Guide to JCAHO Environment of
Care Standard 3.10.1
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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. |
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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Top
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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Top
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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Top
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
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Petroleum Products (see also Used Oil, below)
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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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Top
Used Oil
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Facility has plans on file, readily
accessible by appropriate st | | |
