Guide to JCAHO Environment
of Care Standard 3.10.3
© 2005
Joint Commission on Accreditation of Healthcare Organizations.
Any use of any or all of the Joint Commission standards
and elements of performance beyond this particular tool
is strictly forbidden without the written permission
of the Joint Commission.
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Please note: this page is under development.
Contact
(603) 795-9966,
if you have questions or suggestions.
Introduction Table of Contents Checklist
for 3.10.3
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Environment of Care Standard 3.10: The
organization manages hazardous materials and waste
risks
Element of Performance 3. Implementation
of Hazardous Material and Hazardous Waste Program
The
organization establishes and implements processes
for selecting, handling, storing, transporting, using
and disposing of hazardous materials and wastes from
receipt or generation through use and/or final disposal,
including managing the following: chemicals, chemotherapeutic
materials, pharmaceuticals, radioactive materials
and infectious and regulated medical waste including
sharps.
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This page provides
a set of criteria for evaluating how well
a facility has implemented its procedures
for managing hazardous materials and waste. The criteria have been grouped into categories covering:
- general management topics (procuring, handling,
and disposing of various classes of waste)
- specific materials and wastes of concern
- facilities and
equipment
Categories:
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= Compliance |
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= Environmental
Improvement |
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= Tools
and Resources |
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Hazardous Materials Management
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Purchasing |
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Newly
purchased hazardous materials are added to the inventory.
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Purchasing policy promotes selection
of less hazardous, environmentally preferable products.
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TRACER Staff can describe environmentally
preferable products that are in use, e.g. non-toxic or
less-toxic cleaners, mercury-free medical devices (thermometers,
blood pressure cuffs), or other hazardous chemical alternatives. |
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Purchase
non-PVC equipment to eliminate patient risks associated
with DEHP and environmental risks associated with dioxin
formation from the incineration of PVC. |
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TRACER Staff
are trained to use less hazardous chemicals to reduce
exposures, and generate less waste. |
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- Having
fewer hazardous materials on-hand means having fewer
to manage. Purchase and track products that
are are non-toxic or less toxic, use less energy,
have less waste associated with them and are made
with recycled content materials.
- H2E:
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Handling, labeling,
and storage |
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Facility
maintains a hazardous materials inventory that lists
all hazardous chemicals used, and their locations.
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Facility
maintains an MSDS management program.
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Hazardous
materials are labeled (with name, hazard warnings, hazard
symbols, etc.), and are stored, handled, and used appropriately.
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Personal
protective equipment is available, appropriate to hazards
and maintained.
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TRACER Staff
can describe appropriate handling procedures and personal
protective equipment to be used with hazardous material
in question |
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Storage
cabinets and/or storage rooms are available for the storage
of flammable liquids and other
hazardous chemicals as appropriate.
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Personal protective
equipment is reused whenever possible (e.g. gowns). |
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Spills |
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Spill
clean up procedures are in place in all areas where
hazardous materials are used and/or stored.
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Spill
clean up residues are managed as hazardous waste.
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Spills
are reported to local authorities and National Response
Center, if necessary.
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Spill
control and decontamination
equipment is readily available
in areas where hazardous materials are used.
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Spill
control equipment is maintained in usable condition.
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Eyewashes
and showers (ANSI
approved) are available in
all areas where hazardous materials are routinely used
and/or stored, and
are checked regularly.
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All
employees who may be involved in spills are appropriately
trained. Spill response team members are HAZWOPER trained.
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TRACER Staff respond appropriately to spills
of hazardous material used in patient care (e.g. mercury, formalin,
glutaraldehyde, etc.).
(Staff
competence: HR2.10.9,
Safety roles: HR2.20.2). |
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Hazardous material
elimination or minimization programs reduce the
potential for spills. Where the risk of spills
is high, consider an alternative less hazardous
material, and ensure proper training and education
in that area to reduce the overall risk of spills.
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Hazardous
Material Spill Policy is established and implemented.. |
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Training |
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Staff
are trained on hazards of materials used and appropriate
handling and use of protective equipment.
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Staff
are trained and competency tested in appropriate spill
response for hazardous materials and waste.
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Documentation for all training, including staff trained,
content covered, competency levels attained, and dates
of training, is kept for a minimum of 3 years. |
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TRACER Staff respond appropriately regarding
use of hazardous material used in patient care, e.g.
solvents for specimen analysis, cleaning agents for rooms,
sterilants for surgical procedures. |
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TRACER Staff respond appropriately regarding
clean up of a hazardous material spill used in patient
care, e.g. formalin, disinfectant, glutaraldehyde. |
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TRACER Staff respond appropriately regarding
disposal of hazardous material used in patient care,
e.g. solvents for specimen analysis, aerosols, cleaning
agents for rooms, sterilants for surgical procedures,
drug disposal. |
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TRACER Staff can describe elimination and/or
substitution of less hazardous materials as part of
the facility’s environmental improvement, e.g.
use of biodiesel, rechargeable batteries, energy-efficient
equipment and vehicles, mercury-free devices, ethylene
oxide elimination.
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Mandatory
Hazard Communication Training during new employee orientation
sessions includes environmental improvement elements
such as waste prevention, using less materials, commitment
to environmental performance, etc. |
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Waste prevention
and proper waste handling requirements are included in
all employee job descriptions, according to a progressive
facility-wide policy. (This is important, particularly
where safety issues are concerned. It will also
emphasize the importance of participation in pollution
prevention commitments.) |
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More resources |
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- Hazardous
materials are most often found in Dialysis,
Environmental Services/Housekeeping, Facilities
Management, Laboratories, Nursing Care, Nutrition
Services, Oncology, Pharmacy, Radiology, Surgery,
Emergency Services and Vehicle Maintenance.
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- New
York State Department of Environmental Conservation,
Pollution Prevention Unit:
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- Virginia Department of Environmental Quality, ISO
14001 Environmental Management System, home
page
- US
Environmental Protection Agency
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Hazardous Waste Management
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Recordkeeping and reporting |
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The
facility has obtained an EPA Identification Number.
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Generator
status is determined and reviewed monthly.
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Facility is working toward moving to smaller quantity
generator status by minimizing hazardous
materials present on site.
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The
basis for hazardous waste determinations is documented.
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Facility submits
Biennial Reports on EPA Form 8700-13A each even-numbered
year.
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Manifest
copies are managed properly (e.g. appropriate copies
are received from the treatment facility and are routed
to the regulatory authority).
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Manifests, Biennial Reports, and records
of test results and analyses are kept on site
for a minimum of three years.
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Land
Disposal Restriction notices are kept for a minimum of
three years.
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Weekly
inspections of the hazardous waste storage areas are
performed and documented according to written procedures Inspections
include checking for leaks, corroded containers, and
other potential problems.
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Hazardous waste determination |
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A RCRA hazardous
waste determination has been made for all solid
waste that is generated. Examples
of potential sources of hazardous waste include:
- waste pharmaceuticals HERC: Pharmaceutical
Wastes
- laboratory chemicals
and reagents
- formalin
- chemicals/anesthetics
used in surgery
- waste rags with
solvent
- aerosols
- disinfectants
- sterilants
- x-ray contrast media
- waste electronics
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Containers with hazardous materials, (e.g. aerosol cans,
chemotherapy agents) are completely emptied or managed
as hazardous waste.
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Containers that
held P-listed wastes are managed as hazardous waste.
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Mixed
wastes (e.g., radioactive and hazardous wastes, infectious
and hazardous wastes) are properly evaluated and disposed
of.
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Facility
is minimizing hazardous waste generation to avoid making
and documenting determinations. |
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- National
Cancer Institute: Information
page on Mixed Waste. (The waste management
procedures in the table at the bottom of the page
should be considered to apply only to the facility
that produced the page.)
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Storage |
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Hazardous waste
storage areas are secure, and are operated to prevent
releases to the environment (e.g. facility has provided
for secondary containment of containers).
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Hazardous
waste is stored in non-leaking, sturdy, compatible containers
that are kept closed unless adding or removing waste.
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Storage
areas are clean and organized. |
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Containers
are protected from weather, fire, physical damage, and
vandals. |
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Adequate
aisle space is maintained in the hazardous waste storage
area to ensure access to containers in event of spills
or leaks.
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Weekly
inspections of the hazardous waste storage areas are
performed, and are documented according to written procedures,
to check for leaks, corroded containers, or other problems.
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Containers of hazardous waste are marked with the words ÒHazardous
WasteÓ, and a descriptive name of the waste.
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Incompatible wastes are segregated.
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Precautions are taken to prevent accidental ignition
of ignitable waste, or reaction of reactive waste, by
(among other measures) separating the waste from sources
of ignition or reaction (e.g. open flames, smoking, sparks,
welding, hot surfaces).
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Satellite accumulation |
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