SUMMARY

Climate change has been described as the greatest health threat facing humanity, according to the World Health Organization (WHO). Healthcare systems are accountable for approximately 4.4% of global net emissions, contributing significantly to climate change. With U.S. healthcare accounting for a quarter of global net healthcare emissions, reducing emissions in U.S. healthcare systems can have a positive impact on climate change and human health. As a cutting-edge technology company based in the UK, Ecomedic is focused on assisting healthcare systems to achieve net zero goals by designing emission detection systems, conducting life cycle assessments of medical products, and offering advice on emission reduction strategies.

Ecomedic sought to learn the current landscape of sustainability regulations in the US and Canada, with a focus on federal and state sustainability regulations impacting hospitals, requirements for the measurement and reporting of emissions by hospitals, the methodologies used by hospitals to measure emissions, the types of emissions that are to be reported and guidelines associated with them, emissions reporting requirements for medical suppliers, evaluation of any sustainability plans laid out by hospitals, regulations impacting the materials used in medical devices, any sourcing restrictions placed on hospitals by sustainability regulations and how they navigate these restrictions. For Group 2, the scope of this project has been defined within the Western US States of California, Colorado, and Arizona.

At the federal level, President Biden’s Federal Sustainability Plan (Executive Order 14057) has set sustainability goals and mandated federal health systems (e.g. Veterans Health Administration) to reduce their emissions, and the Executive Order 13693 has mandated them to calculate and report their Scope 1, Scope 2, and Scope 3 emissions. Healthcare systems outside the federal jurisdiction are mandated by relevant State regulations to reduce emissions and report emission inventories or have voluntarily undertaken sustainability goals and reporting mechanisms. Key nationwide voluntary emissions reporting systems include EPA’s Energy Star Program and the Leadership in Energy and Environmental Design (LEED) Certification Program.

The Health Sector Climate Pledge is a sustainability initiative created by the White House and the

U.S. Department of Health and Services (HHS) that healthcare systems may join voluntarily to reduce and report emissions. Also notable is the Joint Commission’s Sustainable Healthcare Certification (SHC) Program. Key State-level sustainability regulations include California’s

Senate Bill (SB) 253, SB 261, Colorado’s House Bill (HB) 21-1286, HB 22-1244, HB 22-1355, and Article 2 of the Arizona Administrative Code.

Executive Order 13693 (federal health systems) and SB 253 (California) require the reporting of all three scopes of emissions; however, other State regulations are largely focused on the accounting of Scope 1 and Scope 2 emissions. Hospitals in the U.S. primarily use the activity- based methodology or the hybrid methodology in the calculation of emissions based on the reporting requirements. GHG Protocol Standards serve as guidelines for the estimation of each emission scope, including the Corporate Accounting and Reporting Standard, the Scope 2 Guidance, and the Corporate Value Chain (Scope 3) Accounting and Reporting Standard.

Medical suppliers are subject to federal and state sustainability regulations to reduce and report emissions. Some of the noteworthy Sustainability Plans include that of Kaiser Permanente, UCLA Health, Boulder Community Health (BCH), and Northern Arizona Healthcare (NAH). Medical devices are regulated under the federal authority of the FDA, under which material restrictions are placed only in the context of biocompatibility. In California, the RoHS law is responsible for restricting the use of hazardous materials in medical devices. Federal health systems are subject to sourcing restrictions under Executive Order 14057 and Executive Order 13693. Hospitals outside the federal system have adopted voluntary sourcing restrictions based on their own sustainability goals (Kaiser Permanente, UCLA Health).

The current landscape of sustainability regulations in the US shows a trend where healthcare systems are increasingly being held accountable for their impact on net greenhouse gas emissions. One of the drawbacks of the current landscape is that it does not hold all U.S. healthcare systems to the same emission reduction and reporting requirements due to the fragmented applicability of federal and state regulations. The current sustainability regulations provide a foundation for the future, where all healthcare systems work together to reduce their emissions.

Federal Regulations

The Biden-Harris Administration has established ambitious sustainability objectives for the United States, aiming to halve greenhouse gas emissions by 2030 and achieve net-zero emissions before 2050 (Sampath, 2022)44. However, U.S. healthcare currently contributes approximately 8.5% of

domestic greenhouse gas emissions and a quarter of global healthcare emissions, with hospital care being the largest emitter, accounting for 35% of U.S. healthcare emissions (Eckelman, 2020)18.

Federal Sustainability Plan

President Biden's Executive Order 14057, known as the Federal Sustainability Plan, signed on December 8, 2021, mandates federal health systems to reduce emissions. However, reporting greenhouse gas emissions is voluntary for healthcare organizations outside the federal system (Singh, 2022)46.

Health Sector Climate Pledge

On April 22, 2022, the U.S. Department of Health and Human Services (HHS) and the White House urged healthcare stakeholders to address climate change by joining the White House/HHS Health Sector Climate Pledge. The pledge includes objectives such as reducing emissions by 50% by 2030, achieving net-zero emissions by 2050, publicly reporting progress, conducting Scope 3 emissions inventories, and developing climate resilience plans (Sampath, 2022)44. By November 16, 2023, 133 organizations representing 900 hospitals had signed the pledge (HHS, 2024)29.

Additional Climate Goals

The Biden-Harris Administration is advancing further climate goals through the 2022 Inflation Reduction Act. Early adopters in healthcare decarbonization include Kaiser Permanente, Veterans’ Health Administration, The Department of Veterans Affairs (VA), and the University of California Health System (UC Health) (Lakatos, 2023)31.

Sustainable Healthcare Certification (SHC) Program

On September 18, 2023, The Joint Commission introduced a voluntary Sustainable Healthcare Certification (SHC) program for U.S. hospitals, effective from January 1, 2024. This program aims to recognize and promote hospitals' commitment to environmental sustainability efforts (Lyons, 2023)32.

Relevant Organizations and Federal Regulations

Key federal regulations and initiatives relevant to sustainability in hospitals include those by the Environmental Protection Agency (EPA), such as standards under the Clean Air Act, Clean Water Act, and Resource Conservation and Recovery Act (RCRA), among others (Council, 2011)14. Additionally, initiatives like Energy Star and green building programs promote energy efficiency

and sustainability in hospitals. Hospitals may also set targets for sustainability, including carbon neutrality, energy efficiency, renewable energy adoption, waste reduction and recycling goals.

B.        California State Regulations

California leads environmental projects in the US. The state has undertaken several policies to promote sustainability in health care facilities, including hospitals. Some of these regulations might cover energy efficiency, conservation on water usage, waste management and emission reduction. The California Department of Public Health (CDPH) and California Environmental Protection Agency (CalEPA) impose specific mandates on California’s healthcare sector that are also liable to state environmental laws and regulations (Novotny)35.

California Energy Commission Standards

The California Energy Commission (CEC)’s statewide 2022 Building Energy Efficiency Standards (Energy Code) update follows 48 California cities and counties that have adopted local energy codes that transition new homes and buildings away from using fossil fuels. The new state building code sets minimum efficiency standards for walls, windows, and heating/cooling equipment. The update with the greatest impact is the shift to electric heat pump space and water heating, which will save at least three-quarters of greenhouse gas emissions when compared to the most efficient traditional gas furnaces (Brightly, 2023)12.

California State Regulations on Hospital Sustainability

California has been actively implementing regulations and legislation to promote sustainability in hospitals, focusing on environmental practices and climate reporting. Here is a comprehensive list of the latest state regulations related to sustainability in hospitals in California:

a. The Joint Commission's Proposed Environmental Sustainability Requirements

The Joint Commission has proposed new accreditation standards that would mandate hospitals and critical access hospitals to reduce greenhouse gas emissions (Hoffman, 2023)30.

b.  California Sustainable Policy and Best Practices Manual

The Department of General Services (DGS) encourages Lessors to implement measures from the California Green Building Standards Code (CALGreen) related to indoor environmental quality for new or renegotiated leases (Dgs.ca.gov.)16.

c.  California Department of Public Health Regulations

The California Department of Public Health enforces various codes, statutes, and regulations related to sustainability in hospitals (Department of Public Health, n.d.)15.

d. Compliance with Organic Waste Requirements

Hospitals must comply with regulations concerning organic waste reduction requirements, emphasizing the need for proper waste management practices (Baker, 2023)3.

e.  New Legislation on Climate Reporting

Recent legislation includes Senate Bill (SB) 253 'Climate Corporate Data Accountability Act' and SB 261 'Greenhouse gases: climate-related financial risk', which expand the disclosure requirements for companies operating in California regarding greenhouse gas emissions and climate-related financial risks (Carroll, 2023)5.

These regulations highlight California's commitment to promoting sustainability in hospitals through stringent environmental standards, waste management practices, and enhanced climate reporting requirements.

Colorado State Regulations

Colorado has also made efforts towards promoting sustainability in health care premises. Although the exact rules may differ, hospitals in Colorado are recommended to engage in sustainability as per state environmental objectives. Moreover, Colorado hospitals could engage in voluntary sustainability programs or initiatives run by state agencies, non-profit organizations, and industry associations.

Regulatory Oversight by CDPHE

The Colorado Department of Public Health and Environment (CDPHE) Health Facilities and Emergency Medical Services Division provides oversight on a number of regulatory standards related to health care.

Colorado Climate Change Program

The Colorado Department of Public Health and Environment (CDPHE) created the Climate Change Program in December 2019 to lead an ambitious effort to reduce greenhouse gas emissions to protect a livable climate. The Program is responsible for conducting the statewide Greenhouse Gas Inventory, developing regulations to reduce greenhouse gas emissions, and gathering input

from stakeholders and communities to shape an equitable and effective response to climate change in Colorado (CDPHE, EPA Mandatory Reporting Rule., n.d.)8.

Colorado Hospital Association (CHA)

Hospitals are facing a plethora of environmental regulations as Governor Polis has made addressing climate change a top priority for his administration. Among the ones CHA is tracking are House Bill (HB) 21-1286 (Energy Performance for Buildings), HB 22-1244 (Public Protections from Toxic Air Contaminants), and HB 22-1355 (Producer Responsibility Program for Recycling). Additionally, CDPHE and the Environmental Protection Agency (EPA) are working to re-classify ozone standards with implications for air permits (CHA, 2023)10.

State Legislation on Climate Goals

Several new bills have been passed by the Colorado legislature on the state’s transition to a low- carbon economy. These new laws help ensure Colorado continues making progress toward achieving its climate goals first laid out in the state’s 2021 Greenhouse Gas (GHG) Pollution Reduction Roadmap. The state’s current action-oriented goal is to reach greenhouse gas emission reduction targets of 26% by 2025, 50% by 2030, and 100% by 2050, compared to 2005 levels. In Senate Bill 23-016, the state legislature clarified that the 2050 target requires net zero emissions and included new interim targets to ensure the state continues to make progress toward the long- term goal. The Polis administration will continue to refine these goals in an updated version of the roadmap, which is currently in development (CDPHE, 2023)7.

Healthcare Sustainability Initiatives

In Colorado, hospitals are actively engaging in sustainability practices to reduce waste and emissions, with notable achievements such as Littleton Adventist Hospital cutting waste by 36% through recycling and reusing materials. Both Children’s Hospital Colorado and UCHealth have dedicated staff for sustainability efforts, tracking waste, and setting annual goals (Sustainability in Health Care., 2023)48.

Opportunities for Collaboration and State Initiatives

Opportunities for collaboration exist through organizations like Practice Greenhealth, which supports environmentally minded health care providers and facilitates climate alliances nationwide. Moreover, the state of Colorado has established the Colorado Healthcare Affordability and Sustainability Enterprise to address healthcare affordability and sustainability issues (Sustainability in Health Care., 2023)48.

Future Research

Colorado's landscape for going green in healthcare emphasizes the importance of hospitals adopting sustainable practices to mitigate future regulatory risks and reduce their environmental impact. The state statutes advise hospitals on potential changes in laws governing medical provision and reimbursement, highlighting the regulatory framework guiding healthcare sustainability efforts in Colorado. Further research is needed to comprehensively understand the current state of sustainability initiatives across Colorado's health care systems and identify opportunities for advancement in this field.

Arizona State Regulations

Arizona integrates state and federal environmental regulations to control sustainability in hospitals. Although there are no specific mandates for hospitals, Arizona encourages the practice to follow federal laws such as the Clean Air Act and Clean Water Act that establishes a green culture, promoting a culture of environmental stewardship (Souder, 1996)47

In Arizona, hospital sustainability regulations are overseen by the Arizona Administrative Code, specifically Article 2 concerning Hospitals. These regulations encompass various aspects of hospital operations and environmental services related to patient care. Arizona Administrative Code R9-10-Article 2 delineates mandates for hospitals, including the necessity for an annually reviewed acuity plan, upkeep of records and documentation, and the appointment of personnel responsible for hospital and environmental services (Sciences, 2013)45.

Sustainability Initiatives

·    The Health and Wellness Village in Northern Arizona underscores sustainability initiatives within its healthcare facility, demonstrating a dedication to environmental stewardship (NAH, 2023)34.

·    The Arizona Department of Health Services underscores the significance of health and wellness for all Arizonans, emphasizing strategic priorities like integrating physical and behavioral health services, advocating for public health, and optimizing effectiveness (Sciences, 2013)45

Transition to Updated Regulations

Transitioning to the Arizona Administrative Rules Document R9-10-Article 10 signifies a move towards updated regulations governing healthcare institutions in Arizona (Sciences, 2013)45.

These regulations highlight the importance of sustainable practices within hospital environments to ensure streamlined operations while prioritizing patient care and environmental stewardship.

Regulations Impacting Medical Suppliers

A.        California

Medical suppliers in California must adhere to stringent regulations regarding emissions reporting and reduction. Senate Bill 253 mandate companies with over $1 billion in annual revenue doing business in the state to disclose greenhouse gas emissions, with reporting starting in 2026. These bills require the annual reporting of Scope 1, 2, and 3 GHG emissions, with penalties for non- compliance. The California Air Resources Board (CARB) oversees the verification of GHG emissions data reports by accredited verification bodies. These regulations aim to enhance transparency regarding GHG emissions and ensure companies are held accountable for their environmental impact (Ghatfield, 2023)25.

B.         Colorado

Industrial sources, fuel suppliers, and electricity importers, including medical suppliers, are subject to the state's Regulation for the Mandatory Reporting of Greenhouse Gas Emissions, which requires them to report their annual GHG emissions to the Colorado Department of Public Health and Environment (CDPHE, 2022)6. The Act on Public Protection from Toxic Air Contaminants also mandates larger stationary air pollution sources to report their emissions of toxic air pollutants, potentially significant sources of emissions from medical suppliers. In addition, the state's building performance standards rule, designed to reduce emissions from large buildings, could affect medical suppliers with large facilities in Colorado.

C.        Arizona

The Emissions Inventory Program of Arizona requires any facility that is required to have a permit, including medical providers, to complete and submit an annual Emissions Inventory Questionnaire to the Arizona Department of Environmental Quality (Emissions Inventories, 2020)19. Vehicle emissions testing is required for vehicles being operated in Maricopa and Pima counties, with the Continuous Testing Program (CTP) pilot providing an innovative approach to smog certification through telematics technology; this could benefit medical providers by making compliance processes simple.

Impact on the Healthcare Supply Chain

Colorado, California, and Arizona laws affect the healthcare supply chain. Medical suppliers must measure and minimize emissions to comply with these requirements, which increases costs. Innovation can result from suppliers investing in sustainable practices and technologies. This sustainability transformation can improve the company's reputation, meet eco-friendly product demand, and open new markets. The company supports healthcare supply chain transparency and environmental care by tracking and reducing emissions. By adjusting to these requirements, suppliers can help healthcare providers meet sustainability targets and fight climate change, making the industry and the globe rich.

Hospital Sustainability Plans and Roadmaps

Several hospitals and healthcare organizations have formulated plans on sustainability to ensure environmental stewardship, public health as well as community welfare. These sustainability plans often cover various initiatives and strategies that would reduce the levels of CO2, efficient use of resources, a focus on renewable energy with good qualitative air and water quality while improving overall environmental performance. Exemplary initiatives have been showcased by several hospital systems in the West US. Discussed below are the noteworthy examples of Kaiser Permanente (California), UCLA Health (California), Boulder Community Health/BCH (Colorado), and Northern Arizona Healthcare (Arizona).

A.        Kaiser Permanente, California

Kaiser Permanente is an American integrated managed care consortium, based in California. Kaiser Permanente works with EPA’s Energy Star Program to achieve Energy Star Certifications. It also works with the U.S. Green Building Council and other green building standards organizations to achieve LEED certifications.

Carbon Neutrality by 2020 (California AB-105)

In 2016, Kaiser Permanente announced its goal to become carbon neutral by 2020. In September 2020, they became the first health care system in the United States to achieve carbon neutral status (Costa, 2020)13. This was achieved in accordance with TheCarbonNeutral Protocol (an annual certification process based on a framework with defined requirements for corporate carbon neutral claims and CarbonNeutral certification) that applies to Scope 1, Scope 2, and Scope 3 emissions (Permanente, Sustainable Procurement, n.d.)38 .

Initiatives

●       Improvement of energy efficiency in its buildings.

●       Installation of on-site solar power.

●       Long-term purchases of new renewable energy generation.

●       Investment in carbon offsets to counter unavoidable emissions.

Net-zero Emissions by 2050

In 2022, Kaiser Permanente announced the goal to reduce emissions by 50% by 2030, and to achieve net-zero emissions by 2050 (Permanente, Sustainable Procurement, n.d.)38.

Strategies

●       Analyzing Scope 1, 2, and 3 emissions for the baseline year 2019, utilizing the Operational Control approach under the GHG Protocol Corporate Standard.

●       Evaluating the feasibility of decarbonizing Scope 3 value chain emissions, as well as continued decarbonization of Scope 1 and Scope 2 operational emissions through clean energy and equipment via third-party analysis.

●       Formation of an emission reduction task force to take action and develop emission reduction strategies.

●       Periodic monitoring of emissions: Annually for Scopes 1 and 2, every three years for Scope 3.

B.         UCLA Health, California

UCLA Health is a health system that comprises of several hospitals and is affiliated with the University of California, Los Angeles. UCLA Health has signed on to the White House Climate Pledge, committing to reporting on greenhouse gas emissions and cutting emissions 50% by 2030 and reach net-zero emissions by 2050

Carbon Neutrality by 2025

As a part of the University of California’s commitment to become carbon neutral by 2025, UCLA Health has developed several strategies to contribute to this goal.

Strategies

●       Analysis of energy sources and generation, followed by energy reduction and efficiency by energy use intensity (EUI) by 2% per year.

●       Adopting green building policies.

●       Mitigating the impacts of operating rooms.

●       Establishing a gaugeable and effective diversity and inclusion process in all procurement activities and increasing the number of small and diverse suppliers in the supplier base.

●       Lowering the impact of employee transportation on the environment.

●       Reducing waste.

Initiatives

●       Reduced EUI by 2.83% since 2020 through energy reduction efforts, decarbonization of energy supply, transitioning to renewable fuels, and installation of solar panels.

●       Adopted LEED as the standard for green building policies.

●       Reduced the use of anesthetic gases implicated in greenhouse gas emissions (desflurane, nitrous oxide), initiated a program for reprocessing single-use medical devices, and recycling operating room waste.

●       Introduced a sourcing process in which 15% of decision criteria and weighted evaluation are based on the potential supplier’s sustainability programs and performance and employing environmentally preferred purchasing of products.

●       Providing alternate transportation options, requiring 4.5% of employees to commute using Zero Emission Vehicles (ZEVs) by 2025 and 30% by 2050, expanding electric vehicle (EV) charger stations, introducing telework policies, and procuring clean fleet vehicles.

●       Managing all waste streams, promoting policies that reduce overall waste production, recycling of products, and reincorporation into the supply chain.

C.        Boulder Community Health (BCH), Colorado

Boulder Community Health is a community owned and operated nonprofit health system in Boulder, Colorado. Their ongoing sustainability goals are to reduce the environmental impact of their operations, reduce the waste stream, increase the use of renewable energy and implementation of sustainable practices (BCH, n.d.)4 .

Initiatives

●       Earned the LEED environmental certification for the Boulder Community Foothills Hospital in 2003. This was achieved through a highly efficient power plant, energy-efficient lighting, conservation of water, and installation of a roof-top solar system.

●       Achieved a 52% waste-reduction rate through collaboration with local partner Eco-Cycle on initiatives like composting.

●       Provided free RTD Eco-Pass to all employees, to make commute via public transportation free or very low-cost.

●       Encouraging suppliers to deliver more sustainable products.

D.        Northern Arizona Healthcare (NAH), Arizona

Northern Arizona Healthcare (NAH) is a nonprofit healthcare system that offers comprehensive healthcare services through two hospitals (Flagstaff Medical Center and Verde Valley Medical Center) as well as clinics, outpatient surgical centers, etc. In 2022, NAH pledged to continuously improve its sustainability initiatives and signed on to the White House Climate Pledge, to reduce emissions by 50% by 2030 and achieve net-zero emissions by 2050 (NAH, 2023)34.

Strategies

●       Retrofitting of existing facilities to improve energy efficiency and optimization through consideration of sustainable options.

●       Holding energy efficiency and optimization as foundational principles for future constructions (such as the proposed Health and Wellness Village in Flagstaff).

Initiatives

●       Implementation of NAH’s Blue Wrap Project, an initiative that re-purposes surgical material into re-usable items that benefit patients and non-profits and has removed approximately 60,000 pounds of blue wrap from landfills.

Regulations Governing Materials Used in Medical Devices

Regulations for medical device materials are driven by patient safety and environmental sustainability. At the federal level, the FDA sets standards for medical device materials (FDA, 2022)21. Medical device material restrictions by the FDA aim for biocompatibility. A material is biocompatible if it won't harm a human's body. They rely on manufacturers' detailed use of information to assess health concerns. To emphasize the need to be transparent about medical device materials that may affect health, the FDA suggests how to communicate information to patients and healthcare professionals.

A.        Colorado

Colorado has no state regulations regarding materials utilized in medical devices beyond what is mandated federally by the FDA. Colorado runs a parallel approach to regulating materials in medical devices, relying on compliance with federal guidelines, including submission of information on material biocompatibility and assessments of potential health risks (FDA, 2022)21. Colorado's dependence on federal standards ensures consistent baseline material safety and efficacy across medical devices.

B.         California

With its RoHS (Restriction on the use of Certain Hazardous Substances) Law, California is unique in its proactive approach to limiting the use of hazardous substances in medical devices. The law restricts the amount of certain hazardous heavy metals in covered electronic devices, including medical devices like blood pressure monitors, glucose meters, and pulse oximeters. These substances include, among others, mercury, lead, hexavalent chromium, and cadmium. The RoHS Law is significant because it directly impacts material choice, forcing manufacturers to choose safer, more environmentally sound materials (DTSC, 2024)17. Furthermore, California adheres to federal standards set by the FDA, ensuring all devices are nationally safe and biocompatible.

C.        Arizona

Arizona's strategy is similar to Colorado's, lacking state-specific regulations for medical device materials and relying instead on compliance with FDA criteria. The reliance highlights how significant federal guidance is in assuring the safety and effectiveness of medical device materials (FDA, 2022)21. Just as in Colorado, Arizona mandates that manufacturers assess the biocompatibility of their devices' materials and disclose the materials used in medical devices, particularly those that could be harmful to patients, to both patients and healthcare providers.

Impact on the Medical Device Industry

Medical device materials restrictions, whether federal or localized like California's RoHS, affect the sector. Medical device makers face biocompatibility testing, material reporting, and ingredient restriction lists. Continually pursuing safety and sustainability drives material science innovation, bringing the industry closer to safer and greener materials. States with specific constraints, like California, may face challenges and opportunities to lead in sustainability and patient safety. However, states like Colorado and Arizona that follow federal guidelines are equal, highlighting FDA authority in medical appliance material selection and use. Medical device innovation is driven by evolving safety and environmental regulations. Medical equipment is safe and effective under these principles, encouraging sustainability and health preservation.

Sourcing Restrictions Influenced by Sustainability Regulations

While sourcing restrictions have been placed on certain US hospitals based on sustainability regulations (such as federal health systems), many hospitals have adopted sourcing restrictions based on their individual sustainability goals.

Federal Healthcare Systems

Federal agencies, including federal health systems, have been mandated by Executive Order 13693, Planning for Federal Sustainability in the Next Decade, to promote sustainable acquisition and procurement practices. The Federal Sustainability Plan (Executive Order 14057) has also required federal agencies to prioritize the procurement of sustainable products and services (Section 208: Sustainable Acquisition and Procurement), especially those identified or recommended by the Environmental Protection Agency (EPA). The Order had additionally established a Buy Clean initiative (Section 303), incentivizing the procurement of construction materials with lower embodied emissions and pollutants for federally funded projects.

The U.S. Department of Veteran Affairs (that governs the Veterans Health Administration) has implemented sustainable procurement policies that include purchase preference for recycled content products designated by the EPA, energy and water efficient products and services (ENERGY STAR qualified and Federal Energy Management Program designated), BioPreferred and biobased products designated by the U.S. Department of Agriculture. They also utilize EPA programs such as the Significant New Alternatives Policy (SNAP), WaterSense, Safer Choice, and SmartWay to procure sustainable products and services identified by the EPA (VA, n.d.)50.

Kaiser Permanente, California

Kaiser Permanente, California has implemented the Environmentally Preferable Purchasing (EPP) Initiative as a part of its Sustainable Procurement Program to facilitate the purchase of products and services that cause minimal damage to the environment and human health. As a part of this initiative, Kaiser Permanente effected EPP Principles (a mandate for specific environmental criteria to be considered in the purchasing decisions) in May 2006 and an EPP Standard in February 2017 (Permanente, Sustainable Procurement, n.d.)38. The EPP Standard has established 11 Chemicals of Concern criteria (BPA, PVC, metals, PFCs, EU Restriction of Hazardous Substances Directive, etc.) and 8 Waste criteria (Recyclability of product/packaging, Recycled content in product/packaging, etc.), that must be considered in the purchase of any electronic or non-electronic products. Any current or prospective suppliers of products to the organization are required to comply with the EPP Standard (Permanente, 2022)37.

UCLA Health, California

UCLA Health (Health, Sustainable Procurement, n.d.)28, California has committed to the Sustainable Procurement Guidelines of the University of California (UC) System to incorporate sustainability into the sourcing processes, identify products with improved environmental performance criteria, and increase the number and diversity of suppliers in their supplier base. Some of the significant attributes of this effort include the collection and reprocessing of single- use medical devices, procurement of electronic equipment that is Electronic Product Environmental Assessment Tool (EPEAT) certified, green cleaning chemicals, and limiting chemicals of concern (PVC or vinyl, antimicrobials, formaldehyde, etc.) (Permanente., 2021)39.