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Best environmental Practices in the healthcare sectorA Guide to improve your environmentAl performAnce

A pArtnership between:

• InstituteforEcopreneurship(IEC),

UniversityofAppliedSciencesNorthwesternSwitzerland(FHNW),

SchoolofLifeSciences(HLS)

• SustainableBusinessAssociate(sba)

• RoyalScientificSociety(RSS)

with the support of:

• Swiss Secretariat for Economic Affairs

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JordanhasanexcellentreputationintheMiddleEastandtheArabianPeninsulaforprovid-

ingadvancedandhighqualityhealthcareservices.Inordertomaintainandfurthercon-

solidatetheachievedqualitystandard,wehavetoconsidernotonlythemedicaltreatment

ofthepatientsbutalsohavetoensurethattheservicesprovidedcorrespondtonational

andinternationalenvironmentalstandards.

Topicssuchasenergyefficiencyorwastemanagementareoftenattheforefrontwhentalk-

ingaboutenvironmentalhealthissues,butgoodhousekeepingpracticesandgoodbehav-

iorofthestaffandpatientsalsohaveaninfluenceontheenvironmentalperformanceof

thehospitals.Lackingofbestenvironmentalpracticeswithinourhospitalswillimpacton

staff,patientandpopulation’ssafetyandwillalsoleadtoadditionalcostsandoveruseof

naturalresources.

It is therefore of high importance to improve the environmental management in the

healthcaresectorwithaholisticapproachandwithoutdecreasingthequalityofservices.

Atthetimeofsustainabledevelopment,thehealthcaresectoralsohastodemonstrateits

commitmenttowardscorporateenvironmentalandsocialresponsibility.

TheRoyalScientificSociety (RSS) incooperationwiththeUniversityofAppliedSciences

NorthwesternSwitzerland(FHNW)andSustainableBusinessAssociate(SBA),arecontribut-

ingtotheseeffortsthroughtheelaborationofthisguideonBestEnvironmentalPractices

in the Healthcare Sector.This guide allows a first audit of the hospital while gaining an

overviewofthestateoftheartinthefield.Itisafirststeptowardsgreenerhospitalsandit

is a tool to implement concrete actions.Thanks to the support and cooperation of two

Jordanianhospitals,itwaspossibletoincorporatepracticalcasestudiestothisguide.

Iamconvincedthattheguidewillbewellacknowledgedbyhealthcareprofessionalsand

managerswhoarecontributingtofurtherpursuetheexcellenceoftheJordanhealthcare

sector.IwishthattheirworkwillhelpimplementbetterenvironmentalpracticesinJordan

hospitalsandneighboringcountriesandthatJordancanplayapioneeringroleinthisfield.

foreword – ministry of HeAltH in JordAn

Dr.NayefAl-FayezMinisterofHealthinJordan

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BestEnvironmentalPracticesintheHealthcareSector

Thehealthcaresectorandespeciallyhospitalsaccountforamassive,butoftenneglected

orevenignoredimpactontheenvironmentandfacehighcostsforuseofenergy,water

anddisposalofmaterial(waste).Otherissuesalsoinfluencesafetyandqualityofservices

provided.Inarecentpaper,theWorldHealthOrganization(WHO)stated:„Weknowthat

climatechangehasthecapacitytoproducesevereconsequencesforhumanhealth.We

alsoknowthatthehealthsectorcanplayapivotalroleinhelpingnationsacrosstheglobe

adapttotheseseriousconsequences.Thispapercouldnotcomeatamoreimportantmo-

ment.“Thisstatementdemonstratestheimportanceandtheinternationalwillingnessto

adoptBestEnvironmentalPracticesintheHealthcareSector.

IntheframeworkoftheCleanerProductionprojectimplementedinJordanbytheRoyal

ScientificSocietyaswellastheFHNWandSBA,theSECObelievesthatthehealthcaresector

is an important field for improving resource management and minimizing negative im-

pactsontheenvironment.Thereishenceaneedforgreenerhospitalsthatareattheheart

ofthehealthcaresector.Withoutcuttingonpatients’safetyandcomfort,manyeffortscan

bemade inthebackstagebythehospitalmanagementthroughtheapplicationofbest

availablepracticesandtechnologicalinnovations.

ThisGuideisdesignedtobeapracticaltoolfordailyimplementation.Itfillsthegapbe-

tweencommitmentstosustainabledevelopmentandtheundertakingofconcretemea-

sures.Bysuggestingeco-efficiencypracticesandprovidingeasy-to-implementtools,the

Guidewillenablehospitalmanagementtohandleandbenchmarktheenvironmentalas-

pectsrelatedtoitsbusiness.Additionally,theGuideinvolveshospitalstaffaskeygreening

actorsandprovidesagoodbasisforintegratedenvironmentalmanagementsystems.

Inafewyears,itiscertainthatenvironmentalprotectionwillbecomealegalobligationfor

hospitals.Let’sbeproactiveandstartfromthismomenton!Thosewhoactfirstwillbeable

toanticipatethelawandwillacquireacompetitiveadvantage.Itistimeforthehealthcare

industrytoacceptitsenvironmentalresponsibilitiestoreducetheenvironmentalimpactof

itsoperations.

HanspeterEgler,HeadoftheTradePromotionDivisionSwissStateSecretariatforEconomicAffairs

foreword from tHe swiss stAte secretAriAt for economic AffAirs

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Thisguideistheresultofintensiveresearch,discussions,hospitals

auditsandassessments,interviews,masterthesis,fieldstudiesand

visitsbothinSwitzerlandandinJordan.Manyactorswereinvolved

inthischallengingprocessandthepartnerswouldliketoacknowl-

edgethemhere.

Theelaborationofthisguidewasonlypossiblethankstotheactive

cooperationofstakeholdersinJordanandinSwitzerland.Among

these in Switzerland: Mr. Raymond Schelker (Schelker Environ-

mental Consulting), Mrs. Sylvia Spahr (University Hospital Basel),

Mr.MarkusLoh(Viamedica,Germany),Mrs.MarieChristineLadouce

(Ladouce Enviromental Management), Mr. Jean-Luc Calantonio

(Inov3),Mrs.Borghini-Polier,Mr.AlainRobertandMr.Pyroth(Uni-

versityHospitalLausanne),Mrs.AndreaBeetschenandMrs.Möller

(Hospital Bülach), Mr. Claus Wittel (Hospital Frauenfeld), Mr.

ReinholdWerlein (SwissTropical and Public Health Institute) and

Mr.DanielHänny(Energho).

InJordan,theparticipationofthefollowingpeoplecontributedto

the success of this guide, namely Mr. Abdullah Ahmad Heyasat

(MinistryofHealth,EnvironmentHealthDirectorate),Dr.KhaderBa-

tah(HeadofServices,PublicHealthandEnvironmentDepartment

of a Jordanian public hospital) and Ms. Joumana Suna’a (Quality

Officer inaJordanianprivatehospital).Furthermore,Mr.Haitham

Adas, Mr. Alaa Qihewi and Mr. Nidal Abdullah from the Jordan

National Energy Research Centre also contributed for the energy

efficiencyissuesinthetwoauditedhospitals.

WhileMr.EmmanuelOertlé,Mrs.OlgaSteigerandProf.DieterMutz

fromtheUniversityofAppliedSciencesNorthwesternSwitzerland

ensured the overall coordination, the guide was realised in close

cooperationwithMrs.MajdoulaineSemlaliWazner,Mr.GaëlCroisier

and Mr. Karim Zein from Sustainable Business Associates and

Mr.NajeebAtiyat,Mr.SalahAbuSalah,Mr.AhmadAbuSafa, Mr.

MohamadMosaandMr.RafatAssifromtheJordanRoyalScientific

Society.

ThepartnerswouldalsoliketoparticularlyacknowledgeMr.Farouq

Omari,masterstudentat thePrincessSumayaUniversityofTech-

nologyinJordanandMr.WolfgangRoenner,masterstudentatthe

UniversityofAppliedSciencesNorthwesternSwitzerlandfortheir

inputandadvicesforthedevelopmentofthisguide.

AcknowledGments

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0 Glossary 6

1 introduction and Concept 8

1.1 Structureoftheguide 10

1.2 Proposeduseoftheguide 11

1.3 CleanerProduction 12

1.4 Conceptofbestenvironmentalpracticesinhospitals 13

1.5 Descriptionofrelevantstakeholdersandassociations 14

1.6 WhatmakesahospitalspecialfromtheCPpointofview 15

2 Know the facility 15

2.1 Datacollectionandmetering 16

2.2 MaterialandEnergyFlowAnalysis(MEFA) 17

2.3 KeyPerformanceIndicators(KPIs)andKeyFigures 17

Assess the facility – the Different Divisions 20

2.4 Administration 20

2.5 Cafeteria&FoodService 21

2.6 Gardening&Outdoors 21

2.7 Laboratories 22

2.8 LaundryServices 23

2.9 PatientCare 24

2.10 Pharmacy 25

2.11 Cleaning&Disinfection 26

3 focus on selected issues 27

3.1 EnergyEfficiency 27

3.2 WasteManagement 29

3.3 WaterConservation 31

3.4 GoodHousekeeping&Behavior 33

3.5 ToxicMaterials 34

3.6 GreenPurchasing 37

4 Decision-making and corrective Measures 38

5 how to implement Cp in a sustainable and successful way 44

6 Case studies 45

6.1 JordanPublicHospital 45

6.2 JordanPrivateHospital 49

6.3 InternationalCaseStudy 53

7 references 57

Appendix 1 – General questions, preliminary energy audit questionnaire 58

Appendix 2 – Checklists 62

Appendix 3 – Matrix 87

Appendix 4 – Action plan 89

content

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ACtion plAn A detailed plan identifying corrective actions,

means,responsibilities,resources,andthetimeframenecessaryfor

theirimplementation.

ApproAChThemethods,proceduresorprocessesusedbyanor-

ganisationtoachieveitsobjectives.

bep / bephs Best Environmental Practices / Best Environmental

PracticesintheHealthcareSectorarethemostsustainableanden-

vironmentallyfriendlyproceduresavailableinahospital.

CleAner proDuCtion (Cp) CPisthecontinuousapplicationof

an integrated preventive environmental strategy applied to pro-

cesses,productsandservicestoincreaseefficiencyandreducerisks

forhumansandtheenvironment.(UNEP,1990)

Continuous iMproveMent A process of progressively en-

hancing the environmental management system to achieve im-

provementsintheoverallenvironmentalperformanceinlinewith

thehospital’senvironmentalpolicy.

eCo-effiCienCyAconceptthatconsistsinofferingcompetitive

goodsandservicesthatmeethumanneedsandguaranteequality

oflife,whileatthesametimeprogressivelyreducingthewhole-life

ecologicalimpactsandresourcedemandsoftheproducts,untila

level at least compatible with the earth’s estimated capacity is

reached.

environMent It is the natural area surrounding the organiza-

tion,includingair,water,soil,naturalresources,flora,fauna,human

beings,andtheirinteractions.

environMentAl iMpACt Anymodificationoftheenvironment

whethernegativeorpositive,totalorpartial,resultingfromtheac-

tivities,productsorservicescarriedoutbytheorganization.

environMentAl MAnAGeMent systeMStructure, organi-

zationandmanagementmethodsimplementedtomeettheorga-

nization’s environmental policy. The goal is continuous improve-

ment.

environMentAl poliCyOrganizationcommitments,orienta-

tions,andgeneral objectiveswithrespecttotheenvironmentas

decidedbymanagement.Observingexistinglawsandregulations

isan integralpartof thispolicy,aswellas theenvironmental im-

provementstrategy.

first-in, first-out teChnique Meansthattheoldestinven-

tory itemsareusedfirst.Appliedtopharmaceuticalor foodstock

thistechniqueleadstolessunnecessarydisposalofgoodsdueto

expiring.

hAzArDous wAsteWastewhichbecauseof itsquantity,con-

centration,orphysical,chemical,orinfectiouscharacteristicsmay:

poseasubstantialpresentorpotentialhazardtohumanhealthor

theenvironmentwhenimproperlytreated,storedordisposedof,or

otherwise mismanaged; or cause or contribute to an increase in

mortalityrate,oranincreaseinirreversibleorincapacitatingillness.

infeCtiousBio-hazardous,whichhavequalitiesthatmaycause

infection.Itcontainspathogens,includingbacteria,viruses,rickett-

siae, parasites, fungi or recombinant micro-organisms that are

known,orreasonablyexpected,tocauseinfectiousdiseaseinhu-

mansandanimalsthatareexposedtothem.

irritAnt It isachemical,whichmaycausereversibleinflamma-

tiononcontact.

Key perforMAnCe inDiCAtor (Kpi) A specific expression,

quantitativeorqualitative,whichprovidesinformationontheper-

formanceofacompanyororganization.

MeDiCAl wAsteAllwastethatcomesoutfromhealthcareactivi-

ties.Itincludes„no-risk“waste,medicalriskwasteandmedicalhaz-

ardouswaste.

0 GlossAry

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MiniMizAtionActionstoavoid/reduceorinotherwaysdiminish

thehazardouswasteattheirsource.Recyclingisnotaminimization

techniquebutisoftenincludedinsuchprogramsforpracticalrea-

sons.

non-hAzArDous wAsteAnywastehavinganatureandcom-

positionthataresimilartothoseofhouseholdwastes.Furthermore,

thehandlingandstorageofsuchwastepresentnoparticularrisks.

Suchwastemaybegeneratedbyindustry,commerce,workshops

oragriculturalactivities.

poisonous A substance that adversely affects one‘s health by

causinginjury,illness,ordeath.Theseareoftenmarkedwithskull

andcrossbones.

reCyClinGRecuperationofmaterialsorproductstoreusethem

eitherintheiroriginalformorasaninputmaterialinamanufactur-

ingprocess.

stAKeholDersAnindividualoragroupconcernedwithoraf-

fectedbytheperformanceofanorganization(employees,govern-

mental authorities, NGOs, clients, neighbors, research centers,

chambersofindustry,suppliers,etc.).

supplierTheproviderofaproductorservicetotheorganization.

sustAinAble DevelopMent Development that meets pres-

entneedswithoutendangeringtheabilityoffuturegenerationsto

meettheirownneeds.Sustainabledevelopmentiscontrastedwith

other modes of development that lead to social and ecological

damage,atboththelocalandgloballevels.

toxiCAnysubstanceproducingaharmfuleffectonlivingorgan-

ismsor theenvironmentbyphysicalcontact, ingestionor inhala-

tion.

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BestEnvironmentalPracticesintheHealthcareSector(BEPHS)isa

subjectwhichisacquiringmoreandmoreconsiderationbyhealth-

care professionals, public authorities and donor agencies. The

healthcare sector and especially hospitals account for a massive,

butoftenneglectedoreven ignored impacton theenvironment

andfacehighcostsforuseofenergy,wateranddisposalofmaterial

(waste).Other issuesdescribed in thisguidealso influencesafety

andqualityofservicesprovided.Inarecentpaper(HealthyHospi-

talsHealthyPlanetHealthyPeople.Addressingclimatechange in

health care settings WHO 2008), the World Health Organization

(WHO)stated:“We know that climate change has the capacity to pro-

duce severe consequences for human health. We also know that the

health sector can play a pivotal role in helping nations across the globe

adapt to these serious consequences. This paper could not come at a

more important moment.” Thisstatementdemonstratestheimpor-

tanceandtheinternationalwillingnesstoadoptBestEnvironmen-

talPracticesintheHealthcareSector.

It is of high importance to notice that actions and measures to-

wards “greener” hospitals must not be understood as restrictive

practicesorasabarriertoqualityofserviceandcomfortofpatients

butonthecontraryasanenrichingandchallengingvisionforlead-

ing hospitals. In fact, the implementation of best environmental

practicesgoeshandinhandwiththeimprovementofsafety,qual-

ity,costsavingsandimprovementofstaffandpatient’shealthpro-

tection.BEPHSasawholeshouldbeunderstoodasa“green pack-

age” proposingaholisticapproachforthehealthcaresector.BEPHS

allowsidentifyingareaswithimprovementpotentialsandtherefore

leads to different kinds of positive impacts and benefits listed in

table1.

sAfety benefits

• Betterhandlingofhazardousandtoxicmaterials

• Awarenessraisingofthestaffandpatients

• Betterandsaferwastemanagement

• Reductionofthenumberofaccidentsandinjuries(e.g.needles)

eConoMiC benefits

• Improvementofefficiency(technological,energetic,

buildingandstaff,reductionoflosses)

• Costreduction(e.g.energypricesareandwillcontinue

increasinginthefuture,highcostsofwastedisposal)

• Improvementofmanagementpractices(e.g.greenpurchasing)

• Reducedturnoverandhigherproductivityofstaff

environMentAl benefits

• ReductionofCO2emissions

• Betterresourcesmanagement

• Watershortageabatement

• Reductionofairpollution

• Climatechangemitigation(e.g.abigamountofelectricity

inJordanisgainedfromoil)

heAlth AnD soCiAl benefits for stAff AnD pAtients

• Improvementofhealthimpact(e.g.airquality)

• Decreasedlengthofstayinhospital

• Nosocomialinfectionreduction

• Awarenessraising(e.g.trainings)

• Motivationincreasethroughinvolvementofstaff

Table1:BenefitsofBestEnvironmentalPracticesintheHealthcareSector(BEPHS)

1 introDuCtion AnD ConCept

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ThisguideforBEPHSisdesignedtofacilitatetheimplementationof

environmentalmanagementpracticesinhealthcarefacilities.Itisa

firststeptooltoimplementCleanerProduction(CP,seesection1.3)

inthehealthcaresector.Itprovidesthemeanstoidentify,inthedif-

ferenthospitaldepartments,opportunitiesforoptimizinghospital

activities while reducing operating costs and environmental im-

pacts.TheBEPHSisintendedtobesimpleandpracticalandhasfol-

lowingobjectives:

• ToprovideasimpleoverviewofCPinhospitalsasentrypointfor

moredetailedassessments

• Tocategorizeanddescribemainsubjectsthatshouldbeconsid-

eredinanenvironmentalaudit

• Tofosterenvironmentalactioninhospitals

• TostimulateawarenesscreationonCPpotentials inhealthcare

facilities

• TosupportafirstCPassessmentwithbasictools(checklists)

• Tofulfillafunctionofplatform(orentrypoint)fordiscussingthe

issue of green health at various levels of decision making and

amongdifferentnationalandinternationalorganizationsactive

inthesector.

The BEPHS guide can be implemented by hospital management,

technical executives or qualified resource persons. Management

mustfirstadheretotheguide’sobjectivesandinvolvetherelevant

staff.Ifinternalexpertiseisinsufficientforundertakingthistask,the

assistance of an external consultant can be sought. The target

groupsofthisguidealsoincludeCPexpertsandpublicauthorities.

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seCtion

1

2

3

4

5

6

7

8

A1

A2

A3

A4

Content

IntroductionoftheBEPHSconceptandhow

tousethisguide

Introduction to data collection and meter-

ingbyapplyingKPIandMEFA

Presentationofthehospitalsdivisions

Focusonselectedenvironmentalissues

Economiccalculationasadecision-making

tool

Suggestions forasustainableandsuccess-

fulCPimplementation

References

Two Jordanian and one international case

study

Preliminary environmental audit question-

naire

Checklists

Matrix

Actionplan

objeCtives / use

Awarenessraisingforthenecessityandthebenefitsofimplement-

ingcleanerproduction.

Provides a method to overview and understand the processes of

hospital activities. It allows situating the hospital status against

similarhospitalsaswellasmonitoringprogressesofBEP.

Introductiontothedivisions`specificitiesandchallengesconcern-

ing CP with“good practice examples” and references for further

reading.

Descriptionofrelevantkeyissueswithsomeexamplesandsugges-

tionsforimprovingtheenvironmentalperformance.

Description of calculations (with examples) to be realized before

optionsimplementation.Itallowsdeterminingtherequiredinvest-

ments,costssavingsandpaybacktime.

Providesalistwithtipsandincentivestoovercometypicalobsta-

clesandtohelpimplementsuccessfullysustainablemeasuresina

hospital.

ListoffurtherinformationaboutBEPHS.

Thecasestudiesareselectedexamplesof twoCPassessments in

JordanandofanimplementationofBEPinahospitalinUSA.

Tablestobefilledoutfordatacollectionbeforethefirstassessment.

Thechecklistsarequestionsforafirstfieldvisitinahospital.They

canbeusedto identifytheenvironmentalproblemsandareasof

improvementineachhospitaldepartment.Thechecklistsareeasy

touseandcaneasilybephotocopied.

Providesatabletobefilledafterfieldvisitasasummaryofoutputs.

Itcanbeusedasabasisfordiscussionwiththemanagementteam

ofthehospital.

Providingactionplanformthatcanbeeasilyadaptedforplanning

theimplementationofselectedmeasures.

1.1 structure of tHe Guide

Table2:Thestructureoftheguide

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• Forselectedareas, identifyCP-optionsandproceedto theneces-

sarycalculation(seemethodologyinsection5).Ifeverybodyagrees,

prepareanactionplanasperformatprovidedinAppendix4.

• Make sure that the actions are monitored and that progress is

measured and documented. If possible, accompany CP imple-

mentation with training sessions in order to inform the staff

aboutwhatyouaredoingandwhy.

use CAse 3:

referenCe DoCuMent

Thegoaloftheguideistobeeasilyaccessibleandeasytoreadwith

directaccesstoneededinformation,resourcesandreference.The

guide should thus be a working tool for every healthcare profes-

sionalwithenvironmentalconcern.

use CAse 1:

AwAreness rAisinG on bephs AnD

proMotion of the ConCept

Readers interested in these aspects should mostly use the first 7

sectionsoftheguideasabasisfordiscussionandcapacitybuilding.

Theguidecanalsobehandedovertointerestedpartiestopromote

theconceptofCPinhealthcaresector.

use CAse 2:

support for A prACtiCAl AssessMent of

A hospitAl, either ConDuCteD internAlly or

with support of Cp-experts

The checklists and the different appendices of the guide allow a

fast,completeandpracticalassessmentofahospital.Forusersof

thisguide(internorextern)aimingatassessingafacility,thefollow-

ingmethodologyisproposed:

• Read the guide to learn about the different issues.You can al-

ways come back to specific issues and/or further information

upontheneedsidentifiedduringtheassessment.

• Organizeafieldvisitinthehospitalofdurationbetweenoneand

twodays,dependingonthesizeandcomplexityofthefacility.

Thevisitshouldstartwithameetingwithmanagersofthehospi-

tal,whocanthendelegatethefieldvisitstothedifferentrespon-

siblepersons.

• Before your field visit in the hospital, you can already transmit

theAppendix1tothecontactpersons,sothattheyalreadygath-

erthenecessarydata.

• Duringyourfieldvisit,trytoanswerallthechecklists(inAppen-

dix2)keeping inmindyourobjectives,namely,measuringthe

environmentalperformanceofthehospitalandidentifyingpo-

tentialareasforimprovement.Also,duringthefieldvisit,system-

atically insistonthe fact thatyouarenotproceedingtoan in-

spection.Itisalsoadvisedtotakepictures,ifauthorized.

• Afterthefieldvisit,fill inAppendix3anddiscussyouroutputs

withthemanagementofthehospital.Togetheryoucanidentify

areaswheretheimplementationofBEPHSshouldbestarted.

1.2 proposed use of tHe Guide

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Asaresultofthenon-sustainabledevelopmentandrapidgrowth,

considerable environmental problems and challenges emerged in

different economical sectors. Given the increasing importance of

environmentalissues,appropriatestrategiesandadaptedmeasures

are needed. In that respect, investing in CP will prevent pollution

andreduceenvironmentalimpacts.Itisusuallymorecost-effective

thancontinuingtorelyonincreasinglyexpensive‘end-of-pipe’solu-

tions.Infact,CPisthecontinuousapplicationofanintegratedpre-

ventiveenvironmentalstrategyappliedtoprocesses,productsand

servicestoincreaseefficiencyandreducerisksforhumansandthe

environment(UNEP 1990).Inotherwords,BEPHSistheapplication

ofcleanerproductioninthehealthcaresector.

CPactivitiesincludemeasuressuchaspollutionprevention,source

reduction, waste minimization and eco-efficiency. This can be

achievedinvariousways.Adivisioninfivepreventionpracticesis

mostcommon:

Table3:PreventionPracticesofCleanerProduction

Good housekeePinG

Product modifications

inPut suBstitution

technoloGy modifications

on-site recyclinG

Changes in operational procedures and management in order to

eliminate waste and emission generation. Examples are spill pre-

vention,improvedinstructionofworkersandtraining.

Changestotheproductcharacteristics,suchasshapeandmaterial

composition. For instance, the lifetime of the new product is ex-

tended,theproductiseasiertorepair,orthemanufacturingofthe

productislesspolluting.

Useoflesspollutingrawandadjunctmaterialsandtheuseofpro-

cessauxiliaries(suchaslubricantsandcoolants)withalongerser-

vicelifetime.

Includeforinstanceimprovedprocessautomation,processoptimi-

zation,equipmentredesignandprocesssubstitution.

Usefulapplicationofwastematerialsorpollutantsatthecompany

wherethesehavebeengenerated.Thiscouldtakeplacethrough

re-useasrawmaterial,recoveryofmaterialsorusefulapplication.

1.3 cleAner production

13


Inhealthcarefacilities,theCPapproachwillcontributetolowering

waterandenergyconsumptionsandwillimprovethewasteman-

agement.ApplyingCPknow-howmeansalsoimprovingefficiency

and adopting better management techniques. CP depends only

partiallyonneworalternativetechnologies.Itcanalsobeachieved

through improved management techniques, different work prac-

tices and many other‘soft’ approaches. CP is as much about atti-

tudes,approachesandmanagementasitisabouttechnology.

Figure1:Theconceptofbestenvironmentalpracticesinhospitals

Infact,CPrequireschangingattitudes,responsibleenvironmental

management and evaluating technology options. For successful

implementation, the concept must be effectively communicated

withintheorganization.Employeesatalllevels,includingtopman-

agement,shouldbeactivelyinvolved.

Thefocusofthisguideliesinoperationsandmaintenanceofhospi-

tal facilities and not in planning, design and construction of new

facilities,althoughtheseissuesarealsorelevanttotheaimofClean-

er Production.The reason of focusing on existing facilities is the

highpotential,forexample,inthefieldofenergyefficiency.Inal-

ready existing buildings in Switzerland, for example, over 12% of

energycanbesavedwithoutsubstantialinvestmentsonlythrough

optimization,technicalcontrolandtheimprovementofworkpro-

cesses.

1.4 concept of best environmentAl prActices in HospitAls

14

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heAlth CAre without hArM (hCwh)

HCWHisaninternational coalitionthatguidesthehealthcaresector

tomakeenvironmentallypreferredpracticesandpolicies,without

compromisingpatientcareorsafety,sothat it isecologicallysus-

tainableandnolongerasourceofharmtopublichealthandthe

environment.

HCWHprovidestechnicalassistance,productresearch,support,ad-

vocacy, and education. Its goals include safer products, materials

andchemicals;alternativestoincineration;greenbuildingandop-

erations;sustainablefoodsandfoodsystems;andsafeandhealthy

placesforworkersandpatients,sothatthehealthcaresectorcan

becomeatruehealingenvironment.

www.hcwh.org/europe

prACtiCe GreenheAlth

Practice Greenhealth is a US networking organization for institu-

tions in the healthcare community, formed out of Hospitals for a

Healthy Environment (H2E), the Healthcare Clean Energy Exchange

(HCEE)andtheGreen Guide for Health Caretoprovidetools,educa-

tionandrecognitiononenvironmentalsustainabilityinthehealth-

care sector. The following web based tools available are open

sourcebutdevelopedaccordingtoUSstandards.

Energy Impact Calculator(EIC)isformeasurementofthehealthim-

pactsandcostsofahospital’senergyuse,andenablesenergypur-

chasers to make business decisions on energy efficiency projects

andrenewableenergypurchasesbasedonafullerunderstanding

ofenergy’struecosts.

HCEE also operates a healthcare focused, web-based clean energy

and environmental commodities reverse auction platform to help

healthcare facilities contain or reduce their energy costs, lock in

morestablepricing,andbegoodenvironmentalstewards.

www.practicegreenhealth.org

sustAinAble hospitAls

SustainableHospitalsisaprojectwhichprovidestechnicalsupport

tothehealthcareindustryforselectingproductsandworkpractic-

esthatreduceoccupationalandenvironmentalhazards,maintain

qualitypatientcare,andcontaincosts.Thewebsiteoffersaccessto

manydocumentsclassifiedindifferentcategories.

www.sustainablehospitals.org

worlD heAlth orGAnizAtion (who)

WHOclaimsthatthehealthsectorcanplayaleadershiproleinmit-

igatingclimatechange.Climatemitigationcancontributetopublic

healthandsavehealthcaresystemsmoney.WHOandHCWHsug-

gest that policy-makers, health facilities and health professionals

aroundtheworldshouldconsideropportunitiesforactiontoplace

thehealthcaresectorattheforefrontofglobalclimatechangemiti-

gation.

www.who.int/topics/environmental_pollution/en

Ministries of heAlth & environMent

ForasuccessfulimplementationofBEPHS,itisimportanttoinvolve

publicauthorities,suchasministriesofhealth(MoH)andenviron-

ment(MoEnv).Theirinvolvementwillincreasethecommitmentof

hospitalsandtheacceptanceofasustainabledevelopmentvision.

Furthermore,theministriescanhaveanimpactonexistingornew

policies.TheministriescanalsobringBEPHSforwardandwithinthe

nationalstrategies.Theycanalsoenableaccesstofinancingmeans

fortheimplementationofbestpractices.

1.5 description of relevAnt stAkeHolders And AssociAtions

15


OriginallytheconceptofCleanerProductiongivesguidanceinop-

timizingindustrialproductionprocesses.ThemainaimsofCPareto

increaseproductivitybyensuringamoreefficientuseofrawmate-

rials,energyandwaterinthefirstplaceandtopromotebetterenvi-

ronmentalperformancethroughreductionatsourceofwasteand

emissions in the second place. Thus CP is keen about economic

profitabilityandenvironmentalbenefits.

Hospitalshavespecificandcomplexstructuresthatdonotbelong

totheindustrybutrathertotheservicesector.Whatmakeshospi-

talsspecialisthatthemostimportantissueinthehealthcaresector

is safety: hospital processes have to be safe for patients and the

staff.Thesecondmainconcerninhospitals istheirprofitabilityas

theyhavetobe ledeconomically.Finally, theenvironmentalcon-

cernscanbetackled.ItisthusthechallengeoftheCPconceptin

the healthcare sector to take into account the three above men-

tioneddimensionsasshowninfigure2.

Furthermore, the implementation of CP in hospitals will not de-

creasethequalityofservicesorcomfortofpatients,butratheroffer

a“greenpackage”improvingthethreedimensionsalltogether.

ThesecondchallengeaboutCPinhospitalsistheimplementation

oftheconcept.Oftentheresponsiblepersonfortheenvironmental

issues is thesameas theone forsafety, logistics,maintenanceor

engineering.Besidesthelackofhumanresourcesthestaffhaslittle

traininginCPorenvironmentalissues.Thisfactresultsinbehavior

patternswhicharenotalwaysorientedtobestenvironmentalprac-

tices.Otherobstaclesarethelackofcontrolandamissingfinancing

system.Keystoaddresstheseissuesandtoovercomeotherpracti-

calbarriersaregiveninsection6ofthisguide.

Figure2:RelevantaspectsfortheapplicationofCPinthehealthcaresector

1.6 wHAt mAkes A HospitAl speciAl from tHe cp point of view

16

h

„Data is a powerful tool. If you don‘t know what you have, how can you

prioritize your action plans, justify your programs, or report on your

success?“

Hospitals for a Healthy Environment

2.1 dAtA collection And meterinG

Data collection is considered an essential step in order to gain an

overviewofhospitalactivities,tounderstandtheprocessesinvolved,

andtoanalyzetheenvironmentalimpactsassociatedwiththediffer-

entprocesses. Incomparisonwithnormaldomesticconsumptions,

hospitalsarebigconsumersofwater(Jordanianaverage:38m3/bed/

month), electricity (average (Jordan): 5’208 kWh/bed/month) and

fuelenergy(average(Jordan):245litersofdiesel/bed/month).They

alsogenerateimportantquantityofmedicalwaste(average(Jordan):

1.5kg/bed/day)(datafromFarouqOmari2010).

Data concerning food consumption, medical supplies as well as

otherrawmaterialscanbegatheredfromthefinancialorfromthe

purchasingdepartment.Waterconsumption,dieselandelectricity

consumptioninrelationwithboilers,airconditioners,chillers,heat-

ers and refrigerators can be gathered from the maintenance and

fromthefinancialdepartments.

Incertaincases,theinstallationofmeteringdeviceswillberequired

in order to undertake measurements regarding water quantities,

temperatureorelectricityconsumptioninspecificsectionsofthe

hospital. Such measurements will help to better understand pro-

cessesinvolved.Similarly,thenumberofpatientsandtheoccupan-

cyrateinthehospitalcanbecollectedfromtheregistrationofficer.

ThesedatawillbeusefulforCPteamstocalculatethekeyperfor-

manceindicators(KPI)foreachmaterialandsupply.KPIcanthenbe

monitoredonamonthlyorseasonalbasis.

2 Know the fACility

17


2.2 mAteriAl And enerGy flow AnAlysis (mefA)

Afterthecompletionofdatacollectionandmetering(ifneeded),a

materialandenergyflowanalysisshallbemadeinordertogetan

overview of energy, materials, water and waste that may flow

throughtheprocessesofthehospital.Thiswillallowidentifyingthe

areasforpotentialimprovements.AnexampleofMFAispresented

inthisguideforwaterflowinthesection4.3(figure8).

ConductingaMEFAprovidesanin-depthunderstandingofthepro-

cesses. It clarifies detailed process steps, quantifies material and

energyconsumption,identifiesthesourcesofwasteandemissions,

anddescribes theamountofeach rawandwastematerial.MEFA

canbeusedtodescribeinefficientpointsintheprocess,todefine

measuresforCPoptimization,andtocreateadatabaselineforas-

sessingtheimprovementslinkedtotheadoptedCPmeasures(i.e.

bycomparingthesituationbeforeandaftertheimplementationof

theCPmeasure).

MefA Consist of four steps:

1. system analysis: Definitionofsystemboundariesinordertofo-

cus on auditing areas and to define reference period (month,

seasonandyear).Descriptionofthesystem;i.e.designingade-

tailedmaterialflowchartforprocesseswithinthesystembound-

aryinordertorepresenttheprocessstepsorunitoperationsby

arrowsandboxes.

2. data definition and identification: whatdatadoweneed,how

andwherecanweobtainit(e.g.measurements,existingrecords,

estimations, calculations) and who is responsible to collect or

elaboratetherequireddataanduntilwhen.Inthisrespect,itis

importantthatdataareexpressedintheadequateunitsprefer-

ablySIunits.Thequalityandreliabilityofthedatashouldalsobe

assessedinordertobasedecisionmakingonaccurateinforma-

tion.

3. calculation of material flows (input and output): This step im-

plieskeepingprincipleofmassconservation,i.e.whatiscoming

inisgoingout.

4. interpretation and conclusions: Usingfishbonediagramsisuse-

fultoidentifythecausesandeffectsofmainproblemsthrough-

outtheprocesses.

2.3 key performAnce indicAtors (kpis) And key fiGures

KPIsareasuitabletooltoinform,monitor,controlandplanallenvi-

ronmentallyrelevantactivitiesofthehospital.KPIscanalsobeused

forexternalcommunicationaswellasforinternalactorswithinthe

hospital.KPIsmostlyhavetwoobjectives:

• compare your hospital with key figurescomingfromothersimi-

larhospitalsinordertosituateyourenvironmentalperformance

(regional, national or international). Unlike in other industries,

thisobjectiveisdifficulttoattain,aseveryhospitalhasitsown

specificities, making a relevant comparison not easy. However,

such comparisons can already provide good information and

shouldnotbeneglected.

• monitor your progress towards best environmental practicesby

comparingyourKPIatdifferenttimes.(e.g.beforeandafterim-

plementationofCPmeasures)Thiscanhelppursuingthecon-

tinuous process of CP by showing the top-management that

BEPHSworksinyourfacility.

Tables4and5showhowtocalculateKPIsforelectricalenergy,wa-

ter and diesel consumption, generation of medical and domestic

waste.

18

h

IthastobementionedthattheuseofKPIandbenchmarkingisnot

verycommoninthehealthcaresectorduetodifferentreasons.One

oftheseisthedifficultytocomparehospitalswithdifferentspecial-

ties and between different countries, as standards differ highly.

However, the following table presents key figures which can al-

readygivesome ideatodeterminewhereyour facilitysituates in

comparisonwithdifferentcountries.

required data symBol unit

Electricityconsumption E kWh/month

Waterconsumption W m3/month

Dieselconsumption D liter/month

Medicalwastegenerated MW kg/month

Domesticwastegenerated DW kg/month

Totalnumberofbeds totalbedsno. beds

Occupancyrate(foronemonth) occ.rate=no.occ.beds/totalbedsno. –

Numberofdays1 no.days days/month

Table4:RequireddatainordertocalculateKPIsdefinedintable5

material key Performance indicator (kPi) unit

1.Electricity KPI=E/totalbedno./occ.rate/no.days kWh/occ.bed/day

2.Water KPI=W/totalbedno./occ.rate/no.days m3/occ.bed/day

3.Diesel KPI=D/totalbedno./occ.rate/no.days liter/occ.bed/day

4.Medicalwaste KPI=MW/totalbedno./occ.rate/no.days kg/occ.bed/day

5.Domesticwaste KPI=DW/totalbedno./occ.rate/no.days kg/occ.bed/day

Table5:HowtocalculatetypicalKeyPerformanceIndicatorsforthehealthcaresector

1ThiswillbeusedtocalculatetheKPIperday.Asconsumptionisgenerallygivenpermonth,itneedstobedividedbythenumberofdaysoftheselectedmonth.Then,theKPIcanbeeithercalculatedforaselectedmonth(valueof28,29,30or31forthenumberofdays)orcanbecalculatedfromyearlydata.Inthiscasethevalueforthenumberofdayswillbe30.

19


indicators tyPical value country

Totalsolidwaste(kg/bed/day) 4.80 Australia

8.46 USA

0.14–3.50 MiddleEast,AsiaandAfrica

1.00–4.50 LatinAmerica

Medicalwaste(kg/bed/day) 1.50–2.00 France,BelgiumandEngland.

1.10 USA

0.01–0.20 MiddleEast,AsiaandAfrica.

0.25–1.13 LatinAmerica

Totalwaterconsumption(m3/bed/day) 0.20 EasternEurope

Consumptionofelectricity(kWh/bed/day) max.6.60 Austria

Table6:InternationalKPIinSectorGuideCleanerProduction:Hospitals,ClinicsandHealthCenters,2001

20

h

The administration of a hospital usually manages and supervises

thehealthcareservices.InthisdivisionCPpotentialscanbeapplied

totheofficeareasthatoftenuselargeamountsofenergyandpro-

ducesubstantialvolumesofwaste.

relevAnt points to be ConsiDereD froM

the Cp perspeCtive

• office equipment

Officeequipment,suchascomputers,printersandotherscon-

sumeelectricpowerevenwhentheyarenotinuse.Encouraging

stafftoturncomputersoffatnightandonweekendsisthemost

effectivewaytoreduceelectricityconsumption.Activatingthe

standbyfeaturewhenthecomputerisnotusedforashortperi-

odoftimecansaveuptotwothirdsofitsenergyconsumption.

• lighting

Theissueoflightingisnotonlyrelevanttotheadministrational

sector and is therefore also considered in the Chapter„Energy

Efficiency“ofthisguide.

> Good Practice example

„Lighting can be adjusted to the actual needs through usage of time

switchers, occupancy and movement sensors as well as day-light or

temporal dimming. These measures altogether can save up to 70%

of electricity.“ (Source: Klinergie 2020, Energy Efficiency in German

Clinics)

for further inforMAtion

It‘seasytobegreen:Aguideforenvironmentallyconsciousoffice.

M.J.Bradley&AssociatesInc.www.mjbradley.com/

• Waste

Officewastemainlyconsistsofpaper.Reducingtheamountof

paperbeingused, recyclingandusingrecycledpaperare low-

costandeasymeasurestomakeadministrationprocessesmore

sustainable.

• heating and air conditioning

Heatingandcoolingarethebiggestenergyconsumersinbuild-

ings.Thisconsumptioncanoftenbereducedthroughoperation

optimizationswhichdoneitherrequiresignificantinvestments,

nor lead to a loss in comfort or hygiene. Such measures and

manyfurtheradvicesaregiveninsection4.1.


By applying such measures a hospital in Langenthal (Switzerland)

managed to cut its energy consumption after five years by 13.2%

and to save an equivalent of 90’000 USD of energy costs per year.

(Daniel Hänny, energho)

Assess the fACility – the Different Divisions 2.4 AdministrAtion

21


Mosthospitalsoperateareasforcookingandcafeteriasforstaffand

guests.Usuallythefoodforpatientsisalsopreparedin-house.Food

preparationconsumesagreatdealofenergyandwater.FoodSer-

vice also produces a lot of waste, which can be prevented, mini-

mizedorrecycled.


the Cp perspeCtive

• Waste

Disposabledishesandeatingutensilsareoftenusedinhospitals.

MostofthewastetypicalofCafeteria&FoodServicecanbepre-

ventedbyusingwashableplates,cups,glassesandeatinguten-

silsforstaffandvisitorscafeteriasandforpatientservice.


In a Swiss hospital in Bülach a flexible ordering of meal sizes (half

portion, quarter portion) is practiced in order to prevent leftovers.

The meal orders are taken each day in advance by trained service

staff. Such measures save money when purchasing food as well as

when disposing kitchen waste.

• energy

Food preparation needs large amounts of energy, especially

whenkitchenappliancesareelectric.Switchingtogasandteach-

ing kitchen staff in energy-efficient behavior will help to save

energyandcosts.

• Water

Waterinhospitalkitchensismainlyusedforcookingandclean-

ing.Areductionofwaterusagecanbeachievedthroughusing

efficientequipmentsuchashighpressure, lowvolumenozzles

andagain,throughtrainingstaffinwaterefficiency.


SustainablefoodprocurementintheNHS(NationalHealthService),

SustainableDevelopmentCommission,2001.

CaseStudy:GreenCafeterias,EPA/EPP,

www.epa.gov/epp/pubs/case/cafeteria.htm

Attractivehospitalgroundscanbeutilizedtospeeduppatientre-

covery, increase patient satisfaction and please staff. Such land-

scapesneedmaintenancewhichcanbeprovidedinamoreorless

environmentallysoundway.Theprocessesofgardeningoftenin-

volveintensiveirrigation,useoffertilizersandpesticidesandcause

substantiallandscapingwaste.


the Cp perspeCtive

• Water

Waterisavaluableresource.Efficientuseofwaterdoesnotonly

mitigatewaterstress,butalsosavescosts.Irrigationforgarden-

ingcanbeorganizedinamoreefficientwaybyadjustingtheir-

rigationscheduleforseasonalchanges,wateringeitherearlyin

themorningorintheeveningandinstallingadripsystem.Leak-

ingwaterlines,valvesandpumpsaccountforwaterwastingand

shouldthereforebeeliminated.Waterisoftenusedforcleaning

ofoutdoorareas,wheredrycleaningcanbejustasefficient.


At the University Hospital in Freiburg (Germany) rainwater from

roofs is not being led in the public drainage but is being collected in

a pond in front of the hospital building. Hence, the rain water en-

riches the ground water reserves. In addition, rain water is collected

for watering the green grounds, which not only saves precious

drinking water, but again, helps to sustain ground water. (Practiced

environmental protection at the University Hospital Freiburg, 2002)

• Waste

Theoutdoorwastesaremostlygrassclippings,leavesandtrim-

ming of the gardening operations. Often these wastes are ne-

glected in the process of waste management in hospitals be-

cause of being generated outside the facility. Composted

gardeningwasteisagoodsoiladditive.


H2E10-StepGuidetoCompostinginHealthcareFacilities,Hospitals

forahealthyenvironment,2003.

2.5 cAfeteriA & food service 2.6 GArdeninG & outdoors

22

h

There are several types of laboratories in hospitals. Among these

arelaboratoriesforresearchandteaching,chemistry,hematology,

pathology,microbiology,immunodiagnostic,grosspathologyand

necropsylaboratories.Numerouslaboratoryoperationsinhospitals

aresourcesofhazardouswaste.Therearevariousmeasureswhich

canbetakentopreventandminimizethiswasteandofferit‘sade-

quatetreatment.


Thesustainablehospitalswebsiteprovidesgoodinformationonits

LaboratoryChemicalsandEquipmentsection:

www.sustainablehospitals.org/cgi-bin/DB_Report.

cgi?px=W&rpt=Cat&id=18

2.7 lAborAtories


the Cp perspeCtive

• management practices and training for waste management

Animportanttaskinhospitallaboratoriestowardscleanerpro-

duction is to manage laboratory waste in an environmentally

soundway.Forthispurpose,policiesareoftennotenoughbut

theinputshouldcomefromthemanagementinordertoinvolve

thestaffinthisongoingprocess,mostlybytrainingthemonhow

tohandlewasteandwhyitisimportanttotakecareofit.

• solvent recovery equipment

Formanysolvents, itmakessensefromaneconomicandenvi-

ronmentalpointofviewtorecoverthem,eitherbydistillationor

by special equipments.The good practice example below tells

moreaboutthisissue.

• favor environmentally friendly products

Nowadays, laboratoryequipment requires tailor-madekitsand

the products used are in these cases difficult or impossible to

change.However,thereareotherproductsusedinlaboratories

(e.g.cleaningproducts for labware) thatcanbeexchangedfor

environmentallyfriendlierproducts(e.g.mercury-free,formalde-

hyde-free).


“Dr. Russell Mankes, Associate Professor of the Albany Medical Cen-

ter points out that Formaldehyde is an EPA regulated hazardous

waste (RCRA-U122) if it is in the original container or is not spent.

Waste from tissue processors or spent fixative may not be RCRA reg-

ulated, but in most areas cannot be discharged to sewers as it ad-

versely affects the bacterial sewage treatment. Besides, Dr. Mankes

asks, why would you want to pour money down the drain? Formal-

dehyde for fixation of tissues is expensive. The Albany Medical Col-

lege has been recycling formalin since 1995. Between 1995 and

2004, they recycled ~40,000 pounds of formaldehyde waste in one 5

gallon capacity recycling unit. The original equipment cost of ~USD

10’000 resulted in avoiding USD 185’000 in disposal costs and USD

142’000 in chemical purchase costs. Even for a small hospital, this is

economically beneficial.”

Source:Sustainablehospitalswebsite

23


LaundryServiceplaysanimportantroleinhospitalssinceitcontrib-

utesnotonlytocomfortandaestheticsbutalsoassistswithinfec-

tioncontrol.Thenegativesideeffectsoflaundryarethelargecon-

sumption of energy, water and chemicals. In addition, a great

potentialisoftenwastedfordischargeofrinsingwaterthatcanbe

usedforotherpurposes.


the Cp perspeCtive

• energy and Water

Manytipsforefficientuseofwaterandenergyforlaundryser-

vicesaregiveninsections4.1and4.3ofthisguide.Butpossibly

themostefficientmeasuretosaveenergy,waterandalsocostsis

to reduce the amount of laundry to be washed. This can be

achieved by changing towels and linens of patients upon re-

questratherthanonaroutinelybasis.Alsoreducingtheamount

oflinenusedforastandardpatientbedorforexampleusingun-

derpadsonlywhennecessarytocutthevolumeoflaundryand

saveenergyandwater.


At the University Hospital in Freiburg (Germany) the weight of a

stand bed lining has been cut in half by omitting unnecessary items.

Handling about 50’000 patients annually, the amount of laundry

has been reduced by 130 t per year. This saved over 2 million litres of

water and 286‘000 kg of steam. (Practiced environmental protec-

tion at the University Hospital Freiburg, 2002)

• chemicals

Manychemicalswhichareusedinlaundrydetergentsaretoxic

to aquatic organisms. Even after wastewater treatment, these

chemicalsareoftenreleasedintotheenvironment.Toreducethe

environmental impact of detergents, the toxicity of chemicals

should be minimized by an increased biodegradability of the

product.


EnvironmentalImprovementsinLaundryEquipmentand

Products,HospitalsforaHealthyEnvironment,2006.

2.8 lAundry services

Figure3:AsewingdepartmentinaprivateJordanianhospital

24

h

Patientcareinhospitalscauseslargevolumesofwaste.Whenthese

wastesarebeingincineratedorlandfilled,potentiallytoxicpollut-

ants may be released into the air, soil and ground water. In both

departments,patient-careandmedicalsupplies,usageofreusable

insteadofdisposablesuppliescanhelpreducethevolumeofwaste

considerably.


ListforAlternativeProducts,SustainableHospitals,

www.sustainablehospitals.org/cgi-bin/DB_Index.cgi


the Cp perspeCtive

• Patient-care supplies

Usingreusableproductsinpatientcarecansavelargeamounts

of money.The main obstacle on the way to convince hospital

stafftoswitchtoreusableproducts isthequestionofhygiene.

Oftentheseconcernsarenotlegitimateaswashinginmostcas-

esisenoughtoeliminatebacteria,providesufficientlevelofhy-

giene, and in addition, costs less than buying new disposable

products.IntheAppendix2ofthisguideyouwillfindalistwith

reusable alternatives for disposable items of patient-care sup-

plies.

• medical supplies

Aswithpatient-caresupplies,switchingfromdisposabletoreus-

able medical instruments is the best way to reduce waste and

costs.Moreover,thereareforexample,surgicalpackscontaining

unuseditemswhichmustbethrownawayonceapackisopened

or itemswhich cause thewholepack tooutdateearly. In such

cases the purchasing departments of hospitals play an impor-

tant role and should contact the manufacturer to adjust these

packstotheneedsoftheusers.


„Legacy Health Systems (Portland, Oregon) eliminated rarely used

items from custom packs of surgical supplies, saving more than

30’000 Dollars per year.“

(Source:Savingmoneyandsavingtheearth,Downinthedumps? FirstMovesMagazine,2004,Vol.1No.12)

• lighting & Bathrooms

Areductionintheuseofelectricityandwaterinpatientcarear-

eascanbeachievedbyinstallationofwatersavingdevicesand

energyefficientequipmentasdescribedinsection4.Moreover,

thisconsumptioncanalsobereducedbyinvolvingstaffanden-

couraging patients to save water and electricity. An increased

useofavailabledaylightingforexamplewillnotonlysaveener-

gybutmayalsomakeacontributiontotherecoveryofpatients.

2.9 pAtient cAre

25


Figure4:Interventionsforreducingthequantitiesofhumanpharmaceuticalsintheenvironment.Source:HCWH,Issues:Pharmaceuticals,2010

FromtheperspectiveofCleanerProduction,theproblemofphar-

macy divisions in hospitals is the generation of pharmaceutical

waste. It includes for example outdated pharmaceuticals, their

packaging,theirpreparation,partiallyusedvialsandsyringes,spills

andbreakagesofmedications.


the Cp perspeCtive

• Pharmaceutical Waste

Manypharmaceuticalspresentathreattopeopleandtheenvi-

ronmentbecauseoftheirpersistence,bioaccumulationandtox-

icity.Therefore,outdatedpharmaceuticalsshouldideallybere-

turnedtothedistributorforadequatedisposal.Furthermorethe

problemofoutdatedpharmaceuticalscanbesolvedbythecon-

sistentapplicationofthefirst-in,first-outtechnique.Areduced

inventoryhelpsalsotodecreasetheprobabilityofexpiredphar-

maceuticalsaswellasdeliveryinappropriatequantities.

2.10 pHArmAcy


Preventing damage to the environment from pharmaceuticals:

Aprimer,AfactsheetbyHealthcareWithoutHarmEurope,2007.

Managing Pharmaceutical Waste: A 10-Step Blueprint for Health

CareFacilitiesIntheUnitedStates,HospitalsforaHealthyEnviron-

ment,2006.

26

h

Cleaninganddisinfectioninhospitalsplayanimportantroleforin-

fectioncontrolandsanitation.Reducingtheamountandthetoxic-

ityaswellaspackagingofchemicalsbeingusedforcleaningpur-

poseswillcuttheenvironmentalpollutioninthissectoraswellas

thecosts.


the Cp perspeCtive

• Water

In hospitals the amount of water used for cleaning can be as

largeas10%ofoverallwaterconsumption.Wateruseforclean-

ingpurposesisaquestionofgoodhousekeepingandstaff’sbe-

havior.Thereforestaffshouldbetrainedtousewaterefficiently.

• cleaning materials

Regarding the quantity of cleaning materials, the first thing to

recognizeisthatusingmoredoesnotnecessarilymeanachieving

betterresults.Cleaningchemicalsshouldbeusedandmixedin

appropriate amounts as suggested by the instructions of use.

Concerning the quality, less toxic cleaning materials should be

used.This will have a positive impact not only on the environ-

ment,butalsoonairqualityandthereforeonpatientsandabove

allonstaff,whohandleit.Bybuyinginbulkandbyusingrefillable

dispensers,packagingwasteofcleaningmaterialcanbereduced.

Allthesemeasureswillsavecostsofpurchasing,wastedisposal

andhandlingthenegativeimpactsofcleaningchemicals.

• disinfection

Disinfectionchemicalsusedinhospitalsareoftentoxicandcause

negativehealtheffectssuchasoccupationalasthmaandhyper-

sensitivitysyndrome.Thenegativeeffectscanbereducedbyus-

ing less toxic disinfectants, ensuring proper disinfectant dilu-

tions and adjusting the necessary level of disinfection for

differentareas.Again,trainingofstaffandpostingtheprocedure

fordisinfectantuseatdispensingstationsarenecessary.


CleaningChemicalUseinHospitals.FactSheet.In:Goinggreen:A

Resource Kit for Pollution Prevention in Health Care, Healthcare

WithoutHarm,2001.

Riskstoasthmaposedbyindoorhealthcareenvironments.Aguide

to identifying and reducing problematic exposures, Healthcare

WithoutHarm,2006.

2.11 cleAninG & disinfection

27


Whilefossilfuelconsumptioninhospitalshasbeenonadownward

trendforthelast20years,electricityconsumptionhasbeengrow-

ingsteadily.Electricityalreadyaccountsforaround18%ofahospi-

tal’sdeliveredenergyconsumptionanditrepresentsover50%(in-

ternational average) of a hospital’s energy costs. By reducing a

hospital’s energy consumption, it is possible to achieve the twin

benefitsofsavingmoneyandensuringalesspollutedenvironment

forthelocalcommunity.

General aspects

• Monitorregularlyenergyconsumptionbycheckingtheelectric-

itymetersatleastonceamonth

• Identifyareas/equipmentshavinghighenergyconsumption

• Implement measures such as installing energy-efficient equip-

ments

heating and air-conditioning

• Inspectorinstallacombinedheatandpowersystem

• Usesolarcollectorsforhotwater

• Usenight-timetemperatureloweringthermostats

• Installseveralsmallboilers insteadofonelargeboilerfor load-

dependentoperation

• Installdoubleglazedwindows

• Forair-conditioning,checkspecificroomparameters(tempera-

ture,humidity,airexchange)

• Checkairflowreductionsareinplaceinunusedrooms

• Cleanandchangetheairconditionerfiltersregularly

lighting

• Reducegenerallightingduringdaytimeandmakesurethatex-

teriorlightingisswitchedononlyatnight

• Useenergy-savingbulbs,especiallyinhighconsumptionareas

• Installtimersandmovementdetectorstoreducelightingtime

cafeteria & food services

• Investinhigh-performancecookingunitsandrefrigeratorswhen

replacingequipment

• Defrostrefrigeratorsandcleanthedoorsealsmonthly

laundry services

• Useheatrecoverytowarmupcleanincomingwater

• Avoidwastingenergyfromover-dryingthelaundrybyfittinghu-

miditysensorstodryers

• Use direct firing of gas for tumble dryers and finishing equip-

ment

• Plantouselaundryequipmentduringperiodsoflowconsump-

tion(off-peakhours)

• Uselowtemperaturewashingprogrammes

“In a typical hospital, the amount of energy consumed each year is

equivalent to 16 tons of CO2 per bed space or, in total, about 8’700 m3

of CO2, which is enough to fill over 60 six-bed wards”.

Source:EfficiencyBestPracticeprogram-UKGovernment’sEnergy.

“Combined heat and power system is 70-95% more efficient than con-

ventional power production. Cogeneration systems are available from

as small as 30 kW to more than 100 MW. By making continuous use of

both electricity and thermal energy, customers can save up to 35% on

overall energy costs.”

Sources:ElisaWood,Environmental-experts.com-CumminsPowerGenerationInc.

“Bellin Hospital, in Wisconsin, U.S., saved USD 21’000 per year by using

variable speed drives in hot water pumps, eliminating exhaust in un-

necessary areas, and recovering boiler heat.”

ArminReller,Greenerhospitals:improvingenvironmentalperformance.

“Every dollar saved on energy costs is a dollar that is devoted to im-

proving medical care for our patients.”

Source:Dr.HerbertPardes,PresidentofNewYorkPresbyterianHospital.

3 foCus on seleCteD issues 3.1 enerGy efficiency

28

h

Figure5:Typicalenergyflowsthroughahospital(HospitalTulln,Austria,1999)

Source:Greenerhospitals:improvingenvironmentalperformanceUniversityAugsburg–Bristol-MyersSquibbCompany

Figure6:AsolarwaterheaterontheroofofthebuildingofaJordanianprivatehospital

29


Hospitalsgenerateuptoaround8kgofwasteperbedperday(in

USA,seesection2)ifnotproperlymanaged.Medicalwasteincin-

erationisaleadingsourceofdioxin,mercuryandotherdangerous

pollutants that threatenhumanhealthandtheenvironment. It is

importanttominimizetheamountandtoxicityofwastegenerated

by the healthcare sector, to ensure the proper management and

segregationofmedicalwasteandtoeliminatethedangerousprac-

tice of incineration by promoting and implementing alternatives,

suchasnon-incinerationtreatment.Recyclingandcompostingcan

alsobeavaluablesolutionforwastevalorization.

3.2 wAste mAnAGement

General aspects

• Elaborateawastemanagementplantoestablishaframeworkof

policiesandprocedureswithanovergoalofzerowaste

• Understandwastecategoriesandsegregation:domesticwastes

(paper,glass,plastics,etc.);regulatedmedicalwaste(biohazard-

ous waste, potentially infectious medical waste, biomedical

waste,etc.);hazardouswaste;low-levelradioactivewaste

• Implement non-incineration technologies: thermal, chemical

process,irradiativeorbiologicalprocesses

• Promotewasterecycling:paper,plastics,glass,batteries,etc.

• Encouragecompostingwastes,suchasgrass,leaves,flowers,etc.

• Trackthetreatmentanddisposalcostsofwastefromindividual

sectionsanddepartments

laboratories

• Promote recycling of paper, X-ray films and solutions, packing

material,etc.

Patient care

• Reprocesssingle-usedevices,suchasarthroscopicshavers,blood

pressurecuffs,softtissueablators,scissorsandstaplers,etc.

• Separatebagsusedfortheregularsolidwastesandrecyclables

• Donateorresalesurplus

• Monitorwastemanagement,andeducatestaff

Pharmacy

• Regulate pharmaceutical wastes: regulate entering products

(greenpurchasing,appropriatedosepackaging,etc.)andmodify

managementpractices

“A hospital’s waste disposal costs ranged from 44 to 68 USD per ton,

according to the Joint Commission on Accreditation of Healthcare Or-

ganizations.”

Source:TheJointCommission

“The Philippine follow-up Measles Campaign 2004 and provided mea-

sles vaccines to about 18 million children in the country, and thus gen-

erated an estimated 19.5 million auto-disable syringes. The used sy-

ringes were collected in safety boxes and treated in autoclave or

microwave facilities, buried in waste pits or encased in concrete vaults.”

Source:PhilippineHealthSecretaryManuelDayrit

“Reprocessing single-use devices provides a cost savings compared to

purchasing new devices for each use (up to 50%) and reduce the

amount of waste both in terms of product and packaging.”

Source:Associationofmedicaldevicereprocesses

“A hospital pharmacy generally stocks between 2’000 and 4’000 differ-

ent items, each of which must be evaluated against state and federal

hazardous waste regulations before being thrown away.”

Source:HospitalsforaHealthyEnvironment(H2E)

30

h

Group A waste like municipal waste

waste with a risk of contamination and/or injury B1/1 anatomical waste

B1 waste with a risk of contamination B1/2 waste with blood and body

fluid B2 waste with a risk of injury (sharps)

B3 pharmaceutical waste

Group B

B4 cytotoxic waste

Med

ical

Was

te

Med

ical

Ris

k W

aste

Group C infectious waste, incl. waste from microbiological labs

Group D all other kinds of hazardous wastes radioactive waste

Group E E1 waste with t1/2 < 60 days E2 waste with t1/2 > 60 days

dead animals

Non

-Med

ical

Was

te

Group F F1 contaminated and/or infectious F2 radioactive

Figure7:InSwitzerland,allwastethatcomesfromhealthcareactivitiesiscalledmedi-calwaste.Medicalwastesinclude:“No-Risk”wastewhichiscomparabletohouseholdwaste;andMedicalriskwaste/Medicalhazardouswaste.(Schelker,Raymond,2010)

31


Manypartsoftheworldarewaterstressed,andtheever-increasing

populationintensifiestheproblem.Prudentuseofthisinvaluable

naturalresourceisessentialfromaresourceconservationperspec-

tive.Water use is driven by the number of inpatients and outpa-

tients,equipmentused,facilitysize,numberandtypesofservices,

facilityageandmaintenancerequirements.Othercontributorsin-

cludesteamsterilizers,autoclaves,medicalprocesses,heatingven-

tilation and air conditioning, sanitary, x-ray equipment, laundries

andfoodservices.Itisrecommendedthatalltheseareasbeevalu-

atedtoidentifyactivitiestohelpreducewaterconsumption.

3.3 wAter conservAtion

General aspects

• Checkthewatersupplysystemfor leaksandturnoffunneces-

saryflows

• Install automatic water volume controls that operate indepen-

dentlyofthewaterpressuretocontroltheamountofwater

• Readwatermetersmonthlyinordertoidentifyleaks

• Recycleandreducewaterusewhereverpossible,consistentwith

healthrequirements.


• Washonlyfullloadsinthedishwasher

• Reusetherinsewaterfromthedishwasherasflushwateringar-

bagedisposalunits

• Upgradeequipmentwithwater-efficientmodel

• Turnoffthecontinuousflowusedtowashthedraintraysofthe

coffee/milk/sodabeverage

Gardening and outdoor

• Waterearlyinthemorningorintheevening

• Considerusinglow-volumeirrigation,suchasadripsystem

• Adjusttheirrigationscheduleforseasonalchanges

laundry services

• Investigateatreatedrinsewatersystemtoreuserinsewaterfor

otherpurposesorrecycleitinthewashcycle

• Instructcleaningcrewtousewaterefficientlyformopping

• Washonlyfullloads

heating & cooling

• Adjustboilerandcoolingtowerblowdownratetomaintaintotal

dissolvedsolidsatlevelsrecommendedbymanufacturers’speci-

fication

• Returnsteamcondensatetotheboilerforreuse

• Shutoffwater-cooledairconditioningunitswhennotneeded,

orreplacewater-cooledequipmentwithair-cooledsystems

““Reducing the time the water runs from three minutes to one minute

results in savings of about 16 liters of water per hand-wash.”

Source:GuideofBestEnvironmentalpractices

“The use of flow regulators on shower heads saves 40 liters per 5 min-

utes shower, which amounts to more than 10% of water consumption

per day.”


“A rinse water reuse system was installed in its laundry: It has been esti-

mated that it will reduce water consumption in the laundry process by

6.8 million litres annually.”

Source:Newton-WellesleyHospital

“Cooling can account for up to 53% of the water use in a hospital.”

Source:SouthWestFloridaWaterManagementDistrict

32

h

laboratories & patient care

• InstallautomaticvalvesonfilmprocessingorX-rayequipmentto

stopwaterflowwhenequipmentisnotinuse

• Determineshorterhand-washcycles

• Reduceflowtosurgicalvacuumpumpstoacceptableminimum

levelandmaintainproperoperation

• Overhaulfaultysteamtrapsonsterilizers

Bathrooms & restrooms

• Shut-offthewatersupplytoequipmentandareasthatareun-

used

• Installelectronicallycontrolledvalves

• Replacetoiletswithlow-volumemodels

• Installlow-volumesshowerheads

“A leaking toilet can waste more than 190 litres of water each day, and

a dripping faucet or showerhead can waste up to 3’800 litres per week.”


Figure8:Waterflowsinasmallhospital(HospitalTulln,Austria,1999)

Source: Greener hospitals: improving environmental performance University Augs-burg–Bristol-MyersSquibbCompany

33


Cleaninginhospitalsisanimportantissue.Forexample,manynos-

ocomialinfectionsoccurinhospitals(hospital-acquired).Thus,hos-

pital staff and administrators often react anxiously to suggested

changesincleaningpractices.Nevertheless,cleaningproductsare

amajorcontributorto indoorairquality issues inclosedenviron-

ments. Many contain high levels of volatile organic compounds

(VOCs)whichcangiverisetorespiratoryirritation,headachesand

othersymptomsforworkersandbuildingoccupants.Alldisinfec-

tants are intentionally toxic to microorganisms, and none can be

accuratelyqualifiedas“green”.However,bestpracticescanassure

thatdisinfectionishighlyeffectivewithoutinvolvingunnecessary

exposureforworkers,staff,andpatients.

3.4 Good HousekeepinG & beHAvior

General aspects

• Adoptacleaningproductsprotocolaspartofyourhazardman-

agementplan

• Foreachproductinuse,determineifthereisa“less-toxic”substi-

tutionthatwillperformthesametask

• Usethemostmodernequipment

• Limittheuseofdisinfectants

equipment

• Replacedustmopsandcottonclothswithmicrofiber

• Purchasevacuumcleanersequippedwithhigh-performancefilters

• Vacuumbeforemopping

• Useadvancedtechnologymopbucketstoreducetheredistribu-

tionofdirtduringcleaning

cleaning

• Cleanbeforedisinfecting

• Usetheappropriateproductfortargetmicroorganisms

• Useproductsattheappropriateconcentrationandfortheprop-

erresidencetime

• Besuretofollowtheinstructionscarefully,andcomplywiththe

recommended“dwell”timeortimeittakesforthebiocidetoef-

fectivelyeliminatethetargetedorganisms(thedwelltimeisgen-

erally10minutes)

• Readyourproduct’slabelandcomplywiththeinstructions

disinfecting behavior

• Determinewheretousedisinfectantsbycarefullydividingyour

facilityintoriskareas

• Identify those areas that need the highest level of disinfecting

and separate them from areas that can simply be thoroughly

cleanedorthatneedtobesanitized(foodserviceareas)

• Identify theorganismsyouneedtoeliminate,suchas those in

bloodandvomitorgeneralpathogens

• Usetheleasttoxicantimicrobialstodisinfectorsanitize

“An estimated 35% of conventional cleaning products can cause blind-

ness, severe skin damage or damage to organs through the skin.”

Source: Strategies for a better environment , INFORM

“The use of microfiber mops can reduce significantly the amount of

chemical and water used. Additionally, they appear to be easier and

more comfortable tools for the workers, which could reduce work inju-

ries, lost work time and compensation claims.”

Source: Are microfibers mops beneficial for hospitals? – Sustainable Hospital Project

“Hospitals that have transitioned to greener cleaners have not had an

increase in nosocomial infection rates as a result of greener cleaners.”

Source: Green Cleaning Implementation, H2E

“Working with or being exposed to toxic chemicals is the single largest

contributing risk factor associated with occupational illness and injury

in healthcare.”

Source: US Bureau of Labor Statistics

34

h

3.5 toxic mAteriAls

Healthcareinstitutionsregularlyuseanimportantamountofhighly

toxicmaterials.Thesetoxinsaffectpatients,hospitalstaff,andhos-

pital visitors. The management of these materials is an essential

part of a hospital’s day-to-day activities. Proper registration, han-

dling,andtrainingarenecessarytoguaranteeasafeworkplaceand

topreventpotentialriskstoemployees,patientsandtheenviron-

ment.Manyof thesetoxinsaredefinedandregulatedby federal,

stateandlocallaws.Othersareuseddailybutarehardlyregulated.

Theyincludecarcinogens,materialsthatdamagetheskinandor-

gans,andmaterialsthatcorrode,irritate,orreleaseothertoxinsin

thecourseofnormaluse,storage,transportationordisposal.

2 Some examples: fixer and developer baths from X-ray departments; heavy-metal-basedcompoundscontainingsilver,lead,copper,cadmium,chromium,mercury,ormanganese;reactive/explosivesubstancessuchasacidesandperoxidecompoundssuchashydrogenperoxide,perchloricacid,peraceticacid,andperborates;concen-tratesofdisinfectantsandcleaningagents,bleachesanddetachingagents;substan-cesfromnuclearmedicine/radiology(includingradioactivesubstancesandiodoor-ganiccontrastmedia);etc.

Potentially toxic materials2 used in hospitals may include haloge-

natedandnon-halogenatedorganiccompounds(e.g.solvents),in-

organic compounds, caustic materials (acids/bases), prescription

pharmaceuticals, disinfectants or other compounds that may be

carcinogenic, mutagenic, or reproductive toxins. This section fo-

cusesandprovidestipsonfourtoxicmaterials:mercury,PVCand

phthalates,flameretardantsandpesticides.

General aspects

• Instituteacomprehensivechemicalmanagementpolicy

• Establishaframeworkofpoliciesandprocedurestoreduceand

eliminatetheuseandimproperdisposaloftoxicmaterials

• Examine all hospital departments and functional areas for the

presenceanduseoftoxicmaterials

• Evaluateandapproveallpotentiallytoxicmaterialsbeforeusingit

• Replace highly hazardous substances (benzene, chromosulph-

uricacid,mercury,chromeVIcompounds,andhydrazine)with

lesshazardousoneswheneverfeasible

• Train thestaffonhowtosafelyusepotentiallyhazardoussub-

stances

• Developwrittenproceduresforreceiving,handling,storageand

disposaloftoxicmaterials

toxic and chemical waste disposal

• Establishspecialdisposalproceduresforcertainchemicals,such

as solvents, halogenated solvents, acids, rinses/washes (saline

solutions, buffers, formaldehyde solutions, aqueous dye solu-

tions),alkaline,olddisinfectantsandcleaningagents,etc.

• Check with pharmaceutical companies for specific information

onproperdisposalofexpiredpharmaceuticalproducts

“The xylene distillation and nitrogen elimination projects alone save

the hospital 8’000 USD annually.”

Source: Saint Barnabas Medical Center, Department of pathology.

“Healthcare facilities have the potential to use a variety of products

and devices that contain varying types of radioactive materials (used

radiopharmaceutical products and vials, Tc-99m eluate vials, lyophi-

lized drug pr oduct vials containing Tc-99m).”

Source: Greener hospitals: improving environmental performance.

35


mercury

• Mercury isapotentneurotoxinthatcanharmthebrain,spinal

cord,kidneysandliver.Itisusedthroughouthealthcareinava-

riety of products including thermometers, sphygmomanome-

ters, dental amalgam, laboratory chemicals and preservatives

suchasthimerosal,cleaningagents,andvariouselectronicde-

vicessuchasfluorescentlampsandcomputerequipment.

• Thereisupto50timesmoremercuryinmedicalwastethanin

general municipal waste, and the amount of mercury emitted

fromgeneralmedicalwasteincineratorsaveragesmorethan60

timesthatfrompathologicalincinerators.

• Ninety-ninepercentofatypicalhospital’smercuryiscontained

inoesophagealdilators,sphygmomanometerserviceskits,and

barometers.

• Total cost to replace mercury devices is modest, especially in

lightofthecostofspills.AccordingtotheEnvironmentalProtec-

tionAgencyofUnitedStates,mercuryspilltrainingandequip-

mentcostsaround649USD.TheGrandRapidhospitalinMichi-

gan invested USD 6’000 for replacing all existing sphygs and

oesophagealdilatorscontainingmercuryandinstitutingapolicy

banning the purchase of mercury-containing thermometers,

sphygs,oesophagealdilators,andbatteries.

Pvc and Phthalates

• PVCplasticisthemostcommonlyusedplasticinmedicaldevices

andhasbeenusedinawidevarietyofotherapplicationsinthe

healthcaresetting,suchasdisposablegloves,curtainsandfloor-

ing.Unfortunately,thistypeofplasticcreatesanumberofenvi-

ronmentalhealthrisks.Thetwomainproblemsare:

• Dioxin:aknownhumancarcinogencanbeformedduringanin-

adequate manufacture of PVC, and during the incineration or

burningofPVCproducts.Therearehoweveralsoenvironmental-

ly-friendlyPVConthemarket.

• DEHP (2-ethylhexyl phthalate): a phthalate used to soften PVC

plastic that can leach from PVC medical devices; it is linked to

reproductive birth defects and other illnesses. Medical devices

made of flexible PVC, such as bags and tubing, can leach the

phthalate DEHP into patients, resulting in some of the highest

exposurestothistoxicchemical.

• Fortunately,medicaldevicesthatdonotcontainvinylplasticor

phthalatesareavailableforuseandmanyhealthcarefacilitiesare

switchingtothesesaferalternatives.

Step by step

• Make a commitment and establish a mercury-free team.

• Conduct a mercury inventory: create a baseline inventory of mercu-

ry-containing products in your hospital.

• Evaluate mercury-free alternatives in the context of your hospital.

• Set short-term and measurable goals that match your hospital’s re-

sources. Reasonable goals, such as the elimination of mercury

sphygmomanometers within 2 years, are easily measured and pro-

posed as part of a hospital’s business plan.

• Institute Best Management Practices (staff training, mercury-free

purchasing, etc.)

• Measure success using your mercury inventory.

• Keep the mercury out of your hospital.

Step by step

• Perform audits to identify PVC and DEHP products (keywords for

products containing DEHP: Polyvinyl chloride, PVC, and Vinyl).

• Identify and evaluate alternatives.

• Prioritize higher risk patient populations for product replacement

(neonates, pregnant women, etc).

• Purchase PVC or DEHP free products of equivalent quality and per-

formance.

PVC and DEHP free?

• Keywords for PVC-free products include: EVA (ethylene vinyl ace-

tate), Polyurethane, Silicone, Polypropylene, PVC-free.

• Keywords for PVC products made without DEHP include: DEHP-free

and TOTM (non-DEHP plasticizer).

36

h

flame retardants

• Inordertomeetfiresafetystandards,chemicalsthatactasflame

retardants are commonly added to a wide range of products

such as pumps, televisions, computers, hospital beds, waiting-

roomchairsandhospitalprivacycurtains.Unfortunatelymanyof

theseflameretardantchemicalsdonotremainfixedintheprod-

uct,andslowlyleakintoourair,dustandwater,eventuallyenter-

ingourfoodandbodies.

• Many chemicals are used as flame retardants. They are called

CFRs(chlorinatedflameretardants)andBFRs(brominatedflame

retardants). Collectively, these are called halogenated organic

flameretardants.Themostcommonlyusedasbrominatedflame

retardantsarepolybrominateddiphenylethers,orPBDEs(poly-

brominateddiphenylethers).

• EvidenceshowsthatBFRsbio-accumulateinpeopleandcause

adversehealtheffectsinchildren.BFRsarefoundinmanyprod-

ucts: bedding materials, furniture cushions, lamp shades, cur-

tains, drapery, electronic equipment, televisions (pulse oxime-

ters, monitors, ventilators, pumps, computers, printers, fax and

copymachines,etc.)andfinally,intheinfrastructureofthebuild-

ing(walls,roofingmaterials,floortiles,carpeting,wiring,electri-

calswitches,sockets,andinsulation).

cleaners and pesticides

• Patientsareparticularlyvulnerabletoindoorairqualitythreats

suchaspesticidesorchemicals,sincemanyhavecompromised

respiratory, neurological or immunological systems and/or in-

creasedchemicalsensitivities.

• Manytraditionalcleaningproducts,floorstrippersanddisinfec-

tantsoftencontributetopoorindoorairqualityandmaycontain

chemicalsthatcausecancer,reproductivedisorders,respiratory

ailments(includingoccupationalasthma),eyeandskinirritation,

centralnervoussystemimpairmentandotherhumanhealthef-

fects. Hospitals also use a variety of methods to disinfect and

sterilizesurfacesandequipment.Someofthemostcommonly

used products, however, such as glutaraldehyde and ethylene

oxide,havebeenshowntocauseserioushealtheffects.

• Pesticides can also cause acute symptoms, including nausea,

headaches,rashesanddizziness.Manyarealsolinkedtochronic

diseasesandconditionssuchascancer,birthdefects,neurologi-

cal and reproductive disorders, and to the development of

chemicalsensitivities.Theelderly,pregnantwomen,chemically

sensitiveindividuals,infantsandchildrenareespeciallyvulnera-

bletothetoxiceffectsofpesticides.

Purchasing recommendations

• Purchasing recommendations

• Require the name and CAS number (chemical abstracts service reg-

istry number) of added flame retardants used in products you pur-

chase.

• Choose products that meet flame retardancy standards without

any added flame retardants or halogenated flame retardants.

• Tell your suppliers that you prefer products that do not contain toxic,

persistent, bioaccumulative toxicants.

Some halogenated flame retardants

• Tetrabromobisphenol-A

• Hexabromocyclododecane

• Deca-BDE (Decabromodiphenyl ether)

• Octa-BDE (Octabromodiphenyl ether)

• Penta-BDE(Pentabromodiphenyl ether)

• Tris (2-chloroisopropyl phosphate) (TCPP)

• Tris(2-chloroethyl) phosphate (TCEP)

• Dechlorane PlusTM

Cleaning and disinfecting tips

• Look for environmental friendly cleaning products.

• Don’t disinfect areas not needing to be disinfected (e.g. offices).

• Work with infection control to divide the facility into areas that pose

noncritical (low), semicritical (moderate) and critical (high) threats

of infection.

• Reject cleaners that contain nonyl- and octyl-phenols.

• Integrated Pest Management (IPM)

• Select the least hazardous pesticides.

• Educate all hospital staff about the hazards of pesticides.

• Provide notification when pesticides are used in the hospital build-

ing or on the hospital’s grounds.

• Provide pesticide-free areas.

37


Healthcare facilities purchase thousands of different products re-

questedbydozensofdifferentdepartments.Asshownthroughout

thischapter,hospitalsmaypurchaseitemsthataretoxictoworkers

orpatients,orhaveseriousenvironmentalimpacts.Fromeliminat-

ing unnecessary packaging, to seeking substitutes for products

containingmercuryorothertoxicsubstances,purchasingdecisions

can have a major impact in providing environmentally friendly

healthcare facilities. Purchased products must be considered in

theirtotality(lifecycle).Indeed,thedifferentstagesofthelifeofa

product (manufacturing,marketing,useanddisposal)allhavean

impact on the environment. The purchasing of green products

helpstominimizetheseimpacts.

3.6 Green purcHAsinG

General aspects

• Buyonlywhatisneeded(avoidunnecessarysupplies)

• Buyinbulkratherthanindividuallypackageditems

• Buyrecycledcontents(officepaper,papertowels,etc.)

• Whenpurchasingnewequipment,taketheirwaterandenergy

consumptionintoconsideration

• Educateandtrainthepurchasingdepartment

• Usestandardlabelsandchoosetherightsuppliers

• Preferreusableproductstodisposableproducts

administration

• Buyreusableinkandtonercartridges

• Purchase paper with at least 50% recycled fibers or non-whit-

enedorchlorine-freebleachedpaper

• Preferrechargeablebatteries


• Choose,wheneverpossible,organicproducts

• Chooseseasonalfruitsandvegetables

• Usefreshproductswithlittleornopreservativesandfood-color-

ingandwithaslittlepackagingaspossible

• Equipthekitchenwithenergy-efficientappliances

laboratories, patient care, pharmacy

• Check foralternative forproductscontainingLatex,PVC/DHEP,

mercury,flameretardants,etc.

• Checkforlesspackagingandreusabletools

laundry service

• EquipthelaundryroomwithmachinesinenergyclassA

• Avoidusingdetergentscontainingbleach(productsofchlorine),

phosphate, EDTA (ethylenediaminetetraacetic acid), NTA (sodi-

umnitriloacetate),etc.

• Preferlowtemperaturedetergents

cleaning & disinfection

• Foreachproductinuse,checkifthereisa“less-toxic”substitu-

tion

• Purchasetheleasttoxicantimicrobialstodisinfectorsanitize

“Choosing products with a minimum amount of packaging can result

in a large decrease in quantity of waste produced, especially when

thousands of units are purchased per year (such as sharps and intrave-

nous products – bags)”.

Source: Green purchasing in healthcare, Health care without harm.

Local food procurement is beneficial for local economy: researchers

from the New Economics Foundation in the UK found that 14 € spent

with a local organic box scheme ultimately generated 36 € for the local

economy, compared to only 19 € generated through spending in a lo-

cal supermarket.

Source: Plugging the Leaks – Making the Most of Every Pound that Enters Your Local Economy.

Some goals examples: reduce packaging waste by 20% in 12 months;

reduce the purchase of products containing PVC by 15% over the next

three years; stop purchasing devices and products containing mercury

in 2 years; etc.

“Substituting mercury thermometers with digital alternatives rewards

investment by eliminating the hazardous waste disposal costs that

come with throwing out mercury.”

Source: Green purchasing in healthcare, Health care without harm.

38

h

Presentation of the set of problems and of the chosen corrective mea-

sure. This part encompasses the following elements:

• Concernedenvironmentaldomain

• Departmentresponsibleforthecorrectivemeasure

• Problemfaced

• Action to be taken (corrective measure) in order to solve the

problem

Comparison of costs before and after the implementation of the cor-

rective measure:

• Annualcostsbeforeimplementation(Ca):costsincurredbefore

the implementation of the corrective measure (consumptions,

lossesofwater,energy,rawmaterials,maintenancecosts,costs

ofequipmentupgrades,etc.).

• Annualcostsafter implementation(Cb): recordedorestimated

costsaftertheimplementationofthecorrectivemeasure.

Capital invested to acquire the means needed to implement the correc-

tive measure. In most cases, the investment creates annual running

costs to keep the measure working effectively and efficiently:

• Investments (Iv): capital needed to implement the corrective

measure.Ifthemeasureincludedseveralinvestments,thevari-

ousamountsshouldbeadded.

• Annualrunningcosts(Rc):additionalrunningcostsrelatedtothe

implementationofthecorrectivemeasure.Insomecases,there

arenorunningcosts.

Savings resulting from the implementation of the corrective measure:

• Grossannualsavings(Gs):annualsavingsobtainedasaresultof

theimplementationofthecorrectivemeasure.Gs=Ca–Cb.

• Netannualsavings(Ns):actualannualsavingsobtainedasaresult

oftheimplementationofthecorrectivemeasure.Ns=Gs–Rc.

Highlighting the economic efficiency of the chosen measure:

• Paybackperiod(Pp):timeneededforthehospitaltorecoverthe

investmentusedtoimplementthecorrectivemeasure. It isex-

pressedinyears.Afterthepaybackperiod,thegrossannualsav-

ings(Gs)becomeprofit.Pp=Iv/Ns.

Afterhavingidentifiedtheactionstobeimplementedinyourhospi-

tal, you can now calculate their return on investment.The table of

economic calculations enables you to evaluate the costs of imple-

mentingcorrectivemeasuresstepbystep,thepotentialsavingsand

theexpectedreturnoninvestment.Itisadecision-makingtoolthat

helpsyouassessthesituationbeforeandaftertheimplementationof

correctivemeasures.Inotherwords,itestimatesthereturnoninvest-

mentofthetargetedactionsbeforetheyareactuallyimplemented.

4 DeCision-MAKinG AnD CorreCtive MeAsures

eleMents of eConoMiC CAlCulAtions forM:

overall description

comparison of costs

investment

Profit

return on investment

Table7:Elementsofeconomiccalculationsform

39


General descriPtion

Water

Tapsandshowersintherooms

Highwaterconsumption

Installationofflow-regulatedshowerheadsineachroom

Installationofwater-reducingfiltersfortapsineachroom

comParison of costs

Showerwatercostsperyear:Ca1=9’566JOD

Tapwatercostsperyear:Ca2=7’653JOD

Catotal=Ca1+Ca2=17’219

Showerwatercostsperyear:Cb1=4’252JOD

Tapwatercostsperyear:Cb2=3’401JOD

Cbtotal=Cb1+Cb2=7’653

investment

Flow-regulatedshowerheads:Iv1=1’050JOD

Water-reducingfiltersfortaps:Iv2=158JOD

Ivtotal=Iv1+Iv2=1’208JOD

0JOD

Profit

Gs=17’219JOD–7’653JOD

Gs=9’566JOD

Ns=9’566JOD

return on investment

Pp=1’208JOD/9’566JOD

Pp=1.5month

exAMple of CAlCulAtion

domain

facilities concerned

Problems addressed

action to be taken

annual costs before action (ca)

annual costs after action (cb)

investment (iv)

annual running costs (rc)

Gross annual savings

(Gs) Gs = ca - cb

net annual savings

ns = Gs - rc

Payback period

(Pp) = iv / ns

Table 8: Example of calculation

40

h

Inordertogetthefinancialreturnfromsuchcorrectivemeasures,

thehospitalmustsetanactionplanforthedailymanagementofits

activities. To identify the hospital’s strong points, recognize its

weaknesses,anddefineitsperspectivesthereshouldbesomekind

of internal organization and a clear allocation of responsibilities.

Thedevelopmentofanactionplanenablestheimplementationof

thecorrectivemeasuresbyspecifyingthemeansallocated(finan-

cial,technical,human,etc.)andthedeadlinefortheactualimple-

mentation.Appointingqualifiedpersonstoimplementthecorrec-

tivemeasuresisessential.Atthesametime,coordinationbetween

the departments that face the same problem (such as excessive

consumption of water or energy, or inadequate waste manage-

ment) isnecessaryforreachingtheperformancetargets.Thecor-

rective measures and their results should be assessed and docu-

mentedregularly inorder toevaluateprogressandplanpossible

additionalimprovementsorcorrectivemeasures.

objective

ImplementIntegrated

PestManagement(IPM)to

preventandmanagepest

problemsintheleasthazardous

mannerpossible.

targeted action

• Regularinspectionforpests,

especiallyinfoodservice

areas

• Identificationofproblem

areas,educationofengineer-

ingandenvironmental

servicesstaffonIPMmethods

cleanliness

• Regularmonitoringand

evaluation

• Programbuyinfromstaff

andpatients

department concerned

• Purchasingdepartment

• Foodservice

• Gardening&outdoor

• Cleaning&disinfecting

Person responsible

• Mr.X

• Mrs.Y

• Mr.Z

• Mr.W

Action plAn

Table 9: Example of an Action Plan

41


means

• Establishpurchasingguide

linesbasedonlabels

withpreferenceforgreen

products

• Selectionofproductswith

ahighdegreeofbiodegrad-

ability

• Selectionoforganicfood

deadline

1year

expected result

• Reductionofnegative

impactonenvironment

• Improvementof5%ofthe

productivityofthestaff

(decreaseofmedical

problemslinkedtochronic

exposuretochemicals)

iv (usd)

2’000

rc (usd)

Normallabor

cost

ns (usd)

6’500

42

h

strenGtheninG AnD Continuous iMproveMent

Becoming an environmentally responsible hospital requires the

adoptionofanewcorporateculturebothwithinthehospitaland

amongitsstakeholders.Tostrengthenthiscommitment,changes

shouldbeimplementedprogressivelywithinthehospital.

organizational change

Toobtainalastingchangeinthehospital,clearobjectivesareneed-

edandfollow-upandevaluationmeasuresmustbeimplemented.

A systematic approach can be adopted by establishing resource

management plans and by communicating factual information.

Therefore, appointing a “task group” made up of selected volun-

teersfromamongthestaffwillcontributetotheimplementationof

concreteimprovementsintheBEPHS’smaindomains.

Behavior change

Influencingstaffbehaviorinfavorofmorerationalresourceusehas

adirectimpactonloweringthehospital’srunningcosts.Itisimpor-

tant to involve staff by giving them specific duties (realistic and

suitedtotheircompetences)andbyprovidingtraining.

technological change

Within the framework of the strategic environmental actions, the

hospital can, when changing equipment or renovating, choose

moresustainabletechnologiesthatconsumelesswaterandener-

gy.The aim of this is to become more eco-efficient and adopt a

moreresponsiblepurchasingpolicy.

In addition, to sustain the efforts made in applying “green” mea-

sures, the hospital must institute corroborative and follow-up ac-

tions.This will support the hospital’s environmental commitment

andhelpmonitoritsperformance.

followinG up AnD sustAininG the

CorreCtive MeAsures

Follow-upgivesmanagersthenecessaryinformationtoassessthe

impactandtheprogressoftheactiontaken.Itcanprovideaneval-

uationoftheadequacyofthemeasures,judgedagainstthehospi-

tal’senvironmentalgoals.Moreover,byusingtheannualfollow-up

results,managerscanidentifytrendsinperformance(benchmark-

ing)and,ifneeded,takecorrectiveaction.UsingtheBEPHSguide

eachyearwillgivethehospitalthedataitneedstodothis,thereby

conformingtotheprinciplesofcontinuousimprovement.Thegoal

istostrengthentheenvironmentalandeconomicefficiencyofthe

hospital departments. After this initial approach to best environ-

mentalpractices,thehospitalcangofurtherinitsadoptionofthe

principlesofeco-efficiencybyofferingguestsadditionalandper-

sonalized services while at the same time limiting environmental

impactsandcosts,andguaranteeingquality.

AwAreness-rAisinG AnD trAininG of stAff

Justasinvestmentsarerequiredtomaintainorreplaceahospital’s

equipment,aninvestmentinstaffawareness-raisingandtrainingis

essential to improve the human capital. Environmental commit-

ment is an opportunity for the hospital to involve its various co-

workers.Stafftrainingmustbecenteredonthehospital’senviron-

mental impacts. For the training to be adequate, training and

awareness-raisingmustalsoberelevanttothetargetgroupsand

berelatedtotheirdailyactivities.Employeesshouldbeinvitedand

encouragedtorespecttheenvironmentalmeasuresthathavebeen

implemented. Finally, because of the high turnover rates in the

healthcarefacilities,trainingcurriculashouldberevisedtoinclude

theBEPHSprinciplesintheinductiontrainingprovidedfornewem-

ployees.Awareness-raisingandtrainingcanbeimplementedinthe

different departments of the hospital. Sessions should be orga-

nized at times of less activity, and should last one to two hours.

Practicaldemonstrationsincreasetheeffectivenessofthetraining.

Inaddition,othermediacanbeusedinthedepartments,suchas

posters,informationnotes,brochures,bulletinboards,andfilms.

improvement, trAininG And perspectivesimprovement, trAininG And perspectives

43


externAl CoMMuniCAtion AnD perspeCtive

Ahospital’sposition regardingenvironmental issuescan increase

itscompetitiveness.Informationonthistopicshould,aboveall,be

addressedtopublicsphere,butalsototheotherstakeholders.Itis

importanttocommunicatewellandgetthemessageacrosswith-

out being sanctimonious. Other stakeholders can be informed of

the hospital’s practices by different means, among which are the

annualreport,theenvironmentalcharter,andthewebsite.Another

way to show one’s commitment is to describe the improvement

measures that have been implemented and to explain their eco-

nomicandenvironmentaladvantages.

Theeffortsundertakenbythehospitalintermsoftheenvironment

canleadtoaconsiderationofeco-labeling.Gettingaccreditationin

thiswayrequiresmeetinganumberofmandatoryandoptionalcri-

teria. Investments may prove necessary to upgrade the hospital’s

equipmentinordertomeettherequirementsofthelabel.Suchcer-

tificationisanimportantcompetitiveadvantagethatcanbeused

asamarketingtool.

44

h

Thisguideprovidesseveraltoolsforapracticalassessmentofafa-

cility. It introducesdivisionsandrelevantissuesinahospital,pro-

videshelpandchecklistsfordatacollectionaswellasguidelinesfor

economiccalculationandtheCPpotentialindifferentdivisionsand

issues.Ideallyanassessmentresultsinanactionplanassuggested

inthepreviouschapter.Though,anassessmentandanactionplan

donotnecessarilyresultinasustainableimplementationofCPop-

tionsinpractice.Thischapterwillprovidesomeideasandsugges-

tions to implement cleaner production in a sustainable and suc-

cessfulway.

Implementingcleanerproductionoftenmeansinternalrestructur-

ingofprocesses.Possiblewaystodothatarebyawarenessraising,

externalconsultingandredevelopmentofcorporatestructuresor

buildingofCleaner-Production-Teams.Thethreetypicalobstacles

onthewaytoacleanerhospitalareusually:notime,nomoneyand

nomotivation.

Belowyouwillfindalistwithtipsandincentiveswhichcanpossibly

helpimplementsustainablemeasuresinyourhospital.

• Togaintimeahospitalshouldgeneratehumanresources.Name

onepersonresponsibleforthetaskofcleanerproductionoren-

vironmentalmanagementonly.

• Bettermanagementcanleadtotimesaving.

• Asithasbeenstatedearlierinthisguide,atthebottomline,im-

plementingcleanerproductionsavesmoney.Oncethishasbeen

proved,itisunlikelythattheprocessesandactionsturnbackto

moreexpensivemanners.Evenmoreiftechnologicalchangehas

takenplace.

• Usecleanerproductionasamarketinginstrument.Anenviron-

mentallyfriendlyhospitalwillbemoreattractiveforpatientsand

employeesandthereforeincreaseitscompetitiveness.Useyour

progressesforexternalcommunicationbydescribingyourenvi-

ronmentalandeconomicbenefits,forexampleinannualreports

oronyourwebsite.

• Seekforexternalfinancingthroughpartnershipsandcollabora-

tion.

• Committhemanagement.Thisisthefirstandnecessarystepto

cleanerproduction.Nosubstantialchangecanhappenwithout

thecommitmentofhospitalmanagers.Ideallymanagersdonot

onlysetgoalsbutalsoactasrolemodels.

• Raiseawarenessofstaff.Investineducationalandtrainingpro-

grams.The behavioral change towards a more efficient use of

resources will have a direct impact on lowering the hospital‘s

runningcosts.

• Involve management, staff and patients. Use posters, informa-

tionboardsorstickerstoremindpeopletoswitchoffthelights,

nottoprintunnecessarily,usewaterefficientlyetc.

• Foster the cooperation of the workforce by organizing an idea

competition.

• Rewardstaffforsavingcostsbyrefundingapercentageofsaved

moneytothemorbygivingothernon-materialincentives.

• Buildagreenteam.Involvecommittedandcompetentemploy-

eesfromdifferentdivisionstoaddresstheenvironmentalissues.

• Communicateconcretegoalsanddesiredactionclearly.

• Communicateenvironmentalprogressandsavedcostsinternal-

lybydivision.

• Trytogeneratefirstresultsasquicklyaspossibletokeepthemo-

tivationlevelhigh.

Abigchallengeforcleanerproductionisthedevelopmentofasus-

tainablestructureforbestenvironmentalpractices.Thiscanbefos-

tered by follow-up actions and by monitoring development

throughrepeatedaudits.

5 how to iMpleMent Cp in A sustAinAble AnD suCCessful wAy

45


publiC hospitAl

GenerAl inforMAtion

fACilities


NorthwesternSwitzerland(FHNW)andSustainableBusinessAssociate(SBA)arecontribut-

ingtoimprovetheenvironmentalmanagementinthehealthcaresectorwithaholisticap-

proachandwithoutdecreasingthequalityofservices.TheaimofthisfirstCPauditofthe

hospitalwastogainanoverviewoftheenvironmentalperformanceofthefacility,toiden-

tifyareaswithCPpotential.Thishospitalwasalsousedasapilotoneinordertofurther

developadequatetoolspresentedinthisguide‘sappendices(checklists,matrix,etc.).Itisa

firststeptowardsgreenerhospitalsanditshouldleadtoimplementconcreteactions.

Inaddition,theaimoftheprojectwastoraiseawarenessaboutCPandthustomotivatethe

hospital to improvesavingrawmaterialsandenergy, reducingthewasteemissionsand

improvingtheenvironmentalconditionsinordertoimprovetheecologicalandeconomi-

calperformance(eco-efficiency).

Enterprise ThesecondlargestpublichospitalinJordan

Sector Healthcaresector

Employees 1000

No.ofbeds 400

Waterconsumption 4200m3(2009)

Electricityconsumption 620’000kWh/month(2009)

Dieselconsumption 10000m3(2009)

Medicalwaste 3300kg(2009)

Departments Administration,kitchen&cafeteria,laboratories,laundry,

pharmacy,patientcareandhousekeeping.

Material Water,soap,cleaninganddisinfectionagents,foods,

medicines,laboratorymaterialsandmedicalmaterials.

Energysources Electricityanddiesel.

Wasteandemissions Wastewater,domesticsolidwasteandmedicalwaste.

6 CAse stuDies 6.1 JordAn public HospitAl

best environmental practices in the jordanian healthcare sectorCaseStudy:PublicHospital

46

h

results Afterthefieldvisitanddiscussions,thefollowingmatrixpresenting

areasanddivisionswithCPpotentialcouldbefilledin:

ManyCPoptionshavebeenidentifiedforthehospital,withfollow-

ing expected benefits upon implementation of the CP options.

Thesewillbringeconomicsavings,environmentalbenefitsaswell

asincreasesafetyforstaffandpatients.

• Reducingrawmaterialandenergyconsumption

• Reducingwasteandemissionatthesource

• Improvingtheeco-efficiency

energy Waste Water Good housekeeping & toxic Green Priority comments efficiency management conservation Behavior materials Purchasing

1.Administration XX XX 0 X 0 X 1 •Lighting •Paperrecycling

2.Cafeteria& X XX XX X 0 X 2 •Watersaving FoodService •Wastemanagement (oilandorganicwaste)

3.Gardening& 0 0 XX 0 X 0 3 •Reuseofgreywater Outdoors •Awarenessraising

4.Laboratories X XX X XX XX X 2 •Wastemanagement •Trainingandawarenessraising

5.LaundryService XX X XX X X X 2 •Detergents •Reuseofrinsewater •Ironingmanagement

6.PatientCare 0 XX XX XX 0 X 1 •Cleaning •Trainingandawarenessraising •Watersaving •WasteManagement

7.Pharmacy XX X 0 0 0 0 3 •Airconditioning •Packagingrecycling

8.Cleaning& 0 XX XX XX XX X 1 •Awarenessraisingandtrainings Disinfection •Wastemanagement

XX Highpotential X Smallpotential 0 Nopotential1 Highpriority 2 Mediumpriority 3 Smallpriority

47


option

option 1:Installwatersavingequipmentfortapsandshowers

andusedualflushingsysteminpublicandpatients

toilets

option 2: Re-useoftreatedgreywaterfromkitchenand

laundryforirrigation

option 3: Re-useofsteamcondensateintothesteamboiler

option 4: Placetimers/occupancysensorstocontrolthe

lightinginthecorridors

option 5:Installsolarheatingsystemtoprovidehotwater

option 6: Improveairconditioninginthestorageareas

forallmedicalsupplies

option 7:Installsunshadeontheglazed-rooftomitigatehigh

temperatureinsidethebuildingduringthesummer

option 8:Improvedomesticwastemanagement

(segregationandrecycling)inoffices,kitchen,

patientcareandpharmacy

option 9: Collectbiodegradableorganicwastetobeutilizedin

thecompostingortobetreatedinabiogasplant

DoMAin

Reducefreshwaterconsumptionfordomesticuse

Reducewastewatergeneration

Reducefreshwaterconsumption



Reduceelectricityconsumption

Reducedieselconsumption

Reduceairpollutionemissions


Reducetheelectricityconsumptionbyairconditioners

Reducetheamountofdomesticsolidwastes

Generateelectricityfrombiogas

Reducethequantityofwaste

followinG Are soMe suGGesteD Cp AnD

GooD houseKeepinG options:

48

h

hospitAl fACilities

Administration

CafeteriaandFoodService

LaboratoriesandPharmacy

LaundryServices

PatientCare

CleaningandDisinfection

WasteManagement

49


privAte hospitAl

GenerAl inforMAtion

fACilities


NorthwesternSwitzerland(FHNW)andSustainableBusinessAssociate(SBA)arecontribut-

ingtoimprovetheenvironmentalmanagementinthehealthcaresectorwithaholisticap-

proachandwithoutdecreasingthequalityofservices.TheaimofthisfirstCPauditofthe

hospitalwastogainanoverviewoftheenvironmentalperformanceofthefacility,toiden-

tifyareaswithCPpotential.Thishospitalwasalsousedasapilotoneinordertofurther

developadequatetoolspresentedinthisguide’sappendixes(checklists,matrix,etc.).Itisa

firststeptowardsgreenerhospitalsanditshouldleadtoimplementconcreteactions.

Inaddition,theaimoftheprojectwastoraiseawarenessaboutCPandthustomotivatethe

hospital to improvesavingrawmaterialsandenergy, reducingthewasteemissionsand

improvingtheenvironmentalconditionsinordertoimprovetheecologicalandeconomi-

calperformance(eco-efficiency).

Enterprise Aprivateacutecareandcommunityhealthhospital

Sector Healthcaresector

Employees 150

No.ofbeds 44

Waterconsumption 2600m3(2009)

Electricityconsumption 27’500kWh/month(2009)

Dieselconsumption 150m3(2009)

Medicalwaste 1800kg(2009)

Departments Administration,Kitchen&cafeteria,laboratories,laundry,

pharmacy,patientcareandhousekeeping.

Materials Water,soap,cleaninganddisinfectionagents,foods,

medicines,laboratorymaterialsandmedicalmaterials.

Energysources Electricityanddiesel.

Wasteandemissions Wastewater,domesticsolidwastesandmedicalwaste.

6.2 JordAn privAte HospitAl

best environmental practices in healthcare sector in jordanCaseStudy:PrivateHospital

Inthiscasestudy,theresultsachievedfromconductingaCPaudit

inaprivatehospitalaresummarized.Theinformationdemonstrates

howbestenvironmentalpracticescanbeimplementedintheJor-

danianhealthcaresector.

50

h

results Afterthefieldvisitanddiscussions,thefollowingmatrixpresenting

areasanddivisionswithCPpotentialcouldbefilledin:

ManyCPoptionshavebeenidentifiedforthehospital,withfollow-

ing expected benefits upon implementation of the CP options.

Thesewillbringeconomicsavings,environmentalbenefitsaswell

asincreasesafetyforstaffandpatients.

• Reducingrawmaterialandenergyconsumption

• Reducingwasteandemissionatthesource

• Improvingtheeco-efficiency

energy Waste Water Good housekeeping & toxic Green Priority comments efficiency management conservation Behavior materials Purchasing

1.Administration X XX 0 X 0 X 1 •Lighting •Paperrecycling

2.Cafeteria& XX XX XX X 0 X 2 •Watersaving FoodService •Wastemanagement (oilandorganicwaste)

3.Gardening& 0 0 X 0 0 0 3 •Reuseofgreywater Outdoors •Awarenessraising

4.Laboratories 0 XX X X X X 2 •Wastemanagement •Trainingandawarenessraising

5.LaundryService XX X XX X 0 X 2 •Detergents •Reuseofrinsewater •Ironingmanagement

6.PatientCare XX XX XX X 0 X 1 •Cleaning •Trainingandawarenessraising •Watersaving •WasteManagement

7.Pharmacy XX XX 0 X X 0 1 •Airconditioning •Packagingrecycling

8.Cleaning& 0 X 0 X 0 X 2 •Awarenessraisingandtrainings Disinfection •Wastemanagement

XX Highpotential X Smallpotential 0 Nopotential1 Highpriority 2 Mediumpriority 3 Smallpriority

51


option

option 1:Installwatersavingequipmentfortapsandshowers

andusedualflushingsysteminpublicandpatients

toilets

option 2: Re-useoftreatedgreywaterfromkitchenand

laundryforirrigation

option 3: Re-useofsteamcondensateintothesteamboiler

option 4: Placeoccupancysensorsinthecorridorsto

automaticallyswitchonthelight

option 5::Improvethesolarheatingsystemforhotwater

option 6: Useofrefillabledispensersinsteadofsoapinorderto

complywithoccupationalandpatienthealthandsafety

option 7:Collectbiodegradableorganicwastetobeutilizedin

compostingortobetreatedinthebio-reactor

DoMAin

Reducefreshwaterconsumptionfordomesticuse






Reducedieselconsumption

Reduceairpollutionemissions

Improvethehygienicstatusforpatientsandworkers

Reducethedomesticsolidwastes

Generatingofelectricityfrombiogas

Reducethequantityofwaste

followinG Are soMe suGGesteD Cp AnD

GooD houseKeepinG options:

52

h

hospitAl fACilities

Administration

CafeteriaandFoodService

Laboratories

LaundryServices

PatientCare

CleaningandDisinfection

WasteManagement

53


ThiscasestudywasdevelopedbyHospitalsforaHealthyEnviron-

ment (H2E)withapprovalandguidance fromBronsonMethodist

Hospital.ItwaspublishedinOctober2004andisreproducedinthis

guideasanexampleofanaward-winninginternationalproject.For

moreinformationabouttheH2Eprogramandawards,visitwww.

h2e-online.org.

wAste MiniMizAtion, enerGy ConservAtion, toxiCs

reDuCtion AnD other environMentAl proGrAMs

bronson MethoDist hospitAl

the hospital

Bronson Methodist Hospital is located in downtown Kalamazoo,

Michigan,USA.ItistheflagshipoftheBronsonHealthcareGroup,a

non-profithealthcaresystemservingallofsouthwestMichiganand

northern Indiana. With 380 licensed beds and all private rooms,

Bronson Methodist Hospital provides care virtually in every spe-

cialty (cardiology, orthopaedics, surgery, emergency medicine,

neurologyandoncology).

By implementing Environmental Programs (waste minimization,

energyconservation,etc.),BronsonreduceditsRMWfrom194’693

to192’102pounds in2003, thusreducingRMWby2’591pounds

even with an increase in patient days of 5’608 (467 patients per

month). This waste minimization/energy conservation program

runsthrougheachdepartmentofthehospital,includingContract

Management, Materials Utilization, Materials, Property Manage-

ment,EnvironmentalServices,FacilitiesandFoodServices.

Waste reduction

Solidwasteincreasedby8%becauseofthefollowingfactors:

• 5%increaseinpatientdays

• 8.7%increaseinEmergencyRoomandExpressCarevisits

• 1.7%increasesinoutpatientsurgeries

• fulloccupancyoftheMedicalOfficePavilion

• AnewCardiacCathLab

• AnewPostProcedureUnit

• 11%increaseinFoodServices

cost savings per year

• Savingsfromopeningacompanystoretoreuseofficesupplies

savedthehospitalUSD1’360.

• 1’100poundsofmedicalsuppliesdonatedtothemissionsaved

USD220inlandfillexpenses.

• SavingsfromaserviceagreementwithStericyclewithastandard

monthly fee. Bronson reduced its Regulated Medical Waste

(RMW)enoughtoqualifyforatotalrebateofUSD9’870.

• Savingsfromreductioninchemicalspurchasedafterupgrading

thechemical feedsystemonthenorthbuildingboilerunit re-

sultedinapproximatelyUSD2’000.

• SavingsfromswitchingtoE3AstralLiteswasUSD2’953annually.

• Savings from monitoring water usage for chiller systems was

USD4’700annually.

• Savings from adding an Aquatrac boiler controller was USD

10’500annually.

• Savingsfromreprocessingsingleusedevices–SDCSleevesand

EPCatheters–wasUSD137’700.

• SavingsfromconversiontoreusablepackswasUSD9’744.

6.3 internAtionAl cAse study

54

h

environmental Benefits

Bronson Hospital has an environmentally preferable purchasing

policyofbuyingitemsthathavearecycledcontentifthecostand

qualityaresimilartotheoriginalproducts.In2002Bronson‘srecy-

clingprogramsaved4’420trees,1’820’000gallonsofwater,15’600

poundsofairpollutioneffluents,1’066’00kWhofenergy,780cubic

yardsoflandfillspaceandUSD4’940inwastedisposal.

Bronson Hospital does not purchase latex and PVC items, items

containingmercuryunlessthereisnoalternative,andmarksitems

that contain recycled ingredients. Bronson‘s green purchasing

meansthehealthcarefacilityis lesstoxic, lesspollutedandmore

energyefficient,therebymakingitsaferandhealthierforpatients,

workers,andtheenvironment.

BronsonHospitalopenedaCompanyStorewhichwasusedtostore

excess office supplies and unused office furniture. New units are

onlypurchasedwhenthecompanystoreisoutofstock.Thisprac-

ticereducedtheamountofsolidwastedisposedofandisaconve-

nientwaytorecycle.

Acytologytechisintroducinganalcoholrecyclingsystemtoboth

cytologyandhistologydepartmentsinordertoreducetheamount

ofalcoholdecantedintothesewersystem,theamountofalcohol

keptonsiteandtheamountofalcoholpurchasedannually.

Byusinglesstoxiccleaningsupplies,BronsonHospitalavoidscon-

taminationofthewatersupplywhendisposingofthedirt.Anin-

creased concentration of mercury in the upper part of the food

chainisavoided.Furthermore,Bronsonreducesthereleaseofper-

sistent bioaccumulative toxins (PBTs), a type of hazardous waste,

whichaddstoenvironmentalpollutionduringtheirmanufacture,

useanddisposal.

Bronsonhospitalcloseddownitsmedicalwasteincineratorin1996.

Thusitreducedtheamountofdioxinreleasedintotheairbymedi-

calwastebeingvaporizedintotheairduringthedisposalprocess.

In2003-2004Bronsonhasalsocontractedamedicalwastevendor

toreducethereleaseofdioxinsbyusingacombinationofmicro-

waveandsteamsterilization.Onlytracechemotherapyandpatho-

logicalwasteisincinerated.

In2003–2004,BronsoncontractedtheRetiredEngineerTechnical

AssistanceProgram(RETAP)toassessawasteandenergymanage-

ment program for the hospital.With their advice, Bronson made

simpleimprovementstoconserveenergy,suchasremovinglights

frombeveragevendingmachines,savinganestimatedUSD600an-

nually.

BronsonHospitalhastakenafirststepinincorporating‘greenbuild-

ing’standardsbycontractingBDNIndustrialHygienecompanyto

handlematerialsuncoveredandproperwastemanagementduring

thedestructionofthenorthtower.BDNhelpedwithidentifyingas-

bestos and ensuring secure disposal of it. In total 21’000 tons of

steeland15’000tonsofconcretefromgeneralconstructionwaste

wererecycled.

health Benefits

ByusingmercuryfreealternativesBronsonHospitalhelpedreduce

the mercury exposure to patients and staff, reducing their risk of

damagetobrain,spinalcord,kidneysandliver.

Bronson Hospital reduced the amount of waste in landfills by

switchingtoreusabledinnerwareanddonatingmedicalsuppliesto

amission.Thisreducedtheamountofchemicalsthatcouldleach

intogroundwaterorsurfacewatersthatmaybeusedfordrinking

orbathing.

By closing down its incinerator, Bronson Hospital ensured a re-

duced risk of exposure to dioxin, a human carcinogen which can

causecancer,birthdefects,learningdisabilities,endometriosis,in-

fertility,suppressedimmunefunction,reducedIQandhyperactive

behaviorinchildren.

ByendingthepurchasingofPVCitems,Bronsonreducedtheriskof

exposure to phthalates present in PVC devices, which can cause

damagetotheliver,kidneys, lungsandreproductivesystem,par-

ticularlythedevelopingtestes,accordingtoanimalstudies.

55


Byswitchingtolesstoxiccleaningsupplies,Bronsonhelpsreduce

poorindoorairqualityforpatientsandstaffaswellasreducingor

eveneliminatingtheexposuretochemicalscausingcancer,repro-

ductivedisorders,respiratoryailments,eyeandskinirritation,cen-

tralnervoussystemimpairment,andotherhumanhealtheffects.

toxicity reduction

BronsonHospital’sRMWwerereducedfrom9%oftotalwastestream

in2001to6%oftotalwastestreamin2002eventhoughtherewasa

significantgrowthinbothinpatientandoutpatientservices.

Solidwaste reduction, recyclingandreuse includesproperwaste

segregationandminimizationofRMW.Thisactionincludesproce-

durestomonitorinstancesofnon-compliance.

Bronsonhospitalreducedtheuseofthefollowinghazardouswaste

products:formalin,Xylene,andbatteriesincludingalkalinebatteries.

Savingsfromreductioninchemicalspurchasedafterupgradingthe

chemicalfeedsystemonthenorthbuildingboilerunitresultedin

approximatelyUSD2’000.

Bronson hospital is testing additional cleaning supplies in search

for chemicals which are less harmful. A program has been intro-

duced that ensures that housekeepers use the right chemical for

specific items and Environmental Services are monitoring the

amount of concentrate dispensed when mixing solutions – thus

avoidinghousekeepers’unnecessaryoverexposuretoconcentrate.

how to iMpleMent suCh A proGrAM?

Planning: conductannualwasteauditsandquarterlyvolume/cost

analysis.

create a unit specific development plan with the aim to reduce

RMW,potentialrecyclables,confidentialdocuments,pharmaceuti-

calwaste,andenergyconservationandpollutionprevention.

start educational services. Bronson hospital includes training on

eliminationofmercurydetailinghowtoidentifymercurycontain-

ingdevicesandhowtocleanupmercuryspillandsafety.Inaddi-

tion,postersprovidingpracticalinformationonwasteminimization

andenergyconservationarehungineachsolidutilityroom.Envi-

ronmental Services and staff of Bronson Hospital receive annual

trainingoncorrectwastesegregation/energyconservation,“what

is”RMWandproperhandlingandpackagingofRMW.

monitor yourprogress.Forexample,Bronsonhospitalholdsweekly

inspectionsofeachunit, focusingon issuesofsafety,compliance

and waste minimization/energy conservation.The unit managers

areemailedtheresultsofthemonitoring,includingphotoswhere

necessary.Inaddition,EnvironmentalServicessupervisorshavean

improperwastesegregationformthattheyfilloutthatissenttothe

appropriateunitmanagerandFacilitiesServicesforfollowup.

establish a Green team. BronsoncreatedaGreenTeamthatinclud-

edmembersfromeachdepartmentinordertomonitorandimple-

ment an energy conservation and waste management program.

The Green Team makes monthly announcements in the hospital

newsletterandatmanagementmeetings.

opening a company storetoreuseofficesupplieshelpsintherecy-

clinginitiative.Bronson,sofar,isingeneralrecyclingthefollowing

items: fiber, wooden pallets, plastic, glass aluminum, batteries,

computer monitors, hard drives and keyboards, formalin and xy-

lene,medicalsuppliesandfurniture.

56

h

create an organization-wide mercury elimination program. Bron-

sonestablishedamercuryeliminationprograminJune1996andin

May1999signedapledgewiththeNationalWildlifeFederationto

goMercuryFree.Bronson’smercurymanagementpolicy includes

protocolsforsafehandling,mercuryspillcleanupprocedure,dis-

posalprocedure-recyclingorregulatedsafedisposaltoavoiddis-

posalinwastestreammercuryanditseffectsonhumanhealthand

theenvironment.Bronsonhospitalevenheldamercurythermom-

eterexchangeatapublichealthfair,inSeptember1999,givingout

digitalthermometerstothepublic.Additionally,Bronsonreplaced

allof itssphygmomanometersandallknownmercurycontaining

stainsorpreservativesusedinhistology/pathologywithstandard

zincformalinones.

set up a battery collection site. Bronson recycled 334 pounds of

batteriesin2002.

focus on energy conservation.Bronsonhospitalpurchaseda100

HPAirHandlertocontrolfrequencydrives.Annualenergysavings

derivedfromnewmotorefficienciesanddamperefficiencieswas

USD339’335.Facilitiesareintheprocessofconvertingallexitsigns

toE3AstralLites,savingBronsonhospitalUSD2’953.Bronsonalso

replacedtheautoclaveinmicrobiologywithamoreefficient(Steris)

systemreducingthepoundsofsteampercyclefrom64to21per

cycle.Bronsonmonitoredwatertreatmentandefficienciesincon-

nectiontochillersystems.Steamproductionreducedby12.5%and

boiler run hours decreased 28%. De-alkalized water usage de-

creasedbyb46%.

reprocess single use devices.BronsonworkedwithSterimedtore-

process single use devices, starting with SDC Sleeves in 2002. In

2003theprogramincludedalsoEPCatheters.

57


referenCes useD in this GuiDe

• Are microfiber mops beneficial for hospitals?

SustainableHospitalProject,2003.

• Best Practices for Creating High Performance Healing Environments,

GreenguideforHealthcare,2008.

• Case Study: Green Cafeterias,EPA/EPP,

www.epa.gov/epp/pubs/case/cafeteria.htm

• Cleaning Chemical Use in Hospitals. Fact Sheet.

In:Goinggreen:AResourceKitforPollutionPreventioninHealthCare,

HealthCareWithoutHarm(HCWS),2001.

• Definition Cleaner Production,

UNEP(UnitedNationsEnvironmentProgramme),1990.

• Eco-efficiencyinhealthcare.Informationsheets,

DevelopedbytheCentreofExcellenceinCleanerProduction,

CurtinUniversityofTechnology,2003.

• Environmental Improvements in Laundry Equipment and Products,

HospitalsforaHealthyEnvironment(H2E),2006.

• Green Cleaning Implementation,


• Green purchasing in healthcare,

HealthCareWithoutHarm(HCWH),2006.

• Greener Hospitals: Improving Environmental Performance,

EnvironmentScienceCenter,Augsburg,Germany.

• H2E 10-Step Guide to Composting in Healthcare Facilities,

Hospitalsforahealthyenvironment(H2E),2003.

• HealthCareWithoutHarm,Homepage,www.hcwh.org/europe

• Healthcare waste management,

PresentationbyRaymondSchelker,2010.

• Healthy Hospitals Healthy Planet Healthy People. Addressing climate

change in health care settings,

WorldHealthOrganisation,HealthCareWithoutHarm,2008.

• Healthy Hospitals: Controlling Pests Without Harmful Pesticides,

KaganOwens,BeyondPesticides&HealthCareWithoutHarm(HCWH),2003.

• HospitalsforaHealthyEnvironment(H2E),www.h2e-online.org

• Issues: Pharmaceuticals,HealthCareWithoutHarm(HCWH),2010,

www.noharm.org/us_canada/issues/pharmaceuticals

• It‘s easy to be green: A guide for environmentally conscious office,

M.J.Bradley&AssociatesInc.www.mjbradley.com

• Klinergie 2020, Energy Efficiency in German Clinics. Energieeffizienz

in Deutschen Kliniken, Viamedica.

• List for Alternative Products, Sustainable Hospitals,

www.sustainablehospitals.org/cgi-bin/DB_Index.cgi

• Makingmedicinemercury-free:aresourceguideformercury-free

medicine,inGoing Green: A Resource Kit for Pollution Prevention in Health

Care, HealthCareWithoutHarm(HCWH),2007.

• Making the Most of Every Pound that Enters Your Local Economy,

PluggingtheLeaks,www.pluggingtheleaks.org/resources/plm_ptl.htm

• Managing Pharmaceutical Waste: A 10-Step Blueprint for Health Care Facilities

In the United States,HospitalsforaHealthyEnvironment(H2E),2006.

• Moving away from PVC, in Going Green: A Resource Kit for Pollution

Prevention in Health Care,HealthCareWithoutHarm(HCWH),2007.

• Omari,Farouq:Implementation of Cleaner Production to the Health Cares.

MasterThesis,(notpublished)2010.

• PracticeGreenhealth,Homepage,www.practicegreenhealth.org

• Practiced environmental protection at the University Hospital Freiburg.

Praktizierter Umweltschutz im Universitätsklinikum Freiburg,

University Hospital Freiburg, 2002

• Preventing damage to the environment from pharmaceuticals: a primer.

AfactsheetbyHealthCareWithoutHarmEurope(HCWH),2007.

• Risks to asthma posed by indoor health care environments. A guide to

identifying and reducing problematic exposures, HealthCareWithout

Harm(HCWH),2006.

• Strategies for a better environment, Mercury-Containing Products and

Alternatives, INFORM,2003.

• Sustainable food procurement in the NHS (National Health Service),

SustainableDevelopmentCommission,2001.

• SustainableHospitals,Homepage,www.sustainablehospitals.org

• Laboratory Chemicals and Equipment, SustainableHospitals,

www.sustainablehospitals.org/cgi-bin/DB_

Report.cgi?px=W&rpt=Cat&id=18

• The Holistic Approach: A Case Study in Waste Minimization, Energy

Conservation, Toxics Reduction and Other Environmental Programs,


• UNIDO Cleaner Production Toolkit. Textbook 2 - Team, policy, motivation.

• Water conservation checklist: Hospital/Medical facilities, Every Drop Counts,

NorthCarolinaDepartmentofEnvironmentandNaturalResources,2002.

• WorldHealthOrganisation(WHO),Environmentalpollutionwebsite,

www.who.int/topics/environmental_pollution/en

other useful referenCes

• UNIDOCleanerProductionToolkit.

www.unido.org/index.php?id=o862050

7 referenCes

58

h

PRELIMINARYENERGYAUDITQUESTIONNAIRE

A GenerAl inforMAtion

Buildingname:

Address: P.O.Box:

Tel: Fax:

Generalmanagername:

Contactpersonname:

Floorarea(m2): No.offloors:

No.ofrooms: No.ofbeds(hospitals):

No.ofemployees: No.ofemployeeslivingonpremises:

No.ofshifts:

b questions

1. Buildingage(includesdateandfloorareaforeachaddition).

2. Briefdescriptionofthebuilding(location,size,typeofbuilding,

indoorarea,outdoorarea,pools,garden).

3. Describeanyplannedfacilityorequipmentupgrades,retrofits,

newconstructionprojects,etc.

4. Describeanyspecificenergyorwaterconservationequipment

orinitiativesalreadytakenorplanned.

5. Doesthepropertyhaveanykindofenergymanagementsys-

temorothercentralizedcontrolsystem?

AppenDix 1 – GenerAl questions, preliMinAry enerGy AuDit questionnAire

59

BestEnvironmentalPracticesintheHealthcareSectorBestEnvironmentalPracticesintheHealthcareSector

mo

nth

en

erG

y co

nsu

mPt

ion

W

ater

occ

uPa

ncy

elec

tric

ity

d

iese

l

oth

er f

uel

s

(h

osP

ita

ls)

kW

h

kW

/ kva

(Bil

led

) k

W/ k

va (a

ctu

al)

Pf

/ va

r u

sd

ton

s u

sd

ton

s u

sd

m3

usd

av

ail

aBl

e Be

ds

o

ccu

Pan

cy

1

2

3

4

5

6

7

8

9

10

11

12

yea

r:

C utility DAtA

60

h

D enerGy & wAter supply & Distribution

1. Briefdescriptionoftheelectricitysupplyanddistributionsys-

tem (includes the number and capacity of electricity meters/

serviceconnections,ratesthemetersrelatedtonumberandca-

pacityoftransformers,supplyvoltages,etc.).

2. Briefdescriptionofthedieselsupplyanddistributionsystem(in-

cludeslocationofstoragetanks,meters,andmajorend-uses).

3. Briefdescriptionofthegas/LPGorotherfuelsupplyanddistri-

butionsystem(includeslocationofstoragetanks,anymeters,

andmajorend-uses).

4. Brief description of the water supply and distribution system

(includes the source of water, number and capacity of water

meters/service connections, major pressure reducing valves,

storagetanks,pressureboostingstations,etc.).

5. Hasthepropertyinstalledanywaterconservationequipment,

such as flow-restrictors, low-flow faucets and shower heads,

pressurereducingvalves,waterconservingtoilets,orwaterre-

usesystems?

6. Does the property have any utility monitoring and tracking

programsinplace?Ifso,describe.

e liGhtinG

1. Brief description of the property’s lighting. Includes: primary

lightingtypes(incandescent,compactfluorescent,fluorescent,

mercuryvapor,etc.)andtheirestimatednumbers.

2. Howareoutsidelightscontrolled?

3. Are photocells, timers, occupancy sensors or other controls

used?Ifso,describe.

f ventilAtion systeMs

1. Briefdescriptionof themainventilationsystemsonproperty.

For each system include: type of system (e.g., natural ventila-

tion,unitventilators/splitsystems,packaged multi-zone roof-

topunits(RTUs),variable-air-volume(VAV)systems,dual-duct

systems,etc.).

2. Areasservedbyeachsystem

3. Hoursofoperation

4. Temperaturesetpoints

5. Capacityofsystem(fansizeand/orairflowrate)

6. Coolingsource(DX,chilledwater)

7. Heatingsourceifapplicable(electric,gas,hotwater)

8. Anyspecialcontrolsystemsorfeatures(e.g.,buildingautoma-

tionorenergymanagementsystem,pneumaticcontrols,DDC

controls,etc.)

fixture type wAttAGe no. operAtion hrs.

61


G lAunDry

1. Quantityorweightofitemswashed(peryear,month,day,etc.).

If possible,provideaseparateestimate for each laundry type

(e.g.,towelsvs.linens).

h KitChens, restAurAnts AnD DininG rooMs

1. Briefdescriptionofeachkitchen,restaurant,diningroom,etc.

(includehoursofoperation,seatingcapacity,andair-condition-

ing.Forkitchens, listmajorcookingequipmentandtheir fuel

consumption(electricorgas),quantityofentriesincoldrooms,

etc.).

EQUIPMENT:

iteM no. noMinAl fuel DAily ACtuAl operAtion CoMMents

CApACity (Kw) operAtinG hrs. perCentAGe (%)

Washers

Dryers

Presses

Drycleaners

Irons

Dedicatedhot

waterheaters

Heatorwater

recovery

equipment?

62

h

Thefollowingchecklistsareintendedtoserveassupporttoafirst

assessmentinahospitalconcerningcleanerproduction.Thecheck-

listsarecataloguesofquestions,whichareputaroundthedivisions

ofahospital,alreadyintroducedinChapter3ofthisguideandmain

issues such as energy efficiency and water management. These

questionsshouldhelptoidentifytheenvironmentalproblemsand

opportunitiesforactionineachdivisionofahospital.

ThesechecklistswereusedandadaptedbyFarouqOmariduring

hisMasterthesisinordertoassessthreeJordanhospitals.However,

theywerefirstdevelopedbyCurtinUniversityinAustraliaandthe

adaptedchecklistscanbefoundinthefollowingdocument:“Eco-

efficiencyinhealthcare.Informationsheets,CenterofExcellencein

CleanerProduction,CurtinUniversityofTechnology,2003”.

AppenDix 2 – CheCKlists

63


yes

no

notes

questions

GENERAL

1. Aretheelectronicmachinessuchascopiersandcomputers

frequentlylefton,evenwhenusedonlysporadically?

2.Doesthehospitaluseinefficientlighting,

lightingaccounts?

3.Doesthehospitalhavefullymaintainedheatingandair

conditioningequipment?

4.Doesthehospitalhaveold,

inefficientwindows?

5.Doesthehospitalhavepoorlyinsulatedwalls,

ceilings,andpipes?

LIGHTING

6.Doyouturnofflightswhen

theyarenotneeded?

7.Doesthehospitalhaveincandescent

bulbs?Ratio?

8.Doesthehospitalhavelightemittingdiode(LED)

forexitsigns?Where?

9.Doesthehospitalhavetubularfluorescent

ballastsandlamps?Where?

10.Doesthedistributionofthelightconsidertheplaces

wherelesslightmaybemoreadequate?

11.Doesthehospitalinstalloccupancy

sensorsinrooms?Where?

12.Isnaturallightobstructedincertainareas,

coulditbeimproved?

OFFICEEQUIPMENT

13.Doyoupurchaseenergy-efficient

officeequipment?

14.Arethereanyareasthatareunusedbutarebeing

airconditionedorheated?Where?

15.Doyoucheckyourtimersandthermostatsalways

andwhichonesarenotchecked?

16.Doesthefurnitureorotherobstructions

blockairflow?Where?

AdministrAtion

>>

64

h

yes

no

notes

questions

WATERHEATERS

17.Istheneededvolumeofheatedwater

calculatedwell?

18.Istheprovidedhotwateratthelowesttemperature

thatisacceptableforthetask?

19.Arethetankandpipesinsulated?

Efficiency?

20.Doesthehospitalhavetimerstoturnthewaterheater

offatnightandduringtheweekends?

WINDOWSANDINSULATION

21.Doesthehospitalhave

windowshades?

22.Doyouinstallwindowfilmstohelpblock

radiantheatgainsandlosses?

23.Havetheinsulationofthebuilding

beenchecked?

24.Arethewindowswellsealed?

Double-glazed?

OFFICEPAPER

25.Doyouinventoryyouruseofpaper(letters,makingphoto-

copies,forms,memos,andfilesaswellaspackagingmaterials)?

26.Whoinyourofficeusespaper,whatisitusedfor,andhowisit

beingdisposed?

27.Whatisthetypeandamountof

paperyouareusing?

28.Isthereapracticeof

paperreuse?

GenerAl CoMMents for this Division:

AdministrAtion

65


yes

no

notes

questions

WATER

1. Doyoupracticewashingonlyfullloadsinthedishwashers?

Ifnot,howisit?

2.Aretheequipmentswaterefficient

models?Ratio?

3.Doyouuseahighpressure,lowvolumenozzles

thatincreasecleaningefficiency?

4.Doesthecafeteriareuseanytypeofwater?

Where?How?

5.Aretherewater-cooledmachinesor

air-cooledmodels?

6.Doyoupre-rinsedishesina

waterbasin?

ENERGY

7.Doyouhaveelectricappliances

orgas?

8.Doyoucookwithlids

orcovers?

9.Doyouconsiderthetemperatureofkitchenroomswhen

installingorrelocatingrefrigeratorsandfreezers?

10.Doyoudefrostrefrigeratorsandcleanthedoor

sealsmonthly?

11.Doyouimplementappropriatetemperature

controlofthecookers?How?

12.Doesthekitchenhavesteamcooking

equipment?

13.Doyoumaintainandcleancookingequipment

periodicallytoremovelimedeposits?

14.Doyouturnoffthesteamsupplyinsteamcooking

vesselswhennotactuallycooking?

15.Doyoucarefullymonitorpreheattimes,cooking

temperaturesandmaintenancechecks?

cAfeteriA & food services

>>

66

h

yes

no

notes

questions

WASTE

16.Doyouusewashableplates,eatingutensils,glassesand

cupsforcafeteriaandpatientservice?

17.Arethereanycampaignsofthekind“thinkbeforeyouuse”

todecreaseuseofdisposableitems?

18.Doyouusea“first-in,first-out”inventorypolicy

forrawmaterials?

19.Doyoubuyinbulk?

20.Doyoubuylocallytominimize

transportationcost?

21.Doyourecycle,sellorstoreanyusedcookingoil,

grease,andmeatfat?

22.Doyoucollectandsendtheusedgrease

toarenderer?


cAfeteriA & food services

67



GArdeninG And outdoors

yes

no

notes

questions

WATERUSE

1. Howdoyoucleansidewalks,driveways,loadingdocksand

parkinglots?Useabroomorahose?

2.Didyouinvestigatetheavailabilityofreclaimedwater

forirrigation?

3.Isthereanirrigationmaintenanceprogram?Doyouroutinely

inspectallwaterlines,valvesandpumpsforleaks?

4.Doyouconsiderthewateruseintheearlymorningorinthe

eveningwhenwindandevaporationarethelowest?

5.Doyouconsiderusinglow-volumeirrigation,

suchasdripsystem?

6.Doyouusemulcharoundplantstoreduceevaporation

andweedgrowth?

7.Doyoucleanwithhighpressurehoses?

How?

68

h

yes

no

notes

questions

GENERAL

1. Whatarethetypesoflaboratories?

Numbers?

MANAGEMENTPRACTICES

2.Arethereanystorageareaslikecentralstorageof

chemicalsandwastes?

3.Arethereanyinventorycontrolprogramstotrace

chemicalusage?

4.Arethereanyinternalauditstominimizereagentaccumula-

tionandmaximizerecyclingandsharingofsurplusmaterials?

5.Arethereanyincentiveprogramsfor

wastereduction?

PURCHASINGPOLICIES

6.Howarethehazardouschemicalsbeingpurchased?

Isitinappropriatequantities,ensuringminimalwaste?

7.Doyouminimizeshelfstocktopreventwastedueto

surplusorshelflifeexpiration?

8.Doyouuse“first-in,

first-out”policy?

9.Doyouconsiderthequantityandtypeofwasteproduced

whenpurchasingnewequipment?

10.Doyoufavorlocalproductswhenever

possible?

11.Doyoufavorbiodegradable,recyclableor

reusableproducts?

12.Doyoupurchaseappliancesandotherequipmentthatare

designedforminimumwaterandenergyconsumption?

13.Didyoureplacethepapertoweldispensersinwashrooms

withenergy-savinghotairblowers?

14.Doyoubuycompact,concentratedproductsand/or

eco-refillstolimitpackagingwastes?

15.Doyoupurchasepaperwithatleast50%recycledfibers,

ornon-whitenedorchlorine-freebleachedpaper?

16.Doyoupreferrechargeable

batteries?

lAborAtories

>>

69


lAborAtories

yes

no

notes

questions

LABORATORYPRACTICES

17.Doyouevaluatelaboratoryprocedurestoseeiflesshazardous

ornonhazardouschemicalscouldbeused?

18.Isthereanysegregationinwaste

streams?

19.Arethereanycasesofmixinghazardouswith

non-hazardouswastes?

20.Doyousegregatewastescontainingvaluablesubstances

orpreciousmetalsforsubsequentrecovery?

21.Aretherefulllabelingsystemsforallincomings,

usedchemicalsandcontainers?

22.Aretherestorageareasforchemicals

andwastes?

STAFFTRAINING

23.Isthewastereductionapartofemployee

training?

24.Doyouencourageemployee’sinvolvementandcontribution

indesignandimplementationwastereductionpractices?

Incentives?Istherearoutinemonitoringofwasteminimiza-

tionprogram?

SOLVENTS

24.Whicharethemainusesofchemicals

inhospital?

25.Whichsourcereductionoptionsforsolvents

youuse?

26.Arethereanypreferablechemicalsthanothers

tobeused?

27.Hassolventusedecreasedinyourlaboratories

duetotechnologicaladvances(solventrecovery)?

28.Doyourecycleanykindofchemicalwaste?

How?

29.Doyousegregatethedifferenttypesofwaste,

liquidandsolid?

30.Isthereanychemicalsdraininthesewage?

Whatisalsodrainedinsewagenetwork?

>>

70

h

yes

no

notes

questions

SOLVENTS

31.Wheredoesthewaste

watergo?

CLEANINGGLASSWARE

32.Whatisthephysicalcleaningmethod

thatyouuse?

33.Whatmayreplaceandreducechemicalcleaning

requirements?

34.Doyouevaluatespecialtydetergents,potassium

hydroxide,orsonicbathstoreplacechromicandsulfuric

acidforcleaningglassware?

35.Doyouusebiodegradableoraqueousdetergents

wherepossible?

lAborAtories


71


lAundry services

yes

no

notes

questions

ENERGYANDWATEREFFICIENCY

1.Doyouwashinanyloadorfull

loadsonly?

2. Arethereanyprogramsforrepairingvalves,sensorsand

othercontrolsregularly?

3.Whatisthewatervolumeyouusein

partialwash?

4.Doyoureuserinsewaterorisitgoingdirectlyto

thesewage?

5.Doyouinstallwatersavingdevicesonall

waterfixtures?

6.Doyousortthelaundryaccordingtothe

degreeofsoiling?

7.Doyouwashtowelsandlinenattherequestof

patientsoreveryday?

8.Isthereanyreuseoftherinsewaterfromrelatively

unsoiledloadsforthenextcycle’sprewashandwash?

9.Canyouusetheequipmentduringperiodsoflow

consumption(off-peakhours)?

CHEMICALS

10.Doyouuselesshazardous

laundrychemicals?

11.Doyouleavethedetergentin

humidplaces?

12.Doyouconsultyoursuppliersinordertoevaluatethe

optimalwashformula(productused,dilutionfactor)?

13.Doyouschedulewashingloadsperlevelofsoiling

tominimizetheneedtochangechemical/detergent

compositionandmachinevariables?

14.Arethereautomatedliquidinjection

washsystems?


72

h

yes

no

notes

questions

PATIENT-CARESUPPLIES

1.Canyoudeterminewhetherclothtowelscanbeused

andlatersoldforrags?

2.Doyouhavepapertowelsor

airdryers?

3.Didyouinstallflowregulatorsontheshowerheadsinorder

todecreasewaterconsumptions?(Someregulatorsdecrease

from20to12liters/minute(40%saving).)

4.Didyouinstalladualflushmechanismintoilet

(offeringachoiceofhalf-orfull-cisternflushes)?

5.Didyoudistributeanybrochuresandflyers,orpoststickers

andposters,invitinggueststosavewater?

6.Isthererefrigerator,television,aircondition,anyelectrical

equipment?

7.Doyoueliminateunuseditemsfromcustomsurgicalpacks

(onceapackisopened,unuseditemsarediscarded)?

8.Doyoucontactthemanufacturerwhenoneitemina

surgicaltrayiscausingthewholepacktooutdate?

9.Didyouinstallrefillablesoapandlotion

dispensers?

10.Doyoupurchasewashablesurgicalandisolationgowns

andsterilizationtrays?

11.Doyoumendgowntiessothey

lastlonger?

12.Doyouconvertsurgicaldrapesinto

biopsycloths?

pAtient cAre

>>

73


pAtient cAre

yes

sinGle-use /

DisposAble

no

not

useD

notes

reusAble

AlternAtive

CoMMents

questions

ITEMALTERNATIVES

13.Didyoutrytoreplacepatientcareitemsasshown

inthefollowingtable?

iteM

Underpads

Ambubags

Ventilatorcircuits

Gowns

Dishware

Single-sidedcopymachines

forpapercopies

Sharpscontainers

Cardboardpackaging

Envelopes

Bedpans

Pillows

Urinals

Emesisbasins

Washbasins

>>

74

h

sinGle-use /

DisposAble

not

useD

reusAble

AlternAtive

CoMMents

iteM

Bowls

Alkalinebatteries

Washcloths

Pitchersandcups

pAtient cAre


75


pHArmAcy

yes

no

notes

questions

1.Doyouencouragewholesaledistributorstodeliversmaller

quantitiesofproductmorefrequentlyinreusabletotes?

2.Doyoureturnoutdatedpharmaceuticalsto

thedistributor?

3.Doyouimplementinventorymanagementcontrols

toprotectagainstwastethroughoutdatedstock?

4.Doyousegregatewaste?

5.Doyousegregatehazardousfromnon-hazardous

pharmaceuticals?


76

h

cleAninG And disinfection

yes

no

notes

questions

WATER

1.Isthereanyawarenessinregardtowaterefficiency

practicesduringcleaninganddisinfection?

2.Doyoucleanthewindowsperiodicallyor

asrequired?

3.Doyoureviewthemethodsusedtocleansidewalks,

parkinglotsandotheroutdoorareas?

CLEANINGMATERIALS

4.Canyoureducethenumberof

cleaningagents?

5.Doesthehospitaluserefillabledispensersforcleaning

chemicals?Where?Doyoumixonlytheamountneeded?

6.Doyoubuyinbulktoreduce

packaging?

7.Doyoudealwiththesupplierswhorecycleand

reusethepackaging?

8.Doyoubuyonlywhatyouneedandavoid

unwantedmaterials?

DISINFECTION

9.Doyouevaluatetheneedtodisinfectinordertodetermine

ifalowerlevelofcleaningissufficientincertainareas?

10.Doyouchooseadisinfectantthatishighlyeffectiveand

leasttoxictoemployeesandtheenvironment?

11.Doyouensuretheproperdisinfectants

dilutions?

12.Doyouregularlycalibratedispensingequipment

andcheckforleaks?

13.Doyoulabelcontainers?

14.Doyoutrainthestaffandclearlyposttheprocedure

fordisinfectantuseatthedispensingstation?


77


enerGy efficiency

yes

no

notes

questions

LIGHTING

1.Whatisthetotalenergyconsumptionof

yourhospital?

2. Doyouknowhowmuchenergyeachdepartment

consumes?

3. Doyouuseprocessesthatoptimizeenergy

consumption?

4.Didyoutrytoincreasetheuseofavailable

daylighting?How?

5. Canyoulimitdecorativelighting?

Inwhichareas?

6. Doyoucontrolexteriorandparkingarea

lighting?How?

7.Doyoureduceilluminationlevelsinnon-critical

areassuchashallways,lobbies,waitingrooms,

storerooms,mechanicalrooms?

8. Doyoureallyturnoffthelightswhentheyarenotneeded?Do

youhaveanawarenessprogramfortheemployees?

9. Doesthehospitalhaveincandescent

bulbs?Ratio?

10.Doesthehospitalhavelightemittingdiode(LED)

forexitsigns?Ratio?

11.Doesthehospitalhavetubularfluorescent

ballastsandlamps?

12.Doesthehospitalinstalloccupancysensorsinr

ooms?Where?

HEATINGANDCOOLING

13.Doesthehospitalhaveshadingdevicesorreflective

windowsonsouth&eastfacingwindows?

14.Doyouplanlandscapeshadingwithfastgrowing

trees?

>>

78

h

yes

no

notes

questions

HVAC-SYSTEM(HEATING,VENTILATING,AND

AIRCONDITIONING)

15.Forheating,whatisthesetpointfor

thermostats?

16.Forcooling,whatisthesetpointfor

thermostats?

17.Doesthesettingofheatingandcoolingdevices

considerwhethertheroomsareoccupiedornot?

18.Howdoyoutrytoreducetheair-conditioning

demandstocuthighcosts?

19.Ifanareaistoowarm,doyoucheckforairleaks,

poorinsulation,orheatgainfromthesun?

20.Doyouconsiderprogrammablethermostatsor

timers?

21. Doyoulockyourthermostats?

22.Doyouchangeairfiltersregularly?

23.Doyoucleanfiltersregularlytokeepdirtand

dustoutoffansandmotors?

24.Canyouvalveofforotherwisecutoffseldomusedareasand

installlocalheatingorcoolingequipmenttoservethem?

25. Inalargeboiler,doyouinstallanautomaticcombustion

controlsystem,whichmonitorsthecompositionoftheexit

gasesandfine-tunestheamountofairtakenin?

26.Istheisolationsysteminpipes,airconditioning

andboilerslinesgoodenough?

enerGy efficiency

>>

79


enerGy efficiency

yes

no

notes

questions

WATERSYSTEM

27.Doyouinspectleaksanddamagedinsulationofpipes?

Isthereaschedule?

28.Doyoutrainstaffinmoreefficientoperationof

cleaningequipmentinkitchenandlaundry?

29.Doyouinsulatehotwaterheatersand

storagetanks?

30.Doyouinstallflowrestrictorsathotwaterfaucets

andshowerheads?

31.Doyouthinkthatthepipeinsulation

thicknessissuitable?


80

h

yes

no

notes

questions

CLINICALWASTE

1.Doyouconductacomprehensiveaudittoidentifywhatgoes

inyellowreceptacles?

2.Whatarethetypesofclinicalwaste

youhave?

3.Doyoutrytoincreasetheawarenessoftheneedto

reducetheamountofunnecessarywasteplacedinclinical

wastecontainers?How?

4.Whereyoudisposethehospitalwaste?

Whichincineration?

5.Whatisthewastequantity?

6.Howmuchdoyoupayforthis

service?

MERCURY

7.Whereisthemercurywastegenerated

inthehospital?

8. Whereisthemaindangerof

mercury?

9.Doyousegregatethewastesthatcontain

mercury?

10.Howdoyouhandlespilled

mercury?

RADIOLOGYWASTE

11.Wherearetheradiologywastegenerated

inthehospital?

12.Howdoyoudealwithphotographicchemicalsand

silverremovedfromthefilmduringprocessing?

13.Howdoyoudealwithscrapfilmsuchaspurged

fromoldfilesorgeneratedfrompoorphotographs?

14.Howdoyoudealwithfixer

solution?

15.Doesthestorageenvironmentconsiderthesensitivityof

chemicals,photoprocessing,forlightortemperature?

wAste mAnAGement

A – speCifiC hospitAl wAste

>>

81


b – wAste MiniMisAtion

>>

wAste mAnAGement

yes

yes

no

no

notes

notes

questions

RADIOLOGYWASTE

16.Doyourecyclespoiledorused

x-rayfilms?

17.Doyourecyclefixer?

18.Didthehospitalhaveanyrisksbecause

ofitswaste?

questions

GENERAL

1.Whatisthecostofwastedisposalandtransportation

inthehospital?

2.Haveyoureceivedanydocuments,legalinstructions

relatedtowastedisposal?

3.Doyouknowhowmuchwasteisgeneratedbyyour

hospital?

4.Wheredoyoudisposeyour

waste?

5.Whatarethefeesand

taxes?

6.Whatarethelabor

costs?

7.Canwasteminimizationreducethecurrent

operatingcosts(rawmaterialcosts)?

8.Whatarethestorage

spacecosts?

9.Howcanwasteminimizationincreasehospitalproductivity,

improveenvironmentalprotection,andenhancecommunity

relations?

10.Foreachoccupiedbed,whatistheaverage

amountofwastegeneratedperday?

11.Doyouhaveateamconsistingofpeoplewhoareinvolved

and/orresponsibleforenvironmentalmatters?

82

h

b – wAste MiniMisAtion

yes

no

notes

questions

GENERAL

12.Didthehospitalconductawasteaudittotakeaccountof

everythingthatcomesinandgoesoutandpreparedalist?

13.Didthehospitalinitiatewastesegregationprogramand

identifiedwastestreamsthatcouldbereusedorrecycled?

14.Aretherecontractorswhohandle

thewaste?

15. Doesthepurchasedepartmentselectreusable

ratherthandisposableitems?

RECYCLING

16.Doyourecycleanyofthiswastel

istedbelow?

wAste mAnAGement

Officepaper

Aluminum

Newspapers&magazines

Steelcans

Tonercartridges

Fluorescenttubes

Polystyrene

HDPE

LDPE

Cardboard

Glass

Books

Silver

waxedpaper

Films

PET

PVC

Batteries

83


wAste mAnAGement

yes

no

notes

questions

WASTESEGREGATION

1.Aretherewastecontainersclosetohand

washingsink?

2.Arethereyellowcontainersintendedfor

clinicalwaste?

3.Arethere“batterywaste”collectioncontainersinevery

department?

4. Arethererecyclingbincontainersbesideevery

copierandprinter?

5.Dothesupplierstakebackpallets,emptybottles,

spoiled?

6.Howisthelabelingsystem?Doyoudistinguishcontainersby

meansofcolors,labels,orsymbols(pictograms)foreachtype

ofwaste?

MATERIALINVENTORYANDSTORAGE

7.Istherecomputerizedinventory

storage?

8.Doyouuse“JIT”or“JustinTime“

ordering?

9.Doyouinspectrawmaterialstoensuretheyare

notdamaged?

10.Doyouuse“first-in,first-outtechnique”forall

materials?

11.Doyoulabelanddatematerialswhenreceived,

usedanddisposed?

12.Doyoumonitormaterials

storagewell?

13.Doyoustorematerialsinreusable

containers?

14.Doyoureturnobsoleterawmaterial

tosupplier?

15.Doesthestoragehavesafetyelementslikeafiredistinguisher,

airconditions,alarmsensor,suitablelight,leaching

conservationareaandseparatedarea?Isitclosedwell?

>>

84

h

wAste mAnAGement

yes

no

notes

questions

MATERIALINVENTORYANDSTORAGE

16.Doyoudischargeoilsintosinksor

toilets?

17.Doyoucheckandmaintainregularlyboilers

andcoolingequipmentforemissionlevel?

18.Doyouchangethefiltersofairconditioning

equipmentregularly?

19.Doyouhaveoldoil-firedburnersornatural

gasones?

20. Doyoumonitorleaksinrefrigerating

systems?

21.Didyoucreatenon-smokingplacesin

publicareas?


85


wAter conservAtion

yes

no

notes

questions

BUILDING/GENERAL

1.Whicharethemostwaterconsumingdepartments

andequipmentinthishospital?

2.Aretheemployeesawareabouttheimportanceand

benefitsofwaterconservation?

3.Doyouputsignsinappropriateareasthatpromote

andencouragewaterconservation?

4.Doyoucheckthewatersupplysystemforleaks,

corrosionandproblems?

5.Doyouturnoffwatersupplytoequipmentandareas

thatareunused?

6.Didyouinstallwatermetersineach

department?

7.Whatisthetotalcostofthehospital’swater

consumption?

8.Whatisthehospital’soverallwater

consumption?

9.Doyoucomparetheresultswiththesameperiod

inthepreviousyear?

10.Doyoucheckthewater

pressure?

OPERATIONSANDEQUIPMENT

11.Whatisthesourceofthewaterusedbythehospital

(publicnetwork,well,borehole,etc.)?

12.Didyousetupasystemforstafftolookandreportleaks

andfaults?How?

13.Doyouconsiderusingfullloadsinsanitizers,dishwashers,

sterilizersandwashingmachines?

14.Doyourecyclesteamcondensateto

heatwater?

15.Doesthehospitalusethesingle-passcoolingsystemsinice

machines,X-raymachines,CATscanners,degreases,hydraulic

equipment,vacuumpumps,condensers,airconditioners,etc.?

>>

86

h

wAter conservAtion

yes

no

notes

questions

BATHROOMS/RESTROOMS

16.Doyoucheckregularlyfordrippingtapsand

leakingtoilets?

17.Doyouhaveflowcontrolfixtureswhere

possible?

18.Doyouusedomesticwaterefficiencytechniquesaslow

flushtoilets,faucetaeratorsandlowflushshowerheads?

HEATINGANDCOOLING

19.Howdoyouadjustboilerandcoolingtowerblow

downrate?

20.WhatisthebestTDSlevelrecommendedby

manufacturersspecifications?

21.Doyoureturnsteamcondensatetotheboiler

forreuse?


87


outlooK of the Cp potentiAl in

the Different Divisions

Thistableshowswhatissuesaremoreimportantinwhichdivisions.

Usethegradingindicationsprovidedunderthetable.Thisevalua-

tionissubjectiveandonlyaimsatgivinganoverallimpressionof

thefacility.Itshouldbeunderstoodasahelpfordecision-making

betweenthefirstassessmentandmoredetailedanalysis.

After filling the white cells with the different levels of potential,

evaluatethepriorityofthedifferentdivisions.Inthecommentcol-

umn,youcanalreadyindicatekeyaspectstobeconsidered.

Atthebottomline,youcanalsoevaluatetheoverallpotentialofthe

differentissuesandthereforeselectareasforaction.

YouwillalsofindalreadyfilledmatrixesinthetwoJordaniancase

studiespresentedinthisguide.

AppenDix 3 – MAtrix

88

h

en

erG

y W

ast

e W

ater

G

oo

d h

ou

sek

eePi

nG

to

xic

G

reen

Pr

iori

ty

com

men

ts

effi

cien

cy

ma

na

Gem

ent

con

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atio

n

& B

ehav

ior

mat

eria

ls

Purc

ha

sin

G

1.A

dmin

istr

atio

n 2.

Caf

eter

ia&

Food

Ser

vice

3.G

arde

ning

&

O

utdo

ors

4.L

abor

ator

ies

5.L

aund

ryS

ervi

ce

6.P

atie

ntC

are

7.P

harm

acy

8.C

lean

ing

&

D

isin

fect

ion

Ove

rall

eval

uatio

n

fill

in t

he

taBl

e W

ith

th

e fo

llo

Win

G s

iGn

s:

Prio

rity

xx

Hig

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ial

1H

igh

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Smal

lpot

entia

l2

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ium

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pote

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l3

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89


oBj

ecti

ve

tarG

eted

d

ePa

rtm

ent

Pe

rso

n

mea

ns

dea

dli

ne

exPe

cted

iv

(usd

) rc

(usd

) n

s (u

sd)

act

ion

co

nce

rned

re

sPo

nsi

Ble

re

sult

AppenDix 4 – ACtion plAn

90

h

eDitors:

• InstituteforEcopreneurship(IEC),UniversityofAppliedSciencesNorthwestern

Switzerland(FHNW),SchoolofLifeSciences(HLS)

• SustainableBusinessAssociate(sba)

• RoyalScientificSociety(RSS)

GrAfiC DesiGn:

UteDrewes,Basel

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