Harm implements many of its goals through strategic partnerships, which broaden our base of talent, expertise, funding and ideas.

We are a founding member of Hospitals for a Healthy Environment – a collaborative initiative also supported by the U.S. Environmental Protection Agency, American Hospital Association, and American Nurses Association. H2E’s members include over 1,400 hospitals and numerous large health systems, Group Purchasing Organizations, healthcare consulting firms and product manufacturers.

We also work with dozens of high-profile architectural, engineering, and construction firms through the Green Guide for Health Care, as well as the U.S. Green Building Council and state agencies. Our initiative in food purchasing has brought in nutritionists from the Harvard School of Public Health, as well as leading organic farmers, hunger advocacy groups, and healthcare service networks. Internationally, we work with Health and Environment Ministries, as well as public hospital networks, patient rights groups, and the World Health Organization. Universities and research facilities support the campaign with valuable scientific expertise.

Over the next 12 months, we expect to launch a major new Research Collaborative with the support of leading healthcare systems such as Kaiser Permanente, to develop evidence-based studies on the interconnection between patient, environmental, and workplace health and safety.

Impact

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Financial Model

Most of our income comes from foundations, governments, and other institutional donors, including UN agencies. The total of these contributions is approximately 93% of our budget. However, we do raise more than $200,000 annually from other sources, and our initiatives benefit from a significant number of in-kind donations (of staff time and other resources) on the part of our members and partners.

As is further described below, we are interested in developing earned income models to support our work, mostly in the form of fee-for-service arrangements, consultancies, and memberships from health care systems. We are seeking support to undertake this work, such as business planning assistance in 2007/2008.

In keeping with the principles of HCWH’s organizing approach, our fundraising plan provides financial support to more than 25 organizations that work together and share their expertise, thus building the long-term capacity of the movement far beyond the reaches that any one organization might have.

What is your annual operating budget?

$3,259,125

What are your current sources of revenue? (please list any sources that are foundation grants)

We have received recent funding from the following foundations and institutional donors:

Tides Foundation, Panta Rhea Foundation, V. Kann Rasmussen Fdn., Winslow Foundation, Johnson Foundation, Merck Family Fund, Barr Foundation, Bush Foundation, Cedar Tree Foundation, Claneil Foundation, Francis Leer Fdn., Clarence Heller Fdn., Columbia Foundation, Oak Foundation, Skoll Foundation, UN Environmental Programme, CEC, Deshpande Foundation, UN/Global Environment Facility, Beldon Fund, Martin Fabert Fdn., Heinz Foundation, Kendeda Fund, Rockefeller Brothers Fund, Overbrook Foundation, Park Foundation, John Merck Fund, Blaustein Foundation, NY Community Trust, and one anonymous donor.

We have also received funding from a legal settlement donation, as well as income from event fees, interest, and other organizations who reimburse us for shared resources.

We are in the midst of conversations with many other potential donors, several of which are considering proposals from HCWH and H2E.

Effectiveness

We have influenced the market for medical devices globally, as well as health system practices in dozens of countries, government policies, and training programs. Domestically, we have shifted procurement and distribution patterns for hospital group purchasing organizations that control 80% of the sector’s purchasing dollars.

A few examples of the fundamental changes that have been set in motion include:

- Virtually eliminating the market for mercury medical equipment in the United States. Beyond the successes listed above, we have also: convinced all of the nation’s top pharmacy chains and 15 national retailers to stop selling mercury thermometers; passed mercury thermometer bans in 11 U.S. states; launched a mercury thermometer exchange program, now institutionalized in many states; and worked with major manufacturers such as Becton Dickenson and Welch Allyn to encourage mercury-free alternatives.

- Promoting a wholescale transformation of the ways in which the health care system manages its waste. In addition to the examples listed above, we have also initiated a computer take-back program in the health care sector, reducing the toxicity of hospital waste. Internationally, we have demonstrated the effectiveness of non-combustion alternatives for medical waste treatment in a variety of settings, including a Philippines measles vaccination campaign that generated more that 18 million syringes.

- Decreasing the use of toxic chemicals in the healthcare industry, from products such as medical devices and building materials, and now in food. Specifically, we: pushed the Food and Drug Administration to issue a warning about the dangers of DEHP leaching from PVC medical products; stimulated important changes in the flooring and carpet industries; & supported the development of a safer chemical policy for healthcare. We also persuaded major health associations to adopt a resolution advocating for meat raised without the use of non-therapeutic antibiotics.

Which element of the program proved itself most effective?

We have demonstrated significant success in all of our initiatives that were established more than 5 years ago, including campaigns on mercury elimination in hospitals and safe and sustainable health care waste management. We have also made major progress in shifting the medical device market away from PVC plastic – a material that is toxic to human health all along its lifecycle (from production to use to disposal) – although the vinyl industry has actively worked against our efforts in this arena, thus leading to slower action on behalf of manufacturers.

More recently, our newer initiatives such as sustainable and nutritious food purchasing in hospitals, and green building for healthcare construction, have experienced an even more rapid uptake in the national health sector. This is likely due to the momentum and relationships that the campaign has established to date, which can now be leveraged to generate further disruptive – and positive – innovations in hospital practice.

Internationally, our campaign is similarly strongest in those countries where we have the longest track record and have established the deepest relationships with major health care systems, such as the Philippines, Argentina, Mexico, South Africa, India, and many countries of Europe (both western and eastern). However, new work is now being done in Brazil, the Caribbean, China, Malaysia, Indonesia, Tanzania, Botswana, Senegal, and many other countries, to good results.

We trust that our programs will continue to be effective, based on our track record, the strength of our partnerships, and the underlying clarity/commonsense approach of our basic organizing principles and demands.

Number of clients in the last year?

As was mentioned above, we have many “clients” who benefit from our work. A few of the most significant include:

o All major Group Purchasing Organizations in the U.S.

o 1,400 hospitals domestically

o 150 construction firms

o Ministers of Health and the Environment in the Philippines, Argentina, India, and several other countries.

o Large health care systems, including both public and private providers (e.g. Kaiser Permanente and Catholic Healthcare West in the U.S., among others, and the National Health Service in the U.K.)

o Health professional organizations and agencies, including international agencies such as the International Council of Nurses, the World Health Organization, and many more.

What is the potential demand?

The demand for our work is huge and growing.

As Dennis O’Leary, President of the Joint Commission, stated earlier this year:

“The green movement is healthcare is going to be a huge tidal wave.”

Scaling up Strategy

We have several inter-related priorities for the next three years:

1) Diversifying our income stream through creating fee-for-service models (and potentially a satellite business). We expect that this will help to build our financial stability while enabling us to offer improved – and more extensive – services to hospitals. It should also help to further leverage change by taking the success that we have experienced with no-cost pilot projects and multiplying it through consultancy efforts.

2) Promoting the creation of hospitals that are cutting edge on all levels: zero waste, climate neutral, PBT-free, and water balanced in both their buildings and their delivery. These system leaders or “Tier 1” facilities will help to define a new framework for quantifying community benefit from healthcare activities, and will lead the way for other facilities to follow. To paraphrase one leader, these organizations will recognize that you “can’t build a green building and still have Styrofoam cups in your cafeteria.”

3) Developing a Research Collaborative for patient, environmental, and worker health and safety (as was described above). This Research Collaborative will help to link innovation in the marketplace and in healthcare systems to scientific knowledge and evidence-based practice for improved medical systems. It will also provide a framework for the creation of multi-disciplinary continuous learning environments, through joint studies, interactive websites, and collective investment in future improvements.

4) The ongoing internationalization of our work, based on the foundations that have already been laid in Europe, Asia, Latin America, and Africa. We have obtained significant investments from the Skoll Foundation, the Oak Foundation, and the United Nations system in order to implement this “scaling up” program, and are now seeking to supplement these income streams with new sources of geographically-diverse donors.

Stage of the initiative:

1

Expansion plan:

In keeping with the priorities established above, we expect to:

1) Conduct a strategic planning process in 2007, with the support of a business and organizational development consultant. This effort will be led by HCWH, and will integrate leaders of other entities, such as Hospitals for a Healthy Environment, the Green Guide for Health Care, and other groups providing implementation assistance to hospitals within our network.

2) Carry out high-level conversations with key stakeholders in potential Tier 1 hospitals, to identify those who are willing to make a facility wide investment in disruptive innovations linking environmental, patient, and worker health. Children’s hospitals are already proving to be particularly receptive to this idea. Funding will be requested from the facilities themselves initially, as well as outside donors.

3) Current health sector leaders who work with HCWH are particularly excited about the Research Collaborative and its potential impact. Several systems have expressed interest in participating in this initiative, which is expected to launch by early 2008. Issues that might lend themselves to future research projects include air pollution (and ventilation systems), chemical impacts on nurse retention, etc. Other issues will be identified as they become relevant to leading partners.

4) We are in the process of creating and/or strengthening legal entities outside of the U.S., in order to facilitate regional funding proposals.

Origin of the Initiative

Our initiative was founded by many leaders. The following is the story of one (edited from Bioneers):

"Nobody breastfed in Charlotte, North Carolina in the late 1970s. So when registered nurse Charlotte Brody decided to nurse her baby, eyebrows went up.

Brody was undeterred. She considered the wellbeing of her son more important than prevailing local mores.

Fast forward to 1994. Brody, now a mother of two, had just resigned as the director of the local Planned Parenthood to join the Citizens Clearinghouse for Hazardous Waste when the EPA released a report that would change her life. The study found that medical waste incinerators were the nation’s number one source of dioxin, a deadly carcinogen.

The thought that Planned Parenthood had been poisoning the air sent Brody reeling. But as an activist, she also spied an opening for change. In 1996, Health Care Without Harm was born."

This Entry is about (Issues)

Sustainability

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What are your two main challenges to finance the growth of your initiative

The largest challenge that we currently face is the lack of money for business development assistance, which is a complex process in a non-profit organization environment. We are looking for $100,000 in outside support to finance this process, which will help us to strengthen our overall financial position (by diversifying our income sources) and scale up our work.

Another challenge that we face is rooted in the success of our programs, which tend to expand in geographic reach and intention soon after launching given their quick uptake by the health care sector in many states and countries. Thus, there is always a financial tension between investing money in program expansion vs. core infrastructure, such as media, fundraising, and the creation of a modest financial reserve. This is particularly notable with our international programs, which are expanding in impact exponentially and are beginning to be limited by the lack of available resources. Raising money for our European campaign, for example, has been especially difficult given the different philanthropic environment in that region.

How did you hear about this contest and what is your main incentive to participate?

We were contacted by Tyler Ahn at Ashoka – thank you! Our main motivation is the increased visibility of our efforts, particularly in the public health & social entrepreneur communities. We are interested exploring further relationships with Ashoka and the judges, and look forward to your comments.

The Story

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Do you have an annual financial statement?

Yes, and it can be made available upon request.

Do you currently have an annual financial statement that tracks profit/loss?

We are audited annually, and this audit includes a statement of financial position and cash flows.

Please describe the amount (and/or type) of funding you need to implement your initiative, at year 1 and at year 5.

Our current budget of approximately $4 million (for HCWH and other related organizations) can be broken down by ultimate funding destination as follows:

US workgroups and efforts: 52%
European campaign: 16%
Global policy & outreach: 8.3%
Latin American campaign: 6.2%
South East Asian campaign: 3%

Other:
Administration: 8%
Fundraising: 3.5%
Media: 3%

As was described above, we are also seeking $600,000 to launch the research collaborative and explore business development models, and are working to establish new donor relationships to sustain ongoing activities. By year 5, we expect that our budget will have increased with fee-for-service income and contracts, in order to underwrite the expected increase in costs.

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