SUPPORT SERVICES DEPARTMENT
An ever-growing area of concern in health care settings is the management of hazardous materials and waste. The number of government regulations concerning hazardous materials handling and waste disposal attest to the priorities our society has placed on worker health and safety, and environmental preservation.
The purpose of the Hazardous Materials and Waste Management Program and Plan is to describe the process of how University Hospital (UH) will provide and maintains a safe and supportive environment for patients and those providing services at University Hospital (UH). The Hazardous Materials and Waste Management Program and Plan is consistent with the UH’s mission to provide quality and excellence in patient care, research and community service.
UH with guidance from the University of Medicine and Dentistry of New Jersey (UMDNJ), is committed to maintaining programs designed to prevent and reduce the risks to patients, staff, visitors, and the community by ensuring proper handling and disposal of hazardous materials and waste.
The Hazardous Materials and Waste Management Plan is designed to comply with all applicable federal, state, and local laws, regulations, and standards relevant to the health-care environment.AUTHORITY
The UMDNJ Board of Trustees has ultimate authority and responsibility for the Hazardous Materials and Waste Management Program and Plan. The Board of Trustees has delegated the authority to develop and maintain the processes and activities described herein to the Vice President and Chief Executive Officer (CEO) for University Hospital.
The CEO for UH has delegated responsibility for ensuring compliance with this Hazardous Materials and Waste Management Program and Plan to the Hospital’s Environment of Care Committee. At the direction of the Hospital Environment of Care Committee Chairperson, the Hospital Hazardous Materials and Waste Management Subcommittee will monitor implementation and compliance with this plan.SCOPE AND RESPONSIBILITIES
The specific hazardous materials and waste categories addressed are hazardous chemicals, infectious materials, chemotherapeutic drugs and radioactive materials. The relevant hazardous materials and waste management documents and program plans are enumerated herein and appended as attachments. These documents define the department responsibility and procedure for the safe handling, storing, use and disposal of hazardous materials and waste.
Additionally, this Hazardous Materials & Waste Management Plan covers the associated emergency response procedures, training and education programs and the Environment of Care Committee's Environment of Care Program for performance measurement data collection and evaluation.
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Hazardous Chemical and Waste
The UMDNJ New Jersey Worker and Community Right to Know Policy (attachment 1) addresses hazardous chemical handling for the entire Newark campus including University Hospital. The Department of Environmental and Occupational Health and Safety Services (EOHSS) administers this policy. Included in the policy are provisions for: inventory of all products and chemicals, material safety data sheets and hazardous substances fact sheets, container labeling, handling and storage, training and education, and monitoring and evaluation of the program’s requirements.
The Laboratory Safety Policy (attachment 2) specifically addresses University Hospital based clinical laboratories. The UMDNJ Laboratory Safety Plan (attachment 3) outlines the duties and responsibilities under this regulation. EOHSS administers this program through the departmental Laboratory Safety Officers.
The UMDNJ Hazardous Waste Management Policy (attachment 4) addresses hazardous waste management, University wide. The department of EOHSS administers this policy through the UMDNJ Hazardous Waste Management Program (attachment 5).
The UMDNJ Physical Plant Department administers the asbestos management program, with the assistance of the Department of EOHSS.
The New Jersey Medical School Occupational Medicine Service (OMS) offers periodic medical evaluations to employees who are potentially exposed to asbestos and to other selected hazardous chemicals, as required by PEOSH.
Infectious Materials and Waste
The UMDNJ Bloodborne Pathogens Policy addresses infectious materials (attachment 6). The Hospital Infection Control department administers this policy along with specific UH infection control policies and procedures outlined in the Hospital Exposure Control Plan (attachment 7).
The UMDNJ Regulated Medical Waste Policy (attachment 8) addresses the management and disposal of infectious waste by the UMDNJ Department of Environmental Services.
Chemotherapeutic Drugs and Waste
The UH Chemotherapy Spill Clean Up Policy addresses the procedure for cleaning up chemotherapy spills in the hospital (attachment 9). The related guidelines for staff training, and the chemotherapy disposal method used at UH is addressed in the Environmental Services Policy (attachment 10).
The Department of Environmental Services administers the chemotherapy drug waste program for all but six drugs: cyclophosphamide, daunomycin, melphalan, mitomycin C, streptozoticin, and uracil mustard, which are considered hazardous waste. The department of EOHSS is responsible for their disposal.
Occupational Medicine Services offers medical evaluations to employees who are potentially exposed to chemotherapeutic drugs at hire and periodically.
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Radioactive Materials and Waste
The UMDNJ Radiation Safety Policy & Procedures (attachment 11) addresses radioactive materials handling and disposal. The UMDNJ-Office of Radiation Safety Services Department is responsible for administering this policy.
Emergency procedures for chemical spills are described in:
a. UMDNJ's Emergency Spill and Mitigation Policy (attachment 12)
b. UMDNJ's Emergency Response Guide (attachment 13)
Additionally, emergency procedures for major releases of hazardous materials or wastes are detailed in the UMDNJ Contingency Plan and Emergency Procedures for Hazardous Material/Waste Releases (attachment 14).
Emergency procedures for blood and body fluid spills are described in:
a. UH's Exposure Control Plan (attachment 7)
b. UMDNJ's Emergency Response Guide (attachment 13)
Emergency procedures for chemotherapy drug spills and cleanup are described in the Environmental Services Policy (attachment 10).
Emergency procedures for radioactive spills are described in the “Emergency Response Guide and the Radiation Safety Policy Manual (attachment 11).
Education and Training
The overall University Hospital Orientation Program includes Right-to-Know and Standard Precautions/Bloodborne Pathogens training. Supervisors will monitor compliance with the requirement stating that all staff members must attend the Right-to-Know training upon hire and every two years. In addition, Supervisors must ensure that staff having direct patient contact or potential exposure to blood or other body fluids must attend the Standard Precaution/Bloodborne Pathogens training upon hire and annually.
The Office of Radiation Safety Services conducts Radiation Safety Training for Hospital staff during the UMDNJ orientation for new employees; and annual refresher training is provided for nursing staff members, housestaff, x-ray technicians, environmental service workers and nuclear medicine employees.
Special Note: All EOHSS emergency response personnel receive an initial forty (40) hours of training in Health and Safety Procedures for Hazardous Waste Operations, within six (6) months of being hired, and eight (8) hours of refresher training annually pursuant to 29 CFR 1910.120.
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Measurement Data Collection and Evaluation
Measurement data are routinely collected to evaluate performance. The UH Environment of Care Committee's Information, Collection and Evaluation System (ICES) is designed to identify and evaluate conditions in the environment of care regarding hazardous materials and waste. The UH Safety Coordinator is responsible for directing the process of collecting performance data about deficiencies and opportunities for improvement in the hazardous materials and waste management program. ICES examples (including all areas: hazardous chemicals, infectious materials, chemotherapy drugs, radioactive materials) are as follows: general safety inspection reports, right-to-know labeling and segregation of hazardous materials.
The effectiveness of the Hazardous Materials & Waste Plan is monitored through the UH’s Performance Improvement Program.
Performance standards are developed to assess staff knowledge and skill requirements, monitoring activities, reporting procedures, preventive maintenance requirements of equipment used in managing hazardous materials and wastes, or inspection and testing requirements of equipment used in managing hazardous materials and wastes. Evidence of corrective actions or performance improvement may include new or revised program document or policies and procedures. Unless stated otherwise the responsible departments review all Hazardous Materials and Waste Management Program and Plans and documents annually and revised as required.
The Hazardous Materials & Waste Plan will be evaluated annually to determine its effectiveness.
The Hazardous Material & Waste Plan is submitted to the Hospital’s Environment of Care for review and approval.
THIS MANAGEMENT PLAN ADDRESSES THE CONTROL OF HAZARDOUS MATERIALS AND WASTE AS REQUIRED BY APPLICABLE NEW JERSEY AND THE JOINT COMMISSIOIN ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO) STANDARD EC.1.3.
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