Health care organizations are recognizing more and more that environmental sustainability is a priority for reducing operating costs, improving efficiency, and building resilience. But in most health systems, sustainability is typically the responsibility of facilities, procurement, energy management, or environmental stewardship teams, with little connection to the clinical and operational groups that manage quality improvement efforts. Although these departments all seek to improve health and make care more effective, they typically operate as silos, with separate reporting structures, teams, and leadership.
This makes it more challenging for health professionals, quality improvement specialists, and health care executives to understand that sustainability and quality are deeply interconnected.
But with climate change increasingly affecting the health of patients and communities, sustainability can no longer be viewed solely as an operational or facilities issue. Many decisions that determine patient outcomes, safety, efficiency, and value also have significant impact on sustainability. For instance, clinical decisions on, for instance, diagnostic testing, medications, procedures, anesthetic gases, supply chains, and care pathways can affect health care’s environmental footprint.
Sustainability has been proposed as a seventh domain of clinical health care quality, along with the other six domains: patient-centeredness, safety, timeliness, equity, effectiveness, and efficiency. But it also fits within each of these. At the health system-level, sustainability has also been proposed as an additional aim beyond the original “Triple Aim” of enhancing patients’ experiences of care, improving population health, and reducing the cost of health care. However, sustainability is likewise integral to the existing Triple Aim, and particularly relevant to reducing costs. Quality improvement initiatives that aim to provide better preventive care, diagnosis, and treatment may also promote sustainability by reducing wasted resources (e.g., medical equipment and supplies, miles driven by the patient to attend visits, days in the hospital). Conversely, sustainability initiatives can improve patient health and outcomes. Reducing unnecessary use of energy-intensive CT scans, for example, would eliminate excess radiation risks and reduce patients’ risk of future cancers. Sustainability is and should be a core component of quality.
Examples of such integration are beginning to emerge. In England, the National Health Service (NHS) has established greener clinical pathways that illustrate how sustainability can be incorporated into evidence-based clinical care. Rather than treating carbon reduction as a separate objective, these pathways redesign care to improve patient outcomes and reduce environmental impacts simultaneously. One pathway focuses on decarbonizing urinary stone care through stone prevention via modifiable risk factors, acute symptom management, improving decisions about procedure choices and their emissions, and streamlining follow-up care, including the use of virtual care. By examining the entire patient journey, the NHS pathways approach identifies opportunities to eliminate low-value care, improve efficiency, reduce waste, and lower emissions — all while maintaining or improving patient outcomes.
Health systems can develop and implement sustainability initiatives using the same quality improvement infrastructure they have relied on for decades: multidisciplinary clinical teams, evidence-based clinical pathways, continuous measurement and improvement, and use of structured improvement methods such as Plan-Do-Study-Act cycles and Lean health care. Health care already possesses the operating system needed to integrate sustainability into routine clinical care.
Recent experience suggests that many organizations are ready to make this transition. In May 2026, at the largest health care sustainability meeting in the U.S. (i.e., CleanMed), a small session to discuss sustainability-oriented quality improvement projects turned into a standing-room-only meeting. Participants presented practical initiatives that simultaneously improved patient care and reduced environmental impacts, demonstrating both strong interest and considerable innovation. These efforts also highlighted the current state of the field. Promising projects remain scattered across organizations, are rarely scaled, and too often depend on individual champions rather than being integrated into the health systems’ quality improvement portfolios.
Achieving scale and integration will require a new generation of quality measures. Many existing measures were developed to improve patient outcomes and experience, not environmental performance. For example, we measure chronic disease prevention and control, hospital length of stay and readmissions, and hospital-acquired conditions, but not the sustainability of clinical care pathways. We do not measure or incentivize actions that promote both quality and sustainability, such as the conversion from intravenous to oral regimens for eligible patients, which can reduce length of stay, protect patients from toxic chemicals, and promote sustainability through waste reduction. For sustainability to become fully integrated into health care quality, payers and accrediting organizations should use quality measures that promote the efficient stewardship of energy, materials, pharmaceuticals, medical devices, and other resources alongside traditional measures of safety, effectiveness, and patient outcomes.
Health systems should convene sustainability leaders, quality improvement teams, clinical leaders, and population health programs to identify opportunities where quality and sustainability reinforce one another.In addition to improving patient care, many of these opportunities will also reduce costs.
The next chapter of health care sustainability cannot be written by environmental departments alone. Sustainability must be embedded within the quality infrastructure. It is time for quality and sustainability leaders to break down organizational silos and use integrated approaches that promote healthier patients, healthier communities, and a more sustainable health care system.
