Standard 64 · applies to every facility
Facility, Environment and Sustainability
Eight criteria on environmental sustainability and climate resilience, whatever its setting or services. They cover access, water, equipment, cleaning, risk, signage, back-up services, endoscope reprocessing and the environmental and climate commitments of the facility. Each criterion shows how it is checked, the evidence to show, what passes, what fails immediately, the e-learning that supports it, and the references behind it.
Two kinds of document
Means of verification. The forms, logs, registers, plans and policies the surveyor checks. The organisation submits them.
Recommended. SOPs, guidelines and protocols that support good practice. They are held on site but are not verified.
How a surveyor reads each criterion
Sample→
Method→
Evidence→
Pass ruleor
Immediate fail
How strict is Basis B3, by setting
Each row adds up to the total number of criteria on this page.
Standard
The facility has a specific, documented environmental sustainability programme — covering energy use, waste reduction, and resource consumption — with tracked progress, not a general statement of environmental awareness with no measurable action behind it.
Sample. Review the sustainability programme and its progress reports for the last 12 months.
How the surveyor verifies this
1. A written programme exists and is approved.
Method. Read the programme and check the approval.
Evidence to show. Approved environmental sustainability programme.
Pass when. Approved, covers energy, waste and resource use, and names an owner.
2. Progress is tracked against targets.
Method. Review the progress report for the last 12 months.
Evidence to show. Sustainability progress report.
Pass when. At least two progress reports in the last 12 months with figures against targets.
3. Actions are recorded.
Method. Check the action list in the progress report.
Evidence to show. Action list.
Pass when. At least one action was taken from the last reporting cycle.
Immediate fail (any one means the criterion is not met)
- No environmental sustainability programme exists.
Documents
Means of verification. The surveyor checks these. Submit them.
- ENV-PLN-001 · Environmental Sustainability Programme
Submit the approved plan or template, completed, with version and date. - ENV-FRM-003 · Sustainability Progress Report
Submit the completed form for the sample period.
E-learning
References
- International Organization for Standardization (2015). ISO 14001:2015 Environmental management systems: Requirements with guidance for use. Geneva: ISO. Open source
Standard
Facility leadership undertakes a strategic-level review of the facility's environmental impact and the sustainability of how it delivers care — not an assumption that environmental questions are someone else's concern or a problem for another department.
Sample. Review the leadership environmental review for the last 12 months and the minutes where it was discussed.
How the surveyor verifies this
1. Leadership reviews environmental impact.
Method. Read the review and check it covers energy, waste and resource use.
Evidence to show. Leadership environmental review record.
Pass when. Review done in the last 12 months, covering all three areas.
2. The review is discussed at leadership level.
Method. Check the minutes where the review was discussed.
Evidence to show. Leadership minutes.
Pass when. Discussed at a leadership meeting with a recorded decision.
3. Decisions are recorded.
Method. Check that decisions from the review have an owner.
Evidence to show. Decision log.
Pass when. At least one decision has an owner and a date.
Immediate fail (any one means the criterion is not met)
- No leadership review of environmental impact exists.
Documents
Means of verification. The surveyor checks these. Submit them.
- ENV-FRM-006 · Leadership Environmental Review Record
Submit the completed form for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
E-learning
References
- International Organization for Standardization (2015). ISO 14001:2015 Environmental management systems: Requirements with guidance for use. Geneva: ISO. Open source
- World Health Organization (2023). Operational framework for building climate resilient and low carbon health systems. Geneva: WHO. Open source
Standard
The facility's approach to environmentally sustainable care, and its goals in this area, are communicated to staff and patients — not confined to an internal policy document nobody outside senior management ever sees.
Sample. Review the sustainability communication plan and the notices issued in the last 12 months. Ask 3 staff and 3 patients what the goals are.
How the surveyor verifies this
1. Goals are communicated to staff.
Method. Check the notices and the induction material.
Evidence to show. Sustainability notice and communication record.
Pass when. Goals were communicated to staff in the last 12 months.
2. Goals are communicated to patients.
Method. Check the patient-facing notices.
Evidence to show. Patient notice (template).
Pass when. A patient-facing notice is on display or in the patient information.
3. Staff and patients can describe the goal.
Method. Ask 3 staff and 3 patients what the facility is trying to do.
Evidence to show. Interview notes.
Pass when. At least 70% of those asked describe one goal correctly.
Immediate fail (any one means the criterion is not met)
- The sustainability goals are held only in an internal document with no communication to staff or patients.
Documents
Means of verification. The surveyor checks these. Submit them.
- ENV-PLN-002 · Sustainability Goals and Communication Plan
Submit the approved plan or template, completed, with version and date. - ENV-FRM-007 · Staff and Patient Sustainability Notice (template)
Submit the completed form for the sample period. - ENV-REG-001 · Sustainability Communication Record
Submit the register extract for the sample period.
E-learning
References
- International Organization for Standardization (2015). ISO 14001:2015 Environmental management systems: Requirements with guidance for use. Geneva: ISO. Open source
Standard
Progress against the facility's environmental sustainability goals is reported to governance on a defined schedule — not tracked informally by whoever happens to care about it, with no visibility at the level that sets institutional priorities.
Sample. Review governance minutes and the progress reports for the last 12 months.
How the surveyor verifies this
1. Progress is reported to governance on a set schedule.
Method. Check the governance minutes for the last 12 months.
Evidence to show. Governance minutes.
Pass when. Reported at least twice a year.
2. The report uses the agreed goals.
Method. Compare the report with the programme goals.
Evidence to show. Sustainability progress report.
Pass when. Each goal in the programme is reported on.
3. Governance responds to the report.
Method. Check the minutes for a decision or question after the report.
Evidence to show. Governance minutes.
Pass when. At least one recorded question or decision followed each report.
Immediate fail (any one means the criterion is not met)
- Sustainability progress has not been reported to governance in the last 12 months.
Documents
Means of verification. The surveyor checks these. Submit them.
- ENV-FRM-003 · Sustainability Progress Report
Submit the completed progress report for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
E-learning
- No course linked yet.
- Planned course: Reporting sustainability progress to governance. New course planned.
References
- International Organization for Standardization (2015). ISO 14001:2015 Environmental management systems: Requirements with guidance for use. Geneva: ISO. Open source
- World Health Organization (2023). Operational framework for building climate resilient and low carbon health systems. Geneva: WHO. Open source
Standard
The facility's procurement and supply decisions take environmental and social responsibility into account — reducing wasteful use of supplies, considering supplier environmental practices, and reviewing single-use equipment decisions against patient and staff safety requirements — rather than treating sustainability as irrelevant to purchasing choices.
Sample. Review the procurement policy and the supplier review records for the last 12 months. Check 5 recent purchase orders.
How the surveyor verifies this
1. A responsible procurement policy exists.
Method. Read the policy and check its approval date.
Evidence to show. Responsible procurement policy.
Pass when. Approved and includes environmental and social criteria.
2. Suppliers are reviewed against the policy.
Method. Check the supplier review records.
Evidence to show. Supplier review record.
Pass when. At least 70% of the key suppliers were reviewed in the last 12 months.
3. Purchases reflect the policy.
Method. Check the 5 purchase orders for the criteria applied.
Evidence to show. Purchase order extract.
Pass when. At least 70% of the sampled orders show the criteria were applied or the reason is recorded.
Immediate fail (any one means the criterion is not met)
- No procurement policy considers environmental or social responsibility.
Documents
Means of verification. The surveyor checks these. Submit them.
- PRC-POL-001 · Responsible Procurement Policy
Submit the approved policy with version and date, and evidence it is in use. - PRC-FRM-001 · Supplier Review Record
Submit the completed form for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
E-learning
- Environmental Sustainability Standards for ASF Accreditation (ENV-001)
- Supplier Evaluation and Purchasing (T-13)
References
- International Organization for Standardization (2015). ISO 14001:2015 Environmental management systems: Requirements with guidance for use. Geneva: ISO. Open source
Standard
The facility monitors its use of electricity, gas, and other fuel sources, and takes steps toward reducing reliance on fossil fuels where this is practically possible — not energy use left entirely unmeasured and unmanaged as a fixed, unexamined operating cost.
Sample. Review the energy use records for the last 12 months and the reduction plan.
How the surveyor verifies this
1. Energy use is recorded each month.
Method. Check the monthly energy use record for the last 12 months.
Evidence to show. Monthly energy use record.
Pass when. At least 10 of the last 12 months are recorded.
2. A reduction plan exists.
Method. Read the plan and check its last review date.
Evidence to show. Energy reduction and renewable options plan.
Pass when. Plan has at least one measure, an owner and a date, and was reviewed in the last 12 months.
3. Use is compared with the previous year.
Method. Compare the last 12 months with the previous year, or with the first recorded year.
Evidence to show. Energy use record.
Pass when. A comparison is recorded and the trend is reviewed by the owner.
Immediate fail (any one means the criterion is not met)
- Energy use is not recorded at all.
Documents
Means of verification. The surveyor checks these. Submit them.
- ENV-FRM-008 · Monthly Energy Use Record
Submit the completed form for the sample period. - ENV-PLN-003 · Energy Reduction and Renewable Options Plan
Submit the approved plan or template, completed, with version and date.
Recommended. Good practice, held on site. Not verified by the surveyor.
E-learning
References
- World Health Organization (2023). Operational framework for building climate resilient and low carbon health systems. Geneva: WHO. Open source
Standard
The facility has carried out an assessment of its carbon footprint — even based on a minimal dataset such as energy use alone — to establish a baseline for monitoring and reducing greenhouse gas emissions, not treating carbon impact as something too complex to ever measure.
Sample. Review the carbon footprint baseline record and the method used.
How the surveyor verifies this
1. A baseline assessment exists.
Method. Read the baseline record and check the date and the data used.
Evidence to show. Carbon footprint baseline record.
Pass when. Baseline is recorded with a date and a stated method.
2. The method is written down.
Method. Read the method and check it can be repeated.
Evidence to show. Baseline method (SOP).
Pass when. Method is approved and states its data sources and limits.
3. The baseline is used for monitoring.
Method. Check whether the baseline is compared with later data.
Evidence to show. Carbon footprint record.
Pass when. The baseline has been compared with at least one later period, or a plan to do so has an owner and a date.
Immediate fail (any one means the criterion is not met)
- No carbon footprint assessment of any kind exists.
Documents
Means of verification. The surveyor checks these. Submit them.
- ENV-FRM-009 · Carbon Footprint Baseline Record
Submit the completed form for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
E-learning
- No course linked yet.
- Planned course: Carbon footprint baseline. New course planned.
References
- World Health Organization (2023). Operational framework for building climate resilient and low carbon health systems. Geneva: WHO. Open source
Standard
The facility considers its resilience to major environmental, climate, or health emergencies that could disrupt service delivery — heatwaves, flooding, extreme storms, pandemic outbreaks — and plans a range of actions in response, not assuming such disruptions are too remote to prepare for.
Sample. Review the climate and health emergency risk assessment, the continuity plan and the test records for the last 12 months.
How the surveyor verifies this
1. Climate and health risks are assessed.
Method. Read the risk assessment and check it covers heat, flooding and other local hazards.
Evidence to show. Climate and health emergency risk assessment.
Pass when. Assessment covers at least two local hazards and is dated within the last 2 years.
2. A continuity plan exists.
Method. Read the plan and check it links to the assessment.
Evidence to show. Climate and health emergency continuity plan.
Pass when. Plan links each hazard to a continuity action and an owner.
3. The plan is tested.
Method. Check the continuity test record for the last 12 months.
Evidence to show. Continuity test record.
Pass when. At least one test in the last 12 months with a recorded result and actions.
Immediate fail (any one means the criterion is not met)
- The facility has no assessment of climate or emergency risk to services.
Documents
Means of verification. The surveyor checks these. Submit them.
- FAC-PLN-002 · Climate and Health Emergency Continuity Plan
Submit the approved plan or template, completed, with version and date. - FAC-FRM-003 · Continuity Test Record
Submit the completed form for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
E-learning
- Environmental Sustainability Standards for ASF Accreditation (ENV-001)
- Planned course: Climate and environmental resilience planning. New course planned.
References
- World Health Organization (2023). Operational framework for building climate resilient and low carbon health systems. Geneva: WHO. Open source
- International Organization for Standardization (2018). ISO 31000:2018 Risk management: Guidelines. Geneva: ISO. Open source