Standards › Standard 2C › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ENV-SOP-004 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2C.1
At a glance
- Leadership reviews the facility environmental impact once a year, as a documented review.
- The review lists specific negative impacts from the facility own activities.
- For each impact, record at least one realistic mitigation, even a partial one.
- Record findings, decisions and an owner for each action.
- Stop and get help straight away if: the review was never done, or it lists no impacts and no actions.
1. Purpose
To make sure leadership looks at the facility environmental impact as a whole each year and decides what to change, rather than leaving it to individual purchases or to one department [E-006, EC].
2. Scope
| Applies to | Chief executive, senior leadership team, facilities manager, procurement lead, waste lead |
| Locations | The whole facility at the facility |
| When | Once a year, and when a major change happens (new building, service change) |
| Does not apply to | Routine energy and waste monitoring, covered by ENV-SOP-006 |
3. Definitions
| Term | Meaning |
|---|---|
| Environmental impact | Effects of the facility activities on air, water, land, energy use, waste and climate |
| Mitigation | An action that reduces a negative impact, even partly |
4. Background
Environmental decisions made one purchase at a time do not add up to a strategy. Criterion 2C.1 asks for a strategic review by leadership, which looks at the whole picture. The ASF environmental principles are used as the starting point [E-006].
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive | Chairs the review; approves actions | Executive leadership |
| Facilities manager | Prepares the data and the impact list | Facilities management |
| Waste lead and procurement lead | Provide data on waste and purchasing | Own area competence |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Review template (ENV-FRM-006) | Current | Available to leadership |
| Data from energy, waste, procurement and carbon records | Latest 12 months | Available before the review |
7. Safety
- Impact reduction must never reduce patient safety. Infection control, sterilisation and clinical waste rules always come first.
8. Before you start
- Collect the last 12 months of data from ENV-FRM-008, the waste records and the procurement records.
9. Procedure
Step 1. Prepare the impact list.
- List the main impacts of the facility: energy, water, waste, transport, purchasing and emissions.
- Use the data, not general assumptions.
Key point: A review without data is an opinion.
Step 2. Hold the review.
- Leadership meets once a year to review the list.
- Record attendance, findings and decisions on ENV-FRM-006.
Key point: The record shows that leadership, not only staff, looked at the question.
Step 3. Identify realistic mitigations.
- For each main impact, record at least one realistic mitigation, even if it only reduces the impact partly.
- Estimate cost and effect where possible.
Key point: A realistic partial step beats a perfect plan that is never started.
Step 4. Set actions and owners.
- Agree actions with an owner and a date for each.
- Link actions to the programme in ENV-PLN-001 and the goals in ENV-PLN-002.
Key point: An action without an owner is not an action.
Step 5. Follow up.
- Check progress at the next review, and record the outcome.
Key point: Follow-up shows the review changed something.
10. Decision points
- If an impact is high and no mitigation is possible, leadership records the reason and reviews it again within 12 months.
11. Special situations
| Situation | Action |
|---|---|
| New building, refurbishment or new service | Carry out an impact review before work starts, as part of the project approval. |
12. Escalation
- Significant environmental incidents are reported under INC-POL-001 at once.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Annual leadership review held and recorded | Yes | Yearly | Chief executive | Escalate to governing body |
| Actions with owner and date | 100% | Yearly | Facilities manager | Add owner within 14 days |
| Actions followed up at next review | 100% | Yearly | Chief executive | Review |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| ENV-FRM-006 Leadership Environmental Review Record | Governance file | the period set by the facility’s records policy years |
15. Training
- Leadership is briefed on this SOP at appointment and before each review (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| ENV-FRM-006 | Leadership Environmental Review Record | Used in steps 2 to 4 |
| SOP-N09 | Environmental Sustainability Policy (generic) | Policy basis |
| ENV-PLN-001 | Environmental Sustainability Programme | Programme links to actions |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Review frequency and scope set by the ASF Expert 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)