Epe

DEVELOPING ENVIRONMENTAL PERFORMANCE INDICATORS
THE CASE OF NORFOLK & NORWICH UNIVERSITY HOSPITAL
by
XINFENG ZHAO
Thesis presented in part-fulfilment of the degree of Master of Science in accordance with

the regulations of the University of East Anglia
School of Environmental Sciences

University of East Anglia
University Plain
Norwich
NR4 7TJ August 2003
2003 Xinfeng Zhao
This copy of the dissertation has been supplied on condition that anyone who consults it is
understood to recognise that its copyright rests with the author and that no quotation from the
dissertation, nor any information derived therefrom, may be published without the authors prior
written consent. Moreover, it is supplied on the understanding that it represents an internal
University document and that neither the University nor the author are responsible for the factual
or interpretative correctness of the dissertation.
ACKNOWLEDGEMENT
I would like to thank Elaine Colk for her helpful guidance. I would also like to thank Dick Cobb
and Jon Gurr for their support. Many people have assisted me with the collection of data, in
particular, Mr. Mark Page arranged all the interviews for me. My special thanks go to Veronica
Mcloughlin for providing guidance on my English. Another special thanks must go to my
husband for all the love and encouragement he has given me.
ABSTRACT
Healthcare sector is usually one of the major economic sectors of a country. Studies indicate that
there are a series of environmental impacts resulted from its operation. However, the
environmental awareness of healthcare sector is relatively low. Few of healthcare facilities
evaluate their environmental performance. This research tries to facilitate the Environmental
Performance Evaluation (EPE) in healthcare sector by selecting a set of Environmental
Performance Indicators (EPIs) applicable to hospitals.
In this paper, the reasons and benefits of using EPIs for EPE are introduced first. The
environmental issues related to hospitals are discussed in a succeeding section. The selection of
EPIs is based on analyzing the current environmental situation of a case study Norfolk &
Norwich University Hospital. Some recommendations for improving environmental performance
and EPE are provided lastly.
CONTENTS
ACKNOWLEDGEMENT
ABSTRACT
SECTION I INTRODUCTION
1.1 Background
1.2 Environmental Performance Evaluation
1.2.1 Why evaluate?
1.2.2 How to evaluate?
1.3 Environmental Performance Indicators
1.3.1 Why use indicators?
1.3.2 Classifications of EPIs
1.4 Objectives, Scope and Limitations of the Research
1.4.1 Objectives
1.4.2 Scope and Limitations of the Research
SECTION II RESEARCH METHODOLOGY
2.1 General Introduction

2.2 Literature Review
2.3 Questionnaire and Interview
2.3.1 Design of Questionnaire
2.3.2 Interview
2.4 Data Analysis and Indicators Selection
SECTION III HOSPITAL AND ENVIRONMENT
3.1 Introduction
3.2 Common Activities in Hospitals
3.2.1 Transport
3.2.2 Laundry
3.2.3 Food Services
3.2.4 House and Ground Keeping
3.2.5 Heating, Ventilation and Air Conditioning
3.2.6 Administrative Activities
3.3 Unique Hospital Activities
3.3.1 Use of Chemicals
3.3.2 Use of Radioactive Materials
3.3.3 Use of Facilities Containing Hazardous Materials
3.3.4 Clinical Waste
3.4 Summary of Hospital Environmental Aspects
3.5 Best Practices
SECTION IV CURRENT PRACTICES IN NNUH

4.1 NNUH in Brief
4.2 Current Practices in NNUH
4.3 Conclusion
SECTION V DEFINITION OF EPIs
5.1 Considerations for the Selection of EPIs

5.1.1 Boundary of EPIs
5.1.2 Emphases placed on selecting indicators for EPE
5.1 Considerations for the Selection of EPIs
SECTION VI CONCLUSIONS AND RECOMMENDATIONS
6.1 Conclusions
6.2 Recommendations
6.2.1 Recommendations for NNUH
6.2.2 Recommendations for NHS
REFERENCES
APPENDICES
Appendix I An Initial Checklist for the Identification of

Environmental Aspects
Appendix II Questionnaire
Appendix III Interviewed People and Information Distributions
LIST OF FIGURES
Figure 1.1 Internal Controls in NHS

Figure 1.2 Pressure- State- Response Framework
Figure 1.3 Environmental Performance Evaluation Process
Figure 1.4 Indicators for Environmental Performance Evaluation
Figure 2.1 Flow Chart of he Research
Figure 2.2 Summaries of Literatures Employed in the Research
Figure 2.3 Input-Output Flow of Hospital and Emphases of
Questionnaire
Figure 3.1 Input- Output Flow related to Hospitals Operation
LIST OF TABLES
Table 1.1 UK National & Sectional Environmental Targets

Table 4.1 Best Practices
SECTION I
INTRODUCTION
1.1 Background
In June 1992, representatives from 176 countries gathered at Rio de Janeiro for the United
Nations Conference on Environment and Development. So far, Rio might be the most important
event in the environmental movement (EU&UN 2001). It established a framework for resolution
of the tensions between environmental management and economic development.
After the Rio Declaration was adopted, a series of global and regional environmental agreements
to reduce pollution and conserve nature resources have been reached. This has strengthened the
intensity and scope of environmental legislation (EP@W 2002). It also dramatically drew the
public attention to the problems of the environment. People are finding that it is nearly impossible
to avoid environmental issues, no matter whether in business activities or in political
decision-making processes.
Environmental Management Systems (EMS) are increasingly adopted, especially the certifiable
EMS, such as the international environmental management system standard ISO14001 and the
European Unions Eco-management and audit scheme (OReilly 2000). The numbers of
organizations certified to ISO14001 show this trend. According to the eleventh cycle survey result,
International Organization for Standardization, up to the end of 2001, at least 36,765 ISO 14001
certificates had been awarded in 112 countries or economies, an increase of 13,868 (+ 60,57 %)
over the end of December 2000 when the total stood at 22,897 in 98 countries (ISO 2001).
Undoubtedly, the industrial sector is at the top of this environmental tidal wave, whereas,
relatively little public attention has been put to the healthcare sector (Hancock 2001). Among the
22,897 ISO14001 certified organizations in 2000, only 43 of them were in the category of health
and social work (ISO 2001).
However, from the following figures, it can be detected that the healthcare sector is usually one of
the major economic sectors of a country. One in seven dollars generated in the U.S. economy is
spent on healthcare; one in nine workers is employed in healthcare facilities (Davies & Lowe,
1999). Hospitals alone constitute approximately 1/30th of the entire Canadian economy (Hancock,
2001).
In the UK, the National Health Service (NHS) is the largest single employer. In England alone, the
NHS employs about a million people - 5% of the working population. It costs more than 50
billion a year to run. This will rise to 69 billion by 2005 (NHS 2003). Apart from a large quantity
of employees, in a typical week, NHS hospital outpatient clinics will treat 800,000 people. Like
many other major economic sectors, especially with the feature of 24hours operation, it can be
deduced that the healthcare sector is a big consumer of energy and variety of materials, a big
waste generator, and a significant potential polluter.
There are several environmental practices in the world since the late 1990s. Most of the activities
have focused on pollution prevention. For example, the U.S. Kentucky Pollution Prevention
Center has issued a guide for healthcare to implement pollution prevention (KPPC undated). It
recommended the Environmental Management Systems as a tool to deal with pollution. In
Canada, Canadian Coalition for Green Health Care is committed to encouraging the adoption of
resource conservation and pollution prevention principles and effective environmental
management systems, without compromising safety and care, so as to protect human health and
reduce the Canadian health care system's ecological impact (The Canadian Coalition for Green
Health Care, 2003).
In 1999, the UK government published A better quality of life: a strategy for sustainable
development for the UK, which brings the environment, social progress and the economy
alongside each other at the heart of policy making. It requires the UK health sector to meet four
objectives at the same time:
Social progress which recognizes the needs of everyone;
Effective protection of the environment;
Prudent use of natural resources;
Maintenance of high and stable levels of economic growth and employment.
Accordingly, a New Environmental Strategy for the National Health Service was published in
2002, which addresses the government policy that environmental considerations must be properly
taken into account in the activities and services of the NHS. It identifies several core
environmental concerns and sets relevant targets (Table 1.1). In addition, it indicates that this can
be achieved through the introduction and achievement of:
Environmental appraisal;
Environmental management systems;
Environmental performance management.
As one of the NHS environmental targets, Control Assurance is "a process designed to provide
evidence that NHS bodies are doing their reasonable best to manage themselves so as to meet
their objectives and protect patients, staff, the public and other stakeholders against risks of all
kinds" (NHS 1999). The NHS Control Assurance framework is illustrated in figure1.1, and the
Control Assurance Standards related to environmental issues include
Environmental Management Standard
Waste Management Standard
Fleet and Transport Management Standard
Health and Safety Standard
Figure 1.1 Internal Control in the NHS
Clinical Assurance
Clinical care CLINICAL (Annual report)
GOVERNANCE
Environmental care ORGANIZATIONAL Organizational Assurance

CONTROLS (Annual report)
Financial resources Financial Assurance

FINANCIAL CONTROLS (Annual report)
Source: Control Assurance Team (1999).
From 2001/2002, all NHS Trust chief executives were required to sign a Statement of Control
Assurance, which will appear in their annual reports (Department of Health 2002). Health care
facilities are facing an imperative duty to measure, evaluate and report their environmental
performance. However, Control Assurance standards themselves focus on strategy level; there are
not explicit requirements on environmental performance. Lack of substantial performance criteria
makes organizations difficult to evaluate their performance against these standards, and makes it
impossible to compare the performance between organizations.
This research intends to use a hospital as a case study to illustrate a framework of selecting
environmental performance indicators to facilitate the environmental performance evaluation. The
ultimate purpose is to find the opportunity for healthcare sector to improve the overall environmental
performance. As the healthcare sector includes a variety of organizations that provide different health
care services to consumers, for this particular research, discussion will focus on the general hospitals.
The case study, Norfolk Norwich University Hospital (NNUH), is a general acute hospital, which
was opened to patients in November 2001. The hard and soft facilities management at NNUH is
undertaken together by the Trust and Serco, a private company who provides management
services. The Trust is introducing Environmental Management Systems (EMS) in accordance
with the NHS Control Assurance Standard for Environmental Management, and has set up an
environmental policy group. Currently, there are at least two drives for NNUH to evaluate its
environmental performance. One is to demonstrate its compliance with the NHS Controls
Assurance Standards. The other is to assess the effectiveness of its EMS.
1.2 Environmental Performance Evaluation (EPE)
1.2.1 Why evaluate?
Concern of environment does not imply performing well environmentally. Adopting EMS only proves
that an organization is recognizing its environmental impacts, not necessarily reducing them
significantly (Yong 1998). Without distinct and quantifiable dimensions that can be understood and
measured using high-quality information, any environmental management will be merely ornamental.
There are increasing demands for evaluating the environmental performance of organizations (Howes,
Skea & Whelan 1997).
Environmental Performance Evaluation (EPE) is being used as a management tool to quantify,

understand and track the relevant environmental aspects of a system. As one of the environmental
performance evaluation guidelines, ISO14031:1999 describes the EPE process as an internal
process and management tool designed to provide management with reliable and verifiable
information on an ongoing basis to determine whether an organizations environmental
performance is meeting the criteria set by the management of the organization. Many
organizations realize that to make their environmental improvement demonstrable, clear
measures of environmental performance are required (Collins, 2002).
Table 1.1 UK National & Sectional Environmental Targets
ENERGY WASTE WATER TRANSPORT PROCUREMENT

Reduce CO2 emissions by Target for LAs to recover DEFRA benchmarking for New Deal For Transport To be based on sustainability
20% of 1990 levels by 2010 45% by 2010 with 30% office premises 13 m3 of Better for Everyone; considerations
+ 10% electricity from through recycling water per annum employee Transport 2010 i.e. sustainable timber
Government
renewable sources by 2010 sources
target/date
UK climate change Waste strategy 2001 Conserving water New Deal For EC Procurement
program Landfill directives advice for government Transport Better for Directives
Revised Building Packaging waste departments Everyone; Transport
Government
Regulation directives 2010
drive Carriage of goods
regulations
Waste electronic and
electrical equipment
directives
Strategy on sustainable Strategy on sustainable Strategy on sustainable Strategy on sustainable Strategy on sustainable
development and the development and the development and the development and the development and the
environment to make 1% p.a. environment to reduce waste environment to set target of environment environment
DoH
energy efficiency saving by 40% and recover/ recycle 13 m3 per person per annum all DH sites to have GTP in 100% contracts to contain
target/date 25% by 2000/1 by March 2001 place by April 2002 green clauses
Reduce primary energy Determine at local level Determine at local Determine at local Determine at local
consumption NHS Exec Controls level level level
15% or 0.15 MtC from Assurance process LOCAL STRATEGY DoH Controls LOCAL STRATEGY
NHS
2000 to 2010 LOCAL STRATEGY OCTOBER 2002 Assurance process OCTOBER 2002
target/date LOCAL STRATEGY OCTOBER 2002 LOCAL STRATEGY
OCTOBER 2002 OCTOBER 2002
Source: NHS Estates. (2002)

1.2.2 How to evaluate?
For conducting effective EPE, a framework, which assists the understanding of environmental issues,
is helpful. The Organization for Economic Cooperation and Development (OECD) developed the
Pressure-State-Response (PSR) framework in 1991, which is adapted and simplified from an
early stress-response model. This is shown in figure 1.2
The PSR framework states that human activities exert pressures (such as air emissions, land
contamination or land use changes) on the environment, which can induce changes in the state of
the environment (e.g. air pollutant level, water quality or habitat). Society then responds to
changes in pressures or state with environmental and economic actions (e.g. policies and
programs) intended to prevent, reduce or mitigate pressures and/or environmental damage.
Figure 1.2 Pressure - State - Response Framework
Source: OECD (1993).
The definition of EPE, showed in Box 1.1, indicates that EPE is not a one-off practice. Contrarily,
it should be a dynamic cyclical process, and along with the process, EPE is improved continually.
Box 1.1 Definition of Environmental Performance Evaluation

Environmental Performance Evaluation(EPE)
Process to facilitate management decisions regarding an organizations environmental

performance by selecting indicators, collecting and analyzing data, assessing information
against environmental performance criteria, reporting and communicating, and periodically
reviewing and improving this process
Source: ISO14031:1999
There are a number of schemes or guidelines, which can be used to assist the EPE. Some
examples are listed in Box 1.2. Among them, some focus on specific issues, such as ecology and
chemical industry, or are applicable to certain regions, for example, EMAS. Whereas, some have
a wider scope and can be used by organizations from different sectors and regions, like ISO14031.
Box 1.2 Examples of schemes and guidelines applicable to EPE
The EU Eco-Management and Audit Scheme- EMAS (European Union)

ISO 14031 Environmental Performance Evaluation Guidelines (International Organization
for Standardization)
Sustainability Reporting Guidelines (Global Reporting Initiative)
A framework for Public Environmental Reporting An Australian Approach (Environment
Australia)
Evaluation Guidelines for Ecological Indicators (United States Environmental Protection
Agency)
Responsible Care: Health, Safety and Environmental Reporting Guidelines (European
Chemical Industry Council, CEFIC)
It is suggested in ISO14031 that EPE should follow a Plan-Do-Check-Act model. This ongoing
process can be illustrated as in figure1.3. ISO14031 is one standard of the ISO14000 series, but it
can be used independently, namely, no matter whether the organizations have EMS or not, they
can use ISO14031 as an evaluation tool (OReilly, 2000). Both ISO14031 and ISO14001, the
EMS standard, are based on a Plan- Do- Check- Act approach, which makes the two standards
link closely. However, ISO14031 is more accessible than ISO14001, because it does not require
written procedures and documentation (Lokkegaard, 1999). So, using ISO14031 as a tool to
conduct EPE can be a good start point for the organizations that intend to develop EMS.
Although EPE is defined by ISO as an internal management tool, organizations should avoid just
measuring what the manager wants to know. In figure 1.1, consulting stakeholders is seen as an
important step. It is based upon the following considerations:
Firstly, in terms of environment, the internal and external perspectives are different; the former
emphasizes business processes whereas the later focuses more on environmental outcomes
(Howes, Skea & Whelan 1997). When publics do not gain the expected information, they might
not trust the organization any more, and this will hurt the organization. So, it is wise to be aware of
the external expectation (Piasecki, Fletcher & Mendelson 1999)
Secondly, from the technology point of view, it is not realistic for the organizations to understand
environmental issues adequately. Both of the above reasons lead to the limitation of the
organizations in dealing with the relationship between environmental performance and their
operations. According to a study conducted by U.S. National Academy of Engineering (1999), the
motivation of measuring and tracing environmental performance in the industry sectors has
mainly fallen into three categories:
Compliance with regulatory statutes,
Achievement or strengthening of competitive advantage, and
Improvement of corporate stewardship and reputation.
Figure 1.3 Environmental Performance Evaluation Process
Identifying environmental aspects
Setting performance Consulting

criteria stakeholders
PLAN
Determining significant aspects
Selecting environmental
performance indicators
DO
Collecting data
CHECK Analyzing and converting data
Assessing information
ACT Reporting and communicating
Review and improvement

The findings of the study also reveal that the measured areas are dominated by regulatory
requirements.
In addition, due to increasing interest in the environmental performance of companies from

various stakeholders (see box1.3 for definition), the needs for environmental information are
becoming intensive and complex. A thorough analysis of internal and external stakeholders
opinions had better be conducted as early as possible (Thoresen, 1999).
Box 1.3 Definition of Stakeholders
Stakeholders
are those who have an interest in a particular decision, either as individuals or representatives
of a group. This includes people who influence a decision, or can influence it, as well as those
affected by it.
Source: Earth Summit 2002
1.3 Environmental Performance Indicators
1.3.1 Why use indicators?
From the definition of Performance indicators in box1.4, it can be educed that they can assist
organizations in understanding their environmental status. It could be said that performance
indicators are central to evaluation of environmental performance.
Box 1.4 Definition of Performance Indicators
Performance indicators compare actual conditions with a specific set of reference conditions.
They measure the 'distance(s)' between the current environmental situation and the desired
situation (target): 'distance to target' assessment
Source: EEA (1999)
Except for the basis function of performance indicators, Jasch, C (2000) and Federal
Environmental Ministry, Bonn & Federal Environmental Agency, Berlin (1997) concluded that
the indicators have several variety of functions:
Illustrate environmental progress over time
Detect potentials for optimization
Derive and pursue environmental goals
Identify market opportunities and cost reduction potentials
Evaluate environmental performance between companies
Provide data for communication
Provide feedback to inform and motivate staff members
Provide technical support for the implementation of the EMAS Regulation and ISO 14001
Additionally, most of the environmental indicators can be quantified. This characteristic

facilitates the time series analysis of a specific performance. If the indicators can be reviewed
systematically, they allow the abnormal state to be detected at an early stage, act as an early
warning system. Therefore, relevant action can be adopted in good time. Thus, not only do
environmental indicators provide information for environmental management, they also serve the
general management as well (Thoresen, 1999).
Furthermore, appropriate indicators can be used for benchmarking within organizations with
similar activities. This helps the organizations to detect their weak points. Often, these weak
points are not realized or neglected during operations, whereas it may not be difficult to improve.
So, environmental indicators provide an opportunity for organization to optimize their potentials
(Jasch, 2000).
1.3.2 Classifications of Environmental Indicators
According to ISO14031, indicators for EPE are categorized into two classes: Environmental
Performance Indicators (EPIs) and Environmental Condition Indicators (ECIs). EPIs are
subdivided into Management Performance Indicators (MPIs) and Operational Performance
Indicators (OPIs). Whereas, Germany Federal Environmental Ministry and Federal
Environmental Agency (1997) give a joint name to EPIs, EMIs and ECIs as Corporate
Environmental Indicators
No matter whether the indicator classifications of ISO14031 or Germany Federal Environmental

Ministry, their substance is the same. They all rely on whether they describe an organizations
environmental impact, the managements environmental activities or the organizations external
condition of the environment.
The general indicators for environmental performance evaluation are summarized in Figure 1.4.
As defined in ISO14031, Operational Performance Indicators (OPIs) are a type of environmental
performance indicator that provides information about the environmental performance of the
organizations operations. They focus on tracing the information directly related to the
environmental impacts arising from the organizations operations, and can be used to assess and
control of environmental impacts (Germany Federal Environmental Ministry and Federal
Environmental Agency, 1997). Namely, they allow the management to know what they are
accomplishing through their efforts.
Management Performance Indicators (MPIs) are a type of environmental performance indicator

that provides information about management efforts to influence the environmental performance
of the organizations operations. They focus on describing the managerial actions that are being
taken to minimize the environmental impacts arising from the organizations operations. For
example, tracking the environmental spending demonstrates the organization is putting
environmental policy into practice. However, MPIs can not reflect the organizations
environmental impacts straightway, because they do not describe the outcomes of the managerial
actions. Therefore, they can just be used as supplement for EPE (Germany Federal Environmental
Ministry and Federal Environmental Agency, 1997).
Environmental Condition Indicators (ECIs) are indicators that provide information about the
local, national or global condition of the environment (ISO 2000). They focus on describing the
quality of the environment surrounding the organization. However, environmental quality is often
determined by many factors, and determining environmental condition indicators is costly
(Federal Environmental Ministry, Bonn & Federal Environmental Agency, Berlin. 1997). In
addition, the environmental data, such as ambient air quality, surface and underground water
quality, are usually measured and recorded by the environmental agency or other governmental
institutions. So, it is not necessary for the organizations to measure the conditions of the
environment, except that the organization has been identified as the main cause of an
environmental problem in its area (Federal Environmental Ministry, Bonn & Federal
Environmental Agency, Berlin. 1997).
Figure 1.4 Indicators for Environmental performance evaluation
Corporate Environmental Indicators
Environmental Performance Indicators Environmental Condition Indicators
Operational Performance Indicators Management Performance Indicators Indicators of the condition of water,
land, air, flora and fauna
Materials & Energy Infrastructure System Function

Indicators Transportation Indicators Indicators Indicators
Input Output Infra- Transpor- System Training

Indicators Indicators structure tation Implementation
Indicators Indicators Health
Materials Waste Legal Matters & Safety
& Complains
Energy Air Purchasing
Emission Environmental
Costs
Water External
Waste Communication
Water
Source: Adapt from ISO14031:1999
Federal Environmental Ministry, Bonn & Federal Environmental Agency, Berlin. (1997)
Products
16
1.4 Objectives, Scope and Limitations of the Research
1.4.1 Objectives
Considering the effect of healthcare sector on environment and its responsibility for
environmental protection, this research uses the Norfolk & Norwich University Hospital (NNUH)
as a case study to achieve the following purposes:
To define the current status of environmental practices in NNUH;
To establish a set of EPIs for NNUH which can meet the current requirements of internal and
external communication;
To identify areas that can be improved both for NNUHs EPE and environmental
performance;
To provide recommendations for NHS in order to promote the overall environmental
performance of healthcare sector.
1.4.2 Scope and Limitations of the Research
The scale and severity of environmental impacts may be slightly different between hospitals with
different size, services and so on. This research focuses on describing the environmental issues of
general hospitals. Due to the single case study, it may not paint a general picture of the
environmental performance of hospitals. Considering that little study regarding the hospitals
environmental performance has been undertaken in UK, it is hoped that this research can provide
useful information for further study.
Restricted by both external and internal factors, although some issues have been realized, they are
not covered by this research, or, some processes of the research are not satisfied. This is mainly
related to:
Stakeholders
Stakeholders opinions are very important for selecting environmental performance indicators.
The key hospitals stakeholders include employees, patients, local community, GPs, local
government and environmental regulator, media, contractors, and so on. A communication team
has been set up in NNUH, but they have not had any information about the view of stakeholders
on environmental issues yet. However, the limited time for this research does not allow a
stakeholder survey because the interview and collecting feedback could be very time consuming.
Therefore, this research concentrates on the environmental concerns, and tries to addresses the
environmental end effect.
Data Quality
NNUH has operated for less than two years so that data are relatively few. In addition, in terms of
data recording, they have just paid attention to environmental issues. Therefore, the information
collected from the NNUH are not comprehensive, especially lack of quantitative data. All of these
constitute the limitation of determining the current status of environmental practices.
However, lack of effective environmental information system can be apparent in any

organizations without EMS and which have never conducted EPE. This research may contribute
to assisting the establishment of environmental information systems.
SECTION 2
RESEARCH METHODOLOGY
2.1 General Introduction
OReilly (2000) claims that ISO14031 has several advantages, such as allowing management to
consider the environmental issues in a language they understand, benchmarking performance
more easily. Some research concludes that the environmental elements of ISO14001 can be
generated using the guidance of ISO14031 (Lokkegaard, 1999). NNUH is introducing EMS and
has the intention of pursuing ISO14001 certification. In order to facilitate the EPE in NNUH, this
research chooses ISO14031 as a main tool.
The methodology used for conducting this research is mainly based on the PSR framework (see
figure 1.2). In ISO14031, it is called cause and effect approach. That is: Understanding the
activities of hospital awareness of the pressure that hospital exerts on environment and the
potential environmental changes developing indicators for evaluation providing
recommendation for improving performance (applicable preventive actions). In order to achieve
the above purposes, some specific methods are adopted. These include:
Literature review
Site visit
Individual interview
Using checklist and questionnaire
Data analysis
2.2 Literature Review
Literature review is conducted through the whole research period. The literatures reviewed can be
classified into three categories:
Literatures of background knowledge for the research;
Literatures of Healthcare sector; and
Literatures of NHS & NNUH
Figure 2.1 Flow Chart of the Research

Research Processes Methods
Understanding Literature review;

hospitals Site visit
Listing all the

Design of activities mentioned
checklist in the literatures
Individual
Screening the interview;
activities Using checklist
Design of Input-output
questionnaire analysis
Individual
Collecting interview;
information Questionnaire;
Site visit
Analyzing the Comparing with best

status of NNUH practices;
Using guidelines;
Setting Indicators used by
indicators other organizations
The information sources employed in this research and the outcomes of reviewing these
literatures are summarized in figure 2.2.
Figure 2.2 Summaries of Literatures Employed in the Research
Resources Literatures Outcomes
Books on environment, EMS,

environmental measurement, etc. Determining the framework
Background
Journal articles about EPE, EPIS of the research
knowledge
Guidelines and reports of for the Criteria for selecting EPIs
Government or NGOs research
Specific articles and reports Questionnaire
on internet
Government/NGOs guidelines
for healthcare to implement Checklist
Knowledge
EMS, pollution prevention of
Articles on environmental Healthcare Questionnaire
issues related to healthcare on Sector
the website of government or
specific organizations, Best practices
e.g. Healthcare Without Harm
Articles/documents of
environmental view and
objectives of NHS Information
NHS guidelines/standards on of Best practices
environmental issues NHS
Information of environmental &
program conducting in NHS NNUH
Emphases of selecting EPIs
General information and
environmental related
documents of NNUH
2.3 Questionnaire and Interview
2.3.1 Design of Questionnaire
A list of healthcare activities that have potential environmental impacts was drawn from the
literatures reviewed; this constitutes the scoping checklist. The full text of the checklist is
included in appendix I. It covers comprehensive areas related to the operation of a hospital,
including specific activities and their potential environmental impacts. It was used to narrow the
survey questionnaire. For example, laundry was screened out from the questionnaire because the
checklist indicates there is no laundry on the case site.
The basis of EPE is the operational system, which can be expressed by an input-output materials
flow (Jasch, 2000). According to this theory, the questionnaire is designed based on the analysis
of the hospitals input-output flow. The input-output flow of hospital and the emphasis of the
questionnaire are shown in figure 2.3. Accordingly, the questionnaire is split into 8 sections,
covering the issues:
use of energy
use of water
use of materials
waste management
transport
emission to air
releases to water
contamination of land
Figure 2.3 Input-Output Flow of Hospital and Emphasis of Questionnaire
INPUT OUTPUT
ENERGY
WASTE
z Amount and types
of energy used; - Amount and types of waste
z Major consumer; - domestic waste segregation
z Energy efficiency - control of clinical waste
WATER - control of hazardous waste
EMISSION TO AIR
z Amount of water used
HOSPITAL
z Major consumer - greenhouse gases emission

z Water recycling or reuse - CFCs emission
z Water efficiency RELEASES TO WATER
MATERIALS
- control of emission
z Paper - amount of wastewater discharge
z Plastics - control of hazardous chemicals
z Chemicals
CONTAMINATION OF LAND
z Ozone depleting substances
z Radioactive waste - existing contamination
TRANSPORT - use of herbicides, fertilizers, etc.
- on-site storage of chemicals, oil
z Traffic flow
z Transport mode
z Vehicle type and maintenance
z Traffic efficiency
2.3.2 Interview
The interview focused on the case hospital, and involved staff both from Serco, the company who
provides supports service for NNUH, and NHS Trust of NNUH. It provided the opportunity to
gain the virtual experiences of the hospitals operation, as well as get the immediate feedback of
part of the questionnaire. Totally, ten people were interviewed. The list of people interviewed and
information gained is shown in appendix II.
2.4 Data Analysis and Indicators Selection
Collected data, which are relevant to the practices in NNUH, are compared with the best practices in
order to appraise the current environmental status of NNUH. Best practices are drawn from the
literatures, for example, guidance for pollution prevention, case studies, NHS documents and so on.
To select proper indicators, some environmental areas that NNUH could consider for setting
environmental performance criteria are determined, according to the guidance in ISO14031. The
EPIs are selected focusing on these areas, and making reference to the examples provided in
ISO14031and other guidelines, as well as the indicators used by other organizations.
SECTION 3
HOSPITAL AND ENVIRONMENT
3.1 Introduction
Hospitals can be classified within the service sector, but the activities of hospitals are more
complicated than that of other service organizations. They encompass a wide variety of practices, and
are supported by a number of industries providing resources to the medical community. Due to its
complexity, the first step in understanding the impacts of hospitals on the environment is to define the
activities are being done in the hospital.
A hospital generally involves two types of activities. Firstly, it performs a number of functions that
provide the basic services for the operation of an organization. These activities are commonly found in
other sectors, such as housekeeping, heating and cooling. Secondly, there are some activities unique to
the hospitals. They are a variety of clinical activities and related service activities, which are unique to
hospitals, for example, surgery, nuclear medicine, dental work, disinfecting and sterilizing.
Researches indicate that these activities pose significant risks to both environment and human health
(Davies, 1999. & Hancock, 2001).
In this section, the activities in hospitals and their related environmental impacts will be discussed in
detail. All of these structure the checklist which is used in this research for scoping the activities in
NNUH.
3.2 Common Activities in the Hospitals
Like any other sector, there are some unavoidable activities for a hospital to maintain its normal
operation. Generally, these include transportation and parking, laundry, food services, house and
ground keeping, heating, ventilation, air conditioning and administrative activities.
3.2.1 Transport
According to purpose, transport in hospital includes:

Medical transport, e.g. ambulance;
Employee and patient transport, e.g. private car, shared car, and public transport;
Goods transport.
Fleet operations and maintenance have several environmental aspects, which can lead to impacts on
the environment (Potter & Enoch 1997). These aspects include use of energy (e.g. gasoline
consumption), air emission (e.g. greenhouse gases), waste generation (e.g. used batteries, tires) and
potential soil/water pollution (e.g. polluted by runoff from the road surface). In addition, in order to
provide enough space for parking, hospitals usually occupy acres of land as parking area, which has an
adverse impact on the land resource.
3.2.2 Laundry
Hospital laundries include bed sheets, pillowcases, gowns, surgical drapes, scrubs, mops and so on.
Hospitals are using more linen now than ever before. Linen use per patient day has increased from
18.3 pounds in 1980 to 22.8 pounds in 1995 (Phillips, 1996).
The big laundry volume results in a large consumption of detergent, water, natural gas and electricity.
In order to meet the requirement of infection control, large quantities of disinfectants are also used in
hospital laundries. In addition, laundries discharge a lot of wastewater to the sewage system, which
may have adverse impacts on the environment. Adsorbable organically bound halogens (AOX) are
substances that are persistent in the environment, accumulate in the food web, and some of them are
toxic to humans and other organisms. A research about AOX found that they can be measured in the
effluents from hospitals laundry, as well as other departments in the hospital (Kmmerer 1998).
3.2.3 Food services
Most of the hospitals provide food services for patients, employees and visitors. Investigation
indicates that the food sales in hospital are tremendous. Long term care facilities and hospitals in
America consumed $9.4 billion dollars worth of food in 1997 (Davies, 1999).
It is said that food quality can influence patients overall satisfaction with their hospital stay (Davies,
1999). Patient satisfaction is one of the criteria of evaluating the hospitals performance (NHS).
However, the concomitants of food services are consuming energy/water/raw materials, air emission,
discharging wastewater and generating waste.
3.2.4 House and Ground keeping
The major work of housekeeping in hospital is facility cleaning, including the patient rooms, which
are potentially infected, and common areas elsewhere throughout the hospital. For this task, large
quantity of water and detergents are needed as well as some other materials, such as scrubs, mops and
gloves. Disinfectants are recommended for cleaning the patient care areas (CDC 2003). Except for use
of water and raw materials, the environmental consequences related to this activity are the potential air
pollution and water pollution due to the use of chemicals.
The ground keeping practices, such as gardening, snow removal/salting during winter, involve in the
use of chemicals (e.g. fertilizers, herbicides, pesticides, salt), energy consumption (e.g. gas-powered
lawn movers), water consumption, use and potential contamination of land.
3.2.5 Heating, Ventilation and Air Conditioning
In order to provide a high quality of indoor microclimate, as well as control the spread of airborne
infectious diseases, heating, ventilation and air conditioning systems (HVAC) is indispensable for
hospitals. For the purpose of reducing the concentration of airborne microorganisms, the ventilation
and air conditioning systems in hospitals are usually designed to have high exchange rates and extra
filtration. In addition, most of hospitals are operated 24 hours a day and year round. Therefore, they
consume more energy than other sectors - the intensity of HVAC energy consumption per square foot
in hospitals is around 2 times as much as in commercial office buildings (Westphalen & Koszalinski,
2001).
CFCs and HCFCs are widely used as coolants in refrigeration and air conditioners. Man-made CFCs
however, are the main cause of ozone depletion. It is well known that ozone depletion leads to the
increased risk of exposure to UV radiation and accordingly, will increase the likelihood of adverse
effects on biological systems, such as sunburn, skin cancers and modifying the development of flora
and fauna (DEFRA, 2002).
3.2.6 Administrative activities
Except for the clinical departments, there are many administrative departments in the hospital, such as
Purchasing, Site Services, Health and Safety and so on. The administrative activities in these
departments involve in the consumption of energy and raw materials, air emission, which is due to the
use of duplicating machines, as well as the generation of solid waste.
3.3 Unique Hospital Activities
Hospitals are part of a special service sector, due to their unique activities. They present some hazards
that are rarely found or never present in other sectors. For example, the nuclear medicine and
radiography, which are extremely important for diagnosis and treatment of disease in modern
medicine, represent the largest source of exposure to anthropogenic ionizing radiation. Another
example is the dental practice, which is one of the largest consumers of mercury in the United States
(Davies, 1999).
Chemical use is another big concern in hospital. As well as pharmaceuticals, a variety of chemicals are
used in hospital, such as reagents used for diagnosis, disinfectants and sterilants used for infection
control. They are necessary, but at the same time, can pose considerable hazards to environment and
human health due to their toxicity.
In addition, hospitals generate a special kind of waste clinical waste, which has the potential to
transmit disease. In order to reduce the risk of infection, many clinical wastes are incinerated.
However, this brings some other serious environmental problems, such as air emissions of dioxin and
mercury.
The clinical related activities in hospitals are multifarious. However, in terms of environmental
impacts, they have some common characteristics. Therefore, the concept of Environmental Aspect
will be used in the following descriptions of the clinical activities in hospital. Before starting the
description, it is necessary to define the Environmental Aspect.
Box 3.1 Definition of Environmental Aspect
Environmental Aspect is the element of an organizations activities, products or services that can
interact with the environment.
Source: ISO14001: 1996
The specific environmental aspects of clinical practices include use of chemicals, use of facilities
containing hazardous materials, use of radioactive materials, and generation of clinical wastes. It
should be mentioned that the following descriptions would focus on the unique environmental aspects
of the clinical practices. Although many other aspects, for example, use of energy and water, do occur
in the clinical practices, they are considered as part of the environmental aspects of common activities.
3.3.1 Use of Chemicals
Pharmaceutical compounds have become a new environmental concern recently, because they are one
of the resources of organic compounds that may enter in the environment (Dietrich, 2002). The
presence of pharmaceuticals has been detected in waste water and sewage treatment plants. Although
they are in low concentration, due to the continual infusion into environment via the sewage system,
they could act as persistent compounds (Daughton, 1999).
The pharmaceuticals of concern include prescription drugs, diagnostic agents and many other drugs,
which may have subtle effects on behaviors, reproductive and developmental outcomes in aquatic
organisms. However, it is not clear whether they are a profoundly bioactive (Hancock, 2001).
Another major category of chemical used in hospital is the disinfectant and sterilant, which are
essential for infection control. Some of the medical equipment can be sterilized by high temperature
sterilizers. However, for some steam or heat sensitive equipment, sterilant is needed, and ethylene
oxide (EtO) gas is commonly used in hospital. Evidences indicate EtO has acute effect and long-term
effect on human health, as well as its unstable physical character (Davies, 1999).
3.3.2 Use of Radioactive Materials
Nuclear medicine is used both for the diagnosis and treatment of disease. For the purpose of diagnosis,
the radiopharmaceuticals are attracted to specific organs, bones, or tissues, and emit gamma rays that
can be detected externally by special types of cameras. These cameras work in conjunction with
computers used to form images that provide data and information about the area of body being imaged.
For the purpose of therapy, nuclear medicine is normally used for the treatment of cancer, where high
level of radiation is administered to kill or damage cancerous cells. An estimated 10 to 12 million
nuclear medicine imaging and therapeutic procedures are performed each year in the United States
(SNM 2003). The main environmental concern of nuclear medicine is the generation of radioactive
waste, as well as the occupational risk to the nuclear medicine technologists.
3.3.3 Use of facilities containing hazardous materials
Hospitals are identified as a source of a number of potentially hazardous substances. Among them,
mercury and dioxin are the substances that are of most concerns.
Mercury-containing products
Mercury is an extremely toxic substance, all forms of mercury are toxic to humans, but the various
forms of organic and inorganic mercury have different toxicity. Generally, organic forms are much
more toxic than inorganic forms. Exposure to mercury occurs from breathing contaminated air,
ingesting contaminated water and food, and having dental and medical treatments. Mercury, at high
levels, may damage the brain, kidneys, and developing fetus (ATSDR, 2001).
Mercury is widely found in a variety of medical products. Products for medical use include
thermometers, sphygmomanometers (blood pressure monitors), esophageal dilators (also called
bougie tubes), cantor tubes and Miller tubes (used to clear intestinal obstructions), feeding tubes,
dental amalgam, laboratory chemicals (fixatives, stains, reagents, preservatives), medical batteries and
so on. Products for non-medical uses but common in Medical Settings include cleaning solutions with
caustic soda or chlorine that were contaminated with mercury during the production process, batteries,
fluorescent lamps and high-intensity lamps, non-electric thermostats, pressure gauges and some
electrical switches for lights and appliances. As some of these products will go to incineration, they are
looked as a major source of mercury pollution (AHA & EPA, 2000).
Polyvinyl Chloride (PVC) Plastics
Dioxin is the name given to a group of persistent, very toxic chemicals. They are extremely toxic
environmental contaminants and one of the human carcinogen, which are formed as a result of
combustion processes such as commercial or municipal waste incineration. Polyvinyl Chloride (PVC)
Plastics are chlorinated compounds, and the precursors of dioxin (HCWH 2002).
PVC plastics are the most widely used plastics in medical devices, such as intravenous bags, blood
bags, tubing, and disposable mattress covers. The use of PVC products by the health care industry has
grown rapidly, especially for the single use or short term use applications (Gould, 1998).
Environmental Canada estimated that medical waste incineration is the second largest source of dioxin
emission, contributing 16% of total atmosphere dioxin emissions in Canada in 1999 (Hancock, 2001).
Products containing heavy metals
Hospitals are a source of a number of toxic heavy metals, such as lead, cadmium, silver and in
particular mercury (Hancock, 2001). Due to the extreme severity, mercury-containing products have
been discussed individually.
Lead and cadmium, as well as mercury, are found in many types of batteries used in the hospital. Silver
is the main component of dental amalgam (DPPEA, 1996) Silver containing products are also used for
x-ray imaging or radiography, which are used for assisting diagnosis in wide areas, such as oncology,
dentistry, and surgery. When the x-rays pass through the body, it produces an imaging that contrasts
the density of tissue or bone. X-rays imaging is recorded on silver-based radiographic films, which is a
significant consumer of commercial-grade silver. And the spent photographic chemicals, which are
commonly disposed into the sewage system, also contain silver as well as many other chemicals
(Davies, 1999). Fortunately, the new electronic technique and computer allow technicians to capture
images digitally, enable "filmless radiography" possible (NDT, undated).
3.3.4 Clinical Waste
There is not a uniform appellation for the waste generated in the hospital. Normally, there are two
major waste streams in hospital, one is general wastes, which are generated from the non-clinical areas,
such as office and cafe, another stream is from the clinical area that can be called clinical wastes,
medical wastes or hospital wastes, which are potentially infectious, radioactive or hazardous. The
WHO category (see box 3.1) of health care waste describes it with detailed and clear examples.
In UK, the waste from hospital is classified as controlled waste. The handling, storage, treatment and
disposal of controlled waste are regulated in England and Wales through the Waste Management
Licensing Regulations3. Clinical waste is defined in the Controlled Waste Regulations 1992 and
covers the similar areas as in WHO categories (DETR, 1999).
From the above description, it is apparently that the clinical wastes have many negative impacts on the
environment and human health duo to its potential infectious and hazardous. In addition, there are
increasing concerns related to clinical waste incineration. As discussed before, clinical waste
incineration is an important source of dioxins and mercury, as well as many other common air
pollutants.
Box 3.1 WHO categories of health care waste
Waste category Description and examples
Infectious Waste waste suspected to contain pathogens, eg laboratory cultures, waste from
isolation wards, tissues (swabs), materials or equipment that have
been in contact with infected patients, excreta
Pathological Waste human tissues or fluids, eg body parts, blood and other body fluids,
fetuses
Sharps sharp waste, e.g. needles, infusion sets, scalpels, knives, blades, broken
glass
Pharmaceutical waste containing pharmaceuticals, eg pharmaceuticals that are expired or

Waste no longer needed, items contaminated by or containing pharmaceuticals
(bottles, boxes)
Genotoxic Waste waste containing substances that are capable of causing damage to DNA,
eg waste containing cytostatic drugs (often used in cancer therapy),
genotoxic chemicals
Chemical Waste waste containing chemical substances, eg laboratory reagents, film

developer, disinfectants that are expired or no longer needed, solvents
Wastes with high content Batteries, broken thermometers, blood-pressure gauges, etc.
of heavy metals
Pressurized Containers gas cylinders, gas cartridges, aerosol cans
Radioactive Waste waste containing radioactive substances, eg unused liquids from

radiotherapy or laboratory research, contaminated glassware, packages or
absorbent paper, urine and excreta from patients treated or tested with
unsealed radionuclides, sealed sources
Source: WHO, 2001.
3.4 Summary of Hospital Environmental Aspects
Like manufactories, hospitals consume manpower and material resource to produce the
productsmedical services, as well as a lot of byproducts. Here, a material-based input-output flow,
which is adapted from ISO14031, is used to illustrate the environmental aspects of a hospital (figure
3.1).
Figure 3.1 Input- output flow related to the hospitals operation
INPUT OUTPUT
ENERGY
Electricity, Gas, Oil WASTE
H O S P I T A L
WATER DISCHARGE
TO WATER
RAW MATERIALS
Paper, Plastic, AIE EMISSION
Chemical, etc.
DISCHARGE
TRASPORT TO LAND
3.5 Best practices
As NHS claims, its aim is to bring about the highest level of physical and mental health for all citizens
(NHS 2003). Ethically, healthcare sector should not to be a source of environmental harm, because
these environmental impacts may have direct or indirect adverse effects on human health.
There are several coalitions that commit themselves to reduce the environmental impacts from the
healthcare sector, for example, Health Care without Harm, and The Canadian Coalition for Green
Health Care. They provide information, suggestion and technical support for the hospitals and other
healthcare industries to deal with the environmental issues. There are also some governmental
programs, such as NEAT of NHS, which aims at raising awareness of environmental issues within
NHS facilities and services. In addition, suggestions can be found in some research reports (Hancock
2001, Davies & Lowe 1999). Drawn from the above sources, some so-called Best Practices are listed
in table 4.1.
SECTION IV
CURRENT PRATICES IN NNUH
4.1 Norfolk Norwich University Hospital in Brief
The Norfolk Norwich University Hospital (NNUH) is a general acute hospital, which was
opened to patients in November 2001. It occupies 25 hectares of green field and is
surrounded by agricultural land. The nearest watercourse, the River Wenson is located
approximately one mile away.
NNUH has 989 beds capacity, and provides 24 hours health services per day year round.
The trust of NNUH employs 5500 people, and serves the northeast, northwest and west of
Norfolk. The hard and soft facilities management at NNUH is undertaken together by the
Trust and Serco, a private company who provides management services. The trust is
introducing Environmental Management in accordance with the NHS Controls
Assurance Standard for Environmental Management. Both the Trust and Serco have an
Environmental Policy individually, however, no integrated environmental objectives and
targets have been set.
4.2 Current practices of NNUH
Awareness of current practices is essential for selecting EPIs, because the selected EPIs
should represent the organizations environmental situation accurately (Federal
Environmental Ministry & Federal Environmental Agency 1997). Without knowing the
current practices, this can not be achieved. In addition, the basis of EPIs is recording the
mass of data (Jasch 2000). So, when selecting indicators, it should be considered what
data can be used and where to get the data. Through analyzing current practices, these
questions can be answered. Furthermore, analysis of current practices enables the weak
points of NNUH to be identified. Accordingly, relevant suggestions for NNUH to
improve its environmental performance could be provided.
Before Looking at the current practices in NNUH, it is better to know some best practices.
The best practices shown in Table 4.1 are mainly drawn from the literatures about
healthcare industry and the NHS Environmental Assessment Tool for New Building and
Refurbishment Projects (Davies & Lowe 1999, Hancock 2001, KPPC undated, and NHS
Estates 2001).
Table 4.1 Best Practices
Environmental Best Practices Current

Aspects Practices
There is comprehensive energy plan in place
There is sub metering of major energy uses in the unit, including
humidification plant, cooling plant, computer room, lighting and
small power, theatre room, scanning department (x-ray, MRI, etc),
Use of energy catering and laundry
Using gas boiler rather than oil boiler
Heating, Ventilation and Air Conditioning system is separated
into zones
Improved lighting controls are installed
Installing A computerized Building management System
using water efficient fittings, such as low flush toilets and spray
head taps
A water leak detection system is installed
Use of water Water meters are installed to monitor all supplies to all buildings
Water recycling scheme
There is a provision for the collection and use of rain water
Establishing toxic materials inventory, such as COSHH
Implementing environmental preferable purchasing
Phasing out the use of mercury

Use of
Eliminating PVC plastics
materials
Using environmental friendly cleaning agents, disinfectants,
pesticides, etc
Avoiding using ozone depleting refrigerants
Reducing the use of paper, reuse of paper
Reducing the use of single-use and disposable products, replacing

them with multi-use/reusable products
Good link to public transport
Transport Restricting staff parking spaces

Good facilities for cycling
Regular maintenance of vehicles
Adopting Green Transport policy
Table 4.1 Best Practices (continued)
Environmental Best Practices Current

Aspects Practices
Using color coding system for waste stream
Individual facilities for recycling paper, glass, drink can etc are
provided for patients, staff and visitors
Training staff on proper waste disposal
Waste Reusing equipment whenever practical and safe
Management
Implementing recycling program
Diverting organic food waste to composting
Adopting a first-in, first-out policy, reducing the volume of

inventories to a level of four weeks or less
Tracking waste generation
Monitoring green gases generation from combustion of gas or oil
Using gas boiler rather oil boiler
Air Emission Using CFC-free fridges
Replacing CFCs with CFC-free refrigerants
Reducing the use and well handling of volatile chemicals in the

laboratory
Controlling the use of hazardous chemicals
Implementing environmental preferable purchasing
Release Having a drainage plan in place, adopting drains colour coding

to Water system
Having a effluent discharge monitoring system in place
Proper instructing staff regarding chemical disposal
Reducing the use of herbicides, fertilizers and pesticides
Contamination Using environmental friendly herbicides, fertilizers, etc.

of Land
Reducing on site storage of oil and chemicals
Regularly detecting oil and chemical leakage on storage site
NNUHs current practices from each environmental aspect will be appraised as Excellent,
Very Good, Good or Bad against these best practices. Box 4.1 shows the rating criteria.
Current practices are summarized in Table 4.2.
Box 4.1 Rating Criteria for Appraising NNUHs Current Practices
% Rating
0 ~ 40 Bad
More than 40 Good
More than 55 Very Good
More than 70 Excellent
Source: Adapted from NEAT (NHS Estates 2001).
It should be noticed that, firstly, the best practices are not exclusive; secondly, the
performance of NNUHs current practices is different from its environmental
performance, which is evaluated using specific environmental performance indicators.
Here, the performance of current practices only reflects the extent of the actions that the
hospital has taken to reduce the risk of environmental damage, other than the outcomes of
these actions. In addition, because that the best practices listed in table 4.1 are not
comprehensive, and the appraisal criteria are set to facilitate the description, to some
extent, the appraisal of NNUHs current practices in this research bears subjectivity.
However, the best practices could be used to assist the selecting of performance indicators
and setting the performance criteria.
Table 4.2 Current Practices of NNUH
Environmental Rating
Aspects Current Practices Existing Data Potential Data
Good Energy used in NNUH includes electricity, gas and oil. Total electricity Type of electricity
Electricity is used for lighting, office appliances, clinical consumption (17,389,200 sources
areas, powering the CHP unit, twelve large chillers, KW/year) Electricity used by
ventilation, air conditioning system, and some other Annual electricity cost specific department or
facilities. (651,000) facility
It is presumed that Block 11, where lodges the boilers and Total gas consumption Peak hour of energy
most of the chillers, and the clinical areas are the major (42,000 MW/year) consumption by
electricity consumers. Total cost of gas energy type
Use of Energy Only two main electricity meters, no sub-meters for (472,000/year)
monitoring specific electricity use Total oil consumption
Gas is used for generating hot water and stream, catering (40,000 liters/year)
and powering the CHP unit. Total oil cost
Two main gas meters and 10 sub meters to monitor the (8,000/year)
gas appliances individually. Online control of
Diesel is used for two vans, four standby generators, lawn temperature and
movers and backing up of hot water boilers. measurement of
Has introduced the computerized Building Management electricity, gas and water
System (BMS) using BMS
Table 4.2 Current Practices of NNUH (continued)
Bad NNUH obtains its water supply from Anglian Water. Total water consumption Water intensity
There is one main water meter for the hospital, two sub (150,000M3/year). Water consumption by
meters for steam boilers and another two for the water Water used for steam Specific area or
softeners, which provide the water supply for the hot boilers and hot water department
water boilers. boilers (212,000 Water efficiency
Major water consumers include steam boilers, hot water liters/day)
Use of Water
boilers, the Renal Dialysis Process Water used for the Renal
In addition, there is a 25M50M swimming pool for Dialysis Process (100,000
Hydrotherapy in the hospital. But no information about liters/week).
its water usage is available, as well as the water usage in
the else areas of the hospital.
No water efficient fittings have been installed
No water recycling has been conducted by far.
Bad Paper Consumption of paper The efficiency of
Main paper products used include paper towel, toilet towel (1600Kg/week blue using copy paper
paper, copy paper and different kinds of disposable paper paper towel, 675Kg/week Information of
products. Among these, the green paper towel and toilet green paper towel) disposable paper
paper are made from recycled paper. Consumption of toilet products
Although it is admitted that there are large numbers of paper (300Kg/week)
disposable paper products used in the hospital, it is Consumption of copy
Use of difficult to provide the exact data. This is mainly due to paper[140 box (5
Materials the sorting methods. All products are recorded according pack/box)/week]
to the designation, department who requests the product,
volume and so on. However, no information about the
raw materials is recorded. Usually, it is difficult to
estimate the raw material from the designation. This
circumstance is also applicable to the disposable plastic
products.
No paper reuse occurs
No intention to reduce the use of disposal paper products
Plastics Use of plastic Quantity and
Variety of plastic products are being used waste bag type of
Few information of plastic use available, neither quantity nor the (7500/week plastic
composition of plastic products yellow clinical products
It is also impossible to get the information about plastics usage via the waste waste bags, The use of
data. Because many plastics go to the clinical waste stream, there is no 15000/week disposable
further clinical waste segregation on site. black domestic plastic
The only information about plastics is the use of plastic waste bags. bags and products
NNUH deems that single-use and disposable plastic products are necessary 1000/week clear
for infection control. Reducing the use of disposable plastic products, and bags for the
Use of
replacing single-use product with multi-use ones have not been taken into dirty mop head)
Materials
consideration.
Radioactive materials Quantity of

There are mainly six radioisotopes used in NNUH radioactive
Information about radioactive materials, including its disposal, is well drugs used
recorded in the Nuclear Medicine Department. Quantity of
The department established a database for recording the usage and disposal radioactive
of the radioactive materials. waste generated
Chemicals Consumption of Quantity of chemicals
Large quantities of chemicals are used in NNUH. detergent (490 used by type
Chemicals are controlled by the Health & Safety liters/week) Information about
Department of the Trust using an Advanced System Consumption of pharmaceuticals
Compliance Made Software, which was bought from herbicides and Efficiency of chemical
Sypol Company. fertilizers (200Kg/year use
Departments or persons are required to fill in a Chemical herbicides, and
Use of
Materials Request Form and submit to the Health & safety 200Kg/year fertilizers)
Department, where information about the safety data and The number of substances
how they use the substance should be provided. If the used with high, medium
substance is in the database, the Health & Safety or low environmental
Department will send a Control of Substances Hazardous and/or human health
to Health Risk Assessment Form (COSHH) to the user. hazard
Otherwise, the Chemical Request Form is sent to Sypol,
who will conduct a detailed assessment and then return
the assessment result to the Health & Safety Department.
Transport Excellent NNUH has good links to public transport. Traffic flow at peak Information
There is a green travel plan in place time (over 1000 of
The Trust has restricted the on site parking of staff and has provided vehicles go to and from contractors
more cycle parking facilities. More policies of encouraging staff to NNUH) and
use bike or public transport will be introduced in the future. Transport mode of suppliers
The movement of patients is contracted to the East Anglia employee (18% of the Information
Ambulance Service. There is a little vehicle operated by the Trust hospital employees of business
and Serco, including two vans for the movement of sterilizing choose public transport, travel
equipment and flammable materials, four electric vehicles for the 76% use their private
internal movement of wastes and goods. All vehicles are maintained cars and the other 6%
regularly. go to the hospital by
bicycle, by foot or any
other mode)
Good The waste streams in NNUH are classified as clinical Total domestic waste generation Waste
wastes, sharps, cytotoxic wastes and domestic wastes. (48 tonnes/month) reduction
A clear colour coding system is used, with black gags Paper waste recycled (11 compare to
and yellow bags to distinguish between domestic wastes tonnes/month) previous year
and other wastes, and with numbered tag, colored lid or Carboard recycled (10 Total Waste
label to distinguish between clinical wastes, sharps and tonnes/month) go to landfill,
cytotoxic wastes. Clinical waste generation (50 to 60 incineration,
Cardboard, uncontaminated glass, confidential paper tonnes/month) or recycle
and special waste, for example, batteries, chemicals and Clinical waste reduction against the Information
oils, are segregated on site for recycling or special year target (200 tonnes clinical about the
Waste
disposal. waste reduction against the year sources of
Management
From September 2003, all domestic wastes will be target) different
sorted and recycled by Norfolk Environmental Waste Cytotoxic waste generation waste streams
Service in a new recycling plant. (350Kg/month)
Waste training programs are in place, especially for Pharmacy waste generation
clinical staff to properly disposal of clinical waste. (650Kg/month)
Package of radioactive drugs are kept in the special Special waste generation (138Kg to
containers for a period of 3 half life until the radioactive 1254Kg per month)
level is below the safety limit, and then collected by a Radioactive package waste
licensed company. generation (10Kg to 20Kg per
month)
Very Possible air emission sources in NNUH include the Total HCFC needed Estimated
Good stream and hot water boilers, laboratories and some (60Kg for each chiller) concentration of
clinical areas that use volatile chemicals or drugs, and Total HCFC specific substances in
leak of ozone-depleting substance from chillers. supplemented (50Kg indoor air, especially
Boilers are all gas powered, and receive emission and during 2001- 2002) in lab
burning efficiency checks twice a year. Percentage of fridge
Every 6 month, NNUH calculates its greenhouse gases discarded against total
generated from the combustion of gas and oil. fridge used (5% during
Air Emission In some laboratories and clinical areas, fume cupboards 2001-2002)
and draft down tables are used to extract certain vapors. Green gas emission
No monitoring, neither indoor air nor ambient air , has
been conducted
HCFCs are used as refrigerant of the twelve chillers in the
hospital. However, according the national policy, ozone
depleting substances (ODS), including HCFCs, will be
completely banned from 2015 (EA 2003)
The entire fridge in the hospital are CFC-free, but it still
contains ODS in the bin.
Release to Bad Many substances are discharged to sinks and foul sewers in laboratories, Total Substances
Water theatres and wards throughout the hospital (National Britannia Ltd. 2002). wastewater discharged to
The only preventive action is to instruct the staff not to put hazardous produced sinks and foul
substances down the drains. However, no monitoring of effluent discharge (370,000 liters sewers
at the hospital has been undertaken. per day) Quantity of
In terms of the radioactive waste discharged into the sanitary, which is polluted
generated by patients after taking the radioactive drugs, there is a disposal waste water,
agreement between the hospital and local environmental agency. It is e.g. from
because that this kind of waste can be exactly calculated, there is no toilet, clinical
monitoring of the radioactive level in wastewater conducted. areas, wards
and labs
Contamination Good NNUH was built on the green land and opened in the end of 2001. There is Quantity and Information
of Land no evidence of land contamination currently. type of about
Potential risk of land contamination due to the use of herbicides/fertilizers. herbicides and chemicals and
Herbicides/ fertilizers used in NNUH are environmental friendly (Head fertilizers oil stored on
gardener, Serco). site
Under abnormal operating conditions, for example, spillage or leakage of
some substances on site, no matter oil or chemicals, land contamination
may occur. Currently, NNUH has emergency plans dealing with major
accidents. However, information regarding to the implementation of the
plans was not obtained.
4.3 Conclusion
Current practices indicate that NNUH has done well in some environmental areas, such as
transport and waste management. As the NHS Control Assurance Standards focus on
strategy level, the existing information of NNUH could reflect the level of compliance. But
in terms of evaluating the effectiveness of EMS, because it covers wider environmental
areas than the Control Assurance Standards do, more data are needed, especially data
regarding to the use of materials and release to water.
Current practices also show that NNUH is in a middle stage of environmental awareness;
some environmental impacts have not been realized, for example, the environmental
impacts derived from the use of mercury-containing facilities, PVC products and
disposable products. In addition, the information that related to general material usage is
disordered and incomplete.
SECTION V
DEFINITION OF
ENVIRONMENTAL PERFORMANCE INDICATORS
5.1 Considerations for the selection of EPIs
5.1.1 Boundary of EPIs
In a broad sense, the environmental impacts of hospital include:

z Direct impacts: impacts caused by the direct activities of the hospital
z Indirect impacts: impacts resulted from the service providers activities, the service
providers could be suppliers, transport contractor, laundry contractor, waste disposal
contractor, etc.
It is important for the hospital management to consider its own potential impacts as well
as the indirect ones before deciding the priority of its environmental actions (Thoresen,
1999). However, it needs to consider how the external data from suppliers and
contractors to be gathered and how the data can be used internally to enable effective
communication. EPE could easily start using more manageable information, and then
extend to broader areas (Federal Environmental Ministry & Federal Environmental
Agency 1997). Considering that NNUH has just started measuring their environmental
performance, the boundary for selecting indicators in this research will be the
environmental areas influenced directly by the hospital. It is suggested that the hospital
could consider using external data after a mature information system has been
established.
5.1.2 Emphases placed on selecting indicators for EPE
Some considerations should be taken into account when selecting indicators to facilitate
EPE, although not exclusively compulsory (ISO14031: 1999). Examples are shown in
Box 5.1.
Box 5.1 Considerations for selecting indicators for EPE
Consistent with the organizations stated environmental policy

Relevant and understandable
Obtainable in a cost-effective and timely manner
Measurable in units appropriate to the environmental performance
Able to provide information on current or future trends in environmental
performance
Responsive and sensitive to changes in the organizations environmental performance
Source: EN ISO14031: 1999
To evaluate the environmental performance, the selected EPIs have to be assessed against
the environmental performance criteria. Currently, NNUH has not set any environmental
objectives or targets, as well as environmental performance criteria. In Table 5.1, some
issues, which NNUH could consider for setting the environmental performance criteria,
are listed according to the guidance in ISO14031. At the same time, they are the
emphases that this research places on selecting EPIs.
Table 5.1 Emphases of the Selection of EPIs
Environmental policy of NNUH

Support the re-use and recycling of materials
Promote the efficient use of energy and water
Prevent the pollution of air, land and water
Increase staffs environmental awareness
Evaluate suppliers and contractors environmental commitment to the Trust
National & NHS & DoH environmental targets
See Table 1.1 for details
Legal requirements applicable to hospital
Part I (Dark Smoke) of the Clean Air Act 1993
EC Regulation on Ozone Depleting Substances EC2037/2000
Water resources Act 1991
Water Industry Act 1991
Special Waste Regulations 1996
Environmental Protection Act 1990
Environmental Protection (Duty of Care) Act 1990
Standards
NHS Controls Assurance standard Environmental Management
NHS Controls Assurance standard Waste Management
NHS Controls Assurance standard Fleet and Transport Management
NHS Controls Assurance standard Health and Safety
Best practices
See Table 4.1 for details
5.2 Definition of the EPIs
Graph 5.1 and 5.2 show the distribution of EPIs, and the proposed EPIs are presented in
Table 5.2. The feasibility of these EPIs is analyzed with regard to the data availability.
Box 5.1 Resources of Renewable Energy
Renewable energy comes from continuously available sources, which do not rely on
exhaustible fossil fuels like coal, oil and gas. The main sources of renewable energy in the
UK are wind, the sun, water and biomass.
Source: UK Department of Trade and Industry (2003)
Graph 5.1 Distribution of EPIs
Tr anspor t
Wast ewat er / Land
Ai r Emi ssi on
Wast e
Mat er i al s
Wat er
Ener gy
0 2 4 6 8 10
Graph 5.2 Distribution of EPIs
32%
OPI s
MPI s
68%
Table 5.2 Proposed EPIs
Environmental Proposed EPIs Unit Type Comments Feasibility

Aspects Able to drive from No existing information,
existing information but could obtain
Total energy used KWh OPI Represent the consumption of energy as a Building
whole Management System
The unit of gas (e.g. m3) and oil (e.g. L) have to
be converted enabling to add or compare
Quantity of energy kWh/ OPI Demonstrate the consumption of energy Building
used per building m3 relative to the hospitals size, enable the Management System
square compare with other hospitals
Represent the efficiency of energy use
Use
Proportion of % OPI National target Electricity suppliers
Of electricity from Represent the effort on reducing the natural
Energy renewable resources depletion
resources (see Box
5.1 for explain)
Total energy KWh OPI NHS target Finance department
savings comparing or NNUH environmental policy
to previous year Represent the benefit gained from reducing
energy consumption
Total expenditures MPI Expenditure could be spends on installing Finance department,
on improving energy efficient facilities, which is a energy need to classify the
energy efficiency efficiency best practice expenditure
Represent the effort on reducing the natural
resources depletion
Proportion of % MPI NNUH environmental policy There is a staff
employees trained Enhancing employees environmental assigned for training
on energy awareness program in Serco
efficiency
Table 5.2 Proposed EPIs (continued)

Aspects
Able to drive from No existing
existing information information, but could
obtain
Use Amount of water M3 OPI Represent the consumption of water as a Finance department
of purchased whole
Water Amount of water used M3 OPI National and DoH target Building Management
per employee per annual Represent the efficiency of water usage System
Enable compare with other hospitals
Percentage of water % OPI Represent the effort on reducing water Currently, there is no
reused against water consumption water reuse in NNUH,
purchased but they need to
consider in the near
future in line with their
environmental policy
Amount of water used M3 OPI Reflect the water intensity of special Need to install sub
by major consumer department or facility meters
against total water Could provide useful information for
purchased effectively control of water usage
Expenditures on MPI Represent the effort on improving water Utility and Controls
installing water efficient efficiency Department, Serco
facilities Evaluate the management commitment (i.e.
promote the efficient use of water)
Savings achieved MPI Represent the benefit gained from improving Utility and Controls
through implementing water efficiency Department & Finance
water efficiency Department
programs

Aspects Able to drive from No existing information,
existing information but could obtain
Proportion of recycled % OPI Reduce the depletion of raw materials Purchasing
paper used Evaluate the management commitment (i.e. Department, Serco
support the re-use and recycling of & Trust
materials)
Amount of cleaning agent L/M2 OPI Represent the efficient use of materials Purchasing
used per square meter Enable compare with other hospitals Department, Serco
Number of high N/A OPI Represent the potential risk that NNUH Health & Safety
environmental hazardous poses on the environment Department, Trust
chemicals used
Use Number of N/A OPI A survey is needed,
Best Practice
of mercury-containing should add this
Evaluate the management commitment (i.e.
Materials facilities reduced information in the
prevent the pollution of air, water and land)
comparing to previous purchasing form
year
Proportion of HCFC gases N/A OPI Best practice Utility and Controls
replaced by non-HCFC Meet the national policy [i.e. a complete ban Department, Serco
gases on the use of ozone-depleting substances
from 2015 (EA 2003)]
Number of PVC-products N/A OPI Best practice A survey is needed,
reduced comparing to Evaluate the management commitment (I.e. should add this
previous year prevent the pollution of air) information in the
purchasing form
Number of programs N/A MPI Represent the management effort on Environmental Policy
associated with reducing conservation of natural resources Group
material usage
Savings achieved through MPI Represent the management effort on Purchasing
reductions in materials conservation of natural resources Department, Serco
Represent the benefit gained from reducing & Trust
materials consumption

Aspects Able to drive No existing
from existing information, but
information could obtain
Amount of hazardous waste generated tonnes OPI Represent the environmental pollution burden Waste
from NNUH Management
Meet the requirement of Controls Assurance Department
Standard (i.e. criterion 3,4,10)
Percentage of waste generated for % OPI Represent the air pollution burden from NNUH Waste
incineration & landfill Evaluate the management commitment (i.e. Management
prevent the pollution of air) Department
Represent the impacts from NNUH on land
contamination, natural resource depletion (land)
Percentage of waste re-used, % OPI National and DoH target Waste
Waste recovered or recycled Best practice, keep waste out of final disposal Management
Management Department
Percentage of domestic waste % OPI Meet the requirement of Controls Assurance Waste
separated at source Standard (i.e. criterion 3,4,10) Management
Best practice, separating at source clearly Department
facilitates recycling
Percentage of reduction in waste % OPI DoH target (i.e. reduce 40% waste) Waste
comparing to previous years by waste Represent the effort on waste minimising at Management
type. source Department
Number of employees trained on N/A MPI NNUH policy (i.e. increase staffs environmental Staff assigned for
proper waste disposal versus awareness) training program,
employees needed training Preventing domestic waste go to clinical waste Serco
stream can reduce the quantity of waste for
incineration and the cost of special treatment for
clinical waste
Savings achieved through waste MPI Represent the benefit gained from waste Waste
reduction reduction Management
Indirectly reflect the effort on reducing the waste Department
generation
Aspects Able to drive from No existing
existing information, but
information could obtain
Release Number of hazardous chemicals M3 OPI Represent the environmental pollution burden Health & Safety
To potentially go to sewage system from NNUH Department, but a
water survey is needed
& Reduction of waste water costs MPI Represent the effort on reducing waste water Utility and Controls
compare to previous years Department & Finance
land
Department, Serco
Quantity of environmental friendly Kg MPI Represent effort on reducing the risk of land Head Gardener,
herbicide/fertilizer used versus total contamination Serco
herbicide/fertilizer used
Transport Proportion of employees by means N/A OPI Evaluate the implementation of green transport Site Service
of transportation (e.g. public plan Department, Trust
transportation, private car, bicycle, Indirectly reflect the level of staffs
etc.) environmental awareness
Percentage of vehicles maintained % OPI Well maintained vehicles can consume less oil Site Service
according to maintenance plans and produce less pollutants Department, Trust
Meet the Controls Assurance Standard
requirement
Percentage of transport contractors % MPI NNUH should consider the transport pollution by Site Service
reviewed its transport contractors Department, Trust
Meet the Controls Assurance Standard
requirement
Number of implemented Green N/A MPI NNUH policy (i.e. prevent the pollution of air) Site Service
Transport Plan Meet the Controls Assurance Standard Department, Trust
requirement
Air Emission Amount of energy-linked CO2 g OPI National target Utility and
emission Represent the impacts on climate change from Controls
NNUH Department, Serco
Number of potential air pollutants N/A OPI NNUH policy (i.e. prevent the pollution of air) Health & Safety
reduced compare to previous years Department, Trust
Amount of HCFC gas supplemented Kg OPI Reflect the quantity of ozone-depleting substance Utility and
emission Controls
Department, Serco
SECTION VI
CONCLUSIONS AND RECOMMENDATIONS
6.1 Conclusions
Selecting environmental performance indicators is an important step of the

environmental performance evaluation process. To ensure that the selected indicators
accurately reflect the environmental situations of the organization, a framework for
selecting indicators is necessary.
The framework adopted by this research is the Pressure State Response framework.
The principle of it is the causeeffect relationship between human activities and
environmental changes. This method was implemented for Norfolk & Norwich
University Hospital (NNUH), a newly opened general acute hospital who is introducing
EMS.
The selection of EPIs for NNUH was based on the understanding of its activities,
corresponding environmental pressures and its current environmental situations. The
selected indicators focus on several issues, which might be the greatest concerns of the
coming environmental management in NNUH. This includes the environmental policy of
NNUH, national & sectional environmental targets, applicable legal requirements and the
best practices.
The process of selecting EPIs, at the same time, provide opportunity to find the
weaknesses in NNUH. Currently, some issues that have severe environmental and human
health harms have not been realized by NNUH, for example, the use of mercury
containing facilities and PVC products. In addition, because NNUH is managed together
by the NHS Trust and Serco-the Service Company, there are gaps in terms of sharing
information, which may obstruct the effective collection of data. For instance, both the
Trust and Serco have purchasing departments, but operate severally, so it is yet difficult to
obtain integrated data currently. Based on these findings, some recommendations will be
provided subsequently.
6.2 Recommendations
6.2.1 Recommendations for NNUH
NNUH needs an effective information system. Many departments in NNUH have

established their own database. To integrate the information for EPE, two solutions
could be considered. Firstly, the existing environmental policy team could consult
with the relevant departments to determine what data can be used and what potential
data could be provided. Departments should record these data in accordance with the
requirement of each indicator, including the data unit, frequency of update, and so on.
The environmental policy team could document these data collection criteria to
ensure the time series analysis. The pattern of recording data in certain departments
may need to be adjusted to ensure compatible. This is particularly applicable to the
departments with similar functions but belong to the Trust or Serco respectively.
Secondly, NNUH could create an intranet allowing authorized staff to access the data
they need. This will dramatically facilitate the data collection for EPIs.
As discussed before, information related to use of materials is disordered and

incomplete. This is partly because the complexity of materials used in hospital.
However, use of materials should not be neglected. NNUH need to do a baseline
survey about the material use. This could include the type of raw material, quantity,
and disposal. These baseline data will be very helpful for EPE.
Although several issues have been considered in this research, the EPIs provided in
this research can just be an initial input for NNUH to conduct an effective EPE. More
issues should be taken into account, especially the view of stakeholders. So, an early
stakeholder survey is advisable.
6.2.2 Recommendations for NHS

Control Assurance Standards could be a good start to urge the healthcare
organizations to improve their environmental performance. However, the items of
the standards seem a little vague. Organizations that indeed want to improve the
environmental performance may find that they can not use these standards to guide
their specific actions whereas other organizations could feel that they could easily
cope with it without too much effort. Both of the situations debase the value of the
standards. Therefore, detailed rules of these standards may be necessary.
Mercury-containing facilities and PVC products are common environmental

problems of all healthcare organizations, not specific to one hospital. It is neither
possible nor necessary for each hospital to establish a inventory of all this kind of
products. NHS could do this by means of specific workshops or projects. A website
could be created to release information, provide support on finding alternative
products and so on.
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Appendix I
An Initial Checklist for the Identification of Environmental Aspects
* Please uses the following code to comment relevant issue:

1- applicable to our hospital 2- certain not applicable 3- uncertain
Environmental Aspect Related Activity Comment*
Electricity Operation of medical equipment

Operation of other equipment, e.g. sterilizer, laundry, dish
machine, food processor, office equipment, boiler
Cooling and heating processes
Operation of Aerator
General hospital-wide operations, e.g. lighting
Any others?
Use of Energy
Gas Operation of cooking equipment

Any others?
Fossil Oil Transport

Any others?
Other Energy?
Water Consumption Film processing

Operation of analysis machines and manual analysis
Housing keeping
Laundry
Operation of sterilizers, e.g. hydrogen peroxide sterilizer,
high temperature/pressure/steam sterilizer
Dish machine and food preparation
Boilers, water softener
Ground-keeping practices, e.g. watering the lawn and tree
General hospital-wide operation, e.g. toilets, sinks, water
fountains?
Any others?
Mercury Thermometers
Use of Raw Mercury Thermometers
Materials Sphygmomanometers (blood pressure monitors)
Some Medical Appliances e.g. Esophageal
dilators, Feeding tubes etc.
Dental amalgam
Laboratory chemicals (fixatives, stains, reagents,
preservatives)
batteries
Fluorescent lamps and high-intensity lamps
Other Appliances e.g. Non-electronic thermostats,
Pressure gauges, Some electrical switches used for
lights and appliances etc.
Silver Use silver-based photographic films in x-ray
imaging
Manufacturing dental amalgam
PVC-containi Hospital-wide activity
ng Products
Paper Products Hospital-wide activity
Disposable Basic patient care
materials Clinical activity
Food services
Radioisotopes Clinical activity
Chemicals Use of Pharmaceuticals
Use of Detergents for house-keeping, laundry
Use of Chemicals for medical analysis
Use of Sterilants, disinfectants
Use of Pesticides/herbicides/fertilizers
Any others?
Land contamination Existing land contamination?

Use of pesticides/herbicides/fertilizers
Chemicals spillage during transport and/or storage
Oil spillage during transport and/or storage
Accident and/or incident
Any others?
Waste General General hospital-wide operations

Generation solid waste Food preparation
or Basic patient care
household Unpacking supplies when receive, store and transport
waste supplies
Clinical Basic patient care
waste or Analysis of urine, blood etc.
Biomedical Biological testing
waste Needle, vial, IV bag, drug return to pharmacy for
disposal
Clinical activity
Hazardous Using batteries ( hazardous heavy metal)
waste Disposal of PVC-containing products
Disposal of PCBs appliances
Disposal of mercury-containing appliances
Disposal of asbestos
Disposal of chemicals
Radioactive Performing invasive procedures and contrast
waste injections.
Minor radioactive excreta sanitary disposal
Disposal of radioisotopes before decaying to safe
level
Any others?
Air Emission Nuclear laboratory work

Chemical recycling
Disinfecting and cleaning procedures
Central sterilization
Ozone Depleting Substances
Transport and parking
Photocopier emission
Any others?
Release to Water Film processing

Medical analysis procedures
Chemical disposal
Disinfecting and cleaning processes
Laundry
Dish machine operation and food preparation
processes
General hospital-wide operation (toilets, sinks etc.)
Any others?
APPENDIX II
QUENTIONNAIRE
SECTION 1: USE OF ENERGY
1. Please provide information on energy use in your hospital.
Energy type Amount Purposes Approximate costs

Electricity
Gas
Fossil oil
Others
2. Which activities or departments are the major energy consumers? Do you measure their energy use?
If so, could you provide details? If not, is it possible in the future?
Major Consumer Energy Type Amount Costs
3. Are there or will there be any controls aimed at improving energy efficiency in the hospital? If so,
could you provide details? How do you appraise the level of the controls (full control, high level,
moderate or minimal)?
4. Is there or will be there regulation/requirement (internal and/or external) related to energy use
applied to your hospital? If so, could you provide details? (monitoring data are preferable)
SECTION 2: USE OF WATER
1. Where does the hospital obtain its water supply from (well or local aqueduct)? How much is this
amount (on a daily, monthly or yearly basis)? Approximate costs are welcomed.
2. Is there any water treatment process for reducing the ion concentration on site? If so, how much
water is treated on a daily basis? How do you treat the wastewater (reuse or disposal to sewage)?
3. Which activities or departments are the major water consumers? Is there efficient water use
metering to measure their water consumption? If so, could you provide quantitative data?
5. Are there or will there be any controls aimed at reducing water consumption in your hospital? If so,
could you provide details? How do you appraise the level of the controls (full control, high level,
4. Is there any water reuse or recycling taking place within the hospital? If so, could you provide
detailed or estimated information? Quantitative data are welcomed.
5. Is there or will be there any regulation/requirement (internal and/or external) related to water
consumption applied to your hospital? If so, could you provide details (monitoring data are
preferable).
SECTION 3: USE OF MATERIALS
1. The raw materials listed in the following table are commonly used in many other commercial
sectors, as well as in hospital. Could you provide an estimate of total amounts used in 2002 in your
hospital?
Raw Materials Total Amounts Main Purpose Major Consumer

Paper
Plastics
Glass
Wood
Metal
Food
2. Is there any reuse of paper, plastic, glass etc. taking place within the hospital? If so, could you
provide detailed or estimated information? Quantitative data are welcomed.
3. How many disposable materials do you use on a daily, monthly or yearly basis? Do you have a plan
for replacing single-use and disposable products with multi-use/reusable products?
4. Could you please provide information on the following hazardous materials used in the hospital?
Materials Amount
Mercury-containing products
Silver-based Photographic films
PVC products
Radioisotopes
5. Are there or will there be any controls on reducing use of raw materials in your hospital? If so,
could you provide details? How do you appraise the control level (full control, high level, moderate
or minimal)?
6. Is there or will there be regulation/requirement (internal and/or external) related to any of the above
hazardous materials applied to your hospital? If so, could you provide details? (monitoring data is
preferable).
SECTION 4: WASTE MANAGEMENT
1. How do you define household waste, clinical waste and hazardous waste? What color scheme do
you adopt? Please provide some details.
Type Definition Color Amount Costs

(daily estimate)
Household
Waste
Clinical
Waste
Hazardous
Waste
Summation
2. Do you segregate household waste on site? If so, do you keep the records of the amounts of
different household waste periodically? Could you provide some details? If you do not segregate
currently, is it possible to do so in the near future?
Type Amount How is it dealt with?

Paper products
Plastics
Glass
Metal, e.g. cans
Foods
Others
3. Do you control clinical waste, in other words, how do you prevent household waste from entering
clinical waste bins in order to reduce incineration and waste treatment costs? Could you provide
estimate of the proportion of household waste in clinical waste bin?
4. As many commonly used medical supplies contain mercury and PVC, do you have the inventories
of the mercury-containing, PVC-containing products in your hospital? If so, could you provide
details? Do you deal with these wastes specially, and do you have a plan for phasing out them?
5. How much radioactive waste was produced in your hospital in 2002? Where and how do you store
radioactive waste? How do you assure the safety before disposal?
6. Do you keep record on the stock of pharmaceuticals and reagents according to their due date? If so,
how many pharmaceuticals and reagents were overdue in 2002?
7. In general, how do you appraise your controls on waste? (full control, high level, moderate or
minimal).
8. Is there or will be there regulation/requirement (internal and/or external) related to waste

management applied to your hospital? If so, could you provide details (monitoring data is
preferable).
SECTION 5: TRANSPORT
1. What is the daily traffic flow in your hospital?
2. Have you ever studied the mode of transport used by your employees? If so, could you provide
details?
Means of Transport Proportion of Employees Kilometers/miles to work site

Public Transport
Private Car
Shared Car
Hospital Bus Service
By Bicycle or By Foot
3. Please provide information on the transport facilities owned by your hospital.
Vehicle Type Amount Operation Fuel Type Amount of Fuel Costs

Hours Fuel Consumption
4. How often do you maintain your transport facilities? Do you keep record on the conditions of the
transport facilities? If so, could you please give the details?
5. If you have contracted out some transport services, e.g. goods transport, ambulance etc, could you
provide estimates?
6. What transport efficient controls are in place? How do you appraise it (full control, high level,
SECTION 6: AIR EMISSION
1. Have there been any systematic studies or measurements of air quality (indoor and/or ambient)
within the hospital? If so, what parameters are being monitored?
2. Is there any relevant legislation specific to air emission applied to your hospital? If so, could you
provide details? Data are welcomed.
3. If fossil fuels are being used in hospital (e.g. for boiler, transport etc.), have you calculated
greenhouse gas (i.e. CO2, SO2 and NOx) emission according to different activities? If so, could you
provide details?
4. Do you use CFCs as refrigerant? If so, could you provide the proportion of CFC-containing
refrigerators in your hospital? How do you deal with them after being abandoned? Do you have a
policy on phasing out CFC-refrigerators?
5. What controls on reducing air emission are taking place or will take place in your hospital? How do
you appraise the control level?
SECTION 7: RELEASE TO WATER
1. How much wastewater is discharged to sewage on a daily basis in your hospital?
2. Have there been any measurements of pollutants level in wastewater discharged from your hospital?
If so, what parameters are being monitored?
3. Is there any relevant legislation specific to water discharge? Can you meet the limits? Please
provide details. Monitor data are welcomed.
4. Are there any substances that are discharged to sewage after being pre-treated on site? If so, could
you provide substances along with their amounts?
5. Are there any controls on preventing hazardous substances entering into sewage in practice? How
do you appraise the control level? Please provide details.
SECTION 8: LAND CONTAMINATION
1. Is there any sign of existed land contamination?
2. How much is the area of land used as garden?
3. Please provide information about the use of pesticides, herbicides, fertilizers etc.
Category Name Environmental friendly? Amounts of total use per year

Pesticides
Herbicides
Fertilizers
Other chemicals
4. With respect to the chemical use for ground maintenance, has any environmental friendly
alternatives been considered? (e.g. composting) If so, please provide details.
Appendix III
Interviewed People and Information Distribution
People Interviewed Information

Mr. Mark Page z General information of the hospital
z Information about administration, strategy,
Health & Safety Manager (Serco)
future plan, etc.
Mr. Mark Hughes z Use of chemicals
z Hazardous chemicals control
Health & Safety Officer (Trust)
Mr. Simon Wardale z General information of transport
z Transport efficiency
Site Service Officer (Trust)
z Transport policy
Mr. John Skrypniuk z Use of radioactive materials
z Management of radioactive waste
Head of Nuclear Medicine (Trust)
z Radioactive emission
Ms. Julia Hodges z General information about use of materials
z Purchasing policy
Purchasing Manager (Trust)
Mr. Gerry Barber z General waste management information
z Waste recycling
Waste Manager (Serco)
z Control of clinical waste
Mr. Andy Barnes z Use of energy and water
z Water discharge
Utility & Controls Manager (Serco)
z Water recycling scheme
z Air quality control
Ms. Jackie Gallant z Use of paper, plastic, etc.
z Use of recycled materials
Purchasing Manager (Serco)
Mr. Andy Symonds z General information of BMS
z Energy, water efficiency
Building Management Systems
Officer (Serco)
Mr. Paul Roberts z Potential land contaminants and their usage
Head Gardener (Serco)

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DEVELOPING ENVIRONMENTAL PERFORMANCE INDICATORS

THE CASE OF NORFOLK & NORWICH UNIVERSITY HOSPITAL

Thesis presented in part-fulfilment of the degree of Master of Science in accordance with

School of Environmental Sciences

2003 Xinfeng Zhao

SECTION II RESEARCH METHODOLOGY

2.1 General Introduction

SECTION III HOSPITAL AND ENVIRONMENT

SECTION IV CURRENT PRACTICES IN NNUH

SECTION V DEFINITION OF EPIs

5.1 Considerations for the Selection of EPIs

SECTION VI CONCLUSIONS AND RECOMMENDATIONS

Appendix I An Initial Checklist for the Identification of

Figure 1.1 Internal Controls in NHS

Table 1.1 UK National & Sectional Environmental Targets

Figure 1.1 Internal Control in the NHS

Environmental care ORGANIZATIONAL Organizational Assurance

Financial resources Financial Assurance

Source: Control Assurance Team (1999).

1.2 Environmental Performance Evaluation (EPE)

1.2.1 Why evaluate?

Environmental Performance Evaluation (EPE) is being used as a management tool to quantify,

ENERGY WASTE WATER TRANSPORT PROCUREMENT

Source: NHS Estates. (2002)

Figure 1.2 Pressure - State - Response Framework

Source: OECD (1993).

Box 1.1 Definition of Environmental Performance Evaluation

Process to facilitate management decisions regarding an organizations environmental

Box 1.2 Examples of schemes and guidelines applicable to EPE

The EU Eco-Management and Audit Scheme- EMAS (European Union)

Identifying environmental aspects

Setting performance Consulting

Determining significant aspects

Review and improvement

In addition, due to increasing interest in the environmental performance of companies from

Box 1.3 Definition of Stakeholders

1.3 Environmental Performance Indicators

1.3.1 Why use indicators?

Box 1.4 Definition of Performance Indicators

Additionally, most of the environmental indicators can be quantified. This characteristic

1.3.2 Classifications of Environmental Indicators

No matter whether the indicator classifications of ISO14031 or Germany Federal Environmental

Management Performance Indicators (MPIs) are a type of environmental performance indicator

Corporate Environmental Indicators

Environmental Performance Indicators Environmental Condition Indicators

Materials & Energy Infrastructure System Function

Input Output Infra- Transpor- System Training

1.4.2 Scope and Limitations of the Research

However, lack of effective environmental information system can be apparent in any

2.1 General Introduction

2.2 Literature Review

Figure 2.1 Flow Chart of the Research

Understanding Literature review;

Listing all the

Analyzing the Comparing with best

Figure 2.2 Summaries of Literatures Employed in the Research

Resources Literatures Outcomes

Books on environment, EMS,

2.3 Questionnaire and Interview

2.3.1 Design of Questionnaire

Figure 2.3 Input-Output Flow of Hospital and Emphasis of Questionnaire

z Major consumer - greenhouse gases emission

2.4 Data Analysis and Indicators Selection

3.2 Common Activities in the Hospitals