ASF Standards · Primary Health Clinic · Standard 9

Standard 9 — Sustainable Care

7 criteria · 2 core · 5 standard-level · Version 1.0 · Aligned to ISQua EEA Principle 6, 6th Edition

Criteria in this standard

9.1 — Environmental Impact Is Genuinely Assessed, Appropriate to a Primary Care Setting
9.2 — Clinical Waste Is Genuinely Segregated and Responsibly Disposed
9.3 — Procurement Genuinely Considers Environmental Impact
9.4 — Energy and Resource Use Are Genuinely Monitored and Reduced Where Possible
9.5 — Patients and Staff Are Genuinely Engaged in Sustainability Practice
9.6 — The Clinic Genuinely Plans for Climate-Related Operational Risk
9.7 — Sustainability Commitments Are Genuinely Reviewed, Not Static

9.1

Environmental Impact Is Genuinely Assessed, Appropriate to a Primary Care Setting

Standard

The clinic genuinely assesses its environmental impact — energy, water, waste — proportionate to its role as a community-facing primary care facility, not assumed unnecessary given its typically modest scale.

In plain terms: The clinic has actually looked at its real environmental footprint — not assumed that being a small, community clinic means it doesn’t need to check.

Facility category	Crisis	Transition	Small	Standard
Applicability	Adapted	Full	Full	Full

Why this matters

Primary health clinics operate at the frontline of population health in many of the communities they serve, often with genuinely limited resources — but with a network of such clinics operating across a region, their combined environmental impact genuinely matters, even when any single clinic’s footprint looks small in isolation. A real, proportionate assessment reflects that scale honestly rather than skipping it entirely.

What good looks like

The clinic has genuinely assessed its impact, appropriate to its size.
The assessment genuinely covers energy, waste, and water.
The assessment is genuinely revisited periodically.

Common failure modes

No assessment has ever been conducted, justified by the clinic’s small size.

Worked example

In practice

A community clinic with no prior environmental review.

BeforeNobody had ever looked at the clinic’s energy, waste, or water use as anything other than routine operating costs.

ActionA simple baseline was compiled using the past year’s utility and waste collection records.

AfterThe Monitor reviewed the baseline document covering all three dimensions. Verified.

If you are starting from zero — do this first

Pull the last 12 months of utility and waste data.
Compile a simple baseline.

The most common mistake: Treating clinic size as a reason real assessment isn’t worth doing.

Self-assessment questions

1. Has the clinic genuinely assessed its environmental impact? — A real, documented assessment.
Evidence: Baseline assessment document

2. Does this genuinely cover energy, waste, and water? — Real, multi-dimensional coverage.
Evidence: Multi-dimensional data

3. Is the assessment genuinely revisited periodically? — Real, periodic review.
Evidence: Review schedule

Common reasons for a PARTIAL answer

Energy use is tracked but waste and water are not.

Implementation plan

When	What
Week 1-2	Compile a baseline covering all three dimensions.

How the Monitor verifies this

Method	What	Detail
DOCUMENT	Baseline review	Reviews the baseline for genuine, multi-dimensional coverage.

Supervisor tips

Ask to see actual figures, not a general statement.

Evidence base

World Health Organization. WHO Guidance for Climate-Resilient and Environmentally Sustainable Health Care Facilities. Geneva: WHO; 2020.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

9.2

Clinical Waste Is Genuinely Segregated and Responsibly Disposed

Standard

Clinical and hazardous waste is genuinely segregated from general waste at the point of generation and disposed of through a responsible, verified pathway — not a waste stream mixed for convenience given the clinic’s typically lower volume.

In plain terms: Medical waste is kept genuinely separate from regular trash, right from when it’s generated, and goes somewhere genuinely responsible.

Facility category	Crisis	Transition	Small	Standard
Applicability	Adapted	Full	Full	Full

Why this matters

Vaccination programmes and routine procedures mean primary care clinics genuinely generate sharps and clinical waste despite their modest scale, and the hazard this waste carries doesn’t scale down with facility size. A real, verified disposal pathway matters regardless of how small the clinic is.

What good looks like

Clinical waste is genuinely segregated consistently.
The disposal pathway is genuinely verified.
Staff are genuinely trained with real, observable compliance.

Common failure modes

Sharps are occasionally placed in general waste under time pressure.

Worked example

In practice

A clinic with an unverified waste contractor.

BeforeA waste contractor was used but its licence and actual disposal pathway had never been checked.

ActionThe contractor’s licence and disposal site were directly verified and documented.

AfterThe Monitor reviewed the verification record. Verified.

If you are starting from zero — do this first

Verify your waste contractor’s licence and disposal pathway directly.

The most common mistake: Assuming a contracted waste disposal company is compliant without ever independently verifying it.

Self-assessment questions

1. Is clinical waste genuinely segregated at every point of generation? — Real, consistent segregation.
Evidence: Direct observation

2. Is the disposal pathway genuinely verified? — A real, verified pathway.
Evidence: Contractor verification record

3. Are staff genuinely trained with real, observable compliance? — Real, demonstrated practice.
Evidence: Training record

Common reasons for a PARTIAL answer

Segregation is good in theory but lapses during busy vaccination days.

Implementation plan

When	What
Week 1	Verify the waste contractor’s licence and pathway.

How the Monitor verifies this

Method	What	Detail
ASK	Direct observation	Observes segregation during an actual busy period.

Supervisor tips

Check a bin during a busy vaccination clinic day.

Evidence base

World Health Organization. Safe Management of Wastes from Health-Care Activities. Geneva: WHO; 2014.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

9.3

Procurement Genuinely Considers Environmental Impact

Core

Procurement decisions genuinely factor in environmental impact alongside cost and patient need — including vaccine and supply packaging common to high-volume primary care delivery — not sustainability treated as an afterthought with purchasing decided purely on price.

In plain terms: When the clinic buys vaccines and routine supplies, it actually thinks about environmental impact as one real factor — not purely the cheapest option.

Facility category	Crisis	Transition	Small	Standard
Applicability	Adapted	Full	Full	Full

Why this matters

Vaccination programmes and routine preventive services generate genuinely high, recurring volumes of packaging and single-use supplies, and across an entire population-health programme this adds up to a real, significant environmental impact. This is marked Core because this is precisely the recurring, high-volume purchasing where genuine environmental consideration, applied consistently, makes the real difference.

What good looks like

Environmental impact is genuinely weighed for high-volume purchases.
A real, documented instance shows this influencing a purchase.
High-volume consumables are genuinely reviewed.

Common failure modes

Vaccine and supply purchasing is decided purely on unit cost.

Worked example

In practice

A clinic reviewing its vaccine supply contract.

BeforeThe vaccine supplier was chosen purely on cost, with packaging waste never considered.

ActionEnvironmental criteria were added to the next supply contract evaluation.

AfterThe Monitor reviewed the documented decision. Verified.

If you are starting from zero — do this first

Add environmental criteria to the highest-volume supply contract evaluations.

The most common mistake: High-volume recurring purchases never actually weighing environmental impact.

Self-assessment questions

1. Does procurement genuinely weigh environmental impact? — Real, documented consideration.
Evidence: Procurement criteria

2. Is there a real, documented instance of this genuinely influencing a purchase? — A concrete, real example.
Evidence: Purchasing decision record

3. Are high-volume consumables genuinely reviewed for lower-impact alternatives? — A real, ongoing review.
Evidence: Consumables review record

Common reasons for a PARTIAL answer

Environmental impact is discussed informally but never actually documented.

Implementation plan

When	What
Week 1-2	Add environmental criteria to supply contract evaluations.

How the Monitor verifies this

Method	What	Detail
DOCUMENT	Procurement review	Reviews a purchasing decision for documented environmental consideration.

Supervisor tips

Ask about the vaccine or highest-volume supply contract specifically.

Evidence base

NHS England. Delivering a Net Zero National Health Service. London: NHS England; 2022.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

9.4

Energy and Resource Use Are Genuinely Monitored and Reduced Where Possible

Standard

The clinic genuinely monitors its energy and resource consumption, pursuing real, achievable reductions appropriate to its scale and the communities it serves — not resource use left untracked because the facility is small.

In plain terms: The clinic actually tracks its energy and resource use and takes real steps to reduce it where genuinely possible.

Facility category	Crisis	Transition	Small	Standard
Applicability	Adapted	Full	Full	Full

Why this matters

A primary care clinic can genuinely track and improve its energy use without sophisticated infrastructure — even a modest, consistent monitoring practice can identify real, achievable savings over time, especially across a network of similar clinics.

What good looks like

Consumption is genuinely tracked.
At least one real efficiency improvement has been pursued.
Progress is genuinely reviewed periodically.

Common failure modes

Bills are paid with no one actually reviewing consumption trends.

Worked example

In practice

A clinic that had never reviewed its energy trends.

BeforeMonthly bills were paid with no comparison month to month.

ActionA simple tracking spreadsheet was set up, and a phased LED conversion begun.

AfterThe Monitor reviewed the tracking data and the conversion record. Verified.

If you are starting from zero — do this first

Set up basic consumption tracking.

The most common mistake: Paying utility bills with no one actually looking at consumption trends.

Self-assessment questions

1. Is energy consumption genuinely tracked? — Real, ongoing tracking.
Evidence: Consumption tracking record

2. Has the clinic genuinely pursued at least one real efficiency improvement? — A real, concrete improvement.
Evidence: Specific improvement record

3. Is progress genuinely reviewed periodically? — Real, periodic review.
Evidence: Review schedule

Common reasons for a PARTIAL answer

Tracking exists but has never led to a real improvement.

Implementation plan

When	What
Week 1-2	Set up tracking and identify an improvement.

How the Monitor verifies this

Method	What	Detail
DOCUMENT	Tracking review	Reviews the tracking record for genuine, ongoing monitoring.

Supervisor tips

Ask to see the actual tracking data.

Evidence base

International Finance Corporation. Greenhouse Gas Emissions Reduction in Healthcare Facilities. Washington DC: IFC; 2021.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

9.5

Patients and Staff Are Genuinely Engaged in Sustainability Practice

Standard

Staff genuinely understand and participate in the clinic’s sustainability practices, and this understanding genuinely extends to the health-promotion and community-education role primary care clinics often play — not a sustainability policy known only to management.

In plain terms: Staff actually know what the clinic is doing to be more sustainable and genuinely take part — and this can genuinely connect to the clinic’s wider community health-education role.

Facility category	Crisis	Transition	Small	Standard
Applicability	Adapted	Full	Full	Full

Why this matters

Primary health clinics genuinely occupy a trusted position within the communities they serve, and sustainability practices that staff genuinely understand and can speak to with patients extend the clinic’s real, broader health-promotion role beyond clinical care alone.

What good looks like

Staff can genuinely describe a real sustainability practice.
Patients are genuinely made aware where appropriate.
Staff input is genuinely sought.

Common failure modes

Staff are unaware of any specific sustainability practice.

Worked example

In practice

A clinic whose sustainability efforts were known only to the administrator.

BeforeA switch to lower-waste supplies had happened with no staff briefing.

ActionA brief team briefing explained the change and its rationale.

AfterThe Monitor asked a staff member who could describe the change. Verified.

If you are starting from zero — do this first

Brief staff on current sustainability practices.

The most common mistake: Sustainability decisions known only at management level.

Self-assessment questions

1. Can staff describe a genuine sustainability practice? — Real, demonstrated awareness.
Evidence: Staff interview

2. Are patients genuinely made aware where appropriate? — Real, visible communication.
Evidence: Patient communication

3. Is staff input genuinely sought? — Real, two-way engagement.
Evidence: Staff suggestion record

Common reasons for a PARTIAL answer

Some staff are aware but awareness isn’t consistent.

Implementation plan

When	What
Week 1	Brief all staff.

How the Monitor verifies this

Method	What	Detail
ASK	Staff interview	Asks a staff member to describe a specific practice.

Supervisor tips

Ask a non-management staff member.

Evidence base

Health Care Without Harm. Global Green and Healthy Hospitals Agenda. Reston: HCWH; 2020.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

9.6

The Clinic Genuinely Plans for Climate-Related Operational Risk

Core

The clinic genuinely considers climate-related risks to its own continuity of operation and, specifically, to the continuity of essential preventive services — vaccination programmes, maternal health visits — that communities genuinely depend on this clinic to deliver reliably.

In plain terms: The clinic has actually thought through what happens to vaccination programmes and other essential services during a climate disruption — because communities genuinely depend on this continuing reliably.

Facility category	Crisis	Transition	Small	Standard
Applicability	Adapted	Full	Full	Full

Why this matters

This is marked Core because primary health clinics often serve as the sole or main access point for essential preventive services in their communities, and a disruption here doesn’t just inconvenience this clinic — it genuinely interrupts population-level programmes like vaccination coverage, with real, measurable public health consequences if continuity planning is absent.

What good looks like

Specific risks are genuinely identified.
A real plan covers continuity of essential preventive services.
This plan is genuinely reviewed and tested.

Common failure modes

No continuity plan exists for vaccination programmes during a disruption.

Worked example

In practice

A clinic with no cold-chain backup plan for vaccine storage during a power outage.

BeforeA previous outage had put the vaccine cold chain at real risk, handled reactively with no formal backup plan.

ActionA backup power solution for the vaccine fridge was installed, with a documented activation protocol.

AfterThe Monitor confirmed the backup system and protocol. Verified.

If you are starting from zero — do this first

Identify the clinic’s most significant risk to essential preventive service continuity.
Build a real response plan.

The most common mistake: No cold-chain backup for vaccine storage during a power disruption.

Self-assessment questions

1. Has the clinic genuinely identified its specific climate-related risks? — A real, specific risk identification.
Evidence: Risk identification document

2. Is there a real plan covering continuity of essential preventive services? — A genuine, usable plan.
Evidence: Response plan document

3. Is this plan genuinely reviewed and tested? — Real, periodic review and testing.
Evidence: Testing record

Common reasons for a PARTIAL answer

A plan exists but hasn’t been tested.

Implementation plan

When	What
Week 1-3	Build a continuity plan for essential services.

How the Monitor verifies this

Method	What	Detail
DOCUMENT	Plan review	Reviews the response plan and testing record.

Supervisor tips

Ask specifically about the vaccine cold-chain backup.

Evidence base

World Health Organization. Operational Framework for Building Climate Resilient Health Systems. Geneva: WHO; 2015.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

9.7

Sustainability Commitments Are Genuinely Reviewed, Not Static

Standard

The clinic’s sustainability goals and practices are genuinely reviewed and updated as circumstances change — not a document written once and never genuinely examined for whether it still reflects the clinic’s actual practice.

In plain terms: The clinic’s sustainability goals actually get revisited — not written once and left to go stale.

Facility category	Crisis	Transition	Small	Standard
Applicability	Adapted	Full	Full	Full

Why this matters

A document written once and filed away stops genuinely reflecting the clinic’s current practice as circumstances change. Real, periodic review is what keeps sustainability commitments meaningful.

What good looks like

Goals are genuinely reviewed on a real schedule.
A real revision instance exists.
Responsibility is genuinely assigned.

Common failure modes

A document was written once and never revisited.

Worked example

In practice

A clinic whose statement predated several supplier changes.

BeforeThe statement referenced a supplier no longer used.

ActionA named person was assigned annual review responsibility.

AfterThe Monitor reviewed the updated, dated document. Verified.

If you are starting from zero — do this first

Assign named review responsibility.

The most common mistake: A document nobody is specifically responsible for revisiting.

Self-assessment questions

1. Are goals genuinely reviewed? — A real, periodic review.
Evidence: Review schedule

2. Is there a real revision instance? — A concrete example.
Evidence: Revision history

3. Is responsibility genuinely assigned? — A real, named accountability.
Evidence: Assigned responsibility documentation

Common reasons for a PARTIAL answer

A schedule exists but hasn’t been followed consistently.

Implementation plan

When	What
Week 1	Assign review responsibility and conduct the first review.

How the Monitor verifies this

Method	What	Detail
DOCUMENT	Revision history review	Reviews the document’s revision history.

Supervisor tips

Ask who is specifically responsible for review.

Evidence base

United Nations Environment Programme. Sustainable Healthcare Facilities Guidance. Nairobi: UNEP; 2022.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

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