The healthcare sector in the Netherlands is responsible for about 7% of the CO2 emissions. The Erasmus Medical Center (EMC) has committed to enhancing its environmental sustainability efforts by signing the Green Deal 3.0. This agreement sets ambitious targets for the EMC, including a 55% reduction in CO2 emissions by 2030 compared to the 2018 Green Deal Samen Werken Aan Duurzame Zorg (Green Deal 3.0) | Greendeals, n.d.). These targets are ambitious and call for immediate action.
The endoscopy department is found as the third highest largest contributor to hospital waste (Siau et al., 2021). This highlights the importance of improving the sustainability of the endoscopy department to meet the set targets.

This project set three main goals:
1. Creating an overview of all the consumables within the workflow of HCPs used in colonoscopy procedures at the Erasmus Medical Center.
2. Identifying and addressing the environmental impact hotspots of colonoscopy procedures.
3. Enhancing the sustainability of the reusable colonoscope with a redesign.

To achieve the first goal, the Product Journey Map method is used. Data on waste streams and the human interactions during the use of the colonoscope are gathered through observations and interviews conducted at the endoscopy department at the EMC.

After visualizing the Product Journey of the colonoscope in the EMC, it was easier to identify the environmental impact hotspots. The Value Hill model with the R-strategies was used to design sustainable interventions, to reduce the environmental impact of the hotspots. The identification of the environmental impact hotspots and the design of sustainable interventions are also carried out in a co-creation session with HCPs. Mapping out the colonoscopy procedure in a visual, including waste streams and human interactions, accelerated the ideation process with HCPs.

Furthermore, the focus of this project was on redesigning the colonoscope to enhance its sustainability. To achieve this, the literature was first explored to compare single-use with reusable colonoscopes. It became clear that implementing single-use colonoscopes would result in a 40% increase in net waste mass compared to reusable colonoscopes (Baddeley et al., 2022). However, one of the advantages of single-use colonoscopes was that they were easy to use. This was as an inspiration for the redesign of the reusable colonoscope which detects maintenance on time and prevents the damage that can occur during the use of it.

Finally, all the designed sustainable interventions and the redesign of the colonoscope are compiled into a revised Product Journey map. This revised PJM compares the new ideas with the practices, illustrating how the environmental impact of colonoscopy procedures can be reduced.

Healthcare is a major contributor to the negative effects on the environment, leading to adverse effects on the physical and mental health of people globally (IPCC, AR6). The Dutch healthcare sector alone is responsible for 7-8% of the national carbon footprint, 4,2% of total waste and 13% of raw material extraction (Steenmeijer et al. 2022).
This project was set up in three main parts to identifying opportunities for sustainable interventions in colonoscopy procedures for the EMC gastroenterology department. Throughout the project, a human-centered design approach was maintained. Research was done in literature on sustainability in healthcare and environmental impact of endoscopy, empirical context research and material flow analysis (MFA) in the form of a waste audit.

Based on circular strategies Reduce and Recycle, the research outcomes were synthesized into an intervention that aligns to the EMC's policy statements for sustainability:
- reduce waste with 10%
- increase recycling with 20%

Waste audit data was used as an input for co-creating with endoscopy nurses, where the focus was put on retrieving plastics from GMW because of their significant contribution to total emissions when incinerated (López-Muñoz et al., 2023).

Ideation was done in co-creation sessions to solve the problem of integrating waste segregation inside the complex environment of a colonoscopy treatment room for current system boundaries.
Outcomes
While it is ideal to implement higher R-strategies for designing out waste early on in the process, waste cannot be ruled out completely. Therefore, implementing a waste segregation system in the endoscopy treatment room presents an opportunity to enhance waste management in EMC and align with sustainability goals.
The proposal is a demonstration rather than a product concept, to show small incremental changes within the current system boundaries can help achieve the EMC goals. The intervention was estimated to reduce the weight of incinerated GMW with at least 40% with segregation of plastic products, and additional 16% by disposing of absorbent products in TONTO. Additional research is needed to determine the true recyclability potential of the plastics.
With the foresight of the implementation of new products in the system and a circular model where materials of these products have to be kept in the loop, the endoscopy nurses will be equipped and trained to accomodate these changes, and maintain sustainable practices.