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With the Joint Commission’s DireCtor of engineering: george mills

HazMat-ter of Fact

Taking a closer look at EC.02.02.01 and the management of hazardous materials and waste

Guest Columnist: Kathy Tolomeo, CHEM, CHSP, engineer, The Joint Commission

An introduction from George Mills, MBA, FASHE, CEM, CHFM, CHSP,

director, Department of Engineering, The Joint Commission: This column clarifies standards expectations and provides strategies for challenging compliance issues, primarily in life safety and the environ- ment of care but also in the vital area of hazardous materials. You may wish to share the ideas and strategies in this column with your organization’s leadership. This month, I enlisted Kathy Tolomeo, CHEM, CHSP, engineer in The Joint Commission’s Depart- ment of Engineering, to further explore aspects and issues related to this topic.

nvironment of Care (EC) Stan- dard EC.02.02.01 is concerned with managing risks related to

hazardous materials and waste in health care organizations. This standard is crucial, with many important elements of performance (EPs) that are often mis- interpreted and improperly addressed. This standard was among the 10 most frequently cited by surveyors during

the first six months of 2015, and 38% of surveyed hospitals were found to be noncompliant with it.

If not carefully inventoried and managed from the moment they enter your facility to the time they are dis- posed of or shipped out, these hazards can lead to serious injuries, illnesses, and code violations. From harmful vapors

to bloodborne pathogens, the related threats are numerous and serious. But with proper preparation and compliance

with applicable laws, regulations, and written procedures, you can better safe- guard your patients, staff, visitors, and surrounding community.

This is the first of two columns focused on EC.02.02.01. This article explores Elements of Performance (EPs) 1 and 3 through 8.

EP 1 The hospital maintains a written, current inventory of

hazardous materials and waste that it uses, stores, or generates. The only materials that need to be included on the inventory are those whose handling, use, and

storage are addressed by law and regulation.

When dealing with hazardous mate- rials and waste (HazMats), important questions need to be asked, including the following:

What are they?
When did they arrive?
What are the safety requirements?
Where are they stored?
What is the quantity?
A HazMat inventory should answer these questions. This inventory only needs to include HazMat items addressed by federal, state, and local regulations and laws, particularly ones specified by agencies like the US Occupational Safety and Health Administration (OSHA), the US Environmental Protection Agency (EPA), the US Drug Enforcement Administration (DEA), the US Nuclear Regulatory Commission (NRC), and

the US Department of Transportation (DOT). Several types of HazMats can be included in your inventory, among them hazardous chemicals, energy sources, medications, and gases and vapors; labo- ratory samples; infectious/medical waste; and radioactive materials.
Your inventory should be documented consistently, accurately, and completely on a paper form or in a database that
lists essential information such as the material’s and manufacturer’s name; the safety data sheet (SDS) on file; maximum quantity on hand; Chemical Abstracts Service (CAS)/catalog number; estimated weight/volume; storage area locations; any health/safety/fire risks; any personal protective equipment (PPE) required; and any staff training required in order to handle the materials. Per OSHA, which the EPA references for chemical inven- tory requirements, the minimal chemical inventory should contain the following:
Chemical name
CAS number
Common name
Synonyms
Product/mixture name (if applicable)

Percentage of ingredients in product/ mixture (if applicable)

See an example of a hazardous materials inventory form on page 7.

The DOT does not require a chemical inventory, since its focus is on the ship- ment of hazardous materials (for example, manifests). However, because Th Joint Commission requires that hazardous waste be included on the inventory, the

Hazardous Materials Inventory Form Example

Hazardous Materials Inventory Form
Organization:
Unit/Area/Dept.:
Building:
Room:
Date:
Inventory Taker:
Material Name	Manufacturer Name	SDS	CAS/ Catalog #	Max Quantity on Hand	Estimated Wt./Vol.	Storage Area	Hazards	PPE	Staff Training Required













© Joint Commission Resources.

use of the DOT UN identifi would be an acceptable identifi for this hazardous waste if no CAS Number is available.

Note that all employers need to understand their SDS inventory in order to provide information to their employ- ees about hazardous chemicals they are exposed to in their workplaces, as stated in the OSHA Hazard Communication Standard, 29 CFR 1910.1200.

EPs 3–4 The hospital has—and implements—written procedures, including the use of precautions and personal protective equip- ment, to follow—in response to hazardous material and waste spills or exposures.

Managing HazMat risks involves following several procedures—includ- ing procedures for selecting, handling, labeling, storing, transporting, using,

generating, monitoring, disposing, documenting, and providing training— that can help your organization decrease the danger.

Many of these recommended proce- dures can be found in the related SDS, which should also include essential information regarding its safe handling, usage, and emergency protocol, as well as any PPE and engineering controls required to maintain and minimize risks. (The SDS may also refer you to further procedures or information that can be found elsewhere, such as within OSHA regulations.)

From SDSs and other resources, orga- nizations can create appropriate written procedures, which should be incorpo- rated in your relevant EC management plan. Staff should also know how to find and follow these written procedures.

The ability to effectively implement these

procedures immediately when a HazMat spill or exposure occurs will depend on the thoroughness of the aforementioned planning and documentation.

EPs 5–8 The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals and radioactive materials; selecting and using hazardous energy sources;

and disposing of hazardous medications.

Reducing threats related to a particu- lar type of HazMats can require a unique approach such as the following:

Hazardous chemicals, including form- aldehyde, glutaraldehyde, and waste anesthetic gas, need to be carefully stored (according to their respective
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HazMat-ter of Fact
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SDS requirements) and adequately ventilated, and staff working with them must be properly monitored and supplied with appropriate PPE, per OSHA.
Radioactive materials must be stored in a locked, secure area and supervised (as mandated by the NRC), affected staff need to be routinely monitored for exposure using a dosimeter, and all radiation-producing equipment has to be carefully inventoried and tracked for service and maintenance.
Appropriate use of, training for, and upkeep of hazardous energy sources like lasers and radiation are vital.
Chemotherapeutic agents must be treated with special care, for example: Tubing and port connections must be properly secured, drug containers have to be transported safely to avoid leakage or spills, and staff must be carefully trained in disposing of these substances.
To more effectively minimize

The substances and materials identified in this graphic represent categories of hazardous materials.
risks pertaining to these four types of HazMats, consider the following tips:
Refer to the respective SDS and the regulations indicated therein.
Implement appropriate engineering controls.
Examine other specific regulations closely, including any issued by the EPA, NRC, OSHA, DOT, and/or DEA.
Conduct risk assessments to identify any environment of care HazMat risks that could affect patients, staff, or other people entering the facil- ity. When evaluating risks, consider factors such as vapors, flammability, corrosiveness, environmental impact, and security and special equipment required.

The value of conducting a risk assess- ment is demonstrated in this example: A staff member is concerned that the clean- ing solution used by custodial workers could splatter or spill, causing eye injury.

A proper risk assessment could determine whether the chemical in question is caus- tic and corrosive (defined by OSHA as having a pH level less than 2.5 or greater than 11.0), which should be indicated on the chemical’s SDS. If a risk for expo- sure is determined, installation of an eye wash station and/or emergency shower is required by OSHA federal regulation 29 CFR 1910.151(c).

Be aware that EPs 5 and 7, pertaining to hazardous chemicals and hazardous energy sources, respectively, are currently hot topics and among the elements of performance that surveyors cite as being most problematic. To curtail risks asso- ciated with EP 5, performing additional risk assessments can ensure a higher level of compliance. And to decrease the risk of staff exposure to hazardous energy sources in EP7, organizations should maintain a complete and accurate inven- tory of policies, procedures, and PPE,

all of which are likely to be meticulously

scrutinized during surveys.

Speaking of PPE, remember that OSHA requires your organization to provide a written “certification of hazard assessment.” This certification documents that you’ve conducted an assessment involving three steps: (1) Identify dangers related to specific hazardous materials;

(2) determine specific staff job functions related to those materials; and (3) assign the appropriate PPE to mitigate hazards for those materials. OSHA mandates that your organization must (1) educate staff on how to correctly use PPE and

(2) prove that staff have been properly trained prior to having contact with any HazMat sources.

Safety requires constant vigilance

Protecting occupants of your facility from hazardous materials and waste takes a dedicated, consistent, and unified effort

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HazMat-ter of Fact

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from staff. This crucial process starts with detailed documentation, continues with the creation and implementation of written procedures (including the use of PPE) to immediately address a HazMat disposer or accident, and carries on with

the identification and abatement of risks related to HazMat sources.

Next month, we will round out this topic by taking a closer look at

minimizing risks associated with select- ing, handling, storing, transporting, using, and disposing of hazardous gases and vapors and their proper monitoring;

complying with applicable laws and regulations pertaining to HazMat threats; properly labeling HazMats; periodically checking of radiation workers to gauge exposure; and creating and following procedures for routine storage and disposal of trash. EC

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