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  • Writer's pictureTom Petersen

10 Elements for Improving Environmental Performance and Compliance

Updated: Aug 28, 2023

On September 12, EES hosted a breakfast seminar on the U.S. EPA’s environmental compliance Audit Policy as it applies to hospitals and universities. This well received seminar featured a presentation from Samantha Beers, the EPA Region 3 Director of the Office of Enforcement, Compliance and Environmental Justice. Those who attended the seminar will receive copies of the presentations. If you couldn’t attend, but wish to receive these presentations, please contact Susan Klein at 215-881-9401 or by email at

In this posting of EES Healthy Environment, we will discuss a tried and true method of ensuring that after you have conducted an environmental compliance audit, you will be on the path of continuous improvement of your compliance systems. This method involves the development of an Environmental Management System (EMS).

10 Elements for Improving Environmental Performance and Compliance

One of the most effective ways for a hospital to ensure that it is meeting its environmental compliance obligations is to conduct an environment self-audit of its facilities and operations followed by the development of an Environmental Management System (EMS).

An EMS is a living system, not a static document. The point is to integrate the procedures into your day-to- day operations, while performing regular reviews of your processes. As new concerns may arise, your EMS will be able to address and resolve them.

This list is not meant to be a new or competing system. Instead, it is intended to provide a simple way of checking whether EMSs include elements to help users comply with regulatory requirements and move beyond compliance. You are encouraged to include all 10 elements in your EMS to achieve maximum environmental benefit.

1. Environmental Policy

The EMS should be based upon a documented and clearly communicated policy. This policy should set out the organization’s commitment towards a cleaner environment. It should include:

  • provision for compliance with environmental requirements;

  • commitment to continuous improvement in environmental performance, including in areas not subject to regulation;

  • commitment to pollution prevention that emphasizes source reduction;

  • commitment to continuous reduction of environmental risks;

  • commitment to sharing information with external stakeholders on environmental performance against all EMS objectives and targets.

2. Environmental Requirements and Voluntary Undertakings

The EMS should provide a means to identify, explain and communicate all environmental requirements and voluntary undertakings to all employees, on-site service providers and contractors, whose work could affect the organization’s ability to meet those requirements and undertakings. Environmental requirements include statutes, regulations, permits, enforceable agreements. Voluntary undertakings include any environmental principles or industry norms that an organization may choose to adopt. Examples include voluntary codes of practice for safety, risk management and energy efficiency issues.

The EMS should include procedures for ensuring that the organization meets these environmental requirements and voluntary undertakings. The EMS should also specify procedures for anticipating changes to environmental requirements–including new requirements that may apply as a result of changes in operations- and incorporating these changes into the EMS.

3. Objectives and Targets

Ensure that the EMS establishes specific objectives and targets for:

  • achieving and maintaining compliance with environmental requirements;

  • environmental performance demonstrating continuous improvement in regulated and non-regulated areas;

  • pollution prevention that emphasizes source reduction;

  • sharing information with external stakeholders on environmental performance against all EMS objectives and targets.

The EMS should establish appropriate time frames to meet these objectives and targets. These should be documented and updated as environmental requirements change or as modifications occur in activities and structures within organizations.

4. Structure, Responsibility and Resources

The organization should ensure that it is equipped with sufficient personnel and other resources to meet the objectives and targets of its EMS. The EMS should spell out procedures and steps for achieving those objective and targets. For example it should define the compliance roles and responsibilities of environmental protection personnel, specify how they and management will be held accountable for achieving and maintaining compliance, and describe how environmental performance and compliance information will be communicated to relevant employees, on-site service providers, and contractors.

5. Operational Control

The EMS should identify and provide for the planning and management of all the organization’s operations and activities with a view to achieving the EMS objectives and targets. For example, facility maintenance may be an important aspect in achieving and maintaining compliance and enhancing environmental performance.

6. Corrective and Preventive Action and Emergency Procedures

The organization, through its EMS, should establish and maintain documented procedures for preventing, detecting, investigating, promptly initiating corrective action, and reporting any occurrence that may affect the organization’s ability to achieve the EMS objectives and targets. Such measures should pay particular attention to incidents that may have an effect on compliance with environmental requirements as well as on environmental performance in regulated and non-regulated areas. Examples of such situations include equipment malfunctions, operator errors and accidental releases of hazardous substances. The EMS should also establish documented procedures for mitigating any adverse impacts on the environment that may be associated with accidents or emergency situations and for ensuring that similar incidents are avoided.

The EMS should include procedures for tracking any preventive and corrective actions that are taken. If the environmental violation or incident resulted from a weakness in the system, the EMS should be updated and refined to minimize the likelihood of such problems recurring in the future. The EMS should also, to the extent possible, provide for the testing of emergency procedures.

7. Training, Awareness and Competence

The EMS should establish procedures to ensure that all personnel (including employees, on-site service providers, and contractors) whose job responsibilities affect the ability to achieve the EMS objectives and targets, have been trained and are cable of carrying out these responsibilities. In particular, the training should highlight means to enhance the ability of personnel to ensure compliance with environmental requirements and voluntary undertakings affecting the organization.

8. Organizational Decision-making and Planning

The EMS should describe how these 10 elements will be integrated into the organization’s overall decision- making and planning, in particular, decisions on capital improvements, product and process design, training programs, and maintenance activities.

9. Document Control

The EMS should establish procedures to ensure maintenance of appropriate documentation relating to its objectives and targets and should also ensure that those records will be adequate for subsequent evaluation and improvement of the operation of the EMS. For example, it should document the organization’s state of compliance with environmental requirements as well as environmental performance relating to non-regulated aspects. All records should be maintained in accordance with relevant laws for document retention and protection.

10. Continuous Evaluation and Improvement

The EMS should require periodic, documented and objective auditing of the organization’s performance in achieving these objectives and targets and on how well the EMS assists the organization in achieving those objectives and targets. The goal of the review should be to allow management to bring about overall improvements. The scope and frequency of the review should depend upon the size and complexity of the organization and other factors that are determined relevant in each organization and country.

This article was adapted from a document developed by the U.S. EPA at this site.

EES provides assistance to hospitals in the development of Environmental Management Systems. We have developed detailed templates for all levels of documentation required for EMS, including Policies, Procedures, and Work Instructions. Contact Tom Petersen, P.E. at 215-881-9401 or by email at for a no-cost assessment of your current environmental compliance systems and recommendations for compliance strategies.

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