WASTE MINIMISATION

in the hospitals

by

HAFIZAH HASAN

THE OUTLINE

Introduction

Steps to Start Minimising Waste

UK Approach Towards Waste Minimisation

in the Hospitals

Making Waste Minimisation Works

Conclusion

INTRODUCTION

INTRODUCTION
Why bother?

All organisations produce waste - even small ones

But what is waste? (Figure 1)

Do you know how much waste is really costing your

organisation?
In the UK, many organisations underestimate how much
waste is costing (Envirowise, 2008; Envirowise, 2004):
Typically 4 - 5% of turnover; can be as high as 10%

The true cost of waste is not limited to that for

disposal (Figure 2):
Inefficient use of raw materials, energy and
water, off-specification products, waste disposal,
waste treatment and wasted effort

Can be 5 - 20 times more than the cost of disposal

Source: Envirowise (2008), Measuring to Manage: a How-To Guide, p. 2.

Figure 2: The true cost of waste.

Source: Envirowise (2002b), Finding Hidden Profits: 200 Tips for Reducing
Waste, p. 40.

Figure 1: 121 euphemisms for waste.

INTRODUCTION
Where are we now?

At the bottom: organisations

for which waste is not
recognised as an issue

At the top: those which have

eliminated waste rigorously at
all stages in their processes
Most organisations are stuck
somewhere in the middle
Waste has become an issue
but the benefits are not being
realised

Source: Envirowise (2002b), Finding Hidden Profits: 200 Tips for Reducing
Waste, p. 5.

Figure 3: The stairway to zero waste.

INTRODUCTION
But how?

We cannot stop producing waste but we can change (Envirowise, 2008):

how much we produce
How we manage it
what we do with it
Applies to both waste and the resources we use
Implementing simple no-cost and low-cost measures to use resources more efficiently and
reduce waste can (Envirowise, 2004):
reduce waste costs: up to 1% of turnover or some RM6,000/employee
cut water and effluent bills: up to 50%
reduce energy bills: up to 20%
improve environmental performance and public image
Waste minimisation is best regarded as an on-going process where a systematic approach
leads to continual improvement.

STEPS TO START
MINIMISING WASTE

STEPS TO START MINIMISING WASTE

Source: Envirowise (2002), Measuring to Manage: How Reducing Waste Can Unlock Increased Profits, nd.

Figure 4: Key steps for a systematic approach to reducing waste.

STEPS TO MINIMISING WASTE

STEP 1: Accounting for waste

Identify how much waste is generating

and the costs involved

Produce a simple list of resources, raw

materials and utilities used and kinds of
waste generated in the processes
Assess key cost areas
Refer to Envirowise (2008) and Envirowise
(2004) for guidelines preparation

INITIAL
PERFORMANCE
BASELINE
As an indicator against which to
measure the future progress

STEPS TO MINIMISING WASTE

STEP 2: Comparing your performance

Compare performance with other hospitals or healthcare facilities

Refer to Envirowise (2004) for guidelines preparation [involved in STEP 1]

STEPS TO MINIMISING WASTE

STEP 3: Identifying waste minimisation
opportunities

Identify the key areas in which to take action

To help gaining more detail about where waste is occuring:

Needs to understand what is involved at each stage of the process or processes

undertaken by the organisation
Walk around the site looking for areas where waste is being generated
Talk to key personnel
Develop a rough plan of ideas to take to senior management by using this
practical information

Refer to Envirowise (1999) for guidelines preparation

STEPS TO MINIMISING WASTE

STEP 4: Commitment to action

Present the case to senior management:

Convince them of the potential cost benefits of reducing waste

Obtain their commitment to providing the necessary resources for implementing
a waste minimisation Action Plan

Start building a team and holding brainstorming sessions with staff to

generate ideas for ways to improve performance and competitiveness
Refer to Environmental Technology Best Practice Programme (1996) for
guidelines preparation

STEPS TO MINIMISING WASTE

STEP 5: Taking action to reduce waste

Take the rough plan and turn it into an Action Plan

Start by identifying obvious areas of waste reduction where immediate
and substantial savings can be achieved by implementing no-cost and
low-cost measures
Make sure the Action Plan is agreed, written and recorded
Use it to take action and start to achieve cost savings and
environmental benefits
Refer to Envirowise (2002b) for guidelines preparation

STEPS TO MINIMISING WASTE

STEP 6: Recognising success and
maintaining momentum

Once the Action Plan have been implemented and savings have been achieved, return to
the original performance baseline assessment and measure the progress
It should be easy to identify the cost savings

Feed back successes and achievements to senior management and staff in order to
maintain motivation and enthusiasm for the plan
This is important for continued waste reduction in the organisation [brief details in the
RECOMMENDED ACTIONS]

Waste reduction is an on-going process

The basis for a systematic approach to continuous improvement
Progress should be reviewed at regular intervals and the targets and Action Plan revised
accordingly
Continue to compare the performance with that of other competitors
Even if the performance matches that of the most efficient organisations, there may still be
room for improvement and additional cost savings

UK APPROACH TOWARDS
WASTE MINIMISATION
IN THE HOSPITALS

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Potential environmental and financial benefits

Introduction

UK government & British Medical Association

Published strategies for greener healthcare 1, 2

An audit of anaesthetic waste at their hospitals:

Although recycling has potential environmental and financial benefits, it is

hampered by:

1
2

About 40% of all waste was potentially recyclable paper, card, plastic, and glass
Only 4% by weight of sharps bin contents was true sharp waste

Convenience
Technology
Lack of knowledge
Concerns about environmental safety
Statutory regulation

NHS Sustainable Development Unit. Saving carbon, improving health: a carbon reduction strategy for the NHS in England. 2008.
British Medical Association. Health professionalstaking action on climate change. 2008.

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Waste management in the NHS

The UK:

Generates 100m tonnes of solid waste each year

85% of which ends up in landfill sites in England and Wales

These sites are reaching capacity and have been linked with environmental and health
problems

An alternative: incineration

Its use is limited according to the EU WID 2000/76/EC to minimise the negative environmental
effect of noxious and other emissions

Less than 10% of total NHS waste is recycled

A comprehensive, coordinated approach to NHS waste management could
have both financial and environmental benefits - a reduction in surface and
deep landfill, incineration, manufacturing waste, and total energy
expenditure

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Waste management in the NHS

In 2005/6, the NHS:

Produced 408,218 tonnes of waste

By comparison to countries which historically have a greater cultural, political and

statutory commitment to waste minimisation and recycling

5.5 kg of waste/patient/day
29% (118,383 tonnes) clinical waste
Spent nearly 73m (80m; $103m) on its disposal

France: 1.9 kg/patient/day

Germany: 0.4 kg/patient/day

Over the past 5-10 years, concerns about the risk of prion3 transmission and
sterility:

Led to large increases the amount of anaesthetic packaging and the use of
disposable devices

Most of the waste is incinerated, although some of it is potentially recyclable

A prion is an infectious agent that is composed primarily of protein. To date, all such agents that have been discovered propagate by transmitting a mis-folded protein state;
as with viruses the protein itself does not self-replicate on its own, rather it induces existing polypeptides in the host organism to take on the rogue form. The mis-folded form of
the prion protein has been implicated in a number of diseases in a variety of mammal (e.g. Bovine Spongiform Encephalopathy (BSE) aka "mad cow disease") in cattle and
Creutzfeldt-Jakob Disease (CJD) in humans). All known prion diseases affect the structure of the brain or other neural tissue, and all are currently untreatable and are always
fatal [URL 1].

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Waste management in the NHS

A two week audit of the waste produced by six operating theatres at the Royal
Sussex County Hospital, Brighton:

Striking results: 540 kg of sharps and non-sharps anaesthetic waste was produced (about
2,300 kg/theatre/year)
About 40%: potentially

Sharps waste accounted for 54 kg: analysis of the contents of five sharps bins

recyclable paper, card, plastic and glass

Only 4% by weight was true sharp waste (needles and broken glass)
57% was glass
39% was other (packaging, plastic, metal and fluid)
A similar analysis in 1998: 14% of waste was sharps

Recycling anaesthetic waste across the trust would save:

Estimated 21,000/year (about 30% of the hospitals annual budget for disposing of
clinical waste)

The sum could increase due to the expected rise of the waste disposal and landfill costs

Estimated 7m operations are performed annually in England and Wales

Their data suggests that clinical anaesthesia accounts for 10,000 20,000 tonnes of NHS
solid waste annually

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Barriers to improvements

Social attitudes

Higher rates of recycling rely on healthcare workers doing

the initial segregation of waste

However, staff are often unsure what can be recycled

safely or may believe that all clinical waste is
contaminated

Staff education is therefore important

Institutional influences, particularly the priority given to waste

management, also affect staff behaviour

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Barriers to improvements

Logistical and institutional barriers

Waste management systems in theatre suites need to be

redesigned to facilitate recycling

Example:

Different receptacles are required to segregate waste appropriately

Should be ergonomically arranged so that the default waste disposal
method is to recycle

Education of hospital waste managers should encourage them to

introduce recycling measures that comply with waste
management law, without exposing the hospital or themselves to
legal liability

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Barriers to improvements

Legal barriers

The disposal of clinical waste (waste that consists wholly or partly of human or animal tissue, blood or other
body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles, or other sharp

is regulated by a number of complex statutes and statutory regulations

that fall broadly into three categories: environment and waste legislation, health and
safety legislation, and transport legislation
instruments)

All waste is now classified according to the European WFD (incorporated into law as
the Hazardous Waste (England and Wales) Regulations 2005)

Recently published guidance provides a framework for hospitals to train staff in

waste segregation at source, for more environmentally sound disposal

Essentially, medical waste is non-hazardous (and therefore potentially recyclable) if:

It is has not come into contact with a patient or their secretions

Has not been in contact with a medicine

Uncontaminated packaging waste and easily recyclable materials (paper, glass,

metals) are subject to less stringent legal controls and are therefore recyclable

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Decreasing waste in clinical practice

Clinicians have an important role in reducing hospital waste and should not be
discouraged by either lack of knowledge or the threat of legal liability
The fundamental principles of decreasing waste at work are the same as those at home:

Be responsible, reduce, reuse and recycle

For each of these targets, input is required from a number of actors: hospital trusts, hospital
employees, patients and drug and medical instrument companies

Responsibility

Concerns about safety, which have restricted recycling initiatives, might be countered by
hospital staff acting as guarantors for the contents of disposed waste, by signing labelled
bags of recycling waste before disposal

Reduce

The most efficient method to reduce waste is to decrease the amount of resource used in the
first instance

Example: single wrapping of sterilised instruments has been found to be as effective as double
wrapping in preventing bacterial contamination

The NHS, which has considerable financial power concerning drug and equipment purchase,
could insist that companies reconsider their packaging strategies without compromising
product sterility or performance

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Decreasing waste in clinical practice

Reuse
Continuing concerns about cross infection have resulted in the phasing out of reusable
anaesthetic devices in favour of single use, disposable items

It remains unclear whether:

The risk of infection is real or perceived, particularly with regard to prion transmission
What is required is more effective sterilisation procedures rather than disposable equipment

Reusing single use devices has been shown to save money, provided:
No adverse events occur
Would reduce packaging and clinical waste

However, there could be legal developments:

Statement from the Medicines and Healthcare Products Regulatory Agency: Anyone who
reprocesses or reuses a device intended by the manufacturer for use on a single occasion,
bears full responsibility for its safety and effectiveness, exposing doctors and hospitals to civil
liability

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Decreasing waste in clinical practice

Recycling
The process of transforming one item into another usable item: less energy efficient than
reduction or reuse because it takes energy to transport and transform materials

However, given the sterility concerns about reducing packaging and reusing equipment,
recycling is important for healthcare waste

The initial segregation of waste is essential because medical waste cannot be recycled
once it is contaminated

All cardboard and paper waste is potentially recyclable and should be separated at source
and flat packed for transfer

About 30% of theatre waste is plastic, mainly from packaging

Recycling plastic:
Expensive, but plastic has a high recycling potential and financial savings are possible
Reduces the demand for oil (4% of annual global oil use is as a raw material for plastic; another 4%
provides energy for the production process)

Reduces the hazardous waste pollutants produced by de novo plastic production

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Decreasing waste in clinical practice

Recycling
The recycling of glass is more advanced than that of other materials:
2007: the UK recycled 57% of the glass it used
Glass can be recycled an unlimited number of times without adversely affecting quality
Reduced quarrying and transport costs and lower furnace temperatures = for every tonne of
recycled glass produced, 1.2 tonnes of raw materials are conserved, compared with the
production of virgin glass
Glass products used in anaesthesia are contaminated with hazardous materials (drugs)
Nevertheless, contaminated glass may be safe to recycle because of the high furnace temperatures
(1,500C) used in the recycling process
In practice, recycling of anaesthetic bottles has been found to be achievable and financially viable

An integrated, sustainable approach to managing hospital waste involving improved disposal

systems, waste reduction, recycling and staff training, has financial and environmental benefits

Example: Cornwall NHS Trust reduced domestic bag and clinical waste by about 15% and
estimates that waste could be reduced by up to 30%, with a similar percentage saving in
disposal costs

Source: Analysis (2009), Coming round to recycling, p. 747.

Figure 5: Some green actions in the

hospitals and healthcare facilities.

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Rethink, research

Suggestion: considering two further Rs in any future process of NHS waste management
rethinking and research
Rethinking is required at several levels:
Nationally: to reconsider some of the stringent statutes that inhibit individuals and organisations
from innovating in this area
Hospitals need:
Government support to change current waste management strategies (with major emphasis on waste
reduction and recycling)

To consider, e.g. entering into partnerships with local recycling firms and accepting input from
environmental groups
New NHS hospitals must incorporate recycling facilities
Waste contracts should be given to contractors with the most comprehensive environmental
practices
Professional bodies and medical publishers also have an important role: the BMA and BMJ have
recently highlighted how doctors can fight climate change, but published guidance e.g. from the
royal colleges - would also be welcome

Web based discussion groups and forums allow for the rapid spread of ideas and solutions

UK APPROACH TOWARDS WASTE MINIMISATION

IN THE HOSPITALS
Rethink, research

Waste management is a relatively new and potentially rewarding field of healthcare research
Example: in anaesthesia, research topics might include:
Redesign of equipment and packaging
Investigation into new sterilisation techniques and their environmental impact
Re-evaluation of airway equipment infectivity
Calculations of energy balance (the energy costs of reuse or recycling compared with single use or incineration)
Investigation of the by-products of incineration
The ergonomic redesign of sharps bins, waste receptacles and anaesthetic rooms
Medicine has a considerable environmental impact
Increases in landfill and incineration costs, coinciding with financial recycling incentives, and
additional to our social and moral responsibilities, should encourage clinicians to improve clinical
waste management, as long as the quality of patient care remains unaffected
Over the past 60 years, the NHS has set a worldwide example in free high quality healthcare at
the point of contact
It should continue to set an example by developing and integrating a national medical waste
management policy, in order to reduce its environmental impact

MAKING WASTE
MINIMISATION WORKS

MAKING WASTE MINIMISATION WORKS

Implications

Implementing a waste minimisation programme may means:

Thus, time required to explain waste

minimisation and involve people in
the programme will differ
Different emphasis depending on the
business:

Major changes to some organisations established operating procedures

Other businesses may be used to significant change and a succession of improvement initiatives

Systems driven
People driven
Combination

The ideal solution: to maximise

the benefit by adopting a combined
systems and people approach

Source: Environmental Technology Best Practice Programme (1996), Saving Money Through
Waste Minimisation: Teams and Champions, p. 9.

Figure 6: Implications of management style for a waste

minimisation programme.

MAKING WASTE MINIMISATION WORKS

Implications

Current management systems are important when considering how to introduce

waste minimisation
Example: in a company with a TQM programme, waste minimisation can be seen as
a logical extension of the process to address further improvements

Source: Environmental Technology Best Practice

Programme (1996), Saving Money Through Waste
Minimisation: Teams and Champions, p. 8.

Figure 7: The links between selected

management initiatives and waste
minimisation.

MAKING WASTE MINIMISATION WORKS

Recommended Actions

Establish top management commitment for waste minimisation

Establish guidelines for waste audit in hospitals and healthcare facilities

Appoint waste minimisation champion to:

Undergo the waste audit activities:

review the true cost of waste

motivate the workforce to reduce waste
Financial aspects
Understanding on waste generation processes and measure as necessary by staff at all levels
Constructing the Waste Model
Produce the Action Plan

Report and feedback to the top management:

Statement of losses (e.g. costs, materials and wastes) by product range / process /
department, etc
Statement of what can be achieved (e.g. action plans, responsibilities, monitoring, costs and
benefits)

CONCLUSION

Proven benefits
of waste minimisation
hospitals in the developed countries

Require thorough efforts

from all involving parties
effective waste minimisation

REFERENCES

Analysis (2009), Coming round to recycling. 28 March 2009, BMJ, Volume 338, pp. 746-748.
Envirowise (2008), Measuring to Manage: a How-To Guide. October 2008 (Revised), Glengarnock
Technology Centre, Envirowise. Available online in pdf. format at www.envirowise.gov.uk
Envirowise (2004), Measuring to Manage: The Key to Reducing Waste Costs. March 2004, Harwell
International Business Centre, Envirowise. Available online in pdf. format at www.envirowise.gov.uk
Envirowise (2002a), Measuring to Manage: How Reducing Waste Can Unlock Increased Profits. March 2002,
Harwell International Business Centre, Envirowise. Available online in pdf. format at www.envirowise.gov.uk
Envirowise (2002b), Finding Hidden Profits: 200 Tips for Reducing Waste. Revised August 2002, Harwell International
Business Centre, Envirowise.

Envirowise (1999), Waste Mapping: Your Route to More Profit. December 1999, Environmental Technology Best
Practice Programme, Envirowise. Available online in pdf. format at www.envirowise.gov.uk
Environmental Technology Best Practice Programme (1996), Saving Money Through Waste Minimisation: Teams
and Champions. March 1996, Environmental Technology Best Practice Programme.
http://en.wikipedia.org/wiki/Prion. Accessed on 4 January 2010 [URL 1].

HAFIZAH BINTI HASAN

Principal Assistant Director,
Engineering Services Division,
Ministry of Health Malaysia.
03-8883 3907 (O)
hafizahh@moh.gov.my