WASTE MANAGEMENT POLICY Policy and Management Procedures for the disposal of clinical/healthcare and household/domestic waste Co-ordinator: Property & Environment Manager Reviewer: Healthcare Waste Committee Approver: Chief Executive NHS Grampian Signature Signature Signature Identifier: Property & Environment Manager Review date: By 31 March 2008 Implementation date: 1 April 2006 Uncontrolled when Printed VERSION - 1 April 2006 (HWC APPROVED)
NHS Grampian WASTE MANAGEMENT POLICY Policy and Management Procedures for the disposal of clinical/healthcare and household/domestic waste This policy is also available in large print and on computer disk. Other formats can be supplied on request. Please call the Corporate Communications Team on 01224 554400 for a copy. 2
NHS Grampian WASTE MANAGEMENT POLICY Policy and Management Procedures for the disposal of clinical/healthcare and household/domestic waste Policy Ref: Controlled Document: Expiry Date: Author: Policy Application: Purpose: NHSG/POL/RM-OH&S/9.3 This document can be copied in part or whole but not altered without the express permission of the author or the author s representative. None, reviewed bi-annually. Property & Environment Manager The policy applies to all waste that arises in premises and land - owned, leased or used in delivering NHS Grampian healthcare services. This includes all scrap, surplus assets and moveable equipment, part or whole, which are defined in law as waste. This policy is to be used and read in conjunction with other NHS Grampian policies in particular, integrated with the Environmental Policy. The purpose of the policy is to set out the policy objectives, the supporting management responsibilities and organisational arrangements, in keeping with statutory and mandatory requirements. This document does not contain the specific details of the statutory or mandatory arrangements for waste management, which are to be found within Legislation and Scottish Executive Health Department Instructions and Support Guidance. RESPONSIBILITIES FOR IMPLEMENTATION Organisational: Departmental: Chief Executive and Management Teams Departmental / Line Mangers/ All Staff Policy Statement: 1. NHS Grampian takes seriously the requirements for a structured approach on the management of Clinical/Healthcare and Household/Domestic Waste disposal, to ensure that health, safety, environment and financial risks are managed and effectively integrated within the overall risk management arrangements, all in accordance with statutory requirements, national waste strategy (Scotland) and mandatory NHSScotland Instructions; 2. NHS Grampian is committed to the effective management of Clinical/Healthcare and Household/Domestic Waste arising through the development of realistic and acceptable risk based procedures, which meet the spirit and letter of the law, the performance standards and the interpretation set out in NHSScotland Scottish Hospital Technical Note No 3 Management and Disposal of Clinical Waste; 3
3. NHS Grampian recognises that the management of Clinical/Healthcare and Household/Domestic Waste disposal is a management responsibility ranking alongside other management and performance objectives; 4. NHS Grampian is committed to undertake, maintain and monitor the performance and risks of Clinical/Healthcare and Household/Domestic Waste management arrangements to ensure compliance with Standing Financial Instructions and all relevant statutory and mandatory requirements; 5. NHS Grampian will, as far as is reasonably practicable, ensure that Clinical/Healthcare and Household/Domestic Waste arising is secure from areas of public access and properly and efficiently managed throughout. All in keeping with the Duty of Care, as prescribed in the Environmental Protection (Duty of Care) Regulations: 1991 and all other relevant waste management legislation and associated guidance. Where appropriate and risks are minimal, consideration will be given to reduce, re-use and recover materials and substances, to avoid unnecessary disposal; 6. NHS Grampian recognises its responsibilities under the Health and Safety at Work etc Act: 1974 and will provide its employees, including agency, contract and volunteer staff with sufficient information, training, supervision, equipment and safe systems of work to carry out their duties to implement this policy; 7. NHS Grampian recognises its responsibilities to ensure the safe management of Clinical/Healthcare and Household/Domestic Waste arising. In order to achieve this, the highest priority will be accorded to the following aims and objectives: a. Keep secure and safeguard against the uncontrolled release or spillage of waste material; b. Minimise the production and environmental impact of waste by reviewing materials used and practices employed; c. Ensure that Clinical/Healthcare and Household/Domestic Waste are properly and efficiently segregated, presented in appropriate fit for purpose packaging, handled, stored, transported, treated and disposed of; d. Ensure procedures for waste management are established, adopted, understood and implemented; e. Provide information, instruction, training and supervision as necessary to ensure the implementation of waste management systems; f. Take cognisance of, and implement any actions necessary, to address relevant matters raised or recommended by Healthcare Waste Control, Infection Control and Risk Management committee meetings. 8. NHS Grampian requires the assistance and co-operation of all employees in the pursuit of this policy. Review: Approved by: This policy will be reviewed bi-annually. Date: Signature: Designation: 4
NHS Grampian WASTE MANAGEMENT POLICY Policy and Management Procedures for the disposal of clinical/healthcare and household/domestic waste INTRODUCTION NHS Grampian delivers healthcare services across a wide portfolio of settings and a corresponding range of clinical/healthcare and household/domestic wastes arise. The presentation of suitably segregated wastes for a wide range of safe disposal technologies comes with many burdens, costs and risks. The Scottish Executive Health Department has provided NHS Boards with specific waste and environmental management responsibilities and obligations whilst delivering services. NHS Grampian is obliged to understand a wide range of statutes and legislation broadly contained within the Health and Safety at Work etc Act: 1974 framework and within the Environmental Protection Act: 1990 framework. NHS Grampian is required to assess the risks in the context of the protection of workers engaged in healthcare and in waste management, and for the protection of the local and wider environment. There are 3 distinct types of waste: clinical/healthcare waste arising directly from the delivery of healthcare by clinicians. This includes a wide range of controlled wastes defined in legislation due to ethics, risk of infectiousness or containing hazardous substances by class, origins or properties Clinical Waste, Healthcare Waste, Special Waste, Hazardous Waste and low level Radioactive Waste; hazardous/special waste arising from the delivery of healthcare in both clinical and non-clinical settings, but are not household/domestic waste. This includes a very specific range of controlled wastes defined in legislation due to containing dangerous/hazardous substances by class, or properties Special Waste and Hazardous Waste; household/domestic waste arising ancillary to the delivery of healthcare in both clinical and non-clinical settings. This includes a wide range of controlled general wastes defined in legislation due to minimal risk of infectiousness or danger from hazardous substances by origins Household Waste, Commercial Waste, Industrial Waste, Construction/Demolition Waste, Non- Hazardous Waste. This may also include wastes defined, under the Freedom of Information (Scotland) Act: 2002 and the NHS Grampian Records Management Policy, as Confidential Waste. RESPONSIBILITIES AND PROCEDURAL FRAMEWORK Organisational: The Chief Executive and the Management Teams are responsible for: Ensuring Operational Procedures and Risk Management arrangements to meet this policy are in place; Providing resources for implementing and maintaining this policy; Reviewing performance of this policy; Reviewing the effectiveness of this policy. 5
Director of Facilities: The provision of adequate facilities support arrangements to implement and maintain the uplift and disposal aspects of this policy; The provision of waste management and annual performance reports to Chief Executive, Management Teams, Infection Control Committee and Risk Management Group: Reviewing the effectiveness of the policy NHS Grampian wide; Waste Management following the requirements of SEHD HDL(2002)43 and SHTN 3 by acting as Waste Management Officer with the following integrated waste management team: Clinical/Healthcare Waste and Hazardous/Special Waste arising from the delivery of healthcare by clinicians Grampian Estates Manager for operational arrangements, training and chair of Healthcare Waste Committee. Contact by 01224 552185; Property & Environment Manager for advice, contractual, legal and performance arrangements, including preparation of reports. Contact by 01224 558732; Environment Manager(s) for monitoring local arrangements across all settings. Contact by 01224 557622 or 01343 567305; Portering Services Manager for portering arrangements. Contact by 01224 552354; Transport Manager for logistical arrangements. Contact by 01224 553654; Infection Control Nurse(s) for clinical producer procedural and training arrangements, including preparation of reports. Contact by 01224 550998. Household/Domestic Waste, Confidential Waste and Hazardous/Special Waste arising ancillary to the delivery of healthcare in both clinical and non-clinical settings Grampian Estates Manager for operational arrangements, training and chair of Healthcare Waste Committee. Contact by 01224 552185; Environment Manager(s) for advice, contractual, legal, operational and performance arrangements across all settings, including preparation of reports. Contact by 01224 557622 or 01343 567305; Portering Services Manager for portering arrangements. Contact by 01224 552354; Transport Manager for logistical arrangements. Contact by 01224 553654; Departmental: Departmental / Line Mangers are responsible for: Making sure that all staff are aware of this policy and the relevant procedures and protocol framework associated with the disposal of segregated wastes; Putting into practice within the protocol framework, the local procedures and safe systems of work which are designed to reduce risks from production to final disposal; Ensuring that all staff and workers engaged in healthcare and in waste management have adequate information, training, instruction, supervision and support. This includes refreshing staff knowledge and skills at regular frequencies; 6
Monitoring the effectiveness of local procedures and safe systems of work, with annual review of occurrence recording, investigation and management inspections; Ensuring that local policies and procedural guidelines are developed and maintained; Ensuring staff receive suitable and effective support following any accidents or incidents involving waste; Ensuring that specialist arrangements for Medicinal Products (medicines) are coordinated with Pharmacy and the associated Policies; Ensuring that specialist arrangements for specimens and potentially infectious substances are co-ordinated with Laboratory services and the associated policies. All staff and workers engaged in healthcare and in waste management are responsible for: Taking precautions and reasonable care of themselves and any other persons who may be affected by their actions and the environment; Co-operating with policy, procedures and safe systems of work that are in place to minimise risk to persons and the environment; Reporting of all incidents, including near misses that arise; Attending the appropriate training and instruction and ensuring practical skills are regularly refreshed; Assisting managers with the identification of any risks arising from waste management. PROTOCOL FRAMEWORK AND LOCAL PROCEDURAL ARRANGEMENTS FOR IMPLEMENTATION Risk Based Approach Risk Assessment is the fundamental process in reducing actual or potential harm to persons or the environment. All risks, by considering the hazards and likelihood of harm, must be identified and assessed by local managers. However, waste management is a complex area, subject to a Duty of Care and not all regulatory aspects are likely to be known by local managers. A core generic protocol framework (NHS Grampian - Waste Disposal Procedures) supports and provides an interpretation of critical requirements. The Director of Facilities (through the Property & Environment Manager, Estate Manager, Environmental Managers and Infection Control Nurses) can provide additional support to local managers on the assessment of local waste management risks. As a result of risk assessment all locations where waste arises should have effective control measures in place to manage identified risk. The NHS Grampian - Waste Disposal Procedures is central to the protocol framework and compiling a risk assessment. However all managers are responsible for developing localised arrangements specific to local needs. Waste Management factors to be considered when conducting risk assessment: Does the waste present a hazard and or harm to persons or the environment by demonstrating/containing: Infectiousness or Biohazard (to Control of Substances Hazardous to Health Regulations [COSHH] with categorisation of hazard groups and Advisory 7
Committee on Dangerous Pathogens [ACDP] guidance on duties and managing the risk)? Hazardous or dangerous substances (Statutory Lists or have flammable, irritant, harmful, toxic, carcinogenic, corrosive, explosive, oxidising, teratogenic, mutagenic, produce toxic gas, yield leachate or ecotoxic thresholds)? Sharp or cutting edges (Glass, Sharps and other intrusive devices etc)? Radioactive substances? Offensiveness (volume, time and temperature controls)? Containment (packaging, storage, handling and transport controls)? Defined as a Controlled Waste? Duty of Care requirements? Does the waste or management regime present a hazard and or harm to persons or the environment by any of the following aspects: Patient contact? Segregation? Fully discharging Sharps? Returning medicinal products to pharmacy? Metal objects? Working with substances hazardous to health? Fit for purpose containment? Labelling and marking? Perceptions about the waste? Secure? Not accessible to the public? Presenting for uplift/disposal? Frequency of uplift? Spillage? Location where the waste arises or is stored? Welfare requirements? Moving and handling? Access and egress? Fire? Temperature? Birds, insects or other vermin? Driving? Training? Experience? Incident Reporting? Immunisation? Any other risk specific to the individual s role? Managing the Risk The risk presented should be reduced to the lowest level that is reasonably practicable. If the risk assessment shows that it is not possible for the waste to be safely decontaminated, treated or disposed of then other arrangements must be put in place. Local managers or the producer of the waste have prime responsibility for the duty of care and all aspects of health, safety and environmental protection. 8
Training The appropriate level of training to staff will be provided based on the needs identified through risk assessment conducted at local level, and where competence to statutory or mandatory NHS requirements is necessary. Advice and guidance on available training can be sought from the Risk Training Co-ordinator or from the Facilities Learning and Development Manager, by contact on 01343 567304. The NHS training directory can be found on the NHS Grampian Internet site. Occurrence Recording All persons and workers engaged in healthcare and in waste management should report all incidents including near misses. Local Managers should be informed and the appropriate form completed and processed as soon as possible following the incident. This will ensure compliance with the Reporting of Injuries, Diseases, and Dangerous Occurrence Regulations: 1995. All incidents must be recorded to ensure accurate information, to enable intelligent trend analysis, which will help with planning for future reduction target initiatives and the introduction of further safe systems of work. MONITORING ARRANGEMENTS Local managers are required to monitor their local policies, the local procedural arrangements, risk register and incident analysis. Director of Facilities will provide an annual report of performance for discussion with Chief Executive, Management Teams, Infection Control Committee and Risk Management Group. REVIEW ARRANGEMENTS The Healthcare Waste Committee meets bi-monthly, and reports progress as a recurring agenda item and on behalf of the Director of Facilities will annually review corporate progress in relation to the effectiveness of the Waste Management Policy. The report will be submitted annually to the Health & Safety Committee, Risk Management Group, Staff Governance Committee and their associated Partnership Committees. DISTRIBUTION LIST Health and Safety Management Committee Risk Management Group Health and Safety Co-ordinators Departmental Health and Safety Committee Chairs Learning and Development Human Resources Occupational Health Service Facilities, Security Services Planning Corporate Communications Global Mail NHS Grampian 9
REFERENCES The following are to be read and used in conjunction with the NHS Grampian Waste Management Policy: Ref Title Comments 1 NHS Grampian Environmental Policy 2 NHS Grampian - Waste Disposal Procedures 3 NHS Grampian Waste Segregation Chart 4 NHS Grampian Waste Segregation Chart - DENTAL 5 NHS Grampian Waste Segregation Chart - DECONTAM This policy provides the NHS Grampian statement of commitment to the Environment, which is central to waste management strategy The core generic protocol framework describing the local procedures and safe systems of work which are designed to reduce risks from production to final disposal of waste in NHS Grampian A3 generic Waste Segregation Chart for all persons and workers engaged in healthcare and in waste management A4 Waste Segregation Chart for all persons and workers engaged in healthcare and in waste management in the DENTAL SETTING A4 Waste Segregation Chart for all persons and workers engaged in healthcare and in waste management in the joint NHSS / Local Authority community equipment low risk decontamination unit 6 SEHD HDL(2002)43 Specific Scottish Executive Health Department instructions and Action Plan on Waste Management in NHS Scotland 7 NHSScotland Property and Environment Forum SHTN 3 (Now known as Health Facilities Scotland) The specific guidance on the management and disposal of clinical waste to meet SEHD HDL(2002)43 8 SOHHD MEL(1993)79 Specific Scottish Office instructions on the use of Ionising and Non-Ionising Radiation 9 SOHHD DGM(1992)4 Specific Scottish Office instructions on the sensitive disposal of Foetuses and Foetal Tissue following termination of pregnancy 10 SEHD the Scottish Infection Manual 11 The European Waste Catalogue (EWC) 12 WM 2 Joint Agencies Guidance on Hazardous Waste (SEPA/EA) Core standards for the control of infection, with co-ordination on disposal of resulting wastes The codes which waste producers have a duty to use to correctly classify and describe their waste when consigned for uplift Hazardous Waste: Interpretation of the definition and classification of hazardous waste. 10