Welcome to a discussion on creating an environmentally sustainable practice. My name is Eden Essex and I will be the announcer for this session. This session is being recorded and will be available to you in the near future via GILeap, ASG's online learning platform. By registering for this event, the program automatically has populated your GILeap account and in about two weeks you will find a recording of the session there. You can also contact the ASG office if you need assistance accessing your account. Prior to opening this session, I shared a PDF of the slide deck with you all via email, so that should be in your inbox. You will be able to submit questions and comments throughout the event via the Q&A box. A panel discussion followed by audience Q&A will be held at the conclusion of the presentations. Now it is my pleasure to introduce our moderators for the session, Drs. Dess Leddon and Dr. Raju. Dr. Dess Leddon is an adjunct professor at Dalhousie University in Canada. Now retired from clinical practice, Dr. Leddon is co-chair of the Canadian Association of Gastroenterology Climate Committee and section editor of the soon-to-be-announced Planetary Health section of the AGA journal GastroHEP Advances. Dr. Raju is the John Strohlein Distinguished Professor at the University of Texas M.D. Anderson Cancer Center, where he leads the Charles Butt HEB-GI cancer prevention, research, and education program. Dr. Raju is recognized for his many contributions to ASG and the advancement of GI endoscopic practice. I will now hand the proverbial floor over to Dr. Leddon. Great. Thank you, Eden. Our first talk is presented by Dr. Frances Mortimer, Medical Director of the Center for Sustainable Healthcare in the United Kingdom. Dr. Mortimer leads the Sustainable Specialties Program, which combines research with practical action to improve patient care at a lower environmental and social cost. She designed the center's principles of sustainable clinical practice and has developed a framework for incorporating sustainability into quality improvement in health care. Given the late hour across the pond, Dr. Mortimer has provided a recording of her talk, which we'll play for you now. Good afternoon. My name is Frances Mortimer. I'm from the Center for Sustainable Healthcare in the UK, but working with organizations around the world. I've been asked to speak today about why is there a need for sustainable practice and what is it? So the why is a pretty big one. We are in the midst of a planetary crisis with six out of nine planetary boundaries now crossed. These boundaries and crossing these boundaries, we're tipping the Earth's natural systems out of their homeostatic stable, steady state that they've been in ever since long before human civilization began to evolve and into an unknown and destabilized system. The planetary boundaries that we're crossing include climate change, which I will speak a little more about in a moment. But there are also boundaries that we're crossing in terms of soil health, water impacts, land system change, biodiversity and plastic pollution. And as a little indication of what the type of impact that we're having on biodiversity or the scale of impact, you may be aware that of all the mammals on Earth, 96 percent now are livestock and humans with only four percent of mammals wild. And that's according to the World Wildlife Fund report from a couple of years ago. So climate change, we are aiming to limit global warming to an average of one and a half degrees above pre-industrial global mean temperatures. But we are not being very successful. And despite the attempts at action over the last 30 years, global climate greenhouse gas emissions continue to increase year on year. And what this means is that we are significantly risking exceeding that 1.5 degrees Celsius. And the impact could be absolutely catastrophic. A four degrees future, which we were on track for at the moment, has been described as incompatible with an organized global community, likely to be beyond adaptation and devastating to the majority of ecosystems. So this decade that we're living through right now is a narrow window of opportunity, but only by major transformation economy wide can we can we secure a livable and sustainable future for all. So economy wide and that includes health sector wide. And if we're threatening the very sort of conditions under which human society has evolved, you can imagine that a planetary crisis is also a health crisis. This diagram from the WHO is trying to show some of the intersection between vulnerabilities in different populations and then the impacts of climate through extreme weather events and impacts on air and water quality, food security and conflict and infectious disease. And then, of course, the capacity of health systems to to support people and care for them when they're ill. And also their resilience to disruption themselves from from climate events. So there is an extremely wide ranging set of health outcomes in the near term, even before we get to the point where the systems are completely destabilized. And yet health care itself is part of the problem. So if the global health care sector were a country, it would be the fifth largest greenhouse gas emitter on the planet. It's responsible for about four and a half, five percent of the world's carbon footprint. And of course, contributing to air pollution in around health care facilities and plastic pollution and to all the other environmental impacts. So this is increasingly recognized and governments around the world are committing to building resilient, climate resilient and sustainable health care system. For 68 countries have committed to reducing the carbon impact and making their health systems more sustainable. But if we want to do that, we need to understand what the carbon, what the where the climate impact is coming from in our services. And this diagram comes from the carbon footprint analysis of the National Health Service in England. It's showing the message I really wanted to show with this slide is that clinical care drives the carbon footprint. So very directly, you can see that the prescription of medicines and the use of medical equipment, the use of anesthetic gases and meter dose inhalers are directly contributing to the large portion of the carbon footprint of health care. But actually, of course, as soon as you think about it, patient journeys, the use of buildings, the water and waste disposal that's needed to run health care facilities is also driven by clinical decisions, drawing patients through the system and drawing the resources through as well. So that means that as well as improving our buildings and improving our procurement practices in liaising with industry to make greener products, we can also have a big impact through our changes to behaviours and change to clinical practice and changes to the design of care pathways. We can have a big impact on reducing carbon. What kind of changes are we talking about that could improve the sustainability of practice? And my organisation has found these principles of sustainable clinical practice that are listed down the middle here under the secondary drivers. We found these principles to be really helpful in thinking this through and generating and organising our ideas for change. So we're talking about reducing activity by improving health, improving and supporting a greater role for patients in their care and in keeping healthy and also making our care leaner and higher value. I'm just thinking through how some of this might apply to endoscopy. Could we promote healthier diet and play a part in reducing the incidence of bowel cancer, for example? An example relating to patient empowerment. There might be a greater role for patients taking decisions about whether or not to use nitrous oxide, perhaps if they were more aware of the environmental impact of that greenhouse gas, which is 300 times more potent than carbon dioxide as a global warming in its global warming impact. Perhaps we could make clinicians, we could make patients more aware of that and aware of the alternative options and come to decisions about where it is most useful and when it could be avoided. And something else used instead. Could we look at endoscopies that are done where they're not really going to contribute to patient care positively? Look at referral guidelines or other ways that we could reduce unnecessary procedures. And then we can look at the boxes in blue. They're all about how we can reduce the carbon intensity of care. Having reduced low value care as much as we can, are we still going to need to provide care? So what can we do to make that greener? Well, I've categorised it into these two separate things. One is low carbon alternatives, and those are really about clinical decisions. So mode of treatment, the choice of device in anaesthetics. It might be whether you give an inhaled anaesthetic or intravenous one. But in endoscopy, there are studies going on looking at whether a colon capsule pathway might be greener than an endoscopy for all patients in bowel cancer screening, for example. Operational resource use. So that's all the things, the good resource management on the endoscopy unit, whether that's to do with energy use and energy efficient equipment or how we deal with our waste, whether we segregate it, whether we recycle packaging waste, for example. So that's some of the knowledge that might be helpful. And how do we get that into action? One tool that we found very useful has been this sustainability in quality improvement or SUS-QI framework, where we put sustainability into the different stages of an improvement project, from setting goals through to studying the system and the environmental impacts that it has at the moment, using those principles that we just talked about to design improvement and then measuring the impact on sustainable value. So that means measuring impact on the outcomes for patients and populations and also measuring impact on environmental, social and financial costs. And this is being used by teams in hospitals in the UK and in some other countries now. And this is one example of a local project that looked at reducing paper, but also reducing use of incontinence pads during procedures and disposable shorts and replacing those with reusable gowns. And they were able to show some environmental and cost savings and with no adverse impact on patient care. If you would like to have a look at SUS-QI.org, you can find lots of resources there to help with the SUS-QI approach, whether it's in your project or in your teaching. And there are also links to case studies and networks, including the Endoscopy Sustainability Network that we host on our website, which we would warmly invite you to join and use to share ideas and resources that you may have for sustainable endoscopy. So thank you very much for your time. And I wish you all the best in making your practice as green as it can be. Thank you, Dr. Mortimer. That was a humbling overview. And it is clear from this beautiful presentation that we have a lot of work cut out for us. Our next two talks will guide us through translating sustainability into our daily practice. And we begin with Dr. Sonali Palchowdhury. Sonali is a gastroenterologist at Mass General Hospital. And she is interested in high value care since graduating from Harvard John A. Paulson School of Engineering and Applied Sciences, followed by medical school at University of Michigan. Subsequently went and did her residency at Hopkins and her GI fellowship from the University of Pennsylvania, where she was the chief fellow. During this training, she also received a master's in health care administration. She is active. She is a she her basic interest is in nutrition. And she says on the ASG Sustainable Endoscopy Task Force. Sonali, we are delighted to hear your presentation. Thank you. Thank you so much for the very warm welcome. So that's a great presentation to follow. So what I'm going to try to focus is what do you what do we need to implement a sustainable practice? Lots of things. No disclosures that are relevant to this talk. I really want to engage you guys in an exercise for the next minute. So I want you to write down two examples of effective change in practice, not necessarily in sustainability, just really anything that you thought was effective. And during this talk, we're going to think about, like, what did that change? How did that change get implemented? Who was part of the team? What contribute to make it effective? Bonuses, if you could write down an example of one that was not as effective as desired. And so you can kind of keep those in mind as we go through our discussion here. And if you're willing to share, I'd love if you can just post it in the chat if you feel comfortable. And then we have a few references that we can even that can even look at while we're chatting here. So take a moment and think about some examples of where you think change was effectively implemented and possibly one where it was not. So my objectives in this talk. So we heard a lot about the why. And you must be feeling very motivated now. So I'd like to really think more broadly about the how. So my first objective is to summarize some really general principles for effecting change and leading successful implementation in sustainability as well as anywhere. I'm drawing from a lot of my experience in other quality improvement projects, but I think it really helps to build that kind of framework. The second will be will propose some specific components necessary for sustainable practice kind of within those general the general recipe that we'll talk about. And my other real objective here is to empower you to move your practice towards sustainability. Now, you know, we heard in the past talk and I've heard you and I'm sure you've heard otherwise. There are a lot of contributing factors in climate change generally. But we've seen how small changes can lead to larger changes. So any bit that we can do to change what what's in front of us can be part of something bigger and has little effects. So I'm hoping that you conclude today a bit more empowered to feel part of that positive change. So this is what I would call the recipe for effective implementation. Generally speaking, we'll bring this to how it impacts projects and sustainability. So we'll talk about having a team with effective leadership, the importance of buy in from all the stakeholders. How we want to build a strong understanding of the current state, as well as have some clear objectives and a plan for how you want to impact that. Methods for assessment and then the resources. So let's start with the team and leadership. Now, we know that the strength of leadership can dictate success or failure. So this is something that it's a very small that chart on the right side, but it's coming from it's coming from a class in one of my it was like a leadership class in that master's program. And it's really looking at, you know, the first being a red bar of 100 percent of what is the financial performance of some company when a CEO is retiring. So this is like not retiring because of something terrible happened, but really just the person is, you know, a retirement age or had some health condition. This is looking at a variety of countries in America. And then it looks at what happened after the first CEO, when things did not work very well. And you can see there's like a 20 percent drop in the financial performance. And in the same set of companies that went on to a second CEO, we're looking at that turnover resulting in 20 percent above the first one. And nothing else has changed in this framework, in the study, in the study that was done in the CEOs. So like all the other workers are generally saying no big layoffs, no big strategic directional change, really just the CEO changing. And you can see that leadership can make a really big impact in success or failure. I'll acknowledge that in multidisciplinary issues like an endoscopy unit or making any change in endoscopic care, it's really hard to know who owns a problem. So that's sometimes like the first question we need to figure out. But I think it's a really important one to settle on. So in those examples that you made of success, in your mind, can you name who owned that problem? Like who is the head person to really be in charge of it? And I would imagine if you ask yourself the same question for the non-successes, was there an owner or was that part of what made it really difficult to succeed? The second part of the slide is that the team must be representative. So endoscopy has a lot of team members and roles. This little diagram here is from one of the guidelines for minimum staffing requirements. And you'll see it has an endoscopist, endoscopy RN who's present the entire time. You might have a floating RN. You have a second endoscopy RN sometimes for assisting and sometimes interventional cases. You have the tech. And if you're using Mac, you have like an RN and that's just a medical doctor. So you have a lot of people playing roles. And so if you're ever doing a project in this kind of space, you want to make sure that the team trying to lead change is representative. That also helps to get buy-in from the other people within the unit. So that brings us to our next topic, which is getting buy-in. And here I want to really talk about a few different aspects. Now, one is the difference between organizing and versus mobilizing. So, here on the right, you have a little small diagram. If you have the entire endoscopy unit and then you have a team that's representative but a smaller component of it. For the team, you're gonna be mobilizing them to work on projects and that's really important. You also wanna make sure that if you're looking for culture change and buy-in from the entire group, that you're able to organize, meaning everyone and bring all the people together, build that trust, build respect, listen, have conversation, all of that to really get everyone's buy-in. So, just kind of, if you think about even that example you wrote down, were they able to organize the bigger group versus did they have people who were mobilized who could work on a project and really move it forward? And that can be really helpful to make sure you separate the roles of people in both categories. The second thing I think is really important, especially in healthcare, we can appeal to people's intrinsic motivation. So people naturally have a desire to do good and be part of something positive, especially in medicine. And so really, in climate change, we often hear in the news about terrible things going on and just the scale of it. And it really, we can feel very helpless. And so reminding people that they can have a positive impact and that it is in concordance with their desire to do good for the people around them can be really helpful and to get some of their buy-in. The messaging can be really important that way. The third part would be to give the opportunity for individual ownership. So doctors hate being told what to do. And so you don't wanna take that sense of agency away. Anytime you say to a doctor, well, you can't order this, they're gonna find a workaround. And so we wanna make sure that we give people an opportunity to opt in and really feel like they've made the decision to make the changes that we're gonna be looking for for a more sustainable practice. And that's a great way to get buy-in. And the fourth is to have an individual feel like they're part of a community. In any sort of change, that's a part of getting that buy-in is making sure they feel like they're part of something bigger. And so in our next example, we'll talk about like examples of how to bring that sense of community. So here I just put a picture of a lapel pin and this is one of the LGBTQ ones where you'll see a lot of people wear it on their white coat, right? I remember seeing a lot of them during many stages of training. And I think what this does is it's a symbol of unity, right? So you pick something that's visible, like signing a pledge or you have a lapel pin or something like that. And it's a symbol of unity where people can feel like they're part of a community of like-minded people who are focused on something together. And if you're wearing something like that, it's a soft reminder of commitment, right? Because it establishes that the idea is being congruent with their individual's self-image. And so if they were to do anything that's kind of labeled a non-sustainable practice, it may cause this cognitive dissonance. And they feel like, well, that's not consistent with what I said I'm going to do as being part of this community. So it can be helpful for that. It's also a social cue. We look to each other for cues of behavior. This is one of the things that Robert Shielding talks about in his book on influence. So providers can really encourage each other to consider sustainability. Now, I don't think we have a pin yet, but maybe that's something we should be looking for. But this is a sense of like in a broader scale of how do you bring change in a group of people, figure out ways to bring a sense of community. And maybe this webinar is one of the ways that we bring some community. Let's talk a little bit about stakeholders in negotiation. We talked about all the different team members. We have to be able to get buy-in from all the different stakeholders. Now, negotiation in business school and whatnot is considered a decision-making process, right? So you have two or more parties aim to agree and how they're going to allocate scarce resources, scarce and independent resources. And we want to acknowledge that both parties have some shared interests. So this is where the difference between distributive versus integrative is important to recognize. Now, distributive is where you're aiming to maximize personal benefits, whereas integrative is where there's a mutual gain and you focus on the interests as opposed to positions. Really, the idea here is to listen and share and understand each other's positions, build trust. And when you're aware of each other's interest and power, you can make a decision that maybe helps both parties. A really great example is this picture of an orange that I give here that's used often, which is the story about these two sisters and they had one orange and it was raining, they didn't want to go outside. And of course, the easy decision is to cut in half and both get half the orange that they both want. But if they were to talk to each other and figure out their positions, they'd realize, well, one really wants their vine because they're just baking a dessert. And the other just wants the juice because they just want a glass of fresh juice. And the way to divide that orange is for one person to take all the vine and the other person to take all the juice and then they both win, right? So understanding each other's position can be really powerful. In something like the endoscopy unit and sustainability, sometimes things in sustainability are presented as what's good for patients versus what's good for the environment. And it doesn't have to be that way, right? We know cutting out procedures that don't need to happen is both good for the patient and for the environment. And so trying to come up with those sorts of positions where we have shared interest can be really useful. And of course, there's persistence involved in getting something done in negotiation and timing or when there's a hot topic. And I think thankfully right now, sustainability is something on people's minds. We have at least the timing behind us to get people on board. So back to our recipe, we spent a lot of time talking about teams and leadership and buy-in because a lot of that really is very important in effective implementation. And so I want you to think back to those examples you wrote down, what was effective? Who was on the team? How did they get that buy-in? If you were one of the people who were on the side of being brought into it, how did you, what did they do to get you more involved and to get you invested and make you feel like you're part of positive change? And for the ones that didn't work, were there ways that they could have gotten better buy-in and could have had better leadership and things like that? So now we'll move on to the second kind of category, which is kind of the mechanics of implementation. And so I'll talk about a couple of different frameworks in this QI toolbox. And so the first I'll talk about is lean. Now this was mentioned before, in terms of eliminating waste, and in our sense is sometimes reducing unnecessary procedures, reducing carbon footprint, alternate tests and thinking about better waste management. In this case, it's like, you want to go to this work site. You want to know your customer, meaning the people who are involved, can figure out what they consider to be valuable and then figure out the flow. There are a lot of aspects. An example here is cutting out short interval surveillances because surveillance colonoscopies, because we know that's waste. It's not helpful. It's not, you know, forwarding patient care. And it's really just, you know, wasting the system. A close sister is Six Sigma. This is where the idea is to reduce errors. And a lot of the frameworks here are trying to remove causes for detect defects and minimize variability. And this kind of process can be helpful for things like, you know, waste handling and why are we making the errors and throwing things in the wrong bin? And so we can think about this framework and how they go through some of the analyses for those sorts of issues. Healthcare innovation is a broader sense of tools. And I think like I'm still getting the handle of how to define this even after that master's, but the idea is to build solutions. You're recognizing design limits. You identify roles of behavior and policy, create solutions, and sometimes even repurpose solutions. And this is something where we're probably really looking to our colleagues in industry to lower footprint in the devices that are being designed. But there are also ways that we can also innovate in our own space, in our own units. And then you have implementation science. And this is where you're trying to take what's in research and what you think is the right answer and bring it into practice. So really disseminate evidence, adopt and integrate interventions. And an example here is broadening the use of stool-based CRC screening as an alternative, which we know is a good idea. We want to bring it into practice. So kind of giving these different frameworks or different ways of approaching a project. We heard about the SUSQI in the last talk, and that's one of many frameworks. One I like here is the DMAIC model, which comes from Lean Six Sigma. And what I like about it is, you know, you're doing the same things as SUSQI and many other models. You have to define the problem, quantify it, analyze it, implement something to improve it, and then verify the solution. And then also make sure you have something to maintain that solution, because we all know, we've all seen projects where something's a great idea, it gets implemented, but then in a couple of years, you wonder what happened to it. So you want to make sure you have things in place to continue it, especially in something in healthcare where we're always moving and things are changing and there's turnover and things like that. So many frameworks. We talked a little bit about understanding the current state, having a clear objective and some methods. And what I'll talk about here, you know, back to our example, think about how clear were the objectives that were outlined by the group putting that together? What was their timeline? What metrics were they following? And so last, we'll talk about some resources. Can't ignore the importance of having the right resources. Now, we've been talking a bit within the ASG group that hopefully we're going to be able to have a call for grant apps semi-soon, and that'll be a great way to get some resources for people who are interested in doing projects related to sustainability. It's important to have the support of your hospital or ASC, of course, in terms of building your team, having leadership, as well as having some of the just on-ground resources needed to kind of make change. We need evidence for sustainable options. You know, we talked about how implementation science centers on narrowing the gap from what we know is the right answer in practice. This is definitely a work in progress. We need to know what the right answers are, and there's a current opportunity or gap to fill, but I think that's really useful as a resource. We talked about we need some options from vendors as well, if that's a resource, of course, in terms of thinking about sustainable equipment. And time might be our most valuable resource as busy clinicians. We want to make sure that we're able to invest some of the time, knowing that it's going to have a big impact, hopefully, on the other side. So, you know, we'd covered some general principles. Let's think about some of how this translates to sustainable endoscopy and our current needs. So propose some specific components. You know, in the beginning, we talked about the importance of the team. So I think it's really important to build a local team. And actually our task force has, or is about to publish kind of a how to build a team. And hopefully that could be helpful in giving a framework of how to go about, you know, having a successful leadership structure. The second part is building your buy-in and getting those stakeholders involved. And I think here the idea is about ask others in your unit specifically, about, you know, what they think, what are their suggestions, what are the concerns, really understand what's happening to be able to create that culture towards sustainability and get buy-in. Third being, in terms of knowing your currency, understand what is and what is not sustainable. So a really objective way to do that would be to do a waste audit. And hopefully we'll have some guidelines for that out soon as well, where you can kind of just like figure out what you're doing in your unit specifically in terms of managing waste and see where the gaps are and see where the opportunities are for improvement. That's one example of understanding your current state. Make a plan. And I say this probably in any, you know, in any setting to make a SMART goal, right? So a SMART goal being specific, measurable, achievable, relevant, and time-bound. So make yourself a plan with your team that you think is feasible, measurable, achievable, or relevant within sustainability that makes sense for your group and see how you can move it forward. And under metrics, Heiko will be talking in the next talk about some few ideas, but really about how to define some metrics and methods for data collection. Data collection is often a difficult aspect of QI, but very, very important because you want to see how things are changing and be nimble and be able to change as you go. And so being able to define those early is really useful for trying to figure out how to do your own project in your space. The other things that we need, of course, is those resources. So hopefully soon you'll be able to apply for grants and ask for support and look out for some of that evidence. I think both in Canada and the U.S. we're looking to integrate the ideas from sustainability into some of the guidelines that are gonna be published in clinical practice support documents so that it's at least one of the variables that are being considered when giving some of that guidance to clinicians. So in conclusion, hopefully you'll be able to apply the general principles for effecting change and leading successful implementation to your sustainability projects. Know your team and your unit and work on what's feasible. It's gonna be different for different places. We know this is a tough battle in front of us, but inching forward with what we think is feasible is our best way to kind of go forward. You can lean on the broader community interested in this work, the people who are in this webinar, as well as the other groups that are being formed and new literature that's coming out in some of the journals. And do look out for some of the resources and support that should be coming soon from things like our task force. And I put in here, an old but well-loved quote from Mother Teresa, I alone cannot change the world, but I can cast a stone across the waters to create many ripples. And hopefully we'll be seeing those ripples and the effects very soon. Thank you. Great, thank you very much Sonali for that excellent presentation. Next we welcome Dr. Heiko Pohl. Dr. Pohl is a gastroenterologist with the VA Medical Center in White River Junction, Vermont, and Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. Dr. Pohl currently serves as chair of both the GI Multi-Society Task Force for Environmental and Practice Sustainability and the ASGE Sustainable Endoscopy Task Force, and is actively engaged in climate change initiatives of the World Gastroenterology Organization. Heiko, the audience is yours. Hello everyone, I'm just trying to start my talk here. Give me a moment, please. But so, well, these were excellent presentations and I'm gonna finish off our talks with how can we measure the sustainable value of care? And in preparation for this talk, all right, my disclosures. In preparation for this talk, I thought it's important to spend some time on what does it mean sustainability and sustainable healthcare? And what does it mean sustainable value of care? And then we'll come to how can we measure sustainable care in endoscopy and give you some examples. So in general, when we talk about sustainability, we have probably the immediate connection to the environment. We wanna lower our environmental impact. If we think about sustainability in healthcare, it's the capacity of health services to maintain or improve the provision of healthcare into the future. So in other words, we wanna be able to provide the high quality services that we provide today, not just for our generation, but also for future generations. I wanna go through a little bit of a broader perspective exercise. In the center of our healthcare, of course, is the patient and we serve the patients or provide the care as healthcare practitioners. And we work in a hospital or clinic setting and we're embedded in the healthcare system, which follows economic principles. And if we think that our, if you just ask the question, is our current model of care sustainable? Some may say, well, we have a lot of challenges and it may not be sustainable. I just wanna give you two different perspectives before we get into the environmental aspect. So if you think about from the healthcare practitioner perspective, we are increasingly faced with, we are faced with increasing demands, higher RVU requirements, we have an increased administrative burden, there's less reimbursement for the same service we provide. And we may face ourselves or may come to ourselves when we make healthcare decisions that may not be totally in line with our own perspective, which is called moral conflict and may also increase burnout and of course, less fulfillment in our job. And that will have an effect on the quality of care that we provide. So that aspect alone is questionable whether this is sustainable. I would say it's not sustainable. Now, if you look at the patient's perspective, the care that we provide is to a great extent related to the care for chronic diseases. And now at the same time, we know that 50, maybe even 80% of chronic diseases could be preventable by a healthy lifestyle, having a healthy diet, living in a healthy environment. But we also faced with the lack of taking responsibility for one's own health and not making good healthcare decisions or healthy decisions for oneself. So that leads to an increased burden to the healthcare system dealing with an increase of chronic diseases. And there's just one example, the so-called obesity epidemic is one of those examples. Now, that in itself one can argue is also not sustainable for healthcare system. Now, on top of that, we have the effects of a changing environment and changing climate. And we've heard about this, the bidirectional relationship between the healthcare system and the environment, particularly the global warming, the effects of the environment put a strain on the healthcare system and delivery of healthcare, but at the same time by providing care in our current system, we contribute to the environmental impact. So all of those perspectives question the current sustainability of our provision of care. So what can we do in terms of, or what are the principles of coming to sustainable healthcare or sustainable clinical practice? And Francis Mortimer has shown this beautiful flow diagram with the key of the principles of sustainable care, prevention, patient empowerment, lean pathways and lowering the environmental impact. And put differently, it's in the same presentation offer group. You have four pillars of sustainable care or clinical practice. One in the right lower corner, the low carbon alternatives or the lowering the environmental impact of our practice. And then at the same time you have prevention, which means promoting health and not just starting with a colonoscopy at age 45 for colon cancer screening, but starting at a young age to follow a healthy lifestyle. And with that goes along patient empowerment and self-care to make good healthcare decisions early on and taking responsibility of one's own health. And on top of that, we heard about lean services before, and particularly I think about this, the administrative burden to simplify that. It has been estimated waste, particularly related to resources and cost is responsible for 25% of the costs in healthcare services in the US. So one in $4 that's spent in healthcare is actually wasted. And that comes from a paper published in JAMA in 2019. So there are a lot of opportunities, but one more thing I wanna say that even though with sustainability, we think about first of environmental, lowering our environmental impact, but prevention of disease, patient empowerment and lean service, they all have secondary effects on the environment in a positive way. So we already heard about something about the sustainable value of care. And I just wanna talk about this as a concept. So think about the value of our care. We used to think about the quality and the cost. So how many, for instance, how many dollars does it cost to save one quality adjusted life years, which we hear from cost effectiveness analysis on the left-hand side, that's more traditional view of quality per cost and the value of care that we provide. So if it costs less than $100,000 to save one quality adjusted life years, we think, yes, that's a high value care. Now the sustainable value of care expands on that principle or on that concept and includes the environmental aspect. In fact, it includes quality and then the three different vectors you might say or principles related to that may be a cost by providing care, the environment, the social and economic or the three-piece people, planet and prosperity. So in other words, for instance, when we perform a colonoscopy, we not only think of providing quality care, but also thinking about the cost that it might incur, but also the environmental aspects of providing that colonoscopy. So we think about the care for the patient, the cost for the society, so the bigger concept, the health for the planet. So transitioning over to if we want to, how can we measure sustainable care in endoscopy? And if we want to do this, we want to identify measures or indicators for sustainable care, I think they need to fulfill three major requirements. One is an indicator or a measure needs to reflect a change in practice. It has to be measurable and achievable, and it needs to reflect a true fundamental solution. We come to that last point after I give you some examples. So to have some idea about possible measures or indicators, we can go back to societal statements, the British Society and the European Society of Testing Endoscopy have published statements related to the unit and our four GI societies have committed to a five-year strategic plan that highlights initiatives and goals, milestones towards a sustainable practice, and those are all resources to kind of understand or trying to understand what you could do in your endoscopy practice. But I want to give you some specific examples related to the lean pathway and low-carbon alternatives and operational resource use. So the first one, and we heard this before, related to lean pathways, and here's the first tip of what you can do in your endoscopy practice, and that's based on the fact that many of the procedures that we perform are really not indicated or of low value. Like as Sonali was saying, is the surveillance interval appropriate? Can we perform a procedure that is really of high value and not of low value? Do we repeat an upper endoscopy a third time for a patient with dyspepsia, for instance? And is the biopsy that I'm about to take truly needed? So the first point is really adhere to the guidelines, because if you adhere to guidelines and you do what it's recommended to do, you provide higher quality care and thereby you lower your environmental impact, or you provide care with a higher value at the same environmental impact. So one possible measure could be here the percentage of procedures that are guideline-conformed. The second tip is related to low-carbon alternatives, and basically the question is, could there be an alternative test than the test that I usually perform? And one thing that comes to mind is full endoscopy for colon cancer screening versus fit for colon cancer screening, which are both considered equivalent, although we're still awaiting some randomized studies that have comparing these two strategies. H. pylori testing could be done less invasive rather than doing an endoscopy with biopsies, or ultrasound with coloprotectin assessment measurement versus a colonoscopy to follow up on the activity in ulcerative colitis. Those are all possible examples for an alternative, less invasive, and possibly lower environmental impact test. So the measurement here could be the proportion of alternative tests by indication. Tip number three is related to resource use. So in other words, plan ahead. Think green. If you do an endoscopy and I see a polyp, don't take out the forceps for a tiny polyp. You might still use a snare for a bigger polyp that's coming along the way. So you save one instrument, or in other words, you only use one instrument that's applicable for several different circumstances. And there are other considerations. What technique is really an appropriate technique and with a lower environmental impact? And one of the things, resect and discard has been actually endorsed by societies but has never really been implemented in clinical practice. So all of these things would result in decrease of waste and the possible measurement would be here, the waste per procedure. And the final tip is related again to resource use and related to appropriate waste segregation. So it would be one big example that we found out in our waste audits is that we had almost a third of the regulated or biohazard waste, or almost a third of the waste was ending up in the red bin as hazardous waste. And examining this, we found out that hardly anything that lands there has to go in there. We can reduce it from like 30% to less than 5% and thereby saving cost and also benefiting the environment. And then the other question is, do you have recycling opportunities? So here could be two measures. The proportional biohazard waste in a unit, recycling effort, whether it's present or not. There are lots of caveats to this and we can discuss that further, but those are just a few examples of possible indicators and measures. I want to just at the end talk about the true or fundamental solution if you find a solution to a possible problem. And if we want to treat a symptom, there's a possibility that it's not contributing a true solution, but that we have a symptomatic solution. And what I'm thinking here about, for instance, the disposable single-use endoscopes. Yes, there are a solution for reducing the immediate risk for patient-to-patient transmission of infection for when you perform an ERCP. But on the other hand, it will increase waste by about 40% total waste. It will increase environmental impact anywhere between 23 and 74 times. And it will actually have a greater health impact downstream related to the environmental impact. And this is based on recent studies that have been published this year. So you might say this is just a symptomatic solution, but not a true solution. And the question is, what is the fundamental solution? Now, we don't really know always what's the fundamental solution, therefore it's important whatever we do, that we also have moments of reflection and re-examine what we have done, whether this really represents a true fundamental solution or that just a symptomatic solution. Because symptomatic solutions may be harder to get rid of, and you're in a lock-in situation and inhibits the fundamental solution. So here are just a list of possible sustainable value measures. For instance, do you have a green team, yes or no? Have you performed, or is your team, your endoscopy team, has there been some educational efforts, and is there some awareness and understanding about sustainable practices in your endoscopy unit? What's the proportion of biohazard waste in your unit? Is recycling available, yes or no? And what's the proportion of high-dose nitrous? Those are just some examples, and as Sonali was saying, we're working on quality indicators together with the Canadian Association of Gastroenterology, and hopefully we can give you some more specific indicators to follow by. I just want to share some resources. As Sonali was saying, this Practical Steps, How to Green Your Endoscopy Unit, will come out hopefully within the next week or maybe next two weeks, and the first paper in this series is How to Get Started. The second paper will be Appropriate Waste Allocation, with the emphasis on reducing hazardous waste. And then we'll have, the next one will be Reducing, and not just waste, but reducing the resources in the endoscopy unit, and then we have a follow-up series. One will be on reusable instruments. We also have an ASG Sustainable website, which will provide some of the resources, including, I believe, this webinar, so if you're looking for some resources, inspiration, you can go there and find those. So in summary, I hope I shared with you what sustainable care means, and trying to share with you to take a greater perspective on sustainability of care. We talked about the concept of sustainable value of care, and I shared with you some approaches how to measure sustainable care in endoscopy. Thank you for your attention. Thank you, Heiko. It's a fantastic presentation, very thoughtful, and I'm pleased to hear several practical approaches to translating sustainability into our everyday endoscopy practice. And let me request my co-moderator, Jess, to ask some questions, and then we'll open it up for others as well. Certainly, thank you very much, Dr. Raju, and thank you to the speakers. They were really, really terrific talks. Sonali, if you were to put on your business administration hat, does going green make economic sense? Yes, that's a wonderful question. I would say, you know, the first answer should be there are so many other reasons besides business to make the transition towards green practices. I would say there are many reasons from a business perspective that it would make sense, right? One is for the value of procedures. So if you're looking at something that I hate talking about as an individual, but I guess like RVUs is something that financial people, you know, the financial side of things would be looking at. You make RVUs if you take out polyps, and if you, you know, take biopsies, and there are actually interventions being done during a procedure. If you do more high-value procedures, you're more likely to actually do more interventions, find more polyps, do all sorts of things, right? If we were to start screening, you know, of course, there's a population and reason to start screening earlier, but let's just say if we take a boundary condition and start screening at age 20, we're not likely to make a lot of change in a lot of those procedures, right? So those would be lower value. And if we started to do colonoscopies every year for screening, we'd probably end up not doing a lot during those procedures. So that's low value and also just less useful society as well as less financial sense than, you know, doing a lot of higher procedure support intervention. So that's a pretty probably basic example of how there can be some financial sense. The second great financial, you know, plus to thinking sustainably would be waste management. We know red bin waste is multiple-fold more expensive to get rid of, not just for the environment, but as well as for a unit that's having to pay for getting rid of it and incinerating and all that kind of stuff. And so financially, that's a great place where you can get some buy-in from the business side of people in your unit. Super. Thank you. Dr. Raju, do you want to take the next question? Yeah. First of all, thank you, Heiko. Thank you, Sonali. A couple of things. I'm delighted to see that our societies have actually put out some position statements. One of the things is on a national level, it will be important for our societies to work with our leaderships and different governmental agencies to figure out how we can take it to the next level. To just give you an example, you know, since COVID came, we all moved to virtual care. My own feeling is without COVID, we would not have moved. And once the COVID pandemic ended, people started shutting down those virtual video visits and going back to in-person care. Part of the problem is I see that different states require licensing. And I'm wondering, you know, how do we actually address those issues? Because 10% of our, 10% of greenhouses, so basically patient visits with physicians. Yeah, the question is, you know, one thing is, you know, each of the society has come up with position statements and some of the position statements are something that the members can do in each of our practices. And some of them needs to be done at a governmental level. Say for example, the JCO comes and says, hey, you need to do this, this, this, this. And these are hard, hard guidelines from the governmental agencies. Every endoscopy unit is afraid if they don't meet those guidelines, they're not going to get certified. Some of those guidelines are probably not necessarily applicable to what we are trying to do in terms of sustainability. Yeah. Is it okay if I respond to this? So, I mean, it's a broad question. I think first there's a lot of government support for sustainable practice. It's really interesting. We have Department of Health and Human Services has invited healthcare institutions to sign a pledge letter to organize their health institutions by 2050, and there are some other components to it. And more than 800 hospitals have signed that pledge letter. The health, the HHS has also announced to make decarbonizing the federal healthcare system, including the VA, the priority. So there's a lot of activities going on. The Joint Commission has actually considered to implement some principles of sustainability to make that kind of mandatory and be put out in public statement to get feedback. But I'm not sure whether they really want to do this because there might be too much resistance. But I just received today a link to a Joint Commission website where they promote how to assess your carbon footprint within your healthcare institution. So in other words, from the very top, there's a lot of activities going on. I think it's important that we don't want really to follow necessarily directives, right? Ideally, we try to help shape how we change our practice. So rather than waiting for directives from the top. So therefore, I believe there's a lot of value for us as practitioners to do what we can to move towards that already and not just wait for when it's really a requirement and when it's becoming a pain. So I think there will be some movements toward that. So this is one whole aspect of carbonization. You also mentioned about the economical aspect and like travel of patients to visits. I just want to say that there's a lot of things we could do, for instance, in terms of travel. I think we should identify what patient groups would be more of the groups that would benefit from a virtual health visit versus those that we should see in person. And so have a little more guidance in that respect. So for instance, if you see someone for a pancreatic cyst evaluation, you might just do a virtual visit to understand if there are any symptoms or just to talk about surveillance implications. But if you have somebody, of course, with IBD, you really want to make sure you have like a personal contact at the first visit and maybe in follow up, you have virtual visits. So I think there needs to be some guidance what is valuable, what's not. And maybe finally, something also to that's what you were saying. It's really hard with the economic issues. Of course, practices don't want to lose money. So the first implications that we should try to strive for is those that save costs and help the environment. And I think there are several that we could do. And then it's also the economic issues, always the question of perspective. You know, from the perspective of a clinical practice, you don't want to lose money. And then you get to a bigger perspective of like the society. You think about low value care, how much money do you really want to spend for screening efforts and so forth. So there was a long answer in different areas. Thank you. Heiko, you've tantalized us with this thought that there's a paper coming out next week on how to get started. Can you give us a thumbnail preview of that? Yeah, so we've been working on this kind of series. We thought after the 39 statements, what a support of doing for sustainable practice, I thought it's important to give end units some kind of practical manual what they can do and really to highlight in each series as visible as possible, as short and condensed as possible, as practical as possible, five or six tips what they can do. And so, and this first, how to get started, the goal is to create a team, to educate, to understand what task to choose. And so those are the first things that you can do. And there are some implementation tips to this. We also talk about pitfalls a little bit. So we hope that those series, initially we thought they come out every three months. I'm not sure it's going to happen. It's that they will be understood as an invitation to take it on and follow this kind of manual and see what endoscopy units experience, what barriers they have, what works, what doesn't work and kind of give that as feedback back to us. Super. Thank you. Drs. Ledin and Raju, I'm the bearer of bad news. We're at the top of the hour. And I just, would you like to make any closing remarks before I do the final housekeeping? I know we just got, it feels like we just got started. Dr. Raju, do you want to say something to wrap up? So first of all, I want to thank my co-moderator, Des, my esteemed colleagues, Aiko and Sonali for presenting, for opening at least my eyes on sustainability and endoscopy. And we have learned a lot. We have a lot of work cut out for us. And I hope this presentation will help energize a lot of young guys to take up sustainability projects almost on the same league as QI projects. And there is a lot of room to publish in this area. It's relatively new. You don't have to quote anybody and you can actually make an improvement in healthcare and in sustainability. And with that, I want to thank everyone. Thank you. Thank you, Raju. Thank you, Des, Sonali. Thanks, Al. So thank you to our presenters, our moderators, and to you, our audience. As a reminder, a recording of this session will populate your GILeap account when it is available. On screen is a view of the ASG Sustainable Endoscopy webpage. This is where we're going to post those two first papers that Dr. Paul was speaking of. We encourage you to bookmark this page as we will be updating it regularly. Again, that is a paper series that will come out. So we know we'll have the paper series and much more to post on there. This concludes the presentation on creating an environmentally sustainable practice. We hope this information is useful to you and your practice.

sustainability

healthcare

sustainable clinical practice

environmental impact

patient empowerment

prevention

lean practices

endoscopy practice

resource use

waste management