Lessons from patient safety to accelerate healthcare decarbonization

Abstract

Climate change and environmental degradation are increasingly impacting human health, with more frequent heatwaves, wildfires, extreme weather events, emerging infectious diseases, increased respiratory, cardiovascular, and mental health conditions, and food and water insecurity.¹ Current projections of global greenhouse gas (GHG) emissions suggest it will be harder to limit warming below the critical threshold of 2°C to avoid the worst predicted harms unless deep and immediate reductions in GHGs occur in all sectors of society. The healthcare sector contributes approximately 4.6% of total global GHGs and 4 million disability-adjusted life years lost from air pollution annually.¹ Health care must do its part to mitigate environmental degradation and pollution and avoid excessive resource consumption.^{2, 3}

One-fifth of global healthcare GHG contributions come from the US healthcare sector despite the United States comprising only 4% of the global population. A number of motivated US healthcare delivery organizations (HCOs) have begun to implement decarbonization initiatives, and these efforts should be applauded.^{4, 5} However, many of these initiatives are not grounded in rigorous measurement and data transparency, making it difficult to judge the veracity of claims or progress consistent with science-based targets.⁶ The nascent state of healthcare sustainability is reminiscent of the early days of the patient safety movement and is experiencing similar growing pains. In 1999, the report “To Err is Human” raised the alarm about patient safety, but demonstrable improvement was slow going and hampered by, among other things, a lack of data and transparency required for guiding and tracking evidence-based performance improvement.⁷ Progress has been made since then primarily through regulatory and payment reforms, and in 2025, the US Centers for Medicare & Medicaid Services (CMS) is expected to implement a Patient Safety Structural Measure that further embeds measurement, accountability, and transparency in assessing how hospitals ensure patient safety.⁸ However, the urgency of the climate crisis and healthcare's significant contribution to it leaves no room for decades-long delays. To ensure progress in the absence of regulation and payment levers, HCOs should apply the principles guiding the patient safety movement to ensure that data transparency and verification are the centerpiece of the transformation to evidenced-based, environmentally sustainable health care.

Previous research has quantified the harmful effects of US healthcare pollution at nearly 400,000 disability-adjusted life years (DALYs) lost in 2018.⁹ Creating effective systems to protect patients, the public, and the planet from harm requires adherence to basic principles of transformational change that include transparency, accountability, standard operating procedures, regulations, commitment to continuous improvement, publicly shared data, and quality ratings. Many of these principles underpin the performance of high-reliability organizations aiming to prevent catastrophic safety lapses. Data verification and transparency ensure accountability and build stakeholder trust. These principles have guided advances in patient safety since the Affordable Care Act-mandated expansion of reporting and accountability in 2010.¹⁰ This led CMS to require public reporting of patient safety measures and implement payment penalties for poor performers, ensuring the availability of credible, consistent, and uniform information about hospital performance. These efforts also served as the basis for an “A” through “F” safety grading system through The Leapfrog Group.¹⁰ Data from the Medicare Patient Safety Monitoring System (MPSMS), which tracks adverse events among hospital inpatients, showed a significant decline between 2010 and 2019, coinciding with major patient safety improvement efforts and enhanced reporting practices.¹¹

So far, however, principles for transformational change have yet to be applied to US healthcare sustainability initiatives that currently encompass programs pledging to reduce GHG emissions, as well as sustainability awards and certificates (Table 1). These efforts, launched over the past few years, aim to motivate HCOs to participate in climate-related initiatives voluntarily. However, these well-intentioned efforts do not yet disclose verified data to support claims. Lack of transparency makes it difficult to evaluate promised improvements and opens the door to greenwashing—the act, whether intentional or inadvertent, of making false or misleading statements about the environmental benefits of a product or practice and one of the biggest threats to effective and timely climate action.¹² The UN Secretary General warns that bold pledges must be matched with concrete, measurable data and calls for zero tolerance for greenwashing. Accountability, transparency, and public reporting of standardized metrics are foundational principles needed to advance patient safety and are also the antidotes to greenwashing.

Several recent voluntary opportunities for HCOs to engage in sustainability efforts highlight the challenges posed by lack of transparency. In 2022, the White House and the US Department of Health and Human Services (HHS) called for HCOs and other healthcare-aligned businesses to sign the Health Sector Climate Pledge to, at a minimum, reduce organizational emissions by 50% by 2030 and achieve net-zero emissions by 2050 while “publicly accounting for progress on this goal every year.” Two years on, HCOs’ progress related to the pledge is unclear as no data have yet been publicly shared. The Joint Commission (TJC), the largest healthcare accrediting agency in the United States, recently announced a voluntary Sustainable Healthcare Certification Program to inspire climate action. Health systems seeking this certification are evaluated by accreditors; however, the certificate does not require public disclosure of measures of sustainable operations such as GHG emissions.¹³ Both of these laudable programs would be strengthened if they incorporated publicly available data to support claims and mark progress toward the pledge or certificate. Data transparency is an opportunity to create a clear accountability structure, build trust from stakeholders, encourage action by other HCOs, and help avoid perceptions of greenwashing. Table 1 describes characteristics related to transparency, verification, and public reporting of current US healthcare sustainability award programs.

More recently, the CMS Innovation Center proposed a voluntary GHG reporting opportunity for HCOs participating in the new 5-year episode-based alternative payment model called Transforming Episode Accountability Model (TEAM).¹⁴ The proposed Decarbonization and Resilience Initiative could help create the foundation for sustainability data capture for the entire US healthcare system, starting with the use of the well-established EPA ENERGY STAR program. To incentivize HCOs, the rule also proposes that “badges” be awarded for varying levels of successful engagement. Making the supporting data for badges or awards public would be an excellent opportunity to align with established sustainability accounting practices routinely used by other sectors where transparency is the norm.

Ensuring transparency would also provide insights into opportunities for continuous improvement at the organizational and sector-wide level necessary to rapidly decarbonize health care. It could help avoid some future challenges that persist in the patient safety movement, such as issues related to insufficient data, unclear performance evidence, and the gamification of safety measures. Lessons from the patient safety movement also provide insight into practical pathways for implementing future sustainability programs. Effective patient safety teams are interdisciplinary, gather relevant data from various sources within an organization, and use a sociotechnical approach that includes technology, process improvement, organizational change management principles, and culture and behavior change. Sustainability teams can adopt these same strategies to build effective programs.

Following the experience in the patient safety field, future regulations, accreditation, payment incentives, and mandatory reporting of metrics will be necessary to advance environmental sustainability.^{2, 9, 15-17} This, however, may be years away. Hence, proactive actions are warranted now to help drive meaningful action and prevent greenwashing. A crucial lesson gleaned from the patient safety experience is that some of the most valuable insights and innovations came from high-reliability industries outside of health care—most notably aviation. The increasingly sophisticated science of sustainable enterprise has been developed almost entirely outside of health care and, if tapped, would expedite the maturation of these efforts. Many corporate entities—both for-profit and non-profit—already publicly share third-party verified sustainability data (most notably, GHG emissions), using well-established sustainability accounting frameworks that provide guidelines and standards for measurement, verification, and disclosure (Box 1).¹² For instance, HCOs could use the Greenhouse Gas Protocol, a comprehensive global standardized framework for measuring and managing GHGs.¹⁸ This framework is used by CDP (formerly named the Carbon Disclosure Project), an international non-profit organization that provides a global sustainability disclosure system,¹⁹ and other not-for-profit sustainability platforms such as the Global Reporting Initiative which incorporates a broader array of sustainability measures (e.g., workforce wellbeing).²⁰ For the healthcare sector, it is critical to provide high-quality care while measuring, mitigating, and reporting emissions. Bringing clinical and sustainability experts together can ensure that decarbonization of care delivery remains appropriately prioritized.

To be consistent with best practices in sustainability, HCOs will need to account for the totality of GHG emissions that stem from healthcare activities, which are categorized by “Scopes” (see Figure 1). Scope 3 emissions, predominantly those embedded in the supply chain, can be the most challenging to measure and manage but must not be ignored as they typically represent 80% of all emissions.⁹ While standards for measuring, managing, and reporting emissions are well established, the healthcare sector has unique challenges. For instance, understanding which healthcare products, procedures, policies, and clinical pathways offer superior environmental benefits without compromising clinical safety and efficacy is in its early stages and will advance as further investigations and research are conducted. Health care should engage experts in sustainability science and accounting to enable progress.

If applied to HCOs, the required transparency associated with these initiatives could improve corporate performance and stakeholder trust, combat greenwashing, and provide a more accurate accounting of sector-wide progress. It will also foster uniformity in data capture and reduce the data burden on HCOs by limiting the need to gather or share different data with multiple sustainability programs.

There are growing global and domestic regulatory pressures for disclosing sustainability data from outside the healthcare sector. Recent laws and regulations in the European Union and the state of California and the US Securities and Exchange Commission's proposed rules make it increasingly likely that corporate entities, regardless of tax status, will be asked to engage in some aspects of verifiable sustainability accounting.²¹ These regulations will likely have significant implications for HCOs even in the absence of regulations specific to health care. HCOs should carefully study how the corporate world is proactively preparing for anticipated regulations and for mandatory reporting of sustainability-related metrics. While the recent decision by the US Supreme Court to overturn the Chevron Doctrine—previously allowing federal agencies to interpret ambiguous federal statutes—has introduced legal and regulatory uncertainty into sustainability accounting, it is unlikely to halt progress. Strong stakeholder demand for transparent reporting and compliance requirements from outside the United States will continue to drive these efforts forward.²²

Significant advancement in patient safety efforts came primarily through regulations and associated value-based payment reform. Short of a mandate, which is unlikely in the near term, several adjustments to current voluntary environmental sustainability initiatives and programs would help boost credibility and accountability and reduce greenwashing. These include (1) requiring baseline and periodic disclosure of third-party verified sustainability data (e.g., GHGs); (2) standardizing sustainability-related metrics; (3) clarifying and publishing methods of data measurement, verification, and disclosure; (4) providing forums for knowledge-sharing and crowd-sourcing of accounting solutions; (5) fostering more inclusive data-driven initiatives and mentoring less-resourced organizations; (6) allowing HCOs to set short- and long-term sustainability goals that are realistically achievable; and (7) requiring transparency of supporting data associated with any sustainability pledge, award, or certificate.

Healthcare workers, students, trainees, and community members are increasingly concerned about the US healthcare sector's outsized environmental footprint.⁹ A recent survey indicated that most physician respondents would like their healthcare organization to undertake climate mitigation initiatives.²³ Given workforce shortages, HCOs with greater credibility in sustainability activities will have a competitive edge in recruiting and retaining talent.⁵ To help evaluate HCO sustainability initiatives, interested stakeholders can look out for “red flags” that might signal less credible claims. These include sustainability pledges, awards, or certificates used in HCO marketing materials or press releases without verified supporting data and periodic disclosure of progress; ambiguity, vagueness, or adjectives in sustainability claims and award titles; publicizing single siloed initiatives instead of comprehensive sustainability accounting tracked over time; lack of third-party verification in HCO corporate filings, annual reports, or published on websites; and excessive use of buzzwords (“green”) or green imagery.

Accountability, data transparency, and public reporting are foundational principles that have guided the field of patient safety. Several insights and lessons learned in the journey toward patient safety could serve as catalysts for accelerating decarbonization in the healthcare sector. By integrating evolving sustainability practices and accounting standards from outside healthcare, HCOs can accelerate evidence-based environmental sustainability initiatives. There is no time left for activities that do not provide proven benefits.

The authors declare no conflict of interest.