Standards › Standard 2B › Plans and templates
Plan / template · ENV-PLN-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2B.7
At a glance
- Measure energy, water and waste use each month.
- Set targets for each, with a date and an owner.
- Reduce waste by segregation and by avoiding single-use items where safe.
- Report progress each quarter to the governing body.
- Review the programme each year.
- Stop and get help straight away if: the programme has no measured baseline or no owner.
1. Purpose
To reduce the facility’s environmental impact through a documented, measured programme covering energy, waste and resource use [E-006, EC].
2. Scope
| Applies to | The governing body, facilities, procurement, clinical and support staff |
| Locations | The whole facility |
| When | Continuously; baseline within 6 months; reported quarterly |
| Does not apply to | Carbon targets set at national level, which the facility follows where required |
3. Definitions
| Term | Meaning |
|---|---|
| Baseline | The starting measurement from which progress is judged |
| Target | A measurable change to reach by a date |
| Waste reduction | Less waste produced, and more segregated and recycled waste |
4. Background
A general statement of environmental awareness does not reduce emissions or waste. Criterion 2B.7 asks for a documented programme with measured progress. The ASF environmental policy provides the principles, adapted here for a hospital [E-006].
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive | Approves the programme and the targets | Executive leadership |
| Facilities manager | Owns energy and water; runs measurement | Facilities management |
| Waste lead | Owns waste segregation and reduction | Waste management |
| Procurement lead | Specifies lower-impact products where safe | Procurement |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Meters and records for energy and water | Read monthly | Working |
| Waste records (WST-FRM-001) | Current | Monthly summary |
7. Safety
- Energy and resource savings must never reduce safety. Do not switch off equipment or ventilation that keeps patients safe.
- Do not reduce disinfection or sterilisation to save water or energy.
8. Before you start
- Set the baseline for energy, water and waste.
9. Procedure
Step 1. Set the baseline.
- Measure energy, water and waste for the most recent 12 months where data exist, or for 6 months from now.
- Record the baseline values and their sources.
Key point: Without a baseline, no one knows whether anything improved.
Step 2. Set targets.
- Set one target each for energy, water and waste, with a date and an owner.
- Agree the targets with the governing body.
Key point: A target with no date and no owner is a wish.
Step 3. Act on the main sources.
- Identify the largest energy and water users and the largest waste streams.
- Plan at least three actions, such as lighting controls, leak repair, waste segregation or buying reusable items where safe.
Key point: Focus on the largest sources first.
Step 4. Measure and report progress.
- Measure each month and report each quarter with the trend against the baseline.
- Explain changes and actions taken.
Key point: Progress is only shown by a trend against a baseline.
Step 5. Review yearly.
- Review the targets, the actions and the results each year.
- Update the programme and record the version.
Key point: The programme must adjust to what the data show.
10. Decision points
- If a target is missed for two quarters, the owner proposes new actions to the governing body.
11. Special situations
| Situation | Action |
|---|---|
| Construction or refurbishment | Include environmental and social screening for the project, as in ASF Policy 33, before work starts. |
12. Escalation
- Significant environmental incidents (spills, emissions) are reported as incidents at once (INC-POL-001).
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Baseline measured | Yes | Within 6 months | Facilities manager | Escalate to governing body |
| Progress reports each quarter | 100% | Quarterly | Facilities manager | Escalate to chief executive |
| Targets met or action plan in place | 100% | Quarterly | Chief executive | Review at governing body |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Baseline and monthly measurements | Facilities file | the period set by the facility’s records policy years |
| Quarterly progress report (ENV-FRM-003) | Governance file | the period set by the facility’s records policy years |
15. Training
- Staff are briefed on the programme and their part in it at induction (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| ENV-FRM-003 | Sustainability Progress Report | Quarterly report |
| WST-SOP-001 | Sharps and Clinical Waste Management | Waste segregation |
| GOV-PLN-001 | Strategic Plan | Programme links to goals |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Targets are set by the facility, to be checked by the committee. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)