Environmental Management towards a Sustainable Development at Danish Hospitals - Perspectives of integrating environmental management and working environment within the concept of Sustainable Development

The story about everybody, somebody and nobody:

“Everybody says somebody should begin. Somebody says he will only begin if everybody does. So in the end nobody begins!”

Kurt Pedersen International Masters Degree Course: Environmental Policy and the Global Challenge – International, Regional and Local Perspectives Department of Environment, Technology and Social Studies Roskilde University 4000 Denmark May 2002

Abstract

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This thesis is a result of completing the International Masters Course on Environmental Policy and the Global Challenge – International, Regional and Local Perspectives 2001/2002 at Roskilde University Centre in Denmark. The title of the project is: Environmental Management towards a Sustainable Development at Danish Hospitals - Perspectives of integrating environmental management and working environment within the concept of Sustainable Development. The problem formulation is: Which values, strategies and methods should be enforced if integrated environmental management should contribute effectively to the idea of a sustainable development? – and what would be the main barriers to such an integration strategy? Based on case studies at 3 Danish public hospitals and case study research on implementation of environmental management systems and integration of environmental management and working environment at private enterprises, I analyse and conclude on recommendations for implementation of environmental management at Danish hospitals. These conclusions and recommendations, in what I have called an adductive analysis, are related to the research questions of the problem formulation concerning values, strategies and methods of integrated environmental management at an institutional and organisational level. Based on theory on the concept of sustainable development, environmental economics, ecological modernisation and risk society I analyse the research questions concerning environmental management and the idea of sustainable development. I analyse and discuss the relations and potential synergy effects of sustainability and environmental management, sustainability and working environment and the integration of environmental management and working environment at a sector and society level partly based on the theory and empirical findings of the case studies and partly based on my understandings and experiences related to my previous work within quality management and organisational development at Danish hospitals. I am searching for development dynamics within the above-mentioned perspectives and end up concluding on needs of improved political and legislative interventions, increased value based management involvement, use of a management systems approach based on strong employee participation as effective means. I recommended strategies of integration of environmental management and working environment within the safety organisation as a starting point and integration within quality, service management and prevention and health promotion at Danish hospital on the further journey towards a sustainable development.

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Table of Content Abstract .........................................................................................................................................................................1 1. Project content and background .............................................................................................................5 1.1 Introduction.............................................................................................................................................................5 1.2 Problem formulation / research questions............................................................................................................6 1.3 Definition of main concepts....................................................................................................................................8 1.4 Motivation................................................................................................................................................................9 1.5 Target group..........................................................................................................................................................10

2. Methodology .......................................................................................................................................................11 2.1 Introduction...........................................................................................................................................................11 2.2 Project design ........................................................................................................................................................11 2.3 Use of theory..........................................................................................................................................................12 2.4 Use of empirical data ............................................................................................................................................13 2.5 Analysis and discussions.......................................................................................................................................15

3. Sustainable Development ...........................................................................................................................16 3.1 Introduction...........................................................................................................................................................16 3.2 Sustainable development as a goal of Environmental Management ................................................................16 3.3 Environmental economic theory and sustainability...........................................................................................18 3.4 Sociological theories on environmental politics and sustainable development................................................20 3.5 Theory on Risk Society in relation to the concept of sustainable development...............................................22

4. Environmental management and working environment.......................................................25 4.1 Introduction...........................................................................................................................................................25 4.2 Environmental Management – development of legislation and regulation methods......................................25 4.3 Environmental management systems..................................................................................................................26 4.4 Working Environment – development of legislation, organisations and regulation methods .......................31 4.5 The concept of integration between environmental management and working environment.......................33 4.6 Empirical findings from case studies on integration of environmental management and working environment.................................................................................................................................................................34 4.7 Theoretical aspects related to environmental management and sustainable development............................36

5. Case – studies ....................................................................................................................................................39 5.1 Introduction...........................................................................................................................................................39 5.2 General about the hospital sector and hospital management in Denmark......................................................39 5.3 Case - RASK, Koege Hospital in Roskilde County ............................................................................................40 5.4 Case – Copenhagen County Hospital in Gentofte (KAS Gentofte) ..................................................................47 5.5 Case – Fredericia Hospital (Fredericia Sygehus - FS) in Vejle County ...........................................................53

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6. Adductive analysis and conclusions based on case studies in the field .......................61 6.1 Introduction...........................................................................................................................................................61 6.2 General characteristics of the 3 case studies of this project..............................................................................61 6.3 Analysis and discussions on empirical findings related to the themes and questions of the problem formulation ..................................................................................................................................................................62 6.4 Conclusions and answers to the problem formulation and the research questions ........................................69

7. Final analysis, discussions and conclusions .................................................................................69 7.1 Introduction...........................................................................................................................................................70 7.2 Analysis Stakeholder Model.................................................................................................................................70 7.3 Environmental management and Sustainable Development ............................................................................72 7.4 Working Environment and Sustainable Development ......................................................................................75 7.5 Integration of Environmental management and Working environment.........................................................77 7.6 Concluding remarks .............................................................................................................................................79

8. Perspectives and further research ........................................................................................................81 Acronyms ...................................................................................................................................................................82 Literature ...................................................................................................................................................................84 Bibliography:...............................................................................................................................................................86 Annex I.........................................................................................................................................................................87 Annex II .......................................................................................................................................................................88 Annex III......................................................................................................................................................................88

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1. Project content and background 1.1 Introduction Sustainable development is on the global agenda at the United Nation International Conference in South Africa in August 2002. Since the UNCED Conference in Rio de Janeiro in 1992, and the formulation of Agenda 21 based on the Brundtland Report: Our Common Future, (Brundtland, 1987) it has been a global issue to define the content and evolve strategies of implementation of the phrase: Sustainable Development in many international communities and organisations and it is expected that member states of UN presents their national strategies on sustainable development at the next world environmental conference, RIO +10 in Johannesburg South Africa. A great number of international conferences have been held and publications written on topics related to strategies on sustainable development within the last 10 years. As a follow up to Agenda 21 and preparations for the UNCED Conference in Johannesburg the Danish Government made a Danish National Strategy on Sustainable Development, called Common future – development in balance by which the visions and goals for a Danish understanding of sustainable development is laid down by the following 8 visions and principles: 1. The welfare society must be developed, with a decoupling of relations between growth and environmental impacts 2. Environment must be safe and healthy for everybody and we must keep a high level of protection 3. High biodiversity and protection of the ecosystems must be secured 4. Resource management must be improved 5. An active international effort must be delivered 6. Environmental protection must be secured within all sectors of society 7. Market must support a sustainable development 8. Sustainable development is a common responsibility, and we must measure improvements (Danish Government, 2002) The concept of sustainable development is about three related and inter dependable issues: • Environmental protection • Social responsibility • Economic development Concerning environmental protection within enterprises, institutions and organisations the European Commission has developed European Eco Management and Audit Scheme (EMAS) in 1993 as an instrument with the purpose of standardizing environmental management systems used in European countries. The latest version of EMAS 2001 is a voluntary program to be used by all types of organisations within all sectors, including the public sector authorities and institutions. Within the private sector an environmental management system called ISO 14001 has been developed and implemented in various companies for several years. Concerning working environmental conditions as part of social responsibility Denmark has for quite some years had specific laws and several regulations on management responsibilities related to working environmental issues. A number of institutions are established in this area, and research has been going on in the field for many years. Denmark has a strategy on working environment called “Clean Working Environment Year 2005” recommending working environment being inte-

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grated in environmental action plans, green accounts and budgets in the Danish public sector (Directorate of the Danish Working Environment Service, 1996). Within economic development of societies, The Brundtland Report focuses on the inequity distribution of economic and natural resources of the globe among the world populations, a development that continues today increasing the differences between the poorest and the richest parts of the world. Essential issues related to economic development is the exploitation of natural resources and the environmental harm related to this, which is a crucial issue in many countries in third world. As concepts of environmental economics, emerging of the “polluter to pay” principles in public taxation and environmental regulation and the spreading of knowledge and use of methods of environmental economics are evolving, it could bee expected that this view would enforce the efforts of environmental management, based on a broader calculation and understanding of the economics of environmental issues, including the economics of a sustainable working environment. Looking into the private sector it seems like some private businesses have worked out strategies of integration of the management systems of environment and working environment and economy in a combination for some years. Concepts of participation of employee’s and views and values of stakeholders are seen as important elements of some of those new business development strategies. With a personal background working within quality management and organisational development at hospitals in Denmark I had never heard about the use of environmental management systems at hospitals and had only shortly heard about green accounts as a new type of administrative demands on documentation related to consumption on energy and water resources at hospitals. How come the rising environmental regulation and the political discourse on environmental management had not influenced hospitals as major public institutions? Are hospital management going to include strategies on environmental management based on the principles of sustainable development like other businesses and organisations? Should integration of environmental management and working environmental issues be part of such a strategy and eventually how? These questions were the background for my interest investigating the perspectives of environmental management in public sector hospital within 3 angles: Environmental management, working environment and the concept of sustainable development. 1.2 Problem formulation / research questions. Talking about sustainable development and environmental management of hospitals it might be useful to list the areas of environmental concern related to hospital services. The following list of topics could be in focus in a hospital environmental management system: ¾ Use of materials (food, chemicals, medicine, hazardous materials) ¾ Energy consumption (electricity, heat, cooling, transport) ¾ Water (consumption, legionella infections, purification of water) ¾ Waste (medicine, bio medicals, water, plastics, paper, carbon, food etc.) ¾ Working environmental issues (occupational health and safety, degradation of employees) ¾ Patient health and safety (infections, allergic reactions, medication failures, etc) Listing these examples of environmental issues I use a broad definition of environmental sustainability including physical and working environmental issues and health and safety for employees and patients.

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Based on a short investigation, I found out, that only a small number of Danish hospitals had shown concern of their environmental pollution and environmental problems related to their services. Rather few hospitals were preparing green accounts, following their use of energy, water and waste, and only 6 to 8 of about 80 hospitals in Denmark have implemented environmental management systems. There might be several reasons for this. Politically there have been rather limited focus on environmental pollution and environmental problems in public institutions and services in Denmark, and especially on hospitals, even though hospital services is one of the biggest sectors within public services. Only rather few regulations have been enforced, and the use of green accounts and systems of environmental management is voluntary for the hospitals to implement. Environmental management systems are developed and implemented in the line of quality, information, knowledge and other logistic management systems in private enterprises, as the public demand and control of the environmental issues are of growing concern. The Danish Parliament passed a Statutory of Green Accounts as part of the Danish law on Environmental Protection in 1995, demanding that certain types of enterprises (approximately 1200) should publish a yearly green account along a prescribed plan, and they recommended other private companies and major public organisations do the same on a voluntary basis. In some private sectors it seem rather favourable to develop and implement environmental management systems, possibly as they are found to be of economic value by the top management and the stakeholders and as such important elements of the strategic management in those businesses. Physical environment and working environment have many different but also many common or interrelated aspects, which support the idea of integration, seen from the perspectives of a sustainable development and perspectives of implementation, participation, personal and collective responsibility and ownership to processes. Looking at potentials of integration of environmental management and the working environmental issues, it must be considered that history, legislation, organisational institutions, knowledge, practical experiences in the organisations and enterprises and even the research traditions are very different and separated within these 2 areas. Mainly experiences of integration projects within private enterprises are known and limited research has been done in this area. Working environmental activities have a long tradition of demand and control on enterprises partly by trade unions fighting for better working conditions for the employees and partly by governmental legislations on perspectives of safety and health issues. The legislation and the institutions in these fields have been rather widely developed within society and in both public and private sectors within the last 20 - 30 years. Much progress has been seen in the standard of the working environment, even though working environmental issues are rather seldom fully integrated elements in the business strategies of development or in the core management systems. Matters of working environment are often only dealt with in the safety organisation handled by middle level management and safety representatives from the staff. In recent years the staff and their working environment are increasingly being looked upon, as a valuable resource, while concepts of Human Resource Management has evolved. Research in the field of working environment recommend a stronger focus on further participation by employees and a stronger priority by top management. A more detailed analysis into the different elements and the answer to essential research questions based on case study analyses will show what are the expected consequences of an integration strategy, and answer the following main question of this thesis:

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Which values, strategies and methods should be enforced in management of public hospitals if integrated environmental management should contribute effectively to the ideal of a sustainable development? – and what would be the main barriers to such an integration strategy ? Some research questions related to this: What are the main environmental and working environmental problems – and how are these problems presently being handled within public hospitals? What are the roles and obligations of national and county policies and regulations in these fields? What would be the potential gains or losses of integration of working environment and environmental management system? From which perspectives should an integration strategy be valued as a benefit? - rationality - efficiency - engagement and participation What could be the potential gains and losses of using acknowledged certification environmental management schemes at hospitals? What is the understanding of a sustainable development in this context, and how could this understanding contribute to improvements within this area? 1.3 Definition of main concepts I use the following definitions of the main concepts in this thesis: Sustainable development The most used definition worldwide is by the Brundtland Commission (1997, page 52 – 54): “Humanity has the ability to make development sustainable – to ensure that it meets the needs of the present without compromising the ability of future generations to meet their own needs.” And the following understanding of the concept: “ The concept of sustainable development does imply limits – not absolute limits, but limitations imposed by the present state of technology and social organisation on environmental resources and the ability of the biosphere to absorb the effects of human activities. But technology and social organisation can be both managed and improved to make way for a new era of economic growth”. Environment Defined by Oxford Learners Dictionary (2001) as: “The natural world in which people, animals and plants live”. Working environment Described by Hans Jørgen Limborg (2002, page 28) as: “The concept Working Environment is generally used to describe a broad range of conditions by which the employees are working, consisting of occupational health and safety, work related

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diseases, physical and psychosocial working conditions and the interventions done to reduce harm or risk to employees”. Management Many different definitions are used in the literature I will use the following by Paul Hersey et al. (1996, page 7) : “Management is a process of working with and through individuals and groups and other resources (such as materials, equipment, technology and capital) to accomplish organisational goals.” By this definition anybody in the organisation is a manager in at least certain activities, and appointed managers need to have interpersonal skills. Environmental management system Defined by Danish Ministry of Environment (2001) as: “A part of the overall management system, consisting of organisational structure, planning activities, responsibilities, customs, procedures, methods and resources used for development, implementation, audits and maintaining the environmental policy of the organisation”. Integrated environmental management Defined by Anette Kamp (1997, page 46 -47) as: “Integrated environmental management is defined as a linking of issues of environment and working environment within the organisations with the aim of achieving one of the following goals: - a unified problem solution within environmental and working environmental issues - strengthening of the efforts within one or both of the areas organisationally - improving efficiency of the work within environment and working environment issues”. Culture Defined by Richard Welford (1997, page 23) as: “A set of beliefs, customs, practices and the ways of thinking that people (or groups of people in an organisations) come to share with each other through being and working together; a set of assumptions people simply accept without question as they interact with each other”. 1.4 Motivation My personal motivation on the topic of this thesis was created partly by the challenge of getting a better understanding of the strength and weaknesses of the political concept of Sustainable Development, a mantra within the present environmental political discourse, and a more detailed understanding of the possible driving forces for change – development dynamics - within the area of improvement of environmental and working environmental conditions at Danish public hospitals. Is it reasonable to believe that this concept of sustainability could be used as an essential political driving force in future environmental politics within an integrated environmental management approach at Danish hospitals? Or is it just “window-dressing” talking about Sustainable Hospitals as an aim of environmental improvements of hospital services in Denmark? Basically my paradigm of understandings of driving forces for development of environmental responsibility within organisations is a mix of several factors, like: • Rising scientific knowledge on environmental harm • Increasing use of specific legislation and regulation on environmental issues • Research and development and use of renewable and cleaner technology

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• • •

Improved environmental knowledge and awareness on institutional issues among managers and employees Development of systematic approaches and methods of handling environmental issues in organisations General changes in the public awareness and attitudes towards environmental political issues influencing private and public priorities and purchase

I do not have the ambition setting up those factors in a recipe on how to implement environmental management in public hospitals, but I hope to get a more detailed understanding on how to cope with these different elements in future public discussions and in the work supporting hospital managers and employees in their organisational efforts on improving environmental responsibility in their possible endeavour towards a sustainable development. 1.5 Target group It is my intention to bring together knowledge and understandings of the issues in focus and I hope this will seem useful for managers at all levels of hospital management, employees in occupational health and safety organisations and staff working with environmental management and working environmental issues. It even might be found valuable reading for internal and external consultants and researchers in the field of environmental management, working environment and organisational development within hospitals.

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2. Methodology 2.1 Introduction In this chapter I present the project design, my paradigmatic assumptions and perspectives of the choice of theory and empirical data from case studies related to the problem formulation and the research questions. I describe and reflect on the reasons for my strategy of the project design and decisions on the use of theory, data production and analysing technics. I present and discuss the methods of analysis and the possible validity and reliability of conclusions. 2.2 Project design The project formulation focuses on 3 main topics and especially on the perspectives of an integrated approach to management values, strategies and use of methods promoting the efforts within these areas at Danish hospitals: 1. Sustainable Development 2. Environmental Management and 3. Working Environment In the problem formulation I laid down the concept of sustainable development as a goal and a possible driving force of development of an integrated environmental management approach at hospitals. For this reason the first part of my thesis contains an elaboration on the concept of sustainable development in general and related to other theories within environmental politics. What is the content and essential meaning of this concept? How is the discourse on this concept in relation to the general understanding and research within environmental political concepts as environmental economics, ecological modernisation, the discourse on risk society and use of the precautionary principle within environmental regulation? I concentrate on the essence of these theoretical frameworks and understandings as a background to my understanding of the present development within the political discourse and use of methods within environmental management and working environmental issues. I continue describing the development of legislation and regulation methods of environmental management and the working environmental area and extract results from research and development within these topics basically related to the private sector as environmental management have been studied mostly within this sector. I extract experiences on strategies and use of methods within implementation of environmental management systems and experiences of integration approaches related to implementation. I did not find case study research on implementation of environmental management systems within public sector institutions, but I include recommendations from a Danish project on the possible use of EMAS within public sector authorities and institutions. After discussions on concepts, theories and empirical experiences I present 3 case studies from hospitals with different engagement and priorities in the field of environmental management and working environment. These 3 case studies can be seen as learning examples for future efforts within other hospitals. They represent 3 individual case stories of different ways of handling the issues including the integration aspects. The essence and learning from the 3 case studies I extract in what I have called an adductive analysis including results and recommendations from the case studies in private sector. The adductive analysis present empirical based knowledge related to the problem formulation and give answers to questions within the following main areas:

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• • • • •

What are the major environmental problems of public sector hospital? What are the activities and developments related to these problems? What are the major working environmental problems of public sector hospital? What are the activities and developments related to these problems? What are the integration approaches to these topics and how is integration aspects handled? Which policies, aims and strategies are present? How much is management and employees involved? What do they do within environmental management and do they know the concept of sustainable development?

The adductive analysis basically combine the empirical findings from the case studies of this project and case studies from private sector enterprises concerning environmental management issues at the organisational level. I take up the challenge analysing the empirical findings related to the concepts of environmental sustainability, environmental economics, ecological modernisation, risk society and use of the precautionary principle at a sector and society level in a final analysing chapter. I close this thesis by giving my final answers and judgements related to the problem formulation. 2.3 Use of theory The choice of theory for this project is based on the following paradigmatic assumptions: Sustainable development and innovation of societies At society level fundamental issues related to a sustainable development is an overall understanding of the consequences of unsustainable praxis’s and the need of changes in values and priorities of development of the society by political means. A change in the political values and priorities will affect the knowledge, public awareness and the use of experimental approaches both at society and at sector and organisational levels. Sustainable development is a matter of innovation in technologies, production- and service systems and work organisations. These innovation processes are depending partly on research and development of cleaner technology and production and service systems, partly on improvements and enforcements of environmental policies, strategies and legislation and largely on commitments and organisational development processes within the individual organisations. Environment and working environment Environmental protection (in a sustainability context) is largely depending on the choice of materials, technical solutions, organisational structures and work processes and partly on the behaviour of employees in work operations. Environmental issues are hereby closely related to the choice, consumptions and flow of materials within the production processes. Working environment is depending on the use of hazardous materials, risky technical solutions, organisational structures, organisation of work processes, cooperation within management and between colleagues and on the individual behaviour of employees in daily work processes. Working environment is hereby closely related to occupational health and safety issues of employees, and organisation of the work processes. Even though there are many connections it is not always, that a good working environment creates a sound environmental protection or vice versa. Both topics are depending basically on management priorities, values, attitudes, strategies, and systems/methods on dealing with environmental and working environmental issues in the organisations, but also partly on the employees values, attitudes, priorities and behaviour at the workplaces in their daily work. For

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these reasons, central issues in both aspects are related to environmental management and strategies of development of work organization, work processes and behavioural change with a participation approach. Strategy and management As sustainable development of environment and working environment at the organisational level is very much depending on management priorities and strategies of development I have chosen the management view as the main angle of my thesis. Management theories are divided in different schools of thought. My understanding of management is basically related to the theory on situational leadership combined with theory of value-based leadership with employee participation, communication and information/knowledge sharing as essential means of management (Hersey et al.1996). Organisational development in public sector institutions, and professional bureaucratic organisations as hospitals, I find described best by the theory on organisational structures and strategy (Mintzberg 1993, Mintzberg et. al 1998,), organisational development by “muddling through” (Lindblom 1959), working with cultural changes of organisations (Welford 1997, Schein, 1986) and by the use of development experiments with a participatory approach (Sæbye 1998, Lorentzen & Remmen 2000). As those theoretical assumptions are part of my general understanding of the field of organisational development processes within hospitals they will be part of the background of my analysis. Considerations concerning choice of theory My personal educational and professional background is within business administration, organisational development and human resource management. I have 12 years of job experiences as organisational consultant and manager within organisational development and quality management at hospitals in Denmark. I choose in this project to focus on theories related to the political science field in relation to environmental management as a new field in chapter 3 and present mainly empirical based organisation theory within the field of environmental management in chapter 4. The research presented in chapter 4 are based on theories within organisational development, strategy, participation and other relevant theoretical fields of organisational processes, why I delimit this project presenting organisation theory in separate presentations, knowing that they are included in the research on case studies and hereby taken into account in the analyses. 2.4 Use of empirical data I started the project with the intention of just one in depth case study at RASK, County Hospital in Roskilde, based on their overall integrated development strategy approach of the hospital, and the fact they had recently been given a price on their efforts within the working environmental field. After the first interviews at the hospital I realized, that they had not done much within the field of environmental management, but were committed to do so based on ethical and environmental conscious considerations towards the external environment in their future development processes. I then decided to enlarge my case study field and included 2 other Danish hospitals publicly known for their efforts within the environmental management field, and to some extent with 2 different approaches to the topics of my problem formulation. The choice on exactly those 3 case studies was partly accidental. In my search for case studies I looked for counties and hospitals with experiences on implementation of environmental management, from which I could expect to get access to information based on some years of experience. I do not know for sure if my case studies are representative of the possible use of environmental management instruments at Danish hospitals, but only around 6 – 8 hospitals in

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Denmark might have serious experiences based on some years of work within this field according to my informers from a recently started network of environmental coordinators at Danish hospital. For the following reasons I expected that different lessons can be learnt: • The 3 hospitals are located in three different counties • Environmental management are not were much improved within the hospital sector • Specific environmental legislation and regulation within the hospital sector are rather limited, and • Working environmental legislation and regulation are rather specific including hospital organisations, but I knew that hospitals generally have a rather limited focus on this issue in their overall strategies and aims of development of care and hospital services. As my time for doing empirical research was limited, I only had the possibility taking a picture at a certain stage of time in the history of 3 different organisational development processes of work on the topics in focus. I was not able to go into details on what they had gone through previously or follow up on what they came through in their future efforts. This could have been preferable and would be relevant in further studies on the implementation and use of management strategies and organisational development processes within environmental management at hospitals. From search in literature and on the web, I found only few reports and publications and a number of interesting but rather new international projects and web sites in this specific field, which indicate that the knowledge about environmental management at hospitals still is rather limited. For those reasons I primarily did the empirical studies as explorative research in a new field, and mainly have collected information and knowledge based on practical experiences and views from experienced key persons working in this new field as basis of my theoretical analysis and discussions of the problem formulation, and encircling possible specific issues for further investigations and research. A semi-structured questionnaire was sent to the interview persons before the interviews, and the individual respondents afterwards corrected and confirmed a detailed resume of the interview. Based on the résumés and the document reviews the case stories were written, commented and confirmed by 2 key persons from hospital management and staff at each hospital. The 3 case hospitals Koege Hospital in Roskilde County (RASK) is a general medium size University Hospital 35 kilometres south of Copenhagen City. RASK has been working on implementation of an overall organisational development strategy, based on the principles of the management concept of Balanced Scorecard. As part of this strategy they had laid down a number of targets and actionplans with a participatory approach towards development of a preventive, healthy and safe working environment and an ethical and environmental conscious behaviour towards the environment. Copenhagen County Hospital in Gentofte (KAS Gentofte) is a major University Hospital in the suburb of Copenhagen City. CHG have been working with green accounts on a voluntary basis for approximately 5 years and has last year ended a 2-year project on “Composition of environmental management in the purchase functions and implementation of environmental management at the department level of the hospital, a project supported by The Danish Ministry of Environment.

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Fredericia Hospital in Vejle County (Fredericia Sygehus - FS) is a smaller general hospital in the province. FS was the first hospital in Denmark working on implementing of an environmental management system since 1996. FS was certified in 1998 along the ISO 14001 standard, re-certified in November 2001 and is now working on registration under the EMAS Scheme. FS has been working with environmental management as an integrated system within an environment- and safety organisation since 1998. Each of the 3 case studies is described as story lines along the same disposition for analysing purposes. 2.5 Analysis and discussions The analysis and discussions are done at 2 levels, the institutional and organisational level with focus on environmental management and integration issues within hospitals based on the empirical findings and observations from case studies of this project and case studies research within private enterprises. Afterwards analysis and discussions are done at a sector and society level with focus on environmental management at hospitals in the context of sustainability, the environmental discourses of environmental economics, ecological modernisation, risk society and the principle of precautionary principle, including perspectives related to integration with working environmental issues. The first analysing chapter I call an adductive analysis based on empirical findings from case studies, as a method used within inductive research methods, by which I extract knowledge related to the questions of the problem formulation from the study of ‘real world’ activities within the fields in focus. The meaning of adduce is: “To provide evidence, reasons, facts, etc. in order to explain or to show that something is true”, e. g.” Several factors have been adduced to explain the fall in the birth rate” (Oxford Advanced Learners Dictionary, 2000). The validity of the analyses and conclusions has to be judged within the perspectives of the researcher and the choice of methods used within this specific project. No research findings can definitely be true, as the scientific value of the results has to be judged partly related to the paradigm of the researcher and the reflections related to the choice of theoretical and paradigmatic perspectives (Pedersen, K. B. and Drewes, L. 2001 page 25-33). The choice of my overall scientific approach within this project can be seen as hermeneutic (science of understandings, here about people and society) and critical realistic (search for empirical based social cause and effect relations) within an epistemological (researcher dependent) approach of my personal paradigm as presented above.

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3. Sustainable Development 3.1 Introduction In this chapter on sustainable development I discuss the concept and reasons for analysing environmental management within hospitals in this context. In the first part of the chapter I describe the background and elaborate on the definitions and understanding of the concept and its relation to the topic of environmental management. Afterwards I discuss the environmental economic understandings related to sustainability and present the stakeholder model on interrelations between consumers / citizens, government and companies. I then go on to a presentation and discussion of the concept of ecological modernisation and theory on risk society by Ulrich Beck (Beck, 1997) within a more sociologically oriented understanding of environmental politics in relation to sustainable development and end this chapter with formulation of hypothesis from these theories related to environmental management at hospitals directing the analysis in chapter 6 and 7. 3.2 Sustainable development as a goal of Environmental Management Background and discussions on the concepts of Sustainable Development and Environmental Management Internationally for many years it has been of rising public concern, that scientific research has brought evidence of an increasing pressure on the environment as a result of production and human activity and improvements of new risks for human health by use of new chemicals in manufactured products and in delivery of services in modern society. The western economic growth model is stronger than ever and seems unchallenged by any other economic models at present. Along the free market economy follows globalisation of capital, markets of consumer goods and production systems, a development that challenge the environment at an even faster speed than ever before. As a reaction to the fast growing global economy and the rising environmental concern many scientists and politicians are absorbed by the idea of sustainability as a strategy of managing the future development of world societies in more environmental responsible ways. In academic and political discussions on environmental concern and development of environmental policies and regulations within the last 10-15 years the goal (in words) of a sustainable development has been a pivotal topic. The understanding of the words sustainable development is mostly related to the scientific field of economic theory, including theories of welfare and public goods, and as such it has to do with managing the technological development and the use of economical resources at a global, regional, national, organisational – and even individual level. Many definitions of sustainable development has been proposed by the years since the first world environmental conference UNCED in RIO 1992, but the most influential definition is probably that of The Brundtland Commission (1987): “Sustainable development is a development that meets the needs of the present generations without compromising the ability of future generations to meet their own needs” (51).” Fundamentally seen sustainable development is a process of change in which the utilization of resources, management of investments, the technological developments, and institutional changes are brought in line with each other and improve the possibilities of fulfilling the needs and hopes of humanity” (Brundtland Report, 1987, page 51-54).

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This definition was the basis of understanding and agreement on Agenda 21 between governments of 149 countries of United Nations in RIO 1992. Some of the weaknesses of this definition are the words: ... the needs of the present generations… … compromising the ability of future generations … … meet their own needs. The weakness of the use of these words raises essential questions. Who decide what are the needs of present and future generations? Is it a global, regional and / or local obligation and responsibility to define the content and the level of those needs? How do the responsible (who are they?) know and make sure that the present developments are not … compromising the ability of future generations… by our present use of materials, organisation of economy and production systems, improvement of societies and the ways of living by the individuals? Who have the right to intervene, to demand and predict future human conduct? Not as an answer to those questions, but more as a development strategy, later in the text on strategic demands for sustainable development it says: “The law alone cannot enforce the common interest. It principally needs community knowledge and support, which entails greater public participation in the decisions that effect the environment. This is best secured by decentralizing the management of resources upon which local communities depend, and giving these communities an effective say over the use of these resources. It will also require promoting citizens initiatives, empowering peoples organisations and strengthening local democracy”. (Brundtlandt Report, page 71) Democracy does not in itself secure a sustainable development of societies and in combination with a traditional welfare oriented economic growth model, it even can contradict the aims of sustainable development. The report also stresses the need of a more ecologic and value based understanding of sustainability and the need of restrictions on and new directions of the growth economy. This combined with the time perspectives of caring for the needs of coming generations, the definitions and especially the understanding of the concept of sustainable development anyway can be seen as showing new ways of development of the society. (Nielsen, Kurt Aagaard, 1996) Despite the weaknesses of the definition and the contradictions within prescribed strategies of a growth economy and a sustainable development of international society, Agenda 21 as a political consensus document created as a result of inter-governmental negotiations and political compromises, must be seen as a document, which is far reaching and impressive as a world action plan for strengthening the global environmental protection. Definitions of the words sustainable development might be easier trying to diagnose, what is the unsustainable development at the moment, a process that has been going on in the academic and environmentalist circles for at least 30-40 years, and a debate that was publicly provoked by the book The Limits to growth. (Meadows D.H. et. al 1972) and intensified by others. As a result of these diagnoses and discussions within 10 – 15 years the following concepts of understanding of the words have gained worldwide acceptance:

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• • • • •

The environment, globally and locally, must be protected so that the critical life-support services it provides are maintained for present and future generations Environmental policy and economic policy must be integrated if this is to happen The main goal of economic development should be to create conditions for people to enjoy a better quality of life, not simply the pursuit of quantitative growth in the economy The pursuit of sustainable development must include policies to eliminate poverty, in the industrialized and developing worlds alike All parts of society must be involved in decision-making about the measures that will bring about the transition to sustainable economic and social systems over the coming decades. (Christie and Warburton, 2001)

Towards sustainability by means of environmental management At the UNCED conference 1992 it was recommended that the member states should develop environmental management systems, which could support the goal of sustainable development. These systems should be compatible in relation to diverse cultural, social and organizational frameworks. It was stated in the conference document, that health protection and health promotion was an essential contribution to sustainable development, quoting “Human beings are at the centre of concern for sustainable development. They are entitled to a healthy and productive life in a harmony with nature” (Agenda 21, 1992). The present definition by WHO on health is: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. An even more holistic approach was emerging defined by the proposal of a think-tank sponsored by WHO and the Rockefeller Foundation: “ Health is a state of complete physical, mental, ecological and environmental well-being”. (Zwetsloot, 1998 page 4) Using these definitions and understandings of sustainable development we are dealing with a rather broad definition, which include as well the outside environmental issues as the working environment, and even the health effects of patients receiving hospital care. In the definition of sustainable development it is stressed as an obligation of everybody in charge of managing economic resources to deal with an understanding of sustainability, and it is predicted that the present un-sustainable behaviour at all levels of society are pushing to the environmental problems of the world in wrong directions. As means of focussing and dealing with the environmental challenges in sustainable ways, new strategies, systems and methods of environmental management have been developed within the last 2 decades and implementation in different forms at macro, meso and micro levels of society are emerging. And it is recommended that environmental management systems should support the aim of sustainability. But what types of environmental management system should be enforced? At which organisational levels should it be implemented and how could it support the aim of sustainability? 3.3 Environmental economic theory and sustainability Within scientific economic theory different schools of thoughts has emerged under the names of environmental economics and ecological economics with different points of view of the needs and methods of intervention, with the aim of managing the future economic development in balance with the environmental capacity. The environmental issues are included in an understanding of imbalances in the market mechanism within the understanding of externalities and public goods

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(Nielsen, Kurt Aagaard, 1996). This understanding predicts some kind of regulations of and restrictions on the free market forces as necessary to make markets provide efficiency with respect to environmental sustainability. But at what levels of environmental concern or scientific evidence of environmental harm should regulations or restrictions be enforced? Which type of market interventions and economic policy instruments are most efficient. Environmental economists are still discussing and researching these questions related to different types of environmental issues. Sustainable development is broadly accepted as a concept within the classic environmental economic theory calling for management of the economic development by political instruments, but differences in belief of necessity of interventions and efficiency of methods are described as different levels of sustainability from very strong to very weak sustainability concepts. (Turner et. al 1994 page 54-61). The prescribed policy instruments vary from pollution taxes, elimination of subsidies and imposition of property rights to natural goods within a very weak sustainability concept to standards and regulations, bands and licenses and extensive public control of business performances within the strong sustainability concepts. In the context of environmental economic theory the Brundtland definition is ranked as a weak sustainability concept. Even though the broad concept of sustainable development has evolved from an understanding of global environmental problems and the inequity economic developments of the world, it is needed to find operational ways of dealing with the concept at a local and organisational level of society, as the activities at this level is creating the environmental problems at the global level. What does sustainability mean to the business manager, the employee and the local politician at county and municipality levels? What are the relations between the different stakeholders in society in the efforts of achieving sustainability? In accordance with environmental economic theory the following idealistic model describes the different roles related to sustainability of the 3 main actors of society: Model of “3 stakeholders and their main interactions” (by Vogtländer J.G. 2001)

Companies

B) Regulations

Government

A) Politics

C) Marketing

Consumer & citizen

A) Consumers and citizens expects the government taking care of their long term interests and a sustainable development of the society B) Government defines regulations and restrictions and creates an even ground of competing companies C) Companies satisfy short term consumer needs in terms of maximum value for money

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This model indicates the conflict between the role as a consumer with short-term interests of value for money and the role as a citizen with long-term interest of a society of sustainable development. This conflict is similar to the traditional conflict of distribution of public goods (for instance free hospitals services and taxpaying) and the needs of public policies and regulations in managing and problem solving in other fields of a democratic welfare society. As such managing environmental problems and sustainable development of society is equivalent to others public policy fields, and the methods might probably be familiar. 3.4 Sociological theories on environmental politics and sustainable development The definition of sustainability by the Brundtland report can even be understood more as a sociological than an economic concept, as the idea of sustainability basically is founded on some very strong ethical principles, requiring as well intergenerational equity rights as equity rights of sharing the world’s wealth among all societies in the world. As a sociological and political concept the Brundtland definition focus on the needs of enforcing limitations and managing development of as well the economy and the technology as the social organisation of societies in ways, that fulfil the aim of strong ethical principles above economic principles of future developments (Nielsen, Kurt Aagaard, 1996). In line with this understanding it can be argued that environmental management should be based on ethical principles above economical principles as an important strategy for creating a sustainable development of society. Since the 1970´s different sociological approaches are seen towards the environmental issues. Often wide spread and antagonistic disagreements on how to react or find solutions to the rising amount of environmental problems are dominating the environmental discussions, i.e. especially related to the nuclear power problematic. On the one-side radical environmentalist movements, who think that the ecological crisis are undoubtedly going to create a major social crisis, call for the need of radical social changes of society if environmental catastrophes shall be avoided. Opposed to this is are more legal administrative pragmatic approaches working on the basis that pollution as such is not avoidable, but the challenges are how to guarantee a certain level of environmental quality, i.e. by legislation and regulation. As a result of this approach an increasing number of governmental environmental departments and institutions all over the western world are established in 70´s and 80´s. These institutions and departments worked on the assumption that “end of pipe” solutions by filters and enforcement of scientific based limitations on acceptable pollution levels were able to challenge the environmental consequences of the fast growing industrial development. From mid 1980´s the concept of ecological modernisation has been the dominating academic discourse on environmental politics. The concept of ecological modernization stands for a political understanding breaking with both of the above mentioned tendencies and argues for a more proactive approach based on the assumptions that the ecological crises should be overcome by a combination of technical and procedural innovations (Hajer, 1996). “One of the core ideas of ecological modernisation, ‘integrating ecological concerns into the first conceptualisation of products and policies’, was an abstract notion in the early 1980´s but is by now a reality in many industrial practices. Especially in OECD countries, eco-modernist concepts and story lines can now be seen to act as powerful structuring principles of administration and industrial decision-making from the global down to the local levels.” (Hajer, 1996 page 250)

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Hajer describe, based on different social scientific understandings, the following three approaches to ecological modernisation (Hajer 1996, page 251-60): Institutional learning perspective, nature is seen as a new and essential subsystem. Integration of ecological rationality is a key variable in social decision-making. It is assumed that the existing political institutions can internationalise ecological concerns or can at least give birth to new supranational forms of management that can deal with these relevant issues. Technocratic project, by which the ecological crises is seen as requiring much more than social learning by existing social institutions. Not nature but technology is out of control. The real problem is how to stop the ‘growth machine’. New institutional arrangements are needed in academia, such as ‘counter experts’ who can illuminate the ‘technocratic bias’ in the official scientific reports. Development of new political institutions and social movements facilitating ‘Right to Know’ schemes and above all decentralisation of decision-making and right to selfdetermination are essential means. Cultural politics, based on the assumption “that there is no coherent ecological crisis, but only ‘story lines’ that problematize various aspects of a changing physical and social reality”. Ecological modernisation is understood as a routinisation of a new set of ‘story lines’ (images, causal understandings, priorities etc.) that provide the cognitive maps and incentives for social actions. By doing so ecological modernisation ‘freeze’ or exclude some aspects of reality while manipulating others. (Hajer 1996, page 256-57). The concept of sustainable development by the Brundtland Report and RIO summit declarations is described as examples of ‘story lines’ which are taken into the institutional learning paradigm, and trying to translate this broad and imprecise concept into strategies, planning procedures and aims of legislation and regulations locally create great difficulties and open up for local interpretations and operations. No matter which of those three perspectives that are at stage within environmental politics, it is concluded, “the main direct effect of ecological modernisation was the rationalisation of ecology, through the conceptual and institutional amendment of existing bureaucratic structures and the creation of new ones, be it by the state or by new eco-corporatist associations.” (Hajer 1996, page 261) A study on conditions for environmental policy success, based on an international comparison of the development of environmental policies, institutions and trends within 32 industrialized countries in the period of 1970 - 85 was done by a German Professor of Political Science, Martin Jänniche. This study is based on the hypothesis: “that the material, institutional and socio-cultural capacity of a country are more relevant in determining the outcome of environmental policies than its choice of policy instruments.” (Jänniche, M 1989, page 47) He examined why some of those 32 countries seemed to be more successful than others in their environmental improvements. What did the most successful countries have in common and which factors could eventually be regarded as explanatory factors for their successes? He compared their relative success on an environmental quality indicator ranking scale and compared this to factors like dates on establishing environmental institutions, enforcing environmental legislation, social factors like level of social services, unemployment rates, capacity for modernisation (political

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capacities within innovation, strategic planning, coordination and consensual solutions) (Jänniche, M. 1989, page 53-56). The most successful countries seem to be those, which do not restrict environmental protection to public policy, but mobilise societal mechanisms against polluters. As indicated above, the welfare state component is important for good environmental policy. The same is true for societal selfregulation. The combination of both may become more and more important” (Jänniche, M 1989, page 57). And the main conclusion of this study is: “Institutionally, the openness of the juridical, political, informational and economic systems for innovation is as important as a country’s capacity for strategic action. Cultural, a tradition of consensus building strengthens both openness and the integration of politics and thereby reinforces the institutional conditions for relative success.” (Jänniche, M 1989, page 47) Environmental management as cultural politics within this understanding is a great challenge to the existing bureaucratic administrative systems of hospitals and the medical natural science oriented professional culture dominating health sectors. 3.5 Theory on Risk Society in relation to the concept of sustainable development Parallel and partly as a reaction to the discussions within 80´s and 90´s on global environmental problems, the concept of sustainability and the ethic and sociological discussions, a new opposing discourse on risk society emerged. This discourse was initiated partly by the book on Risk Society by Ulrich Beck (1986), a German Sociologist, and writings of Anthony Giddens and others focusing on modernity, risk and the cultural dimensions of contemporary environmental issues in 1980´s and 90´s (Lash, S. et al. 1996 page 1-25) Environmental problems and their solutions are so far generally understood and discussed by the public within technologic and economic administrative theories and models and to some extent only by the signals of alert in the public press on new biological and chemical research findings or on actions by NGO´s. The technological and economic development, often with time lack of years or centuries, continue creating increasing amount of severe risk for the life of humans, animals and nature, which are often difficult to predict or even sometimes impossible to avoid. As an increasing number of environmental catastrophes and accidents really happen and are reported world wide, a growing concern on risk and threats among the general population are rising. The increased public concern and prevailing political efforts trying by political means to regulate the risky activities by environmental legislation, regulations and limitations on pollution and production of environmental harmful substances increase the need of a sociological understanding of human and societal reactions to the emerging development (Beck, 1997). The increased focus on risk reduction create dependency of unfamiliar knowledge, with the effect that daily life relations are eventually being turbulent within the political and science based turmoil, as seen related to cow madness disease, reduction of men’s fertility, sexual disturbances of fish in the streams, increased amount of allergic reactions, incidence of cancer, etc. The traditional scientific demand of methodological and theoretical proof of causal cause and effect relations has the effect that risk assessments are weakened, with the effect that risks eventually are increasing – especially mono scientific research that do not assess the causal interdisciplinary scientific connections. Hereby productions of risky products are legitimated in society. The capital interests and the science society demanding high level of scientific proofs strengthen the production of risky sub-

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stances in society. Increase in risk hereby is legitimated implicit by the science (Beck, Ulrich 1997, page 83). This development creates an increasing struggle on knowledge, information and direction and spread of scientific wisdom. Struggle on definitions of risk, the size, degree and intensity of risk are being studied and discussed as well in the scientific circles as among politicians and the press, and the politicians often have to act on the basis on uncertainty and disagreements, as the scientists have different views based on different methods of research (Beck, Ulrik 1997 page 63). The present discussions on the so-called “Lomborg-case” and the new Danish Government establishing a new environmental Institute based on statistical oriented research by Bjørn Lomborg and others show this dilemma. Demands of rationality promote irrationality. Instead of demanding causal cause and effect relations Japanese acknowledge proof based on statistical correlation between harmful substances and certain diseases (Beck, Ulrich 1997, page 85), which promote the use of the precautionary principle within political decision making on environmental issues. Risk society usher by other words a speculative era of everyday thinking and observations of potential risk. Different interpretations always have been subject of scientific and philosophical disagreements. As a result of this, realities of every day life to a greater extend are taken into considerations of the theoretical interpretations and the development of science and philosophy. (Beck, Ulrich 1997, page 98). Within medical research there has been a slightly increased focus on relations between environment and health, and new research centres have been established within this field. In Denmark a small environmental medical research centre Danish Ministry of Interior and Health Research Centre for Environmental Health (ISMF) were established in 1991 focusing on those issues, but with a rather small yearly donation. ISMF coordinate and initiate research projects focusing on effects in human beings due to the exposure from biological, chemical, physical, and psychosocial factors, mediated primarily through air, soil, water, foods, the indoor environment, and the work environment. The medical research on prevention and health promotion has within the last decades increasingly focused on relations between life style and health, such as alcohol, smoking, stress and others, and research within working environment had focused on the visible connections between hazardous substances and the workers health. With no doubt future medical researchers are going to enlarge their research to areas of relation between chemicals and other substances in the environment to human health as the alert on those issues are rising, as well within the organisations as in society. It is no longer possible to oppose nature and society. The real challenges of present times and the future, justifying risk society, consist of a transformation from the civilisation’s threats to nature to its threats to the societal, economical and political system (Beck, Ulrich 1997, page 108). As a result of this prescribed development and the rising focus on risk discussions a working group within ISMF has published a report, Experiences of Risk (Grandjean, P. 2001) in which a team of interdisciplinary researchers recommend improved interventions within several aspects of experiences of risk and risk reactions within research, communication, science- and environmental journalism and an improved educational activity within pre- and postgraduate education of engineers, physicians and media staff. This indicates the improved awareness of the political processes related

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to the societal development within technology, health and media and to people’s reactions to information on environmental risk issues. WHO, Regional Office for Europe are increasingly working on the issues of precautionary policies and health protection and held a workshop on the topic in 2001 prescribing the need of further clarification of the role of using the precautionary principle in public health and by public health professionals and agencies (WHO 2001). There is no universal definition of the precautionary principle, although the following statement is broadly known: “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. The process of applying the Precautionary Principle must be open, informed, and democratic and must include potentially affected parties. It must also involve an examination of a full range of alternatives, including no action.” (WHO, 2001, page 3) Among politician the use of the precautionary principle is increasingly being discussed as the examples of late reactions to severe environmental effects on human health are emerging. Examples as blood samples contaminated with AIDS, the BSE – scandal, the effects of dioxin and the latest fear of relations between increased amount of oestrogenic or alike substances in the environment and fertility and genetic disturbances show this concern. Based on the above-mentioned theories and principles and its expected consequences for development within environmental issues, I will lay down the following theoretical hypotheses as directions for the analysis in later chapters: • • • •

•

Knowledge about environmental issues and risk assessment is crucial in political, administrative and managerial activities within hospitals as in society. Strategies on risk reduction and prevention of environmental harm on human health based on precautionary principles are going to be part of the hospital commitments. Working environmental and environmental issues are closely related in development of hospitals as their activities create or contain correlating risk. Employee and patient reactions, alertness, attentiveness, consciousness and responsibility are important sources of pinpointing new potential environmental problems and risk and hereby predict the need of interventions of elimination of the use of polluting substances at hospitals. Environmental issues are going to be of increasing importance in health care research and the delivery of care and services, possibly as a part of the quality and the prevention and health-promoting concepts.

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4. Environmental management and working environment 4.1 Introduction In this chapter I will shortly describe the development of the legislation and use of regulations and systems within environmental management and the working environmental work in Denmark. I describe the use of the word integration of environmental management and working environment and extract empirical findings based on research of case studies and projects within this field focusing on the results and recommendations. Finally I shortly quote and focus on some organisational theoretical aspects I find essential having in mind when analysing the topics of the problem formulation and lastly a simple model of relation between the stakeholders and the 3 main topics of this thesis: Sustainable Development, Environmental Management and Working Environment within my on stakeholder model. 4.2 Environmental Management – development of legislation and regulation methods As the word environmental management indicates, this topic is about 2 separate but interrelated issues – environment and management. Environmental protection in Denmark was originally handled within the system of the public planning laws until 1970´s. The increasing need of focusing on environmental problems related to specific industrial and human activities had the effect that environmental impact assessments were developed as an important contribution to the decision-making processes related to specific public permissions on individual projects and enterprises. Hereby a more process-oriented regulation with public participation was developed as an instrument within the environmental protection policies (Kjellerup, Ulf 1997 page 234 -252). In 1980´s fulfilling of environmental legislation and regulation and obtaining environmental permissions, once and for all, were no longer seen as sufficient means of environmental protection. A more systematic follow up on performances within an inter disciplinary and inter organisational understanding of the processes, related to legislation and regulation as to production and service systems, were seen to be needed. As a result of this development an increasing focus within the last 10 years has been on the managerial parts of pollution prevention and control, and the development of new strategies, systems and methods of managing the environmental protection as a combination of legislation and regulation and collaborating responsibility of environmental prevention has been a key issue among the involved parties Dealing with environmental management is a rather multi-disciplinary topic including as well natural science as social scientific understandings of problems, methods and perspectives. Traditional environmental research was founded within natural sciences as biology, chemistry, physics, geology, medicine and new emerging sub-disciplines as ecology, toxicology and others. Later on social science perspectives were involved as economics, sociology, political science and even humanistic sciences as psychology, anthropology and others. Tackling environmental problems scientifically has become a rather complex and difficult task, and requires a broad range of knowledge within many scientific areas, and necessity of limitation of the problems in focus without compromising serious relations of the problem within the context it is being handled. For those reasons research and interventions in environmental problem solving and implementation of environmental management are recommended being handled in a problem-oriented manner, and closely related to specific problem areas within a specific sector of society.

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Definition by Jesper Holm and Kaare Pedersen of an environmental problem are: “a human made change in the nature basis, interpreted and articulated as a problem by an actor” (Holm, J, 1997 page 17). It is part of the essence of the rising interest of environmental problems within a critical regulation approach that environmental problems are based on the fact that changes in nature have occurred as a result of human activities. A multi-disciplinary approach within research on environmental issues for good reasons can be based on the following 4 levels simultaneously (Holm, J, 1997 page 18): 1. The material part of the environmental problem, i.e. emissions and impacts on nature and effects of those impacts on life conditions in nature and society 2. Causes of environment problems, i.e. sources and mechanisms which create the environmental problems 3. Scientific and interest related environment- and risk assessments, i.e. knowledge, ideas, threats etc. on seen or expected environmental impacts and risk as effects of human activities 4. Political, institutional and administrative elements of environmental regulation, i.e. policy processes by which environmental problems and their causes are negotiated among involved and interested parties and interventions are decided This approach to research within environmental issues at a society policy level, I use in my final analysis, as I find close relations between the policy level within society and the circumstances it creates for implementation of environmental management within hospitals at an institutional and organisational level. Parts of my analysis are mainly focusing on the social science and political process perspectives of implementation of environmental management within hospitals. Other parts are dealing with a focus on management and development processes within environmental and working environmental issues by which the following organisation theory aspects are essential in my analyses: strategy and design, management, culture, implementation and participation. 4.3 Environmental management systems In this section I will describe the content of the environmental management systems EMAS and ISO 14001 and extract experiences and recommendations on implementation and use of those systems for environmental improvement purposes within enterprises. EMAS The European Commission developed EMAS (Eco Management and Audit Scheme) in 1993 as an instrument with the purpose of standardization of environmental management systems used within European countries. The scheme was based on voluntary participation and was basically devoted to companies in the industrial sector in EU. In March 2001 a revised version was signed. In the latest version of EMAS it is still intended to be a voluntary program, but now it is proposed being used by all types of organisations from all sectors, including the public sector authorities and institutions. Development of the EMAS scheme was done on behalf of the European Commission Treaty article 2 and the strategies within the EU program “Towards a sustainable development” approved by the commission 1993. The aim of EMAS according to the revised edition approved by March 2001 is to promote a continuos improvement of environmental performance and results within organisations by means of (Ministry of Environment, Dep. Order nr 896 of 10/10/2001):

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1. Implementation of environmental management systems in accordance to specifications in annex 1. 2. Systematic, objective and regular evaluations of those systems and results 3. Information on environmental efforts and results and open dialogue with authorities and interested parties 4. An active employee participation within the organisations and sufficient basic and supplementary training of employees enabling an active participation within the annex 1 mentioned tasks. All employee representatives, who want, should be given the right to participate. To obtain a verified EMAS registration at the ministry of environment the organisation must: • Map all activities, products and services related to environmental legislation and regulations, identify all environmental impacts and register the most important impacts, describe criteria on priorities and make assessments on investigations related to previous environmental accidents. • Fulfil internal and external environmental audits within certain specified demands • Prepare an environmental statement and account within specified demands • Fulfil a verification of the environmental mapping, management system, procedures of audits and environmental statement and account on all specified demands by an accredited verificatory • Send a yearly adjustment and follow up on the environmental statement and account and make this available to the public. EMAS is basically by the text focusing on the traditional environmental issues and demands without including issues of working environment or health and safety issues directly. Anyway it is possible that the organisations by them selves include those issues within their environmental management system, as this have to be specifically organised and focused by decisions within the organisations and in accordance with the EMAS demands as a minimum standard. In the revised edition of EMAS focus is improved on environmental harm by products and not mainly by emissions. It has been stated that participation by the employees is compulsory and that the environmental statement and account should be revised once a year and made public available to enlarge the obligations of interested parties involvement and possibility of public control of performances. In the specifications of the text the environmental impacts are defined as impacts, “which have or could have serious impact on environment ” (Ministry of Environment, Dep. Order nr 896 of 10/10/2001 definitions Article 2). This is following the intentions on use of the precautionary principles within the environmental management system, and it is stated in the text, that “determination of environmental policies and goals the organisation have to take into account the relevant legislation and regulations, serious environmental impacts, possible choice of technology, economic, operational and business conditions and the view of interested parties” (Ministry of Environment, Dep. Order nr 896 of 10/10/2001, Annex I A3.3). These demands mean that EMAS organisations are obligated to follow the development of environmental legislation and regulation carefully, the development of environmental friendly new

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technologies and the ongoing research and discussions on environmental issues among interested parties within their field of operations. As such the text of EMAS in many ways could be seen as having a dynamic development approach to environmental management, with obligations of improving environmental performances within a close cooperation and partnership between organisations, authorities, research and environmental agents. But still it has to be remembered that EMAS registration is voluntary and as such probably only used by the more advanced and proactive organisations within the Danish society. By mid 2001 only around 160 Danish companies and organisations in Denmark were registered and among those only few public organisations and no hospitals. Within the last 3 years the total number of EMAS registered companies have been around the same number. ISO 14001 ISO 14001 is an internationally developed and recognized certification system developed along the ISO 9000 Quality Management System approach in 1996 and implemented in various companies throughout the world within the last 5-6 years. The aim of ISO 14001 is to promote environmental protection and prevention of pollution balanced within the economic needs of the society. The only specific demands of the standard are the obligation of fulfilling the existing environmental legislation and consciously improving the environmental performance within the certified companies. (Balder, Christian, 1999) In most aspects ISO 14001 and EMAS are similar in its definitions and understanding of management systems and by revision of EMAS this was made equivalent so all ISO 14001 demands now are included within EMAS. EMAS demands are more ambitious than ISO 14001 and have some more extended and strict demands on several elements, while ISO certification can be seen as a first step towards an EMAS registration. Experiences of the use of environmental management systems Related to implementation of environmental management systems Tine Jørgensen and Arne Remmen (Jørgensen & Remmen, 1995) stressed the following design criteria of implementation based on case study research and general research within this topic: Design criteria: 1. Concrete environmental improvements must go hand in hand with the implementation of the environmental management system 2. Environmental management must be a mean to ensure the continuous improvements 3. Employee participation must anchor environmental management in all parts of the organisation 4. Environmental management must be integrated with other management systems and areas of responsibility 5. Life cycle perspectives must gradually be made the foundation of the environmental efforts These basic design criteria raise some functional demands to an environmental management system: • The organisation must decentralize responsibility and connect to other tasks of the management of the firm

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• • • • • •

The preparatory environmental review must give an overview of resource consumption, environmental impacts etc. and gradually go into details The environmental policy must be visionary and engaging as well as comprehensible and relevant The environmental targets must be measurable, clear and “owned” by the employees The management programme must establish plans of activities and schedules, and also state who is responsible for the implementation of solutions The review and evaluation of the environmental management system must insist on the strategic perspective instead of corrections of details The registers must only include necessary information, not possible information.

These criteria and demands can very well be the foundation of practical environmental management, which does not necessarily have to be a certified management system (Jørgensen & Remmen 1995). The Ministry of Environment published a report in 1999 on “Experiences on environmental management within Danish Enterprises. By a questionnaire survey answered by 107 out of 153 EMAS registered companies 1997/98 following main conclusion were: • • • • •

The main objectives for implementation of EMAS were being ahead of other companies within the sector and expectations of rising demands from authorities besides an expected advantage in marketing image. Internal competent managers and employees basically did the implementation of the environmental management system and 50 % had enlarged their environmental educated staff on that behalf. The implementation was seen to have had major effects on environmental prevention, change in use of raw materials and investments in new technology and productions processes within the companies. Indicators of a doubling effect on improved investment in cleaner technology were seen related to the general knowledge about investments in prevention within enterprises. Related to environmental legislation and regulation and cooperation with authorities and interested parties it was seen, that EMAS companies had improved their environmental demand on contractors and suppliers and had increased their cooperation with local municipalities and employees, but so far not with financial institutions and environmental groups in the local community. (Christensen, Per et al.1999)

These recommendations on design and conclusions based on implementation of environmental management within private sector enterprises seem persuasive and reasonable within an organisational context but with limited focus on the cultural and political process aspects of change processes and integration aspects related to other management areas within the enterprises. Implementation of EMAS in Danish Municipalities and Counties, discussion paper 1999 on results of a project called KEMAS funded by Ministry of Environment. The KEMAS project was running 1998 – 99 primarily within Gladsaxe and Herning Municipality, Vejle County, the national associations of municipalities, a private company, and a finalising workshop with participation from 17 municipalities and 8 counties. The aim of this project was to illustrate certain aspects related to implementation of EMAS in counties and municipalities within all or parts of the organisations.

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Some of the main observations were (Rømer, V. 1999): - EMAS were seen as a useful management tool for many municipalities and counties in their work on fulfilling the rising demands on environmental issues in all parts of society, but it was recommended that EMAS had to be adjusted to the local traditions of management, leadership and regulation within the individual municipalities and counties. -

The use of EMAS would secure a clear division of responsibility, line of command through out the municipality or county and a proper priority of the environmental interventions within the most important issues, which were seen as the mean of giving the most efficient environmental work.

-

Related to the many different roles and tasks of a municipality or county, a lot of decisionmaking and planning procedures were having environmental consequences, and the possibilities of influencing the environmental management activities within the local society are much broader than just focusing on consumption of electricity, water and heat.

-

A great challenge lies within development of operational working methods related to the more indirect environmental issues and activities, with the aim of enlarging the discussions across the administrative departments and within planning, purchase, tendering etc.

-

Participation by employees were seen as an important part of success for environmental management projects, and it was recommended to keep in mind that the environmental work is a process about changing attitudes and behaviour. Participation by employees and a high degree of dialog on aims, activities and results were seen as one of the fundamental issues of success with EMAS.

-

It was seen as essential that the political and top administrative management were positive and confirmed an environmental policy with environmental attitudes to be widespread within the organisations, supported by commitment from middle management and fiery soils.

-

One aim of a good environmental management system could be a successful dialogue on environment, making employees conscious about their influences on environmental issues, giving the politicians a broader platform on decision-making related to environmental consequences and giving the citizens knowledge about the background of political decisions.

-

Another aim of a good environmental management system could be that administrative departments were able to document their environmental achievements within tenders.

-

Related to integration with other systems it was recommended to work on possibilities of integrating environmental management with the efforts of quality and service management and with endeavour securing continuous improvements, employee participation and opinion formation processes on behalf of paper based bureaucratic documentation systems.

These observations will be included in analysis of the case studies in later chapters.

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4.4 Working Environment – development of legislation, organisations and regulation methods The Working Environmental Act of 1975 basically founded the present understanding of working environment. Based on the first broad investigation of the health conditions among Danish workers 1972 - 75 the present division of working environmental factors were described and strategies of technical and organisational interventions and preventions were made (Limborg, B.2001, page 17). The general principles of The Working Environmental Act are announcing enterprises as the key responsible of solving the working environmental problems. This is to be done under guidance of private Occupational Health Services, Sector Safety Councils and in close cooperation within the labour market organisations. The Danish Working Environment Services (Regional Work Inspectorates) provide the legislative guidance and do inspections. Based on European Research for the period of 1990-95 within hospital in 10 countries of the European Union (Verschuren, R.1995) a fairly broad agreement exists with respect to the main problem areas, which the Hospital Sector face. These main risk factors and risk groups was divided into: 7 risk factors Muscular-skeletal loads, biological agents, chemical substances, deviant working hours, relations with clients and the public, division of work and job content and relations with colleagues. 5 risk groups Nurses, service and trade workers, nurse assistants and apprentices, laboratory workers and Anaesthetics. Based on this study it was recommended that priority be given to the following 4 main areas of activities: • Improvements of the physical work environment, and in particular prevention and control of muscular-skeletal loads, biological agents and chemical substances • Improvements of the organizational work environment, mainly time patterns and work organisations and job content • Improvement of the social work environment, in particular relations with clients and the public and relations with colleagues • Health and safety policy A number of more specific intervention activities within organisations, sectors and national level are presented in the study (Verschuren, R. 1995) A Working Environmental Management standard OHSAS 18001 has been developed in line of the international standards for certified quality management system ISO 9001 and environmental management system ISO 14001 in 1999. OHSAS 18001 are developed with purpose of making it easier for enterprises to integrate their quality, environmental and working environmental management systems (Danish Standard, 2001) In the Working Environmental Act great importance are given to employee cooperation and participation in planning and implementation of actions within the working environmental issues. It is required that industrial and service enterprises with 10 or above employees and administrative

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companies with 20 or above employees have to establish a safety organisation in which both managers and employees participate. It is an obligation of the safety committee to control that the working environmental conditions within the enterprises are safe, and to take part in the planning of changes in use of technology or production processes and service delivery affecting the working environment within the enterprises. Lastly it is an obligation of the safety committee to inform the employees about health and safety issues. (Directorate of Working Environmental Service, 1996) Regulations within working environmental issues have a long tradition being approved within cooperation between authorities, employer and employee organisations. Two trends has been seen within the development of working environmental legislation within the last 20-30 years (Limborg, 2002, page 18): • Working environment is getting better, enterprises just have to be guided and encouraged • Working environment are being more dangerous, enterprises have to obey new demands and be controlled On behalf of a EU frame regulation on working environment from 1989 a change in the Working Environmental Act was approved in 1997, by which all enterprises were obliged to do work place assessments (WPA´s) as an instrument of improving focus on occupational health and safety within the organisations. Throughout 1970´s and 80´s the primary focus was on mapping working environmental issues and implementing prevention of work related accidents. As the work in the safety committees were often given low priority within the enterprises, results were seen to be minor and frustrations and lack of engagement within the safety organisations emerged. The demand of obligatory WPA´s was seen as a strategy on revitalising the environmental work in the enterprises (Limborg, 2002, Hasle, P et al.1999). WPA is not a new method within working environmental work. Different approaches has emerged in Great Britain, Netherlands, Sweden and Norway based on expert oriented assessment of risk, use of working environmental management systems and documentation. The Danish approach is merely based on a local participatory approach focusing on certain priorities, systematic actions plans and engagement within the organisations. These different approaches are all based on a rational oriented understanding of organisational changes and with a top-down decision-making approach within the enterprises. New bottom up strategic approaches have emerged as a reaction to this within the last 5 years, focusing on the possibilities of improving motivation, engagement and control by the employees as a mean of creating a better working environment (Hasle, Peter et al. 1999) Since mid 90´s the Danish Confederation of Trade Unions (LO) together with working environmental researchers in Denmark and Sweden have developed new strategies on promotion of good working conditions called “The Developing Work” based on the following principles (Limborg, 2002, page 19): • Flexibility owned by employees, about participation in work organisation and improved possibilities of professional and personal development on the job • Multidimensional interest handling (holistic management), about cooperation and decision making based on dialogue and improved rights and duties • Free public enterprises, about change of organisational culture towards improved accept of multiplicity, responsibility and openness

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This can partly be seen as a result of psychosocial factors of working environment being recognised as essential parts of the working environment since 1975. Psychosocial factors within the working environment had very limited focus before the middle of 90´s, when especially public health care organisations raised the discussions and need of awareness of an increasing number of psychosocial working environmental problems in health organisations. The Danish Confederation of Trade Unions (LO) has made a proposal for the Danish national strategy on sustainable development last year. LO describe a sustainable work place within a private enterprise, as a company that: • Systematically reduce environmental problems and resource consumption • Serious involve the employees within all activities and supply sufficient education and competence development • Reduce run-down of employees, deceases and accidents • Create equal opportunities and a “roomy labour market” • Show social responsibility internal and external • Work ‘life cycle oriented’ in product development reducing environmental harm and resource consumption • Develop sustainable products and services of high quality • Reduce environmental harm caused by transportation • Raise demands on contractors related to ethical issues like child work, human rights, trade union participation, environmental and working environmental conditions • Document honestly and truthful through environmental accounts and other types of accounts • Incorporates the concept of Eco-Efficiency in their business strategies (LO, 2001) And related to development of a sustainable working environment, they suggest the following 3 areas of strategies and interventions: • Improvement of “The developing work” • Increased participation by employees • Environmental competence development 4.5 The concept of integration between environmental management and working environment Understanding of the concept of integration The word integration is one of the essential words of this study, while I have to define and shortly elaborate on the meaning of this concept. Integration is a commonly used word in many connections in our times and the basic meaning of the word is to join or unite two or more separate units or issues to one unit or common course. In the Mamint project (Kamp, A. 1997, page 45-47) they defined the concept of integration within an understanding of a complexity of relations between environment and working environment as: “Integration is defined as a linking of issues of environment and working environment within the organisations with the aim of achieving one of the following goals: - a unified problem solution within environmental and working environmental issues - strengthening the efforts within one or both of the areas organisationally

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-

improving efficiency of the work within environment and working environment”

This definition covers a rather broad range of understandings from what could be seen as a systematic coordination of activities within different organisational structures to a more fully interconnected handling of all activities within the same organisational structure. I will use the same definition in this project. The reasons for using this rather wide definition is that integration of environmental management and working environment is a rather complicated issue involving topics as: - Legislation and regulation - Organisational and societal structures - Management and use of management systems - Leadership and employee participation - Knowledge and communication - Methods of problem solving 4.6 Empirical findings from case studies on integration of environmental management and working environment From the following published literature based on case study research, I will generate some general results of importance in the field of implementation of environmental management and specify some recommendations on integration of environmental management and working environment, which I will discuss within the analyses of my own case studies. Integrated Environment and Working Environmental Work in Danish Enterprises, based on case studies in 3 medium size industrial enterprises and results from the research program: Mamint and a PhD study. The focus of these studies was on integration issues, experiences and results of development projects and from general research in Scandinavian countries by use of different types of integrated systems. The study includes results from general research and investigations within the field of environmental management until 1997. Some of the main observations of this study were, (Kamp, Anette, 1997): - Demands from authorities and workers organisations were the driving forces for an improved focus on working environmental issues, and were partly integrated in the environmental management efforts, but given a minor priority than building an environmental management system based on a technical administrative rationale. It did not seem that working environmental efforts were basically being improved as result of an increased focus on environmental management systems. -

Several interconnections between environmental and working environmental issues supported the idea of integration, while others did not. For this reason integration was often established as bridges between 2 separate, but parallel coordinated systems with a different set of values, use of methods and key actors with different competences.

-

A too strong focus on the use of technical administrative dominated management systems seemed to dominate and oppose the use of learning principles and competence development within the organisations.

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-

Both areas achieved great benefits from increased employee participation, but with different motives, results and capabilities, and a need of competence development of employees within both areas was made clear.

-

Demands, consultancy, and inspections by central and local authorities within both issues had a great impact on priorities within both fields and the use of methods for improvements.

-

Improved efforts within both areas needed increased use of resources, and in several areas the integration efforts were beneficial in this respect.

Based on the study the following strategy on implementation of a learning environmental management system was recommended: “Participation in formulation of visions and aims, in problem formulation and the choice of solutions are essential. Make the employees the real actors within the system and not just receivers and executors of a pre-designed system. Management in learning strategies is about managing the implementation processes from the aim formulation to achieved results, based on knowledge on change processes, giving necessary support, raising the discussions on different opinions and disagreements related to aims, attitudes and means by open and constructive conflicts on different views within the organisation” (Kamp, A 1997 on behalf of Norrgreen, F. 1996). Design for Sustainable Development. Environmental Management and Safety and Health, a report on the EU Environmental Management and Audit Scheme (EMAS) and its interaction with the management of safety and health. This study is based on results of a research programme 1997 – 2000 on design for sustainable development and case studies of EMAS / ISO 14001 implementation at company level in 5 medium size private industrial and service delivery enterprises in 5 different countries in EU. Some of the main observations from these case studies were: - There seemed to be no best way of implementation of management systems within quality, environment and health and safety, often the systems were developed separately and sometimes they were integrated within quality management systems. -

Participation in EMAS was often a result of external pressure from customers, NGO´s and / or rising demands from environmental authorities.

-

Integration of environmental and working environmental issues were in some of the companies done as part of an already implemented quality management system, and as a result of having stated environmental and working environmental issues as important element of the overall business strategies.

-

High priorities by top management on the issues of quality, environment and working environment had a significant contribution to implementation of integrated management systems in these companies, and there were not seen contradictions between the issues within the integration strategy. The main conflicts were seen between speed limits of production processes, service deliveries and health and safety issues.

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-

The works council did most of the work on integration of working environment and environmental issues in some of the companies by focusing on the health aspects, and by organisational means as training, information and motivation of the employees. Active members of the work committee were personally engaged and voluntarily acquiring wisdom and experiences by attending evening school classes.

-

Implementation of EMAS without integration of working environmental issues were done in one of the companies and seemed to have no effect on improvements of the working environment, although employee participation within EMAS was widespread by the use of internal audits. (Zwetsloot, G. 1998 page 28)

Related to the aim of sustainability on business level this study recommends: “Integration of all relevant management areas within the company and the use of synergy between them is a must for the management of sustainable development, because of its broader and more comprehensive scope. As we have seen before, the companies do not accomplish this easily. The joint management of environment and occupational health and safety, however, may form a good starting point for the management of sustainable development. Structural and effective sustainable development can only take place when policies at company level are aligned with regional and national policies aimed at sustainable development.” (Zwetsloot, G. 1998, page 30) 4.7 Theoretical aspects related to environmental management and sustainable development By choice of the following quotations from Richard Welford (an experienced professor within corporate environmental management and sustainable management), on culture and organisations, I want to express my own experiences within change processes and hospital management related to what I find as essential aspects of organisational development within this field (Welford 97): “We can … assume that organizational treatments of environmental management are here to stay. But the journey has just begun, and we have hardly left the starting point” (Welford 97, page 5). “ the mindset of many in the developing field of corporate environmental management is still very technocratic, instrumental, result-driven and solutions-oriented, rather than theory-based, dialectic or problem-driven.” (Welford 97, page 5) “an in-depth diagnosis of organisational culture is essential for the identification of underlying factors that gives rise to unsustainable practices.” (Welford 97, page 11) “The answers however, lies in taking a broader systems approach to environmental problems rather than seeing each and every problem as requiring a specific solution” (Welford 97, page 11) “Companies which are really serious about environmental issues need to relate their environmental strategy to an underlying ecological theory and an analysis of ecological, human and social systems. In so doing they are more likely to choose more ecologically significant issues to tackle.” (Welford 97, page 18) Looking into the topic of environmental management of hospitals and hospital services it might also be useful to consider the characteristics of a hospital service enterprise and how it differs from a

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manufacturing enterprise, from which the most experiences in the field of environmental management above are extracted. Besides focusing on the cultural aspects one of the other important aspects generally to be aware of, are differences related to the production processes and consumption within enterprises of those 2 different types of enterprises. The manufacturing enterprise normally is dealing with a rather intensive take in of materials – a time consuming processing by use of energy, substances, manpower, etc. – and an output in form of products for sale, waste and emissions separated from the consumption. The “production” in a service delivery enterprise normally is less material consuming and more labour intensive and production and consumption within the service delivery often happens at the same time and spot. (Norman, R. 1994) This means that while the manufacturing enterprises normally have to focus intensively on the internal processes of the production and the effects of those to the environment, the service delivery enterprises are often more dependent on materials and substances produced with environmental impacts by other manufacturing enterprises. The service delivery process, which is often immaterial, is most of all results of highly specialised professional processes. Despite this there might be extensive environmental impacts related to the service delivery, but those are often closely related to the intermediate consumption within the service delivery, partly as environmental harm related to other areas of the life cycle of the products and partly to the waste disposal by the service delivering enterprise. For this reason a supply chain management approach to analysing the environmental impacts of service delivery may be effective, and focusing on stakeholder relations seems to be essential. Even though the direct impacts from the use of materials, energy, emissions and waste generally might be comparatively less than manufacturing enterprises, and those basically within hospitals are related to running of buildings, as heating, lighting and substances for patients as food, medicine, laundry or diagnostic processes in laboratories etc. there might be several other social and ethical impacts of service delivery which should not be ignored if the aim is to move towards sustainability (Welford, 2000 page 82).

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Another model of “3 stakeholders and their main interactions” This simple model based on the model on environmental economics at page…. indicates the present main relations between the actors: Employees & citizens A) Developing Working E i t

B) Political processes on Sustainable Development

Government & Political interest groups

Enterprises & Organisations C) Demands and systems of Environmental Management

A. Employees & citizens demand and work for satisfying working environmental conditions in cooperation with Enterprises & organisations. B. Government & political interest groups work on long-term sustainable development of society related to interests of the employees & citizens by means of political processes. C. Government & political interest groups demands environmental regulations and Enterprises & Organisations establish systems within environmental management to cope with those.

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5. Case – studies 5.1 Introduction This chapter I will start by a short general description of the hospital sector and the hospital management systems in Denmark and the economic and quality management issues within Danish hospitals followed by the 3 case studies one by one. Each of the case studies has quite different priorities and experiences related to activities within environmental management and working environmental work. As such they tell different stories about the issues and different learning can be taken from them. They are all told along the same disposition trying to make it possible to extract some general characteristics and experiences related to the topics in an adductive analysis of the 3 case studies. The notable observations are a selection of specific issues from the interview résumés, which related to theories on environmental management are found to be essential for the analysis. 5.2 General about the hospital sector and hospital management in Denmark The Hospital Sector in Denmark mostly consist of public hospital institutions established and managed politically within 14 Danish Counties and Copenhagen Hospital Cooperation (H:S), in the Copenhagen City Area. Public hospital services are run under the Danish National Hospital Law, services are free of charge for the patients and hospitals are financed through tax collections by the counties based on yearly financial agreements between the government and the Danish cooperation of counties and H:S. General and specialized practitioners give admissions to public hospital services on acute deceases or by need of specialized treatment and surgery. Practitioners are privately run clinics paid by public finances related to national agreements on payment per patient and treatments. There are about 80 public hospitals of different size and range of specialities and a small number of minor specialised private hospitals in Denmark. The private hospitals are financed through health care insurances and pay by individual patients. Quality and service management in hospitals The main ‘production or services’ within public hospitals are treatments and care of patients based on referral and diagnostic analyses by professionals in various departments, basically build up on the model of patient flow systems, by which individual patients are dispatched through different functions and departments for diagnostic analyses, treatments, care and other services delivered by a great number of professionals, skilled and unskilled employees along a ‘line’ of clinical pathways. In quality management it has been introduced setting goals and measuring performances related to patient flow descriptions as part of a quality management system combined with selected indicators on results of patient treatments reported to national quality databases for benchmarking purposes. This system is rather new and under implementation in many hospitals and seems to function as a method of improving the quality standards, as the professionals are rather keen about their results in patient care. Besides this different forms of patient surveys, both national and locally are implemented related to measuring general patient satisfaction with the hospital services. Recently 6 major hospitals within H:S have implemented a quality and service management system called hospital accreditation along an international recognized accreditation scheme, based on experiences and methods of accreditation of private and public hospitals especially in United States. Discussions among health authorities on development and implementation of a national scheme of hospital accreditation as a national demand within management of Danish hospitals are going on.

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Administrative and economic systems of management in hospitals Most Danish hospital institutions are individual organisations managed by a group of directors, normally an administrative director, a medical director and a nursing director. At department level the management normally consist of 2 professionals, a physician and a nurse or laboratory technician, and a number of professional health educated managers of individual wards and units within the department. Principles of activity and frame budgeting of the individual hospitals and departments generally rule the economic management system, and as such there is limited connection between volume and quality of ‘production’ and the budgets of individual departments. This economic system has the effect that there are no economic incentives of increasing ‘production’ and few incentives of improving productivity or even quality, besides from external pressures as inflow of acute patients, budget cuts or by published quality indicators or patient satisfaction surveys. It also means that the knowledge on expenses and on quality of the individual treatments and services is rather limited. With the aim of improving the economic management of hospitals a national system had recently been introduced setting a national average diagnostic related group price (DRG) of about 500 groups of treatments in Danish hospitals with the intensions of measuring the value of performances of individual hospitals related to this national price setting. This DRG-system so far is mostly used for payments of treatments on external county patients between counties. The market mechanism in economic management of hospitals in Denmark is for those reasons so far rather limited, or almost not existing within the patient treatment, which limits the possibilities of using classical economic incentives in improving environmental performances at hospitals in Denmark. Within services like laboratory diagnostics, food delivery, cleaning and building facilities the use of supply-side economics by invitation for tenders are emerging. Hospitals in Denmark has within the last 10-15 years been under constant economic pressure and a strong national political and public debate related to waiting times for treatments, quality of patient care and increasing demands of quality improvements of hospital services. Hospital Management at public hospitals are working under rather tense political management formally by the local county politicians and informally by rather strong professional organisations of doctors and nurses, and none of these has so far shown major concern of environmental issues or raised demands on improvements by use of environmental management of Danish hospitals. 5.3 Case - RASK, Koege Hospital in Roskilde County Introduction This case study is based on interviews with 11 key persons within hospital management, service and clinical departments, the safety organisation and staff members. The respondents are covering the major areas of management, working environment and environmental issues at RASK. Besides interviews the case study is based on a review of a number of documents. Occupation, Department of the respondents and a list of documents can be seen in Annex I. The hospital director and the laboratory technician from department of clinical chemistry, (co-chairman of the hospital joint committee) has confirmed the case description below. The organisation RASK – Koege Hospital in Roskilde County is a general medium size University Hospital of approximately 300 beds, about 1000 fulltime employees. The hospital treats around 11.000 inpatients and 46.000 patients at ambulatory visits per year. The organisational structure is like most

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hospitals with a hospital management, the patient services delivered by 6 clinical departments, 3 clinical diagnostic departments, 2 service and technical and administrative departments, in all 11 departments of the organisation. As a specialist function RASK has a department of prevention and health promotion dealing with projects and investigations related to improvement of public health, including initiatives related to health promotion among the employees at RASK. RASK also has a specialist department of occupational medicine, dealing with examination of patients and research related to on the job injuries and working related deceases at private and public work places in the county. Besides a traditional line management structure a number of councils, boards and committees are established with a broad management and staff representation functioning within different specific areas of operations of the hospital. Aims and strategy The hospital is working on implementation of an overall organisational development strategy based on the principles of the management concept Balanced Scorecard. The vision of this strategy is stated as “An optimal patient flow for the individual patient”. In the statement of values of the organisation it is among others written that all employees are obligated to: • •

Participate actively in development of a health promoting working environment internal at RASK and act ethic and environmental conscience in relation to the external environment. Participate in creating a learning environment in their departments and at RASK

The hospital development strategy contain 20 targets and related to each target are laid down a number of specific action-plans. This development strategy for 2001 – 03 is a revised and much more detailed plan of a previous strategy of 1998 – 2000.The outlay of the present strategy is made at a seminar by the management council and discussed in all the local joint committees and at staff meetings in the departments of the hospital. The statements within the strategy on the issues of a strong focus on health promoting working environment at RASK and on acting ethic and environmental conscious was brought up as a result of the hearing process on initiative by some of the employees. As stated by one of the managing respondents: “RASK is only going to be a hospital of prevention and health promotion if it is reliable in the eyes of the employees. Internal organisational obligations must follow this strategy, as the employees did not experience the organisation taking hand on their health and working environment at that time” (2 years ago). The management council and the joint committee discussed this intensively after the hearing process, and broadly accepted and took it in to the strategy in the final version. A county project on environment- and energy management running for more than 2 years 1995 – 98 by a full time environmental project manager and an administrative steering group, resulted in the first county green account 1997. An environmental policy and targets for improvements were written and politically sanctioned. 2 courses in environmental management for managers from different county institutions were arranged. These county activities had only limited impact at

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RASK and were not followed up by the county health administration or by the hospital management. The county environmental policy, environmental targets and green account publication for the years 1997 and 1998 – 99 – 00 was not known by the hospital management and only recently known by the manager of the technical department. There is no formulation on environmental policies in the operational agreements neither with the county nor with the departments or in the terms of references of the committees of occupational health and safety, purchase, external services or food. Environmental issues The technical department, mostly for reasons of economic savings, closely followed the consumption of energy and water, which was low, compared to others; partly because the hospital was rather newly built, and partly as a result of implementation of a number of technical improvements related to energy-savings and an energy management system at the hospital. The manager of technical department generally thought, that hospital management was positive towards certain types of investments if they had a short-term payback period. No specific projects, campaigns or plans were initiated related to environmental improvements among the staff behaviour in the departments. Discussions were going on related to handling of waste, but so fare no initiatives were taken to improve the waste management. Some of the departments like radiology and clinical chemistry had done some improvements related to environmental protection and seemed to be quite aware of the environmental issues related to their activities as part of their professional consciousness. In the radiology department the head nurse had followed the course in environmental management arranged as part of the county project in 1997 and for several years the local safety group in this department had initiated environmental improvements related to water consumption, waste handling and chemistry, partly for working environmental reasons and partly for environmental reasons. Under the headline of “Chemistry out of the department” they had succeeded to get developing agents into closed systems, and invented a system of re-usage of developer in the machinery 2-3 times, reducing costs and the amount of waste materials. The head nurse found it difficult to get improvements financed if they did not have a very short-term payback period by savings in consumption. The radiology department was at the moment heavily engaged in a rather extensive implementation of a new quality management system initiated on the background of EU regulations on prevention of risks related to radiation. The purchasing office was aware of environmental issues related to several of the products used by the hospital. Generally environmental concern was not of high priority in decision making within the purchasing function, partly because the prices of green products were much higher than other products and partly because the staff at the hospital and the members of the purchasing committee had much higher priorities like quality in use, security of supply, good instructions and low cost. The head clerk of the purchasing office was aware of environmental problems related to PVC, Phthalates, hospital waste and the need of general waste reduction from her participation in a network of purchasers from hospitals in Denmark. She knew about green purchasing policies implemented in other Danish counties and hospitals but no green purchasing policy or environmental principles was used at RASK so far. She was aware of several issues within purchase that eventually could be looked upon environmentally for good reasons. The local purchasing committee now and then discussed environmental issues related to specific topics.

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Working environmental issues Related to the development strategy on improvements of the working environment the main issues of the work in the safety organisation were related to implementation of the WPA´s (work place assessments) local and organisation wide. Besides this action plans were laid down on psychosocial working environmental issues, prevention of muscular-skeleton diseases by improved instructions, investments in patient-lifts and electric operated patient-beds. Finally a development project related to prevention of employees threatened of work-expulsion was started in cooperation with an external consultancy firm. As part of the hospital strategy on prevention and health promotion of the employees an action plan on establishment of a physical training facility for the employees, free for use after working hours, educational courses for heavy weight staff, a more healthy food-supply in the staff cantina and courses and local instructions of employees in ergonomic working positions was offered. A Stop Smoking Clinic was established related to the smoke free hospital policy of year 2002 and a proposal of a policy on safety for pregnant employees were being worked out in a working group. Within purchasing functions the purchasing committee had good experiences of forming working groups with specialists from relevant specialities, that worked out investigations and made prescriptions in the form of standards of policies and guidelines for the purchase of certain groups of products, based on quality and working environmental issues. Integration Roskilde County had a working environmental policy from beginning of 1990´s. Within hospitals the county administration had an integrated joint and safety committee, but at RASK the joint committee and the safety committee were two different committees, but with a permanent representative from the safety organisation in the joint committee. At department level it was decided locally whether they organised the work of the joint committee and the safety committee integrated or separate, which differed among the 10 safety groups at the hospital. Generally the safety organisation was well functioning and active, and the working environmental issues were given rather high priorities by the hospitals management. Attitudes and experiences on integration of working environmental issues and joint committee work at hospital level were mixed. There seemed to be a tendency that the joint committee work often took over focus from the working environmental issues. For this reason they had so far not integrated the work of the joint committee and the safety committee at the hospital level, although several topics were discussed in both committees. Discussions on the topic of integration were still going on. The joint committee had been very actively involved in the work on psychological working environment and the action plans related to this and in other working environmental topics like the proposals and projects related to prevention and health promotion of employees. At local levels it seemed to be more obvious integrating the work on those issues, even though limited experiences showed that environmental issues was raised basically because of working environmental concern and less on behalf of environmental concern. On discussions whether an improved effort on environmental improvements should bee organised through the work of the security organisation, opinions were mixed. Some found it obvious, i.e. department of radiology, and had good experiences of handling the environmental and the working environmental issues and even the joint committee work integrated. Others i.e. the security manager and the manager of the

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administration was afraid that issues of occupational health and safety and environmental issues was better off being handled separately to secure a more stringent focus on each of the topics and related issues. Implementation The hospital management at RASK were (as most Danish Hospitals) managing the hospital within some overall general agreements of management and within some rather specific budgets on activities and economical limits of hospital care and services. The main criteria of success for the hospital management were related to budget control and to fulfil the goals of improvements on patient services and quality of care. Since 1994 a system of operational agreements at department level with goals of services and quality improvements, activities and budgets were implemented and used as a management tools at Roskilde County hospitals. The content of these operational agreements were to some extent (within the overall county defined limits) negotiated between department and the hospital management once a year and was followed up monthly by data on activities and economy and quarterly by separate dialogue meetings between the department managers and the hospital management. These operational agreement was supposed to be discussed at staff meetings and local joint committee meetings to secure employee participation in goal setting, implementation and follow up. The operational agreements included targets on working environmental issues defined and agreed locally and other types of local development projects and improvement efforts. The hospital director stressed that a development strategy with specific goals setting, related action plans, use of operational agreements, regular dialog meetings every 2 weeks in the management council with all department managers, continuous follow up on data of budgets, active use of committees in certain areas, working groups and projects on specific development topics were the effective combination of means on continuous organisational development and successful implementation of change in the organisation. Based on information from the case study it seemed like this strategy of development and implementation of changes was acknowledged and being used within issues of working environment, but so fare not within issues of environmental management, as this issue had no management focus so far neither within the organisation nor at the county level. From interviews it seemed that the employees at the hospital was concerned about the environmental issues, and that they would bee proud if RASK had a stronger environmental profile. Monitoring and control In the area of working environment the improved efforts were mostly done by projects, campaigns or educational courses oriented towards limited areas or certain groups of employees. Some of the obligations and targets were included in the operational agreements and the hospital safety committee followed up the projects and as such monitoring and control was done to some degree. Data for the county green accounts was administratively being reported by an intra-net based reporting system, but out-data from this system was not known or used at RASK. There was no structural coordination or follow up on the county environmental policy and targets involving the hospitals besides their obligation of delivering hard data once a year to the county green account. In other management areas like follow up on budgets of activities, staff-employment and economy and patient services, educational obligations etc. they had a tradition of high degree of specific goal

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setting and data-collection on performances, through the budgeting and reporting processes and a continues dialogue between the different management levels. There were no experiences of using standardised or certified management systems like ISO-systems or a like in the hospital management system. The use of indicators was generally being developed in the field of health care and patient services, and could eventually rather easily be implemented in the hospital management system, if or when those were politically approved and professionally accepted as part of the operational agreements of the departments at RASK. The same could possibly be the case of indicators on environmental and working environmental issues if those were developed, approved, accepted and implemented as targets of the hospital strategy of operations. Evaluation and organizational learning As part of the development strategy targets and action plans for the follow up on the strategy was lay down, anyway it seemed from interviews like follow up on the different targets and action plans was one of the weak points of the development strategy. Even though all action plans had been given rather specific responsibility and time frames it was the general impression from respondents, that it might be difficult to secure the follow up on all of targets and development projects noted in the action plans. 9 out of 20 targets were within the perspectives of learning and management. Several of those were related to capacity building of employees, participation approach towards development of a health promoting working environment, an ethic and environmental consciousness towards external environment and improved leadership and dialogue within management. Communication and cooperation It seemed like the structural conditions and possibilities for organisation wide communication and cooperation existed by a well-described organisational structural system and from the terms of references for quite a number of councils, committees and working groups. It also seemed to be the intensions of the hospital director that management was based on continuous dialogue and good information systems. There seemed to be a participation approach towards most operational issues, even though some management interview persons found that hospital management was sometimes much more depending on negotiation, collaboration and accept with and by the staff within the committees, than through involvements and agreements within the group of managers. Whether those assumptions are correct are not possible to judge from this case study. Generally management of hospital organisations as professional organisations with strong subcultures are very much depending on collaboration and participation of employees in the operation of the hospital care and services, especially the strong professional groups of physicians and nurses in clinical departments. Internal culture conflicts and political processes usually are rather strong elements of the organisational culture, while authoritative use of management power often fails. Notable observations The following observations are extracted for the purpose of analysis based on the theories of the previous chapters. Policies, aims and demands County environment policy and aims was not known at RASK several years after approval, as result of weak implementation efforts by the county administration and poor follow up on county environmental policies and targets by the political county management.

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Main focus of the hospitals development strategy was on quality for the individual patient, prevention and health promotion and working environmental issues. Environmental focus was made part of the strategy on behalf of environmental consciousness among employees. Management and participation Hospital management was following a management concept called Balanced Scorecard, based on principles of learning organisation and management by dialogue based on operational agreements as important part of the development strategy and the daily management practises. For unknown reasons hospital management did not use the expertise and knowledge of physicians in department of occupational medicine neither in the prevention and health promotion efforts nor in the occupational health and safety work at the hospital. Working environmental issues and integration Working environmental improvements were handled partly integrated within the safety organisation and the joint committee and partly integrated with prevention and health promoting initiatives, purchase policies and followed up as part of the general operational agreements of the hospital. At laboratory and technical departments integration of working environment and environmental responsibilities were seen and handled integrated within the local safety organisation, and was initiated as part of general professional consciousness and quality development activities. Environmental management issues and integration Several local managers and employees showed environmental awareness and environmental management initiatives were taken locally. Environmental awareness on possibilities of use of green products and possible reductions of environmental harm from services within purchase functions did not change the purchasing policies, because of extra cost and stronger focus on quality and working environmental issues. Sustainable development and other issues The concept of sustainable development were not known or weakly understood by respondents. Potential health risk related to the use of chemicals in care, phthalates, latex, chemicals and infections was basically seen as an organisational issue, but merely seen as a responsibility of producers and the authorities responsible for production permits and environmental regulations. Considerations concerning the respondents and the case study The case study is based on interviews with 11 key persons, mostly managers from hospital management, the administration and clinical and service departments and some employees from the safety organisation and the joint committee. I assume having got a fairly broad perspective of the management views on the topics in focus, but I cannot know if the information given covers the general employee perspectives and attitudes at RASK. The main reasons for choosing this case study was the work along a rather detailed development strategy with a participatory approach of development of the hospital and the fact that they showed rather strong commitments on development of both the working environment and the environmental

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issues. It is part of the history that the hospital director and the medical director at RASK were employed at the hospital, within the last 5-6 years, which might be reason for a strong focus on strategy formulation and development initiatives within the hospital management. It is for this reason not possible on behalf of this study to judge, whether the general development processes at RASK are functioning along the line of the new management strategy and praxis’s or follows another more general hospital organisational discourse within the organisation. 5.4 Case – Copenhagen County Hospital in Gentofte (KAS Gentofte) Introduction This case study is based on interviews with 3 key persons related to the issues of environmental management and working environment at KAS Gentofte and a review of a number of documents related to the topics in focus. The respondents were the environmental coordinator, academic educated in environmental planning, who was employed at this hospital since January 2001, the safety manager, with 15 years of experiences of working environmental consultancy from the Work Inspectorate, employed at KAS Gentofte since beginning of 2000 and a vice-director chairman of the environmental committee at KAS Gentofte employed since summer 2000. Occupation, departments of interview persons and a list of documents can be seen in Annex II. The vice director and the environmental coordinator has confirmed the case description. The organisation Copenhagen County Hospital in Gentofte (KAS Gentofte) is a major University Hospital of approximately 840 beds and about 3.100 full time employees. The hospital treats around 45.000 inpatients per year and 40.000 patients at 274.000 ambulatory patient visits. KAS Gentofte is one of three major somatic University Hospitals in Copenhagen County. The organisational structure is like most hospitals with a hospital management, the patient services delivered from around 20 clinical departments, 5 clinical diagnostic departments, 5 service departments and 4 administrative departments, a total of approximately 34 individual departments of the organisation. A number of standing committees and councils with managers and staff representatives are established within specific areas of operations. A permanent environmental committee with 11 representatives from clinic and service departments, hospital management and administration, was established 1998 headed by one of the vice-directors of hospital management. The hospital safety organisation consist of a safety committee with 2 management and 2 staff representatives and the hospital safety manager, headed by the hospital director, and 32 safety groups at department level with a local safety manager from the department management and one or more local safety representatives responsible for the local safety and environmental work The hospital safety manager, the environmental coordinator always participates in the meetings of the safety committee and the environmental committee for the purpose of coordination between those committees. Aim and strategy Through out the year 2001 the overall aims and vision of KAS Gentofte have been under revision and following the final draft the vision for 2002-05 was going to be: “KAS Gentofte as a University Hospital is recognized as pioneer hospital, and is among the mostly preferred by patients, general practitioners, other cooperation partners and authorities within • Diagnostic, treatment, care and rehabilitation in international elite

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• • •

Job satisfaction and progress through cooperation and education International research and quality in constant development Healthy economy through effectiveness and with respect for the environment”

Related to patients, quality, research, education, staff, economy, physics and administration is mapped out around 27 aims and a huge number of intermediate aims with related action plans. Only rather few of those are focussing on environmental and working environmental issues. Copenhagen County environmental policy for the period of 2001 – 06 demand that all county institutions implement environmental management and green targets, and work on environmental improvements within energy, environmental information and employee consciousness, water management, waste, transport, ecological foods, cleaner technology and every 4 years an environmental benchmarking report on the county environmental harm shall be made. KAS Gentofte has an environmental policy since 1998 stating that • All activities are done with a minimum consumption of energy and resources and the least possible use of environmental harmful materials • The hospital services are managed with optimal care for environment, safety and health • The hospital promote a healthy and safe working environment, and all employees showed co responsibility • The hospital try to promote environmental-, safety- and health consciousness among patients, relatives, producers and other cooperating partners • Information is given internal and external through articles, meetings etc. about the work on reduction of the environmental harm by the hospital The hospital has no specific policy on working environment, besides some general aims in the hospital personal policy. A county working environmental policy and related action plan is about to be approved by the county hospital sector joint committee. KAS Gentofte has been rather intensively engaged in project oriented environmental management work since 1997 started as a pilot project on Green Accounts and Environmental Management at hospitals in Copenhagen County. In 1998 a major project initiated by the County Technical Department and funded by the Ministry of Environment resulted in a rather detailed review of the environmental issues related to the hospital services through out the organisation. A model with recommendations for specific implementation of environmental management were published as a result of the work in a project group and a number of working groups assisted by external consultants. The first hospital green account was published for the year 1997, and environmental statements and accounts for 1998, 1999 and 2000-01 (on the way) specify the aims, activities and results in the following years. Another project 2000 – 01 on “Composition of environmental management in the purchase function and implementation of environmental management at the department level of KAS Gentofte was funded by the Ministry of Environment and the evaluation report for this project was approved in December 2001. Environmental issues The areas of environmental focus have been electricity, heat, water, disposable items, cleansing agents, gasses, chemicals for clinical use, IT and waste. By data collected on 39 environmental indicators they follow the environmental performance and compare those yearly since 1995. Green

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Account KAS Gentofte 1999 show that consumption of water was reduced by 8-9 %, heat by 3,5 %, Oxygen by 10% and laughing gas by 46 % for different reasons and intervention. Despite the environmental improvements, the environmental coordinator mentioned 3 major areas of concern in her present environmental work: •

• •

The municipality of Gentofte demand that the hospital apply for permission on discharge water from the hospital, which had never been given. The preliminary analysis showed too high concentrations of mercury and other substances in the wastewater, why prevention efforts have to be done to obtain permission. A review of the regulation of the municipality waste disposal show that the hospital do not fulfil the demands on scorching of sources, why a project on pre-sorting of waste has been started recently. Focus on regulation of chemical has stared by mapping of chemicals both in relation to environmental issues (storage and disposal) and working environment issues (work place instructions).

These 3 important focus areas was a result of the work on implementation of environmental management, by which it is a demand that the hospital know and fulfil the environmental legislation and the regulations of the local authorities, and as a result of a combined focus on environment and working environmental issues, especially related to handling of chemicals. A project group has been formed on identification and proposals for problem solving within those 3 areas. Working environmental issues 2 years ago the Work Inspectorate has made an adjusted inspection at 12 departments of the hospital, resulting in 81 demands to be corrected. This has given a lot of work and huge costs for the hospital to comply with those demands and has been directing an intensive work of the safety committee within the last 2 years. Beginning of 2002 only 2 demands remain to be fulfilled and the Work Inspectorate has classified the hospital as a grade three hospital. As part of the work within the last 2 years the safety committee has improved the WPA (work place assessment) work locally and overall at the hospital and implemented a systematic continuously improving hospital WPA action plan. Part of the success of this effort was clarifying responsibilities in the security work at the hospital, working out clear procedures and processes of problem solving and implementation of the use of a new standardised reporting scheme on issues, that cannot be handled locally, including as well working environmental as environmental issues. The safety manager found that the WPA work is very essential and the most effective mean of improving working environment in combination with active and engaged safety managers and safety representatives and with the necessary focus and support by the hospital management as well. The safety manager found that psychological working environment is one of the biggest working environmental problems at the hospital presently, but so fare limited activities has been done in this area. Integration Related to implementation of environmental management at department level, the hospital management has decided that the local environmental work should be integrated in the security organisation, and that the local security representatives and managers should as well be the local

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environmental contact persons. For this purpose 70 % of the members of the safety organisation had followed a rather theoretical educational course of one week on environmental management issues in the year 2001. Some of the safety representatives were against their will pointed out as environmental contact persons, which was a problem for integration of the work. Part of this resistance was for reasons that expectations had not been specified and hospital management had not given extra resources to the employees or the departments for the work on environmental management issues. The safety manager found that the integration locally on working environment and environmental issues was a good decision, but the implementation was not successfully done, and had to be improved, partly by more practical educational activities and partly by specifications of expectations and acceptance of the working hours needed to do the environmental activities. At the hospital level the environmental committee and the safety committee had different representatives from hospital management and from middle management and employees. The two committees are each responsible for managing the work on environmental and working environmental issues separately, but coordinated by the environmental coordinator and the safety manager, who attend the meetings in both committees. Discussions on integrating the two committees has been going on for some time, but the present general opinion is that they should be kept separate to keep a stronger focus on the 2 different areas. Different legislations, know how and ways of handling the issues and the amount of work related to those issues are said to be the main reasons for keeping the committees separate, and they find that coordination is well functioning by the close cooperation between the safety manager and the environmental coordinator in their daily work. Integration of environmental work within the safety organisations locally is found to be very relevant partly because of many interrelated issues between environment and working environment at the operational level, and partly because an organisational structure with devoted managers and employees with focus on health and safety already are established. According to the environmental coordinator it might be a good idea to elect some employee representatives who has a special engagement in environmental issues to be members of the safety organisation, in the departments, especially in departments where the safety representatives are resistant to enlarge their obligations. From her experience personal motivation towards environmental work is an essential driving force for improvements in this field. The hospital is not working on integration with quality management and prevention and health promotion at hospital management level, but according to the vice-director probably some departments did this locally. Implementation The environmental work at KAS Gentofte has basically been improved by a group of active members of the hospital environmental committee, supported by external funds and resource persons from the county, and within the last years by a full time environmental coordinator employed at the hospital. The project on implementation of environmental management in the departments and in purchasing functions was focussing on making an environmental action plan with priorities of interventions, education of safety representatives as environmental contact persons, improvements of information and environmental consciousness among staff by campaigns, environmental mapping, networking with other hospitals in the county and with other Danish hospitals and on fulfilling environmental

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legislation and regulations by local authorities. Working with these activities has been a learning experience of the environmental committee and many of the involved employees, but related to the evaluation report and the environmental coordinator and the safety manager, it was found necessary to improve the participation by managers and employees locally through out the organisation, and to spend more resources at the local department level to improve environmental performance further. It was the intention of the environmental coordinator and the committee to develop a strategy in 2002 on a scale of 3-5 years, clarifying responsibilities, competences and communication structures in the environmental work and how to implement environmental aims and areas of intervention in each hospital department. It is the intention that this strategy shall found the basis for the implementation of the environmental work both at management level and the operative level. Monitoring and control Related to the county environmental policy a coordination group among the hospitals was established last year with the aim of defining parameters for the green account and sharing experiences in the work on implementation of environmental management at the hospitals in the county. The county administration had for the first time collected data for a county green account of the year 2001, and asked for the status on the work with implementation of environmental management systems at the county institutions. Besides this no other form of follow up or coordination of the environmental work in the county involving the hospitals were known. It was a responsibility of each hospital to make their own strategies and implementation of environmental management systems along the county environmental and other related policies. At KAS Gentofte collecting of data on the environmental indicators and publishing an environmental statement and account report once a year did the monitoring and control of performance. Evaluation and organizational learning The activities and results within environmental performance at KAS Gentofte, as shown by the green accounts are basically a result of the work within a committed environmental committee and rather few enthusiastic managers and employees at the hospital. According to the evaluation of the latest project and the interviews there was a lack of broad employee participation and local management responsibility in the work. The environmental committee was seen to be isolated from the rest of the organization. It was seen essential in the coming years to work on a much closer integration of the environmental strategies and aims on environmental issues as part of the general management system of the hospital. It was stressed that discussions on environmental issues had to be given a higher priority in combination with other operational issues at the management council meetings. Communication and cooperation Mainly the environmental coordinator and the safety manager were responsible of communication and cooperation within environmental and working environmental issues related to the individual department managers and employees. And the hospital related issues and plans were discussed at meetings in the respective committees as mentioned. The hospital management and all department managers held a meeting every 2 weeks, but it was rather seldom that issues of environment and working environment were discussed in this management forum. The environmental coordinator hoped that the new environmental management strategy by the environmental committee could be presented, discussed and approved at a management seminar in the autumn of 2002. The safety manager and the environmental coordinator regularly informed the employees by articles in the

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staff magazine and distributed minutes from meetings in the safety and environmental committees by the hospitals internal information networks. Notable observations The following observations are extracted for the purpose of analysis, based on the theories of previous chapters. Policies, aims and demands Impressive project oriented development work and green account activities were seen as a result of committed members of the local environmental committee, based on systematic mapping, planning and priority of interventions and by support of environmental expertise. Environmental aims was not a very visible part of a new overall hospital strategy and aims, despite a rather intensive focus on environmental issues at county and hospital level for years; and though the aims were rather detailed and specific concerning operational issues of the hospital services. Management and participation A rather detailed level of problem solving at the hospital administration level indicates a weak decentralisation of initiatives and competences within environmental management. A centralized environmental management structure in a culture, which has a tradition for decentralization and local ownership and responsibility, might be a problem of improving environmental performances locally. Enforcing the local safety representatives to be environmental contact persons without motivation or compensation created resistance towards integration of environmental management activities within the local safety organisation. Working environmental issues and integration Integration of environmental and working environmental issues were seen to be obvious at departmental level, but not at the hospital level, because of differences in expertise, legislation and the amount of issues to bee handled by the managing bodies. The environmental coordinator and the safety manager worked closely together and they both stressed the need of local ownership, participation by managers and employees and the need of a hospital strategy with increased focus on realistic interventions. Environmental issues and integration An intensive (theoretical) course activity did not motivate local activities in the field, no specific obligations was connected to the participation in the course – more practical education in handling of environmental issues was thought to be needed for further interventions locally. Work on green accounts had not improved the focus on several basic problems of environmental legislation and regulations, which was now done as result of working on a more systematic environmental management system approach. Sustainable development and others

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Economic incentives might have been a major reason for hospital management interests in the field of environment, while they did not seem to give much attention on the issues in the overall strategy on the hospitals future development activities. Many problems are related to the use of indicators. These are related to many different aspects and reasons for changes within the organisation, by which many are not closely related to environmental improvements, and for those reasons indicators are difficult to specify within a relevant form. Considerations concerning the respondents and the case study at KAS Gentofte The case study was mainly based on interviews with only 3 key persons, who had been employed at the hospital for less than 2 years and a document review, which had limited value because of lack of knowledge of the organisational processes in the hospital, the picture drawn on organisational development processes as result of environmental management efforts at KAS Gentofte, might for this reason to some extend be rather imprecise. The historical dimension is missing, and employees and managers from the departments were not among the interview persons. Any way the 3 key respondents were very centrally located, and as newcomers they was able to see things, which the more experienced staff might have been blind of. As newcomers they are probably rather critical, impatient and enthusiastic about their work. As the vice-director and the environmental coordinator stressed many results were achieved and members of the environmental committee found, that great improvement was done within the last couple of years. I found that the respondents were very keen on their tasks, and much aware of the further needs of improvements and on the problems of implementation and as such they have given a rather truthful and useful picture of the situation at KAS Gentofte concerning the topics in focus. 5.5 Case – Fredericia Hospital (Fredericia Sygehus - FS) in Vejle County Introduction This case study is based on interviews with 4 key persons related to the issues of environmental management and working environment at Fredericia Hospital (FS) and a minor document review. The respondents were the environmental coordinator and safety manager, chemical engineer with several years of experience in environmental management and quality management in private industries, employed at FS since august 2001, technical manager, who was the previous safety manager and one of the initiators of environmental management at FS, a nursing assistant from department of dialyses, environmental contact person in the department and a clinical photographer from department of radiology, who was environmental contact person in the department and environmental auditor, member of the auditor team at the hospital. Occupation, department of the interview persons and a list of documents can be seen in Annex III. The hospital director and the environmental coordinator / safety manager have confirmed the following case description. The organisation FS in Vejle County is a general hospital of approximately 200 beds and about 600 employees. The hospital treats around 10000 in-patients and patients at 40.000 ambulatory visits and 28.000 dialyses per year. The organisational structures is like most hospitals with a hospital management, the patient services delivered by 5 clinical departments, 3 clinical diagnostic departments, 5 service departments and administrative offices, in all 13 departments of the organisation.

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The hospital environment- and safety committee consist of 6 members, 2 representatives from clinical and 2 from service departments, the manager of hospital administration (chairman) as representative for hospital management and the safety manager / environmental coordinator. At department level the environment and working environmental work is integrated within the 18 environment- and safety groups in which a local safety manager from the department management and one or more local safety representatives and /or environmental contact persons are responsible for the local environmental and safety work FS was the first hospital in Denmark implementing an environmental management system, which was certified according to the ISO 14001 standard in 1998 and was re-certified in November 2001. The hospital is working for registration under the EMAS Scheme in year 2002. The work on environmental management was integrated within the environment- and safety organisation since 1998. Aim and strategy The vision of Fredericia Hospital (FS): Patient first – patient and employee charter, is based on principles of values, participation and responsibility as keywords within health care, services and management processes at the hospital. A number of specific aims and strategies are laid down within the overall concept of the vision and within achieved results of treatments, job satisfaction, development of staff competences, and environmental management responsibilities. Within environmental management it is the aim keeping the ISO 14001 certificate for a second period of 3 years, continuously improving the environmental performances and working on EMAS registration of the environmental management system. Within the aims of a healthy and safe working environment strategies contain a project focusing on the psychosocial working environment at the hospital and continuing development of working methods related to working environmental issues within the integrated environment- and working environment management system. Besides this environmental and working environmental issues shall be given high priority within the planning processes of a major renovation and reconstruction plan for the hospital. Vejle County has an environmental policy since 1995 on promoting an environmental sustainable development and has for many years been a frontrunner in environmental issues partly through intensive development work within the county institutions and partly through the support and close cooperation with environmental committed partners in Green Network, a voluntary cooperation between private companies and local authorities in Vejle County and Middelfart Municipality. The county worked out an environmental statement and account for the most environmental polluting institutions every year. A number of specific environmental aims for the year 2001 were laid down; among others implementation of certified environmental management systems at all major county institutions. Other areas of improvements were reductions in consumption of energy, water, heat and waste and intensified use of recycling materials, besides arrangement of seminars, courses and dialogue with institutions and employees. A special focus in 2001 was on chemicals, where the county demanded a stop for the use of environmental harmful materials in cleansing agents at 23 major county institutions. The environmental policy of FS is within the aim of the county policy: • Evaluation of environmental aspects of operational activities and systems

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• • • •

Environmental prevention and reductions of resource consumption and waste Purchase of environmental friendly products and services Improvement of environmental consciousness among employees and training and education of employees in prevention of environmental pollution Fulfilling relevant legislation and regulations on environmental issues, as well as recommendations by Vejle County.

FS also has a working environmental policy: • Evaluation of working environmental aspects of operational activities and systems • Improvement of consciousness on working environmental issues and training and education of employees in prevention of working environmental problems • Working for a good physical and physiological working environment • Working for connection between working environment and personal policy • Fulfilment of relevant legislation and regulation related to working environment The hospital are working on implementation of a working environmental management system in accordance with OHSAS 18001 in 2002, but so fare the hospital management has not decided if they want to apply for certification of this system. Environmental issues The areas of environmental interventions according to the environmental statement and account 2002 is within construction of new facilities, consumption of electricity, water, heat, oxygen and laughter gas, washing clothes and cleansing agent, chemicals for radiology, paper, waste, food, medicine, oil spill, purchase, service delivery from external companies, and local departmental environmental improvements within consumption of tin foil, medicine trays, garbage bags, reusable cups and paper. By data collection on a number of indicators they follow the environmental performance and compare those yearly since 1996 on a datasheet. Within purchase the purchasing office has safety sheets approved by the environment- and safety committee on all products within the purchasing database, and in need of purchase of new products these have to be environmentally assessed by the environmental coordinator and eventually the committee before they become part of the purchasing database. The environmental issues related to medicine, especially to discharge of wastewater has been discussed, and the pharmacy registers the daily doses of medication for all in-patients at the hospital. Partly for this reason and as result of sampling of all wastewater with fixer and developer from the radiology department the municipality has no longer demands on analysis of the discharge water from the hospital to the public sewage system. At the department of dialysis they have invented a system of heat-converters on the dialysis – machines, which has saved a lot of energy, and a new system of scorching sources while serving the dialyses patients, has reduced the amount of hazardous waste enormously. Besides this the radiology department is engaged in implementation of a new quality management system related to a new EU regulation on radiation, in which the local environment- and safety organisation is also involved. The aims for environmental improvements 2002 are specified with actions plans, control points, responsibilities and deadlines within construction of a new urology ward and a new ventilation system, reduced consumption of energy related to new activities and by staff behaviour, reductions

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in consumption of heat by installation of new windows and by information to staff, reductions in water consumptions by information to staff, reduced amount of waste by improved pre-sorting of waste, purchase of more green products, if possibly without PVC, and increasing the amount of ecological foods to 40 %. Working environmental issues The major working environmental issues in focus were results of the work on WPA´s (work place assessments). Since 1999 83 WPA´s has been fulfilled and within 2001 another 110 new WPA´s were registered and the problems was categorized within 6 categories: physical, ergonomic, chemical, biological, accidents and psychological. The three major problematic areas are physical working conditions, which are often difficult to solve without major renovations and investments in reconstructions, injuries as stitches by needles and psychological working environment with stress symptoms, which are often not found by WPA´s. The Work Inspectorate classified the hospital as a grade 1 organisation as a result of an adjusted inspection in 1999. A grade 1 organisation is assessed doing an active effort in improving the working environment. The working environmental aims, action plans, control points, responsibilities and dead-lines for 2002 is laid down within prevention on back injuries, reduction in needle stitches, assessment of the psychological working environment and implementation of a working environmental management system along OHSAS 18000. A specific project on psychological working environment has been implemented and is a major focus area of working environmental performance in 2002, while an experienced nurse with a working environmental education are engaged part time to the end of the year working on an improved efforts in this field. Integration Going from the project phase to implementation of an environmental management system along ISO 14001 in 1998 they decided to integrate the environmental work within the safety organisation and formed the combined environment- and safety organisation with one or more local environmental contact persons and safety representatives in each department. The environmental contact persons can either be the existing safety representative in the department or another employee, who are engaged in the improved efforts on environmental performance. It differs within the departments whether they have a combined environment- and safety representative or this task is divided between two or more employees in the department, but the representative from department management is obligated to be combined environment- and safety manager of the department level. The environmental contact persons are working closely together with the safety representatives in areas of interdependency and the environmental issues is discussed both at safety group meetings and at staff meetings in the departments. The aims, action plans and responsibilities within both environmental and working environmental improvements are made once a year by the environment- and safety committee and are approved by the hospital management, and followed up at meeting 4 times a year with hospital management. Implementation The environmental development work at FS was initiated as a pilot project by the county, but was primarily developed and implemented by local activities and commitments at FS. It started as a project with focus on environmental performance, and later on it was decided to strive for certification by ISO 14001. Using the standard concept of ISO 14001 improved the efforts with more specific demands on policy formulation and documentation, and a systematic implementation

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and follow up by use of internal audits in the departments. Mainly enthusiastic managers and employees within the environment- and safety organisation ran the activities, among which the hospital director personally was very much engaged and supportive. Continuously they try to motivate more employees to take part in the work by general information on environmental issues and by enforcing participation in the local environmental and working environmental activities. As a policy all suggestions on improvements or problem solving is to be taken seriously under discussion in the environment- and safety committee and given a written response with reasons for rejection in case the proposals are not being followed. The most resistance was among some of the department managers, who were not given extra resources for the improved efforts in the departments and who are more focused on the health care activities for the patients in the departments, and for those reasons not always can see the relevance of the environmental management activities. Related to the county environmental policy, aims and green account the environmental coordinator send in data for the environmental performance at a number of indicators. The county has no formal groups or coordinating bodies within environmental management of the hospitals or any other follow up on performances, it is a duty of the local management implementing the county environmental policies and aims. The environmental coordinator and the technical manager stress that it is a problematical issue setting very specific targets on improvements on environmental performance at a county level, i.e. as a certain percentage of reduction in energy consumption, waste or a like. Environmental improvements have to be measured closely related to the specific activities and the changes of those. Targets shall be related to the specific local conditions, depending on how much had previously been done on improving environmental performances and when investments in new technology are needed improving performance further. They found that general county or national targets and comparisons on indicator between institutions are often like comparing apples and peers grown under different conditions. The environmental coordinator and the technical manager both stress the need of doing a rather detailed environmental survey and some specific analysis on the systems and flow of activities of the organisation as basis of making plans and strategies with priories within the hospital environmental management system. A detailed study was done in 1996 –97 which had been the basis for planning of interventions in the following years, but now they need to do another detailed study before new inventions can be planned for the coming years. At department level the local environment- and safety groups are responsible for making local environmental action plans based on the results of the local WPA´s and the internal environmental audits, which are done in all departments once a year by a group of internal auditors. The technical manager found that it is a major driving force of implementation working with broad scale participation of the employees, as their daily work on the floor has great effect on the consumptions and they are going to follow the systems and regulation of environmental management in their daily activities. If they are closely involved and their working conditions are respected and taken into consideration in the development of new interventions and systems most employees were seen to be positive towards environmental management. “We are properly some of the tough ladies, who do not hesitate to tell our colleagues how to follow the new systems. The basis of the local environmental work is properly the economical fiery souls”, one of the environmental contact persons said.

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The environmental coordinator found that the driving forces among the employees properly was mostly related to the working environmental issues and the environmental issues affecting the working environment, but more and more employees also seemed to worry about the environmental issues more generally. He find that managers are basically concerned about fulfilling the legislation and regulations and some are for different reasons more than others willing to do efforts on environmental improvements within the limits of the available resources, which are often the restriction of improvements. The budgeting procedures at hospitals are a problem, as the running costs and investments are looked upon separately. Many environmental improvements are economically reasonable by investment in new technologies and other types of investments within a number of years. Within the possibilities of the hospital budget FS have invested in new electric lamps, small freezers for storage of patient food in department kitchens and others. Major investments in more environmental friendly equipment at the hospital had to be decided at a County Political Level and is often challenging with the purchase of new medical equipments. Generally the awareness of environmental issues was raised related to the purchase of all sorts of new equipment for the hospital. Monitoring and control The most effective means of monitoring and control of the environmental management system and the improvements were done by the use of internal and external audits. 8 people at the hospital have been educated as auditors, and once a year an internal audit are performed in all departments by a team of 2 of the internal auditors. At the internal audits the local policies and procedures are examined, the performance are assessed and the staff are asked questions related to environmental issues and praxis’s in the department. The internal audit in one department takes about 1-1½ hours and is followed up by a small report on major findings from the survey. This report is given to the local environmental- and safety committee for the purpose of planning and follows up on procedures and to the central committee for information. The internal auditors do not make audits in their own departments, and changes between departments doing audits after each internal audit session. Besides auditing on the local performance, data is collected regularly on environmental indicators and discussed at meeting in the environment- and safety committee and with hospital management trying to keep the focus on as well the performance, the improvements and the results. The hospital makes an environmental account once a year including the local accounts from each department. The environmental coordinator stress that a systematic approach on procedures and processes is needed to obtain results of the efforts. Evaluation and organizational learning As monitoring and control are done by internal audits basically a continuous process is going on with the intensions of keeping focus on environmental performance, improvements, spreading of ideas and inspiration around in the organisation. Twice a year the external auditing bureau makes a survey of the overall environmental management system and a random test of the performance in some of the departments. The external audits are followed by a report on the major finding and advice for improvements. Every 3 years the total environmental management system go through an external audit and the hospital can be re-certified in case they still fulfil the standards and have shown improvements since the last audit for certification. FS was re-certified in November 2001.

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Basically the external audits have not brought much new knowledge into the work, and it have been discussed whether it is worth the money paid to the external bureau. But for reasons of credibility and security of keeping focus on the environmental efforts within the organisation it was seen as necessary continuing external audits and the certificate is thought to be useful in the eyes of some patients and external cooperating parties. Communication and cooperation Internal audits, environmental statements and accounts and continuous distribution of information to the employees in the staff magazine seem to maintain engagement. The new staff is introduced by the environmental coordinator about the general aspects of environmental management and working environment at the hospital, and by the local environmental contact persons and the safety representative introducing the local environmental handbook with politics, procedures and systems to be used locally. The auditors have a meeting 4 times a year arranged by the environmental coordinator sharing experiences from audits and other general questions related to environmental management. Besides this the auditors and environmental contact persons are invited for seminars and courses on environmental issues arranged by the county. The environmental coordinator is member of a national network of environmental coordinators at Danish hospitals, which has started recently. Support by the local management is seen to be essential for the local work on environment and working environment, and for this reason it is stressed as very important that the hospital director has been very much supporting the work since the beginning. The environment- and safety organisation are involved in assessment of all new care- and diagnostic procedures in the departments from an environmental and safety perspective. Notable observations The following observations are extracted for the purpose of analysis, based on theories of the previous chapters. Policies, aims and demands Environmental policies and aims at county level seemed to be rather advanced, specific and directive promoting local environmental management activities. Use of a certified management systems approach along ISO 14001 and EMAS was seen as an effective mean of achieving results in the environmental management work at the hospital. Management and participation Though the county took the initiative, it was local commitment based on intensive employee participation and strong support by hospital management that gave results in the implementation. Economic minded fiery souls, personally motivated on environmental issues, were important driving forces in implementation. Several of those were actively working as environmental contact persons and were not interested being safety representatives as well. The use of internal audits done by devoted employees seem to be a good method of keeping focus on implementation and spreading of ideas and experiences between departments.

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Working Environmental issues and integration Integration of environmental and working environmental issues were done within the structure and systems of a combined environment and safety organisation at the hospital, but the 2 topics were handled separately, and activities were often handled by different staff members in the departments but integrated within the local environment and safety committee. The focus on working environmental issues was increased within the last couple of years, and especially within psychosocial working environment for the year 2002. Environmental issues and integration Some activities within the work as environmental coordinator demand a rather specialized knowledge related to environmental legislation and regulations, administrative procedures, green purchase policy functions, handling of hazardous materials etc., which indicate the need of environmental educated resource persons in the field. A municipal campaign on pre-sorting household waste motivated the implementation efforts among the staff at the hospital in this field as most staff came from the local community. After some years with of strong focus, high motivation and many new activities it seemed to be difficult finding new areas of improvements in the environmental activities locally. Sustainable development and other issues The concept of sustainable development was slightly know by the interview persons, mostly related to international environmental politics and some how to an understanding of problems of pollution and exploitation of nature resources. The employment of a fulltime environmental coordinator and safety manager, experienced chemical engineer, and a working environmental educated experienced nurse half time, at a rather small hospital, show a high priority of those as strategic important element of hospital management and hospital services. Considerations concerning the respondents and the case story The case study is based on interviews with 4 key persons, who are closely involved in the work on environmental management activities at FS, the pictures of the organisational processes might for this reason be drawn more positive and well functioning than it would be, based on interviews with respondent with a broader and more distinct relation to the activities. 3 of the respondents have been employed at the hospital for many years but the environmental coordinator and safety manager was newcomer without any experiences on working within hospitals. He had many years of experience in the field of implementation of environmental and quality management systems in chemical industries, which might influence his judgements. I find the picture is missing some aspects and issues seen from the point of view of the clinical management in departments, which might have given a broader understanding of views of the local environmental management efforts and results, and the perspectives of integration aspects.

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6. Adductive analysis and conclusions based on case studies in the field 6.1 Introduction In this chapter I analyse and discuss the questions of the problem formulation in relation to the 3 case studies of this project and the findings and recommendations from research based on case studies in other sectors at an institutional and organisational level. I begin the chapter by giving a generalized characteristic of the 3 case hospitals as proto-types or models and continue analysing the findings structured within the central themes of the project and related to the questions and sub questions of the problem formulation. In the next chapter I analyse and discuss the empirical findings in a broader context at a sector and society level related to the presented theories of the project as basis for the final discussions and conclusions. 6.2 General characteristics of the 3 case studies of this project If I should give a generalized characteristic of the 3 case studies as proto-types or models of management systems, which is commonly used within the field of management of organisations, I would call them: • • •

The Concept-driven Development Model at RASK The Economic/technical administrative Model at KAS Gentofte The Environmental Management System Model at Fredericia Hospital

The reasons for choosing those names are related to the general scope of management thinking and practises within environmental and working environmental issues at the three hospitals as I see them, based on the case studies. At RASK the overall development strategy of the hospital follow the ideas and concepts of an integrated management model called Balanced Scorecard, based on visions and specific target setting and the use of operational agreements including strategic development initiatives. It seem like they work within the intentions of this concept in their efforts of improving quality, patient service, prevention and health promotion, economic efficiency, working environment and other management areas at the hospital. They had not so far done much in the field of environmental management, but the case study is interesting anyway looking at what happens within their field of working environmental improvements, and their work on integrating this as part of a strategy on prevention and health promoting activities at the hospital. They are committed within the development strategy to improve the environmental work on behalf of the employees and expect to do this within an integrated management approach especially related to integration with the prevention and health promoting activities at the hospital. At KAS Gentofte they are among the first hospitals in Denmark focusing on the environmental issues. They work project oriented, making intensive analyses and impressive green account activities, first of all focusing on the economic and technical aspect of environmental improvements by means of administrative rational management methods and thinking. They seem to have problems integrating the work of environmental management as part of the general management priorities and within the organisation as such but the environmental committee is aware of this and work on a more integrated approach. Depending of their success getting environmental management a more fully integrated part of the general management priorities and systems by change in priorities and attitudes at the hospital, they might end up continuing environmental

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management as what is being called a ‘sidecar activity’ within the organisation (Kamp, A 2001). No initiatives or thoughts were seen related to integration of the work within quality or service management issues at hospital level. At Fredericia Hospital they were the first hospital in Denmark implementing an environmental management system along a certified management approach. By use of ISO 14001 they seem to have success implementing environmental management as an integrated system of environment and working environment through out the organisation. Their system is integrating environmental- and working environmental structures and systems by means of a mixture of several methods based on values, system thinking, learning techniques and continuity in their efforts and by a combination of central and local environmental development activities. The hospital recently passed their second ISO – certification and is now working on EMAS registration of their environmental management system. They seem to be running out of organisation wide commitment at the moment finding new areas of focusing within the field of environment and are intensifying their work on working environmental issues along the concepts of OHSAS 18001. Their future challenges towards sustainability seem to be working on further integration of the work to management systems within quality, patient services and prevention and health promoting activities. 6.3 Analysis and discussions on empirical findings related to the themes and questions of the problem formulation Values, strategies and methods Environmental concern has not been of high priority on the political and managerial agenda within hospital management in Denmark or internationally. The dominating discourse within this sector for the last 20 years has been on economic productivity and efficiency and at the moment increasingly on quality; service and risk management issues within patient care activities. As the general discourse on ecological modernisation and sustainable development has emerged in society some counties and hospitals seem to have taken up the challenge of the environmental topics and with different focus and means worked on environmental improvements within the last 5 - 7 years. Mostly project oriented improvement activities have been seen and only rather few hospitals have implemented environmental management system within the hospital organisations as such, but several others are on the way based on obligations within county environmental policies and indications from formation of a network of hospital environmental coordinators. Even though hospitals are service organisations with limited or no production processes, it was seen within the case studies that they have great potentials of savings and environmental improvements within areas as energy consumption, wastewater treatment, use of ecologic foods, registrations of medicals, reductions in use of chemicals and other substances harmful to the environment. Some of the environmental effects were related to consumption of materials produced within other sectors of society and the environmental harm relates to running of buildings and housing facilities, laboratory processes, treatment and medication of patients and handling of waste and emissions from laboratories and housing facilities. As consuming actors they are indirectly influencing the production of more or les environmental harmful products, especially product that are only used in the care and service processes, and for this reason environmental politics at hospitals in a sustainability context should handle many environmental problems within a life cycle perspective. Both KAS Gentofte and Fredericia Hospital had strong focus on purchasing policies, and as public organisations they have economic potentials of influencing the supply and demand of green

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products and the development of cleaner technology within medico-techniques, especially is this was done nationwide. As major public consumer organisations hospitals could be said to have a certain political environmental responsibility using this means, but as seen from several of the examples related to economic expenses it seems at present to contradict the economic priorities within the hospitals as expenses are rising buying ecologic and environmental harmless products. KAS Gentofte and Fredericia Hospital realised as part of their environmental work that they had several obligations fulfilling environmental policies, laws and regulations like all others enterprises in society, that they were not aware of, which support the need of implementing environmental management instrument in purchase policies, in reductions and use of harmful materials and substances and in their handling of wastewater and hazardous waste related to hospital services. In clinical laboratories and technical departments with the most production oriented processes and responsible for the use of the presently known most polluting substances it seemed to be part of the professional thinking and responsibility of managers and staff caring about as well environmental as working environmental issues related to harmful substances, and several improvements were initiated, even at RASK without an environmental policy. Based on case studies of 2 of the hospitals it seem like the most obvious focus areas of environmental improvements as a starting point are within: • Energy consumption • Emissions of wastewater • Use of chemicals • Handling of general and hazardous waste • Purchasing policies • Use of environmental harmful materials and substances • Working environmental issues related to environmental issues 2 of the case hospitals could be seen as frontrunners within the field of implementation of environmental management. Even though their environmental activities were initiated as county projects 4-5 years ago, they both seem to have developed and continued their activities, mainly on behalf of local enthusiastic managers and employees within the organisations, given only limited support or attention on implementation and results from the county political or administrative management so far. Indications of an emerging society environmental concern and an increasing effort on implementation of environmental management instruments within hospitals can be seen by county environmental policies demanding their hospitals implement environmental management systems and green accounts, public discussions and research on possible harm related to the use of PVC, Phthalates and other materials and substances in hospitals and the fact that 10-12 environmental coordinators from the environmentally most aware Danish hospitals recently formed a network, sharing experiences of their work, show an increasing environmental activity at hospitals in Denmark. At the institutional level it seems like county environmental policies, aims and project support are useful means of initiating the activities, but implementation of environmental management at the hospitals are basically needed to be a local management activity run by committed and knowledgeable managers and staff members as the major driving forces of implementation. As the strategic management of hospitals basically is a concern of the county political management, they

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must engage and set the priorities including the money for an improved effort within environmental management and the working environmental field as essential part of the overall county strategies and aims of hospital services. They must do so based on values in a way that promotes and respect the need of local ownership and local development and implementation at the organisational level within the individual hospitals. Devoted top managers and a broad participatory approach by committed employees from the ground staff and middle management seem to be the most necessary elements related to implementation. It also seem to be essential that values and attitudes towards environmental issues are made part of the overall vision, aim and strategy of the hospitals, and that those are accepted by department managers and employees. Targets and strategies must be realistic and specify expectations and local obligations on environmental issues within a clear priority of economic resources, securing priority of the topics. A systematic and continuous follow up based on hard facts, use of internal audits and dialogues within as well the management group as the employees are seen to be effective from the case study at Fredericia Hospital. Dealing with environmental legislation and regulations, mapping and planning of the environmental improvements need special competencies in the field of environmental management. Besides this opinion formation, training and instructions of the employees and local managers within practical oriented environmental management is needed. Experiences from the 2 case studies showed that environmental mapping as basis for planning processes and priority of interventions with focus on as well short-term results as long-term interventions were needed. As knowledge about the environmental issues are often limited within hospital organisations, and as specialized know how is essential if the hospitals are going to implement environmental management systems, they need to engage educated specialists or educate and point out a responsible staff member. The environmental management responsible person needs to be close to the hospital management. Professional educated staff within environmental and working environmental topics is needed, as both areas require expertises and competences within those fields. Increased use of resources seems to be necessary, but seen from 2 of the case studies some of the resources return as economical savings within reduced consumption, environmental duties and pollution taxes. Integration of environmental management and working environment Related to integration aspects of environmental management and working environmental issues it seems as if experiences from the case studies at the 3 hospitals are in accordance with the results and recommendations from the study by Anette Kamp (1997), by whom the integration issue is illustrated as a ladder, consisting of two parallel systems with a number of bridges in between for integration purposes. Related to Annette Kamp´s recommendations on employee participation in implementation of environmental management al the way from formulation of visions and aims, problem formulation and to the choice of solutions, this study some how ends up with familiar conclusions. It seems like integration of the environmental management work within the existing safety organisation is found obvious at the local level, partly because of the existing organisational structures in this field and partly as many environmental and working environmental issues are interrelated, especially at the department level. As seen from the case study in Frederica Hospital and at RASK even though some environmental issues do not directly affect the occupational health and safety conditions, changes and implementation of new technology on dialyses-machines, new working processes related to pre-sorting of waste in the departments and new systems related to environmental improvements of reductions in wastewater from the laboratories most often influences the local organisation of the work and as such anyway are being discussed by the local

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safety organisations. As the case – studies showed, not all safety representatives found it obvious, that the environmental work should be part of their activity and responsibility, why it seemed to be useful in some departments to enlarge the safety organisation with new environmental contact persons, specialising in the environmental work in the department and securing the coordination and cooperation with the safety representatives on specific and relevant issues. For those reasons integration could be recommended as a rational structural solution with advantages like fewer organisational committees and meetings to join for the managers. From an effectiveness point of view coordination of interrelated topics are done within the same forum and meetings, and discussions of interrelated aspect can be taken at the same meetings. From a participatory and efficiency point of view it can be a disadvantage using the existing safety organisation members in the environmental work, unless it is secured, that commitment on the environmental issues exist among those and the needed time to work on both topics by devoted employees and managers are being used. Otherwise the safety organisation for good reasons should be enlarged including devoted fiery soils within the staff members, and the intensity, time and management priority of both topics anyway have to fit the needs. This requires education, training and change of economic management priorities based on new values and attitudes including environmental concern as an essential part of the organisational and management responsibility. Environmental management and working environment are still to be handled as two separate topics within one organisational framework as policies, laws, regulations and institutional frameworks are separated at the society level. The employee concern and commitment of participation are, for good reasons, seen to be easier related to the working environmental issues and only for some so far they see it as an obligation related to general environmental concern and consciousness based on personal values and attitudes towards environmental protection and prevention within society. As the working environmental issues properly always will be given a higher priority in hospital organisations, because of the labour intensive work processes, it seems reasonable working on integration of the environmental improvements within or by enlarging the existing safety organisational work, or eventually by implementation of an environmental management system parallel to and partly integrated with the safety organisational work. It seems not reasonable to believe, that implementation of an environmental management system by itself will be successful, as it need a new organisational structure through out the organisation, separately dealing with environmental issues, by which a great number of issues anyway have to be coordinated and integrated at the department level. From the case studies it is found necessary within the integrated approach to keep an increased focus on both topics within the hospital safety organisation, as not all issues are interrelated. Psychosocial working environmental problems as stress and others probably have to be handled separately and are seen being handled integrated with the joint committee work at 2 of the case study hospital. FH is integrating the committee work within both environment and working environmental issues at the organisational level and is doing this in accordance with an environmental management system approach. KAS Gentofte is keeping the work in the environmental and working environmental committees separate at hospital level, securing the coordination and integration by the cooperation of the environmental coordinator and the safety manager, while they integrate the work at department level. Possibly there is no best solution to this structural issue, but integration, coordination and a combined priority of improvements within both fields seem to be beneficial for both areas by integration efforts.

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Barriers of integration As seen from the case studies it was found to be difficult motivating the clinical department managers, as their primary focus lies on quality issues, patient services and to some extent on economic aspects of the hospital care processes. This indicates the need of environmental management strategies that integrate this issue within the working environmental work and the quality, service and economic management work at the hospitals. The professional oriented culture within hospitals basically seems to delimit their responsibility from the environmental field as this is seen and understood within the present environmental discourse in society, but the awareness exist among some of the employees and a rising focus on the possible connections between environmental and working environmental issues and health problems are seen. From interviews of 2 physicians at RASK I got the impression that health professionals find that responsibility of environmental harm and risk reduction should first of all be taken by the suppliers, and it is seen as a co-responsibility of the political and environmental authorities and the industries controlling, whether the products used in hospitals are environmental harmful or not as mentioned in the stakeholder relation model. Anyway, it was stressed, that if physicians were aware of any possible harm to the patients by use of products or substances in care processes, those would immediately be eliminated or controlled by responsible health professionals on behalf of suspicion. The main priorities at hospitals are related to cure of acute and scientific recognized diseases on humans based on a medical scientific understanding of course and effects relation. This scientific oriented culture is dominated by natural science perspectives and by a limited focus on cause and effect relations between environmental pollution and human diseases, although this scientific field is advancing slowly within certain areas, as mentioned about the Danish environmental medical research centre. The emerging focus on quality and service issues and risk management related to malpractices of health professionals indicate a rising awareness of patient and public pressure and can be seen as a reaction to an increasing managerial interference of the professional organisational processes at hospitals. As new research and developments within those areas are being expanded to the environmental management field, it might be expected that at change in the professional attitudes, awareness and priorities of environmental prevention related to materials and substances in use in hospital care processes might change, and the professional groups of physicians and nurses will support a higher priority of environmental management at hospitals in the future, depending on development of the environmental discourse in the society within this field. Implementation and use of management systems Based on the case studies it seem like recommendations by Jørgensen and Remmen (1995) on design criteria for environmental management within industries to some extent might be useful within hospital organisations as well. The main differences are related to the need of an even more increased focus on environmental effects seen in a life cycle perspective, as the prevention efforts have to be seen and handled in a collaborating stakeholder perspective. Seen from the case study at RASK development of alternative more environmental friendly products and use of ecological materials and equipment traditionally are being judged within strict professional quality, work effective and work environmental perspectives within the care processes before environmental concern are being accepted and given priority. The environmental harmless or ecological materials and products might not exist and have to be developed or might not fulfil evaluations equivalent to quality and effectiveness of non-ecological or more environmental harmful products. The extra cost for those new products must not exceed the cost of competing products in the market too much, as

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the environmental discourse is at the moment within the professional dominated culture and the political and administrative economic priorities of the hospital sector. The use of an environmental management system approach, like ISO 14001 and EMAS was at Fredericia Hospital seen as a useful instrument getting around all relevant areas of intervention and were seen as useful enforcing as well a systematic follow up and documentation of results in an area which normally was seen as marginal in the organisation. It enforced the use of a rather broad participatory approach within a management system based on local activities and learning principles by use of internal audits. The commitment for certification or registration and hereby demands on use of external audits on the environmental management system as such, was seen as valuable in keeping on the focus and the continuity of the work on improvements throughout the organisation. Even though it was difficult to create general employee commitment towards environmental issues at both Fredericia Hospital and KAS Gentofte, it seemed like the general attitudes and support among the employees were mostly depending on management priorities of the needed time for involvement in activities and that implementation of new processes and systems locally were done on behalf of involvement and in a way that did not make the daily work processes more troublesome or stressful. Even though I know by experience there might be resistance towards the use of certified management systems like ISO and EMAS within the professional culture of hospital staff, I find from the analyses of the case studies and the readings of the EMAS demands, that those are very supportive on implementation of environmental management systems based on theories and knowledge on principles of possibilities for success in implementation of changes in organisations. The fear of implementation of a new bureaucratic paper based management system is still relevant and the efforts and resources used on implementation of an environmental management system should be judged related to the benefits, but if the intentions of the EMAS demands are understood by as well managers as employees and the process of implementation is managed professionally from vision and policy formulation, through environmental mapping, planning and priority, fulfilling participatory improvement projects locally, use of internal audits, follow up on procedures on improvements and continuously setting of new realistic targets the possibility of success in the work seem to be large. The conclusions and recommendations from the project on use of EMAS in Municipalities and Counties (Rømer, V. et al. 1999) equivalents the findings of the case studies of this project. It seems to be essential that political and top administrative management are positive especially the hospital management plays an important role in this respect, while the hospital organisations themselves are going to be one of the major driving forces in development and implementation of environmental management at the individual hospital in accordance with the existing organisational frameworks and the existing management systems at the hospital but based on new environmental values and attitudes. Working on possibilities of integrating environmental management within the efforts of quality and service management and endeavour securing continuous improvements, employee participation and opinion formulations processes seemed to be needed even more intensively within the professional culture among the hospital staff and within the traditional economic / administrative dominated management culture of the hospital management.

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Based on the case study of Fredericia Hospital the basic reasons for success or failure in implementation do not seem to be related to the choice of structural solutions of implementation, but merely relates to the commitment of top management and the use of a participatory approach based on processes through out the organisation working on small development projects initiated locally combined with a management system approach of continuity, follow up and use of organisational learning instruments like internal audits, action planning and environmental accounts. That the “Management learning strategies is about managing implementation processes from aim formulation to received results” (Kamp, A. 1997) are seen to be very important within hospitals, as public service organisations, where the processes are labour intensive and the values, attitudes and behaviour among employees to a great extent has to be taken into account obtaining results. Sustainable development The words sustainable developments are mentioned in some of the environmental policies at county and hospital level but were slightly known and hardly understood by the interview persons. Understandings of the words were mostly related to a general society and international political understanding of environmental issues. Nobody referred to those words as important within their understanding of environmental problems or environmental management at the hospitals and asked whether they found the words useful in the future discourse on environmental improvements at the hospital, most of the interview persons were hesitative, probably as they did not make the connections between global sustainability and local institutional environmental improvements. Even though the words of sustainable development was not used the meaning of the words in the essence of the Brundlandt Report was the background of the motivation of the environmental coordinators and the environmental conscious managers and employees interviewed in the case studies. As by the study of Zwetsloot (1998) on design for sustainable development, based on integration of joint management processes within environmental and occupational health and safety issues in private enterprises, the case studies of this project support the conclusions recommending integration of environment and occupational health an safety as the starting point on the road to joint management of environment, working environment, prevention and health promoting activities, quality, service and economical management. Joint management approaches are essential when talking about sustainable development. Within hospitals an integrated approach seem to be even more necessary while the strong professional groups of doctors and nurses are were much influential of the care and service delivery process planning and as such environmental value and attitudes have to be part of their professional culture before serious improvement can be expected. For this purpose it might be useful working on making environmental management an integrated part of accreditation of hospitals, as this concept of quality management is emerging, including standards related to other types of organisational, health care and facility management areas of hospital management. As development of the use of accreditation within Danish hospitals might take several years it should be recommended continuing the effort of implementation of environmental management within hospitals. The environmental related areas within the existing systems of accreditation only to a limited extent include environmental management issues, (Joint Commission International, 2000) and anyway will respect existing management systems within certain fields of operations of the hospitals if or when accreditation systems might be compulsory at hospitals in Denmark.

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6.4 Conclusions and answers to the problem formulation and the research questions In this section I will shortly résumé the conclusions and answers to the problem formulation of the thesis: Which values, strategies and methods should be enforced in management of public hospitals if integrated environmental management should contribute effectively to the ideal of a sustainable development? – and what would be the main barriers to such an integration strategy ? Those questions were structuring the analysis and discussions of the adductive analysis, stressing the need of Values as visionary, committed, engagement, result oriented, local ownership, participation, continuity and responsibility were seen as important management values. Strategies and methods of environment improvements through vision and policy formulation, environmental mapping, planning and priority, fulfilling participatory improvement projects locally, use of internal audits, follow up on procedures on improvements and continuously setting of new realistic targets were seen to be effective. Main barriers were seen to be a health professional culture within hospitals that seem to delimit their responsibility from the environmental field, as this is understood within the present environmental discourse in society, which support strategies of integrating environmental issues within quality and service management systems at hospitals and strategies on prevention and health promotion efforts. Some research questions related to this were: What are the main environmental and working environmental problems – and how are these problems presently being handled within public hospitals? Are answered within the 3 case studies. What are the roles and obligations of national and county policies and regulations in these fields? Are being discussed in the final analysing chapter. What would be the potential gains or losses of integration of working environment and environmental management system? and From which perspectives should an integration strategy be valued as a benefit? Are discussed and partly answered in the adductive analysis concerning integration and will be further answered in the final analysis and discussions. What could be the potential gains and losses of using acknowledged certification environmental management schemes at hospitals? Are discussed and answered in adductive analysis concerning implementation. What is the understanding of a sustainable development in this context, and how could this understanding contribute to improvements within this area? Are being discussed and answered in the final analysing chapter.

7. Final analysis, discussions and conclusions

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7.1 Introduction This chapter I start presenting an analysis model inspired by the previous shown model of “ 3 stakeholders and their main interrelations” (page 37) which I will use as an overall framework of analysing the results of the empirical findings and the case studies, the presented theories of the project and the following 5 directing hypotheses: • • • • •

Knowledge about environmental issues and risk assessment is crucial in political, administrative and managerial activities within hospitals as in society. Strategies on risk reduction and prevention of environmental harm on human health based on precautionary principles are going to be part of the hospital commitments. Working environmental and environmental issues are closely related in development of hospitals as their activities create and contain correlating risk. Employee and patient reactions, alertness, attentiveness, consciousness and responsibility are important sources of pinpointing new potential environmental problems and risk and hereby predict the need of interventions or elimination of the use of polluting substances at hospitals. Environmental issues are going to be of increasing importance in health care research and the delivery of care and services, possibly as a part of the quality and the prevention and healthpromoting concepts.

I will finalize the chapter by some concluding statements related to the problem formulation. 7.2 Analysis Stakeholder Model By the following model I focus on the 3 main stakeholders of hospital management, the relations between those and within the 3 main themes of the thesis. In the model I try to combine the society and sector level with the institutional and organisational level in the same model, which for several reasons can be contradictory as analysing model, but having the topic of sustainability in focus at all levels of society I anyway find it relevant trying to elaborate on the relations of the main stakeholders at different levels within this final analyses. The model is to be understood as follows: The 3 types of main stakeholders as institutional actors (A, B, C) and their interrelations are indicated by straight arrows in the figure. The curved arrows indicate the possible synergy processes of the 3 main themes of the analysis.

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Analyses Stakeholder Model: A. Employee / Citizens Working Environment (Management) (Environmental Management)

Sustainable Development (Environmental, social and economic politics)

2. 3.

1.

C. Institution / Hospital

B. Government / County Environmental Management (Environmental regulation) (Working Environmental regulation)

The three main actors play different roles in relation to environmental management, working environmental issues and a sustainable development: A. Employee / citizens expects the government and county taking care of a Sustainable Development of society by political means. A. Employee / citizens demands healthy working environmental conditions and to some extent environmental protection participating in working environmental and environmental management activities. B. Government and county regulate environmental and working environmental activities of the institutions and hospitals in a sustainability context, eventually by demands on the use of management systems. C. Institutions / hospitals cope the working environmental demands of employees and obligations by environmental and working environmental regulations by means of employee participation and eventually by use of management systems. Depending on the strength, commitment and the confidence of each of the 3 main stakeholders solving their individual tasks and fulfilling their obligations the development dynamic will vary: Keeping up the tension and cooperation between these 3 groups of actors promotes a sustainable development by synergy processes! Synergy processes between the 3 three main themes: 1. Environmental management and Sustainable Development Environmental management in a sustainability context enlarges the obligations of institutions / hospitals to areas as social responsibility (working environment) and general society development policies. 2. Working environment and Sustainable Development

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Working environment in a sustainability context enlarges obligations of employees / citizens to environmental management responsibility and general society development policies. 3. Integration of Environmental management and Working environment Integration of environmental management and working environment enlarges joint efforts on improvements of environmental and working environmental issues based on improved employee participation within joint management and political processes. The following analysis is structured along the headlines of those 3 possible synergy processes. 7.3 Environmental management and Sustainable Development This relation is the most obvious looking for synergy processes, as the concept of sustainable development is mostly being used and researched within this relation. Whether environmental management and sustainability can be seen a relevant and synergetic within hospital services is to be discussed in this section. Analysis and discussion related to sustainable development From the case studies the concept of sustainable development seems to be used rather limited at the institutional and organisational level within environmental management at hospital. The concept is mostly being used within the overall political discussions on development of society globally and regional and only recently by the Danish national strategy on sustainable development being related to national and local political aims and interventions based on an integrated approach to economic, environmental and social issues at a society and sector level in Denmark. The concept have been on the headlines of intensive academic discussions and scientific research for more than 10-15 years, but is anyway difficult or maybe even impossible to give a clear translation as an aim or a mean of managing human activities within every day life activities. Looking at the newly published Danish strategy on sustainable development, it is obvious that this is more a discussion paper setting the present governmental agenda on the stage of the environmental discourse, than it is a strategy of obtaining specific goals within the environmental, social and economic developmental fields in Denmark. No aims or strategies within this paper are focusing on specific public sector or hospital obligations. Keeping the concept at this level as a political concept for continuous discussions and interpretations and as basis for local target settings it possibly serves a purpose as an overall guideline and ethical principle, which can be useful and agreeable among most actors and all levels of society. It is hard to disagree. After almost 15 years there seem still to be tension in the concept, whenever somebody try to assess the previous and present development or specify new targets of future developments within specific areas of society as being sustainable. From case studies of this project is seem like Vejle and Copenhagen County use the concept of sustainable development within their county environmental policies, and as background of defining aims and strategies for their environmental management efforts. Within the last couple of years they have approved environmental policies and defined obligations on implementation of green accounts, green targets and implementation of environmental management systems as instruments within the county activities, including hospitals as major county institutions, but given a limited political priority and follow up on results. For this reason I find that the present use of the concept at county level mostly align with theories of ecological modernisation as cultural politics, by which aims and strategies of sustainable development are seen as ‘story lines’ or frameworks within the political sphere of continuing political society discussions on environmental issues based on awareness of increasing uncertainties and risks related to a devastating environmental development.

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Hereby they aligned with Jänniche (1989) open up for juridical, political and economic possibilities of self-regulation and innovation within consensus building of the parties involved at hospitals, without specific strategic interventions on certain issues within the environmental field. It is hereby a local obligation how much and where to intervene on the environmental management arena. A strategy, that according to Jänniche seems to be relatively successful at the society level within environmental improvements, but must be seen as very much depended on the future organisational discourse within hospitals in Denmark. Analysis and discussions related to environmental economic theory Sustainability as an environmental economic concept is calling for the needs of political interventions in the market mechanism trying to manage economic resources with respect of environmental effects from production and service systems. In discussion on sustainability as a goal of environmental management in hospitals, is was noted above that hospital management is mainly a matter of managing and developing quality of patient care and treatment of acute diseases of patients within a public service system based on frame budgeting and treatments free of charge for the individual patients. As hospitals are publicly financed and politically managed by local county politicians and by strong professional organisations of employees, environmental issues should be improved in hospital management by political and certain types of economical means. Several of the proposed economical instruments within environmental economic theory used at society level would properly give useful environmental effects within hospitals as well, exemplified as follows: Use of materials (food, chemicals, medicine, hazardous materials) If general market prices included the environmental expenses imposed by governments on producers of different environmental polluting goods on the market a public green purchasing policy probably would be more effective without the extra cost related to generally more expensive green products. Otherwise a green purchasing policy needs to be funded and politically enforced as a general compulsory principle of all hospitals. Compulsory green purchasing policies would improve the market share of green products and hereby motivate producers changing towards more green productions. Hospitals could also be politically motivated to develop and implement environmental policies on improving use of reusable materials, when appropriate, avoid the use of hazardous materials, when substitutions are available, and follow the precautionary principle in use of chemicals and others types of materials which might be harmful to the patients and / or the employees, without the demand of scientific proof. This type of policies is effective at Frederica Hospital and others on behalf of environmental consciousness. Some hospitals might even see it as a marketing advantage being labelled as a green or a sustainable hospital implementing certified environmental management systems in the future, as the patient rights of free choice of hospital services is expected to emerge and when (if) the economic budgets of the hospitals in future regulation to a greater extent reflect the increasing activity by DRG payments to hospitals and departments. Energy consumption (electricity, heat, cooling, transport) Potential savings are possible in these fields as seen from all of the 3 case studies by investments in less energy consuming equipment and implementation of energy management systems motivated by environmentally taxed energy prices. Management focus and employee involvement related to behavioural changes are needed too within the departments as seen at KAS Gentofte, where they run a campaign on energy savings. Economic priority on investments and payback periods of several years has to be introduced in the economic priority and management system of hospital if

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this type of improvement policies is to be enforced, as stated by the environmental coordinator at Fredericia Hospital. Water (consumption, legionella infections, purification of water) Potential savings are possible in these fields as the water consumption charges are environmentally taxed, which could motivate further improvements in management of water savings by different well-known means. Related to legionella infections and purification of water investment in new technology solutions is possible. Waste (medicine, bio medicals, water, plastics, paper, carbon, food etc.) Further pre-sorting and fractioning for recycling and reductions in waste for incineration are generally imposed by municipality regulations, and can be implemented at hospital too. At Fredericia Hospital they have impressive waste sorting systems and has decreased the amount of hazardous waste by approximately 50 %. General increase in waste charges and specifically on hazardous waste would motivate an increased focus on the delivery of goods, materials and services to the hospitals by a minimum amount of waste. Economic incentives with possibilities of budget savings might in this way be a motivating factor. Working environmental issues (psycho-social work conditions, stress, degradation of employees) High absence rates of employees because of stress, increasing workloads and changing working hours are a major problem in many hospitals, which could be challenged by increased focus, experiments of changing work organisations and implementation of systems of working in shorter periods. At the 3 case study hospitals psycho-social working environmental problems and stress was mentioned as a major problem and 2 of the hospitals made strategies and plans for improvements within this field. Besides the human consequences the economic dimension of absence rates between 8 and 15 % of major groups of employees are serious, and a high rate of staff turnover is even more expensive and problematic. Patient health and safety (infections, allergic reactions, medication failures, etc) Environmental problems of this kind are often handled as part of infection control and quality assurance in healthcare, and improved focus is emerging within the general improvement of quality management. Based on the above mentioned examples of environmental economic views to sustainability I find that governmental regulations and county policies and aims of sustainable development can be seen as necessary and useful instruments rising the awareness and showing ways of improvements towards sustainability. National demands of implementation of environmental management systems at sector and organisational levels could be made compulsory for all hospital as it is seen within some counties and in the coming years would be able to have a serious effect in case those systems are implemented along the proscribed recommendations of previous experiences in the field. Besides these efforts I find that national and hospital sector strategies of sustainability and implementation of general environmental management systems within other sectors would influence several of the services and products used in hospitals as well. It should be mentioned that initiatives and activities already are going on within several of the above mentioned areas without a special focus on those areas on behalf of environmental concern, but as a result of general economic and professional management of hospitals, and depending on the knowledge and attention on those issues for reasons of what could be called good governance

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within the hospitals. From the case studies at KAS Gentofte and Fredericia Hospital it was seen that they achieved impressive environmental improvements of energy consumption, waste handling, reductions of emissions etc. by implementation of environmental management, which seem to validate a conclusion that an improved focus and a more systematic approach to the environmental issues within hospitals have great potentials of improvements. Analysis and discussions related to theory on ecological modernisation Within theories of ecological modernisation in an institutional learning perspective striving towards sustainable development by means of government regulations and restrictions alone, are seen to have only limited effect at the operational and organisational levels. Changes in attitudes, understandings and behaviour are needed locally, based on realistic alternative technology solutions, new work processes and the use of new methods in management. Implementation of environmental management systems like ISO and EMAS is developed in accordance with this theoretical thinking, as is the use of sustainable development as ‘story lines’ mentioned above within the political discourse at society level. In the case study at Fredericia Hospital these systems were seen as useful implementing in Danish hospital organisations as well, but as stated previously only done by rather few hospitals in Denmark, possibly because of lack of incentives and due to a general scepticism towards implementation of management system thinking within a professional dominated organisational culture. Other types of environmental management systems could be developed for good reasons where the environmental issues were handled within a more integrated approach together with quality, services and economical issues, as many of the environmental issues in hospitals services are closely interconnected to those as discussed in the adductive analysis. Following my case study at 3 hospitals, environmental management has been initiated as county environmental projects and implemented locally partly by aims of economic savings in consumption of energy, water, waste charges, etc. and partly on the background of ethical considerations by managers and employees acting within frontrunner institutions in the field. Based on these case studies it could be argued that the environmental issues should be handled like the quality issues setting targets and measuring results related to the individual patient flows following the concept of a life cycle flow analysis. It could also be made part of an indicator system measuring environmental management performances like the quality indicators, aiming at benchmarking of environmental sustainability within hospitals services. It would possibly take some years of research and development defining valid and useful indicators of sustainability of hospitals services like it is going on in the quality field before implementation on a national scale. This indicator method is developing within international environmental agencies and institutions and related to the Danish national strategy on sustainable development as well. There seems hereby to be lots of potentials and synergy in promoting the relations between environmental management and the concept of sustainable development based on theories on environmental economics, ecological modernisation and within research on effectiveness of environmental politics. 7.4 Working Environment and Sustainable Development The relations and possible synergy processes between working environmental issues and a sustainable development of society are generally less described and research within the general

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context of the this concept, but are well described and researched in Denmark and countries of European Union related to the meaning and understanding of the social dimension of the concept. Analysis and discussions In the proposal on a Danish national strategy on sustainable development (Government 2002) working environmental issues are mentioned as a sub area of concern within the strategy formulations related to Environment and Health concerning topics as chemicals, environmental pollution, foods, working environment and indoor climate. The aims and interventions of the strategy formulation on working environment for the years 2002-07 are related to a follow up on the Danish strategy on working environment, Clean Working Environment 2005, published in 1995, with a specific focus on reductions in use of hazardous chemicals, work related harm as result of cancer-causing materials, organic solvents and pollution by heavy metals. Interventions are recommended using the substitution principle (use of the least harmful materials or substances available). And it is stressed as an obligation promoting the working environment mainly as a result of dialogue and cooperation between the employer and the employees. This strategy is not new but has in fact some how been effective within the last 25 years in Danish Working Environmental legislation and regulation, based on guidance by the Working Environmental Services and inspections by local Work Inspectorates. As seen within the 3 case studies the structures of central and local safety organisations are established and the use of systems as WPA´s and systematic action planning are being used. Based on the research within development of working environmental conditions it seem like Danish working environmental strategies have been rather successful by a combination of national legislation and institutionalisation and the use of bottom up methods of improvements by local WPA´s and organisational WPA actions planning (Hasle,Peter et al., 1999), even though results depends on the power relations and the priority given the topic within the individual organisations. From the case studies on working environmental issues it was seen that a number of serious working environment and even some environmental problems were being handled within the rather well established security organisations at the hospitals. And the use of WPA was seen as an essential and useful method of improving the working environmental conditions, within some fields of operations. It was also experienced that this tool was not good enough handling the psychosocial working environmental issues, while other methods had to be taken into account in this respect. As in Fredericia they used questionnaires for measuring the psychosocial working environment, and at RASK they made strategies and local action plans related to this area from an understanding of the need of intervention and improvements on issue related to this topic. Looking at the recommendations on improved efforts within the European working environmental issues at hospitals (Verschuren, R.1995) they stressed 4 areas of intervention: physical working environmental conditions, organisation of work patterns, improvement of psychosocial working conditions and health and safety policies, al areas that are in focus and planned interventions for improvements at 2 of the case study hospitals. This also indicates that sustainable working environmental conditions are developing within the Danish hospitals in practise, partly as a result of the general development within the working environmental field and partly on behalf of an increased management focus and priority of this area within the management of hospitals. The aims and interventions taken from a 7 year old strategy on working environmental improvements as a proposal within a new Danish strategy on sustainable development, and the fact

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that improvements and systematic activities have been seen within this field generally within Danish enterprises and specifically within hospitals for many years, indicate that the development within the working environmental area are ahead of the development within the environmental protection and prevention area in Denmark. This situation is mainly a result of a strong and collaborative labour movement fighting for improvements of safe and healthy working environmental conditions for many years, and a concern on serious environmental pollution problems and harm related to the work processes at Danish enterprises. This awareness and concern on working environmental and environmental problems at work places, within specific sectors and even to some extent brought up at the political agenda of society level since 1970´s, resulted in development of the working environmental act and establishment of institutions and improvements at the workplaces and in the Danish society as such by the years. Within the case studies, i.e. in laboratories and technical departments, it was seen that environmental consciousness among local managers and employees already exist at a rather high level and was background for interventions within environmental protection issues long before the present focus on environmental management systems and the concept of sustainable development has emerged. This observation support the recommendation of a further integration of environmental improvement efforts within the working environmental field, eventually within the safety organisations, by intensive employee participation as an effective strategy both at the organisational level and at the institutional levels within sectors and in the society. The development within working environment hereby seems generally to follow the theories of ecological modernisation and the institutional learning perspective as a result of the labour movement stressing the need of participation, education and information within a value based setting of the development of business processes (LO, 2001). It even could be seen quite natural and as an advantage for the employees and the employee organisations integrating the concept of sustainability within strategies of development of the working environmental conditions as many (probably a rising amounts) of causes of work related health problems are caused by unsustainable environmental conditions in the society as such. Especially taken into account the broad definitions of sustainable development and the need of seeing environmental problem solutions within a multidisciplinary and integrated concept of organisational and institutional processes. Based on the case study at RASK this tendency are seen within health care, increasing the focus on prevention and health promotion activities related to every day life relations and the development of departments for prevention and health promotion and departments of the medical speciality on working environment and environmental medicine. For those reasons an integration of working environment and the concept of sustainable development seem to support an already existing understanding of relations between environmental issues and working environmental conditions, but might support an expansion of this understanding to a broader scope of interrelations between working environmental problems, health related diseases and the general environmental and economic development within the society. 7.5 Integration of Environmental management and Working environment As seen within the case studies and in several of the above-mentioned analysis there seems to be evidence of synergy and development potentials in integration of environmental management and the working environmental issues at the organisational level. In this section I will discuss this relation at a sector and society level and the possible synergy effects by use of theories of Risk Society (Beck, 1997) and the precautionary principle (WHO, 2001).

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Analysis and discussions related to theory on Risk Society and use of the precautionary principle The issue of integration of environmental management and working environment within a sustainability context at sector and society level seem relevant as the environmental, working environmental and health related effects of unsustainable practises is often not seen before several years or decades, when the harm is unavoidable (Beck, 1997). As such the time perspective of caring for the need of the coming generations becomes even more challenging for the present decision-making on uncertainties related to the present use of possible hazardous materials and substances in production and service processes. Medical research and development activities have on a minor scale for some years increasingly focused on relations between working environmental conditions and health and on relations between life style and health, as smoking, consumption of alcohol and foods. As mentioned previously also relations between environmental issues, especially use of new chemicals, and human health are increasingly being researched, but so far this area seem to be rather virgin. Causes of major health problems and an increase in the incidence of diseases like cancer, heart-vascular, psychiatric, brain damage and other diseases are suspected having relations to certain environmental issues, but so far research are more focussed on treatment and cure possibilities than on risk reductions on main causes and the possible prevention of those diseases. Increasing research, educational activity and focus on the environmental effects on human health are only slightly emerging within the medical professions and the health care sector. An increasing investigation activity related to the effects of prevention and health-promoting activities are seen and so is an increasing awareness and investigation of possible relations between general environmental and working environmental conditions, every day life circumstances and the public health standards. In Risk Society Ulrich Beck (1997) argues, that it is no longer possible to oppose nature and society, the real challenges at present time and the future consist of a transformation from the civilisation’s threats to nature to its threats to the societal, economic and political systems. Development of society is a threat to itself, why environmental protection and prevention has to focus more intensively on the effect for employees, patients and the civil society of its own processes, and hereby the relations between working environment, health and environmental management are seen to be even more closely connected in the future development of the health care sector. A new area of environmental concern and changed focus are at sight. Risk Society usher by other words a speculative era of everyday thinking and observations of potential risk, and hereby discussions and decisions based on precautionary principles. The constantly need of updating knowledge, skills, development of organisational processes and use of new products and substances based on new chemicals challenge the working environment and demand integration of knowledge from within several scientific fields. Whether such an integration and development of new knowledge are organised within the same organisational structures, systems and procedures of environment, working environment and health institutions or are being handled within well functioning communication systems between the relevant actors and systems and by coordination of relevant activities is not the essential question. What is important are that common efforts are done based on the concept of sustainable development, taking into account the potential risk and by use of precautionary principles. A development in this direction on a very small scale are seen by an improved activity within prevention and health promoting activities, activities of ISMF, enlargement of the small medical speciality of working environmental medicine towards a broader environment and working environmental medicine speciality, and by

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increased in the integration of know how, participation and research within environmental, working environmental and health related issues at work places and at educational and public research institutions. From this point of view, it can be argued that there is a great need of an improved interest and involvement by the professional health employees in the debate of society environmental issues and an improved research activity within these relations in the hospital sector as well. If the medical professionals increasingly took up the challenge using their knowledge on human health processes within the increasing number of difficult political environmental decision-making processes based on uncertainty and by use of precautionary principles in many essential environmental and working environmental questions related to present and future development of organisational processes in society, it might be of great benefit for the society. But such a development probably rely on a paradigmatic change within the medical scientific understanding of health and disease in society, which has to come by needs and pressure from a general political discourse on this topic at a society level. An increased discourse on sustainable development related to health and disease might promote such a change towards a new paradigmatic understanding of health and disease and the role of the hospital and health sector. The theory of Risk Society (Beck, 1997) on relations between demand for scientific proof and the hereby legitimated increase in risky substances used in society already have provoked and intensified political and scientific discussion on the use of the precautionary principle. Even WHO recommend …”activities that raises threats of harm to human health or the environment, precautionary measures should be taken, even if cause and effect relations are not fully established scientifically…” (WHO, 2001 page 3). So far the examples of relations between an unsustainable environmental development and the health and safety issues have not provoked this change dramatically but a rising awareness are seen within the public media and within the research focus on experiences of risk by ISMF (Grandjean, 2001) where a team of interdisciplinary researchers recommend improved interventions within several aspects of experiences of risk and risk reactions in research and in educational activities. 7.6 Concluding remarks But quoting Zwetsloot (1998, page 30): “The joint management of environment and occupational health and safety, however, may form a good starting point for the management of sustainable development. Structural and effective sustainable development can only take place when policies at company level (hospitals) are aligned with …professional (my addition) …regional and national policies aimed at sustainable development”, I find that possible synergies are at stage, but the cultural and the professional involvement and engagement is essential if the environmental management within hospital are not going to end up as a ‘side-car activity’ and use of the words sustainable development is continuously been seen as ‘window-dressing’ (Kamp, 2001). The development dynamics of sustainable development seems to lie in • the global, ethic, and moral context • the political context at a society level • the environmental economic context in society, on the market internal and in the organisations • the social and management context internal in the organisation • the professional context of research and development

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8. Perspectives and further research Understanding the concept of sustainable development within hospital environmental management I found being a difficult subject, as research within this specific field was missing. Choosing a focus on political process perspectives at both organisational and institutional level and sector and society level trying to understand relations and find synergy effects in search for an understanding of the relevance of this combination of concepts made the study even longer. As such this project was done mainly as social science based explorative research in a new field. As the main focus I had chosen the polical and organisational process perspectives of three major topics: environmental management, working environment, the concept of sustainable development, and specifically the perspectives of integration of those, why the natural science part of the project is seen to be minor. In the case studies I mainly focused on the environmental and working environmental issues and integration aspects of handling those within the organisational structures and processes at the hospitals, searching for what could be learnt from those 3 hospitals based on a general search of experiences, observations and attitudes. The interview persons were mainly key persons closely involved or related to the field at the hospitals and most of those were managers or staff members closely related to management, why it must be considered if a broader search among employees and local clinical managers would have given other perspectives of the findings. I learned that an environmental management system approach seemed to valuable and useful within environmental improvement efforts at hospital, if they are handled process oriented and with a high degree of participation approach from vision and strategy formulation to mapping, priority of interventions, choice of solutions, implementation and systematic follow up. I got an understanding of the concept of sustainable development and the related economic and sociological theories related to this concept as basis for at more detailed analysis of the field of environmental management at hospitals. Several new research areas showed up which could be interesting to follow in further research on the topic, among others 1. An in depth study (if possible action research based on a development project) on implementation of integrated environmental management at a Danish hospital, following the change processes and the achieved environmental and working environmental improvements for a couple of years, could give a more detailed understanding of the potential gains and losses, and how the barriers could be overcome. Such a study could be done either at one of the case study hospitals of this project or any other hospital willing to take up the challenge. 2. Further case study research on the perspectives, strategies and methods of integrating environmental management within quality and service management at hospitals seem to be relevant. 3.

Further research on how every day life perspectives of patients and citizens related to their understanding of relations between environment, working environment and health could be seen as a political factor in future health politics and priorities at hospitals based on theories of sustainable development and risk society could also be an interesting research field

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Acronyms BSE

Bovine Spongiform Encephalophaty – Mad Cow Disease A brain disease of cows that causes death.

Balanced Scorecard

A management model, focusing on a vision managed development of an organisation within balance of 4 perspectives: effectiveness, resource management, learning and management, activity processes.

EMAS

Eco Management and Audit Scheme European scheme for standardisation of environmental management systems within European Union.

EU

European Union

European Foundation

European Foundation for the improvement of Living and Working Conditions An autonomous body of the European Union created to assist the formulation of future policies on social and work-related matters based on research within European Countries.

FS

Fredericia Hospital (Frederica Sygehus) in Vejle County A smaller general hospital in Vejle County.

H:S

Copenhagen Hospital Corporation (Hovedstadens Sygehusfællesskab) Public cooperation of 6 University Hospitals in Copenhagen and Frederiksberg Municipalities.

ISMF

Ministry of Interior and Health Research Centre for Environmental Health (Indenrigs- og Sundhedsministeriets Miljømedicinske Forskningscenter) National research centre established by Danish Ministry of Interior and Health within the field of environmental related health deceases.

ISO 9001

International Certified Quality Management System Standard for a quality management system developed by International Standard Organisation: an international cooperation of national standardization organisations.

ISO 14001

International Certified Environmental Management System Standard for environmental management system developed by International Standard Organisation: an international cooperation of national standardization organisations.

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KAS Gentofte

Copenhagen County Hospital in Gentofte One of 3 major University Hospitals in Copenhagen County, located in a suburb north of Copenhagen City.

KEMAS project

EMAS in Municipalities and Counties – Project (Projekt om EMAS i kommuner og amter) A project on certain issues related to implementation of EMAS in a municipality or county within all or parts of the organisation funded by the Danish Ministry of Environment

LO

Danish Confederation of Trade Unions

Mamint project

Environment- Working environment Integration Project (MiljøArbejdsmiljø- INTegration projektet) A research program investigating in which way and to what degree the work on environment and working environment could be integrated at enterprises and which advantages and disadvantages would follow from this integration.

NGO

Non Governmental Organisations

OHSAS 18001

International Occupational Health and Safety Management System Standard for working environment management system developed by 13 international and national standardization organisations.

RASK

Roskilde County Hospital in Koege (Roskilde Amtssygehus i Køge) One of 3 medium size hospitals in Roskilde County, 35 km south east of Copenhagen City

UNCED

United Nations Conference on Environment and Development

WCED

World Commission on Environment and Development

WHO

World Health Organisation An international organisation that aims to fight and control disease

WPA

Work Place Assessment A prescribed assessment method used within occupational health and safety at the work places.

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Literature • • •

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Annex I Interview persons and documents available from RASK case study listed below. Interview persons: Hospital management Hospital director, chairman of the hospital Safety Committee and of the Joint Committee Security manager of 3 hospitals in Roskilde County, member of the hospital Safety Committee Service departments Manager of Service department, member of the hospital committee on health and safety Manager of Technical Department Manager of Hospital Administration Department Head clerk of Purchasing Office Clinical departments Head Nurse in Department of Medicine, member of the hospital Safety Committee Head Nurse in department of radiology Laboratory technician from Department of Clinical Chemistry, co-chairman of the hospital Joint Committee Physician from Department of Organ surgery, member of the hospital Safety Committee Head Physician of Department of Occupational Medicine, a county specialty department Reviews on the following documents: Development Strategy 2001-03 for Roskilde County Hospital in Koege, December 2000 Hospital Operational Agreements of Departments at RASK, year 2001. Tasks and terms of reference of boards and committee’s of RASK, December 2001 Plans for prevention and health promotion in Roskilde County and at RASK, 2000 – 01 County Committee Annual Report: Occupational Health and Safety year 2000. Hospital Committee on Occupational Health and Safety: Minutes of meetings from 2001. Reports, letters and action plans concerning inspection on psychological work environment in 2 hospital departments by the Work Inspectorate’s. 2000 – 01 Staff Policy for Roskilde County, November 1994 Polity on working environment for Roskilde County, 1992 Green Account 1997, Roskilde County Green Account for Roskilde County 1998 – 99 – 00, Roskilde County

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Annex II Interview persons and documents available for case study at KAS Gentofte listed below: Interview persons: Vice-director from summer 2000, Hospital Management Environmental coordinator from January 2001, Department of Education Development Safety manager from 2000, Service Department Review of the following documents: Copenhagen County Environmental Policy published 2001. Copenhagen County Purchasing Policy published 1998 Copenhagen County Food Policy published 2001 Targets and strategy 2002 – 05 for CHG (Final draft) Green Account for CHG 1997 Environmental statement and account for CHG 1998 Environmental statement and account for CHG 1999 Report called Model on Green Account and Environmental management at Copenhagen County Hospital published 1998. Note on statement of affairs in working environmental work at CHG 2001. Annex III Interview persons and documents available for case study at Fredericia Hospital listed below: Interview persons: Technical Manager, Technical Department Environmental coordinator / safety manager, Office of Environment- and working environment Photographer, Environmental contact person and auditor, Department of Radiology Nurse assistant, Environmental contact person, Department of Dialysis Review on the following documents: Vision, Aims and Strategy of Fredericia Hospital 2002 Annual Report of Health Activity at Fredericia Hospital year 2000 Environmental statement and account 1999 Environmental statement and account 2002 (final draft) Homepage of Fredericia Hospital Homepage of Vejle County

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