Green ghosted shapes image

Integrating Environmental Sustainability into the Quality and Safety Agenda: Early Lessons Learned

Why It Matters

Climate change has an impact on all six dimensions of health care quality. 


In June of 2023, as thick orange smog from Canadian wildfires engulfed New York City, a spike in asthma-related emergency department visits served as an undeniable example of the far-reaching negative effects of climate change on health and health care delivery. At NYC Health + Hospitals (NYC H+H), the largest municipal health system in the United States, we dedicate ourselves to serving all who live in New York City, without exception. We see firsthand how health disparities are exacerbated by climate change every day. In fact, climate change has an impact on every dimension of health care quality (see Table 1).


Table 1 - Examples of the Impact of Climate Change on Every Dimension of Health Care Quality

Dimension of Quality Examples Clinical Impact 
SafeWater quality — In 2014, Flint, Michigan found that their water source caused old water pipes to corrode and leak lead into drinking water. Lead and other water contaminants from aging housing infrastructure are especially harmful to children and their developing brains. Without safe drinking water, how can providers give optimal care to their patients, within and outside of health care facilities? 
EffectiveRespiratory illness — People suffering from asthma or COPD are vulnerable during heat waves or periods of bad air quality, particularly those experiencing homelessness, low-quality housing, and/or financial insecurity. Clinical therapeutics alone are no longer enough to help these populations. Effective care must now include multi-sectoral mitigation strategies around the built environment. 
Patient-CenteredChronic disease — For patients with chronic illnesses, such as diabetes and heart disease, patient-centered care can look like implementing a Lifestyle Medicine Program. This targeted program, in part, provides the resources for healthy foods and recipes. Climate change has reduced the supply of healthy foods, which then affects the health care system’s ability to support patients in managing or beating their illnesses. 
Timely Weather-related disasters — Severe flooding and power outages from weather-related disasters, such as Hurricane Sandy in 2012, forced closures of affected health care facilities across New York City. Forced closures not only disrupted services provided to acutely ill patients but also postponed care for emergency and ambulatory care settings, increasing the risk for harm to patients. 
Efficient Wildfires — Climate change has increased the frequency of wildfires, which are disasters that fill EDs and ICUs.  Treating chronic respiratory and cardiovascular illnesses is difficult and inefficient when poor air quality is pervasive, and patients need to continuously enter the health care system for more frequent acute exacerbations. 
EquitableHurricanes — Following Hurricane Maria’s destruction in Puerto Rico in 2018, rates of PTSD were particularly high for climate migrants, or those forced to relocate, compared to those who chose to stay in Puerto Rico.Mental health care is important for all those impacted by climate crises, but especially for climate migrants. 

Health care delivery accounts for 8 to 10 percent of greenhouse gas emissions in the United States and 4.4 percent globally. To do our part to decarbonize our health care delivery, in 2021 NYC H+H signed the Health and Human Services Health Sector Climate Pledge as a commitment to protect our patients’ health outcomes. Since then, NYC H+H/Jacobi/North Central Bronx — which includes a Level-I trauma center and community-based campus in the Bronx — has incorporated environmental sustainability into its Quality Assurance/Performance Improvement (QAPI) strategic planning, recognizing that the functions of quality and safety are perfectly poised to catalyze climate-friendly behavior change and process improvements.  

Here are some early lessons we have learned from integrating a climate lens into NYC H+H/Jacobi-North Central Bronx QAPI activities: 

  • Addressing climate change is a health equity imperative. Climate change does the greatest destruction in our most vulnerable communities, and it is clear that we cannot tackle it without addressing current and potential health injustices. Great QI work starts with an assessment of the current state. A deep dive into the nexus of climate change, health equity, and environmental justice provided us with guidance from which to learn and plan for future climate events in our region. Our Community Health Needs Assessments directed us to where climate action might make the greatest impact. Just as it is essential to use an equity lens in performance improvement, we understand that using a climate lens will help us uncover root causes of climate injustices. 

  • Partner with a range of stakeholders. Climate change influences the quality, safety, and financial health of an entire organization. Understanding the greenhouse gas emissions of our facilities is necessary to decrease our carbon footprint. The US Agency for Healthcare Research and Quality advised health care institutions to utilize the Greenhouse Gas (GHG) Protocol for standardized measurement and reporting of GHG emissions. Many organizations have focused on enhancing facilities to reduce direct emissions from sources owned or controlled by the system or indirect emissions from the generation of purchased energy. Partnership with operations, engineering, and facilities management is essential to do this. Engaging frontline health care teams in promoting environment-positive process improvements can reduce the impact of other indirect emissions (e.g., producing and transporting goods and services, including medical devices, medications, catering, etc.) and result in both clinical and operational efficiencies.  

  • Use quality and safety capacity-building to develop skills for climate action. Just as it can be overwhelming to consider the enormity of improving quality and safety across the continuum of care, the complexity of climate change can make it difficult to feel like meaningful impact is possible. However, like making QI capacity building a strong pillar of a QAPI infrastructure, we must build our skills to act on climate change. To do so, we need to help teams understand the impact of climate change, the data and tools to use, and how to discuss the impact of climate on health. We must also raise awareness of climate-based initiatives happening across our facilities. 

  • Apply a climate lens to quality and safety functions. Seeing improvement work through a climate lens will not only shed light upon how our processes influence our environment, but it will also help us recognize climate’s impact on the health of our patients. Like a framework that intentionally focuses on equity, we want our interventions to promote healthier environments and mitigate climate change.  

There are multiple ways to prioritize environmentally friendly practices in quality and safety functions:   

  • Identify how climate impacts the outcome being targeted as well as patient safety events. (See Table 1 above for some examples.)

  • When planning for and choosing process improvement or implementation projects, calculate potential carbon costs and prioritize those that both advance health care quality and result in lower carbon emissions. This includes avoiding low-value care and limiting waste. 

  • Look for potential carbon savings across a variety of projects and collaborations. Sometimes teams are already doing great planet-friendly work and this outcome is not being tracked.

  • Promote climate resilience through improvement work. As an example, when working to improve maternal morbidity, consider including anticipatory guidance for both patients and providers on how heat or other climate features might impact a particular condition. 

We believe the connection between environmental sustainability and quality and safety is clear. Consequently, it is essential for us to harness quality and safety functions to improve our processes and protect our planet and those who inhabit it.  

Komal Bajaj, MD, MS-HPEd, Chief Quality Officer at NYC Health + Hospitals/Jacobi/North Central Bronx; Lara Musser, DO, Deputy Chief Quality Officer at New York City Health + Hospital/Jacobi/North Central Bronx; Eric Wei, MD, MBA, Senior Vice President and Chief Quality Officer at NYC Health + Hospitals; Jordana Bailey, Chief Operating Officer, NYC Health + Hospitals/Jacobi; Alfredo Jones, Deputy Executive Director, NYC Health + Hospitals/North Central Bronx; Cjloe VinoyaChung, MPH, Associate Director, New York City Health + Hospitals/Jacobi/North Central Bronx.