Guide to JCAHO Environment
of Care Standard 3.10.1
Please note: this page is under development. Contact
(603) 795-9966,
if you have questions or suggestions.
Introduction Table of Contents Checklist
for 3.10.1
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Environment of Care Standard 3.10: The
organization manages hazardous materials and waste risks
Element of Performance 1: Hazardous
Materials and Hazardous Waste Management Plan
The hospital
develops and maintains a written
management plan describing the processes it implements to effectively
manage hazardous materials and wastes.
© 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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This page provides a set
of criteria for evaluating a facility's written plans for
hazardous materials and waste management. In addition
to an overall plan, specialized plans covering certain critical issues or
materials may also be required by regulations.
Implementation of these plans is covered under EC3.10.3. Aspects of worker and patient safety are covered in
Element of Performance EC1.10.1.
Criteria providing evidence of compliance and of environmental
improvement are listed below for the following topics:
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= Compliance |
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= Environmental Improvement |
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=
Tools and Resources |
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General Environmental Management Plan
Hazardous Materials
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Facility has plans on file, readily
accessible by appropriate staff, for:
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--
creating and maintaining an inventory that identifies and provides
the location for all hazardous materials in use throughout the
facility, including:
- asbestos
- chemicals
(laboratory, cleaning, etc.)
- disinfectants and sterilants
- hazardous
gases
- pesticides
- petroleum products
- pharmaceuticals and chemotherapeutic agents
- polychlorinated biphenyl (PCB)-containing equipment
- radioactive agents and associated wastes
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-- reducing use of
hazardous materials through purchasing policies and procedures that
prefer less hazardous materials.
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-- managing hazardous
materials such as compressed gases, flammable/combustible materials,
acids/bases, ionizing radiation, etc
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-- identifying all
hazardous materials that require employee monitoring, e.g. asbestos,
formaldehyde, ethylene oxide, carcinogens, etc.
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-- selecting and maintaining
personal protective equipment.
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-- communicating hazardous chemical handling and use
requirements to employees.
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-- developing a Community-Right-to-Know plan
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Hazardous Waste
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Facility has plans on file, readily
accessible by appropriate staff, for:
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Hazardous waste management
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--
annually determining hazardous waste generator status.
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--
working toward smaller quantity generator status by minimizing hazardous
materials and waste. |
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--
making hazardous waste determinations by applying knowledge or testing.
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-- managing hazardous
waste, including tracking, storing, inspecting, recycling, treating,
and disposing.
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-- eliminating mercury. |
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-- recycling of
solvents and formalin. |
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-- specifying actions
to be taken in response to fires, explosion or any unplanned releases
of hazardous waste, required if the facility is a Large Quantity Generator.
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Disposal and treatment |
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-- eliminating or reducing incineration as waste treatment
method. |
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-- packaging, labeling
and transporting hazardous waste according to DOT requirements.
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General hazardous waste resources |
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Regulated Medical (Infectious) Waste
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A
Bloodborne Pathogens (BBP) Exposure Control Plan is in place that includes identification and proper segregation of waste from generation to disposal according to a management plan that identifies and describes
the appropriate waste containers, manner of waste disposal and methods
to reduce exposure and waste generation.
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Facility has formulated a comprehensive medical waste
minimization plan, that might include choosing reusable medical devices
and supplies over disposables, reducing the volume of laboratory samples . |
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Facility has a plan
for identifying, segregating, and managing any RMW that contains pathology
waste, or non-hazardous “trace” is chemotherapy
waste.
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Facility has a plan
for packaging, labeling and transporting RMW according to
Department of Transportation requirements.
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Facility has developed provisions for ensuring that RMW arrives
at an appropriate destination.. |
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Universal
Waste
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Facility has plans on file, readily
accessible by appropriate staff, for:
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Identifying and
managing Universal Waste for recycling (i.e., fluorescent lamps, batteries,
certain pesticides, and thermostats).
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Establishing procedures for packaging, labeling, storing
and transporting Universal Waste (e.g., structurally sound container
labeled “Universal Waste - Lamps"),
and for recycling within one year of initial accumulation.
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Pesticides
Petroleum Products (see also Used Oil, below)
Radioactive Materials and Waste
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Facility has plans on file, readily
accessible by appropriate staff, for:
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Managing radioactive
materials and waste (10 CFR 35, 70). |
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Eliminating or reducing
radioactive materials and waste. |
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Used Oil
Spills
Training
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Facility has plans on file, readily
accessible by appropriate staff, for:
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Fulfilling the training
requirements of OSHA, EPA and DOT.
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