HCWH: Scaling Strategies to Build a Movement & Move Markets

As part of this Scaling Snapshot, see also Health Care Without Harm’s Organizational Overview, Getting Ready for Scale, and Scaling Pearls of Wisdom. You can find the full snapshot PDF here.

Photo by Ibrahim Boran on Unsplash

Health Care Without Harm (HCWH) is driving impact at scale by building a movement and aggregating the movement’s collective power for change. It has worked to strategically engage a critical mass of hospitals and health systems to fuel and sustain the movement and continues to evolve based on market, policy, and scientific discovery. To execute upon this work, HCWH has become somewhat of an umbrella organization with semi-autonomous entities operating beneath it:

As HCWH began to scale around 2006, after spending a decade positioning itself for such, it pursued four key scaling strategies to meet its goals. Below you will find more detail about those strategies, along with the organizational implications for pursuing each.

STRATEGY: INCREASE SCOPE OF ENVIRONMENTAL HEALTH ISSUES ADDRESSED

Directly support hospitals to deepen impact by addressing more comprehensive range of issues over time.
HCWH has identified a repeatable process to support hospitals in addressing environmental issues within their operations. Through this process, HCWH identifies a sustainability issue, and hospital(s) that are willing to be early adopters support the hospital team (usually the sustainability manager along with interested clinicians) to implement changes and then help to measure the return on investment and develop knowledge sharing materials (including a case study). HCWH can then use those materials to engage and enable other hospitals to replicate the work in their own facilities (as outlined in the next strategy below). Over time, HCWH has repeated this process within its network, enabling hospitals to deepen their impact across multiple sustainability issue areas, such as toxic chemicals, building design, purchasing, climate, water, energy, pharmaceuticals, and food.

YOU SHOULD KNOW: Implications of Increasing Scope of Issues

Resource intensive. Taking on new issue areas with early adopter hospitals is resource intensive and requires HCWH to create teams with niche expertise related to the particular issue.
Time intensive. The timeframe from identifying an issue area, finding an early adopter hospital, and piloting and evaluating a set of solutions could take upwards of one to three years.
Engagement of early adopters. Identifying influential adopters who can not only demonstrate efficacy and the ROI of the environmental innovation but are also willing to promote and scale these solutions is key.
Being outside of common siloes. In some areas of issue expansion, HCWH has had to fit awkwardly into siloes within which funders operate, as an integrated approach to climate, health, and equity is only now being adopted by the philanthropic sector.
Network-led innovation. Through network development, HCWH has been able to surface innovations sponsored and paid for by hospital partners and spread new innovative strategies across the network.

STRATEGY: ENABLE OTHERS TO ADOPT PRACTICES

Enable health care systems to change practices by providing rigorous evidence, knowledge-sharing tools, and peer-to-peer networks.
Knowing that it could not work directly with all hospitals in addressing environmental health issues, HCWH created two membership organizations: Practice Greenhealth, in the U.S., and Global Green and Healthy Hospitals, internationally. The membership organizations provide hospitals with the evidence and tools to implement changes, along with a peer network and infrastructure to enable peer consultation and knowledge transfer. The organizations also generate momentum by leveraging the competitive spirit of members through benchmarking and awards. HCWH has leveraged the power of the peer-to-peer networks to spread innovation by doing the following:

• Providing those working on environmental issues within hospitals a way to short-circuit the learning curve (to achieve results more efficiently and effectively) and gain moral support from others in similar situations.
• Creating learning opportunities for more niche entities within the health care system, such as children’s hospitals and academic medical centers, through cohort working groups.
• Generating recognition for (and thereby elevating the status of) sustainability staff within the hospital through the network awards program.

Practice Greenhealth (PGH) is a membership and networking organization for sustainable health care, delivering environmental solutions to hospitals and health systems across the United States. PGH generates earned revenue from membership fees, consulting fees, and an industry partner program; as of late 2019, has over 1,100 hospitals as paying members. PGH has continued to evolve its thinking about how to capture value from its efforts while continuing to support the network and related programs. In addition to health system membership fees, PGH has developed and launched a set of consulting products (under an Advisory Services offering) to both member and non-member health systems. It has also launched a program offering access to tools and resources for supply chain partners, academic institutions, and nonprofit entities without full ‘member’ designations.

Global Green and Healthy Hospitals (GGHH) works with hospitals, health systems, and health organizations to address and promote greater sustainability and environmental health for the health sector globally. Its staff footprint is smaller than that of PGH, and it has not yet generated revenue from membership given the large percentage of public hospital members (most in LMICs) whose ability to pay network fees can be limited. A key factor of success for GGHH has been deployment of local staff in Asia, Africa, Latin America, and Europe, as well as its network platform which it developed in partnership with Cisco Systems (with support from the Skoll Foundation). The platform allows GGHH to efficiently tap network expertise, share technical knowledge, mobilize members around specific issues, and collect data from its large and growing membership. As of late 2019, GGHH has 1260 institutional members from 72 countries.

YOU SHOULD KNOW: Implications of Enabling Others to Adopt Practices

Adding new skillsets. The skills — and therefore professionals — required to support and enable partners through a membership organization are quite different than those required to test and model the hospital-based intervention. PGH requires professionals who are more like account managers (with deep hospital experience) to run the membership model as well as professionals to develop and manage the educational work.
Aligning within partners’ boundaries. It is important to find the right kinds of engagement for different players within the ecosystem, understanding both potential competing interests (e.g., supply chain members within PGH) and uncomfortable associations (e.g., separating HCWH advocacy arm from PGH for hospital members’ comfort).
Monetizing the value created. Think early about the ways in which you can monetize the value you are creating for your partners; it is more difficult to monetize once programs are in place.
Working behind the scene. Enabling others often means shining the spotlight on their achievements and doing your work behind the scenes. However, being behind the scenes can limit your own name recognition and attributable direct impact and therefore compromise your standing with funders.
Refining the value proposition. Membership alone is not enough of a value proposition for hospitals who generally belong to many different associations. HCWH has realized that the value is in the combination of membership, consulting, data, and advisory services — essentially, helping hospitals solve real problems and supporting them with the bandwidth required for that.

STRATEGY: AGGREGATE COLLECTIVE PURCHASING POWER TO INFLUENCE MARKETS

Given that the health care system represents 18% of the U.S. economy and 10% of the global economy, one of HCWH’s longer-term strategies has been to “aggregate hospital purchasing to move the market toward healthier alternatives.” To support both the supply and demand sides of this equation, HCWH works with hospitals and supply chain partners in Market Transformation Groups to set new product standards it then eases access for hospitals to identify and purchase products through the Greenhealth Exchange procurement cooperative and Greenhealth Approved eco-label.

“We eliminated mercury from healthcare and won a global treaty phasing out its use, even though it was once considered the gold standard for measuring temperature and blood pressure. We are now mobilizing our network and partnerships … to transform the global supply chain, to transform energy and health policy, to transform consciousness, and build the collective will to save ourselves.” Gary Cohen, Co-Founder & President, HCWH

Setting New Product Standards: Market Transformation Groups
Manufacturers and suppliers are eager to anticipate purchasing trends, where to invest their R&D money, and how they can help hospitals solve problems, so PGH created Market Transformation Groups as a collaborative platform. MTGs brings hospitals and health systems together to focus on specific agenda items, such as safer chemicals for furnishings or healthier meat options for food services, and to invite entities along the health care supply chain to participate via meetings, webinars, and more. MTGs works to set new standards for products, and the businesses along the supply chain adapt their practices to be able to attract business from those hospitals.

Setting Global Environmental Standards: UNDP Partnership
Since healthcare is a global marketplace, HCWH teamed up with the United Nations Development Programme to develop globally validated environmental standards for a wide array of products sold into healthcare. In this way, HCWH can leverage its own networks while collaborating with UNDP to implement these standards in multiple markets and shift global production.

Reducing Barriers for Purchasing: Greenhealth Exchange
To reduce time and capital barriers for hospitals to make sustainable, toxic-free purchasing decisions, HCWH and a group of nine health care system partners established Greenhealth Exchange in 2016. GX provides a marketplace through which members can find and procure green products used in the health care setting at competitive prices. GX was created as a B-Corporation cooperative, and HCWH created a for-profit wholly-owned subsidiary (Greenhealth Management) to staff the cooperative — understanding that the talent it would need to run the GX operation was most comfortable operating within a for-profit structure. In addition to creating GX as a strategy to improve the supply of and demand for green products, HCWH believes that the exchange can generate profits to support HCWH’s operating costs.

The success of HCWH’s efforts to move markets has often led to policy change (e.g., the phase out of and eventual global treaty on mercury) and has appeared to be a more enduring pathway than pursuing policy change alone.

YOU SHOULD KNOW: Implications of Influencing Markets

Maintaining control of the agenda. Influencing markets requires collaboration among different groups; for HCWH, the groups are primarily hospitals/health systems and businesses along the health care supply chain. HCWH has noted the ways in which the agenda can be influenced by the businesses in particular so ensures that it maintains control of the agenda when facilitating these collaborations.
Creating effective working groups. Curating and effectively managing working groups are critical components of success, given the goal is to align major procurement contracts across large healthcare entities and stimulate business sector innovation to meet the growing and changing demand.
Adding new skillsets. GX requires professionals with corporate procurement experience. While many NGOs do environmental standard-setting in their respective fields, HCWH and GX require people that can write contracts for specific products so that healthcare procurement staff can simply adopt them.

STRATEGY: INFLUENCE POLICY

Promote policy change directly and through partners, generally once markets are softened.
HCWH has found that softening the market through its purchasing power work can help reduce political barriers and increase momentum for associated policy change. Legislators are often hesitant to clash with the business community, but, if the healthcare systems are already moving in a certain direction, it is safer to codify those changes through policy. HCWH works through its hospital and health system members, as well as on its own as an advocacy department, to pursue this work.

In partnership with PGH, HCWH creates cohorts around key topics (such as climate change, the circular economy, and operating as anchor institutions), allowing its hospital and health systems partners to merge collective knowledge and power that can be used for internal changes and advocacy. HCWH supports these partners in their own advocacy by engaging and providing them with data and talking points. However, this effort has been the accumulation of decades of work and trust-building with the hospitals and health care systems, as HCWH first needed to help them get their own houses in order before expecting them to take on an advocacy role.

HCWH as an organization also works at state, national, and multinational levels to influence climate and health policy and global markets. HCWH developed the Health Care Climate Challenge to engage health systems around the world to make commitments in addressing the climate crisis. The Challenge commits health systems to address both infrastructure and community resilience, reduce their own climate footprint, and engage more broadly in policy and public leadership. By mid 2020, over 300 participating institutions — representing the interests of over 22,000 hospitals and health centers in 34 countries — have committed together to annual reductions of 34 million metric tons of greenhouse gas emissions (the equivalent of closing nine coal-fired power plants).

YOU SHOULD KNOW: Implications of Influencing Policy

The long game. Before most institutions are willing to become vocal advocates on an issue, they first want to ensure that they are already living the practices around which they will advocate. Therefore, it can take a significant amount of time to help an institution feel in a secure enough place to become an advocate.
Leveraging credibility; avoiding bureaucracy. HCWH works to leverage the credibility of government and multilateral organizations — without getting tied up in their bureaucracy — by focusing on very specific outcomes, such as internal procurement standards.
Boundaries of advocacy work. HCWH will work with health partners to develop model policies and educate policymakers on their value, but the organization does little direct lobbying on its own. HCWH relies on other partner organizations to run progressive climate policy campaigns and works to bring in healthcare institutions as political and economic powerhouses to support or advocate for such policies.

Case in Point: Seeing HCWH’s Scaling Strategies Play Out in Greening the OR

HCWH applies multiple scaling strategies to build upon its work in any particular sustainability area, leveraging the resources, knowledge, and momentum of all. See below how it extends the impact of a waste-related project from individual hospitals to manufacturing to policy.

Strategy: Increasing depth of impact by addressing broader range of issues

• Identify issue: HCWH’s research shows that the operating room accounts for a significant percentage of all hospital supply costs — in addition to energy use and waste — but is also key revenue driver. Through Practice Greenhealth, HCWH sought to “coalesce and build the body of knowledge around environmental best practices in the OR that can also improve patient safety, worker health and the bottom line.”
• Identify early adopters: Through the PGH network, HCWH sought hospitals interested to tackle the OR challenge. Yale-New Haven Hospital and Cleveland Clinic volunteered to develop, implement, and test strategies.
• Develop, implement, test: HCWH recognized that key barriers for this endeavor would be perceived cost (including capital investments), uncertain ROI, and concerns about compromising patient safety. HCWH brought together a variety of experts (including those in chemicals, energy, waste, and OR products and procedures) to support the early adopter hospitals in developing revised processes, technologies, and supplies. HCWH supported the creation of case studies, demonstration of ROI, and the development materials to communicate the process and results. This early validation with the initial hospitals took about two years — typical for such a project.

Strategy: Enable others to adopt practices

• Share and enable: Through the PGH network, HCWH ran webinars and shared findings to encourage other members to take on the OR effort. As members did, HCWH collected more case studies and data, and began to build out a toolkit of key interventions with detailed guidance and steps for each. As hundreds of hospitals adopted the new practices, HCWH incorporated the strategy into its annual awards program — which happened five years from the start of the Greening the OR effort.

Strategy: Aggregate collective purchasing power to influence markets

• Aggregate power of adopters: PGH members used their aggregate purchasing power to influence manufacturers to offer products and services aligned with Greening the OR, such as reprocessing medical devices, reducing waste in OR surgical kits, developing reusable sterilization kits, etc.

Strategy: Influence policy change

• Drive policy via markets: Due to HCWH’s market transformation efforts across hundreds of U.S. hospitals, medical device manufacturers abandoned policy campaigns to restrict medical reprocessing in multiple states.

Published September 2020. Find the full Scaling Snapshot PDF at http://bit.ly/ScalingSnapshotHCWH.
Authored by Erin Worsham, Kimberly Langsam, and Ellen Martin.