Guide to JCAHO Environment
of Care Standard 3.10.3
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.
© 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 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.
- Practice Greenhealth:
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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 èHazardous
Wasteî, 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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Containers are located within the immediate operator
control and are inspected daily.
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Containers are labeled with a descriptive name of the
waste and the
words “Hazardous
Waste”.
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When satellite accumulation
containers are full they are moved to the hazardous waste storage area
within three days and marked with the accumulation start date.
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Spills |
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Spill
clean up procedures are in place in all areas where
hazardous waste is handled 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 waste is handled or stored.
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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 waste is routinely handled 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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