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Guide to JCAHO Environment of
Care Standard 3.10.1
Please
note: this page is under development. Contact
(734) 995-7989,
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. Citations from JCAHO standards are ©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. These pages do not reflect any changes in the standards made after 2005. |
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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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