To answer RQ1, this section presents a descriptive analysis of the selected literature on environmental performances measurement in hospitals and healthcare facilities (Table 2). The literature review includes 22 studies, classified into three typologies: Original Articles (n = 14), Literature Reviews (n = 6), and Case Studies (n = 2).
Geographical distribution of the contributions
The 22 studies included in this review cover a wide range of geographical locations, reflecting the global nature of the research on sustainability in healthcare facilities. Several studies originate from Europe, which emerges as a key region in the development of sustainable healthcare frameworks (n = 9). European publications provide the most comprehensive discussion on healthcare practices and sustainable design, with case study analysis in the sustainability field. Notably, Italy is a central contributor with multiple papers focusing on the integration of sustainability into healthcare structures, particularly in terms of building design and infrastructure [38, 39, 46]. Other areas also covered, with Brazil being the leading country for number of contributions (n = 4), showing a prominent focus on the mandatory regulatory framework for environmental sustainability. A significant share of contributions involves international collaborations, with contributions from authors affiliated with diverse countries and academic institutions [7, 47, 51]. These cross-border partnerships reflect the global nature of sustainability challenges in healthcare and enhance the depth and breadth of the research through the integration of varied perspective and expertise. This international coverage underscores both commonalities and regional differences in addressing sustainability challenges, particularly in terms of regulatory frameworks and mandatory measurement requirements.
Findings
Full-text analysis identified the main areas of performance related to environmental sustainability within the selected studies. Environmental sustainability performance include resource consumption reduction (inputs) and mitigation of impacts and emissions (outputs).
When environmental measures are included, they typically reference established regulations or ongoing sustainability initiatives [5]. The resource-oriented perspective has been employed to establish performance measures, focusing on criteria that address the depletion or consumption of environmental resources. The process of criteria definition focuses on identifying the domains in which performance indicators for environmental sustainability are established. To ensure robustness, domains recognized as performance criteria in at least five studies (n = 5) have been selected. These identified domains represent key areas with the most significant potential for enhancing the sustainability performance of healthcare facilities (Table 3).
The key metrics and function units adopted in the analysis of the different criteria and dimensions of Environmental Performance were extracted from the literature reviewed. These metrics were selected based on the frequency of use and alignment with the specific objective of performance measurement within each domain. The approach was evidence-driven, and these units reflect the operational scale and functional characteristics of healthcare facilities, ensuring relevance and comparability across diverse organizational and geographical contexts. The resulting EKPIs represent the metrics that best aligned with the scope and intent of performance assessment in each area.
Energy management and efficiency
The analysis of the literature reveals that energy management is a prominent critical dimension in environmental sustainability for hospital facilities. Indeed, energy management in hospitals is the most frequently discussed and impactful criteria for environmental sustainability performance. Hospitals are among the most energy-intensive infrastructures, consuming vast amounts of electricity and thermal energy for their operations [5, 43]. Multiple studies emphasize the need for performance metrics that capture energy intensity per unit area or per bed, allowing for cross-comparisons and benchmarking across healthcare facilities. For example, metrics like electricity intensity (kWh/m2) and thermal energy consumption have been proposed to guide energy reduction strategies while maintaining operational effectiveness [5, 44].
Technological innovation and the progressive improving of energy performance in hospitals, with constant monitoring have been identified as the key dimensions [36, 40]. Several studies, including those by Blass et al. [56] and Galvão et al. [6], have highlighted the potential of hospital facilities to implement energy-saving technologies and operational improvements. Green building initiatives, such as the incorporation of energy-efficient systems and renewable energy production on-site, have shown significant promise in reducing energy intensity.
Renewable energy integration is increasingly highlighted, with some facilities achieving on-site production capabilities [3, 5, 39, 46, 49]. These initiatives are vital in reducing reliance on non-renewable energy sources, directly impacting greenhouse gas (GHG) emissions and operational costs. However, the adoption of energy-efficient technologies remains uneven, particularly in regions where capital investments are constrained [42].
Furthermore, energy efficiency initiatives often intersect with waste reduction and water management programs, demonstrating the interconnected nature of sustainability measures in hospitals [51]. Advanced modeling techniques, including Building Information Modeling (BIM), have been applied to optimize energy use, showcasing innovative strategies to reduce carbon footprints through better facility design and operational planning. Additionally, hospitals are implementing advanced HVAC systems and efficient lighting to lower energy intensity per square meter [5, 51].
Langstaff et al. [42], Brambilla et al. [46] and Blass et al. [5] explored the role of performance measurement systems in tracking energy use. The authors identified key performance indicators (KPIs), such as electricity energy intensity (kWh/sqm) and renewable energy usage (%), as essential tools for monitoring progress and benchmarking hospital performance. Therefore, the integration of energy management practices into comprehensive sustainability frameworks requires harmonized indicators.
Waste management
Waste management is the second most frequently discussed criterion for environmental sustainability. Waste can be categorized into two types: general waste (i.e. solid urban waste not hazardous or not infectious, typically accounting for about 85%) and biomedical waste (i.e. hazardous and/or infective, radioactive or toxic waste, generally accounting for 15%). Pharmaceutical waste in hospital effluents presents a significant challenge, as local water treatment facilities are generally not equipped to properly manage this type of waste. Furthermore, there is a widespread lack of monitoring and measurement of pharmaceutical and chemicals contaminants in effluent streams [6, 52]. Studies emphasize the importance of standards and regulations in this area while also highlighting the need to go beyond existing, stressing the importance of education in waste segregation program for healthcare staff, as a key strategy to gain effective reduction of waste per capita and an increase in recycling rate. Measuring and tracking waste allows healthcare organizations to benchmark their performance against industry standards and set realistic goals for waste reduction. Similarly to energy management, performance in waste management can be assessed using functional units such as the number of bed (kg/day/bed), the square meter (kg/sqm/bed), or patient (head counts) [52].
Water management
The reviewed studies highlight the critical importance of water consumption and management in hospital sustainability, emphasizing the sector’s significant role as a major consumer of water resources. Water is a crucial factor for clinical activities and hospital infrastructure management, which requires significant amount of water on a daily based. Several water-intensive activities, in terms of total value, represent the highest consumption in terms of m3/year/functional unit (FU) such as washing, sanitation, food preparation, processing and irrigation of external green areas. Studies introduced two key metrics to track water performances: water consumption per bed (m3/bed/year) and per total area (m3/m2/year), to ensure measurability and comparability [5, 36].
Langstaff et al. [42] and Seifert et al. [44] underline the need for robust water management strategies to address operational efficiency and environmental sustainability. The presence of water usage critical area within healthcare facilities, particularly in patient-care activities and sanitation, where consumption is disproportionately high has been highlighted [3]. Brambilla et al. [46] emphasizes the integration of water-saving technologies, such as efficient fixtures and recycling systems, into hospital infrastructure to mitigate water-related environmental impacts. Water is a critical input resource in sustainability performance evaluations, advocating for the inclusion of water consumption per patient or per bed as standard performance metrics [36, 52].
GHG emissions
The reviewed studies underscore the critical role of hospitals in mitigating their carbon footprint through targeted interventions and performance measurement frameworks and confirm the significant contribution of healthcare facilities to global greenhouse gas emissions, [3, 7, 42]. McGain and Naylor [7] emphasized that the healthcare sector accounts for a substantial proportion of global GHG emissions, largely due to energy use in heating, cooling, and lighting, as well as waste management and transportation. Their systematic review calls for the inclusion of GHG emissions as a core component in hospital sustainability assessment models. Similarly, Langstaff et al. [42] highlighted the potential of carbon footprint to identify resource-intensive area in hospital operations, particularly in energy generation and resource utilization.
Blass et al. [56] and Ullah et al. [51] both advocate for the integration of renewable energy sources as a primary strategy to reduce Scope 1 and Scope 2 emissions, which arise directly from hospital operations and indirectly from purchased electricity. Keller et al. [3] further identified the importance of energy-efficient systems and renewable energy adoption in reducing emissions from hospital facilities, particularly in high-energy demand areas like diagnostic imaging and HVAC systems.
Brambilla et al. [46] proposed GHG emissions tracking as a key performance indicator for hospital sustainability, emphasizing its relevance in monitoring progress toward climate goals. Their study included emissions per bed (ton/bed) and renewable energy sourcing (%) as critical metrics to quantify reductions. Galvão et al. [6] also highlighted the role of waste management and sustainable transportation practices in mitigating emissions, suggesting that hospitals integrate these activities into broader sustainability strategies.
Seifert et al. [44] and Esmaeili et al. [43] discussed the indirect emissions associated with supply chain operations and medical equipment manufacturing, arguing that a comprehensive GHG assessment must consider these upstream and downstream processes. However, their findings also revealed gaps in current methodologies, which often exclude these factors due to a lack of reliable data. Another dimension affecting GHG emission performance is waste management. Studies emphasize that improving waste segregation and implementing recycling programs can significantly reduce a hospital’s carbon footprint, particularly for waste disposal methods with high emissions potential [6, 54].
The studies collectively stress the importance of developing standardized measurement tools to track hospital emissions and benchmark progress across facilities. The adoption of international frameworks such as ISO 14064 for GHG accounting can provide consistency and comparability [52]. Moreover, the literature underscores the necessity of aligning hospital emission reduction targets with broader policy frameworks and global climate goals, ensuring that healthcare organizations contribute to sustainability efforts at a systemic level.
Transportation and mobility
The reviewed studies emphasize the critical role of transportation and mobility in the environmental sustainability of healthcare facilities, particularly in reducing carbon emissions and enhancing accessibility [3, 46, 53]. A recurring theme in the literature is the integration of sustainable transportation options, such as public transport accessibility, shared mobility services, and dedicated infrastructure for bicycles and electric vehicles, which contribute to reduced vehicular emissions and encourage eco-friendly commuting [42, 54]. For instance, Brambilla et al. [46] highlight the impact of mobility-sharing initiatives in hospital campuses, while Seifert et al. [44] focus on policies supporting public transit availability.
The inclusion of transportation indicators, such as proximity to public transport and the availability of e-mobility infrastructure, is considered essential in sustainability assessment models for hospitals [6, 51]. These indicators not only reduce the carbon footprint associated with hospital operations but also improve accessibility for patients and staff, fostering social and environmental sustainability. Despite the growing recognition of this dimension, many studies lack a comprehensive analysis of the interdependencies between transportation practices and hospital sustainability goals, leaving room for further investigation and integration of these strategies into broader performance measurement frameworks [38, 52].
Site sustainability
Localization criteria have emerged as a significant factor in sustainability strategies for hospital facilities. While they do not directly align with the operational performance of hospital organizations, they are shaped by a preliminary assessment during the design stage. Site sustainability for healthcare facilities, particularly hospitals, involved the strategic planning and management of physical spaces to minimize environmental impact while enhancing the well-being of patients, staff, and the surrounding community. To reduce the environmental footprint of hospital buildings, the contributions analysed highlight the importance of sustainable materials and site selection. Research confirms that the total heated area significantly influences overall heat demand and connected energy consumption, which are key factor in healthcare’s environmental impact [3]. Other critical aspects include the integration of green spaces and draining areas, such as permeable pavements, which are essential for effective stormwater management, reducing runoff, and preventing soil erosion, thereby protecting local water bodies and infrastructure [45, 46]. Sustainable use of external spaces, such as green roofs and walls, also contributes to insulation, reduces the heat island effect, and promote biodiversity. Implementing these strategies not only supports environmental sustainability but also aligns with health-focused initiatives by creating a more resilient and pleasant environment for all facility users. Research suggests that incorporating sustainable practices into the localization decision-making process for healthcare infrastructure can lead to substantial long-term cost savings, improved patient outcomes, and a reduced carbon footprint, underscoring their importance in modern hospital design and operation [45, 46].
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