Firmly Centered in the Circle of Excellence

Cleveland Clinic shares some secrets to its greening success.

By Kaeleigh Sheehan, Practice Greenhealth Member Engagement Manager, Greening the OR Initiative on May 10, 2016

staff members cleaning operating room

Cleveland Clinic staff members train in an energy reduction program that is changing the way operating rooms function at every level (Courtesy of Cleveland Clinic).


WHAT STARTED as an initiative focused primarily on waste minimization has fundamentally shifted to a multi-disciplinary, multi-stakeholder program resulting in more efficient, healthier, data-driven strategies. All of the Greening the OR Circle of Excellence winners are tracking data to measure success. These top performers have engaged staff and continued the education and communication process to maintain momentum.

For the last two years, Cleveland Clinic has been a recipient of the Greening the OR Circle of Excellence. This year, the academic medical center, with 1,440 beds and 86 operating rooms, has continued to be a leader in the space, ranking first in the Greening the OR Circle of Excellence to earn the Greening the OR Leadership award.

At Cleveland Clinic, a common theme within their program was the deep commitment from staff across departments. From stakeholder engagement like the EcoCaregiver™ campaign, to clinician-led education and fellowship opportunities, to communication and cross-departmental committees, all staff are motivated and responsible for the environmental stewardship of the organization.

In 2015, Cleveland Clinic’s Greening the OR programs diverted over 169 tons of waste, reduced energy by 3.6 million kilowatt hours, and saved the organization $1,015,226.

Among the many impressive programs and projects underway at Cleveland Clinic in 2015, a few that stood out include:


Physician champion Matthew Davis, MD, studied the impact of education and engagement of physicians and OR staff during a project to promote sustainability and waste reduction in the OR.

Davis selected five operating rooms most often used by the department of General Surgery and allowed for case types and length to vary for different waste volumes.

OR waste was collected, separated and weighed to quantify baseline waste production. Ten weekdays were studied for this baseline determination. As an initial intervention, decreasing the size of the receptacles for restricted medical waste was enacted, followed by a second 10-day audit period.

An education seminar was provided to OR nurses, surgical technicians, and physicians within the department of General Surgery. The smaller receptacles were left in place for this phase. A final 10-day audit was then performed.

The study participants were not told which ORs were being audited or when. The investigators chose OR days in advance based on case volume rather than the types of cases.

The baseline audit showed a distribution of 64 percent regular waste, 28 percent RMW and 8 percent recyclables. Investigation of the contents of the RMW bags revealed a potential reduction of 50 to 70 percent, based on institutional policies. For the first intervention, reduction of the volume of RMW receptacles yielded a decrease of 11 percent in RMW waste (27.5 percent of total waste to 24.4 percent). In the post-education audit, RMW was found to decrease an additional 21 percent (24.4 percent to 19.2 percent), resulting in an overall decrease of 30 percent from baseline. When extrapolated systemwide, this represents a yearly reduction potential of nearly 250 tons of waste, with an estimated cost savings greater than $150,000 per year.

During the post-education period, subjective feedback was collected from OR staff and physicians, who noted that an overall greater awareness of sustainability efforts allowed them to focus on proper waste allocation. As well, many participants reported either no prior knowledge of institutional policies or incorrect perceptions of proper waste practices.

While caregivers express interest in improving quality in their work environment, many lack the proper tools or information to do so. Having a dedicated group that is focused on a specific project can provide a better opportunity for a greater number of people to succeed.

The impact of changing the receptacle size shows that a large part of participating in sustainable practices relies on ease and availability. However, with the proper education and an engaged focus, an even greater result can be achieved.


In addition to all of the equipment, instruments and patient monitoring devices, the OR requirements for air changes per hour, strict temperature and humidity parameters, pressure relationships, and energy-intensive surgical lighting systems, make it a large energy consumer. Cleveland Clinic focused on HVAC setback as a strategic priority to help the system reduce its overall energy profile.

ASHE standards require a minimum of 20 ACH and four outdoor air exchanges when the room is in use, and Cleveland Clinic’s operating rooms were at 25 ACH, with no measurable benefits. Per ASHRAE 170 guidance, these ACH can safely be set back when the OR is not in use.

In collaboration with the Infection Prevention Department, Surgical Operations Executive Committee and the Design and Planning Department, the Facilities Department adjusted all main campus ORs to 20 ACH in occupied mode.

The team, which included representatives from facilities, design and planning, surgical operations, infection prevention, surgical staff and other key stakeholders, evaluated and provided recommendations for the unoccupied settings.

Using centralized stations to monitor real-time, on-the-floor operating room conditions linked to patient records, Cleveland Clinic’s main campus implemented HVAC setback in 66 of its 86 operating rooms, saving the organization $255,850 and reducing energy consumption by 3,411,333 kWh.

LED Lighting

LED lighting has been a focal area for a number of years and LED surgical lights were standardized in 2011 and are updated as operating rooms are renovated. In 2015, pattern lights became the next frontier and main campus facilities managers replaced 12,240 fluorescent tubes with LEDs for the pattern lights for the operating rooms, resulting in brighter, cooler ORs with increased light quality. LED surgical lighting and LED pattern lights helped to reduce energy consumption in the surgical department by another 191,308 kWh and anticipate savings of $84,342 annually.


Understanding the role anesthesia plays in greenhouse gas emissions and the impact of pharmaceuticals on the environment, Cleveland Clinic has been working to reduce its footprint for years. Desflurane, the anesthetic gas with the largest global warming potential of the three traditional anesthetic gases, has been removed from Cleveland Clinic’s formulary and is no longer being used. The organization has also worked to reduce both nitric and nitrous oxide use.

Led by Brian Parker, MD, Cleveland Clinic Anesthesia Institute champion and Deepa Cherla, MD, Cleveland Clinic is currently working to implement low flow rates by utilizing new anesthesia equipment using digital flow control technology and documenting the impact on anesthesia usage. In June of 2015, Cleveland Clinic hosted a Grand Rounds with Lauren Berkow, MD, Associate Professor of Anesthesia and Critical Care from John Hopkins. Collaboration is at the heart of success of all these programs and this afforded caregivers the opportunity to learn what other systems were doing to affect change.

Clinician Engagement and Education

A vital component of clinic engagement is the Ken Lee Sustainability Fellowship. This program designates a physician OR champion to drive change in the Greening the OR Committee. Cherla, the third physician champion, is working to drive change along with Davis. This type of clinical engagement has accelerated and deepened the pace of change and helped to get organizational buy in for strategies such as the OR setbacks.

An EcoCaregiver employee engagement program developed an education module on energy management called “Energy Savings & You.” During this course, Cleveland Clinic caregivers explore an energy demand reduction program designed to reduce costs and decrease emissions while providing the highest quality medical care. To date, more than 20,000 caregivers have been trained in this program at Main Campus and more than 50,000 enterprisewide. This complements an “I am Sustainable Healthcare” program that has highlighted the work of Greening the OR champions to inspire others to follow the path. Ultimately, creating champions at every level of the organization makes the changes enduring and has changed the way a Cleveland Clinic operating room works on every level.