Measuring and Minimizing Health Care’s Environmental Impact

Hospitals across the United States rely on dashboards to detect subtle changes in performance, including shifts in patient satisfaction ratings, infection rates, and insurance claim denials. Designed to spur improvement, they tend to revolve around the domains of cost, quality, and patient experience. Providence, a Catholic health care system based in Renton, Wash., is applying this approach to the daunting problem of reducing greenhouse gas emissions in its 51 acute-care hospitals. Called the Providence WE ACT scorecard, the platform was created to help 129,000 employees spread across seven states visualize the health system’s carbon footprint and work toward becoming carbon negative by 2030, a target set on Earth Day 2020.

The scorecard takes the abstract concept of removing carbon dioxide and other greenhouse gases from the atmosphere and translates it into concrete measures that each hospital can monitor over time. The scorecard’s 155 metrics are both vivid and accessible: gallons of water used per square foot, percentage of compression sleeves recycled, and number of business miles traveled per full-time employee, for instance. Taken together, they capture the key drivers of carbon emissions in health care settings, including waste, energy, agriculture/food, chemicals, and transportation.

The metrics are converted into carbon equivalents using emission factors from the U.S. Environmental Protection Agency and other reputable sources and are presented in ways that help employees take action. The scorecard also reveals how hospitals in different states, climates, and regulatory environments and of varying sizes differ when it comes to carbon-intensive practices like managing waste, anesthetic gases, and energy.

“Within a minute you can tell what you’re doing well and where you have opportunities to improve,” says Geoffrey Glass, Providence’s senior manager for energy and sustainability. “We’ve never been able to see that benchmarked to real-world validated data. That’s what’s magical.”

The health system needed to move beyond estimates of savings to mobilize staff, says Elizabeth Schenk, PhD, RN, Providence’s chief environmental stewardship officer. “Educated guesses just don’t have the same power as real numbers when it comes to driving change,” she says.

In this feature article, we describe how the Providence WE ACT scorecard addresses the common challenges that health systems face when committing to carbon-reduction goals: knowing where to begin, what to prioritize, and how to measure impact. While it’s a proprietary platform, its implementation demonstrates how health systems can use detailed measurement to enhance the climate literacy of employees, promote collaboration, and realize cost savings.

Using Measurement to Build a Movement

The prototype for the scorecard was a set of Excel spreadsheets that Schenk and Glass developed more than a decade ago to document how various environmental initiatives at hospitals in Montana and Washington reduced costs and carbon emissions. They wanted to create a more user-friendly version that could quantify the benefits of scaling local projects like composting food waste systemwide.

The idea appealed to executives interested in leveraging information technology (IT) to standardize operations across an expanding health system. A few months after Providence made the commitment to decarbonize and put Schenk in charge of environmental stewardship systemwide, B.J. Moore, chief information officer and executive vice president of real estate operations and strategy, and Ali Santore, chief administrative officer, encouraged Schenk and Glass to partner with the Providence Global Center in Hyderabad, India, a newly established IT outpost.

The environmental stewardship team was still small. (It’s since grown to include 15 employees at the system or hospital level, among them four nurses, a physician, two engineers, and a nun.)

Providence staff in India, many of whom had worked for Fortune 500 companies, brought expertise in user design, data management, and data confidence, but had yet to see a Providence hospital firsthand. Through email and videoconferences, the group strategized on how to a design a platform that would be equally useful to frontline workers, facilities staff, and executives.

To populate it, the team culls data from utility bills, supplier invoices, and electronic medical records, among other sources, and normalizes data to account for variation in hospitals’ square footage, patient volume, and employee head counts. Eighty percent of the data come from Providence’s vendors, who were pushed to report in ways that could be audited. “For the first few years, that’s literally all we were doing,” says Roopa Rangaprasad, executive director of project management in the Global Center. “Vendors were sending us the data files, and we’d say, ‘This data is missing, or this data is incorrect.’” It typically takes two quarters for new data sources to be validated and incorporated. “When we share the results, people are quite surprised at how much information we have,” she adds.

Creating a Culture of Stewardship

The Providence WE ACT scorecard aims to show how hospital design, operations, and employee behavior shape carbon emissions. The first category — waste — illustrates how the scorecard also creates a framework for taking action. Although waste makes up a small percentage of the health system’s tracked greenhouse gas emissions, it’s the most visible sign of excess to staff, who dispose of thousands of masks, gloves, gowns, and other single-use items every day.

“When nurses, doctors, and other staff come to us with ideas, it’s the number one thing they bring forward,” says Sarah Johnson, RN, the environmental stewardship program manager for Providence St. Patrick Hospital, a 253-bed hospital in Missoula, Mont.

The system’s goal is to divert more than half of its waste from landfills and hazardous waste streams by 2030. To track progress, Providence developed a waste optimization score that captures how much of a hospital’s total waste is diverted from landfills or incineration through composting, recycling, and donations and how much waste is avoided by using reusable items, such as cloth gowns and dishware. With the scorecard, hospitals can drill down to see usage data on each metric, presented in pounds, cost, and carbon. In Missoula, for example, a pound of waste disposed in the landfill costs 10 cents, more than double the cost of composting (4 cents).

To promote better segregation of waste, Johnson trains interested caregivers from each unit to act as “waste shepherds.” They share the environmental costs of putting waste in the wrong bins and educate staff about donation programs and other means of diverting waste. Johnson has used the scorecard to illustrate how employees’ ideas have helped move the hospital into the upper ranks on the scorecard. Composting food scraps reduced the hospital’s greenhouse gas emissions by 18,890 kilograms of carbon dioxide equivalent (CO₂e) in 2022 and saved $22,000 in landfill fees, while replacing the warm blankets that nurses used to prop up patients’ legs with reusable leg positioners (total cost $400) saved $13,000 in laundering expenses in a year.

The scorecard also shows areas for improvement. In icy winter months, when staff can’t rinse compost bins outdoors, the facility sends 80,000 more pounds to the landfill, generating $6,400 more in hauling fees and 14,000 kilograms of CO₂e in emissions. Johnson is seeking a local farmer to take the composting in winter. She also ensures containers used for compacting are full before they’re hauled away; that saved the hospital $40,000 in one year.

Identifying Variation and Delving Into its Causes

Water use, a component of the scorecard’s energy category, is a focus because nearly 70 percent of Providence hospitals are in states that have experienced recent droughts. Water use varies based on a hospital’s climate, the acuity of care provided, landscaping practices, and the efficiency of heating and cooling equipment, among other factors.

Providence St. Vincent Medical Center, a 523-bed hospital on the outskirts of Portland, stood out because its water use per square foot was 47 percent below the system average. “I remember Geoff contacting me out of the blue because he noticed we were seeing some significant water savings,” says Andy Mason, director of facilities. “He said, ‘What’s St. Vincent doing?’” A new, more observant groundskeeping crew had detected leaks in the 10-acre campus’s irrigation system. They also recognized the hospital had been overwatering. “The previous groundskeeper had operated on a set-and-forget system,” Mason says. “He hadn’t really considered how much water an adult plant needs versus an adolescent plant or a freshly planted plant.”

These findings prompted two other hospitals in Oregon to begin developing in-house groundskeeping programs, as Mason’s hospital had, rather than outsource. “It’s not less expensive, but you get so much more when the crew sees their job as more than making the grass shorter,” Mason says.

Setting Targets and Prioritizing Mitigation Strategies 

Glass suggested Providence St. Vincent and other Oregon hospitals consider a water audit. Consultants looked at faucets, showerheads, and toilets, among other potential sources of drips and leaks. The audit revealed an opportunity to save 25.5 million gallons per year, nearly 10 percent of the 232 million gallons the hospitals consume.

The Oregon hospitals allocated $923,000 to cover the cost of upgrades, with the expectation the investment would pay off in just two years. Mason says they could have simply divided the money based on water costs; one hospital was paying a fixed rate, while another had consistently lower water bills. But financial return was not the only objective. “It was about achieving the scorecard target, which was using less than 40 gallons of water per square foot. We wanted to make a visible impact in each hospital and do it quickly,” Mason says. 

The work is beginning to pay off. Providence Seaside Hospital, a critical access hospital on the coast, reduced its water consumption from 35.5 gallons per square foot annually in 2022 to 28.3 gallons per square foot annually by the second quarter of 2024.

The water audits and learnings from other health systems prompted Providence to reset the target for all hospitals to 30 gallons per square foot. “We raised the stakes because we are in drought areas,” Schenk says.

Replicating Successful Mitigation Strategies

The scorecard’s chemicals category takes aim at the use of inhaled anesthetics and nitrous oxide, which can account for 5 percent or even more of a hospital’s carbon footprint in the U.S. Brian Chesebro, MD, an anesthesiologist who serves as the system’s medical director of environmental stewardship, persuaded clinicians in his hospital to reduce their use of nitrous oxide, a gas that is more potent than carbon dioxide in heating the atmosphere and persists in the environment more than 100 years after release.

Between 2017 and 2020, electronic medical record data show clinical use of the gas at Chesebro’s hospital dropped 61 percent. But greenhouse gas emissions he tracked didn’t budge. To understand why, Chesebro compared the amount of nitrous oxide his hospital purchased with what clinicians used and found a staggering loss, partly due to the deterioration of seals in the nitrous oxide supply line, which can be difficult to identify for repair.

“One of the reasons this problem hadn’t come to light is because nitrous is so inexpensive. It never rises up someone’s budget sheet to achieve much scrutiny,” Chesebro says. “You have to ask yourself: ‘Where is it going?’”

Once his hospital decommissioned the supply lines and switched to using portable nitrous oxide tanks, the amount purchased fell 99 percent.

To replicate Chesebro’s work, the environmental stewardship team developed reports comparing nitrous oxide purchases to clinical use in each hospital. Reports showed even the most efficient hospitals were losing as much as 67 percent of nitrous oxide purchased. The team created a toolkit to guide hospitals through the clinical, financial, and logistical challenges of decommissioning a central supply line.

In California, where Providence has 17 hospitals, the data created instant buy-in from clinicians, facilities staff, and executives. “When they saw the numbers, there was complete engagement,” says Justin Montoya, executive director for operations in California. Within six months, all California hospitals had decommissioned the supply lines. Montoya believes the smooth implementation will make it easier to enlist hospitals in future environmental stewardship initiatives. “It demonstrated how organized and structured the process could be,” he says.

Fostering Collaboration

The Providence WE ACT scorecard has enabled hospital staff in states like Alaska, Montana, New Mexico, and Texas to learn from those in California, Oregon, and Washington, where more stringent regulations have accelerated conservation efforts. Providence encourages staff who manage hospital facilities in different states to brainstorm strategies for increasing energy efficiency. The scorecard shows significant variation even for hospitals in the same region based on their source of electricity and the design of their buildings. Still, for many, the core issue is the same: Most hospitals are heating and cooling air simultaneously — 24 hours a day — and exchanging that air as many as 15 times per hour to comply with public health regulations. If equipment is inefficient or poorly maintained, cost and energy use escalate.

Glass and Dave Thomsen, another engineer on the environmental stewardship team, watch capital budget requests, looking to leverage high-efficiency equipment to maximize scorecard results. They regularly attend meetings of facility managers to suggest solutions.

Chris Gould, a regional director of facilities engineering, manages seven hospitals across Texas and New Mexico that merged with Providence in 2016. Gould says joining the system enabled him to learn from states with stricter climate policies. Before the merger, he admits, energy efficiency rarely came up. “We’re Texas-minded,” Gould says. “We weren’t worried about the carbon negative side of it. But as Providence, we are.”

The 4 million square feet of property Gould oversees include some newer buildings that aren’t as efficient as the older ones. Meeting with counterparts at other hospitals led him to consider a runaround coil, a high-efficiency means of reclaiming the heat that’s exhausted from buildings. Hospitals in Alaska, Texas, and Washington are hoping to pilot the technology, which could lower energy bills by up to 10 percent.

Gould already sees big gains from switching to renewable energy at three of the seven hospitals, putting those hospitals into the top tier of scorecard performance on electricity-related emissions. “My bosses in Texas say, ‘Keep going. We love this green thing,’” Gould says.

Driving Changes in Commuting Practices

The environmental stewardship team’s visits to hospitals are an opportunity to observe successful practices and promote new ones. “They quickly gain credibility because they have so much data and expertise,” says Jared Amerson, chief administrative officer of Providence Saint John’s Health Center, a 266-bed hospital in Santa Monica, Calif. His hospital, with 1,500 employees and 1,000 physicians, is a high performer in the commuting category even though some staff drive up to 1.5 hours each way to work. “We’re in a community where very few people can afford to live,” Amerson says.

The health center spends roughly $200,000 each year incentivizing staff to avoid single occupancy travel and assigns a staff person to help identify other options. The hospital pays for public transportation; it also pays employees $5 for each day they don’t park on site. For those willing to carpool in groups of three or more, the hospital leases vans and provides free gas and parking.

Amerson has been toying with creating charter bus routes to ferry people from downtown Los Angeles and the San Fernando Valley but hasn’t pulled the trigger because of the challenges of scheduling. Unlike most businesses where employees are arriving and leaving at roughly the same time, hospital schedules vary based on an employee’s role, making it difficult to get the timing right.

Reporting Progress Toward Carbon Negative Emissions

Since setting its carbon negative goal in 2020, Providence has reduced greenhouse gas emissions in the categories it prioritized by 13 percent, from 570,369 metric tons of CO₂e in 2019 to 495,526 metric tons of CO₂e in 2023. Schenk expects sharper declines over the next year as a $50 million investment in LED lighting across the system bears fruit and the practices of leading hospitals are spread. For instance, decommissioning nitrous oxide supply lines in 17 California hospitals, completed in the first half of 2024, is expected to reduce greenhouse gas emissions by 4,000 metric tons. As hospitals in Alaska, New Mexico, Texas, and Washington follow suit, the system may see an additional reduction of 8,000 metric tons of CO₂e.

In relative terms, the health system saw the steepest declines in emissions related to business travel (–66%), anesthetic gases (–56%), and the use of steam (–52%) and electricity (–22%, half of which came from purchasing renewable energy credits). Reductions in business travel and the use of the anesthetic gas desflurane produced immediate cost savings ($5 million and $2 million per year, respectively), while investments in lighting and water conservation are expected to pay off within three to seven years.

If Providence continues at roughly the same pace — achieving 5 percent reductions year over year — it will reduce its greenhouse gas emissions in the areas prioritized by nearly 60 percent by 2040. To become carbon neutral or negative for the broader set of greenhouse gas emissions, Providence faces two significant challenges: reducing emissions associated with purchased goods and services and retrofitting older buildings to improve energy efficiency. The former requires sweeping changes in how manufacturers worldwide produce and transport goods, while the latter requires money. In 2023, Providence partnered with the American Hospital Association and the American Society for Health Care Engineering to estimate the cost of replacing natural gas with electricity in a single hospital, Providence St. Peter Hospital in Olympia, Wash. The price tag — $80 million — was daunting, but Schenk and Glass want to demonstrate that with smart capital planning and emerging technologies, it’s feasible — and cheaper — to decarbonize existing building stock than build new structures.

Lessons for Other Health Systems and State and Federal Policymakers

As these examples from Providence illustrate, hospitals and health systems can engage their staff in meaningful efforts to mitigate their environmental impact. Others could use these lessons to inform their own efforts to reduce greenhouse gas emissions that contribute to climate change.

When it comes to engaging staff in carbon-reduction efforts, transparency can be a force multiplier. The Providence WE ACT scorecard is not the first or only effort to quantify hospitals’ greenhouse gas emissions in granular fashion. Aga Khan University in Pakistan and Practice Greenhealth, an organization that supports health systems in implementing environmental stewardship programs, have created Excel-based tools that health care organizations can adopt. Health systems like Penn Medicine, Cleveland Clinic, and Massachusetts General Hospital have also publicly reported their progress toward carbon-reduction goals using similar categorization. What makes Providence’s scorecard distinct is its benchmarking functionality and how that is being used to make the environmental costs of health care salient and actionable to staff at all levels. Transparency undercuts concerns about greenwashing and helps build trust among staff. Montoya says, “There are no secrets about how or why a particular project has been prioritized.” Making the data visible also promotes friendly competition. “The first thing I look at is the outliers and ask, ‘Where do we need to go to get to the top of this list?’” Mason says.

Good measurement is a balancing act. Constructing a scorecard that captures the complexities of hospital operations without overwhelming users or sacrificing accuracy is an ongoing challenge. In selecting measures, Schenk and Glass must balance their desire for precision with the limitations of existing data sets that weren’t designed with carbon accounting in mind. Take business travel as an example. Corporate accounting systems may be able to report days or dollars spent on car rentals but not miles driven, a far more accurate measure of greenhouse gas emissions. They push vendors to send electronic files with new levels of detail where it makes a material difference. In instances where the cost of capturing such data exceeds the benefit (for example with refrigerants or diesel for generators), they accept estimates. They are also limited to using data from vendors and health system departments that can send automatic feeds that can be updated monthly and audited. At times, it takes a lot of detective work to figure out where the data they want are hidden. Normalizing what they collect to create an apples-to-apples comparison of hospitals also requires careful thought. All energy data are adjusted to account for seasonal weather variation, and all costs are adjusted for inflation, but other measure adjustment is done on a case-by-case basis to ensure comparisons are not misleading. If this sounds challenging, neither Schenk nor Glass see it that way. “It’s a labor of love,” Schenk says.

Technical assistance is as important as data. The Commonwealth Fund’s 2023 Climate and Health Care Workforce Survey found 80 percent of clinicians surveyed wanted their employers to act on climate change, but few were offered training to identify or implement decarbonization steps in their jobs. Providence’s environmental stewardship team acts much like an in-house consulting firm, dispensing advice on how to improve. To assemble such teams, other health systems may want to recruit employees who combine expertise in engineering, nursing, or medicine with a passion for sustainability. Finding the budget for these positions may be a persistent challenge when hospital margins are thin. Providence’s five Alaska hospitals split the cost of hiring Darcy Moxon, sustainability program manager. Moxon, who has Six Sigma expertise, helps hospital leaders and staff find opportunities for carbon savings in a state where municipal recycling is severely limited. Schenk is exploring other ways to fund these positions, including using savings from conservation efforts. The scorecard itself has helped to identify errors in utility bills and reduced the time facilities’ staff spend reviewing them. “I used to have a calendar block to just go in and monitor our utility usage. Now I just open the scorecard to see it,” Mason says.

Prioritize projects that achieve financial and carbon goals simultaneously. As Chesebro’s discovery of nitrous oxide loss and the groundskeeping team’s work at Providence St. Vincent demonstrate, employees play a critical role in identifying potential carbon savings, as well as blind spots in the health care industry’s current accounting for carbon use. Studies of the health sector’s carbon footprint point to a slew of opportunities under employees’ direct control, including reducing avoidable imaging from computed tomography (CT) and magnetic resonance imaging (MRI) scans and preventing medical errors that result in the duplication of services. Health systems can partner with staff to identify and implement projects that advance financial and environmental goals at the same time, says Vivian Lee, MD, PhD, MBA, author of The Long Fix: Solving America’s Health Care Crisis with Strategies That Work for Everyone and a Commonwealth Fund board member. To do so, health system leaders need better tools to quickly and easily assess the return on investments. “Sustainability has to become sustainable, which it’s not right now,” Lee says.

Providence’s WE ACT scorecard is a crucial step in that direction because it enables health system staff to forecast savings based on local commodity costs, state and federal incentive programs, and resource use. Requiring greenhouse gas emissions reporting from other health systems would facilitate comparisons across states, but previous efforts to compel reporting (such as by the Joint Commission) have met with pushback from the industry. If the Centers for Medicare and Medicaid Services made emissions reporting a condition of participation in the Medicare program, the field would see more progress, says Antonia Herzog, PhD, director of climate policy and advocacy at Practice Greenhealth. “That’s the holy grail.”