Regulated Medical Waste Waste Reduction Facilities Management Regulations & Standards
ENVIRONMENTAL COMPLIANCE AND IMPROVEMENT GUIDE

To improve compliance with JCAHO Environment of Care Standards

© 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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Introduction        Table of Contents

Topic Locator

The following table lists the major topic areas covered by this Guide, and indicates which JCAHO Element of Performance pages contain items relevant to each topic.  Clicking on the entries in the table will take you to the corresponding items.

See the Designations Table (below, following the Topic Locator Table) to match each entry with its corresponding JCAHO Element of Performance.

Topic Elements of Performance Referring to Topic
General Plan

Plan

 

Safety plan

 

Hazardous Materials Management

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Purchasing

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Handling, labeling, and storage

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Spills (HazMat)

Plan

Inventory

Implementation Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Training (HazMat)

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Hazardous Waste Management

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Recordkeeping and reporting (RCRA)

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Hazardous waste determination

Implementation   Roles (Risks)

Storage

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Satellite accumulation

Implementation   Tours

Spills (RCRA)

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Disposal and transportation

Implementation

Contingency planning

Plan

Emergency

 

 

Training (RCRA)

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Nonhazardous solid waste Tours   Security Plan   Access   Competence
Regulated Medical (Infectious) Waste

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Universal Waste

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Materials of Concern Documentation

Asbestos

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

CFCs

Implementation

Ethylene oxide

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Access

Security Plan

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Formaldehyde

Inventory   Implementation   Space   Gases   Emergency   Competence   

Glutaraldehyde

Implementation   Gases   Competence

Mercury

Plan   Inventory   Implementation   Emergency   Safety plan

Other air contaminants

Gases      

Pesticides

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Petroleum Products

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Pharmaceuticals and Chemo. Mtls.

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Polychlorinated Biphenyls (PCB)

Inventory   Implementation     

Radioactive Materials and Waste

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

Safety plan

Safety Coord.

Tours

Security Plan

Access

Competence

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Leadership (Rules)

Used Oil

Plan   Implementation   Manifests   Labeling

Xylene

Inventory   Implementation   Space   Gases       
Facilities and Equipment Implementation   Space   Documentation   Separation

Recordkeeping and reporting (F&E)

Implementation

Boilers, generators

Implementation   Documentation

Incinerators

Implementation   Documentation   Safety plan

Tanks

Implementation   Emergency   Documentation   Access

Wastewater

Implementation   Documentation   Leadership (Rules)

 

The designations in the table refer to the JCAHO Elements of Performance as listed below:

 

Designation

Element of Performance

Safety Plan

Safety Coord.

Tours

Security Plan

Access

 

Plan

Inventory

Implementation

Space

Gases

Emergency

Documentation

Manifests

Labeling

Separation

 

Training (Goals)

Training (Policies)

Competence

 

Roles (Risks)

Roles (Risk Min.)

Roles (Incident)

Roles (Reporting)

 

Leadership (Rules)

Leadership (Action)

EC 1.10.1  Written management plan for environmental safety

EC 1.10.2  Safety Coordinator

EC 1.20.1, 4, 5 Environmental tours

EC 2.10.1  Written management plan to effectively manage security risks

EC 2.10.6  Control of entrance and egress from security-sensitive areas

 

EC 3.10.1  Hazardous Materials and Waste Management Plan

EC 3.10.2  Hazardous Materials and Waste Inventory

EC 3.10.3  Implementation of Hazardous Materials and Waste Program

EC 3.10.4  Space & Equipment for Handling of Hazardous Materials & Waste

EC 3.10.5  Hazardous Gases and Vapors

EC 3.10.6  Procedures and Implementation for Emergency Response

EC 3.10.7  Documentation, Permits and Licenses

EC 3.10.8  Manifest Management

EC 3.10.9  Labeling of Hazardous Materials and Waste

EC 3.10.10 Hazardous Materials and Waste Storage

 

HR 2.10.1  Staff oriented to organization’s mission and goals

HR 2.10.2  Staff oriented to organization's policies and procedures

HR 2.10.9  Organization assesses competency

 

HR 2.20.1  Describe and demonstrate environment risks

HR 2.20.2  Demonstrate actions to eliminate and minimize risks

HR 2.20.3  Demonstrate procedures to follow in event of incident

HR 2.20.4  Knowledgeable regarding reporting processes

 

LD 1.30.1  Services provided in accordance with rules

LD 1.30.2  Organization acts upon reports, recommendations as appropriate

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