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Partner for Change Award Award Applicationtest facility - 2013This document was generated at 2013-01-02 07:52:41PM

Application Page One- Facility and Contact Information

1. Table of Contents: Facility Address and Contact Information

Page 2: Facility and Waste Data

Page 3: Environmental Goals - 2012

Page 4: Leadership and Infrastructure

Page 5: Toxic Chemicals - Mercury and DEHP

Page 6: Solid Waste - Reduce, Reuse, Recycle

Page 7: Regulated Medical Waste and GOR

Page 8: Chemical Use and Waste Management

Page 9: Environmentally Preferable Purchasing (EPP)

Page 10: Food

Page 11: Facilities and Construction

Page 12: Transportation

Page 13: Culture of Sustainability

Page 14: Environmental Goals- 2013

Page 15: Statement of Accuracy and Release

Page 16: Appendix A - Reduce, Reuse, Recycle Checklist

Page 17: Appendix B - Single Use Device Reprocessing

Page 18: Appendix C - DEHP-free Award application

Please note that you may use the drop-down menu at the top of this application to jump to a specific page.

2. DIRECTIONS- PLEASE READ!

THIS APPLICATION IS LONG, PLEASE SAVE EARLY AND SAVE OFTEN!! We value your time and appreciate your efforts. Save, Save and View or Next or Previous Step will all save a page.

A note on ZEROS: Please DO NOT PUT IN ZEROS anywhere in the application unless you mean a numerical zero. DoNOT use a ZERO when you mean "NO" or "N/A" - just leave the question blank.

Hitting "ENTER" saves the page and repositions you to the top of the page. To navigate, click in the boxes or use the

key. N/A: If a question is **not applicable**, just skip the question, or mark the question "no", they are scored the same.

Pointsare generally given for "yes" answers or green activities your facility is doing. (Points are not deducted for questions skipped or left at the default "no").

Each applicant should fill out as much of this application as they can, interfacing with appropriate staff in various departments of the facility. **There should be something on every page.**

3. SCORINGA word on how the PFC applications are scored and evaluated. All yes/no questions and drop down answers are automatically scored and given a number. This number is used as a screening tool.Then all the applications are reviewed by "hand" and the narrative answers are evaluated.

Note: On yes/no questions, if a particular question is not applicable, choose "no;" they both score the same. Generally points are given for "yes" answers.

4. Notes on DEHP FreeNote on DEHP-free: If you are filling out the Partner for Change application and wish to apply for the DEHP Free award, please complete page 18 (Appendix C).

If you are NOT filling out the Partner for Change application and wish to apply for DEHP Free award, please complete page 1 and page 18 (Appendix C) only.

5. Facility Information

1. Organization Name

2. Health System

3. Street Address

4. City

5. State

6. Postal Code

7. Main Phone

8. Website

6. Primary Contact Information

1. Primary Contact - First Name

2. Primary Contact- Last Name

3. Title

4. Department

5. Phone

6. E-Mailyour email here

7. Secondary Contact Information

1. Secondary Contact- First Name

2. Secondary Contact- Last Name

3. Title

4. Department

5. Phone

6. E-Mail

8. Award Notification

1. Recipient's First Name (CEO, President, etc.)

2. Recipient's Last Name

3. Recipients Title

4. Mailing Address

5. City

6. State

7. Zip Code

8. Email

9. Plaque Destination- where do you want the Award plaque shipped?

1. First Name of person to receive plaque

2. Last Name of person to receive plaque

3. Title

4. Mailing Address

5. Mailing Address (line two if needed)

6. City

7. State

8. Zip Code

9. Other delivery information

10. Application Checklist 01

1. Reviewed the Eligibility Guidelines and Application Instructions ( http://www.practicegreenhealth.org/awards/ ) No

2. We are a member of Practice Greenhealth ( www.practicegreenhealth.org/community/members ) No

3. Confirmed no EPA Violations in the past 12 months ( http://www.epa-echo.gov/echo/ ) or if a violation exists, contacted Practice Greenhealth to discuss with Lin Hill at 866-998-9973

No

4. If "no" please briefly describe the problem and indicate if you have contacted Lin Hill regarding this violation.

5. Have you completed the application and uploaded all supporting attachments? No

11. Application Checklist 02

1. Has your organization been inducted into the Environmental Leadership Circle in the past?

No

2. Have you won the PFC Award in the past? No

3. Have you won PFC with Distinction in the past? No

4. Are you a for-profit or non-profit hospital facility?for-profit

5. Do you do community benefit reporting? Choose

6. If yes, do you include any sustainability activities in your report? Choose

7. What EPA region does your facility fall into (Region 1-10)? Choose

12. Application Checklist 03Do you participate in any of the following initiatives? Please check all that apply.

1. Climate Action Reserve ( http://www.climateactionreserve.org/ ) No

2. The Climate Registry ( http://www.theclimateregistry.org/ ) No

3. EPA Climate Leaders ( http://www.epa.gov/stateply ) No

4. Energy Star ( http://www.energystar.gov/ ) No

5. Energy Star Water Program ( http://www.energystar.gov/index.cfm?c=business.bus_water ) No

6. WasteWise ( http://www.epa.gov/waste/partnerships/wastewise/index.htm ) No

7. WaterSense ( http://www.epa.gov/WaterSense/ ) No

8. ISO 14001 or EMS ( http://www.iso14000-iso14001-environmental-management.com/iso14001.htm ) No

9. Greenhouse Gas Protocol Initiative ( http://www.ghgprotocol.org/ ) No

10. United Nations Global Compact ( http://www.unglobalcompact.org/ ) No

11. Does your facility create a sustainability report? (If yes, please provide URL or attach it by clicking browse. If no, please leave blank)

12. If yes, do you use the GRI framework? No

13. If yes, do you use the Global Compact? No

14. If yes, do you use another established format?

15. Is the report for Internal use only or released to the Public? Internal

16. Is the report verified/reviewed by a third party accounting firm? No

13. The GREEN NAVIGATION BAR at the bottom of each page.

Please note that once you have a few options at the bottom of each application. In the green menu at the bottom of your screen, you may click "Previous Step" or "Next Step" to save the page you are currently viewing and move forward or backwards through the application. Clicking "Save" saves the information entered on the page you are currently viewing, but does not move you forward of backward.

Use the "Save and View Application" button to see a condensed version of the entire application. This is a good place to monitor your progress. In addition, if you feel the need to create a hard copy of the application, you may copy and paste this condensed version into Word. Once you "Save and View Application", you may simply use your browsers back button to return to the previous screen.

To submit **Completed** application(s), you must click on "Save and View Application" and then click on the "SubmitApplication" button at the bottom of the last screen.

Please note that once an application is submitted, you will no longer be able to edit the application.

Application Page Two: Facility Description and Waste DataFacility Information - Required

1. Facility and Waste DataThis page is quite long, so PLEASE SAVE EARLY AND SAVE OFTEN!!

Please estimate waste diversion and cost savings on an ANNUAL basis in the tables and questions below.

**If you do not have data for a given table**, you may enter "1" or another number of your choice as a **place saver.** To save the page, some data in parts of the tables is required.

Please separate out the long-term care beds from the acute-care beds below and if possible, also separate out the associated adjusted patient days.

2. Facility

1. Adjusted Patient Days per Year

2. Patient or inpatient days

3. Number of Licensed Beds (please list LTC beds separately below)

4. Number of Staffed Beds (please list LTC beds separately below)

5. Do these bed numbers include bassinetts?

6. If bed numbers include bassinetts, how many?

7. Number of Operating Rooms

8. Number of procedures performed annually in these ORs (total, not average)

9. Number of Emergency Room visits

3. Ambulatory Care / Outpatient Clinics

1. Number of Outpatient Visits per Year (exclude the E.R. visits above)

4. What type of Hospital are you?This section is to provide more detail on your activities, please put total beds above in Section 2, and list subsets of those beds here, where appropriate.

1. Are you an acute care hospital? (Includes Trauma levels 1,2,3)

2. Are you a Critical Access Hospital (CAH) (this generally pertains to smaller, rural facilities)

3. Are you primarily a specialty hospital?

4. Number of staffed beds in the specialty area - this is a subset of total staffed beds listed above.

5. If yes, what area(s) do you specialize in?

6. If other, please specify

7. Does your facility operate primarily as an outpatient clinic?

8. Please add any explanation, for Section 4. Hospital Type, as needed

5. Long Term Care

1. Are you primarily a Long Term Care facility?

2. Number of LTC Licensed Beds (do not include in above data).

3. Number of LTC Staffed Beds (do not include in above data).

4. LTC Adjusted Patient Days (do not include in above APD data if possible to separate).

5. LTC Patient Days (use only if you do not have APD data)

6. We could not break out LTC APD numbers.

7. Any other notes on LTC

6. All Staff

1. Please list Full Time Equivalents (FTE) for your staff. Include staff for the buildings/areas you have included waste for.

2. Does this FTE number include PHYSICIANS?

3. Does this FTE number include Medical Students?

7. Waste Assessment SummaryApplications with incomplete waste summaries will not be considered. Please note whether weights are requested in**POUNDS** or in **TONS** and read the notes below the tables for detail. If you need assistance, please contact Lin Hill at [email protected] or 866-998-9973).

For the waste data in this section, we need 12 consecutive months of waste data, primarily from 2012. Please choose a timeframe that is easy for you (calendar year, fiscal year, however you collect the data) and use the same 12 months consistently each year you apply.

**If you do not have data for a given question in this table**, you may enter "1" or another number of your choice as a place saver. To save the page, some data in parts of the tables is required.

For questions, please contact Lin Hill, Awards Program Manager, at [email protected] or 866-998-9973. And thank you for your time spent with the applications.

1. Please add any additional notes needed to clarify the data these Tables if necessary. For example, please explain if your waste data has dramatically changed or if your recycling % is down due to source reduction activities.

8. Baseline YearThis is the year that you started tracking materials and wastes. If this is your first year complete only the CURRENTcolumn.

Year1. Baseline Year

2. Current Year

Adjusted Patient Days (if available)1. Baseline Year

2. Current Year

9. Solid Waste and Recycling**Enter a numerical response.** If you do not have certain data yet, you may put in "1" or anther number as a PLACE HOLDER. This table requires TONNAGE in CURRENT YEAR to save.

Please note that CURRENT RECYCLING and UNIVERSAL WASTE data will be entered automatically from APPENDIX A.Solid Waste and Recycling waste streams

1. Cost (+) or Revenue (-)2. Do NOT include any construction waste here- please include it in the Construction and Demolition Debris table below.3. Recycling data from Appendix A will be entered AUTOMATICALLY for current year. Diversion or prevention data is not included in this data.4. Universal Waste data from Appendix A will be entered AUTOMATICALLY for current year. This data will be counted in your recycling percentages.Universal Wastes are wastes that meet the definition of hazardous waste, but through proper accumulation and transport, pose a relatively low risk compared to other hazardous wastes. Acceptable universal wastes vary by state, but generally include fluorescent lamps and batteries and often includes electronic wastes.

Solid Waste (Non-regulated Medical Waste) (2)1. TONS per Year Baseline

2. TONS per Year Current

3. Annual Costs Baseline (1)

4. Annual Costs Current (1)

Recycling- current data will be entered from App A (3)1. TONS per Year Baseline




Universal Waste- current data will be entered from App A (4)1. TONS per Year Baseline




10. Recycling Program

1. Did your recycling program...

2. What were the over-riding financial factors?

11. Regulated Medical Waste Treated OnsiteSkip this sectin if you do not treat RMW onsite. If you do, we need you to attempt to break out treated RMW data from solid waste data.

1. We treat our RMW onsite and dispose as:

2. We treat our waste onsite using:

3. If you selected Other, please explain below.

4. Tracking waste treated onsite, we:

5. Notes on measuring or tracking RMW.

6. On a scale of one to five, how accurate do you think your measurement is?

7. Do you track the cost of treating RMW inhouse?

8. We include these costs: (check all that apply)

9. If other, please list here:

12. Regulated Medical Waste (b)

Your PHARMACY MANAGER should be a good resource for the waste pharmaceutical weights below. Enter a numerical response for the following.

If you do not have certain data yet, you may put in ZERO or other number as a PLACE HOLDER. This table requiresTONNAGE in CURRENT YEAR to save. RMW Waste Stream1. Please include all RMW in this number- including any RMW that is treated onsite- even if you landfill it. Please include your sharps data here, unless it is incinerated. If you use a reusable sharps container service, make sure the data does not include the weight of the containers. If you normally combine this with your solid waste numbers, please estimate it or contact Lin Hill for guidance at [email protected] or 866-998-9973.

2. Separating non-hazardous pharmaceutical waste is currently considered a best management approach. Please list your non-hazardous pharm waste here so that we can better understand health care's generation rate of non-hazardous pharmaceutical waste.

3. Please include any RMW that is incinerated, such as pathology waste, trace chemotherapeutic agents, or waste that is segregated and removed by a licensed hauler for incineration. This category may be very small.

RMW (treated onsite or offsite) (1)1. Annual Tons Baseline

2. Annual Tons Current

3. Annual Costs Baseline

4. Annual Costs Current

Non hazardous Pharmaceutical waste (2)1. Annual Tons Baseline




Incinerated RMW (3)1. Annual Tons Baseline




13. Hazardous WasteEnter a numerical response in TONS for the following. (Note: make sure if you imported data from last year that it gets converted to tons. Divide pounds by 2000 to get tons).Hazardous Waste stream1. Please note that this number should NOT BE ZERO! Hazardous waste includes all solvents, waste engine oil, Zenker and B5 stains, spill clean-up residue, lab packs, refrigerants, or any “Listed” or “Characteristic waste” per RCRA regulations. Check with your laboratory manager, hazardous waste hauler, accounts payable, or waste removal manifests to identify hazardous waste removal documentation that will provide you with the date needed for this section. If you put a zero in this column, you will be contacted by the Awards review team.... Also, please use 7.5 #/gallon to estimate the weight of a liquid waste.

2. Please separate hazardous pharmaceutical waste here from the rest of the hazardous waste stream, so we can better understand health care’s generation rate of hazardous pharmaceutical waste. This includes hazardous pharmaceutical waste that is either listed as hazardous from EPA’s Resource Conservation and Recovery Act (RCRA) or meets the characteristics of hazardous wastes. This waste stream should not be confused with red bag waste.

RCRA Regulated Hazardous Waste (1)1. Tons per Year Baseline

2. Tons per Year Current



RCRA Regulated hazardous Pharmaceutical Waste (2)1. Tons per Year Baseline

2. Tons per Year Current



14. Waste TotalsThe following items have been calculated based on the information you have provided.

Totals1. Waste (Baseline)

2. Waste (Current)

3. Cost (Baseline)

4. Cost (Current)

15. Waste ManagementThe following data has been AUTOMATICALLY CALCULATED FOR YOU based on the information you have provided. If they do not look accurate, check the tonnages in the tables above.Waste Management Category

1. Solid Waste Percent of Total Waste Baseline

2. Solid Waste Percent of Total Waste Current

3. Solid Waste Percent of Total Cost Baseline

4. Solid Waste Percent of Total Cost Current

5. RRR Percent of Total Waste Baseline

6. RRR Percent of Total Waste Current

7. RRR Percent of Total Cost Baseline

8. RRR Percent of Total Cost Current

9. RMW Percent of Total Waste Baseline

10. RMW Percent of Total Waste Current

11. RMW Percent of Total Cost Baseline

12. RMW Percent of Total Cost Current

13. Hazardous Waste Percent of Total Waste Baseline

14. Hazardous Waste Percent of Total Waste Current

15. Hazardous Waste Percent of Total Cost Baseline

16. Hazardous Waste Percent of Total Cost Current

17. Total Waste Baseline

18. Total Waste Current

19. Total Cost Baseline

20. Total Cost Current

16. Pounds of Total Waste Per FTE

For comparison purposes: Average Total Waste per FTE for last year's Award winners was **1430 #/FTE for PFC**winners, **1410#/FTE for DIST** winners and **1330#/FTE for ELC** winners.(Please note that this measurement is not as reliable as #/APD presented immediately below).

1. Total

17. Pounds of Total Waste Per APDAverage Total Waste per APD for last year's Award winners was **29 #/APD for PFC** winners, **24#/APD for DIST**winners and **23#/APD for ELC**

winners.

1. Total (if your facility does not use APD, ignore this number)

18. Construction & Demolition Debris Enter a numerical response for the following. Construction & Demolition Debris

Disposed as Solid Waste1. Tons per Year

2. Annual Costs

Recycled (segregated onsite)1. Tons per Year

2. Annual Costs

Recycled (segregated offsite)1. Tons per Year

2. Annual Costs

Application Page Three- Goals for 2012

1. Environmental Goals – 2012What were your facility’s environmental and sustainability goals for 2012? Please report on the progress you’ve made toward these goals with a few sentences of explanation for each. Please report on at least three goals or projects.

01. Goal

2. Achieved?

3. Brief Highlights

01. Goal

2. Achieved?

3. Brief Highlights

01. Goal

2. Achieved?

3. Brief Highlights

01. Goal

2. Achieved?

3. Brief Highlights

01. Goal

2. Achieved?

3. Brief Highlights

Application Page Four- Leadership and Infrastructure

1. Leadership and InfrastructureCheck “Yes” boxes where appropriate.

2. Leadership within your facilityActivity

Developed STRATEGIC PLAN around sustainability that identifies short, medium and long term goals.

1. Created or performed previously?

2. Performed in 2012

Shared sustainable activities with SENIOR LEADERSHIP team and/or address board of directors



Developed an ENVIRONMENTAL COMMITMENT STATEMENT1. Created or performed previously?


Added sustainability measures for leadership staff PERFORMANCE EVALUATIONS1. Created or performed previously?


Added language to JOB DESCRIPTIONS on our commitment to the environment and the role that each employee plays.



Include questions about sustainability program in EMPLOYEE ENGAGEMENT SURVEY1. Created or performed previously?


Integrated sustainability into at least one GRAND ROUNDS event this year1. Created or performed previously?


Sent at least one green team member from each site to CLEANMED for Award receipt and education last year



Developed, improved or advertised SUSTAINABILITY WEBSITE or wepage on Intranet (in- house)



Created educational VIDEOS on sustainability for in-house use1. Created or performed previously?


Held THERMOMETER SWAP for employees1. Created or performed previously?


Held PHARMACEUTICAL TAKE-BACK event for employees1. Created or performed previously?


Held ELECTRONICS COLLECTION event for employees1. Created or performed previously?


Handed out or collected CFLs for employees1. Created or performed previously?


Held low or ZERO-WASTE PICNIC for employees1. Created or performed previously?


Created a HEALING GARDEN for patients and staff1. Created or performed previously?


Other - please describe1. Created or performed previously?


Ohter- please describe1. Created or performed previously?


Other, please describe1. Created or performed previously?


3. Environmental Policy

1. Do you have an overall environmental policy that guides your sustainability efforts?

2. If Yes, please provide the URL or attach the document here.

4. Green TeamsPlease answer the following questions and add documentation where requested; check "Yes" where appropriate.

1. Does your facility have a committee or “Green Team” that is specifically tasked with oversight of environmental programs?

2. How often do you meet?

3. Does your team have a mission statement and/or charter?

4. Does your team have a logo?

5. If you are part of a larger System, is there a corporate level greening oversight committee?

6. If yes, are the Green Team metrics reported to the oversight committee?

7. If part of a System, is there an ongoing structure or calls to communicate and share with other green teams in the system?

8. Are there System wide goals?

9. If yes, list the top two or three.

10. Other green team info?

5. Please check Green Team department representation in table below:Department

Environmental Services1. Yes if currently represented on Green Team

Facilities1. Yes if currently represented on Green Team

EH&S1. Yes if currently represented on Green Team

Materials Management/ Purchasing/ Supply Chain1. Yes if currently represented on Green Team

Engineering1. Yes if currently represented on Green Team

Safety1. Yes if currently represented on Green Team

Administration1. Yes if currently represented on Green Team

Nutrition1. Yes if currently represented on Green Team

Nursing1. Yes if currently represented on Green Team

Infection control1. Yes if currently represented on Green Team

Physicians1. Yes if currently represented on Green Team

Communications/Marketing1. Yes if currently represented on Green Team

Food Services

1. Yes if currently represented on Green Team

Risk Management1. Yes if currently represented on Green Team

Other, please describe1. Yes if currently represented on Green Team

Other, please describe1. Yes if currently represented on Green Team

6. Green staff and staff involvement

1. Do you have a designated Sustainability officer (or similar title)?

2. If yes, please list name.

3. If yes, please list formal job title:

4. If yes, is this position a full time job or part time with other responsibilities?

5. If no, is there someone on staff who is responsible for sustainability within their job description? (e.g. Director ofEnvironmental Services is responsible)

6. If yes, please list name:

7. If yes, title of person responsible:

8. If Other, please provide title here.

9. Do you track your environmental improvement initiatives in the Joint Commission structure?

10. If yes, what were the related performance improvement projects this year?

11. Does your facility provide new employee orientation on environmental initiatives?

12. Does your facility provide annual training on environmental initiatives?

13. Are clinicians involved in your environmental programs?

14. In particular, how have nursing staff contributed to your environmental programs?

15. How have physicians contributed to your environmental programs?

16. Has your organization calculated a payback period for sustainability activities that have up-front costs? (such as capital for an energy efficiency project)

17. If yes, please provide an example if available

18. Have the owners, shareholders, Board of Directors, or C-suite been presented with ROI CALCULATIONS for sustainability activities or projects?

19. If yes, please provide an example if available

Application Page Five- Hg, DEHP and PVCToxic Chemicals

1. Environmental Purchasing: Toxic Chemicals- Mercury and DEHP

1. Have you won the Making Medicine Mercury Free (MMMF) Award?

2. If yes, what year?

3. Are you applying for an MMMF Award this year using the separate MMMF Award application?

2. PFC Award mercury qualificationsTo be considered for the PFC Award your facility must have started a mercury elimination program. To be considered for the Making Medicine Mercury-Free Award, you must use the separate MMMF Award application form available at the beginning of this application process. It is possible to apply for, and win, both PFC and MMMF in the same year.

To be considered for the PFC Award your facility must demonstrate some mercury elimination progress below. Please check all that apply to illustrate your mercury elimination work: Check “Yes” boxes where appropriate.

Notes:

1) You may mark “yes” to most questions if your facility was built mercury free

2) For a list of mercury-containing items in clinical areas, see:http://mntap.umn.edu/health/resources/10c-MercPatient.htm

3) For a list of lab chemicals that may contain mercury, see: http://mntap.umn.edu/labs/Resources/92-Mercury.htm and http://www.mntap.umn.edu/labs/Resources/10a-MercLabs.htm

3. Mercury Policies and initiatives

Have you established and implemented a Mercury-free Purchasing policy?1. Please Choose

Have you performed a facility-wide inventory for mercury containing items?1. Please Choose

Have you labeled all remaining mercury-containing items?1. Please Choose

Have you inventoried all mercury-containing chemicals in the laboratory(2)?1. Please Choose

4. Mercury-containing clinical devices

Thermometers1. Please Choose

Sphygmomanometers1. Please Choose

5. Laboratory

Lab thermometers (5 grams mercury)1. Please Choose

B5 and Zenker stains1. Please Choose

6. Facilities

1. Do you use low mercury (green tip) lamps?

2. Do you recycle all lamps?

3. How do you handle your fluorescent lamps?

4. If other, please describe here.

7. Dental

1. Do you have onsite dental chairs?

2. Have you installed amalgam separators for all dental chairs?

8. X-Ray

1. Have you switched to digital X-Ray?

9. Construction

1. Do you require proper mercury disposal in construction and renovation projects?

2. Do you include mercury-free requirements in contract language?

10. Miscellaneous

Have you held a thermometer swap for employees?1. Yes / No

2. Year Held

Have you held a thermometer swap for the community?1. Yes / No

2. Year Held

Other1. Yes / No

2. Year Held

11. DEHP

1. Does your facility have a general DEHP Reduction Program?

2. Does your facility have a program to reduce DEHP-containing products in the NICU?

3. Does your facility have a PVC reduction program?

4. If your facility does have a PVC reduction program, does it include products and supplies?

5. If your facility does have a PVC reduction program, does it include construction and renovation materials?

12. DEHP DetailsIf you answered yes to any one of the three above questions please fill out Appendix C which will qualify you for consideration of the DEHP-Free Award. The DEHP-Free Award is generously made possible by Hospira (http://www.hospira.com), maker of DEHP-free VisIV® containers.

![Hospira](/images/partners/hospira.png)

Application Page Six- Solid Waste and more

1. Solid Waste: Reduce, Reuse, RecycleWaste reduction is an essential component of any comprehensive environmental program. A 15% minimum recycling or prevention rate of your total waste stream is required for the Partner for Change Award, a 20% minimum recycling rate for Distinction, and 25% minimum recycling rate is required for the Environmental Leadership Circle. Thorough and detailed responses in this section are required in order to be considered for an Award. Remember to include waste prevention in your data. Check “Yes” boxes where appropriate.

1. I have completed the checklists in Appendix A

2. DonationsWe donate the following used or excess items to local or national charities for domestic reuse or overseas donation, or recycle for scrap. Please check all that apply and provide approximate tonnage or cubic feet if available:Used or excess item

Expired/opened consumable clinical supplies1. Reuse- Donate

2. Reuse - Sell or Auction

3. Recycle for Scrap

4. Landfill

5. Tons (approx.)

6. Cubic Feet

Capital medical equipment1. Reuse- Donate



4. Landfill

5. Tons (approx.)

6. Cubic Feet

Furniture1. Reuse- Donate



4. Landfill

5. Tons (approx.)

6. Cubic Feet

Linens1. Reuse- Donate



4. Landfill

5. Tons (approx.)

6. Cubic Feet

Books1. Reuse- Donate



4. Landfill

5. Tons (approx.)

6. Cubic Feet

Other supplies1. Reuse- Donate



4. Landfill

5. Tons (approx.)

6. Cubic Feet

Other supplies1. Reuse- Donate



4. Landfill

5. Tons (approx.)

6. Cubic Feet

3. Description of "other"

1. Please briefly describe "other" donations listed in table above.

2. Please describe briefly "other" donations listed in table above.

4. Paper Reduction

1. Have you made a coordinated effort to reduce the amount of paper your facility uses?

2. How many reams (500 sheets) of paper did you purchase in 2012?

3. Have you reduced your number of network printers?

4. If yes, did you do this by reducing the number of desk-top printers?

5. Have you reduced paper use by making double-sided printing the default on your printers?

6. Have you worked with staff to reduce the number of reports that are automatically printed?

7. Have you implemented an Electronic Medical Records system?

8. Comments or other paper reduction efforts:

5. Reusable Transport Packaging

1. Do you use reusable pallets, totes of other transport packaging?

2. If you track tonnage diverted, enter it here:

3. Do you reuse wooden pallets?

4. If you track tons of pallets diverted, enter it here:

6. Describe your most successful and/or innovative Reduce/Reuse/Recycle programs at your facility this past year.Please describe a *minimum** of three projects you are most proud of; one or two of these should address solid waste. Do NOT leave this question BLANK.This is our only window into your successes, please use a few sentences for each project.

1. Description

2. Description

3. Description

4. Description

5. Description

7. Add photos, files or other documentation (optional)**You may attach a single file by clicking "Browse" and then saving your page (using the orange 'save' button immediately below). You may submit more than one file by 'zipping' the files and attaching the zipped file.**

1. Do you have any additional attachments?

Application Page Seven: RMW and GOR

1. Regulated Medical Waste Reduction and Treatment TechnologiesPlease fill out as much as you can for each topic area and estimate waste avoidance and savings on an annual basis.

1. Has your facility engaged in a REGULATED MEDICAL WASTE (RMW) REDUCTION program?

2. If yes, please describe your approach

3. Do you post waste segregation posters at red bag collection areas?

4. Does your operating room or other areas in your facility use a FLUID MANAGEMENT SYSTEM (for suction canister reduction)?

5. How much waste was prevented (enter a quantity and unit of measurement)?

6. What were the annual cost savings (if you can estimate)?

7. What year was this system implemented?

8. Details (optional)

9. Are you using SINGLE USE DEVICE REPROCESSING?

10. How many tons of waste were diverted from RMW or solid disposal?

11. What were the annual cost savings from reduced disposal costs?

12. What were the annual savings from purchasing reprocessed items instead of OEM (original equipment manufactured) items?

13. What year was the system implemented?


15. Have you implemented a REUSABLE SHARPS CONTAINER program?

16. How many tons of plastic waste were diverted from the landfill?

17. How many tons of plastic waste were recycled by your vendor?

18. What were the annual cost savings from avoided landfill fees?



21. Have you implemented one of the new programs to RECYCLE MEDICAL SHARPS such as needles and syringes?

22. How many tons of waste were recycled?

23. What were the annual cost savings?


25. Details for any RMW reduction projects (optional).

2. Waste Reduction and Prevention in the OR

1. Is your facility specifically tracking waste volumes coming from Surgical Services/OR?

2. Is your facility ensuring that all set-up/pre-incision, non-hazardous waste in the OR is going into either a solid waste or recycling container?

3. Is your facility segregating non-infectious from infectious (red bag) waste during/after surgical procedures?

4. Is your facility recycling medical plastics from the OR?

5. Overwraps

6. Rigid trays

7. Blue wrap

8. Saline bottles

9. Other plastics or items

10. Other plastics or items

11. Has your facility purchased reusable rigid cases for sterilization in the OR and Sterile Processing Department?

12. Other waste prevention in the OR

3. Environmentally Preferable Purchasing in the OR

1. Has your facility reformulated OR kits to reduce excess supplies and overage currently going to trash or donation?

2. Does your facility purchase reprocessed medical devices from a third party reprocessor for use in the OR?

3. Has your facility replaced disposable items with reusable items in OR kits where demonstrated safe and economically viable?

4. Does your facility utilize reusable surgical gowns for staff?

5. Does your facility utilize reusable back table covers?

6. Does your facility utilize reusable mayo stand covers?

7. Does your facility utilize reusable surgical towels?

8. Does your facility utilize reusable basins?

9. Are you sterilizing reusable surgical textiles in-house or using a third-party contractor for cleaning, repair and sterilization?

10. If other, please describe:

11. Does your facility use reusable grounding pads in the OR?

12. Does your facility use reusable patient warming devices in the OR?

13. Does your facility use a filter product to prevent contamination of disposable anesthesia circuits (allowing for multiple patient use)?

4. Built Environment

1. Does your facility track energy use specifically in Surgical Services/OR?

2. Does your facility utilize occupancy sensors for lighting to reduce energy use in unoccupied ORs?

3. Does your facility program the HVAC system to reduce air changes when ORs are unoccupied in order to reduce energy use?

4. Does your facility utilize LED surgical lighting to reduce energy use and increase thermal comfort?

5. Does your facility use rubber flooring or other non-PVC flooring in the OR?

5. Success in Greening the OR

1. Please include a short narrative of your biggest success greening your OR. (optional)

6. Solid Waste TreatmentWaste Stream

Solid Waste1. Final Disposal

2. If Incineration, is there an available alternative?

7. RMW TreatmentWaste Stream

General RMW1. Treatment Technology

2. If Other, please specify

3. Final Disposal

4. If Incineration, is there an available alternative?

8. NotePractice Greenhealth strongly encourages the use of *non-incineration technology**when alternatives are available.If your facility uses incineration for solid and/or general RMW disposal, we will take that into account when reviewing your application and assessing comprehensive environmental performance. We understand that in some locations, all municipal waste is incinerated.

Application Page Eight- Chemical Use, Minimization andEnvironmental Purchasing

1. Chemical Use and Waste Management Programs

1. Have you implemented a pharmaceutical waste management program?

2. Our pharmacy utilizes the following to identify hazardous pharm waste:

3. Other or other information

4. We have enacted the following strategies to reduce pharmaceutical waste:

2. Please Check Your Facility's Process for Segregating RCRA-regulated Pharmaceuticals

We separate pharmaceutical waste at the point of generation1. Yes / No

We send pharmaceutical waste back to the pharmacy for proper segregation1. Yes / No

We collect all pharmaceutical waste at the waste collection point and sort in a satellite accumulation area

1. Yes / No

We treat all pharmaceuticals as hazardous waste1. Yes / No

Other, please describe1. Yes / No

3. Ethylene Oxide

1. Has your facility reduced the use of ethylene oxide (EtO) for sterilization? If not applicable, select "no."

2. Have you completely eliminated EtO? If you sterilize but have never used EtO, select "yes."

4. EtO Alternatives

Steam Sterilization1. Yes / No

Ozone plasma (3M Optreoz with TSO3 Sterizone technology)1. Yes / No

Low temperature hydrogen peroxide gas plasma (Sterrad)1. Yes / No

Peracetic Acid (Steris 1 or 1E)1. Yes / No


5. Glutaraldehyde

1. Has your facility reduced the use of glutaraldehyde for disinfection/sterilization?

2. Have you completely eliminated glutaraldehyde?

6. Glutaraldehyde AlternativesAlternative

OPA (ASP Cidex OPA, Metrex Metricide OPA)1. Yes / No

Hydrogen Peroxide1. Yes / No


7. Green Cleaning and Envrionmental Purchasing

1. Does Environmental Services or your cleaning provider have a building specific Green Cleaning Plan or Policy, such as the one outlined in the Green Seal Certification Checklist, standard GS-42 ( http://www.greenseal.org/ ) to minimize chemical use?

2. Cleaning performed by...

3. Does Environmental Services or your cleaning provider use techniques for minimal chemical use, such as techniques to reduce overspray, or a dilution control system for chemicals, etc.?

4. Does Environmental Services or your cleaning service provider use any cleaning chemicals or products certified as environmentally preferable (such as Green Seal or EcoLogo) at your facility?

8. Green Cleaning CertificationsPlease check the green cleaning products that you purchase and indicate the certification, if any. Information on Green Seal and Ecologo can be found at http://www.greenseal.org and http://www.ecologo.org/en/ respectively. If you use other cerrtifications, please list them at the bottom, however only check "yes" for cleaners that are Green Seal or EcoLogo certified..

1. General purpose (hard surface) cleaners

2. Glass Cleaners

3. Carpet and Upholstery Cleaners

4. Cleaning and Degreasing Compounds

5. Floor cleaners, strippers, waxes

6. Metal Polish

7. Drain/Grease trap additives

8. Fragrances/Odor control additives

9. Laundry Soaps/ Cleaners

10. Liquid or foam hand soap

11. Other

12. List Certification other than Green Seal as necessary

9. Cleaners

1. Have you collaborated with the Infection Control Committee to identify areas where use of disinfectants can be minimized or eliminated?

2. Do you use a dilution control system for chemicals?

10. Disposable ProductsDo you:

1. Select bathroom paper products with a preference for recycled content?

2. Select bathroom paper products with a preference for chlorine free products?

3. Use fragrance free products?

4. Avoid aerosolized cleaning products?

5. Avoid fragrance emitting devices, e.g. air fresheners, fragrance or deodorizer sprays and urinal blocks?

6. Have you evaluated paper dispensing systems to ensure optimal product efficacy?

7. Other

11. Powered Cleaning Equipment (2)

1. Do you use, or specify, powered cleaning equipment (scrubbers, burnishers, extractors, vacuums, or power washers)that is Carpet and Rug Institute or other certified?

2. Does this equipment capture fine particulate matter?

3. Is this equipment designed to minimize vibration, noise, and user fatigue?

4. Is this equipment operated with a sound level of less than 70 db?

12. Flooring

1. Do you use micro fiber mops?

2. Has your facility installed flooring that does not require regular stripping and/or polishing?

3. Have you purchased carpet certified to ANSI/NSF 140-2007e at the platinum level? (see http://www.carpet- rug.org/carpet-and-rug-industry/sustainability/sustainable-carpet/sustainable-carpet-list.cfm)

4. Other (or comments)

13. Other Green Cleaning Successes.

1. Please describe any other green cleaning successes you would like to share (optional).

14. Integrated Pest Management (IPM):

1. Has your facility reduced the use of chemical pesticides through the implementation of an integrated pest management (IPM) program?

2. To get credit for this question you must describe at least one actual or anticipated pest problem and IPM solution. Please be specific

15. IPM: Have you

1. Developed an IPM Plan for this facility

2. Designated an IPM coordinator to supervise all pest elimination activity

3. Developed a plan for training of all hospital staff on pests, pesticides, and their role in the facility IPM program

4. Inspected facility for signs of pest activity and conditions that may lead to pest infestation

5. Facilitated removal of food waste consistent with IPM

6. Inspected building roofs, checked bird netting, sealed roof parapets and caps

7. Use and regularly check bait stations (as a last resort) instead of sprays

8. Ensured that devices such as bait stations placed in outside areas are locked, secured, clean and in good working order.

9. Eliminated cracks and holes to keep pests out

10. Installed door sweeps to keep pests out

11. Implemented and enforce sanitation procedures to limit pests’ access to food and drink. (Address leaky faucets, condensation on pipes, and all edibles.)

12. Fixed moisture problems (leaks and condensation on pipes)

13. Used physical barriers to block pest entry and movement (such as door sweeps, screens at chimneys and air intakes, window screens).

14. Minimized the entry of contaminants into the building from pesticides

15. Ensured mulch is not used immediately next to building façade

16. Other effective IPM implemented

16. IPM Policy

1. Have you ensured IPM policy is included in all pest control bid specifications when outsourcing pest elimination contracts?

2. Have you contracted with pest control companies that meet 100% of the requirements for IPM certification?

17. Solvent Distillation

1. Do you have an onsite laboratory?

2. Does your facility have a program to recycle or distill solvents, alcohols or other chemicals from the lab?

18. Solvent Distillation checklist- which solvents do you distill and reuse?Chemical

Xylene1. Yes / No

Alcohol1. Yes / No

Formalin1. Yes / No


19. Solvent and Alcohol distillationPlease quantify annual results and cost savings from solvent and alcohol distillation where possible.

1. Gallons of solvent distilled annually

2. Gallons of distilled solvent reused, annually

3. Annual savings from reduced purchase costs (in dollars)

4. Annual savings from reduced disposal costs (in dollars)

5. What year was the still / equipment installed?

20. Other chemical waste minimization programs

1. Do you have any other chemical waste minimization programs that you would like to share?

2. Description:

3. Do you have a fragrance-free policy at your facility?

Application Page Nine- EPP

1. Environmentally Preferable Purchasing (EPP) Products and PracticesWhile applicants are asked to describe EPP activities throughout this application, Page Nine attempts to collect the bulk ofEPP policy and purchasing information.

1. Have you communicated with your GPO a desire for environmentally preferable products?

2. Does your facility have any specific or general Environmentally Preferable Purchasing (EPP) policies?

3. Does your hospital consider environmental impacts when selecting products and services in general (medical and/or non-medical)?

4. Does your hospital consider environmental impacts when selecting medical devices, specifically?

5. Do you ask suppliers to track and provide EPP purchasing reports in your purchasing contracts?

6. To get credit for this section, please describe in a few sentences, at least one (preferably more), product or service that was impacted by your EPP policy or through supply chain purchasing decisions.

2. Please give us the details in the table below regarding your EPP purchasing activities for products and services in general and your EPP policy.Material/Chemical/Attribute

Mercury1. Specifically mentioned in EPP or environmental policy

2. Evaluated /avoided in purchasing activities

Lead1. Specifically mentioned in EPP or environmental policy


PBTs (persistent bioaccumulative toxics)1. Specifically mentioned in EPP or environmental policy


DEHP (di-2-ethylhexylphthalate)1. Specifically mentioned in EPP or environmental policy


PVC (vinyl, polyvinyl chloride plastics)1. Specifically mentioned in EPP or environmental policy


Halogenated, chlorinated or bromated flame retardants1. Specifically mentioned in EPP or environmental policy


Other Phthalates (DEHP and other phthalates are found in PVC bags and tubing, and other soft plastics)

1. Specifically mentioned in EPP or environmental policy


Carcinogens, mutagens, reproductive toxics



Bisphenol-A1. Specifically mentioned in EPP or environmental policy


VOCs (volatile organic compounds)1. Specifically mentioned in EPP or environmental policy


Latex1. Specifically mentioned in EPP or environmental policy


Halogenated plastics1. Specifically mentioned in EPP or environmental policy


Perfluorinated compounds1. Specifically mentioned in EPP or environmental policy


Benzidine dyes and pigments (used in production of textiles, paints, printing inks, paper and pharmaceuticals, reagents and biological stains in labs)



Lubricant parafins1. Specifically mentioned in EPP or environmental policy


Energy Efficiency1. Specifically mentioned in EPP or environmental policy


Water Efficiency1. Specifically mentioned in EPP or environmental policy


Excessive Packaging1. Specifically mentioned in EPP or environmental policy


Reducing plastics that are not as easy to recycle as #1 and #2?1. Specifically mentioned in EPP or environmental policy


Durability and expected length of service1. Specifically mentioned in EPP or environmental policy


Reusable vs. single use products?1. Specifically mentioned in EPP or environmental policy


Recycled content of product?1. Specifically mentioned in EPP or environmental policy


Whether the product becomes or generates hazardous waste1. Specifically mentioned in EPP or environmental policy


Other, please describe1. Specifically mentioned in EPP or environmental policy


Other (please describe)1. Specifically mentioned in EPP or environmental policy


3. Other considerations:

1. Are there other characteristics that you screen for, not listed on the table above (other than price)?

4. ElectronicsIf your facility purchased these products in the last year, indicate how energy efficiency ranked during that purchasing decision. If not purchased in the last year, indicate how you believe energy efficiency will rank next time your facility purchases these products.

1. Do you purchase EPEAT (Electronic Products Environmental Assessment Tool) registered products (such as computers) that are environmentally preferable?

2. Does your organization have a policy requiring or preferring the purchase of EPEAT-registered products?

3. Are you using (or is your vendor using) an e-Stewards certified recycler for electronic waste?

4. Have you done any Information Technology (IT) energy efficiency upgrades?

5. Do you use rechargeable batteries instead of single-use alkalines where possible?

5. FurnitureDo you require environmental attributes in furniture specifications and/or use them in making purchasing decisions (such as indoor air emissions from volatile organic compounds (VOCs)?

1. If yes, do you require furniture meet specific indoor air emission requirements? (such as not to exceed VOC levels set by California Section 1350)?

2. If yes, do you require VOC testing reports to confirm? (MDBC C2C certification at Gold or Platinum meets this).

3. Do you require furniture to be free of intentionally added halogenated organic flame retardants?

6. Reusable LinensWhat percent of these items used in your facility are reused?

Surgical Drapes

1. Percentage

Surgical Gowns1. Percentage

Patient Gowns1. Percentage

Incontinent Products (Underpads & Briefs)1. Percentage

Isolations Gowns1. Percentage

Scrubs1. Percentage

Surgical Packs (sterile and nonsterile)1. Percentage

7. Reusable Products

1. Have you switched any of these disposable products (in the Resuable Products Checklist, below) to reusables? If yes, please complete the checklist.

2. Please describe and quantify if possible, your biggest challenges or successes.

8. Reusable Products Checklist

Totes for internal Deliveries1. Switched to reusable?

Shipping containers (totes)1. Switched to reusable?

RMW Shipping1. Switched to reusable?

Rigid sterile cases for surgical items1. Switched to reusable?

Pharmacy waste containers1. Switched to reusable?

Surgical basins / biowaste tubs1. Switched to reusable?

Trocar (tubing)1. Switched to reusable?

Other, please describe1. Switched to reusable?

9. Other EPPDescribe other EPP initiatives in your facility, including products or processes that reduce waste volume or toxicity, have recycled content, or are increasing the health of your staff, patients and community. We are particularly interested in your successes and projects that did not work out.

1. Description:

Application Page Ten- FOOD

1. Sustainable Food Service Policies

1. Have you signed the Healthy Food in Health Care Pledge?http://www.noharm.org/lib/downloads/food/Healthy_Food_in_Health_Care.pdf

2. Have you created a Sustainable Food Service Policy?

2. Nutrition Initiatives - We have made our food options healthier by:

Increasing fruit and vegetable options1. Please Choose

Increasing nutritionally dense and minimally processed/unrefined foods1. Please Choose

Offering protein balanced vegetarian and/or vegan options1. Please Choose

Using whole grain options for at least half of your grains and breads1. Please Choose

Creating soups from scratch (with exception of legumes and tomatoes)1. Please Choose

Eliminating trans fats (partially hydrogenated/ fully hydrogenated oils)1. Please Choose

Eliminating deep fried foods1. Please Choose

Reducing products with high fructose corn syrup1. Please Choose

Reducing sodium content1. Please Choose

Reducing portion sizes1. Please Choose

3. Child and Infant Nutrition

1. We address good infant and child nutrition by promoting breast feeding.

2. We address good infant and child nutrition by eliminating the standard practice of free formula giveaways.

3. We have been designated as a baby-friendly hospital.

4. We have programs to address childhood obesity.

5. Please briefly describe your work in child and/or infant nutrition.

4. Beverages and Vending

1. Have you provided healthier, sustainably-produced food in vending machines (such as USDA Certified Organic snacks and beverages, rBGH-free milk and yogurt, Certified Fair Trade coffee and/or tea, etc.)?

2. Have you offered fewer sugar-sweetened beverages in: (select all that apply)

3. Have you offered employees reusable water bottles, coffee or travel mugs?

4. Do you have access to free sources of drinking water?

5. Have you eliminated bottled water in the following portions of your facility? (select all that apply)

6. Have you eliminated bottled water in portions of other areas? (please describe)

5. Local / Sustainable Food ChecklistPlease indicate below, the certified, labeled and local food you purchased in 2012. Local indicates you purchased at least some of a product, at least part of the year from local sources. The GGHC defines **local as "grown/raised and processed within a 200-mile radius."** For a complete list of Eco-labels and the products they apply to, see the GGHC Food Service Credit 3. ( http://www.gghc.org/tools.2.2.operations.php - Click on the blue Food Service bullet in the Operations Credits menu ).PLEASE CHECK ALL THAT APPLY.

**Third Party Certified** means: **USDA Organic Certified, Food Alliance certified**...

**USDA/FDA approved label claims** means:**rBGH-Free, Raised Without Antibiotics, Raised Without Added Hormones, USDA Grass-fed**...

**Local** means **grown/raised and processed within a 200-mile radius**.

Chicken1. Buy Third Party Certified?

2. Buy USDA/FDA approved label claims

3. Buy local

Meats1. Buy Third Party Certified?


3. Buy local

Fish1. Buy Third Party Certified?


3. Buy local

Dairy1. Buy Third Party Certified?


3. Buy local

Eggs1. Buy Third Party Certified?


3. Buy local

6. Local Sustainable Food Questions

1. Do you buy produce that is Third Party Certified (USDA Organic Certified, Food Alliance Certified, etc.)?

2. Do you buy produce that is local (use definition in table above)?

3. Do you buy locally baked goods?

4. What other food products do you buy locally?

7. Sustainable Procurement Initiatives

1. Has your facility taken the Healthier Hospitals Initiative Food Service Challenge?

2. If Yes, has your facility taken the Healthy Beverage Challenge?

3. If Yes, has your facility taken the Local/Sustainable Foods Challenge?

4. If yes, has your facility accepted the Balanced Menu Challenge?

5. Have you made direct purchases from local farmers, ranchers or local cooperatives?

6. If yes, please briefly describe.

7. Has your facility implemented a "Balanced Menus" program?

8. Have you worked with your vendors or suppliers to indirectly purchase locally grown food?

9. Has your facility implemented other programs/initiatives to reduce the amount of meat on the menu, such as implementing Meatless Mondays or Fridays...?

10. If you have implemented ANY of these above programs to reduce meat, list the percent you reduced your meat purchases this year.

11. Have you purchased sustainably produced meat where meat is used?

12. If yes, what % of your meat is sustainably produced?

13. Are you working with your GPO on any healthy food initiatives?

14. If yes, who is your GPO?

15. Please briefly describe initiatives?

16. Have you communicated with your distributor or vendor about your interest in including more healthy, sustainable and local foods?

8. Food and Farm Linkages

1. Do you host a Farmer's Market or Farm Stand?

2. If yes: How many months of the year do you offer it?

3. How often do you hold the farmers market?

4. Do the farmers pay to participate?

5. Do you take food stamps (like WIC)

6. Is it the only local farmers market?

7. To participate, the farmers must be (select all that apply):

8. Do you offer an employee CSA (community supported agriculture) program?

9. Do you have an on-site garden from which you use produce in your food service (employee or patient)?

10. Do you offer garden space to your employees and/or surrounding community?

11. Do you educate your community via classes or literature on healthy eating/ cooking/ etc.?

12. Do you purchase fair trade coffee?

13. Other food and farm linkages?

9. Food Service Ware

1. Have you switched to reusable food service ware in:

2. Have you reduced polystyrene in these areas? Select all that apply.

3. Have you eliminated polystyrene in these areas? select all that apply

4. Have you reduced or eliminated polystyrene elsewhere? (please explain)

5. If reduced, but not eliminated, where are the remaining polystyrene (Styrofoam) items?

6. Do you use Compostable/Biodegradable (BPI Certified) Products in patient service?

7. % of total patient food service ware that is Compostable/Biodegradable?

8. Do you compost these items?

9. Do you use Compostable/Biodegradable (BPI Certified) Products in cafeteria service (including to-go ware)?

10. If yes, % of total cafeteria food service ware that is Compostable/Biodegradable?

11. Do you compost these items?

12. Do you apply these same practices to your cafes, kiosks, and grab-n’go sites?

10. Food Service Waste

1. Do you use strategies to reduce your food waste?

2. Do you have a program to compost these items? Select all that apply.

3. Other items you compost or composting successes you would like to share.

4. Do you compost:

5. Please estimate annual tonnage of compost

6. Do you donate leftover food?

7. If you track your donations, enter annual tonnage here:

11. Food Vendors

1. Do you use a contracted food service provider?

2. If yes, have you worked with your contractor to implement healthy food initiatives (e.g. sustainable and local food procurement; nutrition initiatives; farmers market, CSA, garden; food waste reduction and composting; etc.)?

3. Do you have a fast food restaurant on your campus?

4. If yes, are you considering going to a healthier food provider for your next contract?

5. Who is your contracted food service provider/ vendor?

12. Other

1. Have you implemented any other nutrition initiatives or healthy food projects you would like to share?

2. If yes, please describe.

Application Page Eleven- Facilities (Energy, Water LEED...)

1. Facilities and ConstructionThis page is quite long, PLEASE SAVE EARLY AND SAVE OFTEN!!

Please estimate ENERGY and WATER data and savings on an ANNUAL basis throughout this page.

2. Energy Use**Please provide your Annual Energy Use.** Enter a numerical response in each box. Energy Information

Estimate of annual energy use1. Electricity in Kilowatt Hours

2. Natural Gas

3. Fuel oil in gallons

4. Diesel Fuel in gallons

5. Steam in pounds

Approx. square footage (1)1. Electricity in Kilowatt Hours

2. Natural Gas



5. Steam in pounds

Annual Cost:1. Electricity in Kilowatt Hours

2. Natural Gas



5. Steam in pounds

Helpful notes1. Electricity in Kilowatt Hours

2. Natural Gas



5. Steam in pounds

3. Energy Use1) The average electrical consumption for Award winners reported in the 2012 Sustainability Benchmark Report was **33 kilowatt hours per square foot.**

1. How do we compare? Your electricity use in kilowatt hours per square foot is:

2. In the table directly above, our natural gas consumption is listed in the following units:

3. If other, what are the units?

4. Energy Use 2

1. The energy data above represents the main healthcare facility only.

2. The energy data above represents how many buildings in your campus?

3. What is your primary heating source?

4. What fuel runs your backup generators?

5. Alternative Energy

Solar1. What percentage of your electricity comes from renewable energy (generated in partnership with the hospital or

purchased)?

Wind1. What percentage of your electricity comes from renewable energy (generated in partnership with the hospital or

purchased)?

Geothermal1. What percentage of your electricity comes from renewable energy (generated in partnership with the hospital or

purchased)?

Hydropower1. What percentage of your electricity comes from renewable energy (generated in partnership with the hospital or

purchased)?

Biomass1. What percentage of your electricity comes from renewable energy (generated in partnership with the hospital or

purchased)?

Biogas1. What percentage of your electricity comes from renewable energy (generated in partnership with the hospital or

purchased)?

Other1. What percentage of your electricity comes from renewable energy (generated in partnership with the hospital or

purchased)?

6. Alternative Energy

1. If you are using Hydropower: is it provided from a facility that is certified by the Low Impact Hydropower Institute, or from a Canadian facility that is EcoLogo certified?

2. You may offer other information on your alternative energy projects here if you so choose.

7. NotesThe following Sections pertain to: LEED certification in 2012; LEED certification prior to 2012; LEED building and renovation in 2012that was not certified; LEED building and renovation prior to 2012 that was not certified.

IF you did NOT PERFORM ANY LEED ACTIVITIES please LEAVE this section BLANK. DO NOT ENTER ZEROS!!

8. LEEDPlease list your LEED projects here:

01. Project Name

2. Type of Project

3. Year Completed

4. Square Feet

5. Certification

01. Project Name

2. Type of Project

3. Year Completed

4. Square Feet

5. Certification

01. Project Name

2. Type of Project

3. Year Completed

4. Square Feet

5. Certification

01. Project Name

2. Type of Project

3. Year Completed

4. Square Feet

5. Certification

01. Project Name

2. Type of Project

3. Year Completed

4. Square Feet

5. Certification

9. LEED Project storyPlease provide a brief story for your LEED projects:

1. Brief Project Story

10. Green Building

1. Are you currently building or planning any new building projects?

2. Will the new project incorporate some green aspects?

3. If yes, will it include:

4. Are you currently building or planning any new renovation projects?

5. Will the new project incorporate some green aspects?

6. If yes

7. We are involved in a Pebble Project with the Center for Health Designs(http://www.healthdesign.org/research/pebble/)

8. We practice evidence based design

9. We have a green or living roof

10. We have a healing garden

11. Please indicate your green building activities for the planned projects in Section 9 here.Green Building

We are following the green guide for health care (GGHC)1. Type

We are following LEED guidelines but do not plan on certification1. Type

We are following LEED guidelines and the building will be LEED certified1. Type

12. Sustainable Design and Construction (1)We have incorporated the following environmentally friendly and sustainable features into our facilities design

High-efficiency HVAC1. Type

High-efficiency building controls1. Type

Low-flow water fixtures1. Type

Sustainable wall covering, paints and finishes with low VOCs (2)1. Type

Low-emissivity glass for windows1. Type

Increased day lighting1. Type

Other, please describe1. Type

13. Notes1) Based on Health Facilities Management/ ASHE 2009 Construction Survey2) VOC = volatile organic compounds

14. Sustainable Design and Construction (1)We have incorporated these green construction practices in our building projects

Use of physical and mechanical design and materials to improve indoor air quality1. Type

Optimize layout and orientation of building to optimize energy performance1. Type

Reuse/recycle demolition materials1. Type

Minimize site development footprint1. Type

Add language to contract specifications that constructor will follow LEED or GGHCrequirements

1. Type

Specify cogeneration, fuel cells, renewable energy systems and other alternative energy resources as feasible

1. Type

Other, please describe1. Type

15. Energy Efficiency

1. Are you an Energy Star Partner?

2. If yes, what is your Energy Star rating?

3. How old are your main buildings associated with your Energy Star rating?

4. If you are not an Energy Star member, have you benchmarked your hospital?

5. If you have, how?

6. If you have not, are you planning to?

7. What are your plans to improve or manage you benchmark scores?

8. Have you completed your data collection through Portfolio Manager?

9. Are you participating in the E2C Program (between ASHE and Energy Star)?

10. Do you have an overall written energy policy or plan?

11. Do you house and run your own computer server infrastructure?

12. If yes can you provide the number of computers?

13. Approximate square footage of space housing computer infrastructure:

14. Approximate annual kWh if metered separately:

15. Have you engaged in any energy efficiency projects in recent years? To get credit for your projects, please listproject details in Table 19 below. Complete as much as you can for each project. List most recent projects first, going back up to 5 years.

16. Energy Efficiency: What were the projects that produced the most energy savings/cost avoidance?You may enter data with or without commas, but the commas will not be stored. Projects

0

1. Project Description

2. Amount of energy saved annually

3. Units of Energy Saved

4. Annual savings ($)

5. Year Implemented





5. Year Implemented





5. Year Implemented





5. Year Implemented





5. Year Implemented

17. Energy Efficiency Total: Annual savings ($)

1. Annual Savings Total ($)

2. Are there details you would like to describe about your energy program or projects?

18. Energy Efficiency

1. Have you implemented building envelope improvements to reduce energy requirements, including, for example, insulation, window and door replacements?

2. Do you use evaporative cooling when ambient conditions allow?

3. Do you reset space temperatures based on usage and occupancy?

4. Do you operate chiller plants that use various technologies and strategies to reduce overall plant energy consumption at full and partial loads?

5. Do you integrate day-lighting strategies to decrease building energy demand?

6. Do you utilize a chiller optimization program (software) to determine best use of chiller sequencing based on efficiencies at various loads?

7. Do you minimize leakage in air handling units and ductwork to reduce overall fan horsepower while ensuring that air is properly filtered?

8. Do you retrofit using variable speed drives (VFD’s) for motors and pumps, and Energy Star-rated equipment to reduce electrical consumption?

9. Do you install energy efficiency lighting devices, such as: LED exit signs, fluorescents, Energy Star qualified lighting fixtures, occupancy sensor and sunlight harvesting controls?

10. Have you implemented energy-efficiency retrofits and energy-saving techniques to reduce energy use?

11. Have you increased energy efficiency of computer server infrastructure?

12. Have you evaluated or improved critical equipment electrical distribution systems?

13. Do you have other HVAC improvements to improve energy efficiency?

14. Other, comments, details, explanations (optional)

19. Water Use

1. What is your annual water usage, in gallons?

2. How do I compare? (this number will be automatically calculated for you from the information above).

3. What is your annual water bill?

4. What is your annual sewerage bill?

5. Comments?

6. Have you engaged in any recent water conservation projects? List most recent projects first, in Table 23 below, going back up to 5 years.

20. Water Conservation: What were the projects that produced the biggest savings?


2. Gallons of Water saved annually

3. Water Bill annual savings

4. Sewerage Fees saved annually

5. Year Implemented





5. Year Implemented





5. Year Implemented





5. Year Implemented





5. Year Implemented

21. Water Conservation: Total Annual savings per project

1. Project 1

2. Project 2

3. Project 3

4. Project 4

5. Project 5

22. Water Conservation: Totals

1. Gallons of Water Saved Annually Total

2. Water Bill Annual Savings Total

3. Sewerage Fees Saved Annually Total

4. Total Annual Savings Total

23. Potable Water Use Reduction: Table 1Have you:

1. Reduced fixture water usage through automatic controls and other actions?

2. Specify water conserving plumbing fixtures and fittings that exceed the UPC or IPC fixture and fitting performance requirements in combination with high efficiency or dry fixture and control technologies?

3. Purchase water efficient equipment in the laundry (washers)?

4. Purchase water efficient equipment in the kitchen (washers)?

5. Reclaimed any potable “grey” water drains, cooling coil condensate, and/or captured rainwater for filtration and treatment to use in non-potable process water needs such as process cooling (sterilizers) or cooling tower water makeup?

6. Tracked your facility’s water consumption (for free) using the water tracking feature of U.S. EPA’s Energy Star® National Energy Performance Rating System, found within Portfolio Manager at http://www.energystar.gov/benchmark ?

7. Recorded meter and document reclaimed potable water use for further non-potable process use?

8. Calculated annual fixture potable water use per occupant and per square foot?

9. Implemented and maintain high efficiency irrigation technologies that include micro irrigation, moisture sensors, or weather data based controllers?

10. Fed irrigation systems with captured rainwater, gray water (site or municipal), or on-site treated wastewater?

11. Considered eliminating use of an irrigation system. Consider use of xeriscaping principles. Select water efficient, native or adapted, non-invasive climate tolerant plantings.

24. Potable Water Use Reduction: Table 2Have you:

1. Worked with a water treatment specialist to develop a water management strategy addressing the appropriate chemical treatment and bleed-off to ensure proper concentration levels in the cooling tower?

2. Explored technologies and strategies to eliminate chemical waste to drain in cooling tower and boiler blowdown?

3. Treated blowdown so that chemical treatment can be reclaimed for re-use?

4. Implemented a water management plan for the cooling tower that addresses chemical treatment, bleed-off, biological control and staff training for cooling tower maintenance?

5. Improved water efficiency by installing and/or maintaining a conductivity meter and automatic controls to adjust the bleed rate and maintain proper concentration at all times?

6. Employed non-toxic treatment chemicals or chemical-free cooling tower systems?

7. Used make-up water that consists of at least 50% non-potable water?

8. Used non-potable makeup water? If so, please list below.

9. If yes, please list what types of makeup water you have used.

10. Potable water reduction tables 1 and 2: Other, comments, details, explanation (optional)

25. Refrigerant ManagementAre you using/doing:

1. Use non-CFC-based HVAC&R equipment which is often more efficient than CFC-based equipment and can improve overall facility energy performance.

2. Set up leakage minimization procedures and systems to meet annual leakage minimization standards and reporting requirements.

3. When reusing existing HVAC systems, conduct an inventory to identify equipment that uses CFC refrigerants and provide a phase out schedule for these refrigerants.

26. CommissioningThe commissioning process activities begin by identifying the current building operating intents (Owner’s Operational Requirements) and then proactively making sure that the buildings’ systems are operating as necessary to meet these operating intents. Do You:

1. Incorporate into the commissioning program regular inspections of the mechanical ventilation system to identify if the filters are clean, not overloaded and without leaks or tears and insure that drip pans are free of standing water or other contaminants.

2. Ensure that the commissioning program addresses, at a minimum, the following: heating system, cooling system, humidity control system, lighting system, safety systems, building envelope, domestic water pumping systems and the building automation controls.

3. Other commissioning activities

4. Refrigerants, Commissioning, or other comments, details or explanations (optional)

Application Page Twelve- Transportation

1. TransportationWe support/ encourage alternative transportation through the following activities:

1. Having hybrid, electric or alternative fueled vehicles in our fleet

2. Reimbursing for public transportation fees

3. Facilitating or organizing car pools

4. Making bike racks available

5. Providing adequate locker rooms and shower facilities

6. Offering shuttle services to/from public transportation and/or between our facilities

7. Providing desired parking for carpools or owners of hybrid cars

8. Encouraging teleconferencing instead of meetings

9. Encouraging carpooling to offsite classes and meetings

10. Have a program that allows employees to use pre-tax dollars to purchase public transportation passes or tickets.

11. Have electric vehicle charging stations available

12. Have anti-idling policy, posted signs, or other anti-idling measures

13. Other porjects or comments

Application Page Thirteen- A Culture of Sustainability

1. A Culture of Sustainability: Leadership in your community and the healthcare sectorPlease fill out the tables below and describe any other unique or innovative sustainability initiatives that may not havebeen covered in the categories above or did not provide space for detail. If you are hoping to get PFC with Distinction you need to have something in this section. For members of the ELC, this area is mandatory!

Note: Partner for Change with Distinction and Environmental Leadership Circle selections will be made from the entire pool of PFC Award applications. For more detail on criteria, please see our website at: www.practicegreenhealth.org/awards.

Please feel free to attach details, photos, or examples for any of these initiatives.

1. If you would like to add an attachment, please do so here or at the bottom of Page Fifteen with a brief description.

2. Leadership within your local community (defined as your surrounding community).Activity

Held THERMOMETER SWAP open to the community1. Performed previously


Held PHARMACEUTICAL TAKE BACK event open to the community1. Performed previously


Held ELECTRONICS COLLECTION event open to the community1. Performed previously


Handed out or collected CFLs to community1. Performed previously


Held EARTH DAY EVENT(S)1. Performed previously


Conducted a COMMUNITY NEEDS ASSESSMENT (If unsure, check with your community benefits coordinator)

1. Performed previously


Identified sustianability activities that help MEET THE NEEDS identified in the community needs assessment?



Example of activity that met an identified need1. Performed previously


Developed a SUSTAINABILITY WEBPAGE for the public on facility website1. Performed previously


Displayed SIGNAGE visible to patients describing RECYCLING OR OTHER ENVIRONMENTAL PROGRAMS, please upload at the bottom of this page if possible



Used LOCAL MEDIA to communicate sustainability activities to the community1. Performed previously


Received MEDIA attention /local PRESS around PGH AWARD won.1. Performed previously


WIDELY ANNOUNCED PGH membership to employees and/or visitors (beyond just hanging your Award plaque)



**Met with city government reps** or local organizations to promote sustainability locally or plan local event (like Clean Air days)



Shared information on our sustainability programs with LOCAL BUSINESSES, COMMUNITY GROUPS, SCHOOLS etc.



EDUCATED COMMUNITY on environmental topics (example: provide information on proper medication disposal when issuing prescriptions)



Include SUSATAINABILITY in ADVERTISING CAMPAIGNS1. Performed previously


Other examples of getting out in community1. Performed previously


Other examples of getting out in community1. Performed previously


3. Leadership in the Health Care SectorActivity performed by staff at your hospital

Presented at a STATE-WIDE MEETING on sustainability1. Performed previously


PRESENTED at a NATIONAL meeting (ASHES, ASHE, CleanMed…) on sustainability1. Performed previously


PRESENTED at a HEALTH SYSTEM meeting on sustainability1. Performed previously


Performed MENTORING to another hospital within our health system on sustainability1. Performed previously


Performed MENTORING to another hospital OUTSIDE our health system on sustainability1. Performed previously


Was interviewed by LOCAL TV OR RADIO for broadcast on sustainability1. Performed previously


Signed onto HHI’s Healthier Hospital Agenda (www.healthierhospitals.org)?1. Performed previously


Engaged in SOCIALLY RESPONSIBLE INVESTING1. Performed previously


Other examples of Leadership in the health care sector.1. Performed previously






4. Healthier Hospitals Initiative

1. Have you or your Health System joined the Healthier Hospitals Initiative (HHI)?

2. If Yes, which planks have you signed onto (check all that apply):

5. Upload Display Signage

1. Upload display signage visible to patients describing recycling or other environmental programs

6. Case Studies

1. Please upload or supply a link to any case studies that you have completed that we may post on our website or use for educational purposes.

2. What is the main topic area of this case study?

3. If other, please explain.

Application Page Fourteen- Goals for 2013

1. Goals for 2013Please describe at least three key environmental and sustainability goals your facility plans to focus on in the year ahead. Your application is not evaluated on the basis of your future goals, but they are an important part of your path to sustainability.

1. Environmental and Sustainability goal





Application Page Fifteen- Statement of Accuracy and Release

1. Statement of Accuracy and Release

1. By checking Yes I am certifying that the contents of this application are accurate and true to the best of my knowledge. (primary contact)

2. Primary Contact

3. Title

4. Date

5. By checking Yes I am certifying that the senior leadership person named here is aware of our sustainability activities, has reviewed this application, and certifies that the contents of the application are accurate and true to the best of their knowledge.

6. Senior Leadership Name

7. Title

8. Senior Leadership Phone Number

9. Date

10. To the best of our knowledge, the information represented in this application is true and accurate and provides a reasonable snapshot of our environmental programs and commitment.

11. Our application may be shared with other Practice Greenhealth members for educational purposes.

12. The ATTACHMENTS provided with this application may be shared with other Practice Greenhealth members for educational purposes.

2. Photographs and Additional FilesPlease attach a SINGLE PHOTOGRAPH to be used in the Awards ceremony SLIDE for your organizatioin, preferably something fun (for example: sustainability in action, your green team, dumpster diving, your Farmers Market, Earth Day booths, etc). You may also provide us with any additional relevant photographs or files by attaching them here.

**To add or remove a file or photo: Click the "Browse" button, select the file you wish to upload. After you have selected your file, click on the "open" button or hit the "enter" key. To remove an attachment you have saved, check the "Remove" box and click on the orange "Save" button at the bottom of your screen.**

To submit multiple files (and there are many ways to do this) place those files in the same folder on your computer, right click on that folder and choose "Compress" (on a mac) or "WinZip > Add to Zip file..." (on an older PC) or "send to > zipped/compressed file" (on a newer PC). Browse to the zipped/compressed file and press "Save" at the bottom of the page. To remove your file(s), place a check in the remove box and press "Save."

1. Single photo (with description) to be used in the Awards ceremony.

2. Attachment, with any comments or description you would like to provide

3. Attachment, with any comments or description you would like to provide

3. Feedback to the Awards teamThis section is COMPLETELY OPTIONAL. Thank you for your time and effort in filling out the PFC Award application. We are looking to streamline the PFC application and the associated Sustainability Benchark Report for next year. With that in mind, please provide a few comments if you have time:

1. What are the MOST valuable parts of the Sustainability Benchark report and the associated PFC application (what would you NOT want to see cut)?

2. What are the LEAST valuable parts of the Sustainability Benchark report and the associated PFC application (what would you like to see cut)?

3. What is (are) the most time consuming part(s) of the application?

4. If other, please provide a bit of detail

5. Anything other ideas you would like to share to help us do continuous improvement on the Awards program andBenchmark report

Appendix A- Recycling

1. Recycling only - please note changes from past years (this Appendix is MANDATORY)You MUST fill out APPENDIX A to be considered for PFC or ELC! Please be detailed and thorough. Add comments or descriptions where it would aid in understanding. Please save your work often. If you hit Enter after entering a number, the page will also save, and you will be repositioned to the top of the page.

WHAT IS INCLUDED? The items below are included in our definition of RECYCLING. These items are collected, reworked, and formed into new items. While not included in the list, we also highly value reuse, avoided materials, and source reduction which are given credit elsewhere in the application.

2. Appendix ARECYCLING (in TONS): Includes items recycled in the traditional manner.

For COMINGLED and SINGLE STREAM recycling: fill in the requested data for this waste stream, then complete the commingled and single stream checklist in #8 below. For % of campus covered, please estimate an average for this waste stream.

Commingled and Single Stream recycling combine different materials (such as different types of plastics and glass and aluminum into one collection. It is our understanding that Single Stream also includes paper).

The totals below, “Appendix A Recycling totals” will be AUTOMATICALLY ENTERED on Page Two of the

Application. To convert gallons to tons, multiply: (X gallons)(8.5 # /gallon)(1 ton / 2000 pounds).Material Types (Click on each material to open and close data entry for that item)

Batteries (universal)1. Source of Data

2. Total Tons per Year

3. Cost (+) or Revenue (-)

Boxboard1. Source of Data



Cans - Aluminum1. Source of Data



Cans - Steel1. Source of Data



Cardboard1. Source of Data



Comingled Recycling and Single Steam Recycling - Please put weights here but identify materials collected in the checklist below

1. Source of Data



Computers and Electronics (universal waste)1. Source of Data



Fluorescent lamps (universal waste)1. Source of Data



Food Waste Composting1. Source of Data



Glass, All1. Source of Data



Ink Jet and Toner Cartridges1. Source of Data



Oil (Cooking)1. Source of Data



Oil (Motor- this may only be included if recycled for reuse, you may NOT include any type of fuel blending)

1. Source of Data



Lead Aprons1. Source of Data



Metals, Mixed (include brass, copper, steel, stainless and other metals not entered elsewhere)

1. Source of Data



Paper mixed (including newspaper)1. Source of Data



Paper (White)1. Source of Data



Paper - HIPAA1. Source of Data



Plastic #1PET1. Source of Data



Plastic #2HDPE1. Source of Data



Plastic #3 PVC1. Source of Data



Plastic #4 LDPE1. Source of Data



Plastics #5 Polypropylene (includes blue wrap)1. Source of Data



Plastic #6 PS1. Source of Data



Plastic, Mixed1. Source of Data



Shrink Wrap (list here if not included in your other plastics recycling)1. Source of Data



Steel1. Source of Data



Wood1. Source of Data



X-Ray Film1. Source of Data



Solvent Distillation (not fuel blending)1. Source of Data



Silver from X-Ray1. Source of Data



3. Appendix A (Other Items)

1. Please list other material types not listed above, including tons.

4. Appendix A Recycling totals (excludes Universal Waste totals below). These recycling totals will be AUTOMATICALLY ENTERED into the Solid Waste and Recycling Table on Page 2 of this application.


2. Cost or Revenue

5. Appendix A Universal Waste Totals. These Universal Waste totals will be AUTOMATICALLY ENTERED into the Solid Waste and Recycling Table on Page 2 of this application.

*Universal Wastes** are wastes that meet the definition of hazardous waste, but through proper accumulation and transport, pose a relatively low risk compared to other hazardous wastes. Acceptable universal wastes vary by state, but generally include fluorescent lamps and batteries and may include electronic wastes.

1. Total Tons per Year for universal waste (includes batteries, fluorescent lamps, computers and electronics)

2. Total Cost or Revenue for universal waste (includes batteries, fluorescent lamps, computers and electronics)

6. Commingled and Single Stream Materials Checklist (please enter aggregate data for this wastestream under Co-mingled/ Single Stream Recycling, above).Recycled: Please check all that apply.

Aluminum (Cans)1. Yes / No

Cardboard1. Yes / No

Glass, Mixed1. Yes / No

Paper, Mixed1. Yes / No

Plastic, #1PET1. Yes / No

Plastic, #2 HDPE1. Yes / No

Plastic, #3 PVC1. Yes / No

Plastic, #4 LDPE1. Yes / No

Plastic, #5 Polypropylene1. Yes / No

Plastic, #6 PS1. Yes / No

Plastic, Mixed1. Yes / No


7. Additional Diversion or Source Reduction ActivitiesDiversion and Source Reduction checklists: While we very much value your recycling achievements, we want to adhere to the waste hierarchy of “Reduce Reuse Recycle” and encourage source reduction and reuse over recycling. Opportunities for recognition in this application for items switched to reusables, reused, donated, diverted from the landfill, or prevented are found throughout the application; some are listed on the pages listed below.

1. Please list other significant diversion or source reduction activities not requested elsewhere on this application.

8. Diversion (covered throughout the application)Please note that you have already received points for diversion and source reduction of the following materials by indicating these activities in tables and questions throughout this application.Page 6 Solid Waste, Donations: Clinical items, Medical equipment, Furniture, Linens, and Books ; reusable pallets and transport packagingPage 7 RMW, RMW Reduction: Fluid management in the OR; SUD reprocessing, Reusable Sharps containers.Page 7 GOR reusables: rigid cases for sterilization in the OR; reformulated OR kits to eliminate excess supplies, SUDs, replaced disposables in the OR kits, reusable: surgical textiles/linens, basins, grounding pads, and patient warming devices.Page 9 EPP #6 Reusable Linens: Surgical drapes, surgical gowns, incontinent products, isolations gowns, scrubs and surgical packs.Page 9 EPP, Reusable Products Checklist: Totes for Internal Deliveries, shipping containers, RMW shipping, rigid sterile cases for surgical items, pharmacy waste containers, surgical basins / biowaste tubs, and trocar (tubing).Page 10 Food #7: Service ware: food service ware, Polystyrene (Styrofoam) elimination, compostable and biodegradable products, and #10 Food donation.

Appendix B: SUDS

1. Single Use Device ReprocessingThis section is not mandatory, but is strongly encouraged if you do reprocessing. WHICH ITEMS DO I COUNT? We are looking for the Single-Use Devices you are currently reprocessing using an FDA-approved reprocessor? Note, count only devices that are **sold as single-use** and then reprocessed by a vendor for additional use. Do *not count** devices that are sold as reusable items or items that you clean in-house through central sterile processing.

For REPROCESSING RATE:The Reprocessing rate is the number of reprocessed items purchased divided by the total number of items purchased (where total number of items purchased = the number of reprocessed items purchased + the number of virgin items purchased for this device).

2. Single Use Device Reprocessing Checklist (Anesthesiology)Device

Pulse Oximeter Sensor1. We send these items out-of-house to a reprocessor

2. We purchase these reprocessed devices

3. Reprocessing Rate, if known (=the percentage of devices you buy that are reprocessed (not new), please enter a whole number).

3. Single Use Device Reprocessing Checklist (Cardiovascular)Device

Tissue Stabilizer1. We send these items out-of-house for reprocessing


3. Reprocessing Rate if known (= the percentage of devices you buy that are reprocessed (not new), enter a whole number.

Blood-Pressure Cuff1. We send these items out-of-house for reprocessing



DVT Compression Sleeve1. We send these items out-of-house for reprocessing



Electrophysiology Catheters1. We send these items out-of-house for reprocessing



Diagnostic Electrophysiology Catheter (non-imaging)

1. We send these items out-of-house for reprocessing



Ultrasound Electrophysiology Catheters1. We send these items out-of-house for reprocessing



Imaging Catheter1. We send these items out-of-house for reprocessing



Pulse Oximeter1. We send these items out-of-house for reprocessing



Femoral Compressor Device1. We send these items out-of-house for reprocessing



4. Single Use Device Reprocessing Checklist (Gastroenterology)Device

Stone Retrieval Basket1. We send these items out-of-house for reprocessing


3. Reprocessing Rate, if known (=the percentage of devices you buy that are reprocessed (not new), enter a whole number.)

Biopsy Forceps1. We send these items out-of-house for reprocessing



Endoscopic Electrodes1. We send these items out-of-house for reprocessing



Hospital Bed Patient Monitoring Alarm1. We send these items out-of-house for reprocessing



5. Single Use Device Reprocessing Checklist (General)Device

Electrosurgical Electrode (including RF Probes)1. We send these items out-of-house for reprocessing


3. Reprocessing Rate, if known (=the percentage of devices you buy that are reprocessed (not new), enter a whole number).

Turp Loops1. We send these items out-of-house for reprocessing



ENT Shavers1. We send these items out-of-house for reprocessing



Trocars1. We send these items out-of-house for reprocessing



MultiClip Appliers1. We send these items out-of-house for reprocessing



Pneumatic Tourniquet Cuff1. We send these items out-of-house for reprocessing



Hot Laparoscopic Instruments1. We send these items out-of-house for reprocessing



Cold Laparoscopic Instruments1. We send these items out-of-house for reprocessing



Laparoscopic dissectors, graspers & scissors1. We send these items out-of-house for reprocessing



Scissor Tips1. We send these items out-of-house for reprocessing



Suture Passer1. We send these items out-of-house for reprocessing



Ultrasonic Scalpel1. We send these items out-of-house for reprocessing



6. Single Use Device Reprocessing Checklist (Opthalmic)Device

Phacoemulsification Tip Needle1. We send these items out-of-house for reprocessing



Laser Probe1. We send these items out-of-house for reprocessing



7. Single Use Device Reprocessing Checklist (Orthopedic)Device

Arthroscopy Instruments1. We send these items out-of-house for reprocessing



External Fixation Device1. We send these items out-of-house for reprocessing



Carpal Tunnel Blade1. We send these items out-of-house for reprocessing



Orthopedic Cannulas And Trocars1. We send these items out-of-house for reprocessing



Orthopedic Saw Blades1. We send these items out-of-house for reprocessing



Orthopedic bits and burs1. We send these items out-of-house for reprocessing



8. Single Use Device Reprocessing - Other

1. What items would you like to reprocess that are not available with your vendor?

2. Other issues or comments on SUD reprocessing?

Appendix C- DEHP Free

1. DEHP-Reducing and PVC-Reducing Activities![Hospira](/images/partners/hospira.png)

This award generously made possible by Hospira, maker of DEHP-free VisIV® Containers.Filling out this section is not mandatory, but will make your facility eligible for the DEHP-Free Award, given to the one facility that has made the most progress towards replacing medical devices and other products containing Di (2- Ethylhexyl) Phthalate (DEHP) and Polyvinyl Chloride (PVC) Plastic with safer alternatives.

See the FDA’s Public Health Notification regarding DEHP - http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/default.htm

Find out more about DEHP reduction - http://www.noharm.org/us_canada/issues/toxins/pvc_phthalates/

1. To score your application correctly, please indicate the number of clinical departments in your facility

2. Please indicate if your facility asks all relevant vendors if their products contain DEHP?

3. Please indicate if your facility asks all relevant vendors if their products contain PVC?

4. Do you have a purchasing policy that prefers non-DEHP products?

5. Do you have a purchasing policy that prefers non-PVC products?

6. We have inventoried use of DEHP and PVC MEDICAL DEVICES in use in this many departments at this facility

7. We have inventoried use of DEHP and PVC INTERIOR FLOORING, FINISHES and BUILDING MATERIALS in use in this many departments in this facility

8. What percentage of products containing DEHP have been eliminated from your Neonatal Intensive Care Unit(NICU)?

2. DEHP-free and PVC-free Products ChecklistInstructions: Please indicate if you use any of the products below in your entire facility, and the percentage in use that are both DEHP-free and PVC-free (out of total products in that category in use).

For instance, if all enteral feeding sets used in your facility are DEHP-free and PVC-free, the answer is 100%. If all are DEHP-free but none are PVC-free, the answer is zero. This applies to the entire product, whether or not the PVC or DEHP part comes into contact with the patient. In addition, note that if a product is DEHP-free, this doesn't necessarily mean it is PVC-free, and vice-versa. Make sure you ask your suppliers about both. For disposable products, this can be percentage of products purchased during 2012. For durable products, such as flooring, this must be percentage of products currently in use.Product

Enteral feeding sets1. Do you use this product in your facility?

2. Percentage of PVC-free and DEHP-free items in your facility (enter a numerical response rounded to the nearest whole number)

Feeding and nasogastric tubes1. Do you use this product in your facility?


IV Bags1. Do you use this product in your facility?


IV Tubing1. Do you use this product in your facility?


TPN Delivery1. Do you use this product in your facility?


Hemodialysis tubing1. Do you use this product in your facility?


Peritoneal dialysis bags and tubing1. Do you use this product in your facility?


Irrigation & drainage products1. Do you use this product in your facility?


IV administration sets1. Do you use this product in your facility?


Postoperative Pain Pump and tubing1. Do you use this product in your facility?


Respiratory therapy products1. Do you use this product in your facility?


Umbilical vessel catheters1. Do you use this product in your facility?


Urinary catheters1. Do you use this product in your facility?


Vascular catheters1. Do you use this product in your facility?


Examination gloves1. Do you use this product in your facility?


Patient ID bracelets1. Do you use this product in your facility?


Bedding and padding products1. Do you use this product in your facility?


Breast Pumps1. Do you use this product in your facility?


Carpets1. Do you use this product in your facility?


Ceiling Tiles1. Do you use this product in your facility?


Flooring1. Do you use this product in your facility?


Furniture/upholstery1. Do you use this product in your facility?


Shower Curtains1. Do you use this product in your facility?


Wall coverings1. Do you use this product in your facility?


Wall guards1. Do you use this product in your facility?


Window treatments1. Do you use this product in your facility?


3. DEHP and PVC Reduction EffortsPlease indicate briefly how your DEHP and PVC reduction efforts have been communicated internally and externally during 2012. Leave rows blank if listed audience has not received communication about these efforts during 2012.

Purchasing Department1. Do you have this deparment?

2. Description

NICU staff1. Do you have this deparment?

2. Description

PICU staff1. Do you have this deparment?

2. Description

Ob/Gyn Staff1. Do you have this deparment?

2. Description

Maternal and Child Health staff1. Do you have this deparment?

2. Description

Pediatrics staff1. Do you have this deparment?

2. Description

Other Departments1. Do you have this deparment?

2. Description

Hospital Wide1. Do you have this deparment?

2. Description

Administrative Managers1. Do you have this deparment?

2. Description

Physicians1. Do you have this deparment?

2. Description

Nurse Managers1. Do you have this deparment?

2. Description

Senior Management1. Do you have this deparment?

2. Description

Internal Newsletter1. Do you have this deparment?

2. Description

External Press Release1. Do you have this deparment?

2. Description

4. Other DEHP and PVC Reduction EffortsIn 200 words or less, please list any additional achievements related to DEHP or PVC reduction that you feel were not reflected in the questions above. This can include replacing devices not listed, steps you have taken to ensure DEHP elimination is institutionalized within your facility, in order that DEHP-free purchasing continues in the event of staff changes, etc.

1. Comments:

5. A Special Thanks![Hospira](/images/partners/hospira.png)

This award generously made possible by Hospira, maker of DEHP-free VisIV® Containers.

web viewpartner for change award award application. test facility - 2013. this document was...

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