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Environmental Compliance, Pollution Prevention and JCAHO


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Title: Environmental Compliance, Pollution Prevention and JCAHO

Environmental Compliance, Pollution Prevention
  • Catherine Zimmer, BSMT, MS
  • MnTAP Healthcare Specialist
  • Northwest Healthcare Pollution Prevention
    Conference, Boise, ID
  • October 28, 2004

  • Hazardous Waste Regulations
  • Beyond Compliance with Pollution Prevention
  • JCAHO Standards
  • General
  • Environment of Care (EC)
  • Leadership
  • Performance Improvement
  • H2E Goals
  • Using H2E to meet JCAHO exceed Regulations

Why Reduce Waste?
  • Management of waste is difficult
  • Healthcare multiple waste streams
  • Labor intensive
  • Risk
  • Waste is really lost resources
  • Natural, time and money
  • Waste pollutes air, land and water
  • Incineration
  • Dioxins, mercury, acid gases, particulate, sulfur
    and nitrous oxides
  • Landfill
  • Loss of land and habitat
  • Leachate
  • Heavy metals, solvents, chlorinated compounds.
  • Sewer
  • Many chemicals not treated at the plant
  • End up in lakes, rivers, streams, oceans.

What is Pollution Prevention (P2)?
  • Waste Management Hierarchy
  • Source Reduction Waste volume or the toxicity
    of the waste should be prevented at the source
    whenever feasible.
  • Reuse through Remanufacture or Recycling- Waste
    that cannot be prevented should remanufactured or
  • Treatment Waste that cannot be prevented,
    reused, or recycled should be treated in an
    environmentally sound manner.
  • Disposal Waste disposal or other release into
    the environment should be employed only as a last
    resort, and such activity should be conducted in
    the most environmentally safe manner possible.
  • adapted from EPA definition established in the
    Pollution Prevention Act of 1990.

More About Pollution Prevention
  • Source Reduction
  • Using items that dont create waste. Or using
    items that reduce the toxicity of the waste.
  • Reusable containers
  • Reusable packaging
  • Minimizing the amount used
    or not using it at all (energy,
  • Substituting a non-chlorinated
    product for chlorinated.

Recycling is not Source Reduction
  • Glass bottle reused
  • is cleaned and refilled for reuse.
  • Glass bottle recycled
  • glass is cleaned
  • melted
  • mixed with new glass
  • formed into new bottle.

Recycling better than Disposal
  • If an item is not reusable
  • choose items that are recyclable
  • back into the original item
  • into another item
  • paper
  • cardboard
  • metal aluminum cans
  • glass containers
  • most plastic
  • not recycled back into original item
  • Close the loop
  • Buy Recycled

What is the Joint Commission for the
Accreditation of Healthcare Organizations
  • Accrediting agency for the healthcare industry
  • Accreditation in lieu of licensure by state or
    federal government
  • Required for Medicare/Medicaid reimbursement
  • Goal to ensure appropriate planning, procedures,
    processes policies are enacted improved upon.

JCAHO Standards
  • Leadership (LD)
  • Patient Rights Organizational Ethics (RI)
  • Assessment of Patients (PE)
  • Care of Patients (TX)
  • Education (PF)
  • Continuum of Care (CC)
  • Improving Organization Performance(PI)
  • Management of the Environment (EC)
  • Management of Human Resources (HR)
  • Management of Information (IM)
  • Surveillance, Prevention Control of Infection
  • Governance (GO)
  • Medical Staff (MS)
  • Performance Measurement (PM)

JCAHO Process
  • Surveys
  • reviews records and documents
  • interviews staff patients
  • observation
  • interviews leadership
  • information from public
  • tracer
  • Surveyors doctors, administrators, nurses,

Environment of Care (EC) Standard Areas
  • Safety (General Staff)
  • Security
  • Hazardous Materials and Waste
  • Emergency Management
  • Life Safety
  • Medical Equipment
  • Utility Systems

Environment of Care Standards EC. 1.10 Safety
  • EC.1.10 The organization manages safety risks.
  • EP 1 written management plan describing how it
    manages environmental safety
  • EP 2, 3 safety coordinator with authority
  • EP 4 conduct a proactive risk assessment
  • EP 5 procedures designed to minimize risk
  • EP 6 safety procedures are practiced and
  • EP 9 all grounds and equipment are maintained

Environment of Care Standards EC.1.20 Safe
  • EC.1.20 The organization maintains a safe
  • EP 1, 2, 3 Environmental tours are conducted
    regularly to identify deficiencies, hazards and
    unsafe practices.

Environment of Care Standards EC.2.10 Security
  • EC.2.10 The organization identifies and manages
    its security risks.
  • EP 1 Written management plan with processes for
  • EP 2 Security Manager
  • EP 3 Proactive risk assessments are conducted
  • EP 4 Procedures implemented achieve best
  • EP 5, 6 Access to facility and
  • secure areas is controlled.

Environment of Care Standards EC. 3.10 Hazardous
materials and waste
  • The organization manages it s hazardous materials
    and waste risks
  • EP 1. Written management plan describes
    processes to manage hazardous materials and
  • EP 2. Inventory of where HM W are stored or
  • EP 3. Processes are implemented for selecting,
    storing transporting, using and disposing of HM
  • HM materials whose handling, use and storage
    are guided by state, federal or local regulation,
    e.g. OSHA, EPA. NRC,
  • etc.

EC.3.10 Hazardous materials and waste (cont.)
  • EP 4. Adequate space and equipment are provided
    for the safe handling and storage of HM W
  • EP 5. Monitoring and disposal of hazardous gases
    and vapors
  • EP 6. procedures implemented to manage spills
  • EP 7. Documentation is maintained of permits,
    licenses and adherence to regulations
  • EP 8. Required manifests are maintained.
  • EP 9. HM W are properly labeled.
  • EP 10. HM and W storage and processing areas
    effectively separated from facility.

Environment of Care StandardsEC. 9.10-30
Improvement of Conditions in the Environment
  • EC.9.10 The organization monitors conditions in
    the environment
  • EP 1 Process for tracking
  • Injuries
  • Occupational safety
  • Security incidents
  • Hazardous materials incidents
  • Fire safety
  • Equipment and utility problems
  • EP 2 Coordinator for environmental improvement
  • EP 3 Implement processes for monitoring

Environment of Care StandardsEC. 9.10-.30
Improvement of Conditions in the Environment
  • EC. 9.20 The organization analyzes environmental
    issues and develops recommendations for
  • EP 1,2 A multidisciplinary team is established
    and meets monthly
  • EP 3 EC issues are analyzed in a timely manner
  • EP 4, 5 Recommendations are developed,
    measurement guidelines are established
  • EP 6-9 EC issues are communicated to

Environment of Care StandardsEC. 9.10-30
Improvement of Conditions in the Environment
  • EC.9.30 The organization improves the
  • EP 1 Appropriate staff involved
  • EP 2 Appropriate staff monitor effectiveness of
  • EP 3-5 Measurement is communicated to team and

(No Transcript)
Leadership (LD)
  • Leaders provide framework for
  • Planning, directing, coordinating
  • Providing care, treatment, services
  • Improving care
  • Respond to community
  • Improve healthcare outcomes.

Leadership Standards
  • LD.1.30 The organization complies with
    applicable law and regulation
  • LD.3.10 Leaders engage in short-term and
    long-term planning
  • EP 3.10.1 Leaders create vision, mission and
  • LD.3.90 Leaders develop and implement policies
    for care, treatment and services.
  • LD.4.40 Leaders ensure an integrated patient
    safety program is implemented throughout the
  • LD.4.60 Leaders allocate adequate resources for
    measuring, assessing and improving performance
  • patient safety.

Performance Improvement (PI)
  • Is a continuous process
  • Involves measuring of services
  • And, when indicated changing to enhance
  • Effectively reduce factors that contribute to
    adverse events.

Performance Improvement
  • Must consider principles of good design
  • Consistent with hospitals mission, values and
  • Meets patient needs
  • Reflects currently accepted practices
  • Doing the right thing
  • Using resources responsibly.

Performance Improvement Standards
  • PI.1.10 Data is collected to monitor performance
  • EP 1 data is collected in priority areas, e.g.
  • EP 2 the organization considers collecting data
    in response to staff perceptions of risk to
  • EP 3 the organization collects data on how it
    can improve patient safety.

PI Standards (cont.)
  • PI.2.10 Data is systematically aggregated and
  • PI.2.20 Undesirable trends in performance are
  • PI.3.10 Information from data analysis is used
    to improve performance and patient safety
  • PI 3.20 A proactive program for identifying and
    reducing adverse events is defined and

Crosswalking between Hospitals for a Healthy
Environment (H2E) and JCAHO
What is Hospitals for a Healthy Environment?
  • Partnership between
  • American Hospital Association
  • U.S. Environmental Protection Agency
  • American Nurses Association
  • Healthcare Without Harm
  • Vision
  • All healthcare facilities consider pollution
    prevention and environmental health as key to
    patient safety, community health and their

H2E Goals
  • Virtually eliminate mercury-containing waste from
    hospitals waste by 2005.
  • Reducing the overall volume of waste (both
    regulated and non-regulated) 33 by 2005 and 50
    by 2010.
  • Identifying hazardous substances for pollution
    prevention waste reduction opportunities,
    including hazardous chemicals and persistent,
    bioaccumulative and toxic pollutants.

JCAHO Focus Areas
  • Patient Safety
  • Quality of Care
  • How Environment affects Patient Safety

Meeting JCAHO Standards with Pollution Prevention
  • H2E Goals
  • Virtual elimination of mercury by 2005
  • 50 reduction of solid waste by 2010
  • Identification and reduction of persistent and
    toxic chemicals
  • Meet the following JCAHO standards
  • EC.1.10 The organization manages safety risks.
  • EP 5 procedures designed to minimize risk
  • EP 6 safety procedures are practiced and
  • EC. 3.10 The organization manages its hazardous
    materials and waste risks.
  • EC.9.30 The organization improves the

Meeting JCAHO Standards with Pollution Prevention
  • H2E goals meet the following standards
  • PI.3.10 Information from data analysis is used
    to improve performance and patient safety
  • PI 3.20 A proactive program for identifying and
    reducing adverse events is defined and
  • Mercury reduction makes an excellent performance
    improvement goal to meet JCAHO requirements.
    Environment of Care Essentials for Healthcare,
    2nd Ed.

  • JCAHO standards
  • Have environmental compliance elements
  • Have environmental improvement elements.
  • Community health and patient safety can be
    related to activity of healthcare facilities.
  • Pollution prevention makes ideal improvement
    activity for healthcare facilities.

  • MnTAPs Meeting JCAHO Standards with Pollution
    Prevention. www.mntap.umn.edu/health/jcaho.htm
  • H2Es Mercury Elimination Plan
  • www.h2e-online.org/tools/merc-over.htm
  • H2Es Chemical Minimization Plan
  • www.h2e-online.org/tools/chem-p2.htm
  • H2Es Waste Reduction Plan
  • www.h2e-online.org/tools/waste-rhc.htm
  • Healthcare Environmental Resource Center
  • 2005
  • Watch H2E listserve

Never doubt that a small group of thoughtful,
committed citizens can change the world.
  • Indeed, it is the only thing that ever has.
  • Margaret Mead
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