Frederik: Hello and welcome to the Sustainable Healthcare Podcast. Today is an episode that I have looked forward to recording quite a lot. I have two guests with me, not in the studio but online. And they are both experts in LCAs, in healthcare, especially around hospitals. So the Danish regions are using data to steer the green transition in hospitals, especially through procurement. And today we will unpack why that matters, how it works, and what it actually does. So with me in the online studio today, I have Rasmus and Thea. Welcome to the studio, Rasmus. And Thea, do you want to tell our listeners a little bit about yourself? Maybe if you go first, Rasmus, Thea can have a little bit of lead time.

Rasmus: Again, again. Maybe if I have something new to say now. Well, my name is Rasmus. I work for the Central Denmark region at our Center for Sustainable Hospitals. Where my day job is to calculate the environmental footprint or the difference in environmental footprints whenever someone gets a brand new idea. I’m also helping to build our data system for sustainability. It’s not really, you know, when you get into something like the regions that are pretty good at doing the math when it comes to money, but they don’t really have a system for the CO2. So that has to be built from the bottom up, to fit our purposes. Yeah, and I’ve been doing that for five and a half years now.

Frederik: And you’re calling live from an actual farmhouse?

Rasmus: Oh, yeah, yeah, yeah. We live in a farm in the middle of Jutland, so I’m looking out at the old stables and I can see my tractor if I stretch a bit. So yeah, very rural.

Frederik: Thea, welcome to the show. It’s your first time in the Sustainable Healthcare Podcast, so really glad to have you here. Excited. You wanted to come on. Can you tell us a little bit about yourself?

Thea: My first time in any podcast I can tell. My name is Satya [?]. I’m sitting in a region of Southern Denmark. And it’s actually quite easy to explain what I do because it’s basically the same as Rasmus just in another region. So I have a finger on everything about data, CO2. We don’t have as many projects yet in our region. We’re a bit behind compared to the central region. So my main task for now has been the carbon footprint, like investigating where do we need to do something, where do we need to start projects, and then we’re trying to get these projects up and running. The same as in the central region, and trying to figure out how we can see the results of what we’re doing. Yeah, so basically the same as Rasmus just in another region.

Frederik: Amazing. Thanks a lot and welcome to the show. I’m sure it’s going to be all right, even though it’s your first time on a podcast.

Thea: Thank you. Yeah, I hope so too.

Frederik: So, first off, I wanted to dive into why this matters. So when using a data-driven approach, what is it your model points to? And you’ve alluded to it slightly to me, so I’m not gonna be very surprised. But when you’re looking at the data and you’re analyzing the data, how might we decarbonize hospitals? What are the conclusions from looking at the data?

Rasmus: Well, we sort of have two conclusions. First, we have a conclusion: there’s a very big job. And it’s also a very complex job to do something like this. But if we start easy and look at our green report, our carbon report, what we see in Denmark is that we really have to look into our procurement because it’s all the stuff. And to some degree the building of the buildings that is the most important for us. We have had in Denmark a long tradition for making our houses very warm because outside it’s very cold and that has the added benefit that we lose less heat in our building. So we have a very modern building mass, and we also have very modern hospitals on the most part, at least. So that means that normally, the normal thing, which is the energy, which would be very important, is not very important when you come to Denmark. Also, we have very many windmills and a very nice strategy for getting even more windmills and solar panels. So that also means that the energy we do use also tends to be somewhat green. Secondly, normally we’d look at transport. That’s a big thing. And for us so far, patient and employee transport is out of scope. We have not calculated it in yet, so we also here see very little because what’s in our transport is really just transport of goods. And then because the regions are built in a funny way, we also have some bus transport and everything else like that, but that is also a very small amount compared to all the stuff that we buy. So this is the scope, definitely.

Frederik: So, playing it back to you in other regions, geographically speaking outside of Denmark, energy might matter quite a lot. If there’s not green power purchase agreements in place, transport could matter. Also in Denmark, for now, staff and patient transport is out of scope of the analysis. So it’s the transport that’s happening within the hospital organizations on site and transporting staff to and from the hospital, but not transporting people anywhere?

Thea: No, so our ambulances are in scope. And that’s also the biggest contribution to the transport. We actually didn’t expect that, but it’s hard to do something about ambulances at this point.

Frederik: We did an episode with David Marie from FLK. And it seems that you need to agree on who should account for the emissions because FLK won’t account for the emissions for the ambulances, even though they should belong to the hospitals. So I think you need to strike an agreement with the ambulance operators about who should own these emissions and see who gets there first. But it is one of these tricky things about carbon emissions, the whole accountability and avoiding double accounting. Whereas in the Greenhouse Gas Protocol or the GHG Protocol, you’re only responsible for the emissions that are within your scope of control in Scope One and Scope Two, and that’s where the ambulances get a little bit tricky because the operator oftentimes doesn’t have a lot of control when they win the tender, and it’s strictly shaped what can happen inside the ambulance and how can it be furnished and how can it be powered, where can it go in these things. So there’s a little bit of an argument, but we did a very interesting recording with David from FLK, if you want to dive into that. So, playing it back, we learned that energy and transport that you would normally look to as one of the first big emitters doesn’t matter as much in this scope, and that procurement mattered a lot.

Rasmus: Yeah. Another, just maybe picking up your point, another funny thing for us to see is that when we look internationally at people working with hospital waste, what they’re really working with is to avoid depositing. And that even goes for the developed countries like New Zealand and France and so on and so forth. Whereas in Denmark, we have practically no depositing anymore. So what we are working with is going from incineration to recycling or avoidance. So it is a bit, you know, looking into international, sometimes you actually get a little bit of a feeling that at least in some small ways, we are still a little bit ahead or at least we have different problems. I don’t know if we’re ahead, we just have different problems.

Frederik: I think that’s a very polite way of phrasing it. But also humble enough that I can subscribe to it. If we’re looking at the agency for change, what does procurement really dominate? Because that’s where the hospitals have leverage, they can decide different things. Or how come procurement is sort of picked as the main lever for change?

Rasmus: Well, in the procurement is where we can take the action as in we are doing a green procurement where we get, you know, we talked about that for a couple of years ago, like when we set up the rules, what do we wanna buy? But you can say even in the other way, where we want to make a greener approach that boils down to making doctors or working with doctors or nurses or surgeons to have them change what they usually do, you know, go from one product to another product, or go from a single use product to a multiple use product or whatever. And that also ends out, I mean, the actual saving will come from a different procurement at different purchase. So everything boils down to what we buy as a healthcare sector in Denmark.

Frederik: And I think there’s something a little bit interesting here because it’s actually not, the hospitals’ agency is a little bit diluted, right? There’s of course representatives from the hospitals that have a say in what’s being bought at a regional level, but I think it’s one of the things where when maybe strategy consultants and political advisors are giving advice and saying well, we’ll just fix procurement, that’s easy. Well, it’s procurement is really, really complicated. So can you walk us through if I wanna buy a surgical camera and I’m a surgeon. What is my path to getting a surgical camera in my hand? How does it get in my hand and where the decision made, sort of from a national level and all the way down?

Rasmus: I can try to do this, although that’s mot really, that’s a bit of a curve ball. Well, you can say you have different things. Firstly, if you want to use a piece of equipment, it has to be CE marked. It has to be approved, it has to have the MDR ranging from the European and so on and so forth. So considering that you just want a piece of kit that is approved and that is okay, you have sort of two different ways to go about. We have the way that the series of the administration or the system of the regions really love where you go to the purchasing department and say, I really want this piece of kit, and then if you really, really, really need it now, we might be able to make a purchasing agreement with it now. Otherwise we say, hey, we have a tender coming up in like half a year, so keep your powder dry and then in half a year we will see if we can get this stuff for you, or at least the best stuff available. And that is really the route that we like. Then there is a secondary route where, because they’re surgeons and because they’re doctors, they have a lot of leeway when it comes to how, you know, I need this stuff, otherwise kids die. So they can actually just go up and buy it if they really, really, really want it, because they do have money in their own departments. So that would be the two routes to buying something within the regions. We really like the first route better because it tends to get at the best prices. Plus we can sort of manage what goes into our hospitals so we can make sure they can also manage it going out of the hospital. We also sometimes see that within the same hospital, maybe three doctors has gone out and made separate agreements. So we actually buy the same stuff within the same hospital, especially at three different prices. And that’s also something I really, from the same supply, some the same supplier. Yeah, yeah, yeah. Because they just make individual agreements and it’s a very nice flexible system, but it also has some downsides.

Frederik: Indeed. Okay. So that makes a lot of sense. So there’s kind of a split budget. The hospital has a minor budget on its own, and the main budget is the big procurement budget within the regions. So that’s a good clarification.

Rasmus: Yeah. The hospital has a budget that’s split between the different departments and wards. So they have agency when it comes to something like this. And they can also apply for money from the hospital.

Frederik: When we’re talking about this data model of think, we’ve alluded to it a little bit already. Can we get closer to sort of how it works and maybe create some images in our heads so we understand what it actually is. You know, everyone’s just saying data and we’re, I think it becomes a little bit elusive.

Rasmus: Yeah. Not everyone thinks everyone thinks that Excels are sexy. So sometimes you have to make graphs, because graphs are definitely sexy, right? So we sort of are trying in the regions to build up a data system with sort of different puzzle pieces for different objects. So our objectives, one of the major ones we have, and in Danish it’s “ess during model,” but in English we kind of wanna translate it to the climate management model, not as in managing climate change, but in how we manage our approach to climate change or avoiding it where it’s a back casting model similar to what NHS has done. Where we try to see, okay, what happens if we do nothing? Just imaging in front of you, you have like a graph, the point to the left side, and then if nothing happens, our emissions will just grow and grow and grow and grow. So you sort of have a line going to the right and a bit up, sort of, actually close to a 45 degree angle, which is a bit spooky. And then, similarly you can say, okay, according to the Paris Agreement in 2050 or something like that, we have to be at zero. So in the same graph, that would be a line coming from the same point going to the right and down 45 degrees. So our object when doing this kind of planet management would be to make sure that we move the point at the top part of the graph to the bottom part of the graph. So that is our gap, the space between those two. And just because looking at a big gap is not really very helpful, we then try to divide that gap into different segments according to what we buy and what we think we can do about what we buy. So what kind of reduction strategies do we think can help us here? So, just to dispel a myth, you know, a lot of people just say, well, the industry will take care. And when we look into how the industry is developing and how, you know, national grids are developing and everything else like that, those two lines will sort of take care of maybe a bit of the rise. So instead of the do nothing curve going straight up 45 degrees, instead, it will sort of actually take care of the growth. Meaning that if we do nothing, we just end up where we are in 2050. So all our extra purchasing, all our extra use will be compensated for by greener production and greener energy grids. But it won’t be any more than that. And then of course, that’s not enough. So we have other production strategies that we then wanna work with. We have, we can prevent that people actually come to the hospital, and how much that will make a difference is harder to debate because some say this is where we actually have to find our saving or sort. That will be the saving of us, to actually stop people going to the hospital because we have to get healthier in the future. Otherwise, we have what you talked about, or what we talked about a bit earlier, maybe before you started the recording actually, but telemedicine. And carbon optimized treatments in other ways, which would again, avoid people coming to the hospital in a traditional way. Then we just have stuff falling on. We have a reduction in consumption, which just means waste less or use less products. So, for example, we have had some glove campaigns which says, use fewer gloves because you don’t actually need to use gloves for everything. We have a change in consumption where you can go from a single use to multiple use or to better material or whatever. We have some demands for the supply chain as so this is a hierarchy. So if you can’t do something with a reduction, at least you can change your consumption. If you can’t change your consumption, then demand something from your supply chain: use greener energy, make sure you’re more efficient, yada, yada, yada. And then we sort of go out of the agency box and we go a bit below and we have some lines that we might tentatively call hope, which is Radical Green Product and Service Innovation. And this is sort of where the stuff we can’t imagine right now, there will be stuff that we can write right now that will help us. So we have a little bit of that and then we have some carbon capture and storage within and outside the supply chain. But not a lot of that because we try to follow the Science-Based Targets Initiative rules. I think it’s a maximum of 10 or 15% we can have. So overall, it’s sort of a map for us to look at, at where do we think we will see the reductions in the future? So where should we start to look for reductions? In the beginning, of course, it’s a theoretical map, but as we get stuff and get smarter, it will then become a more empirical map.

Frederik: So in the climate management model is, do you open that as an Excel sheet and then you can mess around inside it and you can build scenarios? What’s the use case? How many people actually are literate to use it?

Rasmus: Well, we have a couple of people at East Region who are literate to use it, and how much people have worked with it is a bit different from region to region. I don’t know, Thea, how you, if you have played around within the Southern Denmark region?

Thea: Well, in my department, but it hasn’t, like, it’s not something that the clinical staff has seen yet. So it’s a small target. We’ve seen this in my region. But what we’re trying to do, I mean, Rasmus and some other people is trying to rationalize. Like, how are we gonna use this? How are we gonna calculate? So if you reduce your consumption, what does that do to the carbon footprint and how can we calculate that? So we’re trying to take all these projects, which is happening and putting it in this model.

Frederik: Can you walk us through a recent project that you, that you looked at? What was it about and what were the results?

Thea: Um, I think actually Rasmus has more to tell about that, but we’ve gotten this regional strategy where all region has, um, suggested to and where there’s a couple of different projects going, and one of the project which all regions are working with is, um, I don’t know how to say it in English, like sheets that you put over tables and with, when you go, when you go to the doctor, there’s like a single use paper sheet that’s put on the bench.

Frederik: Yeah. And then you lie on, on the mattress, on the paper, and then you take the paper away. You throw it out after.

Thea: Yeah. So that’s a classic example because we don’t need that in most cases. So 90% of the time we don’t need that. So we have to reduce the consumption of that. And every region is working with this in different ways. In central Jutland region, they have just said we cannot buy it anymore. In our region, it’s more like bottom up. So every single like, department at the hospital has to choose, or like, we’re trying to nudge people to choose differently. So it has different results. But it’s one of the things that we’ve been calculating through all regions, what is the results of doing this project? And then we’re trying to put it into our climate management model, because we have this strategy, which is reduce consumption. So yeah, that’s one of the main examples. One of the good examples.

Frederik: And did you find out, and did you end up with a concrete carbon number? Did you get end up with a money saving or what were the results when you plugged it through the model?

Thea: Well, we have a carbon footprint for one product, one sheet. And then we have found the consumption in every region. We’re trying to follow the consumption. So we have a saving now in carbon. It’s very different from region to region, but we do have a carbon reduction for this project.

Frederik: Do you know what it is in, in shoe sizes? Is it five kilos or is it 50,000 kilos of CO2?

Thea: More like five, I think, unfortunately.

Rasmus: No, no, I, as far as I’m, it’s something, it’s a couple of tons. It’s some tons of CO2, but it’s not, this is not what will be saving us.

Frederik: I’m glad that sheets of paper is not what it takes to save this, but it is a good case to start building the list and I think it’s because it is like a clinical low impact area, right. And that’s also, of course, a good place to start where you can say, okay, this is something we did habitually. Now we’re stopping doing it. We’re saving money, we’re saving CO2. And you know, I don’t know. As a patient, I always felt weird lying on that paper. Yeah, it was like mentally it was like a really strange experience.

Thea: And I think it’s important that because we have a lot of focus on single use to multiuse and that is important as well. But we do not need to look into reduce waste. We have a lot of products. We use a lot of products that we maybe don’t need, maybe we buy too much of it, so we throw half of it out. And we have a lot of that. So that’s one of the main things right now is to find these products where we might not need as many as we do use.

Rasmus: Coming back to the strategies, when we can reduce something, of course we reduce the emissions from that product and that product category with a hundred percent. And that’s why it’s type of hierarchy when we change something in our consumption, if we move from a single use to multiple use, we are sort of used to numbers ending up roughly 80% reduction, which is still good, but some it will be less, but some it will be more. Then go to making demands on the supply chain, we can maybe save 10, 15, 20% emissions. But you know, we still have the core product made of the same core materials. So it’s really limited how much you can save. And that’s also why, you know, when we look at these things, start from the top of the hierarchy. As Thea just said, if we have something we can just avoid using, then cool, let’s stop and then we can, as soon as we stop doing that, we can just start looking at something else. That’s a really good point. Although sitting here as three desk jockeys actually changing stuff in the real world and the hospitals is somewhat more difficult because, you know, people don’t have a consumption out of, you know, just for kicks. People have a consumption because they think it makes a better treatment or a better experience for the patients. So it is actually hard work to go out and convince physicians and nurses that you don’t actually need this. And some will fight back because we’ve been doing this for the last 15 years, so of course we need this. So in that way working with sustainability in hospitals is like working with sustainability everywhere else. You have to change some minds about what they’re used to doing.

Frederik: I think that’s actually a brilliant note to end off on, because I think we could do an entire new episode on making that actual change just for the sheets of paper that you lay on, on the mattresses in the doctor’s clinic, right. So, playing it back then, you have looked at the data models for the Danish hospitals on the LCAs for a lot of different products, and you can conclude that energy in Danish hospitals is not that big of an issue. It might be in other geographies, but in Denmark we’re doing okay on energy. Transport is not a major issue for Danish hospitals, it’s only the ambulances that are in scope. One major provider at least wants to claim those emissions anyway. Then maybe you’ll get rid of them the easy way. The patient transport and staff transport is out of scope. That might change the picture. Procurement is the main muscle to exercise for decarbonization. The best thing is to not buy anything at all. If that’s not possible, then buy something that is multiple use rather than single use. And if that’s not possible, pushing demands in the suppliers for greener production and greener products is the next sort of step in the priority hierarchy. There’s a lot of work going on across the regions. The regions are trying to cooperate in various ways and learn from one another, which I think is great. And there’s a lot of interest in the field. If the listeners to this show want to learn more, where should they go to provide links for them?

Rasmus: Yeah, I would love to provide links. We are actually working on making our work publicly available, but you know, when we’re a public body and stuff has to be not just good, but you know, approvable or approved, then it takes a little bit longer to make something public. But we’re working on making both our data models public. And in case you’re ever short of guests, I think I would love to come back and talk about how we actually calculate things because we’ve also had to scale that down a little bit from, you know, the traditional EPDs and ISO certified LCAs.

Frederik: I would love to with you. So, let’s extend that invitation to have another episode on and get super nerdy on how we calculate things. Then the ones that don’t wanna listen, they can just skip to the next episode. You have that privilege when you listen to it.

Rasmus: Podcast. You have that privilege. When our colleagues listen to it, they said that they can’t go, you know, poke our phones and say skip. So they have but the privilege of podcasts.

Frederik: Exactly, exactly. But we’ll share some links that are relevant in the show notes. And I’ll just say thank you so much for coming on the show. It was a great pleasure to have you. I look forward to having you back on, on getting geeky on the calculations. I actually can’t wait. So we’ll schedule a day for that on. When, as soon as we start the recording. So dear listeners, you’ve been listening to an episode of the Sustainable Healthcare Podcast. I have been your host. My name is Frederik van Deurs, and it has been a pleasure to have you. And I hope you’ll like the show. Share the show, suggest guests that you would love to hear on the show and recommend it to someone who should listen to the good folks, Rasmus and Thea, and what they have to say to the world. Thank you for listening.