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1. Change Policies, Practices, and Procedures
   
   
   1. Mission Statement: From the Top Down
      Healthcare facilities should re-examine mission statements for evidence of concern about public health and environmental impacts. The institution should examine the social contract that is implicit or explicit with the community in which it is located.
      
      
   2. Departments: From the Ground Up
      Require each department to assess environmental and public health impact of policies, practices, and procedures before adoption
      
      
2. Select Indicators for Evaluating Performance
   
   
   1. Define Boundaries of Analysis
      
      
      1. Consider local, regional, national, and global environmental factors when setting priorities. Describe the condition and character of the environment in which the facility exists and identify unique qualities that may influence the choice of indicators and actions to improve environmental performance.
         
         
      2. Lifecycle Impacts: address upstream and downstream impacts of material and disposal choices; operations
         
         1. Material Choices: for example, mercury and polyvinyl chloride containing products pose serious adverse effects both upstream and downstream of health care facilities.
            
         2. Disposal Choices: for example, if a hospital chooses to close an incinerator because of concerns for impact on public health and environment, but contracts with a waste disposal vendor who autoclaves the waste and then ships disinfected waste to a municipal waste incinerator, there may be no gain.
            
         3. Operations: for example, energy and water consumption
            
            
      3. Stakeholders: solicit input from the community, patients, workers, and environmental organizations on what to cover in the analysis
         
         
      4. Legal and Regulatory Requirements: integrate data collection and analysis with legal mandates.
         
         
   2. Possible Indicators1
      
      
      1. Inputs
         
         1. Materials: including those used in direct and indirect patient care, and organizational support
            
         2. Energy: overall consumption and sources (e.g., coal, gas, oil, etc.). For some facilities this may be normalized by consumption per day-bed occupancy.
            
         3. Transportation: staff and patients
            
         4. Water consumption
            
         5. Service Inputs: including cleaning, janitorial, groundskeeping, maintenance, transport, delivery, information and communication, security, food, waste disposal, and pest control
            
            
      2. Outputs
         
         1. Material Wastes: including hazardous, radioactive, regulated, and unregulated waste. "Pounds of red bag waste per patient day" is an example of a material waste indicator.
            
         2. Materials, Other: recycled materials and reusable products sent off-site for re-processing
            
         3. Air Emissions: toxic emissions, criteria air pollutants (e.g., nitrogen oxides), and greenhouse gases. Sources of air emissions include energy generation, transportation, and waste disposal (e.g., incinerators).
            
         4. Water: total water discharge, toxic contaminants
            
            
3. Monitor and Evaluate Environmental Performance
   
   
   1. Incorporate environmental performance evaluations into the regular business function of the organization - at all levels
      
      
   2. Incorporate economic data into evaluations. For example, compare disposal costs and volume (in each material output category) from year to year.
      
      
   3. Schedule routine assessments of environmental performance.
      
      
4. Change Behavior
   
   
   1. Change Purchasing Policy, give priority to:
      
      1. reusable products
         
      2. products made from recycled materials
         
      3. materials with less environmental impact in manufacturing, use, or disposal (e.g., PVC-, DEHP-, and mercury-free products)
         
      4. products that minimize packaging
         
      5. suppliers/manufacturers willing to label the materials present in packaging and products
         
      6. environmentally and occupationally safer cleaning agents, disinfectants, and pesticides
         
      7. products and procedures that reduce generation of hazardous materials, red bag waste, and radioactive waste
         
         
   2. Institute recycling programs; energy and water conservation programs
      
      
   3. Address Staff and Patient Transportation
      
      1. Promote use of public transportation and car pooling
         
      2. Explore opportunities for electronic education programs that minimize travel

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