Standards › Standard 2C › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ENV-SOP-006 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2C.5
At a glance
- Read each energy meter (electricity, gas, fuel) monthly and record by source.
- Compare with the same month last year and with the target.
- Act on the largest users first.
- Explore a renewable option each year and record the feasibility.
- Never reduce ventilation, cooling or heating that keeps patients safe.
- Stop and get help straight away if: a meter is not read for a month, or a safety system is switched off to save energy.
1. Purpose
To monitor the facility energy use by source, and to take concrete, safe steps away from fossil fuel reliance where practical [E-006, EC].
2. Scope
| Applies to | Facilities team, energy lead, chief executive |
| Locations | All meters and energy systems at the facility |
| When | Monthly reading; quarterly review; yearly feasibility review |
| Does not apply to | Carbon footprint method, covered by ENV-SOP-007 |
3. Definitions
| Term | Meaning |
|---|---|
| Energy source | Electricity, natural gas, diesel, or any other fuel used |
| Renewable option | Solar, or a supply contract with renewable electricity, where available |
4. Background
A facility that does not measure energy cannot reduce it. Criterion 2C.5 asks for monitoring by source, and concrete steps toward less fossil fuel use where practical.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Owns the meters and the monthly record | Facilities engineering |
| Energy lead (named by facilities manager) | Runs the reduction plan and the feasibility review | Energy management (EC) |
| Chief executive | Approves the plan and any investment | Executive |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Meters for electricity, gas and fuel | Working and labelled by area | Read monthly |
| Monthly energy record (ENV-FRM-008) | Current | Completed monthly |
| Reduction plan (ENV-PLN-003) | Current | Reviewed yearly |
7. Safety
- Do not switch off or reduce ventilation, air filtration, sterilisation, medical gases, refrigeration or life-support systems to save energy.
- Changes to electrical or gas systems are done by qualified staff only.
8. Before you start
- Check the meters are readable and labelled.
9. Procedure
Step 1. Read the meters.
- Read each meter on the same day each month.
- Record the reading by source and area on ENV-FRM-008.
Key point: A consistent reading day makes the trend reliable.
Step 2. Compare and analyse.
- Compare each month with the same month last year and with the target.
- Identify the top three users or areas.
Key point: Look for the largest users first.
Step 3. Act on the largest sources.
- Agree at least one concrete step per quarter, such as lighting controls, timers, insulation repairs or equipment shut-down outside use, where safe.
- Record the action and its effect on ENV-PLN-003.
Key point: Concrete steps are the evidence of a move.
Step 4. Assess renewable options yearly.
- Each year, assess the feasibility of renewable options: on-site solar, a renewable electricity contract, or others.
- Record the assessment, cost and decision.
Key point: Even a decision not to proceed, with the reason, meets the criterion.
Step 5. Report.
- Include energy use and trend in the quarterly governance report (ENV-FRM-003).
Key point: Reporting keeps energy on the agenda.
10. Decision points
- If use rises for two months without a reason, the energy lead investigates within 14 days.
11. Special situations
| Situation | Action |
|---|---|
| Power failure or generator use | Record the fuel used by the generator as a separate source. |
12. Escalation
- Safety conflicts with energy saving are referred to the chief executive at once. Safety prevails.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Monthly readings recorded for each source (12 months) | 100% | Monthly | Facilities manager | Escalate to chief executive |
| Concrete reduction step each quarter | 100% | Quarterly | Energy lead | Escalate to governing body |
| Renewable option assessed each year | Yes | Yearly | Chief executive | Escalate |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| ENV-FRM-008 Monthly Energy Use Record | Facilities file | the period set by the facility’s records policy years |
| ENV-PLN-003 Energy Reduction and Renewable Options Plan | Governance file | the period set by the facility’s records policy years |
15. Training
- Facilities staff are trained in meter reading and monitoring (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| ENV-FRM-008 | Monthly Energy Use Record | Used in step 1 |
| ENV-PLN-003 | Energy Reduction and Renewable Options Plan | Used in steps 3 and 4 |
| ENV-FRM-003 | Sustainability Progress Report | Quarterly report |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Energy targets and renewable options are EC and facility decisions. |
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)