Sustainability Beyond Hospital Walls

The next step for health care sustainability involves community benefit—delivering the health care mission within local neighborhoods and communities.

By m. diane mccormick on January 19, 2017

sustainabilityIn 1856, five Sisters of Providence arrived in the rugged Washington Territory to help the region’s pioneers meet basic needs. Today, Dora Barilla, DrPH, marvels that she continues their work in the community, striving to alleviate challenges that include poverty and food insecurity in her role with Providence Health & Services. She is, she said, a firm believer in hospitals as drivers of community health.

“We clearly can have a role, whether it’s as an anchor institution or trusted community partner, really leading the conversation around health,” said Barilla, executive leader for community investment with the system, which stretches across Alaska, California, Montana, Oregon and Washington. “We have hospitals because there are health care needs, but if you’re looking at the totality of the need and much of what’s causing our chronic diseases these days, there are a lot of collective societal issues.”

Barilla and others occupy the forefront of a movement that’s taking health care sustainability beyond hospital walls. Anchor institutions, long accustomed to educating and advocating for improved community health, are adopting environmental leadership, improving the health of the people they serve by greening their neighborhoods and the planet.

Anchor Institutions at the Forefront

Traditionally, hospitals offer their clinical tools to tackle societal challenges such as improved diabetes treatment, said Barilla. But maybe the diabetic patient can’t afford a refrigerator or has no money at the end of the month to afford food to stabilize his or her blood sugar.

That’s when today’s anchor institutions can “lean in,” taking clinical and social tools upstream to address root causes of health issues, she said. “It’s not one or the other. It’s both. We can’t solve all the problems, but we can be a trusted community partner.”
Hospitals acting as community-building anchor institutions “have many spokes or prongs or tools at their disposal,” including employee wellness, hiring, procurement, grant-making and others, said Susan Bridle-Fitzpatrick, senior researcher on a national community benefit study conducted by Health Care Without Harm (HCWH) and funded by the Robert Wood Johnson Foundation.

And then there are community health improvement initiatives supported by community benefit. “Community benefit is one arrow in the quiver,” but it is somewhat constrained by limited resources, said Bridle-Fitzpatrick. “[Hospitals can] make the most of their financial and other community benefit contributions by leveraging their experience and their moral authority to give some support to projects that they think have merit, and also use their influence to bring other players to the table for other sources of funding.”

In the past, health systems invested most of their community benefit resources on indigent care, but the impact of climate change is arriving daily at hospital doors, whether it’s a figurative flood of asthma patients or a literal flood from a superstorm, said Eric Lerner, climate and health director, HCWH.

That visible impact is prompting health-based anchor institutions to tackle environmental threats to air, water and food. As noted in “Community Benefit—Impact on Climate Change and the Environment,” a September 2016 article from Catholic Health Association, HCWH and Practice Greenhealth, “Pollution and other environmental risks are known to affect physical and intellectual growth, child development, allergies and respiratory problems, and illnesses such as cancer and heart disease.”

sustainability2Lerner cited the Evergreen Cooperatives of Cleveland, which convenes anchor institutions in health and other fields to provide green-technology energy solutions, grow fresh produce and operate an energy-efficient laundry.

“[The cooperative is] a great example of how to create wealth in the community, because we know there are connections between having a job and health,” said Lauren Kleinman Koch, outreach and engagement specialist and project manager, Practice Greenhealth and HCWH. “Then, how do we look at it through the lens of sustainability?”

In tackling environmental health, health systems can find they are wading into “big, complicated issues,” and this means the impact of smart interventions might not be evident for decades, said Paul Lipke, senior adviser on energy and buildings, HCWH. “Other entities, such as public health departments or philanthropies, may typically be the primary actors, with hospitals providing important support. Anchor institutions need to identify a range of appropriate actions based on geography, the nature of a population’s health problems and institutional culture.”

However, for nonprofit systems, all the anchor institution good that’s done in communities doesn’t always earn Internal Revenue Service (IRS) recognition as community benefit, said Julie Trocchio, senior director, community benefit and continuing care for the Catholic Health Association (CHA).

Hospitals “use their size and mission to do good in the community,” Trocchio said, but the costs of such beneficial-but-everyday tasks as purchasing from local vendors or hiring locally aren’t reportable as community benefit “because you are going to spend that money anyway.” Within typical anchor institution activities, only health advocacy—such as educating the public on food labeling—have been able to earn community benefit recognition.

Assessing Community Health Needs

But possibilities are arising in the realm where community benefit intersects with sustainability. In fact, it was CHA that prompted IRS to allow reporting of environmental efforts as community benefit work, said Trocchio. And now, CHA and HCWH recommend that “based on the evidence from environmental health research, that attention to environmental factors be a part of an organization’s strategy to improve community health.”

Ever since Dignity Health trained sustainability personnel on the environmental efforts now reportable as community benefit, green team members constantly approach Dignity Health Ecology Director Sister Mary Ellen Leciejewski with questions about new projects. “Do you think this is going to be included?” they say. “We’re going to do it no matter what, but over and above, can we report it as community benefit?”

It’s a matter of connecting the dots from community health work to environmental impact, say leaders in the field. “What actions can we take to ameliorate health-related environmental or sustainability concerns in the broader community, in addition to our own operations?” asked Michael Bilton, senior director, community health and benefit, Dignity Health, which has facilities in California, Arizona and Nevada.

Consider food waste, said Leciejewski. “You think that’s only food. No, it’s not. You’re wasting energy at the same time, because it took a lot of energy to produce that food, and then you’re wasting water, because it took a lot of water. Everything is connected and always has been, but now we’re opening our eyes to that. We have to help one another—educate one another to all those connections.”

Health systems can take three steps to draw environmental co-benefits from their community improvement work, according to the “Community Benefit” paper:

  • Assess existing programs. Many existing community benefit programs also have environmental bonuses. For instance, building bicycling trails can reduce transportation emissions.
  • Plan with the environment and climate change in mind. For example, amp up the environmental benefits of a farmers market initiative by emphasizing plant-based diets.
  • Use the community health needs assessment to identify environmental and climate issues. Nonprofits use mandated, triennial community health needs assessments to determine community health priorities. Resources including Healthy People 2020 and Community Commons can provide the justification to help hospitals slate environmental health and climate issues, such as high heat days and air pollution, as priority community health needs.

“Adding environmental health data and questions to needs assessments can yield a fuller picture of cumulative ‘insults’ for a given locale or population, from poverty and limited education to toxins exposure and air pollution,” said Lipke.

However, once programs are implemented, he noted, there is a lack of evidence proving the effectiveness of community benefit investments, at least as reported by Community Catalyst in an October 2016 look at Massachusetts health systems. Too many hospitals lack “a good, 360[-degree] evaluation of the money being spent, its effectiveness and alignment with long-term priorities,” Lipke said. It’s an area where health systems need to focus their next steps.

Where Sustainability and Community Benefit Intersect

In many hospitals, sustainability and community benefit offices are building working relationships or strengthening existing ones.

“The main purpose of both their works, though they’re coming at it differently, is healthier communities,” said Trocchio. “There are certain natural areas where they come together.”
Health systems taking greening into the community are crafting approaches shaped by data, mission and community needs. By leveraging their anchor institution status, they are addressing some of the hottest issues in sustainability and society today. For example:

Climate change: In Missoula, Montana, Providence St. Patrick Hospital provides financial and staff support to Climate Smart Missoula, “a hub integrating all the different things happening in the broader community,” said Beth Schenk, RN, a Providence nurse-scientist. Summer Smart Missoula—one of its initiatives toward a zero-carbon footprint goal—educates residents, especially vulnerable populations, on safety and health when wildfire smoke fills the air. “That’s a nice intersection of community health, community benefit and science,” added Schenk. Hospital leadership endorsed the hospital’s support for Climate Smart Missoula to assure alignment with mission and core values, because St. Patrick’s is “most definitely a cornerstone of this city.”

Food production and security: From mobile farmers markets and “prescriptions” for fresh fruits and vegetables to matching funds toward fresh, local foods for Supplemental Nutrition Assistance Program (SNAP) recipients, food is probably “the place where anchor institutions and community benefit and sustainability overlap the most,” said Bridle-Fitzpatrick. “The food system is one of the biggest sectors for environmental impact.” In just one example, volunteers at St. Joseph’s Medical Center, a Dignity Health hospital in Stockton, California, created a vegetable garden on their hospital campus. The produce is donated to St. Mary’s Dining Room, a local hunger and health ministry serving more than 410,000 meals a year.

Chemical use: Many hospitals go into communities with the sustainability lessons they’ve learned internally, such as educating families on using green cleaners or running mercury thermometer take-back programs. “It makes a lot of sense to take that expertise gained inside the hospital and use it in the community,” said Trocchio.

Clean water: A $50,000 Social Innovation Partnership Grant from Dignity Health to the Rural Community Assistance Corporation is putting water bottle filling stations in schools and other public spots in two California counties. There, low-income Latino farm families suffer the health effects of poor-quality water plagued with naturally occurring contaminants.

Effective community benefit efforts are data-driven, “but it’s not enough,” said Schenk. At Climate Smart Missoula, “we don’t necessarily want it to be a website with spreadsheets. We want it to be an engaging, inspiring entity.”

Hence, artists painted and decorated discarded doors to express their feelings about climate change. A monthly brewpub meetup focuses on Climate Smart Missoula’s priority issues. “That sort of thing is fun and inspiring, and it takes the edge off the heaviness of data and the heaviness of politics,” said Schenk.

Nationwide, efforts rely on partnering with other community insti­tutions, especially as “funding continues to be an issue,” said Trocchio. Barilla called it “co-creation—coming into a community and collectively identifying what the issues are and co-creating the solution.

“We’re a partner at the table,” she said. “How do we set the table so we can create healthier communities together?”

New Tools for Community Environmental Health

As for the future, said Trocchio, “Stay tuned.” But on the part of nonprofit hospitals, the commitment to improved community health and a cleaner environment “is not dependent on any law. That’s who they are. It’s been institutionalized enough that we don’t have to worry about that going away.”

CHA’s community benefit page on its website,, is stocked with resources on assessing needs, planning and reporting, evaluating, and partnering. Other projects are bringing new tools to community environmental health:

  • The Health Care Climate Council, a convening of sustainability leaders through HCWH, is piloting and scaling up a toolkit. It will include a slide deck for making the environmental pitch to community benefit staff, and a spreadsheet for producing regional data on climate change in coming decades.
  • HCWH’s national study will provide guidance on best community benefit practices to support healthy food access, promote healthier food systems and reduce risk of diet-related disease. The project will also build a network of community benefit, public health and food systems professionals and organizations.

As health care systems continue bridging their sustainability and community benefit operations, they will always adhere to the idea that it’s the right thing to do, whether or not it fits into mandates or social responsibility criteria.

“This is part of our healing mission,” said Leciejewski. “It is integrated into our mission and who we are.”