HAZARDOUS MATERIALS AND WASTE MANAGEMENT PLAN



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2006 HAZARDOUS MATERIALS AND WASTE MANAGEMENT PLAN

EC.3.10.1

I PURPOSE

Your Hospital exists to benefit the people of our region by promoting good health, and by healing, caring and comforting. Consistent with this mission, Your Hospital has established and provides ongoing support for the hazardous materials and waste management program described in this plan.

The purpose of the Hazardous Materials and Waste Management Plan is to define the program to identify and manage materials known to have the potential to harm humans or the environment. The plan includes processes designed to minimize the risk of harm. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures.

The Hazardous Materials and Waste Management Plan provides a programmatic framework to reduce risk. The plan includes processes that are designed to evaluate risks that may adversely affect the life or health of patients, visitors, physicians, staff and volunteers.

II SCOPE

The Hazardous Materials and Waste Management program is designed to address the risks the variety of substances addressed in this plan pose to the environment of Your Hospital and to the patients, visitors, physicians, staff, and volunteers of the organization. The program is also designed to manage compliance with applicable codes and regulations.

III FUNDAMENTALS

A. The scope of the hazardous materials and waste management program is determined by the materials in use and the waste generated by the hospital.

B. Hazards associated with materials and wastes are defined by law or regulation and are identified in Material Safety Data Sheets (MSDS) or similar documents provided by suppliers and manufacturers.

C. Safe use of hazardous materials and handling of waste requires participation by leadership, at an organizational level and a departmental level, and other appropriate staff in the design and implementation of all parts of the plan.

D. Protection from hazards requires all staff that use or are exposed to hazardous materials and waste to be educated as to the nature of the hazards and to use equipment provided for safe use and handling when working with or around hazardous materials and waste.

E. Rapid effective response is required in the event of a spill, release, or exposure to a hazardous materials or waste.

F. Segregation of hazardous waste at the point of generation is an effective means of controlling the potential for exposures or spills during collection, transport, storage, and disposal.

G. Special monitoring processes or systems may be required to manage certain hazardous gases, vapors, or radiation undetectable by humans.

IV OBJECTIVES

A. The processes used to select, transport, store, use and dispose of hazardous materials, and to separate, segregate, transport, store, package and dispose of hazardous waste are defined in written procedures.

B. An inventory of hazardous chemical materials; defined by written criteria is used as part of the process to evaluate and define hazardous materials storage practices and hazardous wastes storage and waste handling practices.

C. The Hazardous waste programs include:

• chemical waste;

• chemotherapeutic waste, where present;

• radioactive waste, where present; and,

• biohazardous waste, sharps, and other physical hazards.

D. Monitoring of gases and vapors, including gluteraldehyde and waste anesthetic gases (recognized hazards), is performed at least annually where used, and the results reported to affected departments, and the Environment of Care (EOC) Committee at least annually.

E. Inspections are conducted at least annually to assure that areas used to store and handle hazardous waste have adequate space, are separated from clean and sterile goods and foodstuffs; and hazardous chemicals are stored appropriately to their hazards.

F. Spills, releases, and exposures to hazardous chemicals and waste are reported, in aggregate, to the EOC Committee at least quarterly.

G. Staff who handles hazardous chemical materials and/or hazardous waste is trained about the hazards of the materials they handle, protective methods, and responses to spills, and exposures. Staff knowledge about personal protection and procedures is conducted at least quarterly, and reported to the EOC Committee.

H. The performance monitor for hazardous materials and waste is evaluated and reported to the EOC Committee at least quarterly.

I. Staff who may discover or be involved with emergency spills are provided with appropriate training to recognize spills that may exceed the ability to respond at that site. Their knowledge is evaluated at least annually.

J. The objectives, scope, performance, and effectiveness of the program are evaluated at least annually.

V ORGANIZATION AND RESPONSIBILITY

A. The Board of Directors, through the Quality Council, receives an annual report of the activities of the Hazardous Materials and Waste Program from the EOC Committee. They review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance to the President/CEO. They provide support to facilitate the ongoing activities of the Hazardous Materials and Waste Program.

B. The President/CEO receives reports of the status of the Hazardous Materials and Waste Program through the Quality Council. The President/CEO reviews the report and, as necessary, communicates concerns about key issues and regulatory compliance to the Safety Officer. Leadership collaborates with the Safety Officer to establish operating and capital budgets for the Hazardous Materials and Waste Program.

C. The Safety Officer is under the general direction of the VP/Clinical, Home Care and Support Services. The Safety Officer manages the Hazardous Materials and Waste Program.

D. Department directors/managers are responsible for orienting new personnel to the department and, as appropriate, to job and task specific uses of hazardous material or waste. When necessary, the Safety Officer will provide assistance.

E. Individual personnel are responsible for learning and following job and task specific procedures for safe handling and use of hazardous materials and waste.

VI PROCESS FOR MANAGING THE RISKS

The organization manages its hazardous materials and waste risks (EC.3.10)

Management Plan for Hazardous Materials and Waste Program (EC.3.10.1)

Your Hospital has developed and maintains a written management plan describing the processes it implements to effectively manage hazardous materials and waste. The plan includes processes to protect the facility, patients, and staff from these materials and minimize the risk of harm and impact from exposure. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures. This plan is evaluated annually, changed as necessary, based on risk assessment of the environment, changes in conditions, regulations and standards, and identified needs.

Inventory of Hazardous Materials and Waste (EC.3.10.2)

The director/manager of each department maintains an inventory of the hazardous materials and wastes they manage. The department leadership assures their safe selection, storage, handling, use, and disposal. The department is responsible for evaluating Material Safety Data Sheets for hazards before purchase of departmental supplies to assure they are appropriate, and the least hazardous alternate practical. The department directors/managers work with the Safety Officer to develop procedures for handling of hazardous materials.

The director/manager of each department has an inventory of hazardous or regulated waste and is responsible for managing their safe storage and handling. Each director/manager is responsible for reviewing MSDS and other information to identify appropriate disposal methods. The Safety Officer, the Director/Engineering, Manager/Environmental Services, and the Radiation Safety Officer share responsibility for the disposal of hazardous waste. Licensed contractors transport chemical, chemotherapeutic, and medical waste. Radioactive waste is allowed to decay below background radiation in a hot room and then is disposed as ordinary waste.

Management of Hazardous Materials and Waste (EC.3.10.3 , EC.3.10.6)

Your Hospital has established and maintains processes for identifying, selecting, handling, storing, transporting, using, and disposing of hazardous materials and waste from receipt or generation through use and/or final disposal, including managing the following:

• Chemicals: Chemical materials are identified and ordered by department leadership. Appropriate storage space is maintained by each department, and reviewed as part of environmental tours in that area. Chemical materials are maintained in labeled containers, and staff is trained in understanding MSDS, and in the appropriate and safe handling of the chemicals they use.

Chemical waste is accumulated in satellite accumulation areas and then moved to the central accumulation area, until arrival of the licensed contractor. The contractor lab packs the chemicals, completes the manifests, and removes the packaged waste. A copy of the manifest is returned to verify legal disposal of the waste.

• Chemotherapeutic materials: Chemotherapeutic (antineoplastic) medications and other hazardous drugs are controlled. Waste materials are collected for special disposal. Staff using these materials is trained in the handling, use and emergency response to spills or leaks.

Chemotherapeutic residual waste is handled as part of the Regulated Medical Waste stream, with additional labeling to assure appropriate incineration as final destruction. Larger than residual volumes of chemotherapeutic waste (liquids) are handled as chemical waste, if not recyclable.

• Radioactive materials: These are handled subject to the Your Hospital Department of Public Health Radiation Control License, and their safety is managed by the Radiation Safety Officer. Materials are handled in accordance with the requirements of the facility license.

Radioactive waste is held in a “hot room” until decayed to background, then handled as the underlying hazard of the materials for disposal. The Radiation Safety Officer manages the waste and determines when it is no longer considered a radioactive hazard.

• Infectious and regulated medical wastes, including sharps: These materials are found throughout the facility. The program is designed to identify, separate, collect, and control potentially biohazardous materials for proper disposal. Staff is trained about handling materials in the regulated medical wastes program. Labeled and/or specialized containers are used to collect and transport these wastes, and all waste removal is manifested, when not autoclaved, shredded on site, and disposed of via the normal waste stream.

• Regulated Medical Waste, including sharps, is collected by Environmental Services staff in patient care areas and transported to the processing area in dedicated carts. Labeled and/or specialized containers are used to collect and transport these wastes, and all waste removal is manifested, when not autoclaved, shredded on site, and disposed of via the normal waste stream.

Management of Hazardous Materials and Waste Storage Space (EC.3.10.7)

The Safety Officer is responsible for assessing the appropriateness of space for handling and storage of hazardous materials and waste as part of the environmental tour program. The intent of evaluating these issues during environmental tours is to determine if current conditions and practices support safe handling and storage of hazardous materials and waste, and separation of the hazardous waste from clean and sterile goods and foodstuffs.

Department directors/managers are responsible for initiating corrective actions on findings related to the appropriate use of handling and storage spaces in their areas of responsibility.

The Safety Officer provides the EOC Committee with reports of findings and follow-up action related to appropriate use of space as determined through the environmental tours program.

Gas and Vapor Monitoring (EC.3.10.8)

Department directors/managers are responsible for managing the program for monitoring gases and vapors. Air contaminants found in Your Hospital during normal use include formaldehyde, xylene, and gluteraldehyde (i. e., Cidex), and waste anesthetic gases. Results of current monitoring indicate that exposure levels are below the regulatory action level. If a monitor result were above the action level, corrective action and additional testing should be done to demonstrate a safe working environment.

Emergency Procedures (EC.3.10.9)

The Safety Officer develops and maintains emergency procedures for the Hazardous Materials and Waste program.

Your Hospital has an organized spill procedure that evaluates spills to determine if outside assistance is necessary. A minor (incidental) spill that can be cleaned up by the staff involved, with their training and personal protective equipment does not require additional response. A spill that requires use of spill kits kept in the department is documented, to assure replacement of the kit contents.

A spill that exceeds the capability of the immediate staff to neutralize and clean up requires a response from outside the facility. In these cases, the area is evacuated, ventilation controlled, and the Weymouth Fire Department is called for assistance. The Weymouth Fire Department and Hazardous Material Technicians from Clean Harbors, in conjunction with hospital leadership, take control of the site and cleanup, or arrange for it to be cleaned up by an outside contractor. Once determined safe, hospital staff finish the cleanup and recovery. Staff, including Environmental Services staff, is trained to recognize the potential for a spill that is not safe to handle, and to contact their manager, and/or the Safety Officer. During off-shifts, the Administrative Clinical Coordinator will make the determination. Staff is cautioned to err on the side of safety, and not to handle chemical spills that exceed their training, or the personal protection they have available.

Incidents involving spill kits, or a response from any outside agency are documented via an incident report.

Documentation of Permits, Licenses, and Manifests (EC.3.10.10)

Your Hospital has obtained, and maintains permits and manifests for the disposal of hazardous wastes, including chemical wastes, radioactive materials, and bio-hazardous (potentially infectious medical wastes) from the appropriate federal, state, and municipal agencies.

Manifests (EC.3.10.11)

Each load of hazardous waste removed from the facility is documented by a manifest, as mandated by federal or state agencies. The manifests have multiple copies, and one remains onsite at the time the hazardous wastes are removed. Another copy travels with the waste, and is returned to the hospital once the wastes have been legally disposed of, to document the completion of the activity. These copies are matched, to assure that no load has been lost or misplaced, and kept for the record. If a completed copy of the manifest is not returned within the deadline established by law and regulation, the appropriate governmental agency is notified, and the information is also shared with the EOC Committee.

Waste Labeling (EC.3.10.12)

All hazardous wastes are labeled from generation to removal. Some wastes, such as bio-hazardous wastes (Potentially Infectious Medical Waste-PIMW) are labeled by placement in a red bag; other wastes are labeled with specific signs or with text labels.

Biohazardous Waste: These are placed in red bags, then placed into cardboard boxes, or plastic bins with external labeling as biohazardous wastes, or in a labeled roll-away container provided by the vendor, also labeled with the OSHA Biohazardous labeling and DOC required placarding. The red bags are deemed to be labeled, as these bags are not used for any other purpose, and any material in a red bag is treated as biohazardous.

Chemotherapeutic Waste: Chemo wastes are placed into labeled RCRA hazardous waste containers (labeled with the OSHA and international symbol for carcinogenic wastes).

Chemical Materials and Waste: Chemical materials are labeled throughout their use and handling in the facility. The label is on the container prior to receipt, or is placed on containers filled or mixed within the hospital. Labeling is evaluated during environmental tours, to assure the labels are maintained and legible.

Chemical wastes are labeled on the containers. In many cases the waste is labeled by the original chemical name, in other cases, where collection cans or containers are used, the container is labeled. These labels are required by the vendors of chemical disposal services to maintain the identity of the materials, and if the identity is lost, the materials are tested and analyzed to identify them for proper handling and disposal.

Radioactive Materials and Waste: Radioactive materials are labeled with the magenta and yellow symbols, defined by OSHA and international use. These materials are handled and stored in accordance with the Department of Public Health Radiation Control regulations and license provisions. Wastes are held to decay to background, when the labels are removed or covered, and wastes handled as the other hazards they may reflect.

Separation of Waste Handling Areas (EC.3.10.13)

Your Hospital maintains appropriate handling and storage areas for hazardous wastes that are separated and maintained to minimize the possibility of contamination of food, clean and sterile goods, or contact with staff, visitors or patients.

Hazardous wastes are moved to designated containers, from holding areas to the storage space designated for processing and handling those wastes. Those spaces are inspected periodically, to assure they are adequate for their intended use, that appropriate equipment and personal protection is available, and that they remain clean and orderly.

Routing of materials during transport is determined to minimize contact with patients and visitors, and to protect staff and the facility from contamination. Where food, clean and sterile materials, and staff are moved on the same transportation vehicle as wastes (e. g., elevators), scheduling and other safe practices minimize the potential for cross contamination.

Regular inspections of the storage areas and of behaviors in transport are included as part of environmental tours and problems are identified and documented as part of the environmental tours program.

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