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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, health care 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 health care.
"Meeting
JCAHO Standards with Pollution Prevention," (2003, PDF: 13 pp, 229 KB) 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.
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 a 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
site provides resources for instituting EPP at your
facility. |
| • |
U.S.
EPA's EPP is a federal-wide 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
Office of Environmental Assistance 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. |
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.
Assistance
For help achieving JCAHO standards and meeting rules,
regulations and the goals of H2E using pollution prevention,
contact Catherine
Zimmer, MnTAP health care specialist, at 612.624.4635
or 800.247.0015 from greater Minnesota.
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