University of Minnesota
Minnesota Technical Assistance Program

Meeting JCAHO Standards with Pollution Prevention

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) requires health care facilities to meet performance standards in specific areas. The standards are set to achieve maximum performance for activities affecting the quality of care at the facility. To meet standards, healthcare facilities must develop performance improvement initiatives. These initiatives help the facility continuously improve and remain competitive.

Pollution prevention (P2) activities make great performance improvement initiatives. They can help you achieve JCAHO standards included in the Comprehensive Accreditation Manual for Hospitals (CAMH)—JCAHO's most frequently used accreditation program-and meet rules, regulations and the goals of Hospitals for a Healthy Environment (H2E). They also promote the health of the public-keeping in line with the basic premise of healthcare.

Meeting JCAHO Standards with Pollution Prevention [2003, PDF, 229KB] outlines pollution prevention activities that achieve JCAHO standards included in the CAMH. Each pollution prevention activity addresses how to achieve the standards and meet many rules, regulations and H2E goals.

The following pollution prevention activities are covered in this document:

JCAHO CAMH Standards

The following standards can be met through pollution prevention activities. We've condensed the standards here for quick reference. For complete standards, refer to your CAMH, or contact JCAHO at 630.792.5000.

EC.1, EC.1.2: The organization plans for a safe environment and implements its plan.

EC.1.3, EC.2.3: The organization plans for managing hazardous materials and waste and implements its plan.

EC.1.5, EC.2.5: The organization plans for fire prevention and implements its plan.

EC.2, EC.2.2: The organization plans for employee safety and implements its plan.

EC.2.8: Personnel have appropriate knowledge and skills regarding the proper management and disposal of hazardous materials.

EC.4: The organization improves conditions in the environment.

GO.2: Performance improvement is financially sound.

PI.1: Performance improvement is system wide.

PI.1.2: Performance improvement is consistent with the organization’s mission as it relates to community health.

PI.2: Improved and new processes are well designed and consider patient safety.

RI.1.2.2: Patient understands outcomes of care including unanticipated outcomes.

TX.3.4.2: Medication recall system provides for safe disposal of recalled and discontinued medications.

Rules, Regulations and Goals

Pollution prevention activities can help you comply with the following rules, regulations and H2E goals. Links to more information are provided if we found useful information on the Web.

Clean Air Act

  • Medical waste incinerator rules. U.S. Environmental Protection Act's (EPA) air emission regulations for medical waste, including rules, and technical and implementation information.
  • Title V Permits. This U.S. EPA page outlines Title V permit programs, requirements and conditions. Permit applications are also available.

Clean Water Act, National Pollution Discharge Elimination System (NPDES), 40 Code of Federal Regulations (CFR) 122 and 403

  • Hospital wastewater, 40 CFR 460
  • Local wastewater permits. Restrict discharge of certain chemicals, heavy metals and high biological loads to sanitary sewer.

Community Right to Know, 40 CFR 302-304, 311, 312.

Plan for and report to local emergency planning committee extremely hazardous substances and certain hazardous materials.

Environmentally Preferable Purchasing (EPP)

Environmentally preferable goods and services are those that have a lesser or reduced effect on human health and the environment when specifically compared with other goods and services that serve the same purpose. These sites provide resources for instituting EPP at your facility.

  • U.S. EPA's EPP. A federal program that encourages and assists Executive agencies in the purchasing of environmentally preferable products and services. The EPA's site explains EPP terms and concepts, and provides a number of tools and case studies that help make environmentally preferable purchasing more tangible.
  • Minnesota Pollution Control Agency. Information about buying environmentally responsible products that have a reduced effect on human health and the environment. Includes a searchable directory of Minnesota products made from recycled materials. Also includes links to the state procurement office and other organizations involved with environmental purchasing.

Additional Resources

Federal Insecticide, Fungicide and Rodenticide Act (FIFRA) Basis for disposal, distribution, regulation, sale and use of pesticides-including algicides, disinfectants, germicides, sterilants and swimming pool compounds-in the U.S. Information from the Cornell Law School on environmental pesticide control including registration of pesticides, record keeping, storage, disposal, transportation and recall.

Food and Drug Administration (FDA) public health notification: polyvinyl chloride (PVC) devices containing the plasticizer diethyl hexyl phthalate (DEHP), June 2002 The FDA Department of Health and Human Services offers steps that you can take to reduce the risk of exposure to PVC devices containing DEHP.

Hazardous Materials Transportation Act, 49, CFR 171-180
U.S. Department of Transportation provides information about regulations, emergency response, training and shipment requirements for transporting hazardous materials. Requirements for packaging, labeling and transporting infectious substances.

Hazardous Spill Response (HAZWOPER), 29 CFR 1910.120 Standards for safety and health protection of employees engaged in hazardous waste operations and emergency response. This U.S. Occupational Safety and Health Administration (OSHA) page answers frequently asked questions about HAZWOPER.

National Fire Protection Association Life Safety Code, 101-1997, Life Safety Code

OSHA Hazard Communication/Employee Right to Know, 29 CFR 1910.1200

  • Kem Medical Products Corp. Information that employees have a right to know about a variety of chemicals including ethylene oxide, formaldehyde and glutaraldehyde.
  • OSHA outlines the Hazard Communication Standard.

Pollution Prevention (P2) Act of 1990, U.S. Code (USC) Title 43 the Public Health and Welfare Chapter 133. Established P2 as a national policy and developed a hierarchy of waste management. This U.S. EPA page contains requirements of the act

Resource Conservation and Recovery Act (RCRA), 40 CFR 261-263

  • Requirements for hazardous waste management
  • Waste minimization sec 3002(b) U.S. EPA outlines the responsibility of waste generators to have a program in place to reduce the volume or quantity and toxicity of the waste.

Spill Prevention Control Countermeasure (SPCC) Plans, 40 CFR 112. Requires spill prevention plans for storing certain quantities of oil.

State Infectious/Regulated Medical Waste Regulations. Defines and describes appropriate management of infectious waste.

Sustainable Hospitals. Resources for the Lowel Center for Sustainable Production for finding non-hazardous product alternatives, organized by product manufacturer and hazard.

Universal Waste Rule. U.S. EPA gives guidelines for dealing with waste batteries, pesticides and mercury-containing equipment.

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