New Metrics
Yes, You Can Learn From a Regulator:
The Pitfalls of Sustainable Business Metrics, Part 17

In 16 earlier parts of this series, Claire Sommer and I developed 29 pitfalls in the sustainable business metrics field, based on the experiences of many mostly non-business fields. (Find them here.) From this point on, the series will be co-authored by Dr. Jill Lipoti.

True confession time — one of us used to be a high-level regulator, the kind you thought of as a major part of your business success (Well … maybe not). Now she’s a sustainability consultant and lecturer at Rutgers University. She learned a lot as a regulator, with a surprisingly long history with internal metrics debates, development, and use in government even before it became so topical in business. And she is finding — believe it or not — that a lot could be applied within business.

The first thing she learned in her former hat is you can have a large positive impact on an industry sector if you both measure the right things and use that information to guide your policy actions. It is important to follow industry trends and to evolve regulatory strategies to encourage the right behavior in the private sector. This is also true within business itself.

As an example, let’s first consider when it is appropriate to look at a sector-specific set of metrics and an associated thought process that might have more general application to other business sectors.

The medical sector, which comprises about 17 percent of U.S. GDP, includes doctors’ and dentists’ offices, chiropractors, and hospitals. A recent report by the American Society of Healthcare Engineering examined sustainability in hospitals, with an emphasis on efficiency. The focus within the healthcare sector has been on energy, water and waste (e.g., minimizing “red bag” waste). The metrics are just like any other business might use, with energy providing the largest measurable cost saving. However, additional sustainability initiatives such as the use of environmentally preferable cleaning products have enhanced the patient’s experience. Hackensack Medical Center is a leader in this area, and the first hospital to join the American Sustainable Business Council. But while it is important to limit patient and worker exposure to toxic chemicals, particularly for patients with compromised immune systems, when we limit our metrics to these areas we miss the body of literature that discusses trends in diagnostic and therapeutic uses of radiation, an area we don’t usually associate with sustainability — but should.

The radiation dosage to the U.S. public has been increasing; this has implications for cancer causation. Without considering radiation dosage, we miss an important element in the system for measuring sustainability in the medical business. This kind of thing, albeit not necessarily radiation per se, can be true in any other business, as well.

Pitfall 30: If energy, water, and waste are the only metrics used, businesses could be missing the need to develop sector-specific metrics,

such as for radiation issues in the medical sector. As you read below about the relevance of radiation exposure to the medical sector, consider whether there are metrics specific to your business sector that have been similarly overlooked — even if you had once done that. Sector-specific professional societies can help sustainability professionals identify trends that may have been minor in the past, but now could have a profound effect on your customers or community.

In 1980, the National Council on Radiation Protection and Measurement found that medical sources constituted only 15 percent of the average annual exposure to ionizing radiation in the United States. The average person was exposed to about 3.6 mSv annually. The study was repeated in 2006 and the NCRP found that medical exposure had grown to over 50 percent of the average annual exposure, with the average person exposed to 6 mSv/year. In 26 years, the average exposure almost doubled, because of medical exposure.

Estimate of changes in U.S. radiation exposure

The use of radiation in medical settings certainly has distinct benefits. Various conditions can be detected, diagnoses made, and treatment begun without the need for surgery (with its inherent risk). X-ray, CT, nuclear medicine, and fluoroscopy are commonly used. Ultrasound and MRI do not use ionizing radiation and are sometimes good alternatives. But how much radiation is too much and when is the use of radiation necessary? Clearly, some metrics would be useful for monitoring dosage, both individually and cumulatively.

One communications challenge is the units that express the metrics in this area are difficult to understand. An excellent article by MIT physicists for laypersons helps put mSv in perspective:

A radiation dose of 500 millisieverts (mSv) or more can begin to cause some symptoms of radiation poisoning. By way of comparison, the average natural background radiation in the United States is 2.6 mSv. The legal limit for annual exposure by nuclear workers is 50 mSv.

So when we say the average radiation dose to a person in the U.S. has increased from 3.6 mSv to 6mSv/year, it may seem trivial compared to the dosage limit for a nuclear worker (presumably a healthy person between 18 and 60 years old) of 50 mSv. However, if we consider that the average dose includes the entire U.S. population, those who are sick and seeking medical treatment could easily be getting more than 50mSv. Many common medical procedures expose the patient to doses of 2-25 mSv per examination.

In the United States, the federal government regulates x-ray machine design and manufacture, but states regulate of x-ray machines in use. In New Jersey, a change in the metric used occurred with a new regulatory strategy in 2000 which de-emphasized prescriptive metrics (e.g. timer accuracy) and focused on performance metrics. Regulators focused on two key parameters: radiation dose and image quality. The idea was to optimize dosage so that just enough radiation was given to the patient to provide a good diagnostic quality x-ray, with no unnecessary radiation beyond that. This provided additional positive effects, including allowing comparisons between medical practices, providing benchmarking for radiation doses, allowing the identification of outliers, and motivating the industry to consider cumulative dosage to patients. Business benefits included fewer repeat x-rays, less wait time for patients, improved office efficiency, and protection of company reputation.

Pitfall 31: Benchmarking and identifying trends are most useful if they lead to a comprehensive plan to reverse an adverse trend.

Pitfall 32: Involving multiple disciplines in the development of a metric helps ensure it can be used in a variety of settings to motivate important, sometimes innovative changes.

Unnecessary radiation can be thought of in terms of unnecessary or excessive procedures. The American College of Radiology has developed "appropriateness criteria" that guide physicians in making the most appropriate imaging or treatment decisions for specific clinical conditions. It may be that a particular condition can be diagnosed using ultrasound or MRI which do not expose the patient to any ionizing radiation. If so, the radiation dose can be totally eliminated.

Unnecessary radiation can also be the result of using x-ray settings designed for adults on children, who are much smaller and do not require the same dose for the x-ray to penetrate the body. The "Image Gently" campaign began in 2006 as an effort to build an alliance to change practices by raising awareness of opportunities to lower radiation dosage in the imaging of children. They have grown from 13 organizations in 2008 to 91 organizations, reaching millions of people worldwide with their campaigns. Their posters and other materials are very creative and serve to spark discussions between parents, physicians, and other health professionals.

Pitfall 33: While getting the international community involved as part of your metrics-informed Action Plan can be challenging, having a global reach, perhaps through your trade association, can address problems in developing nations before they become a big problem such as may have happened in developed countries.

Image Gently is known worldwide. AfroSafe, a campaign developed by the Pan African Congress of Radiology and Imaging (PACORI) and other radiation health workers in Africa, was launched in Kenya in February 2015. Their goal is to ensure that all radiation-based medical procedures in Africa are beneficial to the patient.

Pitfall 34: Stay tuned. This story is not over.

You may have to look at an entirely different metric in the future. As it takes 20 years (the latency period) for cancer to develop, and there are no markers yet identified for cancer caused by radiation versus other causes, we do not yet know the effects of the already-doubled medical radiation exposure on the U.S. population, and how much our actions will help. At this point, we can only project that limiting unnecessary radiation exposure will have a beneficial effect, as we built in a way to accommodate the benefits of absolutely necessary use.

The metrics of the future will likely bring surprises that require potentially new responses.

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