SAMPLE WASTE MANAGEMENT PLAN

MANAGING PATIENT WASTES: TAKING YOUR PROGRAM TO THE NEXT LEVEL
The development and implementation of effective plans and programs to reduce, source separate and recycle hospital waste is among the most significant environmental challenges now facing the healthcare industry. In many states this challenge is powered by the need to meet mandatory recycling goals, some as high as 40%. For many hospitals the need to develop and implement these waste management programs represents a significant cost and a necessary evil associated with the care and treatment of patients. However, for other hospitals like the Albany Medical Center located in Albany, NY, effective waste management programs have provided important opportunities for environmental quality, economic value, quality management and community service.

Many hospitals have successfully implemented "conventional" recycling programs similar to those found in hotels, restaurants and office buildings which recycle office paper, cardboard, glass, tin, etc. These programs and their success are important contributors to the hospital's overall waste management goals, however, such "conventional" programs in themselves may not be adequate to meet the new aggressive recycling mandates established by some states. These conventional programs offer excellent opportunities to promote environmental quality; however, such programs, in themselves, do not always guarantee significant savings.

In view of the above, hospitals must develop and implement new "non-conventional" waste management strategies to meet these waste reduction mandates and the associated challenges. The large volume of waste generated at healthcare facilities is the by-product of a system that has developed the ability to provide the best and most advanced health care in the world, however, little attention has been given to the environmental side effects and waste costs associated with this care, including significant amounts of medical waste, discarded packaging, corrugated boxes, plastic bottles, etc. As a result, there is a great need to develop and implement waste management strategies which include the waste generated by the care and treatment of patients.

THE 'CURE WASTE' PROGRAM
In January, 1991, the Albany Medical Center developed and implemented Phase I of its nationally recognized waste management program known as the "Cure Waste" Program. This Phase of the Medical Center's "Cure Waste" Program was most successful, with over 2.4 million pounds of waste reduced or recycled during the first two years of the program. During the initial phase of the "Cure Waste" Program, the Medical Center's waste management activities were built upon a multi-strategy approach to waste reduction, product reuse and recycling. The Center's recycling activities during this initial phase were limited to the typical "conventional" recycling programs in the support areas and administrative offices. The results of these "conventional" recycling programs produced a recycling rate of 28%. The 28% recycling rate at the Medical Center, which exceeded the New York State recycling mandate of 25%, did not include the waste stream generated by the patient care and clinical areas. The success of the Phase I waste management activities also saved the Medical Center $260,000. These initial savings were attributed primarily to product reuse and reduced medical wastes costs achieved through the use of reusable medical waste containers.

THE PROGRAM PHILOSOPHY
A hospital's waste management program, like any other management and organizational effort, should be developed in accordance with the specific philosophy, values and beliefs of the institution. Will the program be aggressive or passive? Will the facility be proactive or reactive? Will the facility be a leader or a follower? The waste management philosophy at each facility should be site-specific and based on a number of factors, including the facility location, regulatory requirements, available services, waste management alternatives, etc.

The philosophy at the Albany Medical Center and the Center's overall mission, vision and values have played a major role in the character and quality of the Center's Waste Management Program. The "Cure Waste" Program has been built upon the following basic "values and attitudes" which have given it a clear "can do" attitude and a willingness to use a "cutting edge" approach:

• The Center recognizes and respects its role in the community and its responsibility to the environment.

• The Center believes that it has an obligation to develop a strong, financially viable waste management program.

• The Center believes that waste management in patient care and clinical areas is "Product Oriented" material management and that there must be a strong linkage between the Center's waste management and material management responsibilities.

• The Center believes that waste management is much more that just waste disposal and that hospital waste management is much more than just medical waste.

• The Center believes that waste management doesn't happen without an effective plan, and that the plan should be a simple, effective blueprint.

• The Center believes that effective waste management is hard work, requiring the time, effort, and commitment of an aggressive, multi-disciplinary team.

• The Center recognizes and understands that waste management problems will not just go away and that such problems will not be solved by government.

• The Center is confident that waste problems can be solved and that the waste management regulatory picture is clear enough to make decisions and to take action.

• The Center knows that waste management costs are significant, but also confident they can be managed and controlled.

THE MULTI-STRATEGY APPROACH
The "Cure Waste" Program is generally directed by aggressive waste management goals and objectives that are updated annually to provide a program with a cutting edge philosophy focused on the "hottest" and most contemporary issues. The Program is "multi-strategy" in nature, with a sizable list of "action" steps and objectives that deal with a variety of waste-related issues, including waste reduction, etc. The multi-strategy approach also provides an opportunity to involve a greater number of employees and staff in the "Cure Waste" Program activities and the associated detailed development and implementation of each strategy. This increased participation also promotes "ownership" in the program and an increased desire to succeed.

ALBANY MEDICAL CENTER PRODUCT-FUSED WASTE MANAGEMENT MODEL

PROGRAM GOALS AND OBJECTIVES
As indicated above, the "Cure Waste" Program is directed by a number of aggressive goals and objectives focused on a variety of issues. The nature of the Center and the complexity of its waste stream and the associated regulatory requirements could easily bury the "Cure Waste" Program and render it ineffective. To avoid this pitfall, the "Cure Waste" Program has intentionally been developed and built upon a foundation of simple and clear goals and objectives using a simple and effective blueprint. These goals and objectives have changed and grown with the success of the Program; however, they still remain simple in concept as they guide the day-to-day working activities of the Program. The use of clear objectives keeps the Medical Center, its people, audits and "Cure Waste" Partners on a common path. The use of important, yet simple, objectives also makes early success easier, which in turn provides the confidence, motivation, pride and desire to achieve more.

This summary of recent Program Objectives is provided below to demonstrate typical objectives and the general directions followed:

• Expand recycling program to reduce total waste stream by recycling 750,000 pounds per year by January 1.

• Conduct annual review of all aspects of the Center's waste management program. Prepare annual report to the Board of Directors.

• Develop and implement comprehensive plan and procedures for source separation, including patient care areas. Reduce medical waste stream by 200,000 pounds per year.

• Develop and implement a plan for "interim" on-site storage of low-level radioactive waste.

• Expand recycling program to include separation of kitchen and food waste. Reduce kitchen waste stream by 90,000 pounds per year.

• Establish subcommittee to develop and implement Center-wide office paper recycling program and to increase use of recycled paper products.

• Increase coordination between "Cure Waste" Task Force and the Value Analysis Committee. Increase purchase and use of recycled material.

• Develop and present Center-wide education program to promote recycling, product reuse and waste reduction.

• Develop and implement Center-wide source separation program to increase collection of recyclables, including separation of organic materials for compost program.

• Complete installation of new cafeteria dishwasher. Increase use of reusable cafeteria ware. Reduce waste of disposables by 30,000 pounds per year.

• Complete construction of waste processing and recycling center.

• Require that all major product vendors submit evidence of their commitment to waste audit to update the Center's waste management data base.

• Conduct a comprehensive waste audit to update the Center's waste management data base.

• Develop and implement plan for management and disposal of confidential records.

• Conduct comprehensive analysis of major inventory, supplies and materials used by the Center. Assess material content and packaging to identify opportunities for waste reduction, source separation of medical waste and recyclables.

• Develop and implement program to source separate batteries. Where appropriate, implement recycling program. Where required, manage hazardous wastes in accordance with Center policies.

• Reduce disposable of contaminated mercury. Implement program to increase processing and recycling of mercury.

MODEL WASTE REDUCTION PROGRAM IN PATIENT CARE AND CLINICAL AREAS

The Medical Center's project to develop a Model Waste Reduction Program in Patient Care and Clinical Areas was begun, with the following objectives:

• Seek the input and guidance of other hospitals, major product manufacturers, waste service vendors, waste management consultants, material managers, government regulators and the Hospital Association of New York State in the design of the program model and to assure its universal application to other healthcare facilities.

• Develop working relationship with major product manufacturers to promote product changes to reduce the patient care waste stream by eliminating or reducing excessive packaging, eliminating obsolete products, increasing use of reusable or recyclable packaging and containers, etc.

• Develop a practical guideline for conducting an effective waste stream audit in patient care areas, including the development of a Quality Management Audit Tool.

• Develop simple patient waste source separation procedures that identify and classify the items to be separated and recycled.

• Develop sample procedures and guidelines for environmentally sound purchasing and "value analysis" of products, including waste efficient product and packaging "reusable" versus "disposal," etc.

• Evaluate and assess the infection control and the occupational health and safety risks associated with source separation, changes in products, product packaging, product handling and waste management practices.

• Develop staff education and training program.

• Prepare Handbook and "how-to" guidance manual with training aides describing the "Model" with sample policies, procedures, systems and processes.

• Establish pilot programs to test procedures and processes.

THE PRODUCT MANAGEMENT APPROACH
The Medical Center, as the result of its experience with Phase I of the "Cure Waste" Program, learned that effective waste management begins when products are specified, purchased, stored and distributed. The Medical Center believes that this is especially true in the case of medical and surgical supplies. As a result, the Albany Medical Center has developed a "Material Management" approach to the management of their waste. This approach, which analyzes the Center's product and material management practices, includes the following:

• Analyze the medical and surgical products used at the Medical Center to identify, classify and evaluate the waste characteristics of the product and its packaging.

• Evaluate the "cradle to grave" flow, distribution, use and eventual disposal of the product and its packaging from the warehouse to the patient care area to identify opportunities for pre-cycling and source separation.

• Evaluate operational factors associated with source separation issues, including labor, space, equipment, containers, costs, etc.

• Identify specific products, packaging, material management procedures, and/or waste management practices which result in unnecessary waste or significantly limit or prevent source separation opportunities.

• Develop proposed standards for more waste efficient products, containers, and packaging.

• Develop proposed policies and procedures for pre-cycling and source separation.

• Implement "pilot programs" with major product manufacturers and suppliers to develop and test product, container and/or packaging changes.

THE 'VALUE ANALYSIS' PROCESS
The Medical Center's view that effective waste management begins with effective material management became a perfect complement to the Medical Center's aggressive "value analysis" process. This process, which involves the on-going review and evaluation of the Center's products for value, cost, quality, safety and effectiveness, now includes an evaluation and review of a product's waste characteristics. The Medical Center's Value Analysis Committee and its "Cure Waste" Task Force now work in close harmony in an effort to seek and effect change in products and packaging. The marriage of the Center's waste management, value analysis and product management activities include the following activities:

• Conduct on-going assessment of product use and product technology to determine feasibility of using "reusable" versus "disposable" products.

• Establish a policy that requires that all major medical and surgical product vendors submit evidence of their commitment to waste management through more efficient product packaging.

• Implement "pilot programs" with major product manufacturers and suppliers to develop waste efficient changes and/or innovations in products, containers and/or packaging.

THE PRODUCT AUDIT PROCESS
The Audit itself is a fairly simple procedure. Mostly it involves walking around, being observant, asking questions, listening, and looking at trash or potential trash. What is important is that it be done systematically, and that clear and accurate records be maintained for later analysis and the building of recommendations.

When conducting a product-oriented waste management walk-through, the following steps will increase the effectiveness and value of the product audit:

1. Establish Clear Objectives

• Identifying those products that will offer the greatest opportunities to reduce wastes through packaging or component adaptions.

• Possibilities for cooperative working relationships with suppliers who need to be cultivated as allies in your "war on waste."

• Identifying opportunities to remove packaging at the most immediate entry/distribution points within your institution.

• Creating opportunities for better inventory control and distribution practices.

• Finding opportunities to tie product quality review, purchasing, materials management and waste management together in a new partnership

• Engaging clinical staff in problem solving around product use and packaging issues that could eliminate waste.

2. Review the Issues ... The waste audit should be developed to look at a number of specific issues. These issues can best be represented by conducting an audit, which will ask and hopefully answer the following questions:

• Is there a continuing need for the product and/or its packaging?

• Are the products/packaging the most cost effective and environmentally sound available?

• Can functions/features be combined to reduce products without jeopardizing performance?

• Can product/packaging be reduced without sacrificing functionality (i.e. does an item need to be double wrapped)?

• What can be done to increase the in-use life cycle of products - evaluating the reuse of a product versus single use, e.g. investigating in-dwelling times of catheters, reviewing procedures that dictate usage times of a product such as IV caths, connection tubing, etc.

• What can be done to eliminate excessive packaging and/or replace it with re-usable packaging or containers?

• Can outer and secondary packaging be removed prior to distribution?

• Do the purchase/use quantities seem realistic? Are quantities requested a guess or based on patient census or history? How often are these number checked and updated?

• Are the inventories (including the informal inventories) being properly controlled?

• What is done to control samples and "free goods?" At disposal time these items, with their very excessive packaging, are anything but free!

• Are there signs of product abuse? Talk to the users to find why staff may be discarding what appears to be satisfactory product. If there is a reason to change product work with staff to find a more acceptable alternative.

• What can be done to improve the logistical systems? When walking through the facility, talk with the product movers (warehouse workers, distribution staff, waste handlers, etc.).

• Investigate the utility rooms in patient care areas. Take a peek in the open disposal containers, observe the final disposal practices (including a visit to the landfill).

• What is being done with surplus equipment and supplies? There are numerous options available for the redistribution of unused supplies and old equipment in alternative settings.

3. Develop an "Action Plan" ... Upon completion of your audit, take your list of findings and develop a plan, targeting specific materials, products, areas and suppliers. Elements of a plan may include the following points taken from a typical hospital product waste audit:

• Opening cartons in central supply and distributing products on carts to keep the cardboard off the floors.

• Contacting XYZ Supply Company for information on what material their packaging is composed of.

• Requesting that doctors regularly update their inventory of customized pre-packaged surgical kits to reduce supply waste.

• Advocating that the group purchasing corporation the hospital belongs to sets packaging standards for certain materials.

• Contact your battery and equipment suppliers to see if they will take back spent batteries.

• Examine regulatory requirements that restrict reduction, reuse or recycling opportunities, and challenge them if necessary.

• Request information on the environmental impact of disposal of certain types of materials or packaging from the vendor responsible for waste disposal (e.g. PVC in an incinerator; mercury in an autoclave; batteries in a landfill).

Each facet of the plan should be related to a "finding" from the audit. The plan components should be prioritized following the "80/20" rule.

THE SUPPLIER'S
'ENVIRONMENTAL ASSESSMENT'
All major manufacturers and vendors that provide product to the hospital should submit a comprehensive statement and documentation of their corporate commitment to the environment, including waste reduction. The hospital should have a clear list of environmental standards it is seeking to apply to all purchases. This list should be shared with all vendors, and a request would be made for voluntary compliance and cooperation with those standards. A vendor who wants to keep your business will listen to your concerns. Depending on the outcome of your waste audit you may find an opportunity to target one or two vendors to work on solving some of the biggest waste problems. These approaches are best made as solicitations for partnerships.

The "Supplier's Environmental Assessment Statement" used at the Albany Medical Center includes the following issues: 1. State the vendor's environmental policies and demonstrate how these policies are supported by the company.

2. Establish procedures for evaluating product designs, packaging and distribution practices ... and continually seek new waste reduction alternatives.

3. Reduce packaging materials without diminishing product performance.

4. Reduce heavy metals in inks, colorants, plastics, stabilizers, batteries and other toxic materials.

5. Provide non-hazardous alternatives to the hazardous materials being supplied.

6. Increase the use of recycled materials in their product or manufacturing process.

7. Use or develop materials that are easier to recycle or dispose of.

8. Ship in bulk with no, or minimal, packaging.

9. Use returnable shipping containers.

10. Work as a partner to suggest changes in procedures, or products of use, that will help to eliminate problems identified in a cost effective manner.

Let your vendors know that you will favor products that meet your waste-reduction goals, and that changes in product packaging to meet those goals should not increase product prices. You should not have to pay a premium for environmental quality in product selection.