ENVIRONMENTAL AUDITING Environmental Auditing in Hospitals: First Results in a University Hospital MARKUS DETTENKOFER* KLAUS KUEMMERER ARMIN SCHUSTER WILLY MUELLER MARTIN MUEHLICH MARTIN SCHERRER FRANZ D. DASCHNER Institute for Environmental Medicine and Hospital Epidemiology University Hospital, Freiburg Hugstetter Str. 55 79106 Freiburg, Germany ABSTRACT / While medical audit in infection control today is one important element in the quality assurance of health care, environmental auditing, approved in 1993 by the Coun- cil of the European Communities for the industrial sector, so far has not been used as a tool to control and reduce envi- ronmental pollution caused by medical care. The aim of this study was to investigate whether environmental auditing ac- cording to the European Eco-Management and Audit Scheme (EMAS) can be implemented in hospitals as a pro- cess of improvement in protection of the environment. In a prior publication the methodological issues and the organi- zational steps that had to be taken were described. An envi- ronmental review of the activities of the Freiburg University Hospital and an ecoanalysis of the input and output were performed. The results of this analysis, published in an envi- ronmental report, provide a fundamental data set for the consumption of energy, water, materials, and the burdens of major pollutants and waste. Regarding the organizational structure of the hospital, the first steps towards an integrat- ing environmental management system as demanded by EMAS could be taken. Beside supporting advantages, e.g., improvement of environmental safety, public image and staff contentment, and potential economic benefits such as less cost to be paid for energy and water consumption, there are important restrictions of environmental auditing in hospitals. Examples are the lack of basic environmental data, staff mo- tivation (especially of physicians), cooperation of the organi- zational substructures, and funds for prefinancing urgently needed improvements in ecology. Based on the study find- ings, a textbook on environmental auditing in hospitals, in- cluding checklists covering all important environmental ob- jectives, has been published to support hospitals in their efforts to achieve an optimized and sustainable practice of providing health care. Environmental auditing was approved in 1993 bythe Council of the European Communities (Council Regu- lation EEC No. 1836/ 93). The Eco-Management and Audit Scheme (EMAS) is a voluntary environmental policyinstrument that introduces more transparencyin the relationship between enterprises, institutions, and the public. Participation and registration according to EMAS have been hitherto limited to companies in the industrial sector. The aim of our studywas to investigate whether this tool can also be implemented in hospitals to start a continuousprocessofimprovement in environ- mental protection, which should also be cost effective. In this paper the first results are reported, including a critical analysis and discussion of the studyoutcome. Methods The study hospital (University Hospital, Freiburg— UHF) is one of the biggest German hospitals with 1709 hospital beds, 53,709 patients admitted, and 5493 em- ployees in 1996. Since the 1980s several steps have been made towards a more environmentallyoriented organi- zation, e.g., regarding handling of waste and disinfec- tion policy(Daschner 1991). Nevertheless, manyorgani- zational and practical problems remained to be solved. The EEC regulation and general methodological aspects of environmental auditing, the adjustments necessary to apply it to hospitals, and the first actions taken in case of the UHF have been described elsewhere (Dettenkofer and others 1997). The steps required in order to participate in the EEC Regulation No. 1836/ 93 consist of: (1) environmental policy, (2) initial review, (3) environmentalprogram,(4) environmentalmanage- ment system, (5) environmental statement, and (6) first validation or auditing and validation. Amajor objective of the studywas the assessment and KEY WORDS: Audit; Ecoanalysis; EMAS; Environmental manage- ment; Environmental pollution; Hospital ecology; Infec- tion control; ISO 14001 *Author to whom correspondence should be addressed. Environmental Management Vol. 25, No. 1, pp. 105–113  2000 Springer-Verlag New York Inc.