Environmental Performance Indicators Used in Healthcare Foodservices: A Scoping Review

ABSTRACT

Background

Healthcare foodservices are increasingly recognised as a key contributor to advancing the United Nations Sustainable Development Goals, particularly through reducing greenhouse gas emissions, waste minimisation, and promotion of sustainable diets. This scoping review aimed to identify existing international evidence on environmental sustainability indicators used in healthcare foodservices and examine their alignment with relevant Australian standards and policies.

Methods

Following Joanna Briggs Institute methodology and reported against the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews guidelines, systematic searches of Ovid Medline All, EBSCO Environmental Complete, and EBSCO Global Health were conducted. Environmental sustainability indicators were extracted and synthesised into the Foodservice Systems Model and Sustainable Development Goals. The extent to which indicators are reflected in existing Australian standards and policies for food, nutrition and sustainable procurement was assessed through a policy scan and content mapping.

Results

Fifty studies met eligibility criteria. In total, 51 indicators were identified across procurement, facilities, workforce, menu design, production, delivery, waste management, and quality systems. Key gaps included scope 3 emissions reporting, inconsistent waste measurement methods, and limited integration into quality audits. Cross mapping revealed most indicators were absent or only partially embedded in current policy.

Conclusion

These findings highlight the challenges in assessing and benchmarking environmental sustainability in Australian hospitals. In the absence of an agreed set of important and feasible indicators, evaluation of the current state (cross sectional) and change (longitudinal) of progress towards the Sustainable Development Goals in this setting remains challenging.

Summary

• In Australian hospital foodservices, environmental sustainability practices are inconsistent, with existing efforts predominantly focused on waste reduction and menu optimisation rather than upstream procurement or system‐level integration.

• This scoping review identifies a comprehensive set of sustainability indicators relevant to healthcare foodservices, providing an evidence‐informed framework to support Australian healthcare foodservice leaders in prioritising and benchmarking sustainability actions.

• Mapping these indicators against Australian accreditation standards and policy frameworks highlights opportunities to embed sustainability metrics within existing nutrition standards, audits, and quality improvement processes to support implementation in practice.

1. Introduction

Hospitals are central to healthcare delivery but are also significant contributors to environmental degradation. Environmental degradation refers to the harmful alteration of natural systems through activities that contribute to greenhouse gas emissions, excessive resource use, pollution, and waste generation [1]. Within hospital foodservices, there is a broad scope of operational and systems‐level elements, including food waste prevention and recycling, sustainable procurement practices, menu and production systems, packaging and single‐use products, and energy and water use [2, 3, 4, 5, 6]. In Australia, healthcare accounts for approximately 7% of national carbon emissions, with hospitals alone contributing 44% of this burden across expenditure categories [2]. Within healthcare facilities, foodservices are a critical subsystem intersecting patient nutrition, procurement, supply chains, and waste generation. Recent studies highlight the potential of healthcare foodservices to advance multiple United Nations Sustainable Development Goals (SDGs), including responsible consumption and production (SDG 12), climate action (SDG 13), and good health and wellbeing (SDG 3) [7]. The environmental and nutritional responsibilities of hospital foodservices have been recognised by dietitians who frequently lead quality improvement and innovation in environmental sustainability [3, 4, 8].

Australia has a complex health care system with interrelationships between federal and state government, delivered through a public and private health care system. Consequently, accreditation and nutrition standards are decentralised, acknowledging some aspects of sustainability, however concepts are inconsistent, shown in Supporting Information Table S1. This scoping review aimed to identify existing international evidence on environmental sustainability indicators used in hospital foodservices and examine their alignment with relevant Australian policies [9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30]. Existing standards and policies most commonly reference food waste reduction, local or seasonal procurement, packaging minimisation, and environmentally sustainable procurement principles. However, sustainability concepts vary considerably across jurisdictions, with most documents lacking consistent definitions, measurable indicators, standardised reporting processes, or integration into routine foodservice quality management systems.

2. Methods

This review followed the Joanna Briggs Institute methodology for scoping reviews [31] and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) checklist [32]. Because environmental sustainability policy and accreditation information are frequently located outside traditional bibliographic databases, supplementary grey literature search procedures described by Godin et al. [33] were incorporated to enhance methodological rigour and transparency. Specifically, the Godin approach provided structured guidance for identifying and searching government, organisational, and policy‐ based sources relevant to hospital foodservice sustainability [33]. Guided by an expert health librarian, three key concepts were developed: ‘foodservice’, ‘environmental sustainability’, and ‘scorecard’. Grey literature was systematically searched using Google Advanced Search and Google Scholar, following methods described by Godin et al. [8]. These preliminary searches identified five eligible articles (benchmark articles used to refine and validate the search strategy) relating to hospital foodservice sustainability and environmental performance measurement. Keywords and subject terms were extracted from the titles, abstracts, and indexing terms of these articles, with additional synonyms identified iteratively by the research team. These terms informed the development and refinement of the final peer‐reviewed database search strategy. Eligibility criteria were defined a priori and were guided by the PICO framework (Population: healthcare foodservices; Intervention/Exposure: environmental sustainability practices/indicators; Comparison/Control: non‐applicable; Outcome: sustainability metrics; Study design: all empirical and review studies) (Table 1). The review focused on hospital and healthcare foodservice settings (Population/Context) and included studies, policies, and reports describing environmental sustainability indicators, practices, processes, or outcomes relevant to foodservice systems (Concept). Literature relating exclusively to residential aged care, community settings, or non‐hospital foodservice environments (e.g., schools and aged care), animal studies, food safety studies, and sustainability studies unrelated to environmental outcomes (e.g., financial sustainability) were excluded to maintain contextual consistency with acute healthcare systems. Aged care settings were excluded because they operate under substantially different models of care, governance structures, accreditation requirements, and foodservice systems compared with acute hospital environments. Unlike hospitals, residential aged care facilities function primarily as long‐term living environments, where foodservice delivery, dining models, procurement systems, and resident autonomy differ considerably from acute healthcare contexts. Restricting the review to hospital foodservices enabled a more focused and contextually consistent evaluation of environmental sustainability indicators relevant to healthcare foodservice systems.

Table 1.

PICO framework for systematic search.

PICO	Inclusion	Exclusion
P Population	Foodservices in healthcare settings, including hospitals and ward‐level pantries for inpatient use.	Non‐food service systems
		Studies undertaken in residential aged care homes and other healthcare facilities, such as medical centres;
		Animal studies
I (Intervention/Exposure)	Indicators of environmental sustainability	Non‐environmental sustainability studies
		Food safety studies
C Comparison/Control	NA	NA
O Outcome	At least one or more environmentally sustainable site performance metric, either in use or proposed for use.
Study Study design	No restriction on study design Research published during the timeframe January 2015–June 2025 inclusive
	Full text available
	English and non‐English articles that were able to be translated to English using Google Translate

Abbreviations: C, comparison/control; I, intervention/exposure; NA, not applicable. O, outcome; P, population.

Three electronic databases: Ovid Medline All, EBSCO Environmental Complete, and EBSCO Global Health, were searched for studies published during the period January 2015–June 2025. These dates were chosen to capture the increasing momentum in healthcare sustainability initiatives over the previous decade, particularly in response to global climate targets, and growing focus on reducing healthcare‐related emissions, including scope 1, 2, and 3 emissions [7]. Guided by an expert health librarian, the search strategies were developed combining controlled vocabulary and keywords related to ‘foodservice’, ‘environmental’, and ‘scorecard’, with searches run in OVID Medline ALL, EBSCOHOST Environmental Complete and Global Health to end June 2025. Search outputs were imported into Covidence [34] for duplicate removal, screening, and review management. The full search strategy is included in Supporting Information Table S2.

Titles and abstracts were screened independently by two reviewers, with disagreements resolved by discussion. Full‐text articles were then assessed against the inclusion criteria using the same approach undertaken during title and abstract screening. Studies that were not published in English were translated to English via Google Translate. One study [35] required the use to Google Translate for English translations. As this review primarily aimed to identify environmental sustainability indicators rather than interpret complex theoretical constructs or technical frameworks, the risk of substantial misinterpretation was considered lower. Nevertheless, some translation inaccuracies may have occurred.

Data were extracted by one reviewer using a piloted template. Extracted information included: bibliographic details (author, year, country, and journal), title, study design and aim, environmental sustainability indicators reported, and measurement approaches (e.g., audit tools, waste quantification method, and lifecycle analysis) where appropriate. Indicators were further categorised into the Foodservice Systems Model domains of ‘Input’, ‘Transformation’, and ‘Output’, using the framework developed by Vaden [36], Gregoire et al. [37], and others [38, 39]. Environmental sustainability indicators were included if they described measurable or observable foodservice‐related practices, processes, or outcomes with potential environmental implications relevant to hospital foodservice systems. Indicators were subsequently mapped to Gregoire's Input‐ Transformation‐ Output (I‐ T‐ O) framework [37] according to where they predominantly influenced the foodservice system. Input indicators related to upstream resources and organisational structures (e.g., procurement, infrastructure, and workforce); Transformation indicators related to menu planning, production, and meal delivery processes; and Output indicators related to foodservice outcomes such as waste generation, recycling, quality management processes, and patient satisfaction. Given the complexity of environmental sustainability within hospital foodservices, this framework was used to categorise and interpret sustainability indicators identified in the review. The frequency with which each indicator was reported within its domain was tallied.

Sustainability indicators from included studies in this review were then mapped against known hospital accreditation standards, nutrition guidelines, and sustainability‐related policy commitments [9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30]. Each document was reviewed for explicit or implied sustainability indicators relevant to hospital foodservices. Indicators were first summarised descriptively, then consolidated into domains of the Foodservice Systems Model [36, 37, 39]. Indicators were also mapped against relevant United Nations Sustainable Development Goals (SDG) [7] to demonstrate alignment with international sustainability agendas. Findings were synthesised narratively, highlighting areas of strong evidence, variability in measurement, and critical gaps

3. Results

A total of 6694 records were identified through database searches, with 1607 duplicates removed. After screening, 50 studies [5, 6, 35, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86] were included in the review (Figure 1). The included studies represented a broad international evidence base spanning Europe [40, 43, 44, 45, 48, 50, 57, 58, 59, 60, 62, 65, 66, 67, 70, 74, 75, 78, 79, 81, 85, 86], North America [5, 54, 76, 77], South America [35, 42, 49, 51, 53, 73], the Middle East [46, 47, 61, 69, 84], Asia [41, 46, 47, 61, 82], and Oceania [6, 52, 55, 56, 63, 64, 68, 71, 72, 80, 83]. Of these final included studies, two studies [35, 46] required the use of Google Translate for English translations. Considerable variation existed in the sustainability priorities, foodservice models, and indicators assessed across jurisdictions. European studies more commonly focused on sustainable procurement, organic food initiatives, and waste reduction strategies, whereas studies from Australia and North America more frequently examined food waste monitoring, room service models, and patient‐centred foodservice interventions. This geographic variability likely reflects differences in healthcare governance, procurement systems, infrastructure, and sustainability policy priorities across settings. The key study characteristics and environmental sustainability indicators relating to the research question are described in Table 2.

Figure 1.

PRISMA‐ScR flow diagram showing the study selection process for the scoping review.

Table 2.

Study characteristics and environmental sustainability indicators identified in the included studies.

Author, year, citation	Title	Study aim	Study design and method	Environmental sustainability indicator(s)	How were the relevant indicator measured/assessed?
Bux, C. (2023). Italy. J Clean Prod [40].	A combined evaluation of energy efficiency, customer satisfaction, and food waste in the healthcare sector by comparing cook‐hold and cook‐chill catering	To evaluate energy consumption and efficiency by comparing cook‐hold and cook‐chill catering; to estimate the customer satisfaction; to assess food waste quantities at lunch and dinner among hospital patients.	Multi‐site, comparative study	Use of cook‐hold over cook‐chilled food system; customer satisfaction; food waste quantities.	(a) Evaluation of energy consumption was based on primary data collected in a cooking centre with a production capacity of 1590 meals per production cycle; (b) the investigation of the consumers' behaviour among 984 patients located in nine different hospital units in Southern Italy; (c) the measurement of food waste based on questionnaire survey data.
Tagi, Hamada, Shan, et al. (2024). Japan. JMIR Form Res [41].	A food intake estimation system using an artificial intelligence‐based model for estimating leftover hospital liquid food in clinical environments: development and validation study	To develop a food intake estimation system through an artificial intelligence model to estimate leftover food; to compare accuracy of the artificial intelligence's estimation with that of visual estimation for liquid foods served to hospitalised patients.	Validation study	Artificial intelligence‐based model to estimate leftover food.	Estimated leftover liquid food from hospital trays using photographic images taken by artificial intelligence after patient meals. Accuracy was determined by comparing results with the estimation method via direct and image visual estimations by nurses and dietitians respectively, as well as with the method using a weighing scale.
Williams, Pitts, Onufrak, et al. (2024). US. J Hum Nutr Diet [5].	A qualitative exploration of barriers, facilitators, and best practices for implementing environmental sustainability standards and reducing food waste in veterans' affairs hospitals	To explore barriers, facilitators and best practices for implementing environmental sustainability standards in food service among veterans' affairs hospitals in the United States.	Mixed‐methods, qualitative descriptive study and online survey	Increasing plant‐based dishes; purchasing sustainable foods that meet organic, ecological, fair trade, or other ethical certifications; purchasing locally/regionally produced foods; reducing food waste; reducing energy consumption; reducing non‐food waste.	Online survey, 11 qualitative interviews‐ thematic coding of transcripts.
Moura, Mahler, and Caulliraux (2017). Brazil. Ciência e Natura [42].	Assessment of kitchen waste generated in a maternity hospital: a case study in Brazil	To investigate waste generation by the kitchen of a maternity hospital in the state of Rio de Janeiro, Brazil	Case study	Composting waste; better estimation of meal numbers.	Used the World Health Organization method to weigh non‐hazardous kitchen waste.
Buller, di Stefano, D'Anna, et al. (2023). Australia. J Hum Nutr Diet [6].	Benefits, limitations, and implementation issues for integrating organic foods into hospital foodservices: a systematic review	To understand the potential barriers and enablers from the perspective of stakeholders regarding organic food usage within the hospital food system.	Systematic review	Government targets/requirements for organic food use; focused training to upgrade staff competencies; use of relevant nutrition guidelines; menu planning with new production systems; budget for organic foods; education on reuse of leftovers; networking between kitchen staff and suppliers/producers.	NA
Goggins and Rau (2016). Ireland. J Clean Prod [43].	Beyond calorie counting assessing the sustainability of food provided for public consumption	To present an innovative tool for measuring the sustainability of food intended for public consumption in organisations, including hospitals.	Cross‐sectional comparative study	Organic; seasonality; fairtrade produce; reduced meat consumption; sustainably sourced seafood; free‐range eggs; food waste donation; waste prevention; education; origin of food tracking; consumer engagement‐ education; engaging with smaller producers and local communities.	NA
Strotmann, Friedrich, Kreyenschmidt, et al. (2017). Germany. Sustain [44].	Comparing food provided and wasted before and after implementing measures against food waste in three healthcare food service facilities	To reduce food waste in a hospital, a hospital cafeteria, and a residential home through application of a participatory approach where employees were integrated into the process of developing and implementing measures	Quasi‐experimental, pre–post intervention study using a participatory approach.	Improve menu composition and portion sizes; improve patient order‐taking process; topping order quantities aligned with bread order quantities; order assistants trained to avoid encouraging excess; more precise product specification in ordering; real‐time updates on patient discharges/admissions sent to kitchen; enhanced communication between departments; feedback loop analysis at departmental interfaces.	Plate waste was measured by weight and waste rate was determined following an algorithm (control). Measures for kitchen efficiency were developed and implemented, with results compared to the control.
Bux, C. (2024). Italy. J Foodserv Bus Res [45].	Conventional and digital technologies for measuring and monitoring food waste in the healthcare foodservice	To examine studies of hospital food waste management, focusing on practical implications and identifying strategies for improving sustainability in hospital foodservice through artificial intelligence technologies.	Semi‐integrative literature review	Artificial intelligence used to identify plate waste accurately.	NA
Fathi, Nasiripour, Khalesi, et al. (2021). Iran. J Manag Strat Health Sys [46].	Designing a model for managing the food service department in Iranian hospitals	To develop a model for food service management in Iranian hospitals‐ through identification of main factors impacting on food service.	Descriptive correlational study	Issues identified that impacted on food waste (not strategies): poor patient access to food; problems with food ordering system; unpleasant food serving environment; limited food menu; worn‐out cooking equipment; interaction between patients and nurses; lack of cook's skills and failure to follow standardised recipes.	35 operational variables extracted from literature, which were then used in a Delphi study, to develop the Hospital Food Service Questionnaire, which was used to identify the factors that would impact on food service.
Sack, Avisar, Kaplan, et al. (2021). Israel. Environ Sci Pollut Res [47].	Detection of N‐nitrosodimethylamine and its formation potential in hospital wastewater	To evaluate the contribution of hospital wastewater to environmental contamination by N‐nitrosodimethylamine; to identify key internal hospital sources and assess N‐nitrosodimethylamine formation potential before and after biological treatment.	Multi‐site experimental field and lab‐based study	Adopt aerobic biological treatment, reduce use of chlorine‐based disinfectants in kitchens.	N‐nitrosodimethylamine formation potential was measured before and after biological treatment of wastewater. Impact on formation potential reduction was determined.
Ofei, Holst, Rasmussen, et al. (2015). Denmark. Appetite [48].	Effect of meal portion size choice on plate waste generation among patients with different nutritional status. An investigation using Dietary Intake Monitoring System	To assess how patient‐selected meal portion sizes affect plate waste and nutritional intake, in relation to patients' nutritional risk status. To evaluate the use of a Dietary Intake Monitoring System as a practical tool for monitoring food intake and waste in hospital settings	Prospective observational cohort study	Right‐sized portions; use of technology for monitoring; improve communication between kitchen and clinical staff.	Food waste was physically measured before and after meals using the Dietary Intake Monitoring System.
Carvalho, Martins, Custodio, et al. (2017). Brazil. Nutricion hospitalaria [49].	Effect of the implementation of the mixed cafeteria system in a hospital nutrition and dietetic service	To evaluate the impact of transitioning from a simple cafeteria service (divided trays) to a mixed cafeteria service (plates and self‐service elements) on food waste within a hospital's nutrition and dietetics service.	Quasi‐experimental study with a pre–post intervention design	Bulk meal service (mixed cafeteria) over pre‐plated meal service (simple cafeteria).	All food prepared, served, consumed, and wasted was weighed using calibrated digital scales.
Ran, Van Rysselberge, Macura, et al. (2024). Environ Evid [50].	Effects of public policy interventions for environmentally sustainable food consumption: a systematic map of available evidence	Establishing environmentally sustainable food consumption patterns, to answer the primary research question: What evidence exists on the effects of public policy interventions for achieving environmentally sustainable food consumption?	Review	Use of labels, including organic or eco‐labelling, carbon labelling, and labelling for origin of food; information campaigns/education; menu design/menu information changes; restriction/editing choice/choice context; taxes for more sustainable food consumption	NA
Guimaraes, Reis, Costa, et al. (2024). Nutrients [51].	Environmental footprints in food services: a scoping review	To synthesise the existing scientific literature on carbon and water footprints in food services, describing the main methods and tools used, and current proposed strategies to mitigate the high values of these footprints.	Scoping review	Reducing or avoiding beef consumption; promoting plant‐based diets; menu changes and awareness; developing menus prioritising appealing and diverse vegetarian options; meat alternatives in place of beef; flexible portion sizes; hire suppliers with certification of good production practices; improving taste and quality, more proficient chefs, improving ingredient quality.	NA
Carino, Porter, Malekpour, et al. (2020). Australia. J Acad Nutr Diet [52].	Environmental sustainability of hospital foodservices across the food supply chain: a systematic review	To systematically identify and synthesise the following across the hospital patient food/nutrition supply chain: environmental and associated economic impacts of foodservice; outcomes of strategies that aim to improve the environmental sustainability of foodservice; and perspectives of patients, staff, and stakeholders on environmental impacts of foodservice and strategies that aim to improve the environmental sustainability of foodservice.	Systematic review	Food waste generated by patients through various foodservice models designed to increase patients' intake.	NA
Silva, Carneiro and de Morais Cardoso. (2022). Brazil. Braz J Food Technol [53].	Environmentally sustainable practices in hospital foodservices	To assess the environmental sustainability practices implemented in hospital food and nutrition units in the municipality of Governador Valadares, Minas Gerais, Brazil, across various stages of foodservice operation, including infrastructure, procurement, preparation, and waste management.	Descriptive, cross‐sectional, qualitative study	Use of energy efficient equipment; water use and reuse (e.g., leak control, rainwater capture, and greywater systems); use of seasonal and local foods; minimisation of food waste (e.g., portion control, reuse of leftovers, and food temperature control); waste management; recycling (organic and inorganic waste, oil reuse, and proper storage and disposal); use of biodegradable cleaning products	Online questionnaire consisting of 73 structured questions about environmental sustainability practices.
Ranke, Mitchell, St George, et al. (2015). US. Public Health Nutr [54].	Evaluation of the balanced menus challenge: a healthy food and sustainability programme in hospitals in Maryland	To evaluate the outcomes of a sustainability programme in the Maryland/Washington, DC region.	A mixed‐methods retrospective assessment‐ Previous survey reviewed + semi‐ structured interview	Eliminate or reduce meat‐containing meals; use meat as a condiment to meals; reduce portion sizes; purchase whole animals instead of cuts; increase vegetarian balanced protein; substitute cheaper cuts of meat.	Compared existing data with that obtained from a newly developed survey. The objectives were to assess utilisation of the toolkit and achieve 20% reduction in meat purchases.
Carroll, McCray, and Utter. (2024). Australia. HERD‐ Health Env Res [55].	Feasibility of a hospital‐based kitchen garden	To explore the feasibility, staff engagement, and perceived benefits of an indoor hospital‐based kitchen garden implemented to supplement fresh herbs for patient meals and improve staff well‐being.	Case study‐ qualitative evaluation using semi‐structured interviews	Internally grown herbs; local food production within the hospital, food quality and staff engagement; promotion of plant‐based and fresh ingredient usage.	Survey of six chefs on [1] overall experience [2], engagement with the garden [3], any perceived benefits, and [4] opportunities for improvement.
Cook, Goodwin, Porter, et al. (2023). Australia. Nutr Diet [56].	Food and food‐related waste management strategies in hospital food services: A systematic review	To describe the types and characteristics of food or food‐related waste management strategies used in hospital food service settings; their financial, environmental, and staffing outcomes; and the barriers and enablers associated with their implementation.	Systematic review	Consideration of the food recovery hierarchy; waste avoidance using evidence‐based strategies; simultaneously diverting waste from landfill; measuring of food waste; reusing food if food waste cannot be avoided‐ re‐serving to patients or staff or donating to food rescue; sell surplus edible food to visitors and staff; use of anaerobic digester; reporting of non‐food food‐related waste.	NA
Dias‐Ferreira, Santos and Oliveira. (2015). Portugal. Waste Manag Res [57].	Hospital food waste and environmental and economic indicators – A Portuguese case study	To characterise plate waste at an acute care hospital in Portugal, and potential waste reduction measures.	Case study	Bread on demand; bulk system over plated for meal delivery; portion size options; increased menu options; prompt update of patient movement or diet code changes.	Plate waste was derived from measuring the percentage of weighted food waste over food served. Cost of food waste was estimated, and average emission per each tonne of food wasted, as reported by BIO Intelligence Service (2010) was used to estimate the cost and carbon emissions generated by each hospital patient per day. This allowed for estimated impact of cost savings and reduced carbon emissions through ‘avoided tonnes’ of food waste.
Rinninella, Raoul, Maccauro, et al. (2023). Nutrients [58].	Hospital services to improve nutritional intake and reduce food waste: a systematic review	To ascertain which hospital services could overcome both nutritional intake issues and environmental and sustainability burden.	Systematic review	Meal presentation; meal quality; awareness interventions (sensitisation of employees to topic of food waste); food catalogue with detailed description of meals; tailored portion sizes, room service model; electronic ordering system; improving and adjusting the texture of meals.	NA
Antasouras, Vasios, Kontogiorgis, et al. (2023). England. Inte J Health Plann Manage [59].	How to improve food waste management in hospitals through focussing on the four most common measures for reducing plate waste	To identify the most common measures used to reduce plate waste in hospitals.	Systematic review	Flexible portion size; increased food choices through selective menus; additional nutritional support; better ordering and delivery system.	NA
Chatzipavlou, Karayiannis, Chaloulakou, et al. (2024). Greece. Clin Nutr ESPEN [60].	Implementation of sustainable food service systems in hospitals to achieve current sustainability goals: a scoping review	To identify the factors contributing to food waste in hospitals.	Scoping review	Efficient waste management; meal quality; flexible meal sizes; menus to cover nutritional, religious and cultural needs; option of meal location; food waste audits; staff training; integration of sustainable food service system into the quality management system of the organisation; use of PDSA. model in quality management of food system.	NA
Yona, Goldsmith and Endevelt. (2022). Israel. Isr J Health Policy Res [61].	Improved meals service and reduced food waste and costs in medical institutions resulting from employment of a food service dietitian – a case study	To examine the impact of the addition of the role of a ‘Food Service Dietitian’ in medical institutions on suitability of foods served, food costs, and food waste.	National case study	Food service Dietitian service; reduction of unnecessary meals; reducing protein portion size; adjusting staple orders; food safety oversight, switching from bulk to individualised trays.	Food waste was calculated through food cost savings across each indicator.
Piciocchi, Lobefaro, Luisi. (2022). Italy. Nutrition [62].	Innovative cooking techniques in a hospital food service: Effects on the quality of hospital meals	To verify the efficacy of the Nutritional Intelligence project in improving the nutritional and sensorial quality of hospital meals, while reducing food waste and increasing patient satisfaction	Quasi‐experimental, multi‐phase intervention study	The gastronomic method‐ Niko Romito Food Processing Technique; reduction of plate waste and increased patient satisfaction.	Compared percentage of patients discarding >/= 50% across first course, main course and side dish, for both traditional cooking and with Niko Romito Food Processing Technique cooking.
Ellick, Pashley, Cave, et al. (2024). Australia. Nutr Diet [63].	‘On‐demand’ snack service in a rehabilitation setting: impact on satisfaction, intake, waste, and costs	To evaluate the impact of an ‘On‐Demand’ snack service in a rehabilitation hospital setting on patient and staff satisfaction, nutritional intake, food waste, and operational costs	Retrospective pre–post implementation study	‘On‐Demand’ snack service using a digital interface (via app or bedside system); receive snacks at more flexible times; tailored item selection based on needs.	The environmental impact of the hospital snack service was assessed indirectly, using proxy indicators related to food waste and resource use (labour time and efficiency). Leftover snacks were weighed after each service and documented; cost of wasted items was calculated based on unit pricing. Labour hours used per day to operate the snack service were tracked. Labour cost was calculated based on hourly wage and total time.
Lewandowski, Barker, Howard, et al. (2023). Australia. Nutr Diet [64].	Packaged hospital food appears safe and feasible to reuse	To assess the safety, operational feasibility, and environmental impact of collecting unopened, non‐perishable packaged food items from patient trays in a hospital for reuse or donation	Mixed‐methods evaluation	Reuse or donate unopened packaged hospital food.	Over 10 weekdays, unopened, non‐perishable food items were collected off meal trays returning from wards. Items were microbiologically tested to ensure food safety. The process was timed and evaluated for operational feasibility. Environmental impact was estimated via greenhouse gas calculations.
Schiavone, Pelullo and Attena. (2019). Italy. Int J Environ Res Public Health [65].	Patient evaluation of food waste in three hospitals in southern Italy	To estimate the amount of food wasted by hospital inpatients and investigate the reasons behind it, using a patient‐reported method to assess food waste across three hospitals	Cross‐sectional survey	Patient satisfaction through improved food quality, food presentation, and food service.	Data were measured and analysed through patient structured interviews.
Schiavone, Pistone, Finale. (2020). Italy. Patient Prefer [66].	Patient satisfaction and food waste in obstetrics and gynaecology wards	To evaluate patient satisfaction with food and foodservice, patient expectations of food quality, amount of food wasted by inpatients in two obstetrics and gynaecology wards‐ one in Northern Italy and one in Southern Italy.	Cross‐sectional comparative study	Good quality of food and food service; good variety of meals; bedside menu ordering the day before over limited same day options; cook‐fresh over off‐site catering.	Food waste was measured between the two hospitals, using the different models, and compared
van Bakel, Moonen, Mertens, et al. (2024). Netherlands. Clin Nutr [67].	Personalisation in mitigating food waste and costs in hospitalisation	To investigate the impact of transitioning from a traditional paper‐based to a patient‐centred, digital hospital food service system on food waste production patterns and its associated financial implications.	Prospective, longitudinal pre–post intervention study	Use of digital menu management system over paper‐based system; introduction of three channels: (1) point of service selection during main meals, (2) call and order system outside mealtimes, and (3) ward‐based bistro where patients could dine with visitors.	Pre‐ and post‐ implementation of waste was measured and compared. Food waste decreased from ~81 to 33–49 g per meal after implementation.
Collins and Porter. (2023). Australia. Nutr Diet [68].	Quantifying waste and its costs in hospital foodservices	To measure the amount of different types of food and food packaging waste produced in hospital foodservice and estimate the cost associated with its disposal to landfill.	Quantitative research‐ foodservice waste audit	Use of food waste hierarchy ‐ avoiding waste at source; use of digital menu order system over manual paper menus; Use of ‘on demand’ food service system; efficient monitoring of par levels with smart menu design; diverting food waste to animal feed, reusing, repurposing, donating to food rescue and food relief organisations; presence of waste measurement audits.	Effectively tested an environmental strategy by auditing food and packaging waste, calculating the environmental and financial cost, and identifying high‐impact opportunities for future sustainability improvements in hospital foodservices.
Aytekin‐Sahin, Besparmak, Sagir and Somtas. (2023). Turkey. Nutr Food Sci [69].	Relationship between nutrient profiles, carbon footprint, and water footprint of hospital menus	To assess the nutrient quality, carbon footprint, and water footprint of 1‐month menus served in five hospitals in Turkey and compare these with the Mediterranean diet model. It also examined how environmental impact correlates with nutrient profile scores.	Cross‐sectional, analytical study	Use of the Mediterranean diet/‘Healthier menus’.	Tested sustainability scenarios by assessing how current hospital menus compare to the Mediterranean diet model (assumed as a globally recognised environmentally sustainable eating pattern).
Fieschi and Pretato. (2018). Italy. Waste Manag [70].	Role of compostable tableware in food service and waste management. A life cycle assessment (LCA) study	To assess the environmental impacts of using biodegradable and compostable single‐use tableware followed by organic recycling via composting compared to traditional fossil‐based plastic tableware disposed through incineration and landfill.	Comparative LCA	Use of biodegradable, compostable tableware; organic recycling.	The LCA of two different systems of food service in quick service restaurants, contract catering and events, followed by two different waste treatment systems were evaluated and compared.
McCray, Maunder, Krikowa, et al. (2018). Australia. J Acad Nutr Diet [71].	Room service improves nutritional intake and increases patient satisfaction while decreasing food waste and cost	To evaluate the impact of a room service food model compared to a traditional foodservice model on nutritional intake, plate waste, patient satisfaction, patient meal costs.	Retrospective, pre–post quality assurance analysis.	Room service model	Traditional model demonstrated 29% plate waste on average, whilst the room service model demonstrated only 12% (p < 0.001). Most prominent improvements were seen in oncology and surgical patients. Food cost reduced by 15%.
McCray, Maunder, Barsha, et al. (2018). Australia. J Hum Nutr Diet [72].	Room service in a public hospital improves nutritional intake and increases patient satisfaction while decreasing food waste and cost	To measurement and analysis of key outcomes from the implementation of room service in a public hospital.	Retrospective quantitative analysis	Room service model	Traditional model demonstrated 30% plate waste on average, whilst the room service model demonstrated only 17% (p < 0.001). Food cost reduced by 28%.
Carletto, Ferriani and Silva (2023). J Intl Solid Waste Manag and Publ Clean Assoc [73].	Sustainability in food service: a systematic review	To analyse how sustainability indicators related to meal production and waste are assessed in food services, identifying gaps in their evaluation and discussing the implications for sustainable development.	Systematic review	Education for staff and diners; menu optimisation using seasonal and local food; menu satisfaction; use of technical tools (e.g., portion control sheets); solid waste composition; waste management practices (e.g., sorting, recycling, and reuse); environmental practices in kitchen operations (e.g., maintenance and energy‐efficient equipment); and improved operational planning.	NA
Liwinski, Bocek, Schmidt, et al. (2024). Denmark. Front Psychiatry [74].	Sustainability initiatives in inpatient psychiatry: tackling food waste	To assess and reduce food waste in a psychiatric tertiary care hospital over a 3‐year period (2020–2022) through targeted interventions, while analysing the economic and environmental impacts of waste and identifying areas for improvement in specific units	Prospective, longitudinal interventional study.	Cook‐to‐order system; staff training; reduced portion sizes, surplus food resale; nutritionist collaboration; patient feedback loops; sustainable sourcing and regular monitoring.	Ongoing measurement of food waste and patient driven quality ratings.
Sørensen, Lassen, Løje, et al. (2015). Denmark. Public Health Nutr [75].	The Danish Organic Action Plan 2020: assessment method and baseline status of organic procurement in public kitchens	To compare two methods for measuring organic food procurement: the Organic Cuisine Label method (invoice‐based) and the Dogme method (self‐reported). Provide a baseline measurement of organic food procurement in Danish public kitchens participating in the Danish Organic Action Plan 2020.	Cross‐sectional comparative study	Organic procurement.	Comparison study measuring organic food procurement by applying two different methods, one based on the use of procurement invoices (the Organic Cuisine Label method) and the other on self‐reported procurement (the Dogme method).
Spoyalo, Viduka, Dixon, et al. (2024). Canada. Sci Rep [76].	Using salience and availability to promote sustainable and healthy food choices in hospital cafeterias	To evaluate whether behavioural insights interventions – specifically increasing salience and changing availability of food items – can promote the selection of sustainable and healthy dishes in hospital cafeteria settings.	Quasi‐experimental, multi‐site behavioural intervention study	Salience intervention and availability intervention.	Salience intervention: More sustainable meals made more prominent. Availability intervention: Increased the proportion of sustainable dishes available; decreased sustainable dish availability.
Thiel, Park, Musicus, et al. (2021). US. PLoS [77].	Waste generation and carbon emissions of a hospital kitchen in the US: potential for waste diversion and carbon reductions	To measure the total quantity and composition of waste generated in a large hospital kitchen over a 1‐day period and to assess the impact of potential waste diversion strategies in potential weight of waste diverted from landfill and reduction in greenhouse gas emissions.	Case study	Recycling and composting.	The study tested and compared three scenarios based on current practice, ideal goals, and realistic implementation: Cardboard and some metals recycled; rest landfilled (basic), full composting and full recycling of all eligible materials (ideal), composting from feasible areas and increased recycling (not dish room) (likely future).
Santana and Sant'Ana. (2023). Brazil. Eng Sanit Ambient [35].	Water end‐use analysis in a public hospital in Brasília, Brazil	To analyse water end‐use consumption in a public hospital.	Case study	Key opportunities were identified for future water‐saving interventions based on high‐usage zones and inefficiencies (e.g., leaks and oversized flows).	NA
Ryan‐Fogarty, Becker, Moles, et al. (2017). Waste Manag [78].	Backcasting to identify food waste prevention and mitigation opportunities for infant feeding in maternity services	To assess the scale of waste from ready‐to‐use breast‐milk substitutes in Irish maternity hospitals and explore strategies for waste prevention and mitigation using a backcasting approach, with alignment to best practices in healthcare and environmental sustainability.	Desk‐based scenario analysis using a backcasting method	Quantification of food waste; increasing exclusive breastfeeding rates; use of human donor milk; procurement and bottle size reform (use smaller size or decanting from bulk); use of powdered infant formula over RTU; composting; anaerobic digestion; strict prohibition of disposal via sewer or landfill under Irish regulations.	Volumes of waste were estimated for artificially fed and partially breast‐fed infants. This was calculated through volumes of breast milk substitute procured and unconsumed across both high use and low use.
Pörtner, Schlenger, Gabrysch et al (2025). Germany. Lancet Planet. Health [79].	Dietary quality and environmental footprint of health‐care foodservice: a quantitative analysis using dietary indices and lifecycle assessment data	To assess dietary quality and environmental footprint of healthcare foodservices using dietary indices and lifecycle assessment data	Quantitative cross‐sectional analysis	Carbon footprint; land use; water use; dietary quality indicators	Menu and procurement data analysed using dietary indices and lifecycle assessment databases to estimate environmental impacts.
Stiles, Collines, Beck (2025). New Zealand. J Hum Nutr Diet [80].	‘A necessary idea given our current climate’: a qualitative study of stakeholder perspectives and actions required to increase the proportion of plant to animal protein in hospital patient menus	To explore stakeholder perspectives on increasing plant‐to‐animal protein ratios in hospital menus	Qualitative study using interviews and focus groups	Increased plant over animal protein in menu‐ swap ingredients in familiar recipes or replace entire menu items, add plant‐based options, move position of plant‐based meals on menu; menu reform‐ cyclic design with change management plan.	Thematic analysis of stakeholder interviews examining attitudes, barriers, and enablers to menu change.
Hadjimbei, Chrysostomou, Heraclides et al (2025). Cyprus. J Nutr Sci [81].	Evaluation of patients' satisfaction with food services and assessment of plate waste in Cypriot hospitals	To evaluate patient satisfaction with hospital foodservices and assess plate waste in Cypriot hospitals	Cross‐sectional survey with waste assessment	Plate waste; patient satisfaction; food service quality.	Plate waste quantified through photographs and five‐point visual scale; patient satisfaction measured using structured questionnaires.
Manimaran, Razalli, Manaf et al (2025). Malaysia. BMC Health Serv. Res [82].	Challenges and strategies to reduce food waste in Malaysian hospitals from the perspective of multidisciplinary professionals: a qualitative descriptive study	To explore barriers, challenges, and strategies for reducing food waste in Malaysian hospitals from the perspectives of multidisciplinary professionals	Qualitative descriptive study using semi‐structured interviews	Optimise meal ordering system‐ centralised plating; enhancing communication in food waste management; portion control; improving food quality and presentation; strategic menu planning; waste reduction staff training; improve work performance.	Thematic analysis of interview transcripts exploring perceptions of food waste drivers, operational challenges, and proposed mitigation strategies.
Cook, Habel, McCray et al (2025). Australia. Nutr Diet [83].	Quantifying and describing production waste in two urban healthcare centres with differing foodservice models	To quantify and describe food production and packaging waste across two hospitals with different foodservice models	Comparative observational study	Reduce animal‐based foods on menu; use AI to monitor food waste; cook‐fresh on‐demand room service food service model.	Direct measurement and categorisation of food waste generated during meal production.
Hoteit, Khattar, Mohamad, et al (2025). Lebanon. Nutrition [84].	Evaluating plate waste in Lebanese hospitals: Implications for nutrition and resource management	To quantify plate waste and assess its implications for nutrition and resource management in Lebanese hospitals	Cross‐sectional observational study	Adjust serving size‐ selective in portion sizes; bulk delivery system; align food production and consumption; divert food waste to animal feed; donate surplus food to charity; composting.	Direct weighing of plate waste after meals; calculation of waste percentages relative to food served.
Sadler, Bauer and Kassam (2025). UK. J Hum Nutr Diet [85].	How sustainable are hospital menus in the United Kingdom? Identifying untapped potential based on a novel scoring system for plant‐based provisions	To assess the sustainability of hospital menus in the UK using a novel plant‐based scoring system	Quantitative menu analysis using a scoring framework	Reduce red meat; increase proportion of plant‐based menu items; remove process meat; remove negative language from plant‐based diet; work with outsourced catering providers‐ menu design; effective nudging strategies.	Menu items classified and scored based on plant‐based content using a novel sustainability scoring system.
Schwab, Schiestl and Hasenburg (2025). Germany. Front. Public Health [86].	Greening the future of healthcare: implementation of sustainability strategies in German hospitals and beyond‐a review	To synthesise evidence on sustainability strategies around five key sustainability objectives implemented in German hospitals	Narrative review	Energy efficient electrical appliances, creation of regional partnership or network structures for sustainable food supply, fresh seasonal produce, reducing portion size, reducing meat, education for patient and staff, waste reduction strategy.	Narrative synthesis of published literature describing sustainability initiatives and implementation approaches.

Abbreviations: CO₂, carbon dioxide; LCA, life cycle assessment; NA, not applicable; RTU, ready‐to‐use.

Similar indicators with conceptual overlap were grouped into broader environmental sustainability indicator categories during data synthesis. Consequently, frequency counts (n) reflect the number of conceptually related indicator instances identified across included studies, rather than exact duplication of wording.

A total of 51 unique indicators of environmental sustainability were identified across three domains of the foodservice system, shown in Table 3. Of these, 20 indicators were categorised under Input, 19 under Transformation, and 12 within the Output domain.

Table 3.

Environmentally sustainable indicators for healthcare foodservices identified in international literature categorised into the Foodservice Systems Model.

Foodservice systems model domain	Foodservice systems model category	Environmentally sustainable indicator used in healthcare foodservices (n = number of times an indicator was described in the review library)	UN SDG [7]
Input (20 indicators)	Procurement and sourcing	− Sustainable supplier screening (n = 5) [5, 43, 50, 51, 74] − Encourage organic procurement (n = 4) [5, 6, 43, 75] − Good quality ingredients (n = 5) [51, 54, 79, 81, 82] − Tailored and controlled purchases (n = 3) [5, 61, 78] − Use of sustainable packaging (n = 1) [70] − Use of economical packaging (n = 1) [70] − Seasonal food procurement (n = 5) [43, 53, 54, 73, 86] − Local procurement (n = 4) [5, 43, 53, 54]	2, 3, 8, 11, 12, 13
	Facilities and equipment	− Local herb/vegetable garden (n = 2) [42, 55] − Efficient digital food ordering menu system (n = 3) [66, 67, 68] − Energy efficient equipment (n = 3) [53, 73, 86] − Water use and reuse (n = 2) [35, 53]
	Workforce and organisation	− Staff training, communication, and awareness on efficient purchasing and efficient meal ordering (n = 10) [5, 6, 44, 50, 58, 60, 73, 74, 82, 86] − Chef skills upgrade and hiring quality chef (n = 2) [46, 51] − Education for consumers (n = 4) [5, 43, 73, 86] − Sustainability champion (n = 1) [5] − Enhanced communication between new admissions/discharges, patient movements, diet code changes, and the kitchen (n = 2) [44, 57] − Enhanced communication between departments and external suppliers/producers (n = 4) [6, 44, 48, 86] − Use of nutritionists/dietitians (n = 5) [41, 59, 61, 69, 74] − Improved operational planning (n = 3) [73, 80, 82]
Transformation (19 indicators)	Menu design and production	− Increasing plant‐based dishes (n = 5) [5, 51, 54] − Improving appeal to plant‐based meals (n = 1) [51] − Flexible portion size (n = 14) [5, 44, 48, 51, 54, 57, 58, 59, 60, 61, 73, 74, 84, 86] − Promotion of plant‐based diet/menu (n = 5) [51, 54, 76, 80, 85] − Good menu variety (Increased food choices) (n = 3) [57, 59, 66] − Reduction (through substitution) or elimination of beef/meat (n = 7) [43, 51, 52, 54, 80, 85, 86] − Strategic menu planning (n = 6) [6, 50, 57, 80, 82, 85] − Niko Romito Food Processing Technique (n = 1) [62] − Menus to cover nutritional, religious, and cultural needs (n = 3) [6, 60, 69] − Use of visual and descriptive menu (n = 1) [58] − Menu labelling (organic/eco/carbon/origin) (n = 1) [50] − Presence and adherence to standardised recipes (n = 3) [46, 53, 73] − Improved food serving environment (n = 1) [46] − Cook‐hold over cook‐chill meals (n = 1) [40] − Food temperature control (n = 1) [53]	2, 3, 12, 13, 15
	Service models	− Room service model (n = 8) [52, 61, 63, 67, 68, 71, 72, 83] − Bulk meal service over pre‐plated meal service (n = 3) [49, 57, 84] − Tailored ordering process (n = 6) [46, 59, 63, 74, 82, 84] − Option of meal location (n = 1) [60]
Output (12 indicators)	Patient and service outcomes	− Patient satisfaction of meal/menu (n = 8) [40, 58, 60, 62, 65, 73, 81, 82]	9, 12, 13, 15
	Waste and recycling outcomes	− General waste prevention practices in place (n = 11) [42, 53, 56, 59, 60, 68, 73, 77, 78, 82, 86] − Food and non‐food waste monitoring and tracking (n = 12) [41, 42, 45, 48, 53, 56, 57, 68, 74, 81, 83] − Monitoring/Tracking expiry date (n = 2) [5, 82] − Adopt aerobic biological treatment of wastewater (n = 1) [47] − Composting (n = 4) [42, 70, 78, 84] − Donation of surplus foods (n = 5) [43, 56, 64, 68, 84] − Selling or re‐serving or surplus foods (n = 4) [6, 56, 68, 74] − Diverting food waste to animal feed (n = 2) [68, 84] − Use of equipment to reduce carbon footprint of waste (n = 2) [56, 68]
	Quality management integration	− Integration into Quality Management System (n = 1) [60] − Use of Plan‐ Do‐ Study‐ Act model (n = 1) [60]

Abbreviations: UN SDG, United Nations Sustainable Development Goal.

Within the Input domain, the top three cited indicators included sustainable supplier screening (n = 5), use of good quality ingredients (n = 5), and staff training communication and awareness on efficient purchasing and meal ordering (n = 10). Less frequently mentioned indicators included having a sustainability champion (n = 1), use of sustainable packaging (n = 1), products received in economical packaging (n = 1), and improved operational planning (n = 1).

The Transformation domain was dominated by menu design and production strategies, with the top three most frequently identified indicators being flexible portion size options (n = 14), reducing or eliminating beef/meat (n = 7), and room service models (n = 8). Other notable indicators included promotion of plant‐based diets/menus (n = 5), strategic menu planning (n = 6), and tailored ordering process (n = 6). Unique but less common indicators included the Niko Romito Food Processing Technique (n = 1), use of visual and descriptive menus (n = 1), menu labelling (n = 1), food temperature control (n = 1), option of meal location (n = 1), practicing cook‐hold over cook‐chill foodservice model (n = 1), improving appeal to plant‐based meals (n = 1), and improving food serving environment (n = 1). The Niko Romito Food Processing Technique is a culinary approach designed to improve the nutritional, sensory, and textural quality of hospital meals through modified cooking methods that enhance flavour, palatability, and nutrient preservation while reducing the need for excessive fats, salt, or additives [62]. The technique aims to improve patient satisfaction and reduce plate waste in healthcare foodservice settings [62].

In the Output domain, the top three most frequently reported indicators were general waste management practices (n = 11), food and non‐food waste monitoring and tracking (n = 11), and patient satisfaction of meals/menus (n = 8). Rarely mentioned indicators included adopting aerobic biological treatment of wastewater (n = 1) and integration into Quality Management Systems (n = 1), and the use of Plan‐Do‐Study‐Act (PDSA) model in foodservice quality improvement activities (n = 1). To contextualise these findings, indicators were cross mapped against the most current Australian accreditation standards, nutrition frameworks, and procurement policies (Supporting Information Table S3). Collectively, these documents signal a policy shift toward low‐carbon, climate‐resilient healthcare, yet do not provide specific guidance or measurable indicators for hospital foodservices. This analysis revealed that most sustainability practices identified in the literature remains absent or only partially represented in existing standards. Although 51 environmental sustainability indicators were identified, only a subset were consistently reflected within existing Australian accreditation and policy frameworks [9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30]. This suggests that prioritising a smaller number of feasible, measurable, and high‐impact indicators may better support implementation within healthcare foodservice systems. Greater consistency in defining core sustainability outcomes may also strengthen future nutrition policy, foodservice guidance, and workforce capability development. Explicit sustainability requirements are still largely confined to nutrition‐focused domains such as dietitian oversight, portion control, and patient satisfaction. Some states and health services refer to sustainable procurement, local sourcing or waste reduction (e.g., Victoria, Queensland, and New South Wales), but these have not been operationalised into measurable accreditation requirements. At the national level, policy commitments such as the National Health and Climate Strategy [11] and the 2024 Joint Statement on Sustainable Healthcare [13] signal growing recognition of sustainability, but do not provide foodservice‐specific metrics. Sustainability language tended to appear as aspirational guidance rather than mandatory indicators.

4. Discussion

This scoping review provides the first consolidated mapping of environmental sustainability indicators relevant to healthcare foodservices. From the 50 included papers, 51 indicators were identified and structured against the Foodservice Systems Model [36, 37, 38, 39], offering a systems‐level lens that is directly applicable to hospital foodservice operations and aligned with the United Nations Sustainable Development Goals (SDGs) [7]. Several included publications were systematic or scoping reviews that synthesised environmental sustainability practices and interventions relevant to hospital foodservices. Rather than treating these reviews as sources of pooled outcome data, this scoping review extracted and consolidated the environmental sustainability indicators and concepts reported within their narrative and summary findings. As the purpose of the review was to map the breadth and diversity of sustainability indicators, rather than evaluate intervention effectiveness, overlap of primary studies across reviews was not considered to affect the identification of indicators. Consequently, authors did not undertake mapping of primary study overlap in reviews using the GROOVE tool [87], or other. The breadth of indicators demonstrates that sustainability in healthcare foodservices is multi‐dimensional, spanning procurement, facilities, workforce, menu design, production, service models, waste management, and quality improvement processes.

A key finding was the uneven distribution of indicators across domains. Waste management and menu optimisation were the most frequently addressed areas, reflecting their visibility and measurability within foodservice operations. Indicators such as waste prevention practices, monitoring systems, flexible portion sizes, and menu redesign strategies were commonly reported. By contrast, upstream procurement and supply chain impacts, particularly relating to scope 3 emissions, were rarely considered, despite being a major contributor to the healthcare sector's environmental footprint [88]. Scope 3 emissions, are indirect supply‐chain emissions associated with activities such as food procurement, transport, and waste management. Similarly, systems‐level integration into quality management and governance frameworks was infrequently identified, suggesting that sustainability remains peripheral to routine audit and accountability processes. This imbalance highlights the predominance of operational ‘downstream’ interventions, while ‘upstream’ and governance‐related levers remain underexplored.

Another key strength of this review was the comprehensive synthesis and conceptual grouping of environmental sustainability indicators within a hospital foodservice context (Table 3). While previous literature has examined individual sustainability interventions or specific operational practices, this review provides a broader systems‐level categorisation of indicators present or absent across current food and nutrition procurement, policy, and accreditation frameworks. This structured mapping may support future benchmarking, scorecard development, policy translation, and implementation planning within hospital foodservice systems. Many of the procurement policies explicitly reference circular economy principles, energy and water efficiency, and life‐cycle costing (Supporting Information Table S3). However, the translation of these principles into foodservice operations remains inconsistent. For example, while sustainable packaging and local procurement are reinforced by procurement policy [9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30], few health services report tracking metrics such as percentage of local spend, percentage of recyclable packaging, or supplier sustainability compliance. Similarly, staff training, leadership, and consumer engagement remain substantial gaps, representing key leverage points for implementation. At the national level, policy commitments such as the National Health and Climate Strategy [11] and the Joint Statement on Sustainable Healthcare [13] reflect increasing recognition of healthcare's environmental footprint, yet lack sector‐specific operational metrics for foodservices. This mapping exercise underscores a critical implementation gap: international evidence offers a rich indicator base, but frameworks remain narrowly nutrition‐oriented and weakly linked to sustainability measurement. A potential explanation for this limited operationalisation is that many of the identified sustainability indicators are not yet perceived as operationally feasible or viable within healthcare settings. Indicators that require new data infrastructure, supplier transparency, or cross‐departmental coordination, such as scope 3 emissions tracking, local sourcing metrics, or eco‐labelling, can be difficult to implement within existing governance and resourcing structures. Furthermore, competing service priorities (e.g., food safety, cost efficiency, and clinical outcomes) often take precedence [6, 40, 60], leaving sustainability without clear accountability or ownership. Consequently, many indicators remain aspirational rather than measurable, reflecting a disconnect between theoretical value and practical viability in complex healthcare systems.

Even where sustainability actions are mentioned (e.g., composting, waste separation, and local sourcing), they are rarely tied to measurable indicators or audit criteria, underscoring the implementation gap between policy aspiration and practice. This disconnect highlights an opportunity for integration. Many of the identified indicators could feasibly be embedded into existing audit processes. For example, procurement standards across jurisdictions generally acknowledge sustainability principles; however, measurable indicators relating to sourcing and supplier certification are infrequently specified; menu audits could incorporate plant‐forward or climate‐friendly criteria; and waste audits could be standardised within accreditation systems at a federal level.

Several included studies highlighted the role of dietitians and foodservice dietitians in driving environmental sustainability initiatives within healthcare foodservices [56, 61, 69, 71, 74]. Reported contributions included leadership of waste reduction strategies, implementation of patient‐centred foodservice models, menu optimisation, procurement oversight, quality improvement activities, and interdisciplinary coordination [56, 58, 60, 63, 71, 72, 74]. These findings suggest dietitians may play an increasing role in leading and supporting sustainability initiatives within hospital foodservice systems [4, 8, 89, 90]. As sustainability becomes more embedded within healthcare policy and accreditation, there may be value in strengthening foundational sustainability knowledge and leadership capabilities within dietetics curricula, foodservice training pathways, and continuing professional development programmes [4, 8, 89, 90]. Addressing environmental sustainability in healthcare foodservices will also require multidisciplinary collaboration beyond dietetics, across foodservice management, procurement and supply chain teams, sustainability officers, catering personnel, executive leadership, and policy makers [5, 6, 60].

Although this review focused specifically on Australian accreditation and policy frameworks, similar challenges have been reported internationally [51, 53, 60]. Studies from Europe, North America, and the United Kingdom demonstrate increasing policy and organisational emphasis on sustainable healthcare foodservices [5, 6, 51, 53, 60], particularly in relation to food waste reduction, sustainable procurement, and plant‐forward menu initiatives. However, considerable variability remains in how sustainability indicators are defined, operationalised, and embedded within healthcare governance systems [5, 51, 53, 60]. Compared with some international jurisdictions that have implemented more explicit sustainable procurement targets or national hospital food initiatives [5, 6, 75], Australian healthcare foodservice standards remain comparatively nutrition‐focused and fragmented across jurisdictions. These findings suggest that Australia is not unique in facing implementation challenges, but may benefit from stronger integration of measurable sustainability indicators within accreditation, procurement, and quality improvement systems. This alignment is critical for ensuring feasibility and uptake in healthcare contexts where compliance with accreditation standards is a primary driver of change [60].

In summary, the identification and mapping of indicators against policy and nutrition standards demonstrates that Australia's healthcare foodservice sector is at a pivotal point, with emerging national and state procurement frameworks providing a supportive policy environment but insufficient operationalisation at the facility level. The consolidated indicator set from this review establishes both the evidence base and policy rationale the systematic evaluation, for example, baseline (cross sectional) and change over time (longitudinal), of sustainability performance within this context.

This review has several limitations that should be acknowledged. First, while the systematic search strategy was comprehensive and guided by Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) recommendations [31], the review was restricted to literature published between January 2015 and June 2025 and may not capture earlier sustainability initiatives or grey literature not indexed in the databases searched. The use of the Foodservice Systems Model [37, 38, 39] provided a useful structure for categorisation, but some indicators could reasonably fit multiple domains, reflecting the complexity of foodservice systems. In addition, although the cross mapping against Australian accreditation standards and policy frameworks provided valuable contextual insight, this analysis was descriptive and restricted to publicly available documents. As such, the extent to which sustainability practices are embedded at local or organisational levels may be under‐represented. Finally, as a scoping review, this review did not assess the effectiveness of indicators in reducing environmental impacts but instead aimed to map breadth and identify gaps to inform subsequent research.

5. Conclusions

This scoping review identified 51 sustainability indicators currently being used within healthcare foodservices, systematically categorised into the Foodservice Systems Model [37, 38, 39] and aligned against Australian policies and with the United Nations SDGs [7]. The findings reveal that while international literature emphasises waste management and menu optimisation, upstream procurement practices, scope 3 emissions and integration into quality management systems remain under‐represented. Cross mapping against Australian accreditation standards and policy commitments demonstrated that most indicators are either absent or only partially represented, with explicit requirements largely confined to nutrition focused domains. The inclusion of measurable indicators of environmental sustainability into hospital foodservices policies and standards in Australia will support the integration of sustainability metrics into routine healthcare practice.

Author Contributions

Sharon Ong: conceptualisation, methodology, investigation, data curation, formal analysis, writing – original draft, visualisation, project administration. Mark Lawrence: conceptualisation, methodology, supervision, writing – review and editing. Michael Forrester: conceptualisation, methodology, supervision, writing – review and editing. Judi Porter: conceptualisation, methodology, investigation, formal analysis, supervision, writing – review and editing. All authors contributed to the interpretation of findings, critically reviewed, and revised the manuscript, approved the final version for publication, and agree to be accountable for all aspects of the work.

Funding

The authors have nothing to report.

Ethics Statement

Ethical approval was not required for this scoping review as it was based solely on the analysis of data from publicly available, previously published sources and did not involve the collection of primary data.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting File

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.