Assess the big picture. When surgeon Diane Riley, a 1989 DMS alumna, audited her hospital's ecological impact, she discovered numerous isolated efforts, including a lab tech who'd hauled waste to a local recycling center for eight years. When Laura Brannen was environmental coordinator at DHMC, she tracked everything that went through the trash room. Now executive director of Hospitals for a Healthy Environment (H2E), Brannen shares an improved version of her spreadsheet with hospitals nationwide. In 2006, one 12-hospital system used it to save $600,000 in its first year. "You can't manage what you don't know," says Brannen.

Network with peers. Share resources and steal ideas. Dominican Hospital in Santa Cruz, Calif., has adapted such DHMC programs as an online bulletin board for redistributing unneeded furniture and a free reuse center for office supplies. "The first step is reach out to people who can tell you what's worked, what hasn't," says H2E's Brannen. "We're all about helping hospitals stretch their limited resources so they don't have to do this in a vacuum."

Examine your own work processes. "It's something simple, thinking about how to improve efficiency and decrease waste," says Riley, who worked with Mt. Ascutney Hospital's OR staff to clarify her expectations about supplies and preparations for each procedure. Other strategies: Turn off the water while scrubbing in, and toss only actual biohazards into trash bags slated for incineration.

Balance sticker shock with long-term payoff. Vinyl flooring seems cheap and relatively durable until you calculate maintenance costs, not to mention liability for falls on wet vinyl during bad weather. Consultant Jan Stensland recommends rubber. It's attractive and maintenance is quick and easy. In her opinion, the added benefits of reduced toxicity and increased comfort for staff who walk miles on every shift make the choice a no-brainer despite the per-square-foot price. "If you just look at first cost," she says, "you're just doing first-grade economics."

Set clear expectations. Dr. Gus Kious, the president of Huron Hospital in East Cleveland, Ohio, eliminated the guesswork. "I said I wanted waste reduced by 50% within three years," he says. He estimates the facility now saves $50,000 a year from recycling and improved supply-chain management. "Our ability to deal with waste," he adds, "is an

important part of our ability to be perceived as a high-performance operation."

Do your homework. When DHMC considered new cleaning products, staff assessed three for volatile organic compounds—the source of that "new" smell. One marketed as environmentally friendly and containing the fewest chemicals seemed like a great bet—until staff realized the three required applications increased both toxicity and total cleaning time. "You can't just look on the bottle and say, 'Look, it has a green seal,'" says DHMC's vice president of facilities, Gail Dahlstrom. "You have to ask the next question: What does that mean and how are you going to use it and what's the life cycle of it?"

Take it slow. Experiment on a small scale before launching a comprehensive overhaul. At DHMC, a few sample chairs have been reupholstered in an antimicrobial, stain-resistant vinyl substitute free of PVCs, plasticizers, bromines, and azo dyes. After users weigh in, administrators will decide how to proceed. Says Dahlstrom: "I might say, 'Let's . . . implement some of these more innovative methods,' then measure results on a variety of metrics—cost, true energy savings, perceptions, satisfaction—and then see if it's growable."

Make it easy. Make information accessible, provide adequate training, and keep things simple. Efficient lighting fixtures have proliferated but often require not-quite-interchangeable bulbs. At DHMC, implementation has been limited to a few models to reduce confusion and costly mistakes. "If we have two varieties and they can be easily recognized," says Philip Chaput, DHMC's operations and maintenance manager, "it's much simpler."

Have fun. At Dominican Hospital in Santa Cruz, a community-hospital collaboration has yielded an on-site greenhouse populated with bins of earthworms that convert kitchen scraps to compost. It goes on a vegetable garden planted to the hospital chef's specifications and maintained by local vocational students.

Invest in success. "If you're not getting a lot of traction with one project, move on to the next," advises H2E's Brannen. Highlight energy savings, waste reductions, improvements in recycling rates, and new program launches. Communicate. Says Brannen: "You're always telling people you're making strides, and they get excited to take on the next thing."

3,965

A conservative count of the number of energy-saving compact fluorescent bulbs now in use at DHMC

146,000

Number of passengers in 2006 who rode the free public shuttle that links DHMC, DMS, and Dartmouth College with downtown Hanover and Lebanon

$341,000

Estimated amount those riders saved in commuting costs