Environmentally preferable purchasing (EPP)
More on EPP-green
Donations: medical supplies
Hospitals seeking to reduce their carbon footprint have many options today to donate medical supplies to organizations in developing or third-world nations.
- Premier's environmental leadership
- Introduction to EPP
- Federal initiatives
- Healthcare industry initiatives
- EPP implementation
- PVC - Polyvinylchloride
- DEHP - Plasticized PVC
- Bisphenol A - BPA
- Safer cleaners and pesticides
- Strategies and tools
- Premier's position on EPP
- EPP at Premier
Serving 2,500 U.S. hospitals and 73,000-plus other healthcare sites, members of the Premier healthcare alliance are working together to improve healthcare quality and affordability.
Premier leads the industry, being named a "Champion for Change" award recipient from Practice Greenhealth (formerly H2E) eleven years in a row - firmly establishing Premier and its members as leaders in healthcare and setting the bar in the industry for commitment to environmentally preferable purchasing (EPP) and sustainability best practices.
Premier's GreenHealthy® program
Premier was selected for the award for its commitment to a healthy environment, evidenced in its GreenHealthy® program, led by the Premier Safety Institute®. GreenHealthy includes Premier's EPP™ (environmentally preferable purchasing) program, an internal corporate-wide Yes to Green program, leadership education and "quick win" case studies on sustainability best practices, and Premier's healthcare energy reduction initiave, a collaborative climate and energy initiative to reduce the healthcare industry's carbon footprint.
Premier recognizes contracted suppliers with environmentally preferable products
Premier uses a green leaf icon to tag "environmentally preferable contracts" from contracted suppliers in its electronic catalog for members, Supply Chain Advisor. These contracts have products or services with environmentally preferable attributes that reduce the negative impact on the quality and health of the environment and consider, for example, the product materials, potential toxicity, production, packaging, reusability, energy efficiency, disposal, nationally recognized certification, or its impact on the environment.
Premier EPP Work Group
Premier's EPP Work Group provides advice and guidance on our EPP program and other GreenHealthy initiatives at Premier.
More information about Premier's GreenHealthy program
The health and safety of our patients and the public are linked to the health of the environment. The healthcare community therefore has a responsibility to help maintain a healthy environment with a commitment to environmentally sound purchasing. This is accomplished through the purchasing and use of environmentally preferable products and services.. In general, compared to competing products and services, environmentally preferable products are:
- Less toxic.
- Minimally polluting.
- More energy efficient.
- Safer and healthier for patients, workers, and the environment.
What is environmentally preferable purchasing?
Environmentally preferable purchasing (EPP) is the act of purchasing products and services for which the environmental impacts have been considered and found to be less damaging to the environment and human health than competing products and services that serve the same purpose. The comparisons may consider raw materials, acquisition, production, manufacturing, packaging, distribution, reuse, operation, maintenance, or disposal of the product or service. The initiative is an ongoing process, in which healthcare facilities continually refine and expand the scope of such efforts. Facilities may begin on a small scale with recycled paper, or examine potential products at each stage of impact from manufacture through final disposal. The overall goal is the same; careful selection of products and services to reduce the negative impact on the quality and health of the environment.
The basic elements of an EPP program include:
- Preventing pollution at the source.
- Purchasing products that can be recycled.
- Purchasing energy efficient products.
- Working with contracted suppliers to develop/redesign alternative products that are environmentally preferable.
A 1998 Executive Order, Greening the Government Through Waste Prevention, Recycling, and Federal Acquisition, was an important endorsement of the EPP concept. The document outlines multiple steps that can be taken to improve the environment. Greening the Government may be downloaded or located in the Federal Register as Executive Order 13101. The intent of the Executive Order was to incorporate waste and pollution prevention and recycling into daily operations of the federal government and to establish policies favoring the acquisition and use of recycled products and environmentally preferable products and services. Among the highlights of the order:
- Purchasing should be consistent with the demands of efficiency and cost-effectiveness.
- Each executive agency's daily operations should plan to increase and expand markets for recovered materials through greater federal government preference and demand for such products.
- Purchasing preference that prevent pollution whenever feasible are national policy.
- Pollution that cannot be prevented should be recycled.
- Pollution that cannot be prevented or recycled should be treated in an environmentally safe manner.
- Agencies should comply with processes for acquisition and use of environmentally preferable products and services.
- Agencies should implement cost-effective procurement programs that favor the purchase of these products and services.
The President's new Executive Order, approved October, 2009, strengthens internal federal agency activities regarding sustainability and environmental purchasing. Download Federal Leadership In Environmental, Energy, and Economic Performance 13514. Among other issues, federal agencies will be required to advance sustainable acquisition to ensure that:
"... 95 percent of new contract actions including task and delivery orders, for products and services, with the exception of acquisition of weapon systems, are energy-efficient (Energy Star or Federal Energy Management Program (FEMP) designated), water-efficient, biobased, environmentally preferable (e.g., Electronic Product Environmental Assessment Tool (EPEAT) certified), non-ozone depleting, contain recycled content, or are non-toxic or less-toxic alternatives, where such products and services meet agency performance requirements."
American Hospital Association
Hospitals are collaborating on pollution prevention and waste reduction, with a specific focus on eliminating mercury. In June 1998, the American Hospital Association (AHA) and the U.S. Environmental Protection Agency (EPA) formed a historic partnership by signing a Memorandum of Understanding (MOU) to promote a healthy environment. This MOU addressed the development of tools and resources and set forth specific goals, including:
- Virtually eliminating mercury-containing waste from hospitals' waste stream by 2005.
- Reducing the overall volume of waste (both regulated and non-regulated) generated by the healthcare industry by 33 percent by 2005, and by 50 percent by 2010.
The AHA-EPA partnership resulted in the development of an initiative called the Hospitals for Healthy Environment for (H2E). H2E is now called Practice Greenhealth. As part of Practice Greenhealth, several technical tools and resources were developed to help hospitals prevent pollution and reduce the volume of waste. See the Practice Greenhealth Web site for downloadable tools.
Although the formal MOU expired in June 2001, the AHA renewed the partnership and its commitment to the numeric goals for mercury elimination and waste reduction, as well as to the continued dissemination of information and resources to achieve these goals. Premier's Mercury Pollution Prevention module provides additional information on Practice Greenhealth and resources for mercury reduction.
A commitment to EPP communicates to the consumer that a healthcare organization is concerned with:
- Improving its impact on the overall quality of the environment.
- Providing a healthier environment for patients, workers, and employees by reducing exposure to hazardous materials such as solvents.
- Reducing costs due to overhead, avoiding waste disposal liability costs, and reducing occupational health costs.
Environmentally preferable concerns include a number of important topics and issues that need to be considered in the context of emerging information on the potential effects on human health, worker and patient safety, the maintenance of a healthy environment, and the availability of safe and effective alternatives. These topics include:
- Eliminating mercury from the hospital waste stream.Information on this topic is available in the Mercury Pollution Prevention module on Premier's Safety Web site.
- Increasing energy efficiency.
- Reducing the volume of waste.
- Minimizing persistent bioaccumulative toxic (PBT) materials, such
- Polyvinylchloride (PVC) See PVC below for more information.
- Heavy metals (lead, cadmium)
- Preventing sharps injuries. Information is available on the Premier Safety Web site in the Sharps Injury Prevention module.
- Reusing devices.Information on Reuse of Single-Use Devices is available on Premier's Safety Web site.
- Maintaining access to latex--free products.
- Environmentally preferable packaging.
Polyvinylchloride (PVC) has been the most commonly used polymer in the production of plastic hospital products because of its cost effectiveness, flexibility, and optical properties. Two concerns have been raised about PVC:
- Incineration of disposed PVC products can result in the formation of dioxin; and
- The effects of DEHP, di-(2-ethylhexyl)phthalate, a plasticizer (softener) used for most PVC medical devices.
Both dioxin and DEHP have been identified by the EPA as probable carcinogens.
FDA Public Health Advisory, July 2002
In July 2002, the US Food and Drug Administration (FDA) issued a Public Health Notification on medical devices made with polyvinylchloride (PVC) using the plasticizer di-(2–Ethylhexyl) phthalate or DEHP. The FDA provided advice on steps that can be taken to reduce the risk of exposure in certain populations. They noted that there are certain products used in specific procedures that the FDA stated pose the highest risk of exposure for certain populations. The list of those devices and procedures from the FDA advisory is provided below for convenience .
Devices that may contain DEHP-plasticized PVC include:
- Intravenous (IV) bags and tubing
- Umbilical artery catheters
- Blood bags and infusion tubing
- Enteral nutrition feeding bags
- Nasogastric tubes
- Peritoneal dialysis bags and tubing
- Tubing used in cardiopulmonary bypass (CPB) procedures
- Tubing used in extracorporeal membrane oxygenation (ECMO)
- Tubing used during hemodialysis
The following procedures have been identified as posing the highest risk of exposure to DEHP:
- Exchange transfusion in neonates
- ECMO in neonates
- Total Parenteral Nutrition (TPN) in neonates (with lipids in PVC bag)
- Multiple procedures in sick neonates (high cumulative exposure)
- Hemodialysis in peripubertal males
- Hemodialysis in pregnant or lactating women
- Enteral nutrition in neonates and adults
- Heart transplantation or coronary artery bypass graft surgery (aggregate dose)
- Massive infusion of blood into trauma patient
- Transfusion in adults undergoing ECMO
In their July 12, 2002 PVC/DEHP Public Health Advisory, the FDA provided a
link to the Sustainable Hospital Project
sponsored by the University of Massachusetts, Lowell, as one source for
identifying alternative products that do not contain DEHP-plasticized PVC.
Health Care Without Harm also maintains lists of alternative products.
- Alternatives to PVC and DEHP Medical Devices (last update September, 2008)
- Alternatives to PVC Medical Devices for NICU
FDA Draft Guidance PVC-DEHP, September 2002 for public comment
On September 6, 2002, the FDA issued Draft Guidance for public comment: Medical Devices Made with Polyvinylchloride (PVC) Using the Plasticizer di (2-Ethylhexyl) phthalate (DEHP). This draft guidance encourages manufacturers to consider all mechanisms to reduce patient exposure to DEHP, including uses of alternative materials or use of coatings. In addition, FDA recommends that user labeling clearly indicate that the devices contain DEHP. Public comments should be submitted to the FDA by December 5, 2002.
New research on DEHP devices and neonates - 2005
On June 8, 2005, a study was released from Harvard School of Public Health (HSPH) in collaboration with the U.S. Centers for Disease control and two Harvard-affiliated hospitals that found that infants, whose care required the use of medical devices containing DEHP [di-(2–Ethylhexyl) phthalate], had a component of DEHP in their urine. Although the health risks of DEHP were not evaluated, this study did confirm that there was a direct relationship between the levels of DEHP in the urine of neonates and the intensity or amount of exposure to DEHP-containing medical devices.This has implications for product selection as noted. See environmental and safety products lists.
- Harvard study: Harvard School of Public Health and The National Institute of Environmental Health Sciences
- Environmental and safety products lists
- Premier PVC/DEHP-free products lists
Bisphenol A (BPA) is an industrial chemical that has been present in many hard plastic bottles and metal-based food and beverage cans since the 1960s.
Studies employing standardized toxicity tests have thus far supported the safety of current low levels of human exposure to BPA However, on the basis of results from recent studies using novel approaches to test for subtle effects, both the National Toxicology Program at the National Institutes of Health and FDA have some concern about the potential effects of BPA on the brain, behavior, and prostate gland in fetuses, infants, and young children. In cooperation with the National Toxicology Program, FDA's National Center for Toxicological Research is carrying out in-depth studies to answer key questions and clarify uncertainties about the risks of BPA.
In the interim:
- FDA is taking reasonable steps to reduce human exposure to BPA in the food supply. These steps include:
- supporting the industry's actions to stop producing BPA-containing baby bottles and infant feeding cups for the U.S. market;
- facilitating the development of alternatives to BPA for the linings of infant formula cans; and
- supporting efforts to replace BPA or minimize BPA levels in other food can linings.
- FDA is supporting a shift to a more robust regulatory framework for oversight of BPA.
- FDA is seeking further public comment and external input on the science surrounding BPA.
FDA is also supporting recommendations from the Department of Health and Human Services for infant feeding and food preparation to reduce exposure to BPA.
FDA is not recommending that families change the use of infant formula or foods, as the benefit of a stable source of good nutrition outweighs the potential risk from BPA exposure. For more information go to the FDA Web site:
Pesticides and cleaning products
Hospitals and other health care institutions use a surprising number of highly toxic chemicals on their premises, including pesticides and environmental cleaners. These chemicals may contain volatile organic compounds (VOCs) and other toxic chemicals that contribute to poor overall indoor air quality (IAQ) and have been reported to be associated with a host of health problems.
Patients are particularly vulnerable to indoor air quality threats, as many have compromised respiratory, neurological, or immunological systems and/or have increased chemical sensitivities. Health care facilities can manage pests and provide a clean and sanitary environment without the use of toxic pesticides or cleaning products. There are safer, effective methods of controlling pests and cleaning the environment that can improve indoor air quality and will not harm the health of workers, patients and the public.
Several comprehensive reports are available (See Key documents.)
Systemic Review of Pesticide Human Health Effects
A comprehensive review of research by the Ontario College of Family Physicians on the effects of pesticides on humans and implications for family physicians. (2004)
Healthy Hospitals: Controlling Pests Without Harmful Pesticides
A joint report from Healthcare Without Harm and Beyond Pesticides details the results of a survey of hospital pesticide use and provides guidance on safer pest management (2003)
Other resources provide additional guidance (See Links)
- Health Care Without Harm provides more information and additional resources on pesticides and pest management.
- Beyond Pesticides is a non-profit membership organization dedicated to pesticide safety and the adoption of alternative pest management strategies.
- Bio-integral Resource Center is a non-profit offering insight, experience, and leadership in the development and communication of least-toxic, sustainable, and environmentally sound Integrated Pest Management (IPM) methods.
Major resources reviewing cleaning chemicals include the following. (See Key Documents.)
Cleaning for Health: Products and Practices for a Safer Indoor
From INFORM Inc. A guide to environmentally preferable cleaning products and methods, including model specifications (2002).
- Greening Your Purchases of Cleaning Products: A Guide to Federal Purchasers,
A purchasing guide from the US EPA's Environmentally Preferable Purchasing program. More purchasing resources can be found at http://www.epa.gov/epp/pubs/products/cleaning.htm. For more information about EPA's EPP programs' history, tools, and resources, visit http://www.epa.gov/epp/index.htm
Cleaning in Healthcare Facilities:
Reducing human health effects and environmental impacts (2009)
A project of the Lowell Center for Sustainable Production, University of Massachusetts Lowell commissioned by Health Care Without Harm
Cleaning Chemical Use in Hospitals (2004)
A fact sheet from Health Care Without Harm
- 10 Reasons to Use Microfiber Mopping (2003)
A fact sheet from the Sustainable Hospitals Project, a project of the Lowell Center for Sustainable Production, University of Massachusetts Lowell
Using Microfiber Mops in Hospitals (2002)
A fact sheet from EPA on best practices for health care facilities
Other resources for clean chemical information include the following (See Links)
- Environmental Preferable Cleaning Products: State of Vermont
- Integrated Pest Management Contract: State of Massachusetts
- Health Care Without Harm
Many organizations have found that setting up a specific EPP team has enhanced their efforts to initiate and maintain such a program. A discussion of designing such teams, and other tools and strategies for effective action, may be found in resources such as Practice Greenhealth.
Three tools to assist with product identification and selection:
Health Care Environmental Purchasing Tool (HCEPT)
to assist with purchasing decisions and product selection
Premier's EPP Checklist
for healthcare organizations and manufacturers to assess the environmental friendliness of their products
Premier's Resilient Flooring EPP Criteria Sample Tool
Questionnaire for collecting specific information regarding the manufacture, installation, use and resource conservation issues for resilient flooring products.
Resilient flooring and chemical hazards
Brochure analyzes resilient flooring, evaluating potential health impacts of vinyl flooring and the leading alternatives - synthetic rubber, polyolefin and linoleum currently in the health care marketplace.
Premier is committed to working with its members to define what environmentally preferable purchasing means. In addition, Premier will assist its members in identifying environmentally preferable products under contract to meet national or federal requirements. The complete statement of Premier's position on EPP may be downloaded.