138-805 / Implementation of environmental management systems in hospitals according to UNE EN ISO 14001:2004

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Madrid Health Service


Quality indicators
Quality indicators

GOP Description
Implementation level
Clinical settings
The project was implemented in 36 hospitals of Madrid Health Service, at different levels and service portfolio, which showed great heterogeneity in terms of the stages of implementation of Environmental Management Systems.
The project’s objectives are: a) To promote and support the implementation of environmental management systems, b) Promote environmental indicators homogeneous c) Strengthening the activities of the institution its commitment to the environment.
The target population of the project is all professionals of 36 hospitals, as well as users of these facilities as part of our commitment to the environment.
This project is aimed at the implementation of Environmental Management Systems according to the UNE EN ISO 14001:2004.
The results are based on different actions and the information obtained through a broad and comprehensive environmental review questionnaire, aimed at all hospitals from Madrid Health Service (year 2011).
This provided a situation analysis about the specific environmental management in these centers, and several working groups were established according to the different stages of development. For each group specific actions were defined and they were provided with tools and ongoing technical advice. This has led to progress in the implementation process and the unification of environmental indicators.A common methodology framework was applied to implement an Environmental Management System under UNE EN ISO 14001:2004. Four work groups were constituted, which involved experts from hospitals (n= 36) from Madrid Health Service at its implementation stage.We have developed a systematic technical advice as required by the deployment group and specific work tools. Also institutional support has been provided through various reinforcing actions: information, documentation, environmental awareness, and establishment of technical committees, such as those on “Environmental Indicators” and “Environmental Management Technical Committee.”
Timeframe implementation
The estimated time for the proper implementation of this project, in accordance with established work schedule, is two to three years.
Implementation tools available
The main tools available for this project are: databases initial review environmental documentation (rules, procedures, records, instructions, etc. Of environmental management systems) in different media (intranet, paper, electronic); presentations develop training, tabs and records of environmental indicators.
Implementation cost
Management team (environmental management committee): 2 hours per month
Environmental manager: 8 hours per week
Method used to measure the results
To measure the results we take into account:
a) Compliance with annual targets set by Madrid Health Service for the 36 hospitals.
b) The comparison between the baseline and the stages of implementation of the Environmental Management System and the formulation of environmental indicators.
The results have been: a) The percentage of certified hospitals in the UNE EN ISO 14001:2004 has increased from 22.86% to 31.43%; b) 31, 43% of hospitals that were initial stage have advanced stage towards the implementation of the system, c) Agreement was reached ten key environmental indicators, unifying its formulation, on initial variability eighteen formulations for the same indicator, d) institutional support actions (intranet corporate, technical committees and creating environmental awareness) have contributed to the results.
Analysis of the results
There is a major step forward in the implementation of environmental management systems. We need to consider the different types of schools, their heterogeneity in the development of environmental management, and lack of human and financial resources.
It is essential institutional commitment promoter element of all actions, to display information tools, training, measurement, and monitoring, which should be accessible to schools and eminently practical.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
– Staff training
– Technical qualifications and profile of responsible environmental management.
Describe the strategies used to overcome the barriers (If needed)
– Development of training activities in the centers, and availability intranet.
– We have developed a technical assistance to all hospitals, providing concrete tools and practical work.
– Have been named responsible for environmental management in the 36 hospitals.
Other information
Other information about the GOP that you would like to add (Link or attached document)
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