Sustainable QI Resource Repository

Medical Students for a Sustainable Future (MS4SF) Climate Smart Health Care Team

Tools, templates, and guidance for health professions students leading quality improvement projects that shrink health care’s environmental footprint.

National Clinical Sustainability Challenge (NCSC)

About this repository

This repository collects free, practical resources for anyone planning a sustainability-focused quality improvement (QI) project in health care, whether you are a student, a trainee, or a clinician. It is organized around the five stages most projects move through, from spotting a problem to sharing what you learned. Each stage explains the key ideas in brief, offers a quick exercise you can do with your team, and links to the best outside tools we have found.

Teams in the National Clinical Sustainability Challenge (NCSC) can match each stage to a monthly deliverable, using the table below. For a complete worked example, see the NCSC sample project, Breathe Easy, Dispose Safely, an inhaler recovery program.

How to use this repository

Stage	What you will do	NCSC deliverable	Go to
Foundations	Learn the basics of sustainable QI and where health care emissions come from	Before Month 1	Section 1
1. Find and define the problem	Spot an opportunity, find its root cause, write a problem statement, and set SMART goals	Month 1: Problem statement and SMART goals	Section 2
2. Understand the system	Map your stakeholders, how decisions get made, and how the process works today	Month 2: Stakeholder map and current process map	Section 3
3. Plan the change	Anticipate barriers, make the case, build a timeline, and design the new process	Month 3: Barriers, timeline, and proposed process map	Section 4
4. Pilot and measure	Run a small test and measure its environmental, clinical, financial, and social impact	Month 4: Mini pilot	Section 5
5. Report, share, and scale	Write up your results, communicate them, and plan what comes next	Months 5–6: Report, poster, and final presentation	Section 6

1. Foundations of sustainable QI

Start here if sustainable QI is new to you. This section covers the recorded lectures, the core idea behind sustainable QI, and where health care’s emissions actually come from.

1.1 Recorded lectures

Faculty from the Medical Society Consortium on Climate and Health (MSCCH) recorded short lectures on the foundations of sustainable QI.

Lecture	Speaker	Length	Links
Sustainability Fundamentals	Elizabeth Cerceo, MD, DCM, MACP, FHM, FEFIM Chair, Physician Engagement; Cooper Norcross Health Professor of Medicine; Associate Program Director, Internal Medicine Residency Executive Director, Climate Health and Director, Medical Humanities; Cooper Medical School of Rowan University	50:26	https://youtu.be/PaQZpCkJTEc
QI Methodology	Catherine Chen, MD, FACP Associate Professor of Medicine Vice Chair of Quality and Safety Core Faculty, Internal Medicine Residency Core Faculty, Center for Climate, Health & Healthcare Division of General Internal Medicine Rutgers Robert Wood Johnson Medical School	34:03	https://youtu.be/t-7puyTYj9A

^{Topics covered across the series: health care emissions sources, systems-based QI methods, stakeholder engagement, process mapping, and measuring environmental impact.}

1.2 What is sustainable QI?

Traditional QI asks whether care is safe, effective, timely, efficient, equitable, and patient-centered. Sustainable QI keeps all of those questions and adds one more: what does this care cost the planet and the communities around us? The Centre for Sustainable Healthcare frames this as sustainable value, which weighs the outcomes care produces against the full set of resources it uses.

Sustainable value = Outcomes for patients and populations

Environmental + social + financial impacts

Adapted from the Centre for Sustainable Healthcare’s sustainability in QI principles.

In practice, this means a strong project improves (or at least protects) patient outcomes while reducing one or more of the three impacts on the bottom line. The best projects reduce waste, emissions, and cost at the same time, which also makes them much easier to win support for.

1.3 Where health care emissions come from

Health care is a major source of greenhouse gases. One widely cited analysis estimated that the U.S. health sector produced about 8.5% of the country’s total emissions (Eckelman et al., Health Affairs, 2020). Like other industries, health care burns fuel, buys electricity, and depends on long supply chains. But clinical care also releases some gases that are unique to medicine:

• Anesthetic gases. Inhaled anesthetics are potent greenhouse gases, and desflurane has a far larger warming impact than alternatives such as sevoflurane.

• Nitrous oxide. Used in anesthesia and labor analgesia; much of it can be lost through leaks in piped supply systems.

• Inhaler propellants. The hydrofluoroalkane (HFA) propellants in metered-dose inhalers are powerful greenhouse gases.

Organizations sort their emissions into three “scopes,” defined by the Greenhouse Gas (GHG) Protocol. Knowing which scope your project targets helps you choose the right data and explain your impact.

Scope	What it covers	Health care examples
Scope 1	Direct emissions from sources the organization owns or controls	On-site boilers and backup generators, hospital fleet vehicles, anesthetic gases released in the OR, refrigerant leaks
Scope 2	Indirect emissions from the energy the organization buys	Purchased electricity, steam, heating, and cooling
Scope 3	All other indirect emissions, up and down the value chain. For most health systems this is the largest share.	Medical devices and supplies, pharmaceuticals, food (especially meat), waste disposal, staff commuting, patient and business travel

The gases most commonly tracked are carbon dioxide (CO₂), methane (CH₄), nitrous oxide (N₂O), hydrofluorocarbons (HFCs), perfluorocarbons (PFCs), sulfur hexafluoride (SF₆), and nitrogen trifluoride (NF₃). Because they warm the planet by different amounts, results are usually converted into a single unit: kilograms or metric tons of CO₂ equivalent (CO₂e).
Foundations: resources

Resource	From	Format	Use it to
SusQI.org	Centre for Sustainable Healthcare	Website	Explore the SusQI framework, training, and case studies
Sustainability in QI principles	Centre for Sustainable Healthcare	Web page	Understand the sustainable value equation in more depth
GHG Protocol Corporate Standard	Greenhouse Gas Protocol	Standard	Learn the official definitions of Scopes 1, 2, and 3
Diagram of scopes across the value chain	Greenhouse Gas Protocol	PDF	See every Scope 3 category at a glance
Global Road Map for Health Care Decarbonization	Health Care Without Harm and Arup	Report (PDF)	Pick one of the seven High-Impact Actions your project will target
Health Care Pollution and Public Health Damage in the U.S.	Eckelman et al., Health Affairs (2020	Article	Cite national data on health care’s emissions
The growing importance of Scope 3 emissions	Hertwich and Wood, Environmental Research Letters (2018)	Article	Understand why supply-chain emissions dominate

2. Stage 1: Find and define the problem

NCSC Month 1 | Deliverable: Problem statement and SMART goals

The strongest projects start with a problem you have seen with your own eyes, can put numbers to, and can trace back to a root cause.

2.1 Scan your setting for opportunities

Walk through your clinical environment with a “sustainability lens” and note what you see. You don’t need data yet; observations come first, and the data will help you size the problem later.

Area	What to look for
Energy and buildings	Lights and equipment left on overnight, rooms that are over-heated or over-cooled, old controls, no occupancy sensors
Supplies and waste	Overflowing regulated medical waste (red bag) bins, expired or unopened supplies thrown away, items in surgical packs that are never used
Purchasing	Single-use items where reusable options exist, no sustainability criteria in purchasing, outdated preference cards
Clinical practice	Low-value tests and procedures, routine practices with weak evidence, high-impact anesthetic gases or inhalers
Pharmaceuticals	Over-prescribing, medications that expire on shelves, unclear disposal pathways for patients
Food services	Uneaten patient trays, cafeteria food waste, heavy packaging, few plant-forward options
Transportation	Avoidable patient trips that telehealth could replace, idle fleet vehicles, few staff commuting options
Water	Leaks, constantly running equipment, water-intensive reprocessing or scrubbing practices
Policies and governance	No sustainability lead or committee, no environmental criteria in capital or investment decisions

Adapted from the sustainability issue scan in the Sustainable Healthcare Leadership Institute (SHLI) workbook.

2.2 Tell your story: why you, why here, why now

People act on stories, not just statistics. Before you write your problem statement, take ten minutes as a team to answer three questions. Your answers become the backbone of your elevator pitch.

Question	Prompts to get you started
Why you?	When did you first connect environmental health and patient health? What do you notice in your daily work that others miss?
Why your health system?	What is its reputation and role in the community? When has it adapted or innovated before? What local example would convince a skeptical board member?
Why now?	Has heat, smoke, or flooding affected your patients or operations recently? What opportunity exists today (new leadership, funding, regulations) that may not exist in two years?

Then practice saying it in three sentences: “I care about this because… My health system is ready because… We need to act now because…”

2.3 Write a problem statement

A good problem statement is specific, backed by data, and points toward its cause. Use this formula, which matches the NCSC Month 1 rubric:

[Specific population or department] experiences [specific problem], which costs [financial or operational impact] and contributes to [environmental or community impact], primarily because [root cause].

Write a first draft, then revise it twice: once to make it more specific (add exact numbers, departments, or timeframes), and once to make it more compelling (add the urgent consequence or the missed opportunity). Before you finalize it, check that it is:

• Specific: names the exact unit, process, or population affected

• Measurable: includes numbers for cost, time, waste, or emissions (flag any that are estimates)

• Compelling: makes clear why action is needed now

• Actionable: points toward a cause you can address, not just a symptom

• Relevant: speaks to concerns your leadership and staff actually have

2.4 Find the root cause

If your problem statement ends in a symptom (“staff throw inhalers in the trash”), keep asking why. The 5 Whys tool from the Institute for Healthcare Improvement (IHI) walks you through it. You have usually reached the root cause when the answer is something a process change could fix, such as a missing workflow, an outdated default, or a gap in education.

2.5 Set SMART goals

Turn your problem statement into two to four goals. Each goal should directly address the root cause you identified.

Element	Questions to answer
Specific	What exactly will you do? Who is involved, and where will it happen?
Measurable	What will you track, how will you collect it, and what target defines success? Include both process measures (did we do it?) and outcome measures (did it work?).
Achievable	What skills and resources do you already have? What do you still need? What is the biggest obstacle?
Relevant	How does this goal address the root cause? How does it support your institution’s mission, climate commitments, or budget?
Time-bound	What are your key milestones, and what is your final deadline?

For a guided walkthrough, see IHI’s guide to setting SMART aims. For a worked example, see slides 4–5 of the NCSC sample project.

Stage 1: resources

Resource	From	Format	Use it to
Setting SMART aims	Institute for Healthcare Improvement	Guide	Write aims that are specific, measurable, and time-bound
5 Whys: Finding the root cause	Institute for Healthcare Improvement	Tool	Move from a symptom to a cause you can fix
Project Development Template	SusQI, Centre for Sustainable Healthcare	Word template	Scope your whole project on one structured form
Global Road Map for Health Care Decarbonization	Health Care Without Harm and Arup	Report (PDF)	Confirm which High-Impact Action your project targets
Breathe Easy, Dispose Safely	NCSC sample project	Slides	See a finished problem statement and SMART goal

3. Stage 2: Understand the system

NCSC Month 2 | Deliverable: Stakeholder map and current process map

Health systems are complex. Before you change anything, learn who holds influence, how decisions get made, and exactly how the current process works.

3.1 Know who shapes decisions

Every department sees your project through its own priorities. Framing your idea in their terms is often the difference between a polite “maybe” and real support. This table summarizes who you are likely to need and what tends to matter to them.

Domain	Typical roles	What they care about	How sustainability connects
Supply chain	Director of procurement, value analysis committee	Product quality, standardization, cost savings, vendor contracts	Clinicians influence what gets purchased; fewer, standardized products often cut both waste and cost
Finance	CFO, budget managers, value-based care leads	Return on investment, capital budgets, cost avoidance, incentives	Many projects save money over time; show the payback period
Facilities and operations	Facilities director, environmental services (EVS), energy manager	Uptime, safety, efficiency, aging infrastructure	Clinical workflows drive energy use and waste; facilities upgrades need clinician buy-in
Clinical leadership and quality	Chief medical officer, chief quality officer, department chairs	Patient outcomes, safety, care standards	Frame sustainability as quality: less low-value care, fewer harms
Nursing and frontline staff	Nurse managers, charge nurses, unit champions	Workload, staffing, workflow, staff wellbeing	Changes must fit the workflow; a respected peer champion is often key
Pharmacy	Pharmacy director, Pharmacy and Therapeutics (P&T) committee	Formulary, safety, drug cost, disposal rules	Inhaler, anesthetic, and disposal projects usually need pharmacy’s support
Infection prevention	Infection preventionist, infection control committee	Patient safety, accreditation, protocols	Engage early on any reusable product or isolation-practice change
Informatics and IT	Chief information officer, EHR analysts, data teams	System integration, data accuracy, workload	EHR defaults, order sets, and dashboards can make sustainable choices the easy choice
HR and workforce	HR director, wellness lead	Retention, morale, engagement	Sustainability work can build staff pride and engagement
Legal and compliance	Chief legal officer, compliance director	Risk, liability, regulations, contracts	Engage early to find which barriers are real and which are assumed
Community, equity, and communications	Equity officer, community partnerships, communications team	Health equity, community trust, reputation	Connect your project to the communities most affected by pollution

Adapted from the health system domains and key players reference tables in the SHLI workbook.

3.2 Build your stakeholder map

List the people your project depends on, then score each one on influence (how much they can help or block you) and alignment (how supportive they are today), from 1 (low) to 5 (high). The example row shows how to fill it in.

Stakeholder	Domain	What they care about	Influence 1–5	Alignment 1–5	When and how to engage
Example: Director of Supply Chain	Supply chain	Standardization, cost savings, vendor relationships	4	3	Month 2: 15-minute meeting to review purchasing data

Then choose the top three stakeholders to engage first and write down why. Usually these are people with high influence. If someone has high influence but low alignment, plan how you will address their concerns before you need their approval. Finally, share your map with your mentor and ask: did we miss anyone?

3.3 Learn how decisions get made

Sketch how a decision like yours would move through your organization, using boxes and arrows. Use job titles or department names rather than people’s names. As you draw, ask:

• Who owns this decision? Who has to sign off, and who can quietly stop it?

• Which committees are involved, such as value analysis, P&T, capital planning, or policy review?

• When do budgets and capital requests get decided, and how far in advance?

• Who could be an ally or champion? Who has done something similar before?

• What don’t we understand yet, and who could explain it?

Turn the answers into one concrete next step, such as “Ask the procurement lead when the next contract cycle starts” or “Join the hospital’s green team meeting.”

3.4 Map the current process

A process map shows each step of a process from start to finish, so you can see where waste and emissions occur. To build one:

1. Pick one process with a clear start and end, such as a type of surgery, an office visit, or a discharge.

2. Walk through it step by step with the people who do the work. Observe it in person if you can.

3. Mark the “hot spots,” the steps where the most waste, energy, or emissions are produced or disposed of.

4. Build a resource table listing what each step uses: medical and non-medical supplies, energy, water, travel, and waste.

5. Note the departments, protocols, and structures that shape each step. The NCSC rubric rewards this context.

If your project targets physical waste, a waste audit of the process will show exactly where to intervene (see Section 5.3). If it targets travel or other Scope 3 sources, estimate how many trips, miles, or deliveries your change could avoid.

Stage 2: resources

Resource	From	Format	Use it to
Process mapping guide	Centre for Sustainable Healthcare	PDF	Learn how to draw a process map step by step
Waste audit templates	NorCal Waste Audit Toolkit	Google Drive folder	Run a waste audit of your chosen process
Example QI template: Reducing inhaled anesthetic gases	CRHE	Google Doc	See how a real project framed its aims and process
Breathe Easy, Dispose Safely	NCSC sample project	Slides	See an example stakeholder map and process map (slides 7–8)

4. Stage 3: Plan the change

NCSC Month 3 | Deliverable: Anticipated barriers to change, timeline, and proposed process map

Resistance is normal, as it usually means you are working on something that matters. It is critical to plan for it in advance to avoid delays to your project timeline.

4.1 Anticipate barriers to change

Work through these five steps for the barrier you think is most likely to slow you down.

Step	What to do
1. Name the resistance	Describe a specific situation where you expect progress to stall, and who is involved.
2. Understand it	What type is it? Common types: systemic or bureaucratic, burnout or change fatigue, competing priorities, power or turf, lack of information, or a clash of values. Then ask why it might be happening.
3. Choose an adaptive strategy	Options include reframing your pitch, building trust first, finding a champion, starting with a small pilot, naming the loss with empathy, waiting for better timing, or asking a question that opens dialogue.
4. Decide your next move	Persevere (keep going, maybe adjust your approach), pivot (change strategy or direction), or pause (gather information or wait for better timing). Explain why.
5. Line up support	Identify a sounding board, a senior champion, someone who has done this before, someone with the data you need, and someone who supports your own resilience.

It also helps to notice your own reaction. Are you tempted to avoid the conflict, push harder, or work around it quietly? Naming your default response makes it easier to choose a better one.

4.2 Common objections and how to respond

The objections below come up again and again in sustainability projects. Prepare a short, respectful response to each one that applies to your project.

Who you might hear from	What it sounds like	What is usually underneath	Ways to respond
Finance leader	“This isn’t the year for extra projects.”	Margins, staffing, and capital pressure	Lead with costs avoided and the payback period; start with a no-cost or low-cost pilot
Unit or nurse manager	“My staff can’t take on one more thing.”	Burnout, staffing, and workflow safety	Design the change to remove a step, not add one; recruit a peer champion; pilot on one shift
Facilities or operations	“Come back when you have funding and approvals.”	Risk, compliance, and projects that stall	Bring a scoped plan with an owner, a budget, and a clear end date
Infection prevention	“We’d need a lot of validation first.”	Patient safety and accreditation	Involve them from the start; bring the evidence and offer to co-design the safety checks
Procurement	“We’re locked into our current contract.”	Contract terms and group purchasing rules	Ask when the contract renews and how to add sustainability criteria to the next bid
Supportive executive	“Great idea. Let my team know what you need.”	Limited time and political caution	Make a specific, small request, such as one email of support or a slot at a leadership meeting
Equity or community lead	“Why this, when we have urgent equity problems?”	Competition for limited attention and resources	Show how the project protects communities that bear the most pollution

Informed by the barrier navigation exercises in the SHLI workbook.

4.3 Lead the change

John Kotter’s eight-step model for leading change is a useful checklist for a student-led project. You likely won’t complete every step in six months, but each one is worth planning for.

Kotter’s step	What it can look like in a student QI project
1. Create a sense of urgency	Share your baseline data and a story that makes the problem real
2. Build a guiding coalition	Recruit a clinical champion, a manager, and someone from operations or supply chain
3. Form a strategic vision	Describe in one sentence how the process will work after your change
4. Enlist a volunteer army	Find frontline champions on each unit or shift
5. Enable action by removing barriers	Fix the workflow problem, such as a missing bin, a default order, or a supply location
6. Generate short-term wins	Celebrate your first week of pilot data publicly
7. Sustain acceleration	Use early results to expand to a second unit or site
8. Institute change	Write the change into a policy, order set, or orientation so it outlasts your team

4.4 Make the case: mission, value, and equity

Leaders approve projects that advance goals they already have. Connect your project to your institution’s mission statement, climate pledge, quality goals, or budget priorities.

Be honest about money. Sustainability projects often save money by reducing waste, energy, and unnecessary care, but not always: switching to reusable products or new equipment can mean upfront costs. Present costs and savings over a realistic time period, and include savings that are easy to overlook, such as lower waste-hauling fees. The COST framework from Costs of Care is a helpful structure for designing high-value care interventions.

Then think and ask about equity:

• Who benefits from this change, both inside the institution and in the community?

• Could anyone be burdened or left out, such as patients without internet access or staff on night shifts?

• What can you do to share the benefits and burdens fairly?

• Which of your institution’s stated values does this project put into practice?

Case study: medical waste and environmental justice in Curtis Bay, Baltimore The Curtis Bay neighborhood of South Baltimore is home to a large medical waste incinerator that burns waste from hospitals across a wide region. The facility’s operator pleaded guilty to charges related to its handling of medical waste, and residents have continued to report pollution since. A 2025 study estimated that waste incineration in Baltimore causes substantial health damages that fall hardest on socially vulnerable communities. Discussion question: Where does your institution’s waste go, and who lives nearby?
• Largest U.S. medical waste incinerator pleads guilty (AP News)
• Baltimore medical waste incinerator still pollutes (Baltimore Brew, 2024)
• Health damages and disparities from municipal and medical waste incineration in Baltimore (Tu et al., 2025)

4.5 Build your timeline

Lay out your project phases in a Gantt-style chart that shows tasks, owners, and which tasks depend on others. Two additions make a timeline much stronger:

• An early “small win” that you can achieve in the first few weeks, such as one unit trained or one bin installed, to build momentum.

• A contingency trigger: a date or signal that tells you it is time to switch to Plan B (for example, “If we have no vendor approval by Week 4, we will pilot with existing supplies”).

For the next 90 days, use this short action plan to help keep your team focused:

Component	Prompt	Your response
Goal	What is your north star for this project?
First action	What is one concrete step you will take in the next 30 days?
Next action	What builds on it in the following 60–90 days?
Allies	Who can open doors, give feedback, or lend support?
Barriers to watch	What could slow you down or stop you?
If you meet resistance	Which adaptive strategy will you try first?
Early sign of progress	What will short-term success look like, even if it’s messy?
Check-in date	When will you pause to reflect and adjust?

4.6 Design the proposed process

Redraw your process map to show how it will work after the intervention/change, and mark every step that is new or different. The strongest proposed maps also show where your project connects with other initiatives already underway (a hospital green team, a supply chain review, a quality program) and what each change will cost or save. See slide 14 of the NCSC sample project for an example.

Stage 3: resources

Resource	From	Format	Use it to
CRHE QI project guide	Climate Resources for Health Education	Google Doc	Outline a sustainability QI project step by step
Kotter’s 8-step process for leading change	Kotter Inc.	Web page	Plan how you will build support and make change stick
COST framework for high-value care	Costs of Care	Framework	Design an intervention that improves value
Cost of Care curriculum	Costs of Care	Learning modules	Build skills in making the financial case
Curtis Bay health damages study	Tu et al. (2025)	Article	Bring an equity lens to waste projects

5. Stage 4: Pilot and measure

NCSC Month 4 | Mini pilot

Test your change on a small scale, measure what happens, and learn from it before you scale up. Good data shows where the problem is worst, proves your change works, and lets you compare options.

5.1 Test small with PDSA cycles

A Plan-Do-Study-Act (PDSA) cycle is a short, structured test of a change. Run several quick cycles rather than one big one.

Phase	What to do
Plan	State what you will test, your prediction, and who, what, where, and when. Decide what data you will collect.
Do	Run the test on a small scale, such as one unit, one shift, or one week. Record problems and surprises.
Study	Compare your results with your prediction. What did you learn?
Act	Adopt the change, adapt it and test again, or abandon it.

Download IHI’s PDSA worksheet to plan each cycle.

5.2 Measure all four sides of value

Measure more than emissions. Tracking every part of the sustainable value equation makes your results more convincing, and it protects patients.

Domain	Example measures
Clinical outcomes	Patient outcomes, guideline adherence, patient experience
Environmental	Kilograms of waste diverted, kWh of energy saved, kg CO₂e avoided, liters of anesthetic gas used
Financial	Supply spend, waste-hauling fees, energy bills, staff time
Social	Staff engagement and satisfaction, workload, equity of access
Balancing measures	Unintended harms, such as incident reports, delays, or complaints before and after your change

5.3 Choose your environmental data

Choosing the right data to display is important. Many simple, routinely collected numbers move in step with emissions, and reducing them almost always reduces emissions too.

Data source	What it tells you	Where to get it	Watch out for
Utility meters	Electricity, gas, and water use (Scope 2)	Facilities or energy manager; utility bills	Building-wide totals hide detail; temporary meters on equipment can help (see a radiology example)
Waste hauler records	Total weight of each waste stream leaving the site	Environmental services; waste vendor manifests	Record-keeping quality varies by vendor
Waste audits	What is in each bin: unused items, sorting errors, materials by type	Your team, with EVS and infection prevention approval	Safety and personal protective equipment; keep samples representative
Purchasing data	Quantities and spend for supplies, drugs, and anesthetic gases	Supply chain; pharmacy	Confidential pricing; inconsistent units (each, box, case); purchases don’t always match use; price changes
Product carbon data (LCA)	Emissions per product or per use	HealthcareLCA, MCF datasets, published studies	Studies use different methods, so compare carefully
Spend-based estimates	A rough, organization-wide Scope 3 total	Practice Greenhealth calculator	Too coarse to compare products, because dollars stand in for emissions

5.4 A short primer on life cycle assessment

A life cycle assessment (LCA) estimates the environmental impact of a product or process across its whole life: raw materials, manufacturing, transport, use, and disposal. Results are usually reported in kg CO₂e, based on a functional unit (for example, “one surgical procedure” or “one month of inhaler therapy”) so that different options can be compared fairly. LCAs follow international standards (ISO 14040 and 14044, or ISO 14067 for carbon footprints only).

Strengths	Limitations
• Captures many types of impact, not just greenhouse gases • Uses a recognized scientific method with international standards • Boils results down to a single number that supports decisions • Lets you compare products by the function they serve	• Results depend heavily on the assumptions and data used • Studies using different databases are hard to compare • It is a model, which is difficult to check against real-world measurements • Can be slow and costly to commission

There are two main approaches. A process LCA adds up physical inputs, such as kilograms of material or kWh of electricity, and is best for comparing products. An environmentally extended input-output (EEIO) model multiplies dollars spent by average emissions per dollar for each economic sector. EEIO is useful for big-picture estimates, like a whole health system’s Scope 3 total, but poor for product choices: a glove and a surgical device in the same sector look identical apart from their price. Because U.S. medical prices often don’t reflect production costs, treat spend-based numbers with extra caution.

Don’t wait for perfect data. Thousands of health care LCAs already exist. Use the published evidence, measure what you can, and act.

Lasting change depends on people. Consider tracking how your initiative is received:

• Staff awareness, engagement, and satisfaction (a short pre- and post-survey works well)

• Policies adopted, and how many departments or people they reach

• Visible leadership commitment, such as endorsements or resources provided

• Integration with existing quality improvement programs

Stage 4: resources

Resource	From	Format	Use it to
PDSA worksheet	Institute for Healthcare Improvement	Worksheet	Plan and document each test of change
HealthcareLCA database	HealthcareLCA	Database	Find published environmental impact studies of health care products and services
Carbon footprinting for health care	Centre for Sustainable Healthcare	Word document	Estimate emissions using standard emissions factors
MCF API Dataset	Medicine Carbon Footprint project	Dataset (Zenodo)	Look up carbon footprints of active pharmaceutical ingredients
MCF Product Dataset	Medicine Carbon Footprint project	Dataset (Zenodo)	Look up carbon footprints of medicine products
Health Care Emissions Impact Calculator	Practice Greenhealth	Tool	Estimate a facility’s emissions (may require Practice Greenhealth membership)
Scope 3 GHG Emissions Accounting Tool	Practice Greenhealth	Tool	Estimate supply-chain emissions
Energy consumption of CT and MRI	Heye et al., Radiology (2020)	Article	See how equipment-level metering can reveal savings
Environmental Life Cycle Assessment	OAPEN Library	Open-access textbook	Learn LCA methods in depth

NCSC Months 5–6 | Deliverables: Preliminary report and poster; final presentation

Your results matter beyond your own unit. Sharing them helps other teams adopt what works and avoid what doesn’t, including what you learned from barriers you couldn’t overcome.

6.1 Write it up

Use the SQUIRE 2.0 guidelines (Standards for Quality Improvement Reporting Excellence) to structure your report. Their 18-item checklist runs from title and abstract through context, interventions, measures, results, and limitations. For a shorter format, try the SusQI sample case study template.

If you could not complete a pilot, you still have meaningful results: document the barriers you encountered and estimate the impact your intervention would have if implemented.

6.2 Plan your communications

Tailor your message to each audience, and choose the format that will reach them best.

Audience	What they want to know	Formats that work
Executive sponsor and leadership	Results, cost, risk, and the ask for next steps	One-page brief, short presentation at a leadership meeting
Frontline staff	What changes for them, and why it matters	Huddle talks, unit newsletters, posters near the workflow
Patients and community	How the change affects their care and their neighborhood	Patient handouts, community meetings, local media
The wider field	Methods, results, and lessons learned	Conference posters, journal articles, op-eds

6.3 Think beyond year one

Scaling your project may take longer than one program cycle; in fact, most projects will. Use this year to lay the groundwork: collect data, build relationships, and document what you learned for the next team.

Ask yourselves: Where else could this model work? Could another unit, site, or specialty adopt it? If your project is specialty-specific, presenting at a specialty conference can reach clinicians who have never encountered health care sustainability.

6.4 Where to present

Conference	Notes
CleanMed	Annual U.S. health care sustainability conference from Health Care Without Harm and Practice Greenhealth
SHARE: Sustainable Healthcare Academic Research and Enterprise	Annual free, virtual conference hosted by Brighton and Sussex Medical School (UK)
Practice Greenhealth forums	Regional and topic-based forums for health care sustainability professionals
Health Care Without Harm events	Webinars and events on climate and health care
AAMC Integrating Quality (IQ)	AAMC meeting on quality and safety in academic medicine
SHM Converge	Society of Hospital Medicine annual meeting, with a strong QI track
SGIM national and regional meetings	Society of General Internal Medicine; accepts QI and innovation abstracts
Vizient	Health care performance improvement conferences
Your specialty society meetings	Reach clinicians in your field who are new to sustainability

6.5 Where to publish

Check each journal’s current author guidelines and article types before submitting.

Journal	Focus
Quality and safety
BMJ Quality & Safety	Quality and safety research and QI reports
BMJ Open Quality	Open-access journal for QI project reports
JAMA Internal Medicine: Teachable Moments	Short cases about harms from overuse of care; the first author must be a trainee
American Journal of Medical Quality	Quality improvement and patient safety
Joint Commission Journal on Quality and Patient Safety	Quality and patient safety
Implementation Science Communications	Implementation research and practice
International Journal for Quality in Health Care	International quality improvement
Climate, sustainability, and health
The Journal of Climate Change and Health	Climate change and health research and practice
BMJ: Sustainability	The BMJ’s sustainability content
The Lancet Planetary Health	Planetary health research
Frontiers in Public Health (Planetary Health)	Open-access public and planetary health
Medical education
MedEdPORTAL	Peer-reviewed teaching materials, including QI curricula
Journal of Graduate Medical Education	Residency and fellowship education
Teaching and Learning in Medicine	Medical education research

Stage 5: resources

Resource	From	Format	Use it to
SQUIRE 2.0 guidelines	SQUIRE	Guidelines	Structure a QI write-up for publication
SQUIRE 2.0 checklist	SQUIRE	Checklist	Check that your report covers every required item
Sample case study template	SusQI, Centre for Sustainable Healthcare	PDF	Write your project up as a short case study
Breathe Easy, Dispose Safely	NCSC sample project	Slides	See an example preliminary report outline (slide 18)

Suggest a resource

Know a tool, template, lecture, or case study we should add? Email the MS4SF Climate Smart Health Care Team at climate_smart_health_care@ms4sf.org.