The sustainability audit: Performative or transformative, the choice is ours

“We'll go down in history as the first society that wouldn't save itself because it wasn't cost effective.” This Vonnegut quote contextualizes our climate change catastrophe; relative global inertia where concentrated greed prevails over addressing the welfare of our communities. This commentary will address the zoomed out (“bird's eye”) view of the problem, next will consider the zoomed in (“worm's eye”) view, and will end with considerations for next steps, implementation of local quality initiatives. Doerr's book Speed & Scale provides a bird's eye vision and plan for transition to sustainable energy use, which addresses both technical and social policy issues. People can evaluate, discuss, and debate the technical issues proposed by Doerr, with relative ease and clarity. However, the social policy issues are complex, abstract, and more difficult to grasp. Addressing these complex issues are necessary “to turn movements into action.”1 Doerr notes studies that found transformative change possible when 3.5% or more of the population is involved in a nonviolent political movement. Because the dominant global form of capitalism is structured to serve power and greed rather than thriving communities, to enable a sustainability vision like Doerr's, a new form of capitalism is needed. The economist Mazzucato proposes “Mission Economy,” asserting: “In it [the book] I have argued that tackling grand challenges will only happen if we reimagine government as a prerequisite for restructuring capitalism in a way that is inclusive, sustainable, and driven by innovation. First and foremost, this means reinventing government for the 21st century—equipping it with the tools, organization and culture it needs to drive a mission-oriented approach…. The reason for the emphasis on rethinking government is simple: only government has the capacity to bring about transformation on the scale needed.”2 This is not a new idea, and Mazzucato uses the example of the US Government's NASA led mission in the 1960s to send a person to the surface of the moon and back. Consequently, “mission capitalism” can inspire a global social movement whose chief mandate is for our governments to lead, take risks, and co-create a market economy tilted toward the kind of economy that innovates, and drives international solutions and actions. As an example, addressing the engineering challenges of slowing polar melting could be one of many productive international mission-oriented actions. In addition to the large-scale change at national levels, transition to sustainability also relies upon global scaling numerous bottom-up local level initiatives such as those proposed by Romano and colleagues.3 Their study estimates the financial savings for three common general surgical operations; however, if they had included all surgical operations, then the gains would likely be about 10 times greater, demonstrating an impressive financial and ecological impact. To achieve these gains, they focus on accurate sorting and separating waste as hazardous, nonhazardous, and nonhazardous recyclable. Even larger gains could be achieved if anesthetic waste were included and if there were additional opportunities to reduce and reuse OR materials. As surgeons and leaders, Romano and colleagues impart the first steps to providing local actions that we can all take toward sustainability. They conclude: “There could be a great potential for reducing environmental and economic footprint of the operating rooms by promoting waste recycling protocols. Surgeons are in a unique position to implement for these protocols. Interventions should be codesigned with theater staff to create a ‘green culture.’”3 We value this bold conclusion and the power of citizen engagement. One of the authors (KSG) is engaged in a similar local recycling business and provided the following five questions for consideration by Romano and surgeons who engage in their local sustainability initiatives. (1) Does the carbon footprint also address the transportation of the different waste streams to the appropriate facilities, (2) as responsible end markets are significant, where will the recycled materials end up, (3) can materials be processed locally and not transported large distances or to unknown markets, (4) who in the operating theater will organize and oversee proper and consistent sorting and separation of the materials (e.g., to recycle foot covers, the elastic band must be removed), and (5) will chemical recycling be used and performed responsibly, noting that this is controversial practice? Tackling these issues and other similar issues, which may emerge within the different local contexts, will help surgeons adapt when implementing their version of Romano's work. Because organizational change initiatives face resistance and usually grimly underperform, we suggest surgeons strive to tackle this truth. High levels of workplace burnout and turnover emphasize the importance of making sense of the employee experience. Numerous change management frameworks exist, including a recent report by Ko and colleagues, which provides a literature synthesis and recommendations for surgeon led local quality initiatives.4 While this and similar work can be helpful, there does not exist a framework guiding surgeons on HOW to implement and evaluate such strategies. In one of the author's experience (RKG), essential elements include leadership engagement as demonstrated by their behaviors and physical involvement promoting a safe, fair, and inclusive workspace and problem solving on the front lines, as both these activities build trust, without which employee engagement and team performance suffer. Further, through trialing of multiple action items, leaders interacting with employee networks can then add intentionality around supporting the initiatives that they are working. By these acts, a positive reinforcing cycle emerges. Focusing on human interactions and monitoring and addressing the emergence of novelty (in this complex system) and limiting the use of the traditional reductionist methods to tasks where all the interactions and effects are predictable and known (in an ordered system) are additional important principles. In other words, how leaders act, what they value, and what they support as well as fostering high functioning team interactions in the workplace can produce high levels of employee engagement and authenticity. Repeating these experiences moving toward desired goals, then drives local culture shifts and meaningful change or, in the words of Nelson Mandela, “It always seems impossible until it's done.” Robert K. Goldman: Conceptualization; writing—original draft; writing—review & editing. Kathryn Goldman: Conceptualization; writing—original draft; writing—review & editing. The authors declare that they have no conflict of interest. The authors have nothing to report.