v>EPA
Unted Stales
Environmental Protection
Healthcare Environmental Assistance Resources
Pollution Prevention and Compliance Assistance
for Healthcare Facilities
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EPA/625/C-05/003
May 2005
HEALTH CARE GUIDE TO
POLLUTION PREVENTION IMPLEMENTATION
THROUGH ENVIRONMENTAL MANAGEMENT SYSTEMS
m _
U.S. Environmental Protection Agency
Office of Research and Development
National Risk Management Research Laboratory
Center for Environmental Research Information
Cincinnati, Ohio
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-NOTICE-
The U.S. Environmental Protection Agency through its Office of Research and Development partially
funded and managed the research described here under Cooperative Agreement #R-83045301-1 to the Kentucky
Pollution Prevention Center at the University of Louisville, Louisville, Kentucky. It has been subjected to the
Agency's peer and administrative review and has been approved for publication as an EPA document. Mention
of trade names or commercial products does not constitute endorsement or recommendation for use.
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-FOREWORD-
The U.S. Environmental Protection Agency (EPA) is charged by Congress with protecting the Nation's
land, air, and water resources. Under a mandate of national environmental laws, the Agency strives to formulate
and implement actions leading to a compatible balance between human activities and the ability of natural
systems to support and nurture life. To meet this mandate, EPA's research program is providing data and technical
support for solving environmental problems today and building a science knowledge base necessary to manage
our ecological resources wisely, understand how pollutants affect our health, and prevent or reduce environmental
risks in the future.
The National Risk Management Research Laboratory (NRMRL) is the Agency's center for investigation
of technological and management approaches for preventing and reducing risks from pollution that threaten
human health and the environment. The focus of the Laboratory's research program is on methods and their
cost-effectiveness for prevention and control of pollution to air, land, water, and subsurface resources; protection
of water quality in public water systems; remediation of contaminated sites, sediments and ground water;
prevention and control of indoor air pollution; and restoration of ecosystems. NRMRL collaborates with both
public and private sector partners to foster technologies that reduce the cost of compliance and to anticipate
emerging problems. NRMRL's research provides solutions to environmental problems by: developing and
promoting technologies that protect and improve the environment; advancing scientific and engineering
information to support regulatory and policy decisions; and providing the technical support and information
transfer to ensure implementation of environmental regulations and strategies at the national, state, and community
levels.
This publication has been produced as part of the Laboratory's strategic long-term research plan. It is
published and made available by EPA's Office of Research and Development to assist the user community and
to link researchers with their clients.
Sally C. Gutierrez, Acting Director
National Risk Management Research Laboratory
in
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- ACKNOWLEDGMENTS -
This second edition of the Health Care Guide to Pollution Prevention Implementation through Environmental Management
Systems was developed by the Kentucky Pollution Prevention Center (KPPC) and the United States Environmental Protection Agency
(U.S. EPA) Health Care EMS Workgroup under the leadership of Tim Piero and Linda Longo respectively. The Health Care EMS
Workgroup consists of participants from U.S. EPA; the Veterans Health Administration; the Kentucky Pollution Prevention Center; the
Detroit Medical Center; and the University of Texas M.D. Anderson Cancer Center.
Health Care EMS Workgroup members from EPA Headquarters offices:
Office of Enforcement & Compliance Assurance/Federal Facilities Enforcement Office/Planning Prevention & Compliance
Program (Federal Facilities) - Diane Lynne, Greg Snyder, Will Garvey
Office of Enforcement & Compliance Assurance/Office of Compliance/Sector Analysis & Implementation Branch (Sector
Notebook/Compliance Assistance Center) - Seth Heminway
Office of Prevention Pesticides & Toxic Substances/Office of Pollution Prevention & Toxics/Pollution Prevention Division
(H2E) - Chen Wen, Paul Matthai, Tom Murray, Christopher Kent, Kathy Davey
Office of Policy Economics & Innovation/Office of Business & Community Innovation/Sector Strategy Division (Sector
Strategies) - Shana Harbour, Leigh Cash, Janice Bryant
Office of Policy Economics & Innovation/Office of Business & Community Innovation/Performance Incentive Division
(Performance Track Program) - Tim Stuart (retired), Michael Kane
Office of Solid Waste & Emergency Response/Office of Solid Waste (EMS) - George Faison, Bob Springer, Mimi Guernica
Office of Air & Radiation/Office of Atmosphereic Programs/Climate Protection Partnerships Division (Energy Star Program) -
Clark Reed
Health Care EMS Workgroup members from EPA Regional offices:
Rl - Martha Curran, Anne Fenn, Janet Bowen
R2 - John Gorman, Kathleen Malone, Diane Buxbaum, Linda Longo
R3 - Jeff Burke (retired), William Arguto
R4 - Dan Ahem, Anthony Shelton, Mark Robertson, Becky Allenbach, Delane Anderson, Stacey Bouma
R5 - Donna Twickler, Lee Regner, Dolly Tong
R6 - James Sales, Joyce Stubblefield, Gabriel Gruta
R7 - Gary Bertram, Ruben McCullers, Diana Jackson
R8 - Whitney Trulove-Cranor, Dianne Thiel
R9 - Eileen Sheehan, Piper Stege, Larry Woods, Kelly Doordan
RIO - Domenic Calabro, Viccy Salazar, Robert Drake, Michael Fagan, Michele Wright
Health Care EMS Workgroup additional members:
Kentucky Pollution Prevention Center - Tim Piero, Chris Wooton, Terry Durham
Hospitals for a Healthy Environment - Laura Brannen
Detroit Medical Center - Sheila Finch
University of Texas MD Anderson Cancer Center - John Gamble
Veterans Health Administration - Arnie Bierenbaum, Jack Staudt, Linda Martin
US EPA Region 2 - Special thanks to the following for compliance section contributions: Adrian Enache, Dan Kraft, Ellen Banner,
Kathleen Malone, Diane Buxbaum, Harish Patel, John Gorman, Phil Greco, Chris Jimenez, Bruce Kiselica, Mike Lowy, Linda Longo.
Special thanks to Sheila Finch (mailto:sfinch@dmc.org) and the Detroit Medical Center and John Gamble
(mailto:jgamble@mdanderson.org) and University of Texas M.D. Anderson Cancer Center for their input and review for this guide.
Mention of trade names, products or services does not constitute and should not be interpreted as constituting an actual or implied
endorsement or recommendation for use by the U. S. EPA, the Kentucky Pollution Prevention Center, Detroit Medical Center, the University
of Texas M.D. Anderson Cancer Center, St. Mary's General Hospital, Cambridge Memorial Hospital or any other organization(s) affiliated
with or mentioned in this manual. The tools and examples used to illustrate points made in the text of this manual are provided by the
Kentucky Pollution Prevention Center, Detroit Medical Center, University of Texas M.D. Anderson Cancer Center, St. Mary's General
Hospital and Cambridge Memorial Hospital.
The term "ISO 14001" may be mentioned throughout EMS implementation in this guide. It is simply the international benchmark
by which EMSs may be audited and registered by an outside third party. ISO 14001 registration is voluntary. A benefit of ISO 14001
registration is that a third party helps maintain a health care facility's focus on maintaining and improving its environmental performance.
However, registration requires extra financial resources and time involved. Health care facilities can still achieve the benefits of an EMS
with or without ISO 14001 registration.
Considerable effort has been taken to ensure the accuracy of information in this manual. Regulatory requirements can vary based
on locale. Please verify your requirements with applicable federal, state, and local authorities.
May 2005 (September 2002,1st Edition)
iv
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-ABSTRACT-
Medical waste incineration, persistent bioaccumulative toxins (PBTs) and hazardous material use and
disposal have heightened scrutiny of the health care industry's impacts on the environment. Given the mission
of health care to promote health and wellness, hospitals must proactively manage activities, products and services
to minimize these significant environmental impacts.
While many hospitals voluntarily undertake environmental initiatives, their efforts often fail due to the
lack of an established and sustainable environmental management system (EMS), which uses proven business
management practices to integrate environmental concerns into an organization's activities, products and services.
In response, the Kentucky Pollution Prevention Center (KPPC) worked with the United States
Environmental Protection Agency (EPA) and hospital administrators from across the country to revise the
Health Care Guide to Pollution Prevention Implementation through Environmental Management Systems.
The manual is written for EMS implementers and covers the following key areas:
• Strategies for getting started;
• Components of an EMS;
• Example health care environmental aspects;
• Strategies for developing staff buy-in and participation in the EMS;
• Focusing on a performance-based, results-oriented EMS;
• Setting goals and objectives with specific examples of health care programs;
• Implementing and maintaining an EMS.
The Health Care Guide to Pollution Prevention Implementation through Environmental Management
Systems provides example EMS procedures and forms used in four ISO 14001 EMS certified hospitals. The
latest revisions include more EMS hospital case studies, more compliance resources, the KPPC EMS Auditing
Tool, the EPA Region 1 Compliance Audit Tool, and a supplement to legal and other requirements for EMS
implementation.
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- TABLE OF CONTENTS -
PAGE
Section 1: Introduction 1
What are Environmental Management Systems? What are the Benefits? 1
U.S. and Canadian Case Studies 3
University of Texas M.D. Anderson Medical Center (U.S.) 4
Detroit Medical Center (U.S.) 7
Cambridge Memorial Hospital (Canada) 10
St. Mary's General Hospital (Canada) 12
Section 2: Getting Started 17
Introduction 17
Structure, Responsibility and Accountability 18
Getting Support and Buy-In for an EMS 18
Senior Management and Board 18
Overview of Hospital Corporate Structure and EMS Roles and Responsibilities 18
Board of Trustees 18
Senior Management 18
Middle Management 19
Hospital Employees 19
EMS: Choosing the EMS Representative(s) 20
EMS Management Representative 20
Environmental Coordinator/EMS Specialist 21
Choosing the EMS Team 21
Green Team Members 22
Green Team Expectations 22
Meeting Structure 23
Reporting Structure 23
Standard EMS Implementation Cycle 24
Section 3: Components of an EMS 25
EMS Component Description 25
Environmental Policy 26
Developing the Policy 26
Things to Consider When Writing the Policy 26
Communicating the Environmental Policy 27
Hospital Staff 27
Patients, Visitors and the Community 28
Contractors and Suppliers 28
EMS Example 28
Environmental Aspects and Impacts and Determining Significance 29
Introduction 29
Standard Pick List of Aspects and Impacts 31
Roles and Responsibilities in Identifying Aspects and Impacts 32
Determining Significance 32
Change Management and Continual Improvement 33
EMS Examples 33
VI
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Helpful Hints for Getting Started 33
EMS Examples 34
Legal and Other Requirements 35
Additional Information 36
Objectives and Targets 37
Setting Performance-Based Objectives and Targets 37
Implementation Tips 37
Additional Information 38
Environmental Management Programs (EMP) 39
Saint Mary's General Hospital EMP Example 39
Biomedical Waste Reduction EMPs 39
Recycling and Reuse EMP 40
Spill Response and Emergency Preparedness EMP 42
Landscaping Practice EMP 42
Mercury Reduction EMP 43
Additional Information 43
Training 44
Contractors and Suppliers 45
Getting Started 45
Lessons Learned 45
Communication 46
External Communication 46
Internal Communication 46
Contractors and Suppliers 48
Additional Information 48
Documentation/Document Control 49
Kinds of Documents a Hospital will have in its EMS 49
List of EMS Documents 49
Additional Information 50
Operational Controls 51
Hospital Considerations 51
Additional Information 51
Emergency Preparedness and Response 52
Implementation Tips 52
Monitoring and Measurement 53
Additional Information 53
Nonconformances and Corrective and Preventive Action 54
Additional Information 54
EMS Records 55
Additional Information 55
EMS Auditing 56
Types of Audits 56
Internal Auditing Program Components 56
Audit Program Tips 57
Additional Information 58
Management Review 59
Section 4: Continual Improvement 61
Pollution Prevention Opportunities for the Health Care Industry 61
Introduction 61
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Materials Management 62
Environmentally Preferable Purchasing (EPP) 63
EPP Best Practices 64
Additional EPP Resources 64
Cleaning Products and Chemicals 64
Energy Efficiency 67
ENERGY STAR: Strategies for Superior Energy Management 68
How Health Care Facilities Can Leverage ENERGY STAR 68
ENERGY STAR Tools and Resources Available Online 70
Case Study: Shriners Hospital for Children - Houston 72
Join ENERGY STAR 73
Additional Pollution Prevention for Hospital Waste Streams 74
Chemotherapy and Antineoplastic Chemicals 74
Formaldehyde 74
Inventory Control 74
Laundry and Laundry Detergent 75
Aerosols 75
Batteries 75
Mercury 76
Sphygmomanometers 77
Gastroenterology 77
Thermometers 77
Nonclinical Mercury 77
Additional Information 78
Pollution Prevention Opportunities for Mercury 78
Pesticides and Landscaping 79
Polyvinyl Chloride (PVC) and Dioxin 79
Additional Information 80
Pharmacy 80
Radiology 80
Recycling/Safe Disposal 81
Solvents 82
Conclusion 84
Appendix A: EMS Examples 85
Appendix B: Additional Resources 157
Appendix C: Kentucky Pollution Prevention Center
Environmental Management Systems (EMS) Auditing Tool 183
Appendix D: U.S. EPA Region 1 Compliance Audit Tool 241
Appendix E: Compliance - A Supplement to Legal and Other Requirements 251
Federal Regulation of Medical Waste 251
Code of Federal Regulations and the Federal Register 252
Clean Air Act (CAA) 252
Air-Conditioning and Refrigerator Service 253
Asbestos 253
Boilers 253
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CAA Title V Operating Permit 254
Medical Waste Incinerators 254
Clean Water Act (CWA) 255
Wastewater Dischargers 256
Indirect Dischargers 256
Direct Dischargers 257
Stormwater Discharges 257
Aboveground or Underground Oil Storage Containers 258
Emergency Planning and Community Right to Know Act (EPCRA) 259
Federal Insecticide, Fungicide and Rodenticide Act (FIFRA) 261
Resource Conservation Recovery Act (RCRA) 263
Safe Drinking Water Act (SDWA) 266
Toxic Substances Control Act (TSCA) 268
U.S. EPA Voluntary Audit Policy 269
U.S. EPA National Environmental Performance Track Program 273
Standard Criteria for Program Eligibility 273
Environmental Management Systems (EMS) 273
Continuous Improvement Criteria 274
Community Outreach 274
Sustained Compliance 275
Small Business Criteria 276
Other Organizations 277
American Hospital Association (AHA) 277
Hospitals for a Healthy Environment (H2E) 277
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 278
IX
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- SECTION 1 -
INTRODUCTION
What are Environmental Management Systems?
What are the Benefits?
Environmental management systems (EMS) represent a new and systematic approach to environmental
performance. Successful EMSs apply the building blocks of effective organizational management to
environmental performance through accountability, assigned responsibilities, employee involvement, written
policies, training, corrective action, senior management review and senior staff involvement. All components
work together to continually improve a hospital's environmental performance.
An EMS challenges an organization to identify its most significant environmental issues and to
address these through objectives and targets. By using pollution prevention in this process, a hospital can
achieve improved operating efficiencies and cost savings through implemented waste reduction and energy
efficiency opportunities. This provides economic benefit increasingly important to successful hospitals.
The most effective EMSs are built with the hospital mission in mind: patient and community health
and well-being. This mission should be used to help determine which of a hospital's environmental issues are
most significant. This gains support for the EMS both inside and outside of the hospital. Inside the hospital,
management and staff see how good environmental performance supports the mission, helping the EMS
become part of how things are done. Outside the hospital, it demonstrates good corporate citizenship which
is respected in the community. U.S. EPA offers programs such as the National Performance Track Program
and the Voluntary Audit Program, which provide additional recognition opportunities that capitalize on EMS
success.
Atypical hospital can build an EMS on many of the organization's practices already in place through
other requirements such as the Joint Commission on Accreditation of Healthcare Organization (JCAHO),
other state and federal regulatory requirements and other facility-wide mission statement/goals. For example,
the JCAHO Environment of Care standard contains numerous opportunities for managing environmental
operations, procedures and staff training. An EMS encompasses these requirements together and give staff an
important opportunity to play in minimizing hospital waste and preventing compliance violations. As
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compliance is a core component of environmental performance, this manual features an updated section on
common federal environmental compliance requirements in the health care industry.
Building an EMS to fit a hospital's needs can be done within a small area of the hospital or for the
entire hospital all at once. Applying the EMS concepts to one department initially can help identify gaps and
determine where to improve for the next department or for the entire hospital. By starting with a smaller area,
required staff resources can be less intense and lessons learned can be applied to streamline subsequent
efforts later on.
This manual is organized following successful implementation of EMSs in numerous organizations
health care and private industry organizations. The manual describes each part of an EMS and provides EMS
examples (including EMS documentation) that can be downloaded and adapted for the reader's own use. It
also provides useful references to other programs and web links, information on U.S. EPA voluntary programs
and federal compliance resources to help in understanding applicable legislation. Immediately following are
case studies featuring both U.S. and Canadian hospital experience in implementing and benefiting from an
EMS. All of the hospital examples that follow have an ISO 14001 registration for their EMS program. An ISO
14001 registration is not required and a hospital can achieve the same benefits from an EMS whether or not it
pursues registration.
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- U.S. AND CANADIAN CASE STUDIES -
Table of Contents
PAGE No.
I. University of Texas M.D. Anderson Cancer Center
II. Detroit Medical Center
III. Cambridge Memorial Hospital 10
IV. St. Mary's General Hospital 12
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I. The University of Texas M.D. Anderson Cancer Center
The University of Texas M.D. Anderson Cancer Center knows how to take care of its patients and its
community. Under the guidance of Linda Lee, Executive Director of Environmental Health, the health care
facility achieved International Organization for Standardization (ISO) 14001 and Occupational Health and
Safety Assessment Series (OHSAS) 18001 registration-an unprecedented effort in the U.S. health care
industry. M.D. Anderson Cancer Center management chose an Environmental Health & Safety
Management System (EHSMS) approach to elevate Environmental, Health and Safety (EHS) programs from
compliance to a leadership level. Lee also credits the EHSMS with assisting the center's ongoing efforts to
operate safely for its patients and the community, to meet compliance efforts and implement best practices.
Such innovation is encouraged at M.D. Anderson Cancer Center, a research-driven cancer center with
the mission to eliminate cancer in Texas, the nation and the world through outstanding integrated patient
care, research, education and prevention programs. For Lee, it made sense to implement a comprehensive
EHSMS within the center's Facilities Management Division, which consists of 1,400 employees who work
at the center's main campus in Houston and the Science Park campus in Bastrop, Texas.
"M.D. Anderson Cancer Center's EHS programs continue to grow together," says Lee. "We focused on
the center's Facilities Management Division because many of the environmental impacts reside here. We
needed to consider these programs more holistically."
Initially, Lee began EHSMS efforts by taking on many of the responsibilities of implementation within
the Environmental Health and Safety Department. "It was our product to begin with, but I soon learned that
the nature of the work was going to require spreading responsibility around the division. And really that's
what a systems-based approach is meant to do."
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Lee initially relied on representatives, or "champions" from each of the eight departments within the
Facilities Management Division to promote and complete the EHSMS efforts in their respective areas. Lee
expanded this effort into what she calls the "systems and programs champions" concept in which the
EHSMS is now broken down into program and media areas-air, safety, construction, water, etc.-with a
representative from each program area along with champions on the EHSMS systems side.
The EHSMS Work Group led by John Gamble, Director of Environmental Quality, Matt Berkheiser,
Occupational Health and Safety Programs Manager, and Devina Patel, JCAHO programs manager, provide
overall EHSMS direction. Environmental health and safety staff provided EHSMS training to hospital staff
during initial implementation efforts and continue to provide EHSMS training as part of orientation training
for new employees.
The EHSMS Work Group drives the significant environmental aspects identification process through
the EHSMS Core Team. The team is made up of representatives from each facilities management
department. They help promote EHSMS throughout the center and provide input on the significant
environmental aspects. The final aspects list is presented to the vice president of operations for review and
approval.
Gamble credits the risk discovery process for identifying opportunities for improvement in pollution
prevention, reduction of accidents and energy conservation. Key targets are set for each of these objectives.
This discovery, hazard prioritization and risk management have been the greatest benefits of the EHSMS
says Gamble since, "it allows us to focus our efforts and resources."
M.D. Anderson Cancer Center's environmental management program (EMP) targets in energy
conservation, pollution prevention and chemical procurement facilitated the hospital's participation in U.S.
EPA's Performance Track Program, which looks for measurable and continually improving environmental
performance, something that M.D. Anderson Cancer Center already tracks and reports semiannually
through its EHSMS. Gamble says, "The EHSMS helped make our existing monitoring and measuring
efforts more robust." The center also launched a comprehensive environmental health and safety
compliance initiative in parallel to its EHSMS system auditing program. Both programs are now
integrated. Task and process mapping will add additional sustainability to the EHSMS program.
Gamble also notes that EHSMS brings environmental visibility and management of environmental
change to the center's construction projects. Project managers are more aware of environmental issues and
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can now navigate through the maze of environmental impacts with the Project Managers Handbook for
Construction Safety and specific environmental health and safety design criteria.
Hospitals may or may not choose to pursue ISO 14001 and OHSAS 18001 registration, but Gamble
stands by M.D. Anderson Cancer Center's decision to do so.
"We see the value in a third party auditor coming in every six months to examine what we do," says
Gamble. "It helps drive continual improvement and maintain focus on the system and environmental health
and safety performance results."
John H. Gamble, P.E.
Director of Environmental Quality
University of Texas M.D. Anderson Cancer Center
Houston, Texas 77030
Tel: (713) 745-1422
Fax: (713) 745-2025
Email: mailto:jgamble@mdanderson.org
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II. Detroit Medical Center
Detroit Medical Center (DMC) is the city's leading health care system and largest private employer
with more than 13,000 employees. Comprised of 10 hospitals and institutes, two nursing centers and more
than 50 primary care practices throughout southeast Michigan, the DMC medical system features 2,000
licensed beds, 3,000 affiliated physicians and is the teaching and clinical research site for Wayne State
University.
Following this spirit of community leadership, DMC's board of directors expressed interest in having
a system-wide plan to assure compliance with applicable laws and regulations and to track ever-changing
environmental standards.
"Senior management saw the EMS approach as the most effective and efficient way to achieve
management of the environmental processes," says Sheila Finch, DMC's Interim Director of Environment
of Care and ISO Administrator. The DMC achieved the ISO 14001 registration in December 2001 making
it the first hospital in the United States to achieve registration in the environmental system.
Finch credits this top management support and teamwork throughout DMC for success in EMS
implementation and operation. DMC organized EMS teams at each facility. The safety officer led the
teams. Members of the team were comprised of representatives from key stakeholders with environmental
process functions. The safety officers served as the site management representatives and helped to
facilitate the EMS process in the facility. Pharmacy, environmental services, laboratory, epidemiology
(infection control), plant operations, patient care services, radiology/nuclear medicine, respiratory and
food and nutrition services were key members of the site team. A DMC management representative
functioned as the corporate oversight representative for the EMS/ISO 14001 implementation.
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Facility teams were also essential in taking the EMS message to their facilities including the medical
staff. Teams provided EMS awareness training and updates through department meetings, email and
newsletters. Posters, flyers, reminder cards on identification badges and computer-based training modules
were developed for employees. Training was one of the most important resources committed to EMS
implementation.
"At first, the EMS was viewed as additional work and a separate program. Now the EMS process is
viewed as an expansion of the JCAHO Environment of Care Standards. Utilizing the JCAHO
Environment of Care Standards as a baseline, EMS was implemented to improve environmental processes,
identify pollution prevention initiatives, address environmental regulations and identify cost savings by
improving efficiency of the processes. Integration of EMS standards with established processes helped to
make a smooth transition, gain support and help the staff relate to the EMS program," says Finch.
According to Finch, the staff's challenge was to learn and understand the EMS/ISO terminology.
There were many similarities. The "Plan, Do, Check, Act" in EMS was similar to the JCAHO model of
"Design, Implement, Monitor and Measure." EMS management programs were similar to the JCAHO
performance improvement initiatives, and EMS determination of significant environment aspects was
similar to the JCAHO emergency management requirement for performing a hazard vulnerability study.
Finch constructed a crosswalk comparison that linked each EMS requirement to the DMC-related policy.
Finch states that the most challenging EMS element was the development of the environmental
aspects. "This element was tedious, time-consuming and a little frustrating at times," she says. "Aspects
is not a term used in health care and thus required many sessions to complete the "Master Environmental
Aspects List." Departments worked together to identify the aspects. Identification of activities and
services was the starting point. Once that was developed, staff was asked the consequence of ignoring or
not addressing the aspect to the environment; that determined the impacts."
One lesson learned was to implement discovery methods to capture more quantitative, baseline data
early in EMS implementation on environmental performance.
"It is difficult to go back and capture EMS-related cost data, number of training hours and the like,"
says Finch. "But we are beginning to see tangible, quantifiable achievement from three years of EMS
operation, mostly in cost savings from medical and solid waste reduction." There are additional intangible
benefits to having an EMS states Finch. "We see achievements in process improvements and level of
ownership,
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increased regulatory compliance, more pollution prevention initiatives and an overall increase in
environmental awareness as part of how we do business."
With any new process there are lessons learned, adds Finch. Implementation lessons learned that
Finch would not change were: involving key stakeholders in the implementation phase; maintaining shared
electronic files with EMS resources for each site management representative; use of templates, flow
sheets, quick reference tools and preprinted forms to help communicate the EMS process; and involving
staff in the setting of objectives and targets.
Things that Finch would change if implementing the system today include: providing more resources
to key stakeholders; spending more time on training the staff on the terminology differences; the use of
existing management tools, including financial accounting methods in the EMS design phase; and
identifying personnel that would be responsible for legal and other requirements.
There have been benefits outside of the traditional environmental arena. Communication, initially a
challenge because of the breadth and scope of EMS implementation efforts, became one of the chief
benefits.
"We established 'read-only' access to a shared electronic folder for key stakeholders and provided
templates, flow sheets, quick-reference tools, preprinted forms and templates that helped communicate the
EMS process quickly and efficiently," states Finch. "As we implemented, we really saw strong
communication take root across the facilities that resulted in expertise sharing, a spirit of cooperation and
team building that comes from working for a common goal."
Sheila A. Finch, CHSP, CHMM, M.S. MT(ASCP)
Interim Director, Environment of Care/ISO Administrator
Detroit Medical Center
6071 West Outer Drive
Detroit, Michigan 48235
Attn: Sinai-Grace Hospital L439
Tel: (313)966-1297
Email: mailto:sfinch@dmc.org
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III. Cambridge Memorial Hospital
an in
Cambridge Memorial Hospital (CMH) is a 277-bed facility that provides the 120,000 residents
of Cambridge and North Dumfries, Ontario, Canada, with acute, ambulatory and long-term care
services. This health care facility was the first hospital in North America to implement an EMS and
obtain ISO 14001 registration.
During recent years, the board of directors established a new vision, moving from a model of
"curing the sick" to one focused on improving the health of the community and the local
environment. Implementing an EMS was seen as a milestone in achieving this vision.
In June 1998, CMH's board of directors approved an environmental policy for the hospital,
which marked the beginning of EMS implementation. Work on the EMS implementation continued
through year 2000.
Cambridge Memorial achieved a 20 percent reduction in biomedical waste in each of the first
two years of EMS operation. The hospital implemented an integrated pest management program,
eliminating the use of chemical pesticides and herbicides and added criteria for energy conservation
into the process of selecting new products and equipment. As part of its chemical substitution
program, CMH initiated a mercury-free medicine campaign to phase out products containing mercury
and eliminate the release of mercury into the environment. Prior to EMS inception in May 1998, the
hospital shut down its 25-year-old incinerator, eliminating its contribution to local air pollution and
reducing greenhouse gas and energy consumption. Staff training and community awareness is key to
meeting the hospital's environmental goals. CMH actively pursues Green Team initiatives to promote
environmentally friendlier and healthier alternatives to transportation, such as carpooling, public
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transportation, biking, walking, etc.
Sustainable building design is a key element used in planning a new 115,000-square-foot
addition to the hospital, which has participated in the Commercial Building Incentive Program
(CBIP) and C-2000 Advanced Commercial Building Program through the Office of Energy Efficiency
in Natural Resources Canada. CBIP buildings must use less than half the energy of conventionally
designed buildings.
The CMH Green Team made a formal pledge to develop a comprehensive program to eliminate
the release of mercury to the environment. A mercury audit was completed to identify all mercury
sources. Twenty-one staff members representing three hospital areas received educational in-service
sessions to alert the staff about mercury spills response procedures as well as the environmental and
health consequences of the use of mercury. Measures continue to be implemented to phase out
products containing mercury, such as blood pressure measuring devices. A final sweep through CMH
was completed to verify that all mercury blood pressure cuffs and thermometers have been properly
removed and replaced.
CMH pledged a 30 percent reduction in biomedical waste as part of the Ministry of the
Environment P2 Pledge Program (P4). The P4 program is a voluntary initiative that encourages
companies and organizations to commit to reducing pollutant releases, hazardous or liquid industrial
waste or toxic chemicals. Cambridge's reduction in biomedical waste in 1999 earned the P3 (People,
Prosperity and the Planet) Reduction Achievement Award. CMH continued its track record with a 20
percent reduction in 2000.
CMH credits the Green Team's approach with speeding EMS implementation efforts and
providing not only an effective training outreach mechanism throughout the hospital, but also a
support network for EMS implementation efforts as well.
Mary Jane Hanley, Environmental Specialist
Cambridge Memorial Hospital
700 Coronation Boulevard
Cambridge, ON N1R3G2
Tel: 519-621-2333ext.l720
Fax: 519-740-4928
Email: mailto:mhanley@cmh.org
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IV. St. Mary's General Hospital
St. Mary's General Hospital is a 168-bed facility that serves nearly 500,000 people in southern
Ontario. St. Mary's was recently designated the region's Cardiac Care Center.
The hospital began to develop its EMS under a university-planned venture between St. Mary's,
Cambridge Memorial Hospital, Cambridge, Ontario, and the University of Waterloo, Waterloo,
Ontario. In October 2001, St. Mary's became ISO 14001-registered, the second North American
hospital to achieve this distinction. As a result of the hospital's EMS, St. Mary's has been the
honored recipient of a number of provincial and regional awards.
Board of Trustee environmental concerns about chemical usage spearheaded an initial
investigation of how the hospital managed its environmental affairs. Investigation results led to
additional board and senior management-level discussions concerning other environmental issues and
identified the need for the hospital to proactively address its internal and external environment.
After reviewing recommendations outlined in reports from a local university environmental
class, the hospital's Director of Facilities Services brought the idea of an EMS to senior management
and the Board of Trustees. The Board hired a recent graduate to implement the EMS. Through this
joint effort with Cambridge Memorial, St. Mary's planned, developed and implemented its EMS
using the ISO 14001 standard as a guide.
St. Mary's is committed to promoting "Health care for a healthy environment," and through
continual environmental education, promotion and awareness, all levels of hospital staff and
volunteers are aware of and participate in the hospital's environmental pledge.
Principle EMS accomplishments to date include the following:
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Waste Management
Improved biomedical waste segregation and establishment of comprehensive recycling
programs are two key achievements. Since 1998, St. Mary's has reduced biomedical waste by 38
percent by weight and implemented programs to recycle the following:
• Glass, cans (aluminum and steel), plastic, newspaper, cardboard, boxboard, paper (all
grades), alkaline and nickel-cadmium batteries, all types of metal, photocopier cartridges,
cold packs, Styrofoam boxes.
• Fluorescent tubes. St. Mary's recycled the mercury, glass, aluminum and phosphor powder
in more than 2,000 florescent tubes.
• Cardboard through a take-back program with its suppliers.
• Unused patient and cafeteria food through a local organics composting company.
• Biomedical waste containers through newly selected medical waste hauler.
Energy Conservation
St. Mary's "energy plan" addresses new construction and renovation projects; equipment
(lighting, powerhouse equipment, etc.); and internal energy education/communication of hospital
staff. The hospital formed a multidisciplinary team of energy conservation consultants, architects,
mechanical and electrical engineers to design an energy-friendly addition to house its new Cardiac
Care Center. Design plans will allow St. Mary's to reduce energy usage 30 percent compared to
conventionally designed buildings.
In addition, St. Mary's:
• Purchased a hydro usage software program to identify and target energy usage patterns;
• Performed a steam trap survey and implemented resulting recommendations;
• Replaced all T12 fixtures with more energy-efficient T8s;
• Developed an energy education program with a mascot that provides energy tips and
reminders;
• Formed an "Energy Team" to standardize purchases of energy-conserving office equipment
and small appliances;
• Plans to upgrade to more energy-efficient windows.
Landscape Management
In 2000, St. Mary's was among the first hospitals in Ontario to eliminate chemical pesticide and
herbicide usage on hospital grounds. By working with the hospital's current landscaping company
and landscaping professionals, St. Mary's maintains a healthy, chemical-free landscape. St. Mary's
no longer mows on smog-alert days. Newly designed landscape plans will incorporate, where
possible, drought-resistant/salt-tolerant/native plants, ground covers and other environmentally
conscious options.
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Alternative Transportation
To promote green transportation, St. Mary's:
• Circulated an Employee Alternative Transportation Survey for staff to evaluate
transportation habits and identify future initiatives that the hospital staff would like to see;
• Purchased additional bicycle racks;
• Implemented a "Share-a-Ride" program on the hospital's internal email system that allows
staff wishing to carpool to find another individual in their area.
This goal is ongoing, and future plans provide staff with discounted bus passes, safe biking
lessons and improved showering facilities.
Chemical Recycling & Wastewater Discharges
St. Mary's is a member of the Health Care Without Harm's Mercury Medicine Campaign. To
date, the hospital eliminated all mercury-containing devices in patient care areas. The hospital works
to identify alternatives for pressure and floating switches in powerhouse equipment and to find a
replacement for the mercury thermometer standard for calibrating medical equipment.
Through a regional business water quality program, St. Mary's has identified and remediated
many water-polluting processes. In particular, St. Mary's installed xylene and formalin recycling
equipment and eliminated related discharges.
Senior Management Approval and Support
Senior management support and buy-in is critical and needs to be communicated to all staff
prior to starting the process. A letter of support circulated throughout the hospital is one way to
communicate this support.
Staff Involvement
Everyone has responsibilities under the EMS - not just the EMS management representative.
Be sure to ask staff (front line, nursing, physicians and management) to participate in the EMS
wherever and whenever possible (e.g., Green Team, hospital auditing team, implementing objectives
and targets, fun initiatives, etc.).
Integration of Documentation
Designing an EMS involves the development of policies, procedures and work instructions by
the EMS representative and department managers/supervisors. Integrate document formats with the
hospital's existing systems.
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Recognize the Efforts of Individuals and Departments
To maintain momentum, formally recognize individuals and departments that demonstrate
enthusiasm, participation and involvement in the EMS.
Be Creative
Come up with fun ideas and initiatives to get staff involved. Use existing national holidays,
such as Earth Day, to organize fun events.
Shannon-Melissa Dunlop, Environment, Health and Safety Specialist
St. Mary's General Hospital
911 Queens Boulevard
Kitchener, ON, Canada
N2M 1B2
Tel: (519)749-6406
Fax: (519)749-6426
Email: mailto:sdunlop@stmaryshosp.on.ca
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- SECTION 2 -
GETTING STARTED
Introduction
Getting started on an EMS can be a daunting experience, making top management support and a team
approach vital to success. Getting started requires senior management approval and buy-in. Management
needs to understand the benefits of the EMS, why it will be good for the hospital and how it will save the
hospital money. Keep in mind that cost savings from pollution-prevention projects (including energy
efficiency) is just one benefit to communicate to management. EMSs also provide improved operational
efficiencies, increased staff ownership of environmental performance and opportunity for enhanced hospital
image in the community.
An EMS does not have to be established for the entire hospital. It can simply focus on a smaller area
within the hospital (one or more departments). Possibilities include facilities maintenance, purchasing, food
services or environmental services. Starting on a pilot scale allows transfer of "lessons learned" to other
departments later in their implementation. A team effort includes laboratory staff, food service personnel,
facilities management, the surrounding community as well as top management. This bottom-up philosophy
to getting started and understanding all roles will make the EMS experience more productive and meaningful
in the end.
Also consider the benefits of International Organization for Standardization (ISO) 14001 registration.
While there are other EMS certification organizations [e.g., Code of Environmental Management Principles
(CEMP)], ISO 14001 is the most commonly used standard to benchmark EMSs. The decision to pursue ISO
14001 is completely voluntary and involves third party auditing of the EMS. This "outside set of eyes" often
helps a hospital maintain and improve its environmental performance, foster a continual improvement ethic
and contributes to a more efficient and maintained EMS.
However, registration requires extra financial resources and time involvement. Health care facilities
can still achieve all of the benefits an EMS provides with or without ISO 14001 registration. This manual is
designed to assist with implementation of a successful EMS in either case.
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Structure, Responsibility and Accountability
Getting Support and Buy-In for an EMS
Senior Management and Board
It is essential to gain senior management and board support before implementation. Schedule a meeting
with senior management to discuss and provide the following:
• A description of what an EMS is and why it will benefit the hospital.
• The environmental issues, particularly compliance-related, that the hospital currently faces (highlight
environmental legal concerns and due diligence issues, such as incineration, biomedical waste,
hazardous waste, PVC/mercury, spill response, etc.).
• The expected resources and time requirements for initial development and implementation of an EMS.
• Senior management's roles and responsibilities in implementing and maintaining the EMS.
Overview of Hospital Corporate Structure and EMS Roles and Responsibilities
While internal management structures may vary from hospital to hospital, all operate with distinct levels
of senior management, middle management and associates. All levels have active roles to play in
environmental management.
Board of Trustees
This governing body is often comprised of hospital staff as well as community and health care
professionals. Board members are responsible for the overall direction and planning of the hospital. Trustees
approve corporate programs, make significant hospital decisions and discuss current and future hospital
initiatives. Their EMS responsibilities should include the following:
• Establish the environment as a priority by approving and abiding by the environmental policy.
Support cost-effective environmental initiatives that protect the hospital from legal and financial
liability and promote environmental health in the community.
Look to board members as potential environmental allies. Board members may live in the local
community and share the same environmental concerns as staff and local residents. Tap into these influential
and professional resources for EMS implementation support.
Senior Management
Senior management consists of the president, chief executive officer and vice presidents/directors/
program managers from various functional centers throughout the hospital. These managers plan present and
future hospital programs/operations and ensures that they remain efficient, effective and fiscally responsible.
The decision to implement an EMS should first be presented to and approved at the senior management
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level prior to going to the board for comments and final approval. Senior management is the first line of
communication to the board of trustees and is often aware of agenda items and topics to be reviewed at
monthly board meetings. The hospital's senior management team also approves and allocates funds for the
hospital's upcoming operating budget. Senior management's EMS responsibilities include the following:
• Approve the overall EMS and ensure that EMS remains suitable, adequate and effective.
• Appoint EMS representative(s). Define EMS management representative and EMS administrative
representative positions as job functions (either one person with a dual role or two separate
positions). For more information, see the "Choosing the EMS Representative" in this section.
• Establish the environment as a priority by approving and abiding by the environmental policy.
• Support cost-effective environmental initiatives that protect the hospital from legal and financial
liability.
• Ensure that the resources (e.g., human, physical and financial) essential to the implementation and
continuation of the EMS are available.
• Conduct management review of the EMS.
Without senior management support, the EMS will likely fail.
Middle Management
Hospital middle management includes program/department managers, supervisors and coordinators that
oversee the day-to-day management of such hospital programs as patient services, support services and
facility management. Middle management plays a significant role in the EMS, particularly in the follow-
through stages associated with staff environmental training, awareness activities and standard operating
procedures. Middle management EMS responsibilities include the following:
• Implement, comply with and maintain the EMS within the scope of their functional roles.
• Comply with all applicable environmental requirements, policies and procedures.
• Attend EMS general awareness training.
• Ensure employees are given the time and opportunity to attend EMS and other relevant environmental
training, participate as auditees and auditors (as interested or chosen) and assist in writing effective
work instructions for their respective work areas.
Hospital Employees
Excluding management, hospital employees include physicians/doctors, nurses, specialists,
technologists, support staff and all other union and nonunion staff. Hospital employees' responsibilities
include the following:
• Implement, comply with and maintain the environmental management system within the scope of
their functional roles.
• Comply with all applicable environmental requirements, policies and procedures.
• Attend EMS training, participate as auditees and auditors (as interested or chosen) and assist in
writing effective work instructions for their respective work areas as it relates to EMS objectives.
• Give ideas to middle management on how the system can be improved, provide feedback on EMS
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and waste minimization ideas.
Recruit keen frontline staff to assist with identification and communication. Ask each department to
designate one employee as an EMS contact or delegate. Use this person to transfer environmental
information to and from the department.
Choosing the EMS Representative(s)
Depending on the management structure, there are a number of ways to delegate responsibility for
developing an EMS. Some organizations have two individuals who coordinate all aspects of the EMS -
usually an existing hospital management representative at the senior administration level that functions as the
EMS management representative and an environmental coordinator/EMS specialist at middle management or
specialist level.
The environmental coordinator/EMS specialist performs the majority of EMS procedure development
and hospital-wide communication. In turn, the EMS management representative, with the ability to allocate
funds, approves all resulting EMS-related procedures and programs. This structure ensures that a hospital
management representative oversees the performance of the environmental coordinator/EMS specialist and
the overall system performance.
EMS Management Representative
In two of the case study examples, the senior management position responsible for materials
management and support services (e.g., housekeeping, maintenance, nutrition, purchasing, sterilization,
waste, health and safety, etc.) was appointed as the EMS management representative. This is because many
of the perceived high-risk or environmentally significant issues fell within these departments. The
responsibilities of the EMS management representative include the following:
• Provide leadership in environmental management and environmental performance.
• Ensure that the resources (e.g., human, physical and financial) essential to the implementation and
continuation of the EMS are available.
• Review and define employee roles and responsibilities as they relate to the EMS.
• Provide feedback and sign off on EMS team requests as appropriate.
• Report on the performance of the EMS to senior administration for review.
The EMS management representative's position should receive acknowledgment and support from the
hospital's senior administration. (See the "Interoffice Memo" on page 86.)
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Environmental Coordinator/EMS Specialist
When selecting the environmental coordinator/EMS specialist, consider these main things:
• Knowledge of environmental programs and issues
• Knowledge of basic EMS elements
Knowledge of the ISO 14001 standards
• Experience in developing and leading training sessions
If internal resources are available, assign the role of environmental coordinator/EMS specialist to a staff
member (possibly someone in the health and safety department with environmental interest). If not, hire
someone to fulfill the role (which is often the case). EMSs are still new in the health care sector and it may
be unlikely to find an individual on staff who has both hospital knowledge and EMS experience. More often,
someone with environmental knowledge is hired and learns the industry.
Consider hiring a student to assist with EMS development, or recruit local college students with an
interest in the environment and knowledge of ISO 14001 to help with EMS development. Students are
enthusiastic and are willing to learn the necessary skills of EMS implementation at a fraction of the cost of a
full-time professional.
Choosing the EMS Team
In health care, it is a common practice for management to assemble multidisciplinary teams of hospital
staff for development and implementation of new patient care programs. Likewise, a multidisciplinary
"Green Team" can help develop EMS objectives and targets, awareness programs, research and staff
communications.
When considering who should be a member of the hospital's Green Team, identify departments that
traditionally have many environmental issues. EMS team members should have substantial knowledge and
experience in these areas. For example, many facilities adopt waste management issues as an initial EMS
objective or environmental program. Typically custodial services handle waste management and would be
good to include as would those who generate waste.
Secondly, it is essential to have representation from management and other departments that influence
the decision-making process of environmental programs. For example, the purchasing department is
responsible for products, services and equipment brought into the hospital, communicates with contractors
and suppliers on a regular basis and is closely linked to the finance and other departments. Purchasing can be
a key player in "green procurement," which is critical when working on reducing polyvinyl chloride (PVC)
medical supplies, mercury thermometers and disposable versus reusable products. The largest group will
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probably be medical and/or nursing staff; therefore a medical/nursing representative should be on the team.
A member from the financial department can prove beneficial to the Green Team. When determining
significant aspects and impacts, the Green Team member from the financial department can provide specific
cost information for different processes and procedures. This type of accounting for information related to
specific environmental activities is called Environmental Management Accounting. Environmental
Management Accounting (EMA) makes capital investment decisions, process/product design decisions and
performance evaluations. EMA differs from traditional accounting in that it includes societal and private
costs across the entire life cycle of an activity or use of a product. This accounting provides a more accurate
cost assessment during the significance determination step in an EMS. Visit http://www.epa.gov/oppt/acctg/
indexold.html for more information.
Green Team Members
The Green Team should represent key departments in the hospital - especially those that deal firsthand
with environmental issues. An ideal Green Team will consist of members from the following areas:
• Purchasing • Nursing
• Housekeeping • Finance
• Management • Worker representation
• Surgery • Laboratory
• Cafeteria • Facilities Management
• Infections Control • Safety and Health Coordinator
Green Team Expectations
The Green Team's role in EMS planning and implementation may differ from site to site. The following
is a list of possible responsibilities for the Green Team:
• Aid in the identification of environmental aspects, associated impacts and determination of
significant aspects.
• Provide input into the development of environmental objectives and targets, environmental
management program(s) and other related EMS programs (e.g., members as "champions" of certain
objectives).
• Assist in the development and maintenance of EMS documents, particularly work instructions that
may apply to specific areas.
• Help identify the hospital's training needs. Train individuals on the EMS, the environmental policy,
objectives and targets applicable in their work areas and work instructions to follow in order to
meet the objectives and targets or otherwise minimize environmental impacts.
• Facilitate communication with frontline staff concerning environmental issues and relevant sections
of the EMS. Direct questions, issues and any external communications to the EMS representative(s).
• Provide input on environmental issues that may affect the hospital.
• Build enthusiasm in the hospital for environmental performance, programs and changes.
• Make recommendations for continual improvement in the hospital's environmental performance.
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These responsibilities should be clearly explained and communicated to all members during the first few
Green Team meetings to ensure that everyone clearly understands their roles and the team's focus.
Meeting Structure
The Green Team may need to meet monthly as various components of an EMS require input on a regular
basis. If it is possible to meet at this frequency, utilize interhospital communication modes such as email and
interdepartmental mail between formal meeting as needed. Set meeting agendas and keep them. People
become less attentive if meetings continue past the allotted time. Designate someone to take notes/minutes of
each meeting. Minutes document proof of meetings and discussions EMS internal audits and external audits
(if ISO 14001 registered).
Promote open dialogue and communication among members. Begin meetings with "icebreakers" to
introduce members to one another. Incorporate short activities into the team's agenda to facilitate members'
discussion of environmental issues in health care, their communities and their neighborhoods. Provide
education, information and an inclusive environment during meetings. Open discussion of issues is essential
to the progression of the EMS and the success of the team's goals.
Reporting Structure
The Green Team should report back to the EMS coordinator as necessary (e.g., quarterly updates,
monthly reports and annual reports). When the team focuses on specific EMS-related decisions, such as
recommending/setting environmental objectives and targets, they must report back to senior management for
budgeting approval.
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Standard EMS Implementation Cycle
to
Management Review
Periodically report overall
EMS progress and other
related information to senior
management for review,
approval, and to ensure the
continual improvement
overall system.
4. Checking &
Corrective Actions
Tracking key environmental
performance indicators,
identifying and remediating
nonconformances,
maintaining records and
performing regular EMS
audits.
1. Environmental Policy
A statement of the health care
organization's environmental
intentions.
PLAN
ONTNU
CHECK
DO
Planning
Identify compliance
requirements, and the
significant environmental
issues associated with a health
care organization's activities
and operations. Developing
documented objectives,
targets and management
programs to address these
areas.
Implementation &
Operation
Identification of EMS
responsibilities, training
requirements, communication
methods, documentation
control, operational control &
emergency response.
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- SECTION 3 -
COMPONENTS OF AN EMS
EMS Component Descriptions
ENVIRONMENTAL
POLICY
PLANNING
IMPLEMENTATION & OPERATION
CHECKING &
CORRECTIVE ACTION
Environmental
Aspects and
Impacts
Legal and Other
Requirements
Environmental
Objectives and
Targets
Environmental
Management
Programs
Structure and
Responsibility
Training,
Awareness and
Competence
Communication
EMS
Documentation
Document
Control
Operational
Control
Emergency
Preparedness and
Response
Monitoring and
Measurement
Nonconformance
and Corrective
and Preventative
Action
Records
EMS Audits
MANAGEMENT REVIEW
A statement of a hospital's
commitment to compliance, pollution
prevention and continual improvement.
An analysis of the hospital's activities,
products, services to identify those that
may have a "significant" impact on the
environment.
A method of identifying, applying and
updating all environmental compliance
requirements.
Set achievable goals based on the
hospital's significant aspects or issues,
legal requirements, financial
capabilities, etc.
Develop specific actions; designate
resources and timelines for the
completion of environmental
objectives and targets.
Determine responsibilities under the
EMS (to ensure that adequate
resources are allocated).
Ensure that hospital staff receives
training that relates to their
environmental responsibilities.
Establish methods for relaying and
documenting environmental
communications with staff, patients,
visitors, contractors, etc.
Maintain all EMS-related
documentation to ensure that they are
available and up-to-date. Promptly
remove obsolete documents.
Ensure that all documentation
(policies, procedures, etc.) are
controlled, dated, approved and
reviewed.
Review operating procedures that
relate to positions/processes to address
significant environmental impacts.
Train staff on the importance of
conforming to the procedures.
Establish procedures to address
environmental disasters and accidental
releases to air, land and water.
Track key components of
environmental performance.
Provide a means for documenting
environmental issues/hazards. Identify
corrective and/or preventive actions to
prevent reoccurrence.
Maintain records that relate to
environmental performance,
compliance, inspections, etc.
Perform periodic audits to ensure that
all components of the EMS work
properly.
Provide EMS-related information to
senior management for periodic review
and/or approval to ensure continual
improvement of the system.
Similar to a hospital's mission statement, health and safety
policy, etc.
Examples: use, handling and proper disposal of radioactive
materials, use of significant amounts of energy and water
in facilities management, etc.
Also include voluntary- or industry-specific codes,
(Accreditation Standards), memorandums of
understanding, codes of practice, etc.
Can be hospital-wide (e.g., reducing energy use) or
department-specific (e.g., implementing an organics
recycling program in Food Services.)
Use as a way to determine budgetary requirements for
implementation of an objective.
Include the roles of senior management, management,
front-line staff, patients, contractors, etc.
Some training may require general awareness (e.g., overall
knowledge of environmental policy), and others may
require competence (e.g., spill training).
Use existing modes of internal communications when
possible (e.g., hospital newsletters, emails, displays,
posters, staff meetings, etc.)
Consider creating an electronic version of the EMS manual
(for a hospital-wide system available to all staff).
Updating and editing an electronic system requires much
less time than revising paper manuals.
Utilize existing hospital formats/templates of
procedure/policy documentation.
Example: Ensure all staff handling chemicals (especially
laboratory, diagnostic, housekeeping and maintenance
staff) are aware of and utilize proper chemical handling,
transport and disposal procedures.
Hospitals commonly use universal "Emergency Codes"
(e.g., Code Red/Fire, Code Brown/Chemical Spills, etc.)
Track the progress of objectives, occurrence of regulatory
inspections, calibration records, etc.)
Tap into existing means for reporting hazards and incidents
(e.g., employee incident reporting forms, departmental
inspections, etc.)
Keep in a centralized location (if possible, the EMS
administrator's office/work area)
Example: Form an EMS audit team of a few keen staff
members.
Tap into existing reporting structures (e.g., monthly
reports, annual reviews, management meetings, etc.)
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It takes parts working together for an EMS to work. The table on the preceding page presents these
parts with a short description; more detailed descriptions will follow throughout the manual with in-depth
suggestions for implementation and examples of EMS documentation. Modify and use these examples as
appropriate.
Realize that a typical hospital has some of these components already in place. A complete gap audit
using an assessment tool (see p. 182 of this manual) will help identify which EMS components are in place to
build on and which components are missing. A hospital may implement the components of an EMS in an
order different from that presented in this manual or may find itself working on several components at a time.
Flexibility is the key.
Environmental Policy
Developing the Policy
The environmental policy can be created any time during EMS implementation. Some organizations
draft the policy first and use it as a primary communication from top management to all employees. Others
identify their significant environmental aspects, legal requirements and objectives and targets prior to
developing the policy in order to accurately depict the organization's future environmental goals and guiding
principles.
In either case, the environmental policy is the cornerstone of an EMS. Like other hospital mission
statements or policies, the environmental policy should ultimately reflect the environmental values and senior
management's commitment. Some environmental policies are short and concise; others are more elaborate
and detailed. Review hospital policies and procedures to help identify the context in which this document is
developed.
Things to Consider When Writing the Policy
1. The policy should be appropriate to the activities and services. For example, what are the
significant aspects and impacts associated with the operations, activities and services?
Consider these when developing the wording in the policy. Also, is the scope of the EMS
intended for one or several departments in the organization, or will it apply to all departments?
This details the scope of the policy or, in other words, areas of the hospital where the EMS
applies.
2. The policy should include a statement of commitment to comply with relevant environmental
legislation and regulations as well as with other requirements to which the organization
subscribes.
3. The policy should include a statement of commitment to continual improvement in
environmental performance and pollution prevention. It should also provide a framework for
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establishing and reviewing progress toward objectives and targets. An organization achieves
continual improvement by setting and meeting objectives and targets. The EMS provides an
administrative framework for systematically establishing, reviewing progress toward and
achieving objectives and targets.
4. The policy should also include a statement of management commitment to keep the EMS
suitable, adequate and effective. The policy is the driving instrument for crystallizing senior
management support of and resources for the EMS. Senior management's signature on the
policy represents this commitment.
5. Ensure that the policy reflects the values set forth in the hospital's mission statement. Hospital
mission statements often include a commitment to provide quality patient care services,
promote healthy living and to provide a healthy and safe workplace for staff and volunteers.
Consider including supporting statements from the mission when writing the policy. This helps
integrate the policy into the overall management of the hospital and may help cement senior
management's approval.
6. Is the policy clear, concise and understandable? The policy will be a tool for EMS
communication both internally and externally and should be developed with the end user in
mind. One facility implementing an EMS wrote a three-page environmental policy. It was
difficult for the employees to relate to the length and wording of the policy. Generally, an
environmental policy should be no longer than one page. Some EMS organizations wish to
have an environmental policy statement in addition to the environmental policy itself. The
policy statement is a condensed version of the policy and consists of a statement of the
hospital's commitment to continual improvement, compliance with legal and other
requirements and pollution prevention.
Communicating the Environmental Policy
Hospital Staff
Communicate the environmental policy to all hospital staff. The following are examples of ways to
communicate the policy to hospital staff:
1. Post copies of the policy in highly visible, frequently visited locations within the hospital (e.g.,
cafeteria, near the time clock, front or main lobby area, outside main elevator landings, within a
permanent environmental display board, outside the CEO's office, on a hospital
accomplishment board and at any other location that staff frequently visit). One environmental
health and safety management representative posted the policy, significant aspects, objectives
and targets and contractor environmental information sheet on a bulletin board in the hallway
between the work and break area. Area supervisors would take their teams to the bulletin board
and review this information at the end of the weekly health and safety meeting.
2. One facility put a copy of its environmental policy on the back of the vacation/holiday leave
schedule handed out to employees. By hanging onto the vacation/holiday leave schedule,
employees would always have a copy of the environmental policy.
3. Many organizations place the environmental policy on a business card-sized insert that can be
slipped into the back of staff/visitor identification badges. Other ways of communicating the
policy include showing it on the hospital television network, at hospital entrances/exits and in
environmental training.
4. Post a copy of the policy within the hospital's main policy and procedure manual (either paper
or electronic version).
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5. Include the policy in the hospital newsletter.
6. Post the policy on the hospital's Web site.
7. Ask to include the policy as an agenda item at each departmental staff meeting.
8. Ask to be included on the agenda at the hospital's management meetings. Ask for enough time
to cover the definition of an EMS, the contents of the environmental policy and the EMS roles
and responsibilities of management staff. This can be an EMS training opportunity.
9. Educate new staff on the environmental policy during their hospital orientation. Attach a copy
of the environmental policy to the orientation package for reference.
Patients, Visitors and the Community
The environmental policy is the only document in the EMS that must be publicly available (for
organizations pursuing ISO 14001 registration). Posting the policy in a highly visible location within the
hospital or on the hospital's Web site are just a few ways to provide the policy publicly. Share more
information about the EMS than the policy, such as environmental aspects and progress toward objectives and
targets. Most of an organization's environmental information is already publicly available due to
environmental reporting under applicable regulations.
Contractors and Suppliers
Contractors and suppliers should be aware of the hospital's commitment to the environment and the
environmental policy. They can impact a hospital's environmental performance and should follow EMS
procedures. Their commitment is essential, particularly on such issues as reducing product packaging, green
procurement and products and services they provide.
St. Mary's General Hospital sent recent contractors and suppliers (those with whom the hospital had
done business in the prior two years) an environmental awareness brochure, which outlined the hospital's
environmental commitment. The hospital also sent a questionnaire asking for input on how the contractors
could help the hospital attain certain environmental goals. Supplier and contractor response was positive and
assisted hospital purchasing in developing a "green" products and services database. In turn, participating
suppliers were able to promote additional product lines to the hospital for future possible business.
EMS Example
Example of Detroit Mercy Hospital's EMS/Environmental Policy Pages 87-93
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Environmental Aspects & Impacts
and Determining Significance
Introduction
One of the first steps to implementing an EMS is for the hospital to identify environmental issues (also
called environmental aspects) to determine the associated impacts, or environmental changes, and identify
which are not significant to the hospital. A hospital must consider these significant environmental impacts
when setting its EMS objectives and targets. Establishing and implementing operational controls, such as
work instructions, will minimize the significant environmental impacts and help an organization meet its
objectives and targets. Monitoring and measurement requires the hospital to track its progress against the
significant environmental impacts and objectives and targets.
The end of this discussion covers topics, such as training, communication, documentation/document
control and other EMS support components, that support a fully functional EMS.
Environmental Aspect: An element of an organization's activities, products or services, that can
interact with the environment. (Definition from ISO 14001 Standard.) Environmental aspects are
often referred to as the cause of change to the environment.
Example: Environmental aspects for landscaping practices may include air emissions, natural
resource consumption (e.g., water or fuel), chemical usage and possible spillage.
Environmental Impact: Any change to the environment, whether adverse or beneficial, wholly or
partially resulting from an organization's activities, products or services. (Definition from ISO 14001
Standard.) Environmental impacts are the resulting change in the environment.
Example: The environmental impact(s) associated with landscaping chemical usage may include air
pollution, human health effects, groundwater and/or storm sewer contamination as well as flora and
fauna (plant and animal) health effects.
While identifying the aspects and impacts can be daunting, it is critical to identify all of the possible
aspects because subsequent EMS requirements are based on them. It is quite possible to have numerous
aspects of which only a few were significant according to a facility's criteria. One manufacturing facility had
550 aspects of which 50 were significant according to its criteria. Eventually the facility set objectives and
targets for 10 of the most significant aspects. There will be many aspects, but not all of them will be
significant, and not all significant aspects need objectives and targets.
The first step in identifying aspects is setting the scope of the EMS. Is the entire hospital included, or
selected hospital buildings on site or just specific departments? An EMS can be implemented in one part of
the hospital on a pilot project basis and then use lessons learned from that experience to implement the EMS
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throughout the entire hospital. A positive experience with implementing an EMS in one department can build
momentum as the EMS is started in other departments.
Next, identify activities and services within areas of the hospital where the EMS will apply. As a
starting point, identify aspects and impacts associated with each activity or service. Techniques used to
identify aspects include process mapping (charting how materials flow from entry into the hospital, how/
when/where the materials are used, and disposal/recycling of the materials); interviewing; benchmarking
against other hospitals and health care organizations; and inspections and audits.
Environmental aspects drive the EMS. An EMS encourages health care organizations to systematically
address the environmental aspects and impacts associated with its activities, products and services. This is a
perfect opportunity for pollution prevention, which can often eliminate or greatly reduce many environmental
aspects. For those aspects that cannot be eliminated at the source, other pollution prevention alternatives can
be used to manage them in a more environmentally friendly manner.
Identify the impacts associated with each aspect. Impacts are the changes in the environment that occur
as a result of the aspect. Examples of impacts include increases in ground level ozone (air pollution);
degradation of water quality or drinking water supplies; conservation of natural resources (through recycling,
for example); and soil pollution (from accidental spills). Ask whether or not the organization can control or
influence each aspect. The degree of control or influence over different aspects will vary. For example, energy
usage is an aspect. While a hospital may not control what kind of fuel the utility burns to provide power, the
hospital does have considerable control over how much energy it uses and requires from its utility and in turn
how much air pollution the utility produces in generating electric for the hospital.
Table 1 and Table 2 on pages 102-109 show example aspects and impacts for a health care organization.
Essential information to include in an aspects/impacts inventory include the following:
1. The name of the activity, product or service with a short description;
2. The environmental aspect(s) associated with each activity, product or service;
3. Legal Requirements: Is the environmental aspect(s) of the activity, product or service
regulated?
4. Actual/potential impacts associated with each aspect;
5. Significance rating. (In the example, frequency, consequence and degree of control are each
independently rated and then combined for a "total significance" score.) Determining
significance is explained in detail later in this section.
Aspects identification is a perfect opportunity for pollution prevention, which can be used to eliminate
or greatly reduce an aspect. For aspects that cannot be eliminated, pollution prevention can often be used to
minimize them.
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Standard Pick List of Aspects and Impacts
Aspects:
Air Emissions
Energy Usage
Raw Material Usage
Water Usage
Hazardous Waste Generation
Solid or Hazardous Waste Generation
(Incineration)
Solid Waste Generation
Solid and Hazardous Waste Generation
Recycling/Reuse
Wastewater Recycling/Reuse
Wastewater Discharge
Potential for spills
Impacts:
Increased air pollution
Decreased air pollution
Elimination of air pollution
Depletion of natural resources
Conservation of natural resources
Depletion of natural resources
Conservation of natural resources
Increased landfill loading
Decreased landfill loading
Conservation of natural resources
Increased air pollution
Depletion of natural resources
Increased landfill loading
Decreased landfill loading
Conservation of natural resources
Increased landfill loading
Decreased landfill loading
Conservation of natural resources
Decreased landfill loading
Conservation of natural resources
Conservation of natural resources
Increased water pollution
Decreased water pollution
Potential for air, soil, and water
contamination
Other Impacts:
Increased noise pollution
Decreased noise pollution
Elimination of noise pollution
Increased light pollution
Decreased light pollution
Elimination of light pollution
Increased land use
Decreased land use
Elimination of land use
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Roles and Responsibilities in Identifying Aspects and Impacts
It is possible to identify environmental aspects and impacts individually or to enlist help from staff
throughout the hospital. Involving staff on a Green Team divides the workload and gives the members more
of a "hands-on" involvement early in EMS implementation. Provide aspects/impacts training to the Green
Team and review and monitor the department's work outcomes to ensure continuity among the department's
lists. This approach is an effective way to build rapport with department managers and personnel and to begin
building buy-in to the EMS.
Alternatively, it is possible to develop the aspects inventory as an individual. This approach may take
longer to complete and will require frequent updates for the Green Team, but allows greater control over and
continuity of the aspects list.
Either way, it is beneficial to involve frontline staff and departmental managers in completion and
maintenance of the aspects inventory. Employees may be aware of environmental issues and opportunities
unknown to management and have ideas on how to address them. Employee involvement also builds interest
and understanding in ways that are real to work areas and their experience. This builds employee ownership
in and understanding of the EMS, which is essential when asking employees to develop work instructions that
address significant aspects in their work areas, to measure environmental performance, track progress against
hospital EMS objectives and targets and significant impacts and otherwise do their jobs with the environment
in mind.
Determining Significance
Once aspects and impacts are known, determine which are most significant. While there are no hard and
fast rules or requirements, commonly used significance criteria include cost, volume/toxicity of waste,
frequency of the environmental aspect and whether the aspect is regulated or has compliance concerns. Some
examples of hospital-specific criteria include JCAHO requirements or other regulatory requirements, patient
care, employee risks and community concerns. These criteria become the filter used to tell which aspects are
most important.
Table 3 on page 110 shows one approach to determining significance. The significance ranking method
is based on a scale of one through five. Each impact is given a score from one to five for its relative
consequence importance, frequency of occurrence and the degree of control the hospital can exert over the
impact; these three scores are multiplied to give the impact an overall score which is used compare that
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impact to others. The hospital in this example shows that any impact that ranked 27 or higher or had legal
requirements associated with it was considered significant.
Change Management and Continual Improvement
With this initial list of aspects in hand, begin addressing the most significant aspects first; remaining
aspects can be addressed later as part of continual improvement process.
How the hospital identifies aspects and determines significance is information to include in a written
procedure. As shown in the example, aspects procedure, scope, responsibilities and references to related
documentation are all necessary components to address.
A current aspects list is important, and should be included as part of the aspects procedure with
reference to how the organization reviews its activities, products and services for new aspects and impacts.
This keeps perspectives current and will provide potential new objectives and targets. In one case, an
automotive manufacturer changed from a lead-based electro-coat material to a lead-free alternative. During
the six-month surveillance audit to maintain its ISO 14001 registration, the facility proudly showed this to its
auditors as an example of continual improvement. The auditor congratulated the facility and promptly asked
the facility if it had updated its list of aspects to reflect the new waste stream resulting from the modified
process.
Train departmental managers to evaluate any new or future processes, activities or services for new
aspects and impacts and to communicate this information to the EMS representative. Involving and providing
training to purchasing staff is especially important. Purchasing often has firsthand knowledge of new
equipment and processes and can notify the EMS representative of new significant environmental issues.
New pieces of equipment may be acquired during the capital budgeting process. Work with the finance
department to identify opportunities to evaluate the environmental impacts of equipment prior to its approval.
Such notifications also allow the EMS representative to identify any potential new regulatory requirements as
well.
EMS Examples
Environmental Review of New Projects Pages 94-95
Project Environmental Checklist Pages 96-97
Helpful Hints for Getting Started
1. Keep categories of aspects and impacts general. While technical proficiency as an
environmental specialist allows greater detail, consider that most people in a hospital do not
have an environmental/technical background and experience. Keep categories general to
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facilitate staff participation.
2. As the aspects/impacts list is developed, certain activities, aspects and impacts may repeat (e.g.,
energy usage) and apply across departments. In these cases, a hospital may choose to manage
the aspects through many departments, rather than through an individual department.
3. Not all aspects and impacts are negative or detrimental to the environment. Recycling
programs, household hazardous waste collection days that the hospital sponsors and other
environmental improvement efforts will have positive aspects and should be included when
identifying aspects and impacts. Recycling, for example, reduces raw material and energy
usage. Include positive activities in the aspects/impacts inventory, and designate the outcome
as a positive impact (+).
4. Impacts can relate to the immediate changes to the environment (e.g., vapors from chemical use
affecting human health) or eventual changes to the environment (e.g., the generation of garbage
will eventually impact natural resources as a landfill utilizes land space).
EMS Examples
Aspects and Impacts Inventory for a Health Care Facility Pages 98-104
Master Environment Aspects List Pages 105-107
Environmental Aspects and Impacts Inventory Template Page 108
Significant Evaluation Criteria Page 109
Tool to Determine Significance Page 110
Environmental Aspects - Laboratories Page 111
Environmental Aspects and Impacts: Energy Use Example Page 112
Environmental Aspects - Janitorial Operations Page 113
Identification of Aspects, Determination of Significant Aspects
and Setting of Obj ectives and Targets Pages 114-116
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Legal and Other Requirements
Unlike many other EMS components, management of legal and other requirements (e.g., compliance
paperwork and obtaining environmental permits) generally remains under the direction of the environmental
specialist due largely to its specialized nature. However, everyone in the health care organization can affect
whether the hospital stays in compliance by following necessary instructions and working in an
environmentally friendly manner. Compliance resources, such as the U.S. EPA Healthcare Environmental
Resource Center (www.hercenter.org), help hospitals identify and track legal and other requirements.
The desire to improve/assure compliance and keep current with changing environmental regulations
may be initial reasons the board of trustees or senior management want to implement an EMS. Therefore, it
is important to provide an initial baseline of the organization's environmental legal requirements. One of the
best ways to do this as part of an EMS is to develop a table or matrix of all the environmental legal
requirements (including applicable citations and where pertinent files are kept electronically or on paper) and
to conduct a thorough compliance audit against these requirements. (See "Compliance Resources" in
Appendix B for common hospital compliance requirements and commonly found violations). This status can
be reported as one of the first steps of progress toward an EMS. It is important that trustees and senior
management understand that while an EMS does not assure compliance with U.S. EPA or JCAHO
requirements, it puts mechanisms in place that make compliance more likely. Many organizations conduct a
comprehensive compliance audit annually.
Compliance findings should be corrected as soon as possible. Once the EMS is fully implemented,
these findings can be addressed through the checking and corrective action system.
There are also additional reasons for addressing compliance early in the EMS implementation process.
First, compliance issues that come up later in the EMS implementation process have the tendency to divert
necessary resources, time and attention from EMS implementation efforts. It is sometimes difficult to refocus
and get EMS efforts back on track. For this reason, a hospital should conduct a compliance audit prior to
EMS implementation. Successfully addressing compliance problems through the EMS builds credibility and
encourages others to use the EMS to address environmental concerns in work areas. Second, failure to find
and address compliance findings can result in fines, penalties and poor publicity.
Once the initial list of compliance requirements is identified, keep this list up-to-date. Environmental
managers use a variety of resources to stay current on compliance requirements including the following:
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• Legal counsel (e.g., attorneys)
• Regulatory inspectors
• Health care associations and associated resources such as workshops, newsletters and updates
• Professional journals
• Commercial updates and databases
• Environmental consultants
• Web sites
• Contractors and suppliers
EMS also includes "other" requirements as part of what an organization must track and use in assessing
its performance. Others include requirements an organization undertakes voluntarily, such as the U.S. EPA's
Hospitals for a Health Environment (H2E), which sets voluntary goals of eliminating mercury-containing
products and waste by 2005 and a 33 and 50 percent reduction goal for waste by 2005/2010 respectively. Visit
the H2E Web site at http://www.H2e-online.org.
Once these initial steps are completed, it may be good to write an EMS procedure for administering
environmental legal and other requirements. In addition to assigned responsibilities, the procedure should
include the list/matrix of environmental legal and other requirements, how the organization stays current with
its legal and other requirements and how the organization assesses its performance against these
requirements.
Write the procedure to reflect how steps are actually performed in the organization. Writing a procedure
that does not match the sequence can result in a discrepancy between what is documented and actual practice,
or in other words, a nonconformance in the EMS.
Remember that it is important to keep abreast of all state and federal regulations as they may change
over time. For example, the U.S. EPA recently promulgated a revised final Spill Prevention Control
Countermeasure (SPCC) under the Clean Water Act. There are new compliance dates under this new rule that
someone, such as the facility manager, may need to know. Refer to the compliance section in the back of this
manual for current federal regulations and references to Web sites and the Federal Register. It may be helpful
to assign one person to keep track of changes to state and federal regulations and notify any departments that
might be affected by such changes.
Additional Information
Legal and Other Requirements Procedure Pages 117-118
Appendix E: Compliance Resources: A Supplement to Legal and Other Requirements Pages 251-279
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Objectives and Targets
Setting Performance-Based Objectives and Targets
An EMS requires setting performance-based objectives and targets. Objectives are overall
environmental goals. Targets are detailed performance guidelines, quantifiable where possible, set to achieve
the objectives. The more measurable the objectives and targets, the easier it will be to track performance.
Use the EMS Green Team(s) to help identify possible objectives and targets. There is no required
number of objectives and targets; however, consider the following factors in setting objectives and targets:
• Significant environmental aspects. These are the environmental aspects rated most significant. For
example, for mercury reduction, consider an objective of "reduce mercury waste" in the hospital with
a target reduction of 10 percent per year.
• Compliance. Consider compliance-based guidelines as an EMS objective and target. For example,
an EMS objective of "maintain compliance with applicable environmental regulations" and a
related target as "submit all necessary paperwork on time" or "no written notices of violation."
• Views of external parties. This is essential for hospitals. Input from patients, visitors and community
neighbors is important particularly considering the hospital's mission to protect the health of the
community for which it serves.
• Technological options. Current technology may limit pursuing certain objectives and targets. Atone
EMS facility, ink cartridges from office copy machines could not be recycled because cost-effective
technology was not available. At some point, cost-effective technology could become available, but
until then the toner requires landfilling.
• Financial guidelines. Pursue objectives and targets that make financial sense.
• Operational and business guidelines. Many EMS organizations include environmental objectives
and targets in the annual business plan, ensuring that they are in line with overall hospital
requirements and receive the necessary resources. Are there objectives and targets that can operate in
line with or otherwise complement other hospital objectives and targets?
Implementation Tips
Consider the following tips:
• Focus on setting pollution prevention-based objectives and targets. Pollution prevention eliminates
waste before it is created.
Make sure the objectives and targets are challenging, yet attainable.
• Choose a manageable number of objectives for the available resources, time and personnel. Narrow
the possibilities by considering the necessary financial and physical resources to reach each objective.
Initially, objectives and targets with high payback and low cost may be needed to maintain senior
management support. Be aware of senior management's expectations; high payback/low cost may not
be possible all of the time.
Objectives and targets should be S.M.A.R.T (Specific, Measurable, Achievable, Results-oriented and
Time-dependent.)
• Don't try to address all environmental issues the first time around.
• Objectives can focus on individual activities or processes, be department-specific or hospital-wide.
• Develop performance indicators for each objective and target that can be used to track and evaluate
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progress.
• Regular updates of progress toward objectives and targets should be communicated throughout the
hospital, especially to those who work to achieve them..
• Document objectives and targets, and train staff on what they must do to help meet objectives and
targets that apply to their work. Do this by posting a display, writing an article for the hospital
newsletter, etc.
Additional Information
Objectives and Targets Procedure Pages 119-120
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Environmental Management Programs (EMPs)
EMSs require identifying the organization's environmental aspects; determining which are most
significant; and considering objectives and targets for the selected significant aspects. Environmental
Management Programs (EMPs) are the plans that define how to achieve the objectives and targets. EMPs
outline roles/responsibilities, action plans, deadlines and resources needed to accomplish objectives and
targets much as is done with JCAHO Environment of Care requirements (e.g., hazardous material and
emergency preparedness). These plans are examples for how to establish and maintain EMPs; or the EMP
and JCAHO planning under environment of care can be integrated into one process. For example, JCAHO
requires an annual review of the overall performance and effectiveness of the plan and evaluation of
progress toward performance improvements. This is an effective management framework for reviewing
progress toward EMS objectives and targets under the EMPs as well.
Key things to consider when working on EMPs:
• Delegate responsibility for tasks among associate managers, members of the EMS teams, staff, etc.
• Do not reinvent the wheel. Find out how other hospitals address similar environmental aspects
impacts.
• Utilize the resources and pollution prevention programs highlighted in this manual.
• Not all objectives may be completed in a one-year time period (e.g., energy consumption can be a
multiyear objective that requires substantial financial budgeting).
• EMPs should be periodically reviewed and revised to incorporate any changes. As the
organization achieves objectives and targets and sets new ones, EMPs should correspondingly
come into and go out of existence.
• Regular updates of the EMPs should be given to the EMS teams as well as senior management
(e.g., management review).
• Look at the full range of options before making a decision.
Example: Saint Mary's General Hospital EMP
Biomedical Waste Reduction EMP
Biomedical waste management and disposal was one of St. Mary's General Hospital's most
significant aspects (e.g., highly regulated, costly, potential health and safety issues).
The first step in St. Mary's biomedical waste reduction program was to address the risk, cost and
compliance associated with the operation and maintenance of the hospital's incinerator. A formal review
of the incineration equipment and usage indicated that the incinerator would be shut down permanently.
St. Mary's contracted the waste disposal services of a responsible, licensed medical waste hauler who also
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contractually assisted in the hospital waste reduction efforts. The hospital performed a biomedical waste
audit of all departments, focusing primarily on the departments that produced the largest amount of
biomedical waste (e.g., emergency room, operating rooms, laboratory). The waste audit's goal was to
review current proper container usage, review staff's knowledge of proper disposal methods and to
determine possible waste reduction actions for each area.
The audit revealed these findings:
• 70-80 percent of all of the biomedical waste bags were filled with garbage (gloves, plastic, cups,
paper towels, etc.).
• Proper signage was not adequate on containers.
• Some rooms only had biomedical (red) bags, and all garbage was being disposed in that container.
• Staff were putting objects that could be recycled into red bags and garbage bags.
• Rooms that produced no biomedical waste had red bags ("Just in case!").
• Staff were not aware of what went into the red bags and did not know what constituted
"biomedical waste."
• Departments often used large containers for red bags and small containers for garbage. Staff often
migrated to the largest, closest container for waste disposal.
Following are actions resulting from the audit:
• Red bag containers were removed from rooms that produced only garbage.
• Proper signage was placed above the majority of containers to dispel myths about what was to be
placed in a red bag.
• Biomedical and garbage containers were switched so that the larger containers contained a black
bag (garbage).
• Environmental services (housekeeping) staff received training on how to properly segregate
biomedical waste to help identify departmental problem areas in the future.
• Hospitalwide waste education was delivered to all floors. (Light snacks and beverages were
brought to each floor, which boosted attendance.)
In one year the hospital decreased its biomedical waste stream by 22 percent, even with an eight
percent increase in surgeries in the hospital's operating rooms (main generators of biomedical waste) and
ongoing hospital growth. Overall, the initiative resulted in a 38 percent reduction in biomedical waste
weights since 1998.
It is important to understand that the waste separated out of the biomedical waste stream will
primarily be garbage and hence garbage to be landfilled will increase. Evaluate existing hospitals' reuse
and recycling programs and modify/expand these to divert additional possible trash from the landfill.
Recycling and Reuse EMP
When St. Mary's General Hospital began developing its EMS, the hospital had already implemented
a few recycling and reuse programs. Most departments used a "blue box" for glass, cans, plastic,
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cardboard and newspaper. Many administration offices and clerk areas had deskside cardboard boxes for
paper waste (colored paper, magazines, envelopes, etc.). The Nutrition and Food Services Department
already collected food waste from the cafeteria trays and sent it to a local pig farmer for reuse.
When the EMS team cited improved recycling as one of its objectives and targets, the hospital
evaluated current recycling service providers and investigated many nonconventional recycling and reuse
opportunities. St. Mary's joined forces with two other regional hospitals to develop the Regional Hospital
Recycling Initiative. By combining negotiations for contracts, the hospitals increased their buying power
and received discounted prices for pick-up services. The chosen recycling company would be able to
perform "milk runs" to pick up the hospital's glass, cans, plastic and paper/newsprint recycling containers.
With pick-up service of the "general" recyclables underway, newly purchased recycling containers
were dispersed throughout the hospital to incorporate a "segregated" recycling system. The "recycling
stations," which were primarily located in kitchenette areas, lunchrooms, lobby areas and the cafeteria,
consisted of three slim plastic containers that contained glass, cans and plastic. The blue boxes that were
previously in place were redesignated for cardboard and newspaper. Widely distributed plastic deskside
recycling containers replaced the cardboard deskside paper recycling containers.
Other recycling efforts included the following:
• Pagers, personal electronic organizers and other information technology devices generate a large
number of alkaline and nickel-cadmium batteries. Due to the hazardous nature of this material if
disposed (metal and battery acid), the hospital ships these materials out for recycling and reuse.
Plastic buckets (reused from the Nutrition and Food Services Department) are placed on floors for
battery collection. When the containers are full, Environmental Services personnel transport the
buckets to battery disposal drums and return empty buckets to the floor. The hospital pays for
disposal of alkaline batteries while nickel-cadmium batteries are collected free of charge.
• Fluorescent tubes contain mercury vapor, and as a "Mercury-Free Medicine Campaign" hospital,
St. Mary's needed to dispose of the mercury content properly. The hospital enlisted the service of
a local company that recycles all fluorescent tube components. When a tube is changed by
Engineering Services, the spent tube is placed back in its original box and attached to a skid for
transport. In 2001, St. Mary's collected 1,414 florescent tubes resulting in the recycling of 393 kg
of glass, 5 kg of aluminum, 6 kg of phosphor powder and 0.04 kg of mercury.
• The hospital was recycling cardboard, but not boxboard (tissue boxes, glove boxes, various supply
boxes, etc.). The hospital implemented this recycling alternative and now collects and bails
boxboard along with cardboard.
• The pharmacy department also identified reuse opportunities. Drugs and medications that need
refrigeration are always delivered in Styrofoam containers with cold packs. The pharmacy
department now offers the Styrofoam containers and cold packs to staff for reuse.
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Spill Response and Emergency Preparedness EMP
Health care facilities with on-site laboratories utilize a large number of chemicals on a daily basis. In
addition, health care facilities receive numerous shipments by trucks that carry chemicals or hospital
supplies. At any given time, these situations could result in a chemical spill, internally or externally. For
this reason, one of St. Mary's objectives focused on spill prevention and response.
First, the hospital performed an emergency preparedness audit of high-risk areas. Inventory was
taken of all equipment. Findings showed that all aspects of emergency preparedness and response that deal
with fires, evacuation, disasters and bomb threats were adequately addressed through the hospital's
emergency code system. However, little information was available on emergency response for internal
and/or external chemical spills and handling chemically contaminated casualties. Personal protective
equipment and spill clean-up equipment was lacking.
In response, the hospital's environment health and safety specialist developed a "Code Brown-
Chemical Spill Response Procedure" and assembled a Hospital Spill Response Team. The Code Brown
procedure dictates what the Hospital Spill Response Team and the hospital staff should do in a case of a
chemical emergency. The hospital also purchased three hospital spill kits, four full-face respirators (in
addition to what the hospital already had) and personal protective equipment (chemical-resistant gloves,
suits and goggles). Each member of the Hospital Spill Response Team receives annual comprehensive
spill response training, respirator training and Code Brown responder training. All new hospital staff
receive Code Brown training during their hospital orientation session, and existing staff receive annual
Code Brown training as part of the hospital's code review sessions. Since program inception, there have
been no reportable chemical spills.
Landscaping Practice EMP
Landscaping provides a variety of environmental challenges, such as pesticide usage and lawn mower
emissions. Hospitals often have immune-deficient individuals entering and leaving the hospital's property.
For this reason, St. Mary's recognized the importance of being proactive and eliminating pesticide and
herbicide use in current landscaping practices. The hospital worked with its current landscaping company
to investigate the opportunities available to the hospital. Identified options included the following:
• The hospital developed a "green landscaping policy."
• All spot spraying was stopped.
• Increased aerating, reseeding and fertilizing are used to reduce herbicide use.
• Shrubbery and other vegetation prone to attacks by pests were promptly removed and replaced
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with native and drought- and insect-resistant alternatives.
• St. Mary's uses microbial pest intervention to kill lawn grubs.
• Future landscaping plans will reduce the amount of grass around the facility to promote the usage
of groundcover, gardens and other vegetation that does not require labor-intensive upkeep.
• Scheduled mowing to avoid smog alert days.
• Use of a natural fertilizer (corn gluten meal) with inherent herbicidal qualities.
• Use of environmentally friendly alternatives to salt for ice removal on walkways.
Mercury Reduction EMP
Consider mercury reduction as one hospital EMP. Links to the Sustainable Hospital Project and the
Hospitals for a Healthy Environment are in the reference section of this manual. Consider the following
ideas in EMP development:
• Eliminate, reduce or recycle products or waste that contain mercury wherever possible.
• Assess inventory of mercury in equipment, materials (also chemicals and pharmaceuticals), in
storage and in waste streams. Check cleaning supplies for mercury content.
• Gather life cycle cost information of purchasing/using products that are mercury-free compared
to those that are not.
• Switch to mercury-free products (e.g., thermometers, lab reagents).
• Separate products that contain mercury before they get into the incinerator waste stream.
• Use fluorescent lighting. Fluorescent lighting requires four times less energy than incandescent
lighting. This means less mercury emissions at the point of power generation.
• Eliminate purchase of products that contain mercury through environmentally preferable
purchasing. Create and enforce agreements with vendors to supply only mercury-free products.
• Develop a broad-based communications program to increase awareness of human health and
environmental dangers of mercury.
• Include articles devoted to mercury reduction, handling and proper disposal in staff newsletters.
• Include specific information about the proper handling of mercury in employee orientation and
"right-to-know" training.
• Ensure that all personnel—including temporary workers—are familiar with the facility's mercury
handling procedures and protocols to prevent mercury from being disposed in sharps
containers, red bags or solid waste containers.
• Include information about waste reduction and pollution prevention at in-service training
sessions.
• Encourage personnel to read labels.
• Place placard or labels on or above red bags, sharps containers and solid waste containers that
state "No Mercury."
• Make sure mercury spill kits are available in all labs, nursing stations, ICU/ER/Surgery rooms,
patient rooms and storage/maintenance facilities.
Additional Information
Procedure for Environmental Management Programs Pages 121-122
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Training
Training is essential to the success of any EMS because employees have potential significant
environmental impacts and ideas on how to improve environmental performances. Existing environmental,
health and safety training are opportunities to conduct EMS training.
An EMS requires the following kinds of training:
1. EMS awareness training for all employees should be conducted. It highlights the policy,
objectives and targets that apply hospital-wide as well as general roles and responsibilities
(e.g., who the EMS representative is). Employees need to know and understand why the EMS
and related information is important. There are many ways to provide this training. One
company created a bulletin board displaying the company's policy, significant aspects and
impacts and objectives and targets. During morning meetings, the line supervisors went with
the line team to the bulletin board and reviewed this information until the time of the ISO
14001 registration audit. This approach was excellent for several reasons: 1) It built on a
system already in place; 2) The regular meeting established and reinforced the importance of
knowing the information; and 3) The employees knew where to go when the auditors asked
them questions about these areas of the EMS.
2. Work area training provides task-specific training to employees to understand the
environmental impacts of the work, how to minimize the environmental impacts and what must
be done to meet their work area's EMS objectives and targets. Training should cover written
work instructions, particularly those that minimize significant impacts or help meet objectives
and targets. Employees should also be acquainted with any monitoring and measurement
responsibilities that apply.
3. Compliance training ties into training specific to the work area. Employees should know what
they must do to help ensure compliance in this work area.
4. EMS internal auditor training for employees who are expected to perform this function.
5. Senior management may need additional training to address their roles and responsibilities in
the system. In short, senior management ensures the continued suitability, adequacy and
effectiveness of the EMS. In addition, they do the following:
• Provide essential resources that implement and control the EMS, such as human resources
(employees' time and skills), technological resources and money.
• Appoint a management representative who 1) ensures EMS requirements are established,
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implemented and maintained; and 2) reports on EMS performance and possible need for
improvement.
• Participate in EMS Management Review.
6. Lead auditor training - should the hospital choose to pursue ISO 14001 registration, have at
least one person attend ISO 14001 lead auditor training.
Contractors and Suppliers
It may be necessary to have on-site EMS training for contractors and suppliers, perhaps in conjunction
with safety training provided to suppliers and contractors during orientation.
Getting Started
Providing EMS training is time-intensive. EMS training starts with identifying significant
environmental impacts and determining where these are in the hospital. Next, determine which job positions
are tied most closely to the impacts. These are the people who will need EMS work area training. In some
cases, it may be possible to combine EMS and compliance training. Establishing a training matrix that
outlines which work positions are tied most closely to the significant environmental impacts and objectives
and targets, as well as training each job function should receive, will facilitate development and delivery of
training at the right time.
Lessons Learned
• Incorporate EMS training into existing training or meetings. For example, use management review
as a time to provide EMS training to senior management. Employees will prefer this approach to
attending additional meetings.
• The method of training is optional. One environmental health and safety manager posted the
policy, significant aspects, objectives and targets on an EMS bulletin board near the time clock
where employees punch in/out.
• Look for opportunities to begin training early. Training is one way of communicating EMS efforts
and building familiarity. Communicate the results of staff's work back to them, particularly on
successes.
• Remember training qualifications for the individual who provides the EMS training. How are
instructors prepared and qualified to give EMS training?
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Communication
External Communication
An EMS calls for effective internal and external communication. The environmental policy is the only
information an EMS representative must communicate to others outside the hospital; in practice, however, a
typical hospital provides information about the environmental efforts through publicly available pollution
prevention plans, annual reports, regulatory records and emergency response training. Develop a procedure
to handle external requests for information on the EMS. The basic elements to document external requests
include who made the contact, the date, the nature of the request and response and what, if any, materials
were sent.
There are various interested parties who may request information on the EMS. Potential interested
parties include the public, environmental groups, other hospitals, state and federal regulatory authorities,
contractors/suppliers, local emergency officials and neighbors. External communication procedures could
consider requests on a case-by-case basis. This allows the flexibility to assess the credibility of the contact
and what information to provide.
Communicate environmental expectations to contractors and suppliers. They should be aware of the
environmental policy and hospital's significant environmental impacts; objectives and targets particularly
those they can affect. Contractors and suppliers are EMS partners. For example, hospitals may set an
objective to purchase only mercury-free products. The extent to which suppliers are invited to participate
could directly impact whether the hospital achieves mercury-free status.
Internal Communication
Develop a formal procedure for communicating EMS information at various levels and functions
throughout the hospital. It is important to consider both top-down communication, as well as bottom-up
communication throughout all levels and functions of hospital personnel. While communicating with senior
management is important and necessary, there are many benefits to tapping into the knowledge of custodial
staff nurses, purchasing and the cooking staff, to name a few. The formal procedure does not preclude
informal communication, but rather attempts to ensure consistent and systematic communication is occurring.
EMS policy, responsibilities, results and environmental aspects (and subsequent changes to aspects) are
examples of items to communicate internally. Changes, such as revised objectives and targets, progress
toward achieving objectives and targets, updates to existing procedures, environmental incidents and new
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regulatory requirements should be communicated. In addition to establishing a framework for relaying
information to employees, internal communication should also include how employees provide EMS-related
information.
Training is the most common way to communicate with employees, but there are many other ways, such
as email, in-house television and newsletters. The type of EMS information shared depends on the audience.
Tailor the nature and frequency of communications to employees' expectations and needs. This varies from
organization to organization.
Once senior management grants approval for the EMS, communicate with hospital staff. Examples of
communication tools follow:
• Work with the communications and public relations personnel to create a letter of support from the
CEO/president to all hospital staff. This letter reinforces the senior management's commitment to the
project when staff ask the question, "Why are we doing this?" Use the environmental policy as part
of the first communication of the EMS if the policy has been developed.
• Develop department-specific training sessions on what the EMS is and why the hospital is proceeding
with development.
• Develop displays, table cards, emails and articles in the hospital's newsletter to get the word out.
Focus on the environmental issues faced by the health care industry and how the EMS will encourage
and support the statements set forth in the hospital's mission statement.
• Ask for involvement and input from staff. They are an excellent source for good ideas, and sharing
ideas builds ownership in the EMS.
• Plan an environmental fair. Include information on local recycling programs; composting programs;
hazardous waste depots; healthy landscaping ideas for home; mercury take-back programs;
local environmental not-for-profit groups; environmentally safe hospital products; energy
conservation and efficiency; alternative transportation methods (busing, biking, carpooling to and
from work); and water conservation initiatives.
• Always be enthusiastic. Enthusiasm is contagious and makes sessions fun.
Ideally, hospital staff will embrace the idea of "green health care" as it goes hand-in-hand with the
overall mission of the health care industry. To promote interest in the EMS among hospital staff, illustrate
how the EMS makes work easier, makes the workplace safer and/or addresses problem(s) in each area. Here
are some keys to success:
• Find ways within the hospital's culture to show how the EMS advances the hospital's mission. If
cost-cutting is a key factor that motivates people, show how the EMS will save money. If patient care
and staff safety is key, show how the EMS accomplishes this.
• Ask skeptics for possible environmental problems in their area(s) and use the EMS as a way to fix
these problems. This creates opportunities for changing attitudes and garnering enthusiasm.
• Listen to outspoken resistors, but be more aware of those who say nothing or agree very easily.
Generally, vocal resistors will vent, get on board and exceed what is asked of them. Silent resistors
or those who agree very easily tend to fall short of expectations.
Whenever possible, recognize individuals who make success possible. Acknowledge individuals in
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newsletters and any other hospital staff appreciation programs.
Keep the staff aware of the program's continuing success. This promotes enthusiasm and encourages
the staff to put forth their best effort to make the program work.
Contractors and Suppliers
Communicating environmental requirements to contractors/suppliers is often one of an environmental
manager's least favorite things to do. However, it can be one area of tremendous "bang for the buck" when it
comes to environmental performance, particularly considering the contractors' environmental impacts.
Contractor performance can directly impact whether an organization meets objectives and targets. For
example, solid waste left by a contractor can affect whether an organization meets a solid waste reduction
objective and target.
Hospital EMS information sent to corporate office addresses may not always be communicated on their
end to the people that actually come out and do the work. Consequentially, it may be important to find
alternate ways to make sure such EMS information is provided to workers. One way is to include it in the
safety/health training or in contractor handbooks. Another way is to distribute it at check-in points (e.g.,
security checkpoints or information desks) at the hospital.
Additional Information
External Communication Procedure Pages 123-124
Internal Communication Procedure Pages 125-126
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Documentation/Document Control
Document control ensures that everyone works from the latest operational guidelines. Along with
training, documentation development and control are among the more time-consuming tasks in implementing
an EMS. Unfortunately, some environmental managers dismiss out-of-hand implementation of an EMS
because they perceive the documentation component as overly burdensome with no added value. As with
other system components, an EMS spells out the minimum requirements and leaves discretion on how to meet
the requirement to the hospital. Consequentially, the hospital determines whether the requirements are met in
an easily managed or difficult manner and what benefits the hospital achieves through the effort. Generally
speaking, effectively written and administered documentation prevents the loss of "institutional memory" and
ensures the consistency of results in operations. Documentation, such as written work instructions, is also a
valuable training aid during the EMS process.
Kinds of Documentation a Hospital will have in its EMS
Environmental Policy. This is the capstone document of the EMS that provides the overall direction, context
and organizational commitment to the EMS and environmental performance. Once established and approved
by senior management, the policy will likely have few changes.
EMS Manual and Systemwide Procedures. These procedures describe how basic EMS functions (e.g., aspects
identification and significance determination) are accomplished. There should be a procedure for each EMS
component. Make note of how these procedures reflect how the requirements are completed. Because many
parts of an EMS will be new to the hospital (e.g., aspects), these will be new procedures; however, other EMS
areas, such as training and communication, may build on existing hospital procedures. Once written, these
procedures may change more frequently than the policy but less so than work instructions. Systemwide
procedures should be included in the EMS manual.
Work Instructions. These are work area or activity-specific documents that spell out how to perform activities
in the hospital. Cross-reference work instructions to the significant environmental aspects and objectives and
targets to which they relate. Work instructions can also be referenced under the "Resources" section of the
environmental management program (EMP), where a hospital describes how it will complete the EMP. A
hospital may also likely need to create new work instructions to conform to newly discovered activities found
in the EMS process. Work instructions should be reviewed/updated 1) during system implementation; and 2)
during the annual review/update of hospital aspects/impacts.
Forms, records, labels, tags, etc. These types of documentation are used to show that the system is
functioning as indicated in the other levels of documentation.
List of EMS Documents
(there may be additional documents the hospital wishes to include)
• Environmental Policy
• Objectives and targets
• EMPs and action plans to achieve objectives and targets
• Master Document Control List (lists all EMS documents across all levels)
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• Systemwide procedures (note: each major component of the EMS as shown following should have a
procedure)
-Environmental aspects and impacts (include significance criteria)
-Legal and other requirements
-EMPs
-Structure and responsibility
-Training, awareness and competence
-Communication (internal and external)
-Documentation/document control
-Operational control, including work instructions
-Emergency preparedness and response
-Monitoring and measurement
-Nonconformance and corrective and preventive action
-Records
-EMS Audit
-Management Review
• Records
There may be additional documentation a hospital wishes to document. Practical considerations in
deciding whether to document include the following:
• If a task is important enough for two people to do the same way, document.
• Determine if there is any existing documentation within the hospital that meets the need. Try to
incorporate existing documentation by reference, ensuring that it is current, or modify existing
documentation to fit the EMS need. The more consistent EMS documentation is with existing hospital
documentation, the more likely people will follow and feel comfortable with what is asked of them in
following what the documentation asks.
• Use the "new employee" test to determine if there is sufficient detail in the procedure or work instruction.
Could someone new in the position pick up a work instruction, for instance, and successfully complete
the specified task? This is critical because a good work instruction contains institutional "know-how"
gained from experience not just rote steps.
Document control requirements are pretty straightforward and common sense. EMS documents must be
legible; identifiable (someone should be able to pick up a document and know what it relates to); and
maintained in an orderly fashion. For these reasons, EMS documentation has document control headers/
footers like those shown in examples in this manual.
Additional Information
EMS Document Control Procedure Pages 127-128
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Operational Controls
Hospital Considerations
An EMS requires an organization or hospital to put operational controls in place for the activities and
services associated with the significant aspects and objectives and targets. This is to help minimize any
determined significant impacts and to help ensure that objectives and targets are met. Generally, operational
controls are written work instructions but can also include training, test results and "control points" such as
those found in air and water discharge permits. When determining which of these additional work
instructions should be documented, consider such factors as task frequency and complexity, personnel
turnover and level of supervision. Written work instructions are also excellent training aids.
For example, one facility's EMS set an objective and target to reduce its hazardous waste by 10 percent
over the upcoming year. It generated one hazardous waste stream associated with lacquer coating copper
winding used around electric motors. It implemented three work instructions to help get to the 10 percent
reduction. One work instruction specified that employees chip lacquer off the mix beaters instead of using
new solvent. Another instruction directed the use of used solvent to purge lines, and the third specified
cleaning the lacquer measuring cylinder at the end of the day instead at the end of every shift. All of these
together helped the facility reduce the lacquer use and corresponding hazardous waste generation.
If any operational controls involve contractors and suppliers, make sure they are aware of their
responsibilities.
Additional Information
Operational Control Procedures Pages 129-133
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Emergency Preparedness and Response
EMS emergency preparedness and response has four requirements:
• Assess potential for accidents and emergencies.
• Prevent incidents and associated environmental impacts.
• Respond to incidents.
• Mitigate impacts associated with incidents.
Often, an EMS serves as an opportunity to view existing plans and regulations (e.g., Resource
Conservation Recovery Act, Emergency Planning Community Right to know Act) and to apply a more
preventive approach in these areas by focusing on the potential for accidents and emergencies. Ask
hypothetical questions that relate to hazardous materials, activities and processes. Consider normal scenarios
as well as start-up, shutdown and other abnormal scenarios for possible emergencies.
Periodically test emergency response procedures (at least annually). Review and revise emergency
preparedness and response procedures, particularly after accidents or emergency situations and make any
necessary improvements. This ensures that emergency response remains suitable, adequate and effective.
Write down how these are accomplished in an EMS procedure.
Implementation Tips
• Make sure emergency evacuation routes are clearly posted. At one facility, intricate facility layout
diagrams were photocopied on an 8.5" by 11" sheet of paper. This made it difficult to read. Some
diagrams were actually posted in nearly hidden areas - in one case, at floor level near an ice machine
in the break area. Emergency evacuation routes should be legible and posted prominently in each
work area.
Correct deficiencies in the emergency system. At one facility, managers realized they had a low head
count during a recent emergency. The missing worker was wearing required hearing protection in a
loud area and did not hear the emergency alarm. No one was assigned to notify him in this
circumstance. Address emergency preparedness and response findings promptly.
Visitors and contractors should also be aware of emergency systems. Address who will be responsible
for patient and visitor safety and evacuation in an emergency and what procedures will follow. This
is critical in a hospital environment with a continual flux of visitors.
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Monitoring and Measurement
It is critical to monitor and measure performance against the EMS objectives, targets and significant
environmental impacts. One of the best ways to accomplish this is to write monitoring and measurement
requirements, including EMS control point measurements, into EMS work instructions to help ensure
completion. The JCAHO requires monitoring conditions of the environment and recommends at least one or
more performance improvement initiatives that could include hazardous material and waste spills, exposures
and other related incidents and reporting of these results to the organization's leaders and multidisciplinary
improvement teams. Measures used in JCAHO efforts may be cross-referenced and leveraged for the EMS.
Choose measures carefully. Too many create information overload and an ineffective system; too few
do not provide enough information to make good decisions. Information gathered through monitoring and
measurement should be used strategically to detect overall performance trends and possible need for
corrective and preventive action. This allows for identification and correction of gradually declining
performance before it becomes a nonconformance in the system. Some possible measures include the
following:
• Number of computers and monitors recycled/diverted from landfill (mercury) compared to previous,
baseline years. There is mercury in the computer relays and switches in laptop screens and batteries.
Computer monitors contain lead. Recycling or otherwise reusing computer electronics keep mercury
and lead PBTs out of the environment.
• Number of mercury spills compared to prior years.
Annual or monthly energy usage (electricity and other).
• Water use (normalized).
Pounds of red bag waste is reduced (normalized).
• Number of mercury products replaced with mercury-free alternatives.
• Results of periodic compliance audits.
Calibrate and maintain equipment used to measure environmental performance. This ensures that
readings are correct. For example, one facility set a goal of recycling a set percentage of scrap rubber. The
facility collected scrap rubber in gaylord-style crates and fork-lifted the crates onto a scale for measurement.
It then calibrated the scale annually and kept records of calibration. In many cases, it is possible to refer to
guidelines in equipment manufacturer manuals, to rely on calibration already being performed or otherwise
subcontracted . When calibration is performed by outside parties, keep an in-house record of calibration.
Additional Information
Monitoring and Measurement Procedure Pages 134-135
Calibration Procedure Page 136-137
Regulatory Compliance Audit Procedure Page 138-140
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Nonconformances and
Corrective and Preventive Action
Identifying and addressing nonconformances ensures an effective checking and corrective action system,
which, in turn, drives continual improvement. Nonconformances are opportunities to continually improve
work performance. They come from any number of sources including: 1) internal EMS audits; 2) external
EMS audits as conducted by third parties, such as ISO 14001 auditors; and 3) the hospital's own employees.
Corrective actions refer to actions taken to address nonconformances that have already occurred.
Preventive actions are actions taken to prevent a nonconformance from occurring. Preventive actions are
often made as a result of effective monitoring and measurement. For example, watch trends in hospital
wastewater discharge data, and take action when concentrations of pollutants become excessive.
Identifying the root cause of the corrective/preventive action is key. This often demands more intense
time and focus to determine why the problem occurred or could have occurred, but is worth the investment.
With respect to compliance, an effective corrective/preventive action procedure is the component that
provides an EMS the most credibility in the eyes of environmental regulators. If a nonconformance repeatedly
occurs, it may be that the true root cause has not been correctly identified.
The hospital should have a procedure for how it addresses nonconformances. Begin by having auditors
and employees fill out a corrective/preventive action form. Department managers are often responsible for
suggesting the remedy on the corrective/preventive action form with approval coming from the environmental
management department or senior management, particularly if and when a capital investment must be made.
Environmental management may present suggested corrective/preventive actions at management review
meetings. Senior management plays a key role in ensuring that corrective and preventive actions are suitable,
adequate and effective.
Additional Information
Procedure for Nonconformance, Corrective and Preventive Action Pages 141-143
Nonconformance Recommendation Form Pages 144-146
Audit Report and Corrective Action Summary Page 147
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EMS Records
Records demonstrate that the EMS is working. As with all other EMS components, designating
responsibility is an important first step. The hospital should determine who will be responsible for
maintaining the various EMS records. In some cases, this may be more than one person (responsibilities
should be documented). For example, the environmental specialist may continue to be responsible for
completing and maintaining paperwork that is submitted to environmental regulators, while records that
demonstrate the completion of EMS training specific to the work area may be kept with the work area
supervisor.
A hospital should consider keeping the following EMS records on hand:
• Aspects/impacts inventory and significance determination
• Communication records (internal and external)
• Documented roles and responsibilities (usually done at front of EMS manual, in systemwide
procedures and/or work instructions)
• Monitoring & measurement records (to track progress against significant impacts and objectives and
targets) including compliance audits and calibration records
• Monitoring equipment calibration
• Sampling monitoring data
• Compliance-related materials, such as permits, reporting, notifications, etc.
• Testing of procedures (e.g., under emergency preparedness and response)
• EMS audit records
• Corrective/preventive actions including changes such as those to documentation
• Training records
• Management review records (agenda, sign-in sheet, meeting minutes including action items)
Hospitals may be able build on existing recordkeeping procedures, including retention/destruction
guidelines. Factors to consider in how long to keep records include: 1) any legally mandated retention
requirements (e.g., U.S. Clear Air Act sets five-year retention requirements); 2) hospital requirements; and 3)
the ongoing usefulness of the records versus potential liability concerns. While there are only several places
that an EMS requires records be kept, there are additional records a hospital should keep.
Additional Information
EMS Recordkeeping Procedure Page 148
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EMS Auditing
Types of Audits
There are three different types of EMS audits: compliance audits, internal audits and EMS gap audits.
Compliance audits compare performance against a set of environmental requirements (e.g., table of
legal/other requirements) that rely largely on following a paper trail of permits, sampling data and reports.
Gap audits are audits conducted EARLY in the EMS implementation process and identify the EMS
components already in place as well as areas that need work in order to have a complete EMS. Many times,
senior management prefers to conduct the gap audit prior to deciding to implement an EMS in order to
estimate the level of resources necessary for implementation. An example gap audit tool can be found on the
beginning of page 181.
Internal audits drive continual improvement by checking system performance against the EMS
documentation. Initially, EMS internal audits will focus on ensuring the EMS components in place. As a
system evolves, focus will shift to environmental performance results.
Internal Auditing Program Components
Internal EMS audits check to see if the system is performing as indicated in the EMS manual and work
instructions. There are several components of an internal EMS audit program.
• An EMS audit procedure. The procedure covers audit team selection and training, preparing a
written audit plan, prior notification of audits, audit scope (areas and activities covered), audit
frequency, key roles and responsibilities of audit methods and how to report and follow up on audit
results. Audit results are addressed through the corrective and preventive action processes.
• An internal audit team. The size of the internal audit team depends on the size of the hospital and the
number of significant environmental impacts in the hospital. There should be enough auditors to
prevent one from auditing his/her own work area and enough backup auditors on hand in the event of
illness or turnover.
• In manufacturing facilities with 200-300 employees, it is common to see four to nine internal EMS
auditors. Typical internal auditor training includes in-class instruction as well as on-the-job auditing.
EMS internal auditor training courses, such as those American National Standards Institute-Registrar
Accreditation Board offers (http://www.rabnet.com), are available. These should cover EMS
components and effective auditing techniques. On-the-job training helps new auditors better
understand environmental standards, facility operations and
environmental science.
• Another effective training technique is pairing an experienced auditor with the trainee. At one
automobile manufacturer, an internal audit team conducted an EMS audit in the paint booth facility
on its own and with the EMS management representative to provide ISO 14001 interpretative
guidance. The employee auditors on the team led the audit, conducted the questioning, identified
findings and presented these findings to the paint booth facility managers.
• Audit frequency and audited areas. Audit frequency correlates to the importance of the activity being
audited and the results of previous audits of that area. Generally, organizations conduct internal
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audits of all areas at least once or twice a year.
• Maintaining audit records. Audit agendas, audit notes and checklists, and most importantly,
nonconformances written as a result of the internal audits are the most common records that show an
EMS audit program is in place.
EMS audits maintain management and employee focus on the EMS and environmental performance,
find opportunities to improve the EMS and environmental performance and ensure that environmental efforts
remain cost-effective and tied to the overall hospital mission. At the paint booth facility mentioned above, the
audit team began its audit in the control room, where readings on the thermal incinerator were at the correct
800 degrees Fahrenheit. Subsequent audit team investigations at the incinerator showed readings of more
than 1,200 degrees Fahrenheit. The manager took great interest in these readings, realizing energy and cost
savings that could result by lowering the operating temperature.
Audit Program Tips
Successful audits help the EMS and improve environmental performance. While there are many classes
that cover the technical aspects of effective auditing techniques, effective people skills are just as important
and should be considered in establishing internal auditor teams or selecting an outside contractor to conduct
audits. The perceptions auditors create with hospital staff and management should reflect positively on the
EMS efforts. Some things to consider are:
• Understand that auditing may impose on those who are audited.
• Find hospital personnel who have auditing experience. Their familiarity with auditing will be an
asset, even if they need environmental training. They should be familiar with how to put those being
audited at ease.
• Depending on the size of the hospital and the nature of the auditing, utilize teams of auditors
throughout the hospital. Put at least one experienced auditor on each team. Two to three auditors per
team allows one person to ask questions and the other to write responses and observe the work area.
Several pairs of eyes are better than one.
• Good listening and effective questioning are key in the auditing process. "Yes/No" questions leave
too much room for misinterpretation and generally fail to provide the auditor with enough
information. People generally like to talk about what they do in their job. Detail-driven questions
provide the auditor with an honest assessment of operations within the work area.
• Audits are like an "open-book" test. Auditees can use resources around them to answer auditor
questions. Information doesn't have to be memorized.
• Provide advance notice to areas that will be audited. People generally do not like "surprise"
inspections" audits. One EMS representative set the audit schedule for areas six months in advance
and would send reminders two weeks and one week before the audit.
• Set an audit schedule and stick to it. It is impossible to review every record or talk to every employee
during each audit. Sampling helps stay on schedule.
• Conduct questioning within the scope of the audit.
• Report in terms of departments or areas audited. Do not reference specific individuals. Audits are not
meant to get people in trouble.
• Audit findings can be positive. Be positive on accomplishments. Pay compliments when in order.
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• Disagreements within the audit team should be handled outside of the auditee's presence.
• Consider the auditors'experience. Do the auditors have any health care experience? Auditor
familiarity with health care means a more focused audit.
• Don't let company politics interfere with the audit.
• Collect objective evidence (e.g., documentation, forms, memos, procedures, policies and records) of
EMS conformance. Auditing should check management commitment to EMS conformance and
environmental performance (not focus on why something did or didn't work). Identifying root causes
comes later in the corrective action request.
• Auditors should focus on what is seen during the audit and how it meets a given standard.
• Use audit results to identify trends and patterns in EMS deficiencies. These become opportunities for
continual improvement.
Address audit findings in the corrective and preventive action system. This enhances system growth and
development.
To learn more about EMS auditors, auditing and training courses log on to http://www.rabnet.com.
Additional Information
Sample Environmental Management System Audit Checklist Pages 149-152
Kentucky Pollution Prevention Center Gap Audit Checklist Pages 183-240
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Management Review
Management review serves several functions in the EMS to ensure that: 1) the system remains suitable,
adequate and effective as senior management promised in the environmental policy; 2) the EMS remains cost-
effective; and 3) suitable progress is made toward the EMS objectives and targets and approving new
objectives and targets as needed. The management review examines long-term environmental management
and EMS performance trends. For this reason, organizations will conduct the management review once a year.
Questions to consider during the management review include the following:
• Are EMS roles, responsibilities and procedures current? Do any need to be updated?
• Do objectives and targets need to be updated?
• Are there any repeat nonconformances or other patterns in nonconformances that show up from EMS
audits or compliance audits that need to be addressed? Are there any trends in monitoring and
measurement data that require management attention?
• Are there anticipated environmental regulatory changes that need planning and resources?
• Are there any new stakeholder concerns to address?
Managing expectations regarding the EMS is key. Depending on the aggressiveness of hospital pollution
prevention and energy efficiency efforts prior to EMS implementation, cost savings in the early years of the
EMS may be considerable. Later, as the "low-hanging fruit" is achieved, subsequent pollution prevention and
energy efficiency efforts may yield smaller cost savings. This is important to convey to senior management,
particularly if significant cost savings are expected early in the EMS' operation.
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- SECTION 4 -
CONTINUAL IMPROVEMENT
Pollution Prevention Opportunities
for the Health Care Industry
Introduction
Much of this guide focuses on EMS implementation. Implementation should be a means to an end, not
the end itself. Once the EMS is implemented, it will serve as a tool to help achieve environmental
improvements. Pollution prevention is an excellent way to get these results. With the numerous, products and
services that hospitals employ, there are many pollution prevention opportunities to save materials, energy,
time and reduce expenses. This is one of the most important areas of financial return for an EMS.
Pollution prevention is any practice that reduces the amount of any hazardous substance,
pollutant or contaminant entering any waste stream or released into the environment prior to
recycling, treatment or disposal. Examples include environmentally preferable purchasing, raw
material substitution, process or procedure modification, improvement in inventory control, training,
maintenance and housekeeping.
Consider pollution prevention while identifying significant aspects and setting objectives and targets.
The U.S. EPA ranks options for managing waste in descending order of preference. This ranking encourages
reliance on those approaches that minimize the generation of waste and environmental releases.
SOURCE REDUCTION is assigned the highest priority because it emphasizes elimination or
reduction of wastes at the point of generation. Specifying purchase of a digital thermometer, rather than one
containing mercury, for example, reduces the heavy metal content in the waste and reduces the need for
recycling, treatment or disposal. Source reduction is typically less expensive than collecting, treating and
disposing of waste. It also reduces risks for workers, the community and the broader environment.
REUSE is the next preferred option. Implementing measures to reuse products and packages for the
original purpose reduces purchasing costs and packaging wastes as well as wastes from patient care activities.
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Health care facilities find that reusable linens, reusable patient supplies, such as bedpans and emesis basins,
as well as reusable dishes and cutlery for food service are generally economically and environmentally
preferable to disposable counterparts, although there are costs incurred in cleaning and sterilizing items for
reuse.
RECYCLING encourages regeneration of materials into usable items. Paper and paper products, such
as corrugated cardboard, glass food and beverage containers, metals and certain plastics may be recyclable.
However, important factors in evaluating recycling options include the local environmental and economic
consequences associated with the collection and processing of materials for recycling as well as the
associated energy and resource costs.
TREATMENT to reduce the volume or the potentially harmful environmental impacts of the waste is
ranked at the lowest end of the spectrum. Medical waste treatment technologies include autoclaving,
hydropulping, pyrolysis, microwave, incineration, chemical treatment and irradiation. Treatment precedes
disposal, the least favored option. Ultimately, however, some wastes and medical waste treatment residues
require land disposal. The costs of treatment and disposal are significant, and both have inherent
environmental impacts, including emissions to air and water.
Materials Management
This section identifies key pollution prevention concepts in the areas of materials management including
strategies such as environmentally preferable purchasing. There are generally three ways to manage materials
effectively to reduce waste, cost and environmental impact. From most to least desirable: 1) during
acquisition (use environmentally preferable purchasing techniques to screen materials); 2) during product use
through best practices to maximize material life; and 3) reuse/recycle/safely disposing of materials as last
resorts. Pollution prevention focuses on the first two. Measures of success for effective materials
management include reduced purchase expenses, reduced waste generation and reduced waste management
costs.
Some examples include:
Legacy Good Samaritan Hospital purchases permanent waterproof mattresses instead of
disposable egg crate foam mattresses in 95 percent of its bedding. The initial purchase was
significant, but the decision paid for itself in just one year. The savings in purchasing costs per year
were $80,710. The disposal savings per year were $817 and prevented 16,350 pounds of waste
annually.
• The Legacy Health System switched from paper/plastic blend disposable coffee cups to an all-plastic
recyclable cup. Employees were encouraged to bring their own mugs to the cafeteria for a discount.
Savings in purchasing costs per year were $24,000. Savings in disposal cost per year were $1,417.
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Waste reduced was 28,333 pounds.
• Mercy Healthcare of Sacramento purchases reusable liquid-proof surgical gowns and towels at six
facilities, which saves $60,000 per year and prevents 50,000 pounds of waste per year.
Environmentally Preferable Purchasing (EPP)
Environmentally Preferable Purchasing (EPP) is the purchase of products or services that have a lesser
or reduced effect on human health and the environment when compared with competing products or services.
EPP includes the total effect of the product including packaging, disposal, quality and cost.
While biomedical and radiological wastes have received considerable attention, many health care
organizations have overlooked everyday solid waste. U.S. hospitals generate close to two million tons of
solid waste per year, of which nearly half is paper and cardboard, and the remainder is plastics (15 percent)
and food (10 percent). EPP directly impacts solid waste generation as the following success story shows.
EPP can also screen out mercury-containing and PVC-containing items.
The University of Texas-Houston Health Science Center arranged with its office supplier to
deliver supplies in reusable organic cotton bags instead of cardboard boxes. This step saved the
university recycling and waste disposal costs. The Health Science Center also replaced all mercury
thermometers with alcohol thermometers and has worked to purchase radioactive chemicals with
shorter half-lives. From Health Care EPP Network Information Exchange Vol. 2, No. 1, January
2000.
Group Purchasing Organizations (GPOs) can facilitate EPP implementation because they leverage
volume to achieve discounts on pricing. The same principle applies to packaging issues as packaging costs
the supplier also. In one instance, a medical supply distributor saved $22,500 annually in purchase of new
cardboard boxes by saving and reusing boxes from suppliers to ship customer orders. Other benefits included
reducing staff time to flatten boxes for recycling and assembling boxes for new orders.
Another way to improve purchasing is to create a Preferred Vendor Program. Any list of preferred
products or vendors should have clear environmentally friendly criteria and avoid unfair trade or liability
issues. There are many ways to create a Preferred Vendor Program.
Some businesses require suppliers to do one or more of the following:
• Achieve and maintain ISO 14001 registration.
• Maintain and provide a current list of environmentally preferable products.
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Complete environmental impact questionnaire(s) for total operations.
EPP Best Practices
Purchase products in bulk, totes or in recyclable containers.
• Purchase products with less packaging or reuse packaging.
Take care in ordering "custom packs." While there is less waste on individual item packaging,
waste from unused supplies can generate more waste. Negotiate to exclude certain items in
patient care kits that are repeatedly not used in patient procedures and become unused waste.
• Monitor requests for chemicals and implement policies to reduce over-purchasing that result in
waste generation.
• Procure chemicals through a central department or person.
Purchase smaller quantities of chemicals and supplies not frequently used.
• Control acquisition and use of reagents that have limited shelf life. These supplies should be
ordered in smallest practical container (e.g. ethyl ether and its formation of explosive peroxides).
• Avoid over-purchase of supplies. Order reagents and chemicals in exact amount to be used. Be
careful when ordering extra quantities to take advantage of unit cost savings. Net savings can be lost
through increased disposal costs of unused chemicals.
Encourage suppliers to become responsible partners by providing quick delivery of small orders
and accepting the return of unopened stock such as sealed bottles of stable chemicals.
Additional EPP Resources:
• Hospitals for a Healthy Environment Web site for a How To Guide on Hospital EPP
(http://www.geocities.com/EPP_how_to_guide/EPP 1 .htm)
• The Massachusetts Office of Technical Assistance EPP newsletter
(http ://www. state .ma.us/ota/otapubs .htm#eppnet)
• The Nightingale Institute for Health and the Environment's EPP tool
(http://www.nihe.org)
• HealthCare Purchasing News Online
(http: //www. hpnonline.com)
Cleaning Products and Chemicals
Environmentally Preferable Purchasing (EPP) of cleaning supplies and other common cleaning
chemicals positively impacts the health of staff, patients and visitors. Many cleaning chemicals are
flammable and contain chlorinated solvents. The choice of chemicals may also provide an opportunity for
reducing and eliminating hazardous wastes.
Some advantages of establishing an EPP program for chemicals including the following:
Creation of a safer environment
• Continued cleaning effectiveness. Many of the new-generation environmentally friendly cleaning
products are high-level disinfectants and include the same infection control/sterilization capabilities
that the old chemicals possessed.
Reduced concerns about potential chemical incompatibility.
• Environmentally friendly cleaning attributes including biodegradability and reduced toxicity.
Potentially fewer cleaning products.
• Potential to streamline purchasing with fewer products.
Reduce the chance for exposure to dangerous chemicals.
• Environmental stewardship - "Lead the Charge."
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Some people may oppose EPP for many of the same reasons they might oppose an EMS.
• It is new - people may not want to cooperate.
It is different - people are unsure of different ideas.
• Change is often challenging and can be time-consuming.
• Training will likely be necessary.
EPP helps evaluate the use of less hazardous materials and cleaning agents in noncritical requirements.
Examples and tips for chemical change-out in a hospital environment include the following:
• Using simple alcohols and ketones instead of petroleum hydrocarbons. Toluene and xylene are
examples of compounds to replace. Terpene-based solvents and naphtha isoparaffinic hydrocarbons
may be substituted for xylenes used in slide-cleaning in some applications. Citrus-based alternatives
may reduce worker exposure but may produce hazardous waste due to possible flashpoints less than
140 degrees Fahrenheit.
Evaluate physical cleaning methods that may replace and reduce chemical cleaning requirements.
• Evaluate the use of sonic or stream cleaning instead of alcohol-based disinfectants or other forms of
chemical sterilization.
• Evaluate specialty detergents, potassium hydroxide or sonic baths to replace chromic and sulfuric
acid for cleaning glassware. Sodium or potassium dichromate dissolves in sulfuric acid and chromic
acid cleaning solutions are common methods of cleaning glassware. However, there are alternative
cleaning agents that are effective and less hazardous.
• Use biodegradable or aqueous detergents where possible. In some cases, powerful cleansers are still
essential.
The following are EPP criteria used to evaluate cleaning and other chemicals. Failure of a product to
meet any of the criteria listed below should trigger search for a more environmentally friendly product.
Carcinogen: Try to eliminate the use of products containing known and probable carcinogens. The
following organizations classify known or probable carcinogens.
• American Conference of Governmental Industrial Hygienists (ACGIH)
International Agency for Research on Cancer (IARC)
• National Institute of Occupational Safety and Health (NIOSH)
• National Toxicology Program (NTP)
• Occupational Safety and Health Administration (OSHA)
Flammability/Flash Point: Use products that do not ignite easily.
Corrosiveness (pH): Use products that have a pH closer to neutral (pH7).
Chronic Health Risks: Use products that pose no potential for chronic health risks.
Skin/Eye Irritant: Use products that are less irritating to the skin and eyes.
Volatile Organic Compound (YOG) Content: Use products with the lowest VOC levels possible. Products
that contain less than 10 percent VOC by weight are best.
Ozone-Depleting Compounds: Use products that do not contain ozone-depleting compounds.
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Biodegradability: Use products that are partially or completely biodegradable.
Product Packaging: Use products that are packaged in recyclable or reusable containers (such as use of
refillable product distribution devices and/or concentrates) and containers made with a percentage of post-
consumer recycled materials. Additionally, products that use little or no polypropylene and/or polystyrene
("Styrofoam") packaging are favored.
Energy Needs: Use products that work effectively in cold water, which decreases the amount of energy
consumption necessary.
No Sealed Aerosol Spray Cans: Chemical cleaning products should be available in either a liquid form or
manual pump action sprays and/or concentrates that can be dispensed into pump bottles for use.
Dyes and Fragrances: Use products that do not contain dyes or fragrances.
Many floor cleaners used in hospitals contain harsh chemicals, such as quaternary ammonium chlorides
and butoxyethanol, which can be harmful to human health and the environment. To reduce risk of cross-
contamination for patients, conventional mopping techniques require janitors to change the cleaning solution
after mopping every two or three rooms. This means that cleaning solutions are constantly being disposed
and replenished. There are three drivers for changing the way custodial staff maintain floors in patient care
areas: 1) to reduce chemical and water use and disposal; 2) to reduce cleaning times for patient rooms; and 3)
to reduce custodial staff injuries and workman's compensation claims from the repeated motions of mopping
and wringing.
Microfiber mop heads, a relatively recent innovation, may help. These mop heads weigh approximately
five pounds less than conventional loop mops and are changed after each room. This benefits the custodial
staff by reducing the effort of wringing a conventional mop and not changing the water between rooms
(provided the mop head is not put back into the water once used in a room).
Pilot test results indicate a 60 percent lifetime cost savings for mops, a 95 percent reduction in chemical
costs associated with mopping tasks and a daily 20 percent labor savings associated with mopping. There
were only a few limitations to this option. The medical center found that it was best to use conventional
mops in areas contaminated with an extraordinary amount of blood or other bodily fluid and in greasy, high-
traffic kitchen areas. Microfiber mop heads are best laundered in a standard commercial washer and dryer
with controlled heat settings and standard laundry detergent is used.
Test products for effectiveness. A chemical-cleaning or recycled-content product that meets the
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desirable attributes still may be deemed ineffective for its intended purpose(s) after testing.
Energy Efficiency
Energy Efficiency Success Story
A well-designed and researched energy conservation strategy can provide significant immediate,
short- and long-term cost-saving benefits. Saint Joseph's Medical Center in Yonkers, New York,
achieved savings of more than $250,000 a year through energy conservation efforts. (Source: Dunn,
Philip, Hospitals and Health Network).
The health care industry is one of the most energy-intensive in the United States annually spending $6
billion on energy costs and using an average 228 kBtu energy usage per square foot per year - more than twice
the energy as atypical office space. Hospitals run continuously, and certain uses, such as diagnostic
equipment, large air-handling systems and technical equipment are particularly energy-intensive.
Consequently, energy efficiency presents a great cost savings opportunity. Every dollar a nonprofit
health care organization saves on energy equates to generating new revenues of $20 for hospitals or $10 for
medical offices. For medical offices, for-profit hospitals, and nursing homes, a five percent reduction in
energy expenses can boost earnings per share by a penny.
In the long-term, gaining control over energy use begins by examining the facility's historical electric,
gas, oil and steam use as well as peak demand periods. Convert energy usage to a standard measure, such as
Btu/square foot. Where possible, use such measures to compare energy performance against other hospitals
and institutions. This can highlight higher-than-expected usage and allow for corrective action.
A further reason for facility managers to understand energy use is to guard against major cost swings
due to variations in electric and gas rates. Emerging utility deregulation creates opportunities to purchase
electricity and gas from the lowest cost supplier. Energy managers who know the most about their energy use
will be able to leverage that knowledge to obtain the best energy contracts. Health care organizations have
the opportunity to conserve energy as part of an EMS.
Energy Efficiency Success Story
Mercy Hospital in Pittsburgh, participated in Energy Star and instituted a comprehensive energy
plan that resulted in operational and cost savings of more than $1 million. Mercy accomplished this
by retrofitting lighting to high efficiency T8 lamps and electronic ballasts, expanding its energy
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management system to allow for better monitoring and control, installing variable speed drives on
chilled water pumps and replacing chillers and cooling towers with new high efficiency equipment.
CHANGEFORTHE
BETTER WITH
ENERGY STAR
ENERGY STAR: Strategies for Superior Energy Management
Energy Star is a U.S. EPA program that works to make energy efficiency easy by recognizing the best
performing products, homes, buildings and organizations. Energy Star's approach, tools and resources give
health care facility managers an easy way to gauge the facility's progress. For health care organizations,
superior energy management is an important aspect of environmental management that can provide healthy
dividends. Energy Star offers superior energy efficiency strategies and resources to help health care
organizations achieve and be recognized for leadership in energy management.
The U.S. EPA's Energy Star uses a systems approach comparable to the EMS Plan-Do-Check-Review
cycle of continual improvement to achieve energy conservation. More than 875 hospitals and health systems
across the country have partnered with the U.S. EPA Energy Star. Energy Star Buildings and Green Lights
Health Care Partners have experienced an average annual savings of $0.63 per square foot1.
'Source: 1995 Energy Information Agency, Commercial Building Energy Consumption Survey data for health care, converted to 2002
dollars.
How Health Care Facilities Can Leverage Energy Star
The Value of the Energy Star Approach
Organizations that adopt a systematic approach to energy management can achieve cost savings as high
as 35 percent. Energy Star identifies an effective approach for a high-performance energy management
strategy.
Commit to Continuous Improvement: Organizations seeing the financial returns from superior energy
management continuously strive to improve energy performance. Success is based on regularly assessing
energy performance and implementing steps to increase energy efficiency. No matter the size or type of
organization, the common element of successful energy management is commitment. Organizations make a
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commitment to allocate staff and funding to achieve continuous improvement. To establish an energy
program, leading organizations form a dedicated energy team and institute an energy policy.
Assess Energy Performance: Understanding current and past energy use is how many organizations identify
opportunities to improve energy performance and gain financial benefits. Assessing performance is the
periodic process of evaluating energy use for all major facilities and functions in the organization and
establishing a baseline for measuring future results of efficiency efforts.
Set Performance Goals: Performance goals drive energy management activities and promote continuous
improvement. Setting clear and measurable goals is critical for understanding intended results, developing
effective strategies and reaping the financial gains. Well-stated goals guide daily decision-making and are the
basis for tracking and measuring progress. Communicating and posting goals can motivate staff to support
energy management efforts throughout the organization.
Create an Action Plan: Successful organizations use a detailed action plan to ensure a systematic process to
implement energy performance measures. Unlike the energy policy, the action plan is regularly updated,
usually on an annual basis, to reflect recent achievements, changes in performance and shifting priorities.
Implement Action Plan: Gaining the support and cooperation of key people at different levels within the
organization is an important factor for successful implementation of the action plan. Reaching goals
frequently depends on the awareness, commitment and capability of the people who will implement the
projects defined in the action plan.
Evaluate Progress: Evaluating progress includes formal review of both energy use data and the activities
carried out as part of the action plan compared to the performance goals. Evaluation results and information
gathered during the formal review process is used by many organizations to create new action plans, identify
best practices and set new performance goals.
Recognize Achievements: Providing and seeking recognition for energy management achievements is a
proven step for sustaining momentum and support for the program. Recognizing those who help the
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organization achieve these results motivates staff and employees and brings positive exposure to the energy
management program. Receiving recognition from outside sources validates the importance of the energy
management program to internal and external stakeholders and provides positive exposure for the entire
organization.
ENERGY STAR Tools & Resources Available Online
Energy Star provides the tools and resources needed to implement a successful energy management
strategy. Technical guidance, procurement policies, demonstrated best practices, communications resources
and awards can distinguish the organization as an environmental leader.
EPA's National Energy Performance Rating System
http://www.energystar.gov/benchmark
The U.S. EPA's National Energy Performance Rating
System in Portfolio Manager is a free Internet-based system
specifically designed to help businesses track and
objectively compare energy use on a continual basis for both
individual and large groups of buildings.
The rating system uses a 1 - 100 scale to give relative
meaning to energy use: Hospitals that rate high on the scale
are considered better energy performers (lower energy use)
than those with low ratings (higher energy use). A rating of
50 is defined as the industry average.
Make Commitment
Assess Performance
& Sat Goals
The rating system assists in the following:
Establish a baseline energy performance for the hospital or hospital campus.
Compare the hospital's energy performance to other similar hospitals across the United States.
Track and manage progress overtime by regularly re-benchmarking.
ENERGY STAR Target Finder fhttp://www.energystar.gov/index.cfm?c=target_fmder.bus_target_fmder)
Target Finder is an Internet-based tool that helps manage energy during the design of a new building. It
allows selection of an aggressive energy performance target for a building design and compares estimated
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energy consumption to the established target. Target Finder provides an energy performance rating for whole-
building energy use.
ENERGY STAR Delta Score Estimator (http://www.energystar.gov/index.cfm?c=delta.index)
The Delta Score Estimator provides a quick way to identify the relationship between the percent energy
saved in a building and the energy performance rating score of a building using Energy Star. Once a facility
is benchmarked and a current energy performance rating established, Delta Score can:
• Estimate a new energy performance rating by entering a percent reduction in energy use.
Given a target energy performance rating, estimate the percent energy reduction needed to move from
the existing to the target energy performance rating.
ENERGY STAR Financial Value Calculator (http://www.energystar.gov/
index.cfm?c=assess_value.bus_fmancial_value_calculator&layout=print)
The Financial Value Calculator analyzes portfolio-wide or single building opportunities using a variety
of metrics that range from simple payback to increased earnings per share based on various levels of energy
reductions.
ENERGY STAR Products (http://www.energystar.gov/index.cfm?fuseaction=fmd_a_product)
Choose Energy Star qualified products such as TVs, VCRs, computers and other office equipment when
purchasing products. Visit http://www.energystar.gov and select the "Products" link to learn more about
potential savings when procuring products that use 25 to 50 percent less energy without compromising quality
or performance.
ENERGY STAR Training (http://es.netspoke.com/attendee/default.asp)
Free online training sessions help establish the partnership with Energy Star, educate staff on the use of
Energy Star tools and provide further education to staff about the depth of Energy Star's tools and resources.
Participation is easy and convenient.
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Case Study: Houston Shriners Hospital
Houston Shriners Hospital was built in 1996 and is dedicated entirely to children's acute care
specialty services. As with the other 21 Shriners hospitals, Houston Shriners Hospital stands out
because it does not have a billing department - all operations and services are funded by donations
from individuals and corporations.
Houston Shriners Hospital's energy management team consists of an energy manager, four
engineers, a laborer, a biotech professional and a secretary. Since beginning its Energy Management
Initiative in 1997, the hospital's utility costs have decreased 40 percent.
When the hospital first benchmarked its energy performance in 2002 using Energy Star's
Portfolio Manager, it received a rating of 42 (for 1996 data) and began investigating energy efficient
strategies. It instituted several low-cost operations and maintenance opportunities as well technology
upgrades that improved the hospital's energy rating to 75. Details follow.
Lighting: Houston Shriners Hospital installed LED exit signs that use one-tenth the amperage of
standard signs; occupancy sensors in public areas and mechanical timers in nonpublic areas to keep
the lights off when areas are not in use.
Fan Systems: Houston Shriners Hospital balanced the air and water systems throughout the hospital,
decreasing usage by 68,900 kWh in nine months. The hospital also installed energy-efficient motors
and variable frequency drives.
HVAC: Houston Shriners Hospital installed new energy-efficient motors and two new chilled water
pumps. For one area, the hospital installed a split-HVAC system so that rooms are air conditioned by
the larger part (87.6 ton) of the system when they are fully occupied and by the smaller (1.5 ton)
when they are not. With the enhanced split-HVAC system in place, Houston Shriners Hospital
interlocked a new air-conditioning unit through the energy management system and allows only one
of the units to operate at a time. HVAC certification and refrigeration maintenance were considered
essential to optimize performance.
Houston Shriners Hospital energy manager maintains and regularly reviews records of all of the
energy bills, savings, anticipated savings, future technologies for investment and opportunities for
savings. The hospital keeps detailed spreadsheets regarding energy use and uses the Portfolio
Manager tool track progress. To date, Houston Shriners Hospital has achieved a gross savings of 24
percent in energy consumption (and additional savings through energy contract negotiations),
prompting the associate executive administrator to request that energy managers at the other Shriners
hospitals consider energy saving opportunities.
Increased energy savings translate directly to increased funding for the hospital's mission - to
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provide the quality of pediatric orthopedic care necessary to provide children the opportunity to be
productive and involved members of their communities.
Communications: Houston Shriners Hospital has communicated with its employees, board of
directors, headquarters and community through emails and phone calls. Communication to
headquarters led to the implementation of energy efficiency efforts at that hospital.
Testimonial: While some facility managers do not believe they have the funding or time to
implement energy saving measures, Houston Shriners Hospital believes they can ill afford not to look
at opportunities to increase energy efficiency. Technologies and operational changes save a
significant amount of money every month that can be used to further the hospital's mission.
- Delbert Reed, Director of Engineering & Maintenance, Houston Shriners Hospital
Join ENERGY STAR
To partner with Energy Star, the hospital's CEO, CFO or senior administrator must sign the partnership
letter, committing the organization to continuous improvement of energy efficiency. As part of this
commitment, the hospital agrees to:
Measure, track, and benchmark energy performance.
• Develop and implement a plan to improve energy performance, adopting the Energy Star strategy.
Educate staff and the public about the hospital's partnership and achievements with Energy Star.
For more information, visit the ENERGY STAR Web site, http://www.energystar.gov.
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Additional Pollution Prevention for Hospital Wastestreams
Chemotherapy and Antineoplastic Chemicals
Chemotherapy and antineoplastic chemicals are generally handled through a central clinical laboratory
or pharmacy. Administrative controls represent the best alternative to reducing these wastes.
Minimize the cleaning frequency and volume of gauze materials used for the compounding hood.
Cleaning frequency depends on drug handling volume and the amount of spillage that occurs in the
hood. Emphasize proper handling practices and techniques to minimize hood cleaning frequency and
waste generation. These instructions can be added to existing OSHA training conducted for the
hoods.
• Purchase drug volumes according to need. Overpurchasing results in the generation of outdated
materials that must be disposed. Reducing waste is accomplished by computing daily
compounding requirements of each drug and ordering appropriately sized containers. Work with
the supplier to return outdated drugs.
• Centralize the location of chemotherapy compounding areas.
Formaldehyde
Formalin (formaldehyde and water) is used to disinfect dialysis machines. Check with the machine
vendors to determine if bleach, paracetic acid or other disinfectants can be used instead of formalin.
Carefully evaluate all substitutes for cleaning effectiveness and comply with all machine manufacture
requirements. If formaldehyde must be used, use the smallest sized container (quantity) of
formaldehyde possible. Provide training to staff on the importance of this in reducing waste and
costs.
• Determine the minimum required formalin concentration. Effective formalin concentration for
disinfecting and cleaning machines and disinfecting dialyzers is in the Centers for Disease Control
guidelines. Formalin concentrations used to disinfect dialysis machines vary among machines and
hospitals. Formalin is typically purchased in concentrations that range from 10 to 37 percent. Many
machines will dilute the 37 percent formalin to a 10:1 ratio to achieve a 4 percent disinfecting
concentration. Formalin concentrations of 2 percent are not recognized as effective disinfectants.
In autopsy and pathology laboratories, it may be possible to reuse formaldehyde in specimen
preservation. These solutions retain their desired properties for periods far longer than the usual
holding times for specimens. In addition, the desired preservation properties may be effective at
concentrations less than the standard 10 percent.
Formalin usage may be reduced in dialyzers. The use of special incubators to heat dialyzers in 1
percent formalin solution at 40° C for 24 hours is an effective alternative to using 4 percent
formalin at room temperature for 24 hours.
Inventory Control
After environmentally preferable purchasing (EPP), effective inventory management is the next strategy
for waste reduction. A good inventory control program includes the following:
• A first-in, first-out chemical policy. For example, chemicals purchased first should be used first.
Reduce high-volume chemical inventories to a supply of four weeks or less.
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• Central distribution. Chemicals should be delivered to a central location at the hospital (one common
dock area) and distributed throughout the facility by a designated individual. Ideally, this individual
would be a central supply/stores staff member.
Chemical standardization promotes sharing of chemicals between users. A computerized, running
inventory of unused reagent chemicals for reuse in other departments is helpful.
Develop data (chemical inventories) by user groups identifying high volume users and
generators.
Locate caches of unused reagents/chemicals and determine why they are accumulating.
• Monitor reagent/chemicals half-life and expiration dates.
Ensure that the identity of all chemicals is clearly marked on all containers. It is illegal to
ship unused reagent chemicals, containers, and solution mixtures and unidentified wastes for
disposal without proper labeling.
Laundry and Laundry Detergent
Optimizing the use of laundry chemicals and minimizing accidental spills is achieved through work
training, prepackaged laundry chemicals or the use of automated laundry feed. Laundry chemicals are often
supplied in five-gallon containers; instead consider receiving chemicals in totes.
Poor handling of laundry chemicals leads to accidental spills, underuse or overuse of chemicals.
Underuse of laundry chemicals results in poorly cleaned articles that must be cleaned again. Overuse of
laundry chemicals increases the volume of chemicals and increases raw material costs. Optimizing the use of
laundry chemicals and minimizing accidental spills is achieved through worker training, prepackaged laundry
chemicals or the use of an automated laundry chemical feed system. While laundries might incur capital
costs to install an automated system, the savings from optimal chemical usage and reduction in labor costs
may have long-term benefits.
Aerosols
Aerosols are present in many areas throughout the hospital but primarily in the facility maintenance
areas in health care organizations. Aerosols include adhesive cleaners, electronic solvent cleaners, touch-up
paints and ceiling tile renewers.
Discourage the use of aerosols.
• Request products in recyclable nonaerosol pump sprays.
Dispense a full aerosol can upon return of an "empty."
• Recycle aerosol containers.
Batteries
Batteries are used in numerous applications including cameras, pagers, flashlights, exit signs, alarm
systems, backup power sources in medical monitors, hearing aids, smoke detectors, glycometers and many
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others. Common varieties of batteries include alkaline magnesium, nickel-cadmium, silver-cadmium
mercuric oxide, lithium and zinc-air. Check state regulations regarding how to handle these spent batteries, as
they often must be considered hazardous waste due to the metal content. In some cases, recycling spent
batteries may be possible.
Carefully consider the use of rechargeable batteries. They may not be appropriate in all situations,
especially those involving lifesaving equipment where a partially recharged battery could result in equipment
failure and death. While some batteries such as the nickel-cadmium are rechargeable, they will eventually
need disposal.
Contact the hospital's commercial hazardous waste provider to find out if they will recycle batteries.
For information on rechargeable battery recycling visit Rechargeable Battery Recycling Corporation at
http://www.rbrc.org/consumer/uslocate.html to find the rechargeable battery recycling location closest to you
or call (800) BATTERY. To recycle lithium batteries, call Battery Solutions, Inc., at (313) 467-9110. For
additional resources on other types of batteries, visit Recycler's World at
http://www.recycle.net/battery/index.html.
Mercury
Mercury is probably the most common persistent bioaccumulative toxin (PBT) in hospitals. Ten to 20
percent of mercury released into the environment in the United States comes from the health care industry,
with medical waste incinerators as the fourth largest point source of mercury. Local wastewater treatment
plants identify hospitals as industrial pollution sources and impose strict wastewater limits for mercury
(hospitals are known to contribute 4-5 percent of the total wastewater mercury load). Mercury releases
impact human health as well as the environment. In a survey conducted by the National Institute for
Occupational Safety and Health, researchers estimated that 70,000 American workers are potentially exposed
to mercury vapors on the job, including nurses, lab technicians and others working in health care facilities.
Identifying starting points for mercury reduction is easy.
Mercury Success Story
Newton Wellesly Hospital in Massachusetts significantly reduced its use of mercury compounds
by identifying mercury-containing compounds in use and requiring department managers using these
products to develop a time frame for elimination. Where elimination is not possible, the manager
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must present an acceptable rationale to the hospital safety committee. The safety committee, in turn,
is required to maintain a readily retrievable log of mercury-containing products and processes in use,
the rationale for continued use and a time frame for the reconsideration of available alternatives.
Sphygmomanometers
A California Department of Health Services found that Sphygmomanometers and gastroenterology
accounted for approximately 90 percent of the mercury in seven surveyed hospitals. Each mercury
sphygmomanometer (sphygs) contains between 70 to 90 grams of mercury. Of additional concern is that most
sphygs are located in patient rooms, waiting areas, triage centers, offices where the risk of patient or health
care worker exposure to mercury is higher, through potential breakage of these devices. Cost associated with
a mercury sphyg spill cleanup ranges from $600 to more than $10,000. The accuracy of readings from
mercury-based sphygs can be affected by lack of proper equipment maintenance and training.
Gastroenterology
Various tubes used to clear the gastrointestinal passages, such as Cantor, Blackmore, bougie and
Miller-Abbot tubes account for the second largest volume of mercury in the hospitals inventoried in
California. A single set of bougie tubes contain up to 454 grams of mercury. Internal breakage can occur.
The Food and Drug Administration reports more than 58 incidents from 1991 to 2000 in which such mercury-
containing tubes broke inside patients, releasing mercury internally. Nonmercury substitutes are available for
all of these tubes. Some substitutes can be weighted with air, water or mercury while others are preweighted
with tungsten. Because the mercury in G.I. tubes functions as a weight rather than a measurement device, the
performance of alternatives is less questionable. Tungsten-weighted alternatives have the advantage of being
opaque in X-rays allowing detection of the dilator as it moves through the body.
Thermometers
Although fever and lab thermometers accounted for less than 1 percent of the mercury sources identified
at the seven California facilities audited, they are important sources of mercury contamination in
nonhazardous waste streams. They are often disposed improperly in red bag waste, which is incinerated and
releases mercury into the air.
Nonclinical Mercury
Nonclinical mercury is generally found in sphyg repair kits as elemental mercury (at about 800 grams of
mercury). The elimination of mercury sphygs from a hospital can potentially reduce a facility's nonclinical
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mercury load by up to 40 percent. Additionally, because aneroid units often do not require calibration using a
mercury barometer, the barometer can usually be eliminated. If other devices require calibration, consider
replacing the mercury barometer with a one-millibar precision aneroid (these can cost less than $250).
Another option is to simply call the local airport or weather station for a mercury column reading.
There are many viable mercury-free products for hospitals pursuing a mercury-free environment. The
Sustainable Hospitals Web site (http://www.sustainablehospitals.org) is perhaps the most comprehensive
resource available for finding alternatives.
Additional Information
Possible Sources of Mercury Pages 153-155
Pollution Prevention Opportunities for Mercury
• Conduct an inventory/preliminary assessment of mercury in equipment, materials (also chemicals and
Pharmaceuticals), in storage and in waste streams. Examine cleaning supplies for mercury
content.
Gather life cycle cost of purchasing/using mercury-containing products versus mercury-free products.
Consider potential risk of mercury spills and regulatory fines/penalties associated with unintentional
releases.
• Eliminate purchase of mercury-containing products through environmentally preferable purchasing
and purchase contracts with vendors/suppliers.
• Segregate mercury-containing products before they get into incinerator waste stream (conduct
training for proper disposal).
• Use T8 fluorescent lighting. T8 lighting is more energy efficient than incandescent T12 bulbs. This
allows hospitals to place less demand on the utility company. Coal combustion is one of the
largest sources of mercury in the United States.
Communicating and involving employees in mercury elimination is critical to success. At one hospital,
a worker reported that broken thermometers are sharp and disposed of them in "sharps" containers used for
waste hypodermic needles. In other instances, workers reported throwing away materials used to clean up
mercury spills in infectious "red bag" waste. The contents of these containers were later incinerated,
resulting in an otherwise preventable release of mercury into the environment.
Some mercury reduction opportunities follow:
• Include articles devoted to mercury reduction, handling and proper disposal in staff newsletters.
Include specific information about the proper handling of mercury in new-employee orientation and
"Right-to-Know" training.
Ensure that all personnel, including temporary workers, are familiar with mercury
handling procedures and protocols to prevent mercury from being disposed in sharps containers,
red bags or solid waste containers.
• Include information about waste reduction and pollution prevention in in-service training sessions.
Encourage personnel to read labels.
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• Place placard or labels on or above red bags, sharps containers and solid waste containers that state
"No Mercury."
• Have mercury spill kits available in all labs, nursing stations, ICU/ER/Surgery rooms, patient rooms
and storage/maintenance facilities. Provide training on proper usage of the kits.
Pesticides and Landscaping
Reduce generation of pesticide waste by grounds maintenance activities with the following tips and
techniques:
• Work with a contracted grounds maintenance service to eliminate pesticides and herbicides and to use
plants that are native to the area that do not have to be watered or treated with pesticides as often.
• Use mulching mowers to eliminate bagging grass wastes.
Use nonchemical pest control methods such as cornmeal gluten as a natural herbicide.
• Use dry pesticides that are spread on the ground and watered into the ground. This may
eliminate the need for pesticide spraying containers and the resulting contaminated wastewater from
clean-up.
Polyvinyl Chloride (PVC) and Dioxin
Polyvinyl chloride (PVC) is a commonly used polymer in the production of plastic hospital products
because of its low cost, flexibility and optical properties. Twenty-five percent of all health care products such
as IV bags, blood bags and tubing are made with PVC. Other PVC hospital products include: basins,
hemodialysis equipment, patient identification bracelets, bedpans, inflatable splints, respiratory therapy
products, stationary supplies, catheters, lab equipment, drip chambers, medical gloves, thermal blankets,
internal feeding devices and packaging. Hospitals also have basic construction materials and furnishings such
as water pipes and wall coverings that may contain PVC.
When burned, PVC releases dioxin, a PBT (persistent bioaccumulative toxin) and probable U.S. EPA
carcinogen. Hospital PVC incineration accounts for nearly half of all dioxin released into the environment in
the United States. This is almost completely avoidable considering that only 1-2 percent of a hospital's waste
stream needs incineration. The first step for the hospital is to ask its vendors which products contain PVC.
Then, identify alternatives and develop and implement a PVC reduction plan as part of the EMS.
Potential for patient exposure to diethylhexylpthalate (a softener added to PVC plastics); potential for
the PVC product to be incinerated upon disposal; volume of PVC use; and availability of substitute products
are all drivers for PVC reduction. When establishing an organizationwide PVC reduction plan, include the
following priorities:
• Target disposable PVC health care products, especially within neonatal intensive care units, maternity
departments and pediatrics.
• Phase out the purchase of PVC-containing office supplies, furnishings, furniture products
and construction products. Specify PVC-free purchases.
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Additional Information
Polyvinyl Chloride (PVC) Products in Hospitals Page 156
Pharmacy
Open formularies make monitoring patient drug use more difficult and can significantly contribute to
the volume of drugs that must be disposed. Open formularies allow providers to dispense samples to patients.
This dispensing practice encourages the development of secondary storage areas. Once established,
secondary storage areas and their environments cannot be controlled. When drugs are improperly stored
(e.g., improper cooling requirements), they may become obsolete and require disposal, increasing disposal
costs. The U.S. EPA states that pharmaceutical products do not become waste until the decision is made to
discard them. If the damaged or outdated products are returned to the manufacturer, distributor or third-party
processors with the intent to receive, reclaim or destroy, they are regarded as products (not waste) at the time
they are shipped. The only requirement for shipping becomes proper Department of Transportation labeling.
Monitor outside drug sources. Medical providers (who may have off-site offices) with hospital
privileges accumulate samples that may become a disposal problem for pharmacies. Typically, pharmacies
dispose of these drugs gratuitously for the provider.
Radiology
Full-service hospitals usually have a radiology department. The main waste stream is water containing
used photographic developing solutions (fixer and developer) and silver. Silver-containing effluent from the
fixer is passed through a steel wool filter and otherwise treated to recover this metal.
Store materials properly. Many chemicals are sensitive to temperature and light. Chemical containers
list the recommended storage conditions. Meeting the recommended conditions will increase shelf life.
Extend processing bath life. Techniques for extending bath life include: 1) adding ammonium
thiosulfate, which doubles the allowable concentration of silver buildup in the bath; 2) using an acid stop bath
prior to the fixing bath; and 3) adding acetic acid to the fixing bath as needed to keep the pH low. Accurately
adding and monitoring chemical replenishment of process baths will cut down chemical waste.
Use countercurrent washing to replace the commonly used parallel tank system. This reduces the
amount of generated wastewater. In countercurrent washing, water from previous rinsing is used in the initial
film-washing stage. Fresh water enters only at the final stage, at which point much of the contamination is
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already rinsed off the film.
Implement dry laser film processing. This process reduces the chemicals that are manually poured into
the machine and does not need to be connected to the sanitary sewer for chemical discharge.
Recycling/Safe Disposal
General Recycling Success Story
Thomas Jefferson University Hospital in Philadelphia has cut in half the amount of trash it
sends to the landfill since implementing its program to recycle paper, glass, metal and plastic. This
resulted in a savings of $150,000 a year in waste disposal costs. To educate and motivate staff,
Support Services Manager Ed Barr takes representatives of various departments on monthly visits to
the landfill, where they sort through and audit the hospital's trash.
Generally, recycling is the most common of all the available solid waste reduction options for hospitals.
In order to have a successful recycling program, education is essential. Educate staff about proper waste
segregation practices as soon as they enter the organization to ensure that they are aware of the hospital's
recycling programs and the costs and liabilities associated with improper disposal of hospital wastes.
Administrative and office areas - office paper, corrugated cardboard, other paper, cans, bottles.
Foodservice areas - glass, metal, cans, plastic containers, corrugated cardboard.
Public areas - newspaper, magazines, bottles, cans. Make sure bins in public areas as well as bins with
specialized openings (e.g., holes big enough only for aluminum cans, slots for newspapers instead of large
openings where it might look like a trash can) are clearly marked.
Due to such large quantities of paper and cardboard, many hospitals choose reusable totes. Reusable
totes are most cost-effective when used to replace a constant cardboard need, such as distribution from central
supplies to satellite locations. Color-coded, stackable containers are the most feasible option.
The Nightingale Institute estimated that approximately 19 percent of waste stream generated by surgical
services is blue sterile wrap. Other hospital areas that typically generate considerable quantities of this waste
include central distribution, purchasing, pharmacy and labor/delivery rooms. This makes collection within
the hospital relatively easy because it is already well known where the waste is coming from and staff can be
easily trained to collect the wrap from these key areas. Due to the relatively low value of this material for
recycling, attention must be given to keeping costs as low as possible because the facility is not going to get
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much money back in return for the recycled product, especially if the material is collected internally. The
best thing to do in this situation is to identify a local market for polypropylene or No. 5 plastics to minimize
transportation distances and in turn save money on the facility budget. Establish a low-cost collection and
transport system and generate a significant quantity to encourage vendor interest.
Kitchen and food service operations are also often overlooked. Although food waste itself represents
only 10 percent of the hospital's waste stream, nearly 15 pounds of associated waste glass, cans and
cardboard are typically generated per patient from food trays. One option for food waste is to divert organic
food waste to composting. When considering this option, consider space limitations and fitting the size of the
compost container/system to the amount of food waste generated. Obtaining management buy-in for
employee support and properly running the composting bin both help overcome misconceptions associated
with this recycling program. Case study examples suggest that properly administered food composting
systems can handle 100-300 pounds of food waste daily.
Solvents
Solvents are predominantly a laboratory-related waste stream and are used for fixation and preservation
of specimens in histology and pathology and for extractions in laboratories. Halogenated solvents are
generally more toxic and persistent than nonhalogenated solvents. Halogenated compounds used in hospitals
include methylene chloride, chloroform, tetrachloroethylene, chlorobenzene, trichloroethylene, 1,1,1-
trichloroethane and refrigerants. Pollution prevention is the best option for solvents, but if use of a solvent
cannot be eliminated, work practice modification may be the next best bet.
• If using solvent, conduct initial cleaning with used solvent and then fresh solvent for the final
cleaning. This countercurrent cleaning decreases the amount of solvent used. When solvent
used for the initial cleaning step becomes too dirty, replace it with solvent from the second cleaning
step and so on.
• Using a wide variety of solvents will produce a wide variety of waste streams to manage.
Investigate the possibility of using one type of solvent for equipment and other cleaning. By
switching to one type of solvent, it may be cost-effective to have onsite distillation.
• Before placing labware in autoclaves or other cleaning equipment, drain chemicals out of containers
and collect in proper disposal receptacles. This significantly reduces the amount of contaminated
wastewater entering the publicly owned treatment works (POTW) system.
• Carefully evaluate citrus-based substitutes. Citrus-based alternatives may reduce worker exposure
but may also produce a hazardous waste due to flashpoint less than 140°F. These citrus-based
solvents may process samples slower than xylene and will require temperature and time
modifications. Generally, these products are effective on samples in the micrometer range. However,
thicker samples may be difficult or impossible to process. Evaluate hazardous waste and quality
issues before using xylene alternatives.
• Do not mix wastes unnecessarily. Sometimes wastes are mixed without respect to characteristic and
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compatibility at the point of generation.
Mounting chemicals are used to stabilize the sample on the slide and contain polymers and solvents
such as toluene and xylene. Control the inventories of these chemicals because they have limited
shelf lives.
Evaluate routine laboratory processes or tests such as fixation and extraction to determine if
quantities of reagents are reducible. The evaluation can include using calibrated solvent dispensers
and unitized test kits; reducing volumes of reagents; and increasing the use of instrumentation in tests
and experiments.
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Conclusion
Those who use this manual as a guide to environmental management system implementation may find a
new perspective on environmental management and realize the potential opportunities and benefits that EMSs
can provide.
An EMS challenges all hospital employees to identify and prioritize its environmental aspects, take
steps to minimize adverse environmental impacts and set new objectives and targets to continually improve
environmental performance.
A successful EMS builds on effective environmental performance—including environmental
compliance and pollution prevention—in conjunction with the hospital mission of patient care and
community health and well-being.
We hope this manual continues to serve as a useful resource to your hospital with the same rewards as
many other organizations have seen from their efforts.
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- APPENDIX A -
EMS EXAMPLES
NOTE: This appendix includes actual environmental management system tools used by hospitals that
provided assistance with the development of this manual. These documents are not indicative of all
such documents used by the health care industry for implementation of environmental management
systems. For the purposes of this manual, these documents are simply models by which representatives
of the health care industry may use and/or reference to develop and implement environmental
management systems within their own health care organizations.
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INTEROFFICE MEMO
TO: Hospital Staff CC:
FROM: President
DATE: 8/13/98
SUBJECT: ISO MANAGEMENT REPRESENTATIVE
APPOINTMENT/APPROVAL
As President at [insert hospital name and location] I appoint [insert name] to assume the
responsibilities as EMS Management Representative and [insert name] to assume the
responsibilities as EMS Coordinator/Specialist. Responsibilities and reporting functions
will be consistent with those outlined in [insert hospital name] EMS Policies and
Procedures.
[signature]
President
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Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
OBJECTIVE
UBJJU^llVJL
To establish a framework for effectively managing environmental aspects associated with operational
activities and controlling their impact on the environment.
SCOPE
All employees, physicians, students and volunteers within the EMS scope.
DEFINITIONS
The following definitions apply:
• Continuous Improvement - Process of enhancing the environmental management system to achieve
improvements in overall environmental performance in line with the organization's mission and
environmental policy.
• Environment - Surroundings in which an organization operates, including air, water, land, natural
resources, flora, fauna, humans and their interrelation.
NOTE - Surroundings in this context extend from within an organization to the global system.
• Environmental Aspect - Element of an organization's activities, products or services that can interact
with the environment.
NOTE - A significant environmental aspect is an environmental aspect that has or can have a
significant environmental impact.
• Environmental Impact - Any change to the environment, whether adverse or beneficial, wholly or
partially resulting from an organization's activities, products or services.
• Environmental Management System - The part of the overall management system that includes
organizational structure, planning activities, responsibilities, practices, procedures, processes and
resources for developing, implementing, achieving, reviewing and maintaining the environmental policy.
• Environmental Objective - Overall environmental goal, arising from the environmental policy, that an
organization sets itself to achieve and which is quantified where practicable.
• Environmental Performance - Measurable results of the environmental management system, related to
an organization's control of its environmental aspects, based on its environmental policy, objectives and
targets.
• Environmental Policy - Statement by the organization of its intentions and principles in relation to its
overall environmental performance, which provides a framework for action and for the setting of its
environmental objectives and targets.
• Environmental Target - Detailed performance requirement, quantified where practicable, applicable to
the organization or parts thereof, that arises from the environmental objectives and that needs to be set and
87
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Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
met in order to achieve those objectives.
• Interested Party - Individual or group concerned with or affected by the environmental performance of
an organization.
• Prevention of Pollution - Use of processes, practices, materials or products that avoid, reduce or control
pollution, which may include recycling, treatment, process changes, control mechanisms, efficient use of
resources and material substitution.
• EMS Committee: Site EMS representatives are core members of the EMS Committee. Additional key
stakeholders will be added to the committee as determined by the agenda. Other interested parties will
attend meeting on a periodic basis.
POLICY
The (insert hospital name) will establish and maintain an Environmental Management System (EMS), as
outlined in the ISO 14001:1996 Standards.
PROVISIONS
General
The (insert hospital name) shall establish and maintain an environmental management system, the
requirements of which are described in the ISO 14001:1996 Standards. Senior leadership will convey the
importance of the EMS to employees in the following manner:
a. Establish policies and methods of mechanisms for communication;
b. Allocate resources;
c. Establish support systems;
d. Mandate necessary training; and
e. Monitor conformance and implement improvement strategies when necessary.
Environmental Policy
The environmental policy serves as a framework for setting and reviewing environmental objectives and
targets. It has been implemented, maintained and communicated to all employees and made available to
the public. The hospital environmental policy is as follows:
"In accordance with its mission, the (insert hospital name) is dedicated to the health and safety of its
patients, employees, customers, community and environment. Further the (insert hospital name) is
committed to continuous improvement, prevention of pollution and compliance with relevant
environmental regulations and other requirements. "
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Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
PLANNING
Environmental Aspects
Processes, services, products, activity or changes to an existing process, service, product or activity will be
evaluated for environmental impacts. The evaluation will consider normal operating conditions, shutdown
and start-up conditions and the impact when normal operating conditions are not followed and an
emergency situation occurs. Consideration will also include the regulatory status of the new process and
the potential to:
a. Produce emissions to the air;
b. Release to sanitary sewer or water source;
c. Generate waste (hazardous, solid or recyclable);
d. Contaminate the land;
e. Use raw materials or natural resources;
f Cause negative impact to human health.
The evaluation results will be documented and forwarded to the site EMS representative. The EMS
Environmental Aspect Checklist can be used to document the evaluation. The EMS Committee will
review all documentation for significance of environmental aspects and the placement on the Master
Environmental Aspect list in an existing category or new category of activity. The environmental aspects
will be grouped according to category of activities. Environmental aspects that are regulated, impact air,
land, water, human health, generate waste or use raw materials or natural resources will be considered
significant.
Legal and Other Requirements
Management staff must ensure that department operations are in compliance with applicable
environmental requirements. Corporate Audit and Compliance will assist managers in obtaining
information related to new regulations. A number of resources are utilized in managing regulatory
oversight, including, but not limited to:
a. The Federal Register
b. Web-based software
c. Professional journals and publications
Environmental objectives and targets aimed at the prevention of pollution are established and documented
at the system and department levels. Objectives are based on legal requirements, technological, business,
financial and operational requirements, as well as views of interested parties. System level objectives and
targets are documented as continuous improvement initiatives, and the EMS Committee tracks progress.
At the site level, each EMS site representative is responsible for reporting on the system objectives and
targets at the environment of care and/or leadership performance improvement committee meetings.
Environmental Management Programs
Programs or methods for attaining system environmental objectives and targets have been established and
are monitored by EMS representatives. Documentation, on a Program Tracking Form identifies the
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Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
following:
a. Designation of responsibility for achieving objectives and targets;
b. The necessary time frames and resources; and
c. Scheduled review and updates as necessary.
The EMS Committee maintains documentation on the environmental management programs. Progress on
the EMS objectives and targets is reported to the System Quality Medical Safety Council at a minimum of
annually.
IMPLEMENTATION AND OPERATION
Structure and Responsibility
Senior leadership has ensured the success and maintenance of the EMS through the following actions:
a. Roles, responsibility and authority have been defined within (insert hospital name here) policies
and procedures.
b. Resources have been provided; this includes human resources, specialized skills, technology
and financial resources.
c. A management representative has been appointed who ensures that:
The environmental management system is established, implemented and maintained in
accordance with ISO 14001 standard; and
The performance of the environmental management system is reported to senior leadership for
review and as a basis for improvement of the EMS.
Training, awareness and competence
Department managers identify training and competency needs. All staff will receive general awareness of
the EMS. Personnel whose work may create a significant impact upon the environment will be competent
on the basis of education, training and/or experience. Training programs ensure that employees are aware
of the following:
a. EMS requirements, as appropriate to their scope of responsibility;
b. Work activities that pose either an actual or potential significant environmental impact;
c. Roles and responsibilities related to EMS conformance, including emergency management,
response requirements and regulatory compliance; and
d. Potential consequence(s) of departing from operating procedures.
Communication
Communications regarding the EMS have been established and maintained in the following manner:
a. Methods for internal communication include electronic mail correspondences, employee
newsletters, management forums and department meetings.
b. Methods for external communication include receiving, documenting and responding to
communication regarding environmental issues from external interested parties.
c. The (insert hospital name), as policy, does not make available to the public information about
its significant environmental aspects.
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Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
Environmental Management System Documentation
Documentation that describes the core elements of the EMS and provides guidance to related documents
is found within this policy. In addition to this, the following documentation has been established and
maintained:
a. Master Environmental Aspect List
b. ISO 14001 Standard and Related (insert hospital name) Policies
Document Control
EMS documents are controlled as stated in (policy number) (policy name) and (policy number) (policy
name).
Operational Control
Operational controls, in the form of policies, procedures or management operating directives ensure that
work is performed under controlled conditions. Operational controls include the following:
a. Documented procedures to cover situations where, without them, deviations from the
environmental policy and the objectives and targets could occur.
b. Procedures that include operating criteria.
c. Communication with suppliers and contractors regarding policy and procedures related to the
identifiable significant environmental aspects and other relevant requirements.
Emergency Management and Response
The (insert hospital name) has established procedures and plans that identify the potential for and
response to accidents and emergency situations. The policies and procedures aim to prevent and mitigate
the environmental impacts that may be associated with accidents and emergency situations. Emergency
management and response is addressed in, though not limited to, the following policies:
• Safety Management Plan (policy number)
• Hazardous Material Management Plan (policy number)
• Emergency Management Plan (policy number)
• Related Emergency Code Plans
• Interim Life Safety (policy number)
• Fire Drills (policy number)
Emergency procedures/plans will be reviewed and revised where necessary, particularly after the
occurrence of accidents or emergency situations. These procedures/plans will be tested where practicable.
CHECKING AND CORRECTIVE ACTION
Monitoring and Measurement
The (insert hospital name) evaluates and improves its environmental performance through monitoring and
measurement activities (performance improvement). Key characteristics of (insert hospital name)
operations and activities that may have a significant impact on the environment are monitored and
measured as part of the environment of rounds. Results from environmental rounds are reported at the site
environment of care meetings.
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Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
Equipment used for monitoring purposes is calibrated and maintained. Records of theses results are
maintained as stated in (policy number).
Through internal monitoring (audits) (policy number) and environment of care rounds (policy number),
compliance with relevant environmental legislation and regulations will be evaluated at least every 12
months. Findings, corrective/preventive actions and other recommendations from these audits will be
reported to the site Environment of Care Committee and/or the site Leadership Performance Improvement
Committee. External audit results may also be used to document compliance.
Nonconformance and Corrective and Preventive Action
Responsibilities and authority for documenting corrective and preventive action are defined in (policy
number) (policy name), Incident Reporting (policy number) and quality and environmental management
system audits (policy number). Potential nonconformances are also identified through the Compliance
Hotline, where environmental issues are referred to safety officers.
a. Handling and investigating nonconformance;
b. Taking action to mitigate any impacts caused;
c. Initiating and completing corrective and preventive actions.
Corrective and preventive actions eliminate the causes of actual and potential nonconformances and are
appropriate to the magnitude of the problem and its associated impact. Any implemented changes shall be
recorded in documented procedures.
Records
Control of records is defined within (policy number) and (policy number). Retention periods for
environmental records are defined in the (policy name/number). Where regulatory requirements dictate a
retention period differing than the stated (insert hospital name) standard, the regulatory requirement
supersedes (insert hospital name) retention policy.
Environmental Management System Audit
Internal audits are conducted at planned intervals to determine whether or not the EMS:
a. Conforms to established requirements;
b. Has been properly implemented and maintained.
The process and methodology for conducting internal audits is outlined in (policy number). Internal audit
results are reported at site Environment of Care and/or Leadership Performance Improvement Committee
and are part of the management review process.
Management Review
Management review occurs at least, annually, at the System Quality Medical Safety Council (Attachment
8). As part of management review, the following elements of the EMS are reviewed:
a. Results from audits;
b. The extent to which objectives and targets have been met;
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Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
c. The continuing effectiveness and suitability of the environmental management system;
d. Concerns from relevant interested parties; and
e. The need for changes to policy, objectives and other elements of the EMS.
ADMINISTRATIVE RESPONSIBILITY
President
The president of the operating units/designee has overall administrative responsibility for this policy.
Management Representative (MR)
The site safety officer is responsible for overall implementation of the EMS.
Chief Executive Officer/President Date
(Insert Hospital Name)
Executive Vice President and Chief Operating Officer Date
(Insert hospital name)
Chief Nursing Officer, Senior Vice President, Patient Care Service Date
(Insert hospital name)
Supersedes:
Review Date:
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Title: ENVIRONMENTAL REVIEW OF NEW PROJECTS
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
PURPOSE/SCOPE
This procedure defines the method for identifying and evaluating the environmental issues of new
projects at the (hospital name) to:
a) Ensure that appropriate consideration be given to environmental issues prior to project
approval and funding.
b) Ensure that new environmental aspects generated by projects are identified and their
significance evaluated.
c) Provide a mechanism for the amendment of environmental management system elements
and programs, where relevant, to ensure that the environmental management system applies
to such projects.
ACTIVITIES AFFECTED
All areas and departments
FORMS USED
Project Environmental Checklist
REFERENCES
(Policy number) Environmental Aspect, Objectives and Targets and Management Programs
DEFINITIONS
None
EXCLUSIONS
None
PROCEDURE
7.1 Areas/departments initiate Project Appropriation Requests when needed for project
funding to become apparent.
7.2 The initiating activity or designee shall identify and evaluate environmental issues
associated with the project. A summary of this evaluation shall be documented on a
Project Environmental Checklist form and the form added to the Appropriation Request.
This process may be undertaken in liaison with the Environmental Coordinator (or other
competent individual) at the discretion of the initiating activity and shall include an
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Title: ENVIRONMENTAL REVIEW OF NEW PROJECTS
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
identification of environmental aspects and requirements for obtaining approvals from
environmental regulatory agencies.
7.3 The initiating activity shall submit the Appropriation Request and complete Project
Environmental Checklist for review to the environmental management representative.
7.4 The environmental management representative or designee shall review the proposed
project to ensure that all relevant environmental issues have been identified, and if
incomplete shall return the Appropriation Request and Project Environmental Checklist
to the initiating activity for alteration.
7.5 The environmental management representative or designee shall review the
environmental aspects of the project, considering their significance in line with (policy
number).
7.6 Following appropriate review, the environmental management representative or designee
may approve the project by returning the Appropriation Request to the initiating activity
for further processing. If a project is not acceptable, the initiating activity will coordinate
any necessary actions to satisfy concerns identified. The initiating activity in conjunction
with the environmental management representative or designee will coordinate any
necessary prevention, mitigation or control activities associated with the project.
GENERAL RULES
U
8.2
RECORDS
Environmental aspects associated with projects shall be evaluated for significance by the
Cross Functional Team per (policy number).
Changes to the Environmental Management System resulting from an environmental
review of a project will be approved by the facility/plant management.
Records shall be retained consistent with (policy number).
RECORD OF REVISIONS
Revision Date
Description
Sections Affected
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Title: PROJECT ENVIRONMENTAL CHECKLIST
Project Number: Hospital Name: Project Description:
Date Approved:
Next Revision Date:
AIR EMISSIONS
Will this project/process change/produce air emissions?
Will this project/process change an air permit or permit modification?
Does the change require air pollution controls?
Does the project/process change/require the use or purchase of ozone
depleting substances?
WATER DISCHARGES
Does the project/process change results in a wastewater, sanitary or
stormwater discharges?
Will the project/process change/result in changes to water discharge flow
rates?
Will the discharge require a permit modification?
Will new or additional pretreatment be necessary?
Are facility discharges to a common sewer altered?
STORAGE TANKS
Will underground storage tanks be installed?
Will tanks be installed to store hazardous waste or materials, petroleum
products or propane?
WASTE GENERATION
Will the project/process change/produce a waste or recyclable material?
Will the waste be classified as special or hazardous?
Will off-site disposal be necessary?
Are special handling, abatement or disposal measures necessary?
ENERGY USE
Will the project/process change/affect facility energy usage?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
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Title: PROJECT ENVIRONMENTAL CHECKLIST
Project Number:
Date Approved:
Next Revision Date:
Hospital Name:
Project Description:
OTHER CONSIDERATIONS
Do recycling options and costs need to be considered?
Does the project/process change/require use of toxic, hazardous
or carcinogenic materials?
Do project/process materials require special handling or storage?
Does the project cause land disturbances?
Do pollution prevention issues need to be addressed?
Does the project/process change/impact the surrounding community
(e.g., odor, noise, etc.)?
Are there any wildlife or land use issues?
Does the project/process change/alter or add to current facility aspects?
Does the project/process change/require a change to emergency
response methods?
YES
NO
Initiating Activity Manager
Date
Environmental Management Representative
Date
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Activity/Service
i tii ii iiKivi IISM Km in • i in i HIM Km in m>,\ • ran i i jmWn ^M VKN] [L&9
Aspect
Possible Impact(s)
1. Nursing/Medical Floors/Operating Rooms/Day Surgery/Emergency/Intensive and Critical Care Units/Isolation Areas, etc.
Basic Patient Care (including
surgical procedures, daily care,
isolation cases, etc.)
Operation of Medical and
Other Equipment
Compressed Gas Usage
(oxygen, nitrous oxide, etc.)
Laser Usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Biomedical waste generation (sharps,
items contaminated with blood and/or
body fluids, isolation supplies, etc.)
Raw material usage (cleaning chemicals,
sterilants, high-level disinfectants,
formaldehyde, medications, etc.)
Potential chemical spills (emergency)
Energy usage
Hazardous waste generation (batteries)
Raw material usage (chemicals)
Possible fire hazard (emergency)
Chemical leakage (emergency)
Energy usage
Possible fire hazard (emergency)
Possible occupational exposure to
radiation
Potential water pollution from leaking landfill,
Natural Resource Depletion (Land), Resource
Depletion (e.g., raw material depletion)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air/Water Pollution, Resource
Depletion (e.g., raw material depletion)
Air, Water, and Soil Pollution (e.g. air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. smoke)
Human Health, Air Pollution (e.g. chemical vapors),
Resource Depletion (e.g., raw material depletion)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air emissions (smoke)
Human Health
2. Diagnostic Imaging (Nuclear Medicine, X-Ray, Radiology, Ultrasound, Cat Scan, Cardiac Catheterization Procedures, etc.)
Basic Patient Care (Operating
Medical Equipment,
Performing Invasive
Procedures and Contrast
Injections)
Film Processing (Wet and Dry
Laser)
Biomedical waste generation
Radioactive biomedical waste generation
(Half-life of radioactive isotope must be
spent before leaving department)
Solid waste generation (packaging, use
of disposable materials, etc.)
Raw material usage (cleaning, high-
level disinfectant, etc.)
Possible ehemical spill (emergency)
Possible occupational exposure to
radiation during x-ray process
Minor radioactive excreta sanitary
disposal
Possible radioactive spill (emergency)
Solid waste generation (packaging, film,
etc.)
Raw material usage (film processing
chemicals, plastic film, etc.)
Water consumption
Wastewater discharges (depends on state
or socal water regulations)
Silver recovery from film
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. incineration),
Natural Resource Depletion (Land), Resource
Depletion (e.g., raw material depletion)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous)
Human Health
Natural Resource Depletion (water)
Human Health, Waste (Hazardous)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Natural Resource Depletion (water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Positive Impact (reduced impacts on air, water, soil
(pollution); reduced energy resources impacts
(combustion & depletion of natural resources);
reduced impacts on mineral resources (depletion)
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Nuclear Laboratory Work
Possible Occupational Exposure to
Radiation
Possible Air Emissions (often fume
hoods are used as precautionary
measures when preparing injectables)
Human Health
Human Health, Air Pollution (e.g. vapors discharged
through fume hoods)
3. Laboratory (Histology, Pathology, Morgue, Autopsy, Blood Bank,
Daily Operation of Analysis
Machines (Aspects may differ
depending on the type of
equipment and how the
chemical waste is disposed)
Manual Analysis (urine, blood,
staining, etc.)
Chemical Use, Transportation,
& Disposal
Flammable Storage Rooms
Chemical Recycling (Process is
used to reclaim used chemicals
such as alcohol, Formalin,
Xylene, etc.)
Processes Utilizing Fume
Hoods and Ventilation
Equipment
Performing an Autopsy
Biomedical waste generation
Hazardous waste generation
Raw material usage (chemicals)
Possible Chemical Spill (Emergency)
Energy usage
Water Consumption
Wastewater Discharges (depends on
State or Local Water regulations)
Biomedical waste generation
Raw material usage (chemicals)
Possible Chemical Spill
Water Consumption
Wastewater Discharges (depends on
State or Local Water regulations)
Raw material usage (chemicals)
Possible Chemical Spill
Air Emissions
Hazardous waste generation
Possible Fire/Explosion Hazard
Possible Wastewater Discharges
(depends on State or Local Water
regulations)
Chemical Storage & Raw material usage
(chemicals)
Possible Chemical Spill (Emergency)
Possible Fire/Explosion Hazard
Air Emissions
Raw material usage (chemicals)
Chemical Recycling
Air Emissions
Hazardous waste generation
Possible Chemical Spill (Emergency)
Possible Fire/Explosion Hazard
Air Emissions
Energy usage
Raw material usage (a primary use
is formaldehyde)
Possible Chemical Spill (Emergency)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Resource Depletion (e.g. raw material
depletion)
Positive Impact (+) (e.g. reduced purchase of
chemical, reduced impacts associated with disposal)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
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4. 1 j) vii iimiii'iihil Si'i'vicfs- Him
1 Jigh-level Disinfecting and
Cleaning Procedures.
Transporting Biomedical Waste
Laundry (may be a separate
department or contracted
off-site)
5, Central Slerili/ation
Operation of Ethyiene Oxide
Sterilizer
Oper ation o f 11 yd roge n
Peroxide Sterilizers
Operation of High
Temperature/ Pressure/ Steam
Sterilizers
Biological Testing
Biomedical waste generation
(Anatomical)
Air Emissions- (aerosol/cutting bones)
Energy usage
kekeeninu
Raw material usage (chemicals)
Possible Chemical Spill (Emergency)
Water Consumption
Wastewater Discharges
Air Emissions (ex. chemicals used for
stripping floors)
Possible Biomedical Waste Spill
(Emergency)
Energy usage
Raw material usage (detergents, fabric
softeners)
Possible Chemical Spill (Emergency)
Water Consumption
Wastewater Discharges
Compressed Gas Storage and Raw
material usage
Air Emissions
Energy usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Raw material usage (Hydrogen peroxide,
packaging, etc.)
Energy usage
Water Con sumption
Wastewater Discharges
Water Consumption
Wastewater Discharges
Energy usage
Biomedical waste generation
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human neaitn, Air roliutiori (e.g. dust)
impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion). Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. ctiemieal contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion). Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
impacts to A ir, Water or Soil (e.g., air pollution arid
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion). Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
6. Nutrition/ FIMK! Service*/' Ctifcleria.''Kv
-------
Solid waste generation (packaging, use
of disposable materials, etc.)
Solid waste generation - Recycled (food
waste, plastic, cans, glass, etc.)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Positive Impact (+) (reduced natural resources needed
for landfill)
7. Pharmacy
Preparing Antineoplastic/
Cytotoxic Drugs
Disposing of Narcotics
(Possible on-site disposal by
Pharmacists)
Needle, Vial, IV Bag, Drug
Return Disposal
Biomedical waste generation
(Cytotoxic/Antineoplastic drugs)
Air Emissions (Requires Fume Hood)
Possible Occupation Exposure to
Cytotoxic Material
Biomedical waste generation (May be
regulated in your area-to dispose of
narcotics already rendered
unrecoverable)
Generation of Biomedical Waste (May
be regulated in your area)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
8. Physiotherapy/ Occupational Therapy, Wellness Clinics, Recreational Therapy, etc.
Daily Operation of Equipment
(ex. Wax Machine,
Hydrocollator, Whirlpool,
Ultrasound, Laser, etc.)
Energy usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Water Consumption
Wastewater Discharges (depends on
State or Local Water regulations)
Raw material usage (These departments
mainly use cleaning chemicals and
possibly chlorine for the whirlpool)
Possible Chemical Spill
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
9. Engineering/Maintenance
Operation of Powerhouse
Equipment (Boilers, Water
Softeners, Dealkalizers, Fire
Pumps, Vacuum Pumps,
Medical Air Pumps,
Cleaning Salt (Brine) Tank
Welding/Cutting Metal
PCB Storage (Outside or
Inside)
Asbestos Handling and
Removal
Energy usage (Powerhouse equipment
are high consumers of energy- often to
produce energy)
Air Emissions (often regulated
discharges through a stack)
Water Consumption
Wastewater Discharges (ex. blow down
from boiler, flushing pumping systems,
etc.)
Raw material usage (There are a number
of chemicals, mainly in drums, used for
Powerhouse equipment)
Possible Chemical Spill (Emergency)
Fuel Consumption- Natural Gas (back-up
Diesel Fuel)
Hazardous waste generation
Air Emissions
Scrap Metal Recycled
Chemical (Compressed Gas) Use as
Fuel- acetylene, oxygen, argon, etc.
Compressed Gas Storage
Noise/Heat/Radiation Exposure
Possible Fire/Explosion (Emergency)
Possible PCB Leak (Emergency)
Hazardous waste generation (Asbestos)
Air Emissions
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. emissions as a
result of combustion, chemical emissions, etc.)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (e.g. natural gas, oil,
hydro-electricity, etc.)
Human Health, Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health
Positive Impact (+)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health
Human Health, Air
Human Health, Groundwater, Storm Sewer
Human Health, Air Pollution (e.g. airborne asbestos
fibers), Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Air Pollution (e.g. airborne asbestos
fibers)
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Above-Ground and/or Under-
Ground Storage Tanks
Operation of Diesel Generator
(Back-Up Power)
Electrical Operations (repairing
electrical equipment, changing
light fixtures and ballasts, etc.)
Cooling and Heating Processes
Painting Processes
Possible Improper Handling of Asbestos
Waste (Emergency)
Possible Fuel Spillage (Emergency)
Air Emissions
Energy usage
Fuel Consumption (Diesel)
Air Emissions
Possible Fire Hazard (Emergency)
Hazardous waste generation- Possibly
Recycled (Fluorescent Tubes, Ballasts)
Hazardous waste generation- PCB
Ballasts (if you have these in your
facility), Mercury (small mercury pods in
light switches)
Solid waste generation (packaging, use
of disposable materials, etc.)
Possible Electrical Fire/Electrical Shock
Scrap Electrical Wire - Recycled
Water Consumption
Wastewater Discharges
Air Emissions
Energy usage
Raw material usage (biocides)
Possible Chemical Spill (Emergency)
Raw material usage (Latex, alkyd and
oil-based paints, varsol, urethane, etc.)
Possible Chemical Spill (Emergency)
Air Emissions (chemical, dust from
sanding drywall, etc.)
Water Consumption
Wastewater Discharges (process of
cleaning brushes)
Hazardous waste generation
Solid waste generation (packaging, use
of disposable materials, etc.)
Human Health, Air Pollution (e.g. airborne asbestos
fibers)
Human Health, Air Pollution (e.g. vapors)
Human Health, Air Pollution (e.g. vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (e.g. diesel oil)
Human Health, Air Pollution (e.g. vapors)
Human Health, Air Pollution (e.g. smoke, vapors)
Positive Impact (+) if Recycled, if not, Human Health,
Air Pollution (e.g. mercury vapor), Waste
(Hazardous), Natural Resource Depletion (Land)
Human Health, Air Pollution (e.g. chemical/mercury
vapor), Waste (Hazardous), Natural Resource
Depletion (Land)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Air Pollution (e.g. smoke)
Positive Impact (+) - (decreased natural resources
required for landfill)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. dust, chemical
vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
10. Shipping/Receiving/Stores
Receiving, Storing and
Transporting High Risk
Supplies (Chemical, Pharmacy,
Radioactive, etc.)
Unpacking Supplies
Chemical Storage (Priority, high risk
items should be transported to their
designated destination immediately after
arrival, however, due to timing there may
be a period of time where these items are
stored)
Possible Radioactive Isotope Spillage
(Emergency)
Possible Chemical Spill Internal/External
(Emergency)
Possible Fire/Explosion Hazard
Solid waste generation (packaging, use
of disposable materials, etc.)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health
Human Health, Air Pollution (e.g. chemical vapors),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
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Solid waste generation - Recycled
(cardboard, boxboard, plastics, etc.)
Positive Impact (+) (decreased natural resources
needed for landfill)
11. Landscape Management/ External Environment
Grounds-keeping Practices
Snow Removal/Salting During
Winter Months
Use of Equipment (Gas-
Powered Lawn Mowers)
Water Consumption
Raw material usage (Pesticides/
Herbicides/ Fertilizers)
Possible Chemical Spill (Emergency)
Raw material usage (salt, sand,
environmental alternatives available)
Air Emissions (Particularly problematic
to passing staff, visitors, etc., on high
SMOG Days)
Fuel Consumption
Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion), Air Emissions, Groundwater
contamination , Impact to local Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora Fauna
Human Health, Resource Depletion (e.g. raw material
depletion), Other- Flora and Fauna
Human Health, Air Pollution (e.g. combustion
emissions), Other- Flora and Fauna
Natural Resource Depletion (e.g. gasoline, oil)
12. General Hospital Operations & External Concerns
General Hospital-wide
operations and Administration
Processes
Use of Mercury Containing
Devices
On-Site Waste Disposal
(Incineration)
Compressed Gas Storage
Parking Lots
Railway or Highway
Environmental Incident (in
close proximity to your
hospital's location)
Local Industry Environmental
Incident (in close proximity to
your hospital's location)
Solid waste generation (packaging, use
of disposable materials, etc.)
Solid waste generation - Recycled
(paper, cardboard, boxboard, plastic,
cans, glass, etc.)
Energy usage (office equipment-
computers, photocopiers, personal
radios, heaters, fax machines, lighting,
etc.)
Air Emissions (possible photocopier
emissions)
Water Consumption (toilets, sinks, water
fountains, etc.)
Wastewater Discharges (toilets, sinks,
water fountains, etc.)
Possible Chemical Spillage (Emergency)
Air Emissions
Heat/Noi se/Vibration
Generation of Hazardous and Non-
Hazardous Waste (Ash may be
considered hazardous or non-hazardous
depending on your state regulations)
Possible Fire/Explosion Hazard
(Depending on what is put into the
incinerator- look to state regulations to
determine what waste can be disposed of
by incineration)
Possible Air Emissions/Gas Leak
(Emergency)
Possible Fire/Explosion Hazard
(Emergency)
Possible Chemical Spill (Emergency)
Possible Chemical Spill (Emergency)
Possible Fire/Explosion Hazard
(Emergency)
Possible Chemical Spill (Emergency)
Possible Fugitive Air Emissions
(resulting in external air exclusion
procedures)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Positive Impact (+) (decreased natural resources
needed for landfill)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. combustion
emissions)
Human Health
Human Health, Air Pollution (e.g. combustion
emissions), Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Air Pollution (e.g. smoke, combustion
emissions)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
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Construction- Demolishing and
Re-building Structures
Solid waste generation (materials not
reusable or recyclable)
Fuel Consumption- (mainly mobile
equipment)
Energy usage
Air Emissions- exhaust from forklifts,
trucks, dust, fugitive emissions, etc.
Compressed Gas Use and Storage
Possible Fire/Explosion Hazard
Noise and Vibration
Raw material usage (chemicals,
construction materials, etc.)
Possible Chemical Spill (Emergency)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Natural Resource Depletion (e.g. natural gas, oil,
hydro-electricity, etc.)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. combustion
emissions), Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. smoke, chemical
vapors), Other- Flora and Fauna
Human Health
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors),
Other- Flora and Fauna
Other Areas to Consider Including:
Day Clinics
Special Testing
Off-Site or Satellite Facilities
Mobile Units owned and operated by the hospital such as Ambulance and Patient Transport services
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Sample Master Environment Aspects List
Aspect #
Gl
G7
G10
G12
G14
G15
G16
G17
G18
G19
Aspect Description
Generation and disposal
of recyclable materials
Response to emergency
situations-external and
internal
Release to Sanitary
Sewers
Handling and Storage of
Compressed Gas
Cylinders
Generation and disposal
of solid waste
Generation, handling and
disposal of Medical Waste
Air Emissions from
Hoods
Release to Indoor Air/ Air
emissions from room
Air Emissions from
Vehicles and Utility
Systems
Generation, handling,
storage, disposal of
Potential Environmental Impact
Contamination of Soil, Air, Human
Health Exposures, and
Groundwater
Contamination/negative affect on
People, Property, Equipment,
Community, Air
Release to and Potential to add
contaminates to Public Owned
Treatment Work Facility or Storm
Water
Contamination of Air and Human
Health Exposure
Contamination of Soil, Air, Water
Groundwater, Storm Water and
exposure to Human Health
Contamination of Soil,
Groundwater/'Storin Water and
Human Health exposure
Potential effect on Air Quality
Potential contamination of Air,
Human Health exposure,
degradation of Air Quality
Degradation of Air Quality
Contamination of Soil,
Groundwater/ S toiin Water,
Product, Activity, SeiTice
Plastics, Glass, Batteries, Toner Cartridges, Aluminum
Cardboard, Disposal Supplies, Fluorescent Bulbs, Used
Oil, Old Refrigerator Units, Fat, Oil & Grease
All Emergency Codes, Accidental Spills, Releases to the
Environment
Sinks, Hoppers, Floor Drains, Eye Wash Fountains,
Emergency Showers, Decontamination Showers,
Portable AC Units, Humidifiers, Walk-in-Refiige raters.
Automated Equipment, Morgue Grinder, Wastewater
Discharge, leaky pipes, scrub agents, RO water system.
Snow Plowing
Compressed Gas Cylinders, Hyperbaiic Chambers
Everything not hazardous or recyclable, Lawn Debris
Cultures and Stocks of Infectious Agents, Pathological
Waste, Liquid Human and Animal Waste, Blood and
Blood Products, Body Fluids, Shaips, Needles, Syringes,
Scalpels, IV Tubing with needles attached, Laboratory
Instruments or Glassware that could cause puncture.
Pneumatic Tubes
Hoods, Mop Head Dryer, Cheino hoods. Chemical'
Biological Hood, ETO, Mold Room, Paint Hood
Rooms designed to exhaust to the outside (Negative
Pressure Room, Soiled Utility Rooms, Housekeeping
Closets, Staff Restrooms)
Security Vehicles, Plant Operations, Delivery Trucks, All
Department Owned Vehicles, Utility Systems
Radioactive Materials
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Sample Master Environment Aspects List
Aspect #
G20
G2I
G22
G23
F8
F15
FIT
F18
F22
F23
F25
F3Q
Aspect Description
Radioactive Material &
Waste
Exposure to Specimens
and Blood Products
Generation, handling,
storage, disposal of
Hazardous Materials
Charging Batteries
Generation, handling,
storage, disposal of
Chemo Materials and
Waste
Consumption of
Natural Resources
Above Ground and
Underground Diesel
Storage Tanks
Emergency Generator
Cogenerator
Potential for release of
Liquid Oxygen
Excessive Noise Level
(Internal/External)
Hot Work Operations
Heat Stress
Potential Environmental Impact
Human Health exposure
Potential for Spills and Human
Health exposure
Release to Air, contamination of
Soil, Groundwater/Storna water,
Human Health exposure
Contamination of Groundwater,
Soil, Sanitary Sewer, Storm Water,
Air Quality and Human Health
Exposure
Contamination of Soil,
Groundwater/ Storm Water,
Human Health exposure
Depletion of Natural Resources
Contamination of Soil,
Groundwater Sanitary Sewer, Air
Emission, Potential for Fire.
Energy Use
Energy Use
Potential for Fire
Damage to Human Health due to
Noise Exposure
Potential for Fire
Human Health exposure
Product, Activity, Service
All Patient Specimens, all Personnel coming in contact
with Patient Specimens, Specimens transported by
Pneumatic Tub System.
Listed as hazardous in 40 CFR 261, Exhibit Hazardous
Characteristics, Toxic, Reactive, Ignitable, Flammable
and Combustible, Corrosive, Listed as Hazardous on the
MSDS, Hazardous bv definition or bv regulatory agent,
? « i S » O ~
Gasoline, Weed Control Products, Pesticides
Battery Charging of Motorized Equipment
Cytotoxic Drugs, Antiueoplastic Drugs,
Cheinotherapeutic. (Preparation, Handling,
Administration and Disposal)
Heating, Electricity, Natural Gas, Cooling Towers,
Water Treatment, Oil, Emergency Generator
Above Ground and Underground Storage Tanks
Operation of emergency generator
Operation of Cogenerator
Liquid Oxygen Cylinder
Activity that produces noise that exceeds the permissible
noise levels
Activity that could result in a fire or monitoring
required by insurance agents
Excessive heat conditions or clothing that generates heat
duiing prolonged use
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Sample Master Environment Aspects List
Aspect #
F41
F46
F57
F62
F64
F68
F72
F75
F76
Purl
Aspect Description
Construction Projects
(Internal/External)
Heliport
Ventilation
Confined Space Entry
Operation of Powered
Equipment
Retention Pond
Storage of Bulk Salt
Acquisition of Property
Consumption of Natural
Resources
Acquisition of SEA
Supplies/Services.
Potential Environmental Impact
Air, Sanitary Sewers, Ground
Water, Human Health exposure,
Waste Generator, Consumption of
Natural Resources (Depletion), any
Renovation, Remodeling, and/or
New Construction
Potential for Spills, Noise, Fire,
Human Health Exposure
Indoor Air Quality Degradation
Human Health Exposure to Hazard
Human Health Exposure to Hazard
Contamination of Ground Water
Contamination of Ground Water,
Soil, Sanitary Sewer, Storm Water
Potential for Purchasing of
Contaminated Property
Water C onsumption
Potential to Exceed Quantity
and/or Purchase Items not in
Conformauce
Product, Activity, Service
Any Renovation, Remodeling, and/or New Construction
Arrival of helicopter on the grounds of the facility
Fresh Air Intake, Filter Changes, HYAC
Servicing equipment/systems that require entry into
permitted confined Spaces
Activity requiring lock out /tag out procedures
Activity that could release to the retention pond on the
grounds of the facility
Internal/External storage of salt for deicing activities
Leasing of space or purchase of a building/property
Cooling Tower,, Water Treatment, Electricity, Gas, Oil,
Chillers, Filtration of Drinking Water
All Items Obtained and/or Purchased.
o
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SAMPLE ENVIRONMENTAL ASPECTS AND IMPACTS INVENTORY FORMAT
DEPARTMENT: Nursin
DATE APPROVED:
g/Medical Floors
DATE LAST REVIEWED:
Impact Abbreviation Definitions: AIR: Air/ Atmosphere, SOIL: Soil, GW: Groundwater/Waterway, ST.S: Storm Sewer, SN.S: Sanitary (City) Sewer (water to be treated at wastewater treatment plant), WASTE- HAZ:
Hazardous Waste, WASTE-NON: Non-Hazardous Waste (i.e. recycled, garbage, etc.) , HH: Human Health effects (patients, visitors, staff, community), NR: Natural Resources (renewable or non-renewable) , OTHER: Other
negative environmental issues
ACTIVITY/SERVICE
Basic Patient Care (including
surgical procedures, daily care,
isolation cases, etc.)
Operation of Medical and Other
Equipment
Compressed Gas Usage (oxygen,
nitrous oxide, etc.)
Energy usage
Possible Fire Hazard (Emergency)
Possible Occupational Exposure to
Radiation
ENVIRONMENTAL ASPECT
Solid waste generation (packaging, use
of disposable materials, etc.)
Biomedical waste generation (sharps,
items contaminated with blood and/or
body fluids, isolation supplies, etc.)
Raw material usage (cleaning
chemicals, sterilants, high-level
disinfectants, formaldehyde,
medications, etc.)
Potential chemical spills (Emergency)
Energy usage
Hazardous waste generation (batteries)
Raw material usage (chemicals)
Possible Fire Hazard (Emergency)
Chemical Leakage (Emergency)
Energy usage
Possible Fire Hazard (Emergency)
Possible Occupational Exposure to
Radiation
LEGAL
REQUIREMNTS
POTENTIAL AREA(s) OF IMPACT
(positive impacts +)
AIR
X
X
X
X
X
X
X
X
SOIL
X
X
X
GW
X
X
ST.S/
SN.S
WASTE
HAZ
X
X
X
X
NON
HH
X
X
X
X
X
X
X
X
X
NR
X
(land)
X
(land)
X
(oil,
natural
gas)
X
(land)
X
(oil,
natural
gas)
OTHER
Resource
Depletion
Resource
Depletion
Resource
Depletion
CONSEQ.
RATING
FREQ.
RATING
DEGREE
OF
CONTROL
TOTAL
SIGNIF.
Source: St. Mary's General Hospital, Ontario, January, 2001
-------
SIGNIFICANT EVALUATION CRITERIA FOR ENVIRONMENTAL IMPACTS
Total Significance = Consequence x Frequency x Degree of Control
Note: **Any Environmental Impact at or above 27 is "Significant."
CRITERIA
Consequence
The severity of an
anticipated impact.
Frequency
The likelihood of the
impact occurring.
Degree of Control The
amount of control the
facility currently has over
the occurrence of the
impact.
RANKING
Critical- 5
Major- 4
Significant- 3**
Marginal- 2
Negligible- 1
Positive- 0
Frequent- 5
Probable- 4
Possible- 3**
Remote- 2
Improbable- 1
Positive- 0
No Control- 5
Minimal- 4
Moderate- 3**
High Level- 2
Full Control- 1
Positive- 0
DESCRIPTION
Non-reversible, major environmental damage, OR the
possibility of endangering human life.
Major reversible environmental or human health (long term)
damage, OR currently exceeds regulatory limits.
Moderate reversible environmental or human health (short-
term) damage, legislative/regulatory/other requirements
apply.
Minimal loss to the environment, reversible, within
regulatory limits.
Insignificant effects on environment (i.e. nuisance, odor,
noise, etc), within regulatory limits, OR no loss to the
environment.
Positive Environmental Impact
Impact occurs continuously or in intervals throughout the day
and/or night.
Impact is expected to occur at least once per day.
Impact is expected to occur occasionally (at least once per
week or once per month.)
Impact is expected to occur at least once per year.
Impact is unlikely to occur or is not expected to occur during
the lifetime of the facility.
Positive Environmental Impact.
The facility has zero preventative measures in place.
The facility has minor preventative measure in place.
The facility has some preventative measures in place.
The facility has numerous preventative measures in place
The facility has extensive preventative measures in place.
Positive Environmental Impact
Source: St. Mary's General Hospital, Ontario, January, 2001
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TOOL TO DETERMINE SIGNIFICANCE
LisI lap 5 aspects/impacts Mow, Rank them using the scale uf 1-5. five Dicing,
the moMJ siftnifkanL Add the stores to gel a first cut priori Iv^
» How la P rlarilke? (ONE SUGGESTION far Searing C uM«?)
Scale
1
2
J
4
5
Scope
uanotit cable
only «B€ department
o rganization-wide
outside tie
organiialioa; local
inip«t
outside the
otxanuation;
regional impact
SeTeritj-
no potential impact OB
he alth/emlroa me nt
no actual impact un
bealtJi/eBvirQntaent
low impact on
healtb/environinent
sigiiflcant damage to
bealth/emironment
sen re damage to
oealtb/eovininment
Cost
$tt- 200
$200-5,000
$5,000-
5IMMM)
$50,000-
250,000
greater
than
$2MM1W
Co nip Ha ncc
minimal
recordkeepins
only, warning
oily
chil penalty :
minor fine
chil peraaltj1 :
major fine
criminal penalt}':
striped suit
Do-abk
rewurces in-
liouse
time
available and
budget
planned
time
availabk
planning wfll
he done
no planning
done
Occurrence of
Impact
improbable /
ie«r
infrequent (!/}' r
but I/mo)
continuous n>n-
foiig basis)
AspMl / Imptttl
Scape
Srvtritv
Cost
Ctinip]i»iKf
Do-abk
Occu rrewct
Tola!
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o
ENVIRONMENTAL ASPECTS - LABORATORIES
DEPARTMENT:
LAB SUPERVISOR:
B TYPE OF LAB: Q Chemistry Q Biological Sciences Q Medical Science
"g
Responsible Person
Effective Date
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ENVIRONMENTAL ASPECTS AND IMPACTS: ENERGY
EXAMPLE
USE
Activity or
Operation
Computers/
Information
Systems
Heating and
Cooling
Lighting
Lab
Equipment
Refrigeration
Common Sources
O Personal Computers
O Servers
O Computer Lab Operation Overhead
O Air Conditioners
O Furnaces
O Fans
O Boilers and Water Heaters
O Offices/ Admin Lighting
O Outdoor Lights
O Laboratories
O Operating rooms
O Spectrometers
O Ovens
Q Hoods
O Cleaning Equipment
O Microscopes
O Food Service/Campus Dining
O Vending
O Laboratory Cooling Needs
Q On-campus Commercial
Use Rate per Month
(therms or kw/mo and
$/mo)
1 56,250 kw/month
$25,000 mo
390,625 kw/month
$62,500 month
3 12,500 kw/month
$50,000 month
109,375 kw/month
$17,500
234,375 kw/month
$37,500 month
Reduction Efforts
0 Auto-sleep mode
O Shut-down enforcement
0 Lab Management
O System upgrades
Q Insulation/windows
0 Temperature Controls
0 O&M BMP's
0 Sensor Controls
Q Delamping
0 High efficiency bulbs
Q Relamping
Q Tandem wiring
0 O&M BMPs
Q Technology upgrade
Q Coil maintenance
0 System upgrade
Q O&M BMPs
Responsible Person/Date
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o
ENVIRONMENTAL ASPECTS - JANITORIAL OPERATIONS
ACTIVITY OR
OPERATION
BATHROOM
CLEANING
•/ Toilet Bowl
•S Cleaners
•S Disinfectants
FLOOR CARE
S Carpet Cleaners
S Floor Finish
S Hard Floor Care
FIXTURE/FURNITURE
CLEANING
' Furniture Polish
' Metal Cleaner
' General Purpose
Cleaners
GLASS CLEANING
•S Glass Cleaners
COMMON CONCERNS
LJ Hydrochloric acid
LJ Phosphoric acid
LJ Sulfamic acid
CJ Other acid
CJ 2-Butoxy ethanol
LJ Isopropyl alcohol
LJ Other toxic ingredients4
LJ Carcinogens / Neurotoxins
Q Solvents
Q VOC's
LJ Other toxic ingredients
Q 2-Butoxy ethanol
LJ Isopropyl alcohol
LJ Chlorinated solvents
LJ Hydrocarbon solvent
LJ Other toxic ingredients
Q 2-Butoxy ethanol
LJ Isopropyl alcohol
LJ Other toxic ingredients
USE RATE PER MONTH
REDUCTION EFFORTS
LJ "Environmentally Preferable" Productl
Q Dilute
LJ Use Reduction and Minimization Method2
Q Other:
LJ "Environmentally Preferable" Product
Q Dilute
LJ Use Reduction and Minimization Method
Q Other:
LJ "Environmentally Preferable" Product
Q Dilute
LJ Use Reduction and Minimization Method
Q Other:
LJ "Environmentally Preferable" Product
Q Dilute
LJ Use Reduction and Minimization Method
LJ Other-
3
fa
Notes:
1. Environmental Preferable Product refers to an alternative product that eliminates or minimizes common chemicals of concern.
2. Minimize use of product by only using product when needed, rather than following predetermined schedule. Also, minimize exposure through use of personal protective
equipment and/or alternative product forms (for example, trigger vs. aerosol container).
3. See Occupational Safety and Health Administration's website: http://www.osha-slc.gov/SLTC/carcinogens/index.html or U.S. Department of Health Information Service
National Toxicology Program's website: http://ehis, niehs.nih.gov/roc for listing of known carcinogens.
4. See the Janitorial Pollution Project's website for listing of potentially harmful chemicals: http://www.westP2net.org/janitorial/jp4.htm
Responsible Person/Effective Date
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Title: PROCEDURE FOR IDENTIFICATION OF ASPECTS, SIGNIFICANCE AND OBJECTIVES AND
TARGETS
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
PURPOSE
The purpose of this procedure is to determine the method by which aspects are identified and by
which significant aspects are determined.
ACTIVITIES AFFECTED
Cross Functional Team
• Plant Operating Committee (OCM)
• Internal Auditors
FORMS USED
None
REFERENCES
• Aspects, Significant Aspects and Establishing Environmental Objectives and Targets
• Environmental Regulations and Other Requirements - Obtaining and Maintaining Information
• External Communications
• Internal Environmental Communications
• Internal Environmental System Audits
Compliance Assurance
• Responding to Community Complaints/Inquiries
Contractor Management
• Aspects Database
• Environmental Aspects Identification Worksheets
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DEFINITIONS
SARA - Superfund Amendment Reauthorization Act
- Tier II Reporting Levels (10,000 Ib)
Toxic Chemical Release Inventory Levels (25,000 Ib manufactured, processed,
10,000 Ib - otherwise used)
EXCLUSIONS
None
PROCEDURE
• Aspects will be identified, significance determined and objectives and targets set following
Aspects Procedure.
• A Cross Functional Team (CFT), whose membership shall represent each functional activity
of the facility, is responsible for the identification of aspects, the determination of significant
aspects and the setting of objectives and targets.
• Aspects are identified by using Aspects Spreadsheets, expert knowledge and interviews of
functional areas.
• Aspects encompass all functional areas whose activities, products or services the plant can
control or over which the facility can have influence.
• Consideration of interested parties shall be utilized in the determination of significant aspects.
Interested parties are defined as employees, customers, stockholders, agencies, business and
residents adjacent to the facility. Views of interested parties are received through the external
communications procedure, Responding to Community Complaints/Inquiries.
• Legal and other requirements are considered to be significant.
• Volumes of materials stored/consumed are considered significant when meeting SARA
reporting.
• Other criteria used for significance determination shall include but, not be limited to, emission
inventories, pollution prevention and waste minimization programs, property assessments,
contractor activities, and environmental compliance audits.
• Objectives and targets shall be established at each relevant function and level within the plant
organization.
• Legal and other requirements, significant environmental impact, technology options, financial,
operational and business requirements shall be considered in setting of objectives and targets.
• Objectives and targets shall be established for all significant aspects.
• The aspects, significant aspects and objectives and targets shall be summarized and presented
at the Operating Committee Meeting (OCM) for review and concurrence.
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GENERAL RULES
Exceptions to the criteria listed in Section 7, shall be justified and noted in the Aspects Database.
ENVIRONMENTAL RECORDS
• Completed Aspects Spreadsheets
• Completed Aspects Database
RECORD OF REVISIONS
Date:
Description:
Converted into a procedural format
Reformat header and footer
Pages affected:
All
All
Authorized by:
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Title: PROCEDURE FOR LEG ALAND OTHER REQUIREMENTS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
To ensure that appropriate persons have access to and understand all legal and other requirements that are
applicable to the environmental aspects of (hospital name)'s activities.
SCOPE
This procedure governs the operations and programs conducted by (hospital name), located at (hospital
address).
RESPONSIBILITY
It is the responsibility of the EMS representative and/or designee to ensure that all legal and other
requirements are maintained and to inform staff of the legislative, regulatory and other requirements with
which the hospital must comply.
It is the responsibility of the department managers/supervisors to implement new or to revise existing
programs or operations to meet applicable regulation requirements and to ensure that employees are aware
of the legislation, guidelines, regulations, etc. that affect their area(s) of operation.
It is the responsibility of all employees of (insert hospital name) to inform the EMS representative and/
or designee should they learn of new and changed legislation and other requirements.
PROCEDURE
The EMS representative and/or designee is responsible for identifying and documenting the legislative and
other requirements associated with the hospital's aspects.
The EMS representative and/or designee is responsible for identifying new or changed legislation,
regulations and bylaws by reviewing the federal, state and municipal legislative Web sites and any other
tools that may be available for updating compliance on a regular basis.
The EMS representative and/or designee retains copies of applicable environmental legislation for referral.
Copies of legal and other requirements are retained in the Environmental Legislation and Regulations
binder. Discard obsolete documents when new changes are made.
Department managers must communicate and implement changes that occur as a result of amendments to
legal or other requirements within their departments.
117
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The EMS representative, in collaboration with associated management, will address legislative or other
changes that affect the hospital corporation and/or nonspecific departments.
In the incidence of noncompliance with changes in regulatory requirements, the EMS representative and/
or designee, in consultation with department managers/supervisors, will create a corrective action plan to
address the issue(s).
DEFINITIONS
Definitions relating to the content of the EMS are contained in the glossary.
REFERENCES
ISO 14001 - 96 - Environmental Management System Standard
EXHIBITS
N/A
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Title: PROCEDURE FOR OBJECTIVES AND TARGETS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
To describe the methods utilized by the hospital to identify environmental objectives and targets.
SCOPE
This procedure governs the operations and programs conducted by [hospital name], located at [insert
hospital address}.
RESPONSIBILITY
It is the responsibility of the EMS representative and/or designee, in consultation with the Green Team, to
ensure that environmental objectives and measurable targets are set on a regular basis.
It is the responsibility of the EMS representative and/or designee to track environmental performance of
the environmental objectives and targets and to communicate progress to the Green Team, senior
management and hospital staff.
It is the responsibility of senior management to designate resources and staff to ensure that environmental
objectives are met.
PROCEDURE
Annually, the EMS representative and/or designee, the Green Team and/or senior management (if
objectives require actions that have a financial cost of >$1000.00) will set and approve environmental
objectives and targets based on:
• The environmental policy
• Significant hospital environmental impacts
• Input from hospital staff, senior management and interested parties
• Changes in legal or other requirements
• Compliance and other internal audit findings
• Environmental emergencies or incidents
• Technological options available
• Tinancial and operational requirements
The environmental targets must be S.M.A.R.T (Specific, Measurable, Achievable, Results-oriented and
Time-dependent.)
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The approved environmental objectives and targets will be documented on the "Objectives and Targets
Chart" (Exhibit 1- EMS-4.3.3-1).
Refer to the Procedure for Environmental Management Program(s) (EMS-4.3.4) for the identification of
actions to achieve designated environmental objectives and targets.
The EMS representative and/or designee will communicate objectives and targets to the hospital staff via
email, displays, environmental information sessions and hospital orientation on a regular basis.
The EMS representative and/or designee monitors the progress of environmental objectives and targets by
identifying performance indicators. Regular progress reports are presented to the Green Team during
monthly meetings. Maintenance of data pertaining to progress of environmental objectives and
environmental performance is outlined in the Procedure for Monitoring and Measurement (EMS- 4.5.1).
If at any time, the EMS representative and/or designee, Green Team and/or senior management wishes to
change, revise or alter the approved environmental objectives and targets to represent progress or lack
thereof, the EMS representative and/or designee will make the necessary changes and send the revised
document back to the Green Team for approval.
Significant aspects and environmental issues not formally addressed through this procedure will be
addressed/managed on a priority/as-needed basis by the EMS representative and/or designee and the
Green Team.
DEFINITIONS
Definitions relating to the content of the EMS are contained in the glossary.
REFERENCES
ISO 14001 - 96 - Environmental Management System Standard
EMS- 4.2 Environmental Policy
EMS- 4.3.1 Procedure for Environmental Aspects
EMS- 4.3.2 Procedure for Legal and Other Requirements
EMS- 4.3.4 Procedure for Environmental Management Program(s)
EMS- 4.4.7 Procedure for Emergency Preparedness and Response
EMS- 4.5.1 Procedure for Monitoring and Measurement
EMS- 4.5.3 Procedure for Records
EXHIBITS
Exhibit 1- EPPM-4.3.3-1, Objective and Targets Chart
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Title: PROCEDURE FOR ENVIRONMENTAL MANAGEMENT PROGRAMS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
To ensure that a procedure is in place to establish and maintain Environmental Management Program(s)
to achieve the identified objectives and targets.
SCOPE
This procedure governs the operations and programs conducted by [hospital name], located at [insert
hospital address}.
RESPONSIBILITY
It is the responsibility of the EMS representative and/or designee, in consultation with the Green Team to
develop, on a regular basis, Environmental Management Program(s) for each environmental objective and
target.
It is the responsibility of the EMS representative on behalf of the Green Team, to approve the
Environmental Management Program(s) under $1000.00 and to designate appropriate resources and staff
to ensure that these programs are implemented and maintained.
It is the responsibility of a representative from senior management to comment and approve those
Environmental Management Program action(s) that require $1,000.00 or more (capital) for
implementation.
It is the responsibility of designated staff to follow through with the Environmental Management
Program(s) and to track and report progress of activities to the EMS representative and/or designee.
PROCEDURE
Annually, the EMS representative and/or designee, in consultation with the Green Team, will develop and
set environmental objectives and targets as described in the Procedure for Objectives and Targets.
The EMS representative and/or designee, in consultation with the Green Team then develops and
documents the "Environmental Management Program(s)" (Exhibit l-EMS-4.3.4-1) for achieving the
appointed environmental objectives and targets.
Environmental Management Program(s) must include (but is not limited to): actions for achieving the
objectives and targets, responsible parties, the time frame(s) for completion and other stakeholder
involvement.
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A member of senior management will review the Environmental Management Program(s) to ensure
economic feasibility, appropriateness and to allocate adequate resources for implementation.
After inputting comments from the representative of senior management, the EMS representative
approves the Environmental Management Program(s) for under $1000.00. Senior management approves
all actions with a cost of $1000.00 or more (capital).
The EMS representative and/or designee, Green Team members and other designated personnel, will
accomplish the duties set forth in the Environmental Management Program(s) in the time frame
determined.
The EMS representative and/or designee monitors the progress of Environmental Management
Program(s) and reports the progress of the program(s) to the Green Team, senior management and
hospital staff on a regular basis. Maintenance of data pertaining to the progress of the Environmental
Management Program(s) is outlined in the Procedure for Monitoring and Measurement (EMS- 4.5.1) and
the Procedure for Records (EMS- 4.5.3).
If at any time, the EMS representative and/or designee, members of senior management and Green Team
wish to change, revise or alter the approved environmental management program(s) to represent progress
or lack thereof, the EMS representative and/or designee will make the necessary changes and send the
revised document back to the Green Team for approval.
Upon completion of the Environmental Management Program(s), the EMS representative and/or designee
will review the overall effectiveness of the program(s) against the intended objective and target. If any
issues or concerns arise, action plans may be developed to correct any deficiencies.
DEFINITIONS
Definitions relating to the content of the EMS are contained in the glossary.
REFERENCES
ISO 14001 - 96 - Environmental Management System Standard
EMS -4.3.3 Procedure for Obj ective s and Targets
EMS- 4.5.1 Procedure for Monitoring and Measurement
EMS- 4.5.3 Procedure for Records
EXHIBITS
Exhibit 1- EMS-4.3.4-1, Environmental Management Program Chart
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Title: EXTERNAL COMMUNICATION PROCEDURE
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
To define the method(s) that will be utilized to receive, document and respond to relevant communication
from external interested parties.
SCOPE
All of the external communication that relates to environmental aspects.
DEFINITIONS
External Communication - That communication that occurs with interested parties in which there is a
concern or a complaint from the external interested.
REFERENCES
Emergency Preparedness & Response Procedure
Significant Aspects
Environmental Policy
Environmental Communications Request Form
Emergency Response List
PROCEDURE
The communication from an external interested party is received by the company receptionist, Corporate
Communications or by a member of the Environmental Affairs Section.
Information received by the company receptionist or Corporate Communications is forwarded to
Environmental Affairs.
The members of Environmental Affairs will verify the nature of the communication and either address it
immediately (not requiring written documentation) or record the individuals/groups name and phone
number and nature of the communication on the environmental communication, and Environmental
Affairs will either address the communication in a timely manner or consult with upper management if
necessary.
The decision to communicate significant environmental aspects is done on a case-by-case basis by the
manager of Environmental Affairs and upper management if necessary. An environmental communication
will be used to document the communication.
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Once in the tracking system, the communication will be kept for consideration during updating significant
aspects and objectives and targets.
The communication will be completed by Environmental Affairs or Corporate Communications
depending upon the nature, size and scope of the situation.
A summary of the response or a copy of the response (if written) will be logged into the environmental
communications environmental communication tracking system.
In the event the emergency response system is activated, communication methodologies will be
implemented consistent with those outlined in the Emergency Response Plan.
RETENTION REQUIREMENT
This document will be retained until revised.
SPECIAL CIRCUMSTANCES
N/A
MEASUREMENT OF PERFORMANCE
The performance of this portion of the EMS shall be measured through audits conducted by internal
auditors, audit team and third-party auditor of which certification is acquired.
EXHIBITS
N/A
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Title: INTERNAL COMMUNICATION PROCEDURE
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
To establish the methods that will be utilized to communicate internally on environmental aspects and the
Environmental Management System.
SCOPE
The scope includes all of the internal communication that relates to environmental aspects.
DEFINITIONS
• Internal Communication - That communication that occurs between employees, or contractors
suppliers who work on behalf of [insert hospital name] within the confines of the site.
• Reference Material
• All EMS Procedures
All EMS Records
• Environmental Policy
PROCEDURE
Environmental Affairs communicates to facility personnel relevant information regarding the
environmental management system in the following manner:
• Policy - Distribute Policy Cards and send fliers to all employees
• Significant Aspects - The list is discussed with section managers.
• Legal and Other requirements - Distribute a list of general regulations through General Awareness
Training. Distribute specific legal requirements to relevant engineering sections.
• Objectives and Targets - The objectives are discussed with section managers.
• EMP - The EMP's are given approval or disapproved with reason why disapproved.
• Structure and Responsibility - Roles and responsibility are distributed.
• Training Awareness Competency - All training is considered communication.
• Communication - The methods to communicate to Environmental Affairs through general
awareness training.
• EMS Documentation - Copies of the manual will be communicated via the web site.
• Document Control - General document control requirement are communicated to section managers
via review meeting and section ISO Representatives via Internal Auditor Training Class.
• Operational Control - General document control procedures are reviewed and recommendations
are communicated to relevant sections via the Environmental Key Point proposal.
• Emergency Preparedness and Response - The Emergency response are communicated during the
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annual RCRA training.
• Monitoring and Measuring - The requirements for generating documented monitoring measuring
Procedures and to perform calibration on monitoring/measuring equipment is communication to
section ISO representatives via "objectives and targets". Performance tracking for objectives and
targets are communicated back to the responsible sections.
• Nonconformance Corrective and Preventive Action - Nonconformance reports will be reviewed
and response will be communicated back to the report initiator.
• Records - General record keeping requirement will be communicated to section managers.
• EMS audits - Results of EMS audits are communicated to upper management and relevant section
managers. Training requirements for internal auditors and training schedules are communicated to
relevant ISO section representatives.
• Management Review - The necessary information to carry out the review will be communicated to
senior management.
Facility personnel communicate to Environmental Affairs and other relevant sections regarding the
environmental management systems in the following manner:
• Significant Aspects - New developments that might impact the environmental Impact Assessment
Form.
• Objectives and Targets - Relevant sections will communicate status.
• EMP - Relevant sections will communicate status.
• Structure and Responsibility - Changes in the organizational structure will be communicated from
HR.
• Training Awareness and Competency - Training personnel and reporting results back to E/A.
• Document Control - More specific (section) document control requirements are communicated to
those employees who have responsibility to generate or modify documents.
• Operational Control - Status of controlling the relevant operations (activities).
• Emergency Preparedness and Response - Report emergencies.
• Monitoring and Measuring - Inform E/A of the current monitoring/measuring and calibrations
being done or needing to be done. Report appropriate monitoring and measuring results to E/A.
• Nonconformance Corrective and Preventive Action - Report nonconformances and communicate
new procedures or requirements that are a result of corrective and preventive action.
• Records - Submit Environmental related records to E/A.
• EMS audits - Communicate results within own section and to Environmental Affairs to promote
awareness and to prevent future occurrences.
• Management Review - Communicate results to relevant personnel within own sections.
a. Retention Requirement
This document will be retained until revised.
b. Special Circumstances
None.
c. Measurement of Performance
The performance of this portion of the EMS shall be measured through audits
conducted by internal auditors, audit team and 3rd party auditor of which
certification is acquired.
EXHIBITS
N/A
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Title: PROCEDURES FOR DOCUMENT CONTROL
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
To ensure that all EMS documentation required by the ISO 14001 Standard is established and maintained
so that they can be located, periodically reviewed and kept up-to-date.
To ensure documentation is available at all locations where operations essential to the effective
functioning of the environmental management system are performed.
SCOPE
This policy governs the EMS documentation related to the operations and programs conducted by
[hospital name], located at [insert hospital address].
RESPONSIBILITY
It is the responsibility of the EMS representative and/or designee to maintain the EMS documentation in a
manner consistent with the ISO 14001 requirements.
PROCEDURE
An electronic version of the EMS Policy and Procedure Manual is available to all hospital staff on the
hospital's computer system.
The EMS representative and/or designee is the only individual with open access to the electronic EMS
Policy and Procedure Manual. The EMS representative and/or designee is responsible for maintaining the
electronic version of the manual.
A paper copy of the EMS Policy and Procedure Manual is retained and available for use in the EMS
repre sentative 's office.
Both the paper copy and electronic copy of the EMS Policy and Procedure Manual are "Master"
copies and are maintained by the EMS representative and/or designee.
If a new document supersedes an existing document, the existing document is removed and
recycled by the EMS representative and/or designee.
The EMS representative and/or designee must ensure that "Obsolete" documents are replaced
with dated "Master" copies.
Documents retained for legal and/or knowledge preservation are identified in the Master
Document Control List.
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Versions or specific components of the manual are available to community members and/or staff as
Educational/Informational Tools only.
If at any time, an employee wishes to comment on an EMS procedure, he/she must contact the EMS
representative to request needed changes.
If at any time an employee would like to report a nonconformance, he/she must fill out an Employee
Incidence Report, and/or inform the EMS representative of the occurrence.
The following is documented on the Master Document Control List:
• Identification, location, current revision number, revision schedule and the retention time of key
EMS documents required to ensure compliance with the ISO 14001 Standard.
• Applicable environmental legislation, and/or potential liabilities.
DEFINITIONS
Definitions relating to the content of the EMS are contained in the Glossary.
REFERENCES
ISO 14001-96- Environmental Management System Standard
EPPM-4.4.3- Procedure for Communication
EPPM-4.4.4- Procedure for Environmental Management System Documentation
EPPM-4.5.2- Procedure for Nonconformance and Corrective and Preventative Action.
EXHIBITS
Exhibit 1- EMS-4.4.5-1- Master Document Control List
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Title: DIESEL GENERATOR INSPECTION & TESTING PROCEDURE
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Maintenance, Engineering
Services
Approved By:
Director, Engineering Services
PURPOSE
To ensure the diesel generator is in proper working order, tested and inspected regularly in order to
provide backup power for the hospital.
PROCEDURE
The diesel generator must be tested every week for a maximum of 0.5 hours to ensure the machinery is in
proper working order.
Inform switchboard operators of testing prior to performing any tests.
Perform following testing perimeters on a weekly basis:
Pre-checks of diesel generator:
a) Perform pre-checks & record levels:
- oil level
- coolant level
- battery electrolite level
- battery electrolite level
- block heater
- dip day tank
Starting diesel generator:
a) In lower powerhouse (transfer switch area) perform:
- lamp tests
- turn control switch to "Test" position to start diesel generator
- reset any resulting alarms.
Running tests of diesel generator:
a) Once diesel generator is running perform running checks of the louvres and
battery charger and record the following:
- starts
- lube oil pressure
- lube oil temperature
- coolant temperature
-RPM
- percentage load
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- battery voltage (during test)
- generator voltage phases 1, 2 & 3
- generator amperage phases 1, 2 & 3
- frequency
b) After performing running checks, proceed back to lower powerhouse (transfer
switch) and record:
- normal power voltage phases 1, 2,& 3
- normal power frequency
- emergency power voltage phases 1, 2 & 3
- emergency power frequency
Shutting down diesel generator tests:
a) Prior to the 30-minute mark, turn the control switch to the "Auto" position. (Machine
will run for 5 minutes before it transfers back to normal operating power.) Wait for
power to transfer.
b) Reset any power alarms that may have gone off.
Aboveground storage tanks:
a) Dip aboveground storage tank(s) and record level(s).
b) Visually observe and record condition of tank(s) (e.g., rusting, leakage, other
abnormalities).
c) Ensure all other safety features are working properly.
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Title: SAFE STORAGE OF COMPRESSED GAS CYLINDERS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Health and Safety Specialist
Approved By:
Director, Human Resources
PROCEDURE
Proper Storage:
Store cylinders in a well-ventilated area.
Store cylinders away from fire risk and away from sources of heat or ignition. Mark the area "No
Smoking."
Store cylinders upright, on a firm, level, well-drained surface, and secure cylinder (with chains) to
prevent from falling.
Store nothing else in the cylinder storage area. In particular avoid oil, paint and corrosive or flammable
liquids.
Segregate full and empty cylinders.
Segregate cylinders in the storage area according to gas type (e.g., flammable, inert, oxidizing, toxic,
etc.).
Cylinders containing oxygen or oxidizing gases must be separated from cylinders containing flammable
gases by minimum 3 meters or by a fire resistant partition.
Cylinders containing inert gases may be stored with cylinders containing oxygen or oxidizing gases.
Toxic or corrosive gas cylinders must be stored separately from ALL other gas cylinders. Follow the
instructions on the gas Material Safety Data Sheet.
Propane or butane cylinders must be stored a minimum of 3 meters away from ANY other gas cylinder
type.
Transportation To and From Departments
Move one tank at a time for transporting to and from department(s).
Ensure tanks are tied to wall when they reach their destination points.
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Title: MERCURY SPILL CLEAN-UP AND DISPOSAL
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Supervisor, Housekeeping and
CSR
Approved By:
Environment, Health and Safety
Specialist
PURPOSE
To ensure that mercury spills are cleaned up properly and promptly and disposed of in accordance with
applicable legislation.
POLICY STATEMENT
The hospital is committed to the to the immediate reduction and eventual elimination of mercury.
PROCEDURE
1. Clean-Up
1. In case of a large uncontained mercury spill, call a "Code Brown" (procedure found in
Hospital Policy and Procedure Manual.
2. For a small contained mercury spill, secure spilled area and immediately obtain the
mercury spill kit and a full-faced respirator (with mercury cartridges) from the hospital
spill kit in the Housekeeping Department.
NOTE: Only those individuals who have received fit-testing and fit-checking training are
to use the respirators. If you have not received training call an Environmental Services
personnel.
3. In all cases, wear gloves and a full-face respirator when treating mercury spills.
4. Block the area from foot traffic for a large radius (minimum 6-foot radius) around the
center of the spill site.
5. Check clothing, footwear, bedding, etc. for mercury and mercury debris. Remove
contaminated clothing, footwear, etc. and place at the edge of the spill site.
6. Collect and treat any visible and collectible mercury using VYTAC MIS from mercury
spill kit.
7. Wet the MIS with a water spray and agitate the mixture with a stirring stick or similar tool
to assure that all the mercury is in contact with MIS. In less then a minute, all the mercury
should be amalgamated and solidified. If drops of liquid mercury remain, add more MIS
and repeat the procedure until all the mercury is solidified.
NOTE: It will require approx. 120-150 grams of MIS to treat 100 grams (only 8 ml) of
mercury.
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8. The solidified amalgam is safe to collect using the brush and dust pan that is provided in the
mercury spill kit. The collected residue should be placed in a closed plastic container and clearly
marked as "containing mercury."
9. Store the bucket the hospital's Flammable Storage Room for disposal by a licensed hazardous
waste company.
10. Apply VYTAC MVS to all areas that might be contaminated with mercury particles. Make sure
that crevices, cracks and inaccessible areas are covered. For maximum vapor suppression, it is
recommended that a 3-5 mm coverage be applied.
NOTE: MSV should only be regarded as a temporary solution.
11. MSV will immediately suppress any further generation of vapors. Remove at the earliest
convenience. Contaminated residues should be collected by either sweeping up or the use of a
high filtration (HEPA) vacuum which is available through Engineering Services. The residue
contains mercury and should be disposed of in the same sealed plastic container. MSV darkens as
it becomes contaminated with mercury, indicating its presence.
12. If visible mercury is coated with MSV it can be treated using MIS, following standard procedures.
Caution: A slight hydrogen sulphide odor may develop during the neutralization process.
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Title: PROCEDURE FOR MONITORING AND MEASUREMENT
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
To ensure that the key characteristics of the hospital's operations and activities that can have a significant
impact on the environment are tracked and measured on a regular basis to ensure environmental
compliance and to provide a basis for environmental performance.
SCOPE
This policy governs the operations and programs conducted by (hospital name), located at (insert hospital
address).
DEFINITIONS
Definitions relating to the content of the EMS are contained in the glossary.
RESPONSIBILITY
The EMS representative and/or designee is responsible for establishing and maintaining the monitoring
database on a regular basis.
Department managers/supervisors are responsible for ensuring that regular monitoring of key
characteristics of their departments operations are monitored and documentation is maintained
PROCEDURE
Compliance
An Environmental Compliance Audit will be conducted by the hospital at a minimum of every
three years using the hospital's subscription compliance software program or by an outside
consulting firm to assess regulatory compliance issues relating to all "significant environmental
aspects" and issues identified in previous audits, inspections and assessments.
Monthly workplace safety inspections performed by the members of the Health and Safety
Committee will identify hazards that may have the potential to have negative environmental
impacts. The members of the HSC performing the monthly inspections will relay this
information to the EMS representative through monthly reports/meetings.
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Control of Monitoring and Measurement Equipment
Any equipment used to measure and monitor key characteristics of the environmental
management system is maintained in order to provide confidence in the accuracy of the
measurements. The following outlines the components of the system designed to provide that
confidence.
Department managers/supervisors inform the EMS representative and/or designee when new
measuring and monitoring equipment has been purchased in their departments. The EMS
representative and/or designee enters the information into the Monitoring and Measurement
Documentation Chart.
Operating procedures relating to the calibration and monitoring processes of departmental
equipment are developed and maintained by the department managers/supervisors and/or
designees.
Trained individuals within each department, Engineering Services personnel and/or external
companies perform the calibration of hospital monitoring equipment. Hospital equipment
calibrated by Engineering Services is included in the preventative maintenance computer
program in Engineering Services. Work orders are printed and performed based on the frequency
of calibration for each piece of equipment entered into the system (frequency based on
manufacturers guidelines and/or vendor's recommendations). Records of calibration are placed
on, or in a close proximity to, the piece of equipment undergoing calibration testing and/or are
kept by the external company performing the regular calibration of equipment.
The EMS representative and/or designee periodically reviews the calibration records, to ensure
that the operations are being performed as scheduled. If not, the EMS representative will notify
the department, individual and/or Engineering Services to request that it be done.
Monitoring of Environmental Performance Indicators
The EMS representative and/or designee will compile, on a regular basis, data required for
ensuring objectives and targets are met in the Environmental Performance Indicator Binder.
Data relating to, and/or location of data relating to the key characteristics of the facilities
operations are documented in the Environmental Performance Indicators Binder.
REFERENCES
ISO 14001 - 96 - Environmental Management System Standard
EXHIBITS
Exhibit 1- EMS- 4.5.1-1 Monitoring and Measurement Documentation Chart
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Title: CALIBRATION AND MAINTENANCE OF MONITORING EQUIPMENT
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
PURPOSE
This procedure defines the mechanism and requirements for verification of measurement and testing
equipment used to monitor and control significant environmental aspects.
SCOPE
This policy applies to associated operations and activities conducted by (hospital name), located at (insert
hospital address).
RESPONSIBILITY
N/A
PROCEDURE
The hospital shall identify and list measuring and testing equipment deemed necessary to monitor and
control significant environmental aspects for permitted sources and other appropriate equipment.
The list should include definition of the characteristics, frequencies and location of the equipment
requiring calibration. Verification will be maintained in the using department. All equipment not owned
by (hospital name), such as utility meters, will be calibrated and maintained by the owner.
Approved outside testing organizations may be used to verify measuring and testing equipment at a
prescribed interval.
All other applicable measuring and testing equipment shall be maintained and verified by facilities
personnel according to manufacturer's recommendations/guidelines.
The department manager/supervisor or designee is responsible for maintaining lists, verification and
maintenance records (if any) for equipment in this area.
Any deviations from the proper operation or verification of measuring and testing equipment shall be
reported to the department manager/supervisor and/or the EMS representative for the appropriate actions
to be taken.
Deviations from procedures which affect environmental compliance shall be reported immediately to the
EMS representative.
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DEFINITIONS
N/A
REFERENCES
ISO 14001 - 96 - Environmental Management System Standard
Environmental and Energy Reports
Air Emissions Management
Significant Environmental Aspects
Calibration Matrix of Key Activities
Agency Reporting
Internal Environmental System Audits
EXHIBITS
N/A
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Title: REGULATORY COMPLIANCE AUDITS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
Regulatory Compliance Audits
1. Purpose/Scope
This procedure defines the mechanism for the planning and implementation of regulatory
compliance audits at [hospital name].
2. Activities Affected
All areas and departments
3. Forms Used
3.1 Audit Checklist
3.2 Corrective and Preventive Action Request (CAR)
3.3 Internal Environmental Audit Summary Report
3.4 Audit Schedule
4. References
4.1 Nonconformance and Corrective and Preventive Action
4.2 Environmental Management System Management Review
4.3 ISO 14001:1996, Elements 4.5.1 and 4.5.4
5. Definitions
5.1 Auditee: individual audited.
5.2 Auditor: audit team member performing the audit.
5.3 Audit Criteria: policies, practices, procedures or other requirements against which the
auditor compares objective evidence about the subject matter.
5.4 Audit Program Leader: individual responsible for maintaining the Environmental Audit
Program.
5.5 CAR: corrective and preventive action request that identifies observed nonconformance.
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5.6 Finding: an existing condition supported by objective evidence.
5.7 Nonconformance: the nonfulfillment of specified system requirement.
5.8 Objective Evidence: qualitative or quantitative information, records or statements of fact
pertaining to the existence and implementation of an EMS element, which is based on
measurement or test and which can be verified.
6. Exclusions
None
7. Conducting the Compliance Assessment Audit
7.1 The environmental management representative (EMR) or designee is responsible for
planning, scheduling and implementing internal environmental regulatory compliance
assessment audits, including the identification of necessary resources. These audits
should be objective. Those running the department should not do their own audit (e.g.,
housekeeping should not do the audit for the housekeeping department).
7.2 The EMR or designee develops and maintains the environmental compliance assurance
program and issues program support documents, based on company environmental
compliance assurance guidelines, where available.
7.3 During a compliance assessment audit, assessment team members will record
information, such as: items checked, individuals interviewed, any possible regulatory
noncompliance issues. The assessment team shall promptly notify the EMR or designee
of any possible regulatory noncompliance. Upon verification of noncompliance, the
EMR shall notify facility management.
7.4 The assessment team reviews possible regulatory noncompliance issues with the
responsible and accountable area department representative. The team also prepares a
CAR identifying the issues, necessary corrective and preventive actions and the
individuals responsible for completing the actions. The EMR or designee and area or
department manager will concur with the CAR before its issuance.
7.5 Upon completion of the corrective and preventive action, the area or department manager
will acknowledge completion of these actions by signing the original CAR and returning
it to the EMR or designee.
7.6 A member of the assessment team will verify corrective and preventive actions in a
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timely manner. When full compliance is determined or corrective and preventive
actions are accepted, the assessment team member will sign the original CAR and
return it to the EMR or designee for the closure and filing.
7.7 Each calendar quarter, the EMR or designee will present a summary of open CARs that
are based on regulatory noncompliance to facility management for review.
8. General Rules
8.1 Records, including CARs, that relate to potential or actual noncompliance issues will be
treated as confidential and will be kept separate from those that relate to internal EMS
audits.
8.2 Potential nonconformance issues (Note: a noncompliance is a nonconformance) must
receive prompt attention and timely corrective and preventive action.
8.3 All audit records shall be marked "Environmental Audit Report: Privileged Document"
(U.S. only) and distributed to individuals who need to know their contents in order to
assess, respond to or remedy a potential or actual nonconformance.
9. Records
Records shall be retained consistent with record keeping procedure.
Record of Revisions
Revision Date
Description
Sections Affected
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Title: PROCEDURE FOR NONCONFORMANCE, CORRECTIVE AND PREVENTIVE ACTION
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
1. Purpose
1.1 To ensure that a process is in place to define responsibility and authority for handling and
investigating nonconformances, take action to mitigate resulting impacts and initiate and
complete corrective and preventive action.
2. Scope
2.1 This procedure applies to the operations and programs conducted by (insert hospital
name), located at (insert hospital address).
3. Definitions
3.1 Definitions relating to the content of the EMS are contained in the glossary.
4. Responsibility
4.1 It is the responsibility of the EMS representative and/or designee to:
• Lead the Environmental Auditing Team to find hospital nonconformances.
• Investigate the occurrence of nonconformances.
• Aid in the development, follow through and evaluation of corrective/preventive actions in
consultation with the department managers/supervisors.
• Revise EMS procedures as a result of nonconformances.
• Organize staff retraining when necessary.
4.2 It is the responsibility of the department managers/supervisors to:
• Verify the occurrence of nonconformances within their departments.
• Identify and follow through with corrective/preventive actions.
• Evaluate the effectiveness of the corrective/preventive actions taken.
• Prevent reoccurrence of nonconformances.
5. Procedure
5.1 Nonconformances can be identified by:
• Internal/external audits
• Compliance audits
• Regulatory inspections
• Observation by staff members
• Internal/External communications
• Review of emergency preparedness and response procedures after the occurrence of a
spill or environmentally related accident
• Management review process
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5.2 Nonconformances not identified through an EMS Audit are to be recorded on the
hospital's current Employee Incident Reporting Form, and/or an employee can contact
the EMS representative to report the nonconformance. (This will be documented on an
Employee Incident Reporting Form.
5.3 When the EMS Internal Auditing Team finds a nonconformance during an audit, the
nonconformance is formalized and documented in the EMS Audit Report. Identified
nonconformances are also documented on the Nonconformance Corrective Action Report
and sent to the associated department managers/supervisors for remediation.
5.4. The EMS representative and/or EMS Internal Auditing Team conducts an initial severity
evaluation of the nonconformances identified to determine if it is a MAJOR or MINOR
nonconformance:
• MAJOR- a serious, possibly reoccurring deficiency within the EMS that adversely
affects the hospital (e.g., a missing requirement of the ISO 14001 standard, and/or a
system is not functioning as it is documented).
- Requires documented corrective and preventive actions.
• MINOR- an isolated deficiency in the functioning of a system that does not affect the
performance of the hospital's overall EMS (e.g., a documented procedure is not
followed consistently, and/or a part of a procedure is missing).
- May not require documented corrective and preventive actions."
(Taken from St. Mary's General Hospital's EMS, Kitchener, Ontario, Canada, 2001)
5.5 The EMS representative and/or associated department managers/supervisors address
major and minor nonconformances as they occur.
5.6 For major nonconformances, the associated department manager/supervisor, EMS
representative, and/or other responsible position identifies and documents corrective and/
or preventive actions in the "Correction" section of the Employee Incident Reporting
Form. Proposed actions, responsibilities and target dates are to be included in this
corrective and/or preventive action plan.
5.7 The EMS representative and/or a management representative approves corrective and/or
preventive actions.
5.8 Department managers/supervisor and/or delegated departmental staff follow through
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with identified corrective/preventive actions.
5.9 If the nonconformance relates to EMS documentation or legislative and other
requirements, the EMS representative will proceed with the identified corrective and/or
preventive actions.
5.10 The EMS representative conducts a follow-up inspection/audit/review to determine if
corrective/preventive action(s) has been completed and is effective.
5.11 If hospital staff identified the nonconformance, the EMS representative will report
progress back to the initiating staff member within two weeks.
6. References
ISO 14001 - 96 - Environmental Management System Standard
EMS-4.3.2- Procedure for Legal and Other Requirements
EMS-4.4.3- Procedure for Communication
EMS- 4.3.7-Procedure for Emergency Preparedness and Response
EMS- 4.5.1- Procedure for Monitoring and Measurement
EMS-4.5.4 Procedure for Environmental Management System Audits
EMS-4.6 Procedure for Management Review
7. Exhibits
N/A
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NONCONFORMANCE/RECOMMENDATIONFORM
As per the Nonconformance, Corrective and Preventative Action of the hospital's
Environmental Management System (ISO 14001), all *major nonconformances identified
through the process of internal inspections (performed by the EMS Internal Auditing
Teams) must be documented, have corrective/preventative actions identified,
responsibilities designated and timelines set for remediation.
Department: ENGINEERING SERVICES/LABORATORY
Program Manager/Supervisor: BILL JONES
Return Form To: EMS REPRESENTATIVE
By Date: (2 weeks from Audit Date) APRIL 15, 2002
Audit Team: SALLY WILSON, JOE PALMER, MELISSA SMITH, PAUL TAIT
Audit Date: APRIL 1, 2002
Nonconformance
(Site section of Standard/
EMS in contravention)
Recommendation(s)
Corrective/
Preventative Actions
Dates of Completion
4.3.1-Aspects and
Impacts Manager audited
were unaware of their
responsibilities to update
the aspects list annually.
Increase awareness
through education
(managers meetings and
emails).
Attended Manager's
Meeting on May 23,
2002 to discuss
Aspects updating
process. Managers
were given a copy of
their department and
are to respond with
any changes by June
30, 2002.
May 23, 2002 -
Managers Meeting
June 30, 2002-
Receive all updated
aspects list
July 19, 2002 (have
aspects list updated).
4.3.1-Aspects and
Impacts
Managers were unaware
of their responsibilities to
inform the EMS
Representative of any new
products/equipment that
may have a significant
impact on the
environment.
Increase awareness
through education
(managers meetings and
emails).
Same as above
Same as Above
* Major Nonconformance. a serious, possibly reoccurring deficiency that adversely
affects the Hospital, a missing requirement of the CAN/CSA ISO 14001: 1996 Standard,
a system is not functioning as it is documented. Requires documented corrective or
preventative actions.
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Problem Identified: June 2001
Resolution Due Date: July 2001
Problem Identified By: Laboratory Supervisor
Problem (described existing or anticipated problem): EMS Management Team failed to
conduct a cost-benefit analysis on implementation of new chemical tracking and
inventory system, which was identified as an action item during the first quarter EMS
steering committee meeting. Original due date for analysis was May 1, 2001.
Most Likely Cause(s):
• EMS Management Team focused on preparing for regulatory compliance audit during
June 2000.
• Laboratory did not follow-up with EMS Management Team.
• Lack of information to estimate costs of implementing system above.
Possible Solution(s):
* Schedule working meeting between laboratory stall and EMS Cost-Benefit
Analysis team.
• Research chemical tracking and inventory systems (assign to laboratory staff)
• Report to EMS Management Team.
Implemented Solution (s):
Due Date: July 2001 Completed: July 2001
• Laboratory staff researched existing chemical tracking and inventory systems and
reported to EMS Management Team on June 30, 2001.
• Laboratory and EMS cost-benefit team met on July 7. 2001 to discuss findings.
• EMS Management Team completed cost-benefit analysis on July 15, 2001 and plans to
implement new systems are being determined cooperatively between laboratory staff and
EM'S team.
Resolution (confirm effectiveness of i m pi em en ted solutions):
Responsible Pefson Effective Date
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Problem Identified: May 25, 2001
Resolution Due Date: May 30, 2001
Problem Identified By: Hazardous Waste Management Staff
Problem (described existing or anticipated problem) Requires Corrective Action:
Four of 17 drums of hazardous waste stored in storage area B behind the Maintenance
Building were improperly labeled; one had no waste accumulation start date, two had no
waste description, and one had no label.
Most Likely Cause(s):
• New employee in Maintenance Building started at the beginning of May and didn't
receive training during first week of work.
• Laboratory where new employee works didn't receive phone number for waste
management department to receive support in handling and storing waste.
• Supply of labels was low and existing labels were old and ineffective.
Possible Solution(s):
• Schedule and complete training for new employee(s).
• Meet with all laboratory managers in Maintenance Building to review hazardous waste
management procedures.
• Provide new supply of labels and phone number magnets.
Implemented Solution(s):
Due Date: May 30 Completed: May 30
• Trained new employee May 28
• Conducted meeting with laboratory manager May 28
• Resupplied labels and magnets May 30
Resolution (confirm effectiveness of implemented solutions): Maintenance Building
staff has been trained/briefed on hazardous waste handling procedures and no further
deficiencies have been noted for 3 months. (Dates September 1, 2001)
Responsible Person Effective Date
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Tier 0000
System Administrative
o
o'
a
"g
Site/Dept.:
Date:
Audit Report and Corrective Action Summary
it Scope:
(Organizational units, activities and processes to be
audited)
Audit Criteria:
(Set of policies or requirements)
Audit Report (To be completed by internal auditor)
Corrective Action Summary (To be completed by dept. manager within 30 days)
*CAR#
Standard or
Regulation
Issues/Findings
Action Plan
Opportunities for Preventive Action Identified:
Responsible Person
Target
Date
Status
of CAR
Date
completed
Comments/ Areas of Strength:
Auditor Signature/Date:
*Assign Corrective Action Request (CAI) # by hospital prefix (DRH, HTZ, HUH, CHM, SG, HVSH, ffl), then dept. (PHA, LAB, EPI, RESP), then two digit month, two digit date, two digit year and CAR # as 01,02,03...)
Date completed: Manager or auditor has verified that the action plan is complete and effective.
Revision 10/24/02 This is a Confidential Professional/PEER Review Document of (insert hospital name). It is protected from disclosure pursuant to the Provisions ofMCL 333.20175, MCL 333.21515, MCL 331.531 and MCL 331.533. UNAUTHORIZED
DISCLOSURE OR DUPLICATION IS ABSOLUTELY PROHIBITED. If you receive this transmission in error, immediately contact the sender and destroy the material in its entirety, whether in electronic or hard copy format.
-------
Title: EMS RECORDKEEPING PROCEDURE
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
PURPOSE
This procedure is used to maintain EMS records.
Stepl
Step 2
Step 3
The EMS manager and other personnel selected by the EMS manager are responsible for
identifying records that are maintained by the hospital as part of the EMS.
Step 4
StepS
The EMS manager and other
personnel will maintain all
records in a single location.
The EMS manager and other
personnel will maintain a
document index of all records
that are maintained as part of the
EMS, the data and person
responsible for the length of
retention for each type of
record.
The EMS manager and other
facility personnel will identify
and note on the document
index any restrictions on
records necessary for security.
The EMS manager and other
facility personnel will review
the records and purge obsolete
records at least every (insert
time frequency appropriate for
your hospital and circumstances).
Types of Records To Maintain (Examples):
Legal, regulatory and other code requirements
Results of environmental aspects identification
Reports of progress toward meeting objectives
and targets
Permits, licenses and other approvals
Job descriptions and performance evaluations
Training records
EMS audit and regulatory compliance audit
reports
Reports of identified nonconformities,
corrective action plans and corrective action
tracking data
Hazardous material spill/other incident reports
Communications with customers, suppliers,
contractors and other external parties
Results of management reviews
Sampling and monitoring data
Maintenance records
Equipment calibration records
Responsible Person:
Signature and Date:
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ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
Complete all applicable audit items. S = Satisfactory, D = Deficient.
Document evidence and comments. Standards being audited:
Auditors:
Date:
(S)
(D)
Item
4.2 Environmental Policy
a) Staff can correctly verbalize Environmental
Policy (prevention of pollution, compliance
with legal requirements, and continuous
improvement)
b) Environmental Commitment/Policy is posted
4.3 Planning
4.3.1 Environmental Aspects
a) Staff can identify environmental aspects for
their department. (Reference: Master
Environmental Aspect List)
b) Staff has knowledge of how to handle
significant environmental aspects in their area.
4.3.2 Legal and Other Requirements
a) Dept. manager can correctly verbalize
regulatory requirements that are applicable to
their department.
b) Dept. operations are compliant with
regulatory requirements (e.g., JCAHO, CMS,
NFPA, EPA, OSHA/MIOSHA).
c) Compliance with relevant environmental
legislation and regulations has been periodically
evaluated. (4.5.1)
4.3.3 Objectives and Targets
a) Dept. manager and staff can speak to hospital
system EMS objectives [prevention of pollution
(recycling), generation and handling of medical
waste, handling and disposal of chemotherapy
waste].
b) Progress on system objectives and targets
have been reported at EOC and/or LPICC
meetings.
4.3.4 EMS Programs
a) Managers have knowledge/awareness of
system EMS objectives and targets.
b) Copies of tracking forms have been
maintained at each site (Safety Officer, LPICC,
and or EOC Committee).
c) Managers and staff can speak to
environmental measures or indicators tracked
within the department.
Evidence/Comments
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ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
Complete all applicable audit items. S = Satisfactory, D = Deficient.
Document evidence and comments. Standards being audited:
Auditors:
Date:
(S)
(D)
Item
4.4.1 Structure and Responsibility
a) Staff correctly verbalize that environmental
concerns are referred to the site safety officer
(EMS management representative).
b) Resources to implement and maintain the
EMS have been provided (human,
technological, financial).
4.4.2 Training, Awareness & Competence
a) Training needs/competencies have been
identified and effective training has been
provided (competency records/employee files).
b) Employees demonstrate awareness of:
• Department procedures.
• Significant environmental impacts,
actual or potential, associated with their
work activities.
• The environmental policy, emergency
preparedness procedures and responses
required.
• Risks associated with deviating from
environmental and safety
policy/procedures.
4.4.3 Communications
a) Internal communication is effective: staff has
knowledge of how to report environmental
concerns, understand how to report concerns via
the Compliance Hotline.
b) External communication phone logs have
been kept up to date, and issues are addressed.
4.4.4 EMS Documentation
4.4.5 Document Control
a) Master document control list references
departmental documents and procedures
necessary for an effective EMS.
b) Documents and posted instructions are dated
and have been approved (manager's
initials/signature).
c) Master document control list has been
updated.
d) Documents not in use are removed from use
and labeled "obsolete," or "for reference only"
or "retired."
Evidence/Comments
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ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
Complete all applicable audit items. S = Satisfactory, D = Deficient.
Document evidence and comments. Standards being audited:
Auditors:
Date:
(S)
(D)
Item
4.4.6 Operational Controls
a) Employees can access on-line policies.
b) Department procedures for managing
significant environmental aspects have been
established and implemented.
c) Policies and procedures have been
communicated to suppliers and contractors.
4.4.7 Emergency Preparedness and Respons
a) Staff has knowledge of Emergency policies
and procedures, know what action to take in an
emergency.
b) Emergency codes and drills have been tested.
4.5.1 Monitoring & Measurement
a) Environmental Rounds have been conducted
as scheduled; results have been documented.
b) Monitoring equipment has been calibrated as
scheduled; records are retrievable.
4.5.2 Nonconformances/Corrective &
Preventive Action
a) Staff has knowledge of how to report an
incident or nonconformance (safety
officer or Compliance Hotline).
b) Corrective and preventive actions are
appropriate to the nature and magnitude
of the problem identified (e.g., critical
problems are addressed promptly with
action to prevent recurrence).
4.5.3 Records
a) Environmental records are stored and
retained as stated in 1 CG 017. (Where
applicable, regulatory requirements may dictate
retention period.)
b) Records are retrievable.
c) Records are stored to protect from loss and/or
damage.
4.5.4 EMS Audit
a) Internal monitoring (audit) results are
maintained and retrievable.
b) Action plans are documented and have been
implemented. Action plans are effective.
Evidence/Comments
e
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ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
Complete all applicable audit items. S = Satisfactory, D = Deficient.
Document evidence and comments. Standards being audited:
Auditors: Date:
(S)
(D)
Item
4.6 Management Review
a) Management review has been conducted at
least annually.
b) Management review includes:
• Internal audit results
• Changes in EMS policy, objectives or
other elements of the EMS
• A review of the EMS for continued
suitability, adequacy and effectiveness.
c) Management Review is documented; records
are retrievable.
Evidence/Comments
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Possible Sources of Mercury
Thermometers
Body temperature thermometers
Clerget Sugar test thermometers
Heating and cooling system
thermometers
Incubator/water bath thermometers
Minimum/maximum thermometers
National Institute of Standards and
Technology calibration
thermometers
Tapered bulb (armored) thermometers
Sphygomanometers
Gastrointestinal tubes
Cantor tubes
Esophageal dialators (bougie tubes)
Feeding tubes
Miller Abbott tubes
Dental amalgam
Pharmaceutical supplies
Contact lens solutions and other
ophthalmic products containing
thimerosal, phenylmercuric nitrate
Diuretics with mersalyl and mercury
salts
Early pregnancy tests kits with mercury
containing preservatives
Merbromin/water solution
Nasal spray with thimerosal,
phenylmercuric acetate or
phenylmercuric nitrate
Vaccines with thimerosal (primarily in
hemophilus, hepatitis, rabies,
tetanus, influenza, diphtheria and
pertussis vaccines)
Batteries for medical use
Alarms
Blood analyzers
Defibrillators
ECG monitors
Fetal monitors
Hearing aids
Hofler monitor
Meters
Monitors
Oxygen monitors
Pacemakers
Pumps
Scales
Telemetry transmitters
Ultrasound
Ventilators
Lamps
Fluorescent
Germicidal
High-intensity discharge (high pressure
sodium, mercury vapor, metal halide)
Ultraviolet
Tilt switches
Air flow/fan limit control
Building security systems
Chest freezer lids
Fire alarm box switches
Lap top computer screen shut-off
Pressure control (mounted on bourdon
tube or diaphragm)
Silent light switches (single pole and
three way)
Temperature control
Washing machine power shut off
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Float control
Septic tanks
Sump pumps
Thermostats (nondigital)
Thermostat probes in electrical
equipment
Reed Relays (low voltage, high precision
analytical equip)
Plunger or displacement relays (high
current/high voltage)
Thermostat probes
Gas Appliances
Flame sensors
Gas safety valves
Pressure gauges
Barometers
Manometers
Vacuum gauges
Chemicals that contain mercury
Acetic Acid
Alum hematoxylin (Solution A)
Ammonium reagent/Stone Analysis kit
Antibody test kits
Antigens
Antiserums
B5 fixative
Buffers
Bleach solutions containing sodium
hypochlorite
Cajal's
Calibration kits
Calibrators
Cameo
Carbol Gentain violet
Chloride
Carnoy-Lebrun solution
Diluents
Enzyme Immunoassay test kits
Enzyme tracers
Ethanol
Extraction enzymes
Fixatives
Gomori's
Golgi's
Chemicals that contain mercury cont.
Gram Iodine
Helly solution
Hematology reagents
Hitergent
Hormones
Immunoelectrophoresis reagents
Immunofixationphoresis reagents
Immun-sal
Mercury chloride
Mercurochrome
Mercurophyline
Mercury iodide
Mercury nitrate
Mercury sulfate
Merthiolate
Million's reagent
Mucolex
Negative control kits
Nessler's solution
Ohlamacher
Phenobarbital reageant
Phenol Mercuric Acetate
Phenytoin reagent
Positive control kits
Potassium hydroxide
Pregnancy test kits
Rabbit serum
Shardin Solution
Shigella bacteria
Sodium hypochlorite
Stains
Stabilur Tablets
Standards
Takata's reagent
Thimerosal
Tracer kits
Urine analysis reagents
Wash solutions
Zenker solution
Other
Devices, such as personal computers that
utilize a printed wire board
Blood gas analyzer reference electrode
(Radiometer brand)
Cathode-ray oscilloscope
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Other continued
DC watt hour meters (Duncan)
Electron microscope (mercury may be
used as a damper)
Flow meters
Generators
Hitachi Chem Analyzer reagent
Lead analyzer electrode (ESA model
301 OB)
Sequential Multi-Channel Autoanalyzer
(SCMA) AU 2000
Vibration Meters
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Polyvinyl Chloride (PVC) Products in Hospitals
Blood Products and Transfusions: apheresis circuits, blood bags and tubing,
extracorporeal membrane oxygenation ciruits
Collection of Bodily Fluids: dialysis, peritoneal: drainage bags, urinary collection
bags, urological catheters, and irrigation sets, wound drainage systems
Enteric Feeding Products: enteric feeding sets, nasogastric tubes, tubing for breast
pumps
Gloves
Intravenous (IV) Therapy Products: catheters, solution bags, tubing
Kidney (Renal Disease) Therapy Products: hemodialysis: blood lines and catheters,
peritoneal dialysis
Packaging, Medical Products: film wrap, thermoformed trays for admission and
diagnostic kits, and medical devices
Patient Products: bedpans, cold and heat packs and heating pads, inflatable splints and
injury support packs, patient ID cards and bracelets, sequential compression devices
Respiratory Therapy Products: aerosol and oxygen masks, tents, and tubing,
endotracheal and tracheostomy tubes, humidifiers, sterile water bags and tubing, nasal
cannulas and catheters, resuscitator bags, suction catheters.
Office Supplies: notebook binders, plastic dividers in patient charts
Durable Medical Products: testing and diagnostic equipment, including instrument
housings
Furniture Products and Furnishings: bed casters, rails and wheels, floor coverings,
furniture upholstery, inflatable mattresses and pads, mattress covers, pillowcase covers,
shower curtains, thermal blankets, wallpaper, window blinds and shades
Construction Products: doors, electrical wire sheathing, water and vent pipes, roofing
membranes, and windows
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- APPENDIX B -
ADDITIONAL RESOURCES
Table of Contents
PAGE No.
I. Compliance Resources 158
Web sites 158
• Other Compliance Resources 158
II. Environmentally Preferable Purchasing (EPP) Resources 159
Web sites 159
III. Energy Efficiency Resources 160
Web sites 160
IV. Environmental Management Accounting Resources 161
• Guides, Articles and Manuals 161
Web sites 161
V. Small Business Resources 162
VI. General Pollution Prevention Resources 170
Check Lists 170
Fact Sheets 170
Guides 170
• Manuals 171
Reports 172
• Compact Disc 173
Web sites 173
VII. Water Permits/Effluent Limits 176
• Factor 2 Screening Level Information on the Health Care Industry 176
• U.S. Department of the Interior Geological Survey 180
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I. Compliance Resources
Web sites
Health Care Compliance Association
HCCA's mission is to champion ethical practice and
compliance standards in the health care community
and to provide the necessary resources for
compliance.
http: //www.hcca-info .org/
Health Care Corporate Compliance Supersite
Complianceinfo.com provides compliance news,
newsletters and other resources to covering a variety
of general hospital compliance issues.
http://www.hcpro.com/corporate-compliance/
National Compliance Assistance Centers
The U.S. EPA sponsors partnerships with industry,
academic institutions, environmental groups and
other agencies to launch sector-specific Compliance
Assistance Centers. Each Compliance Assistance
Center addresses real-world issues in language that
speaks to the regulated entities.
http://www.assistancecenters.net/
A new compliance assistance center for the health
care sector will be available in the first quarter of
2005. http ://www.hercenter.org
National Environmental Assistance Clearinghouse
This Web site provides easy access to compliance
assistance tools, contacts and planned activities from
the U.S. EPA, its partners and other compliance
assistance providers.
http://cfpub.epa.gov/clearinghouse/
U.S. EPA's Oil Spill Program Web site
The U.S. EPA's program for preventing, preparing
for and responding to oil spills that occur in and
around inland waters of the United States.
http://www.epa.gov/oilspill/
U.S. EPA's NPDES Web site
Provides technical and regulatory information about
the National Pollutant Discharge Elimination System
(NPDES) permit program, which controls water
pollution by regulating point sources (e.g., pipe,
ditch) that discharge pollutants into waters of the
United States, http://cfbub.epa.gov/npdes/
Code of Federal Regulations
Database of the Code of Federal Regulations (CFR)
http://www.gpoaccess.gov/ecfr/
Other Compliance Resources
American Hospital Association (AHA)
The American Hospital Association (AHA) is a
national trade organization that represents hospitals,
health care networks, patients and the communities
they serve. As many as 5,000 institutions and 40,000
individuals belong to the AHA. The AHA's mission
is to advance the health of individuals and
communities.
AHA provides representation and advocacy
activities to ensure that members' perspectives are
addressed in national health policy development,
legislative and regulatory debates and judicial
matters. In addition, AHA provides resources to help
health care leaders implement change at the
community level. The AHA helps hospitals and
other health care providers form networks for patient
care. AHA conducts research and demonstration
projects; provides educational programs; performs
data gathering and information analysis to support
policy development and track trends and keeps
members informed of national developments and
trends and their impact on local communities.
The AHA also works for its membership to track
international and federal rule-making to educate
members of the health care community on the
potential impact of new legislation and regulatory
initiatives, http://www.aha.org
Clean Air Technology Center (CATC)
The Clean Air Technology Center (CATC)
serves as a resource in all areas of emerging and
existing air pollution prevention and control
technologies and provides public access to data and
information on their use, effectiveness and cost. The
CATC also provides technical support, including
access to the U.S. EPA and other government
agencies as resources allow, related to the technical
and economic feasibility, operation and maintenance
of these technologies, http: //www.epa. gov/ttn/catc/
or call 919-541-0800. For publications, call 919-
541-2777.
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Hospitals for a Healthy Environment (H2E)
The Hospitals for a Healthy Environment (H2E)
is a voluntary program, which was formed as a result
of the American Hospital Association and the U.S.
EPA's Memorandum of Understanding (MOU) dated
June 24, 1998.
This landmark agreement calls for:
• Elimination of mercury-containing waste
from health care facilities' waste streams by
2005.
• Reduction of the overall volume of waste
(both regulated and nonregulated waste) by
33 percent by 2005 and by 50 percent by
2010.
• Identification of hazardous substances for
pollution prevention and waste reduction
opportunities, including hazardous chemicals
and persistent, bioaccumulative and toxic
pollutants (PBT).
The Hospitals for a Healthy Environment
program helps health care facilities enhance
workplace safety, reduce waste and waste disposal
costs and become better environmental stewards and
neighbors. This is done by educating health care
professionals about pollution prevention
opportunities in hospitals and health care systems.
Through such activities as the development of
best practices, model plans for total waste
management, resource directories and case studies,
H2E provides hospitals and health care systems with
enhanced tools for minimizing the volumes of waste
generated and the use of persistent, bioaccumulative
and toxic chemicals (PBT). Such reductions are
beneficial to the environment and community health.
Furthermore, improved waste management practices
reduce industry waste disposal costs.
To take advantage of the opportunities the H2E
program offers, visit the H2E Web site http://
www.h2e-online.org and/or participate in one of the
H2E programs as either a partner or champion.
Partners are health care facilities who commit to
making changes in their facilities that protect
community and environmental health. Champions
are organizations that encourage and aid health care
facilities to participate as H2E partners and/or who
make changes in their own institutions that support
the goals of the H2E program. Partners and
champions receive local and national recognition for
the work they do to reduce waste and protect the
environment through the H2E recognition and
awards program.
Visit the H2E Web site for a complete list of
current partners and champions; tools and resources
including many items such as mercury, green
buildings and green purchasing; environmental
management systems; technical resources with links
to mercury recyclers and consultants and vendors;
news and events; videos and much more.
http://www.h2e-online.org
II. Environmentally Preferred Purchasing (EPP) Resources
Web sites
APIC Guideline For Selection/Use of
Disinfectants
The Association for Professionals in Infection
Control and Epidemiology (APIC) assists health care
professionals in selecting and using specific
disinfectants.
http://www.apic.org
U.S. EPA's Environmentally Preferable
Purchasing (EPP) Web site
Among the tools on this Web page include EPP
general training tools, a database of information of
contacts for environmentally preferable products and
services and a practices guide for "greener"
contracts.
http: //www. epa. go v/oppt/epp/
EPP Database
A tool to make it easier to purchase products and
services with reduced environmental impacts.
Environmental information on more than 600
products and services is included in this database.
http ://yosemite .epa. gov
EPP Newsletter
This monthly newsletter provides updates on health
care environmental purchasing innovations from
across the country.
http://www.epa.gov/epp/pubs/
update 13_final_l 24 .pdf
Health Care Purchasing News Online
http://www.hpnonline.com/
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Green Seal Standard
Green Seal is a labeling standard for industrial and
institutional cleaning products. The standard helps
users and purchasers of cleaning chemicals select
products that clean effectively while minimizing
negative health and environmental effects.
http: //www. greenseal. org/standards .htm
INFORM, Inc
Provides a report on changing to green janitorial
products. Has large list of green cleaning products
that are reviewed by existing state or local
government green cleaning programs. Contains
vendor information.
http://www.informinc.org/cleanforhealth.php
The Nightingale Institute for Health and the
Environment
This Web page provides resources including
manuals, news and tools for environmentally
preferable health care purchasing called the HCEPT
Tool.
http://www.nihe.org/
Zero Waste Alliance - Unified Green Cleaning
Alliance
Promotes credible and reliable criteria to distinguish
cleaning product formulations that perform and are
preferable with respect to human and environmental
health. Such products are referred to as "sustainable"
or "eco-effective."
http://www.zerowaste.org/ugca.htm
III. Energy Efficiency Resources
Web sites
Energy Efficiency in Health Care Facilities: A
Hot Opportunity to Chill
Philip J. Kercher. September 1999. Available
through the American Hospital Association (800)-
242-2626 or the hyperlink below. The manual
describes preventive maintenance, performance
contracting and energy management teams as
component of successful energy management.
Reviews three programs along with costs and
benefits.
http://www.ahaonlinestore .com/
Managing Utility Cost in a Health Care Facility
Michael Brian Cotton. August 1999. Available
through the American Hospital Association (800)
242-2626 or visit the American Hospital Association
Web site at the hyperlink below. The manual
describes energy controls and management
opportunities available to hospital facility managers.
http: //www. ahaonline store .com/
Energy Savings in Hospitals
Caddett Analyses Series 20. June 1996. Available
for purchase through the American Council for an
Energy Efficient Economy.
http://www.aceee.org/index.htm
EnergyStar for Hospitals
An easy way to evaluate and compare energy
performance against others across the country.
http://www.energystar.gov/
index.cfm?c=healthcare.bus healthcare
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IV. Environmental Management Accounting Resources
Guides, Articles and Manuals
Accounting and Capital Budgeting for Pollution
Prevention
Martin A. Spitzer, Robert Pojasek, Francis L.
Robertaccio, Judith Nelson. Pollution Prevention in
South Carolina. Winter 1996
http: //www.umich. edu/~nppcpub/re sources/Re sLists/
acctlistl.html
An Introduction to Environmental Accounting as
a Business Management Tool: Key Concepts and
Terms
U.S. EPA, Design for the Environment Program,
Environmental Accounting Project
http://www.greenbiz.com/toolbox/
reports Jhird.cfm?LinkAdvID=13759
Total Cost Assessment: Accelerating Industrial
Pollution Prevention Through Innovative Project
Financial Analysis
U.S. EPA Office of Pollution Prevention. May 1992
http://www.epa.gov/reg3rcei/genlib/pollprev.htmtfTB
Web sites
Environmental Management Accounting Network
A network of researchers, consultants,
businesspeople and policy advisors interested in
environmental management accounting as a tool for
corporate environmental management.
http://www.emawebsite.org/
Environmental Management Accounting
Research and Information Center
A source of comprehensive information in
environmental management accounting for the
international community.
http://www.emawebsite.org/about_emaric.htm
Tellus Institute, Business and Sustainability to
Environmental Management Accounting
Tellus environmental management accounting
projects have covered booth the materials and cost
accounting aspects of environmental management
accounting for a wide variety of applications such as:
Capital Budgeting and Project Profitability
Assessment; Pollution Prevention and Cleaner
Production; Environmental Supply Chain
Management; Environmentally Preferable
Purchasing; and Environmental Management
Systems.
http: //www.tellus. org/
United Nations Sustainable Development
Environmental Accounting Initiative
Background information on environmental
management accounting.
http://www.un.org/esa/sustdev/sdissues/technology/
estemal.htm
U.S. EPA's Design for the Environment
One of the U.S. EPA's premier partnership programs,
working with individual industry sectors to compare
and improve the performance, human health,
environmental risks and costs of existing and
alternative products, processes and practices.
http: //www.epa. gov/dfe/
EMS Primer for Federal Facilities
Informative guide on EMS for federal facilities.
http://nepa.fhwa.dot.gOv/ReNEPA/ReNepa.nsf/0/
a6399e41bab0239085256fl5004e2562?QpenDocument
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V. Small Business Resources
ALABAMA
Gary Ellis, (SBO)
Office of Education and Outreach
AL Department of Environmental
Management
P.O. Box 301463
Montgomery, AL 36130-1463
(334) 394-4352
(334) 394-4383 (F)
(800)533-2336
mailto:gle@adem.state.al.us
Mike Sherman (SBAP)
Air Division
AL Department of Environmental
Management
P.O. Box 301463
Montgomery, AL 36130-1463
(334)271-7873
(334) 279-3044 (F)
(800)533-2336
mailto:mhs@adem.state.al.us
ALASKA
Bill Smyth (SBO)
AKDEC
610 University Avenue
Fairbanks, AK 99709
(907)451-2177
(907) 451-2188 (F)
(800) 520-2332
mailto :Bill_smy th@dec. state .ak.us
ARIZONA
Brian Davidson (SBO)
Deputy Director
Air Quality Division
1110 West Washington Street
Phoenix, AZ 85007
(602) 771-2365
(800) 234-5677
mailto:domsky.ira(S!ev.state.az.us
Emily Bonanni (SBAP)
Compliance Section
Air Quality Division
1110 West Washington Street
Phoenix, AZ 85007
(602)771-2324
(800)234-5677
mailto:Ebl@state.az.us
MARICOPA COUNTY
Richard Polito (SBAP)
Maricopa County SBEAP
1001 N. Central, Suite 500
Phoenix, AZ 85004
(602)506-5102
(602) 506-7303 (F)
mailto :rpolito@mail.maricopa.gov
ARKANSAS
Ron Alexander (SBO)
Department of
Environmental Quality
P.O. Box 8913
8001 National Drive
Little Rock, AR 72219-8913
(501)682-0866
(501) 682-0880 (F)
(888)233-0326
mailto: alexander@arb .ca.gov
CALIFORNIA
Kathleen Tschogl (SBO)
Ombudsman
Air Resources Board
10011 Street
P.O. Box 2815
Sacramento, CA 95814
(916)323-6791
(916) 322-4737 (F)
(800) 272-4572
mailto:ktschogl@arb.ca.gov
Terrell D. Feirra (SBAP)
Air Resources Board
10011 Street
P.O. Box 2815
Sacramento, CA 95 814
(916)322-2467
(916) 322-4737 (F)
mailto :tferreir@arb .ca.gov
SOUTH COAST
Anupom Ganguli (SBO)
Public Advisor
South Coast Management District
Small Business Ombudsman
21865 E.Copley Drive
Diamond Bar, CA 91765
(909)396-3185
(909) 396-3335 (F)
(800)388-2121
Larry Kolczak (SBAP)
Community Relations Manager
South Coast Air
Management District
Small Business Assistance Office
21865 E.Copley Drive
Diamond Bar, CA 91765
(909)396-3215
(909) 396-3638 (F)
(800)388-2121
(800) CUTSMOG
mailto: Lkolczak@aqmd .gov
COLORADO
Nick Melliadis (SBO)
CDPHE
OCSINFA1
4300 Cherry Creek Drive
South Denver, CO 80246-1530
(303)692-2135
(303) 691-1979 (F)
(800)886-7689
mailto:nick.melliadis@state.co.us
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Joni Canterbury (SBAP)
CDPHE
APCD/55/B1
4300 Cherry Creek Drive
South Denver, CO 80246-1530
(303)692-3175
(303) 782-0278 (F)
mailto:joni.canterbury@state.co.us
CONNECTICUT
Robert Kaliszewski (SBO)
Small Business Ombudsman
Department of Environmental
Protection
79 Elm Street
Hartford, CT 06106-5127
(860) 424-3003
(860) 424-4153 (F)
mailto:robert.kaliszewski@po.state.ct.us
JoAnn Smith (SBAP)
Permit Assistance Office
CT Department of Environmental
Protection
79 Elm Street
Hartford, CT 06106-5127
(860) 424-3003
(860)424-4153
mailto:joann.smith@po.state.ct.us
DELAWARE
Kim Finch (SBO)
DE DNRC
89 Kings Highway
Dover, DE 19901
(302) 739-6400
(302) 739-6242 (F)
mailto :kimberly. fmch@state. de .us
DISTRICT OF COLUMBIA
Sandra Handon (SBO)
DC Dept. of Health/EHA
Air Quality Division
51 N Street, N.E., 5th Floor
Washington, DC 20002
(202)535-1722
(202)535-1371(F)
mailto: sandra.handon@dc.gov
Olivia Achuko (SBAP)
Air Quality Division
EHA/Department of Health
51 N Street, NE, 5th Floor
Washington, DC 20002
(202)535-2997
(202)535-1371(F)
mailto:olivia.achuko@dc.gov
FLORIDA
William Davis (SBO)
Small Business Ombudsman
Bureau of Air Monitoring and
Mobile Sources
Division of Air Resources
Management
2600 Blair Stone Road, MS5510
Tallahassee, FL 32399-2400
(850)921-9580
(850) 922-6979 (F)
(800) 722-7457
mailto:william.davis@dep.state.fl.us
Stephen McKeough (SBAP)
FL SBAP Technical Advisor
Division of Air Resources
Management
2600 Blair Stone Road, MS5510
Tallahassee, FL 32399-2400
(850)921-9539
(850) 922-6979 (F)
(800) 722-7457
mailto:stephen.mckeough@dep.state.n.us
GEORGIA
Anita DorseyWord (SBO)
GA SBAP
DNR/EPD
4244 International Parkway
Suite 120
Atlanta, GA 30354
(404) 362-4842
(877) 427-6255 (Toll Free)
(404) 363-7100 (F)
mailto: adword@mail.dnr. state .ga.us
Lee Tate (SBAP)
GA SBAP
DNR/EPD
4244 International Parkway
Suite 120
(404) 362-4854
(404) 463-7100 (F)
mailto: lee_tate@mail .dnr.ga.us
HAWAII
Patrick Felling (SBO)
Environmental Ombudsman
Compliance Assistance Office
Hawaii Department of Health
P.O. Box 3378
Honolulu, HI 96801
(808) 586-4528
(808) 586-7236 (F)
mailto:cao@eha.health.state.hi.us
Robert Tarn (SBAP)
HI Department of Health
Clean Air Branch
P.O. Box 3378
Honolulu, HI 96801
(808)586-4200
(808) 586-4359 (F)
mailto: rtam@emd .health. state .hi .us
IDAHO
Sally Tarowsky,
Environmental Assistance
Coordinator
Idaho Small Business
Development Center
Boise State University
1910 University Drive
Boise, Idaho 83725-1655
(208)426-1839
(208) 426-3877 (F)
mailto: starowsk(3>boise state .edu
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ILLINOIS
Donald Squires (SBO)
Illinois EPA/DAPC
Small Business Ombudsman
P.O. Box 19276
Springfield, IL 62794-9276
(217) 785-1625
(217) 785-8346 (F)
(888) 372-1996
mailto:don.squires@epa.gov
Roslyn Jackson (SBAP)
Small Business Env.
Assistance Program
Dept of Commerce and
Economic Opportunity
620 East Adams, 4th Floor
Springfield, IL 62701
(217) 524-0169
(217)557-2853(F)
(800) 252-3998
mailto:roslynjackson@illinoisbiz.biz
INDIANA
GaylaMcCarty(SBO)
Program Director
IDEM CTAP
ISTA Building
150 W. Market Street
Suite 703
Indianapolis, IN 46204-2811
(317)233-1046
(317) 233-5627 (F)
(800) 988-7901
mailto:gkmccart@dem.state.in.us
Marc Hancock (SBAP)
IDEM CTAP
ISTA Building
150 W. Market Street
Suite 703
Indianapolis, IN 46204-2811
(317)233-6663
(317) 233-5627 (F)
(800) 988-7901
mailto:mhancock(3)/dem.state.in.us
IOWA
Wendy Walker (SBO)
Small Business Air Quality
Liaison
Iowa Department of Economic
Development
200 E. Grand Avenue
Des Moines, IA 50309
(515)242-4761
(800)351-4668
(515) 242-4795 (F)
mailto:wendy.walker@ided.state.ia.us
John Konefes (SBAP)
IA Waste Reduction Center
University of Northern Iowa
1005 Technology Parkway
Cedar Falls, IA 50613-0185
(319)273-8905
(319) 268-3733 (F)
(800)422-3109
mailto: konefe s@uni. edu
KANSAS
Cathy Colglazier (SBO)
Environmental Ombudsman
Kansas Dept. of Health and
Environment
1000 SW Jackson St., Suite 430
Topeka, KS 66612
(785) 296-0669
(785) 291-3266 (F)
(800)357-6087
mailto:ccolglaz@kdhe.state.ks.us
Nancy Larson (SBAP)
P2 Specialist
K. State Pollution
Prevention Institute
7001W. 21st St. North
Wichita, KS 67205
(316)722-7721
(316) 722-7727 (F)
(800)578-8898
mailto:nlarson@ksu.edu
KENTUCKY
Rose Marie Wilmoth (SBO)
Air Quality Representative for
Small Business
Office of Commissioner
Department for Environmental
Protection
14 Reilly Road
Frankfort, KY 40601
(502)564-2150, x!28
(502) 564-4245 (F)
(800)926-8111
mailto:RosdVlarie.Wilmo1r@mail.statE.ky.us
Gregory C. Copley (SBAP)
Director
Kentucky Business Environmental
Assistance Program
Gatton College of Business and
Economics
University of Kentucky
Lexington, KY 40506-0034
(859)257-1131
(859) 323-1907 (F)
(800) 562-2327
mailto:gccopll@uky.edu
Cam Metcalf
Executive Director
Kentucky Pollution
Prevention Center
420 Lutz Hall
University of Louisville
Louisville, KY 40292
(502)852-0965
(800) 334-8635, Ext. 0965
(502) 852-0964 (F)
mailto:cam.metcalf@louisville.edu
LOUISIANA
Roger Ward (SBO)
LADEQ
P.O. Box 4301
Baton Rouge, LA 70821
(225)219-3956
(225)219-3971 (F)
(800)259-2890
mailto: roger.ward@LA.Gov
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Dick Lehr (SBAP)
Environmental Assistance
Division
Small Business Assistance
Program
Baton Rouge, LA 70821-4313
(225)219-3258
(225) 219-3309 (F)
(800) 259-2890
mailto:dick.lehr@LA.Gov
MAINE
Ron Dyer (SBO)
Department of Environmental
Protection
Office of Innovation and
Assistance
State House Station 17
Augusta, ME 04333
(207)287-4152
(207) 287-2814 (F)
(800) 789-9802
mailto:ron.e.dyer@maine.gov
Julie M. Churchill (SBAP)
Small Business Assistance
Program
State House Station 17
Augusta, ME 04333
(207)287-7881
(207) 287-2814 (F)
(800) 789-9802
mailto:julie.m.churchill@maine.gov
MARYLAND
Andrew Gosden (SBO)
MD Dept. of the Environment
1800 Washington Blvd., Suite 735
Baltimore, MD 21230-1720
(410)537-4158
(410) 5 3 7-4477 (F)
(800) 633-6101
mailto: agosden@mde. state .md.us
MASSACHUSETTS
Robert Donaldson (SBO)
MA Department of Environmental
Protection
1 Winter Street, 8th Floor
Boston, MA 02108
(617)292-5619
mailto:robert.donaldson@state.ma.us
William McGowan (SBAP)
EOEA/ Office of
TechnicalAssistance
251 Causeway Street
Suite 900, 8th Floor
Boston, MA 02114
(617)626-1078
(617) 626-1095 (F)
mailto :william.mcgowan@state.ma.us
MICHIGAN
Susan Holben (SBO)
Business Services
Michigan Economic Development
Corporation
300 North Washington Square
Lansing, Michigan 48913
(517)335-2168
mailto:holbens@michigan.org
Dave Fiedler (SBAP)
MDEQ Env Science and Services
Division
P.O. Box 30457
Lansing, MI 48909
(517)373-0607
(517) 335-4729 (F)
(800) 662-9278
mailto: fiedlerd@michigan .gov
MINNESOTA
Troy Johnson (SBAP)
MPCA/MAR/SBAP
520 Lafayette Road
St. Paul, MN 55155
(651)296-7767
(651)297-8701 (F)
(800) 657-3938
mailto :troy.j ohnson@pca. state .mn.us
MISSISSIPPI
Jesse Thompson (SBO)
Small Business Ombudsman
MSDEQ
2380 Hwy. 80 West
P.O. Box 20305
Jackson, MS 39289-1305
(601)961-5167
(601) 961-5541 (F)
(800)7256112
mailto :jesse_thompson@deq.state.ms.us
Randy Wolfe (SBAP)
Small Business Technical
Assistance Director
MSDEQ
2380 Hwy. 80 West
P.O. Box 20305
Jackson, MS 39289-1305
(601)961-5166
(601) 961-5541 (F)
(800)725-6112
mailto:randy_wolfe@deq.state.ms.us
MISSOURI
Byron Shaw (SBAP)
Missouri DNR
1659 E. Elm Street
P.O. Box 176
Jefferson City, MO 65102
(573) 526-6627
(573) 526-5808 (F)
(800)361-4827
mailto:nrshawb@mail.dnr.state.mo.us
MONTANA
Bonnie Rouse (SBO)/(SBAP)
MTDEQ
P.O. Box 200901
1520 E. 6th Avenue
Helena, MT 596200901
(406)444-3641
(406) 444-6836 (F)
(800)433-8773
mailto:brouse@ateat.mt.us
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Brian Spangler (SBAP)
Manager of Business and
Assistant Prog. Pollution
Prevention Bureau
Montana Dept. of Environ Qlty.
1520 E. 6th Ave
P.O. Box 200901
Helena, MT 5 9620-0901
(406) 444-5307
(406) 444-6836 (F)
(800)433-8773
mailto:bspangler@state.mt.us
NEBRASKA
Tom Franklin (SBO)/(SBAP)
Small Business and Public
Assistance
NEDEQ
P.O. Box 98922
Lincoln, NE 68509-8922
(402)471-8697
(402) 471-2909 (F)
(877)253-2603
mailto :tom.franklin@ndeq. state.ne.us
NEVADA
Marcia Manley (SBO)
NV Division of Environmental
Protection
333 West Nye Lane
Carson City, NV 89706-0851
(775) 687-9309
(775) 687-5856 (F)
(800) 992-0900, x4670
mailto: mmanley @ndep .nv.gov
NEW HAMPSHIRE
Rudolph Cartier (SBO)
Air Resources Division
Department of Environmental
Services
6 Hazen Drive
Concord, NH 03301-2033
(603)271-1379
(603)271-1381(F)
(800) 837-0656
mailto: rcartier@des. state .nh.us
NEW JERSEY
Joe Constance (SBO)
Small Business Ombudsman
20 West State Street
P. O. Box 820
Trenton, NJ 08625-0820
(609)984-6922
(609) 777-4097 (F)
(800) 643-6090
mailto:ceacons@commerce.state.nj.us
KyAsral(SBAP)
Small Business Assistance
Program Manager
NJDEP/SBAP
P.O. Box 423
Trenton, NJ 08625-0423
(609) 292-3600
(609) 777-1330 (F)
(877)753-1151
mailto:kasral@dep.state.nj .us
NEW MEXICO
Rita Trujillo (SBO)
NMED AQB
2048 Galisteo Street
P.O. Box 26110
Santa Fe,NM 87505
(505)955-8091
(505) 827-1523 (F)
(800) 224-7009
mailto:rita_trujillo@nmenv.state.nm.us
Steve Dubyk (SBAP)
NMEDAQB
2044 Galisteo
Santa Fe,NM 87505
(505)955-8025
(505) 827-1543 (F)
(800) 224-7009
mailto:steve dubyk@nmenv.state.nm.us
NEW YORK
Keith Lashway (SBO)
Environmental Service Unit
SBEO Director
Environmental Ombudsman Unit
30 S. Pearl Street
Albany, NY 12245
(518)292-5340
(518) 292-5886 (F)
(800)782-8369
mailto:klashway@empire.state.ny.us
John P. McKeon (SBAP)
Technical Advisory Services
Division
Business Assistance Unit
NYS Environmental Facilities
Corporation
625 Broadway
Albany, NY 12207-2997
(518)402-7461
(518) 486-9248 (F)
(800)780-7227
mailto:mckeon@nysefc.org
NORTH CAROLINA
Edythe McKinney (SBO)
NC DENR Cust. Service Center
Small Business Assistance
Program
1640 Mail Service Center
Raleigh, NC 27699-1640
(919)733-0823
(919) 715-7468 (F)
(877)623-6748
mailto: edythe .mckinney @ncmail .net
Tony Pendola (SBAP)
NC DENR Cust. Service Center
Small Business Assistance
Program
1640 Mail Service Center
Raleigh, NC 27699-1640
(919)733-0824
(919) 715-7468 (F)
(877)623-6748
mailto :tony.pendola@ncmail .net
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NORTH DAKOTA
Dana Mount (SBO)
ND Department of Health
1200 Missouri Avenue
P.O. Box 5520
Bismarck, ND 58506
(701)328-5150
(701) 328-5200 (F)
(800) 755-1625
mailto: dmount@state .nd.us
Tom Bachman (SBAP)
ND Department of Health
1200 Missouri Avenue
Division of Air Quality
P.O. Box 5520
Bismarck, ND 58506
(701)328-5188
(701) 328-5200 (F)
(800) 755-1625
mailto :tbachman@state .nd .us
OHIO
Mark Shanahan (SBO)
Clean Air Resource Center
50 West Broad Street, Room 1901
Columbus, OH 43215-5985
(614) 728-3540
(614) 752-9188(F)
(800)225-5051
mailto:mark.shanahan@aqda.state.oh.us
Rick Carleski (SBAP)
Ohio EPA/DAPC
Lazarus Government Center
P.O. Box 1049
Columbus, OH 43216
(614) 728-1742
(614) 644-3681 (F)
mailto:rick.carleski@epa.state.oh.us
OKLAHOMA
Judy Duncan (SBO)
Director Customer Service
P.O. Box 1677
Oklahoma City, OK 73101-1677
(405) 702-1000
(405)702-1001(F)
(800) 869-1400
mailto:judy.duncan@deq.state.ok.us
Kyle Arthur (SBAP)
Dept. of Environmental Quality
P.O. 1677
Oklahoma City, OK 73101-1677
(405)702-9132
(405) 702-1000 (F)
(800) 869-1400
mailto:kyle.arthur@deq.state.ok.us
OREGON
Rich Grant (SBO)
Small Business Ombudsman
Office of Compliance and
Enforcement
OR Department of Environmental
Quality
811 SW 6th Avenue
Portland, OR 97204
(503) 229-6839
(800)452-4011
mailto:grant.richard@deq.state.or.us
Linda Hayes-Gorman (SBAP)
Air Quality Business Assistance
Program
Oregon Department of
Environmental Quality
2146 NE 4th Street
Bend, OR 97701
(541)388-6146x274
(541) 388-8283 (F)
(800)452-4011
mailto :hyes-
gorman.linda@deq.state.or.us
PENNSYLVANIA
Jeanne Dworetzky (SBO)
Small Business Ombudsman
PA Department of Environmental
Protection
Office of Pollution Prevention and
Compliance Assistance
RCSOB, 15th Floor
P.O. Box 8772
Harrisburg, PA 17105-8772
(717)772-5942
(717) 783-2703 (F)
mailto: Jdoretzky@state .pa.us
Jon Miller (SBAP)
PA Dept. Bureau of Air Quality
400 Market Street
Harrisburg, PA 17105-8468
(717)787-7019
(717) 772-2302 (F)
(800) 722-4743
mailto:Jonmiller@state.pa.us
PUERTO RICO
Evelyn Rodriguez (SBAP)
Environmental Quality Board
Air Quality Program Director
PO Box 11488
Santurce, PR 00919
(787) 767-8025
(787) 756-5906
RHODE ISLAND
NO SBO/SBAP
SOUTH CAROLINA
Phyllis T. Copeland, (SBO)
Small Business Ombudsam
SCDHEC EQC Administration
2600 Bull Street
Columbia, SC 29201-1708
(803) 896-8982
(803) 896-8999 (F)
(800)819-9001
mailto:copelapt@dhec.sc.gov
James Robinson (SBAP)
Technical Assistance Engineer
SCDHEC - EQC Administration
2600 Bull St
Columbia, SC 29201-1708
(803) 896-8984
(800)819-9001
(803) 896-8999 (F)
mailto: robinsj c@dhec. sc.gov
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SOUTH DAKOTA
Joe D. Nadenicek (SBO)
Small Business Ombudsman
Department of Environment and
Natural Resources
Joe Foss Building
523 East Capitol
Pierre, SD 57501
(605) 773-3836
(605) 773-6035 (F)
(800) 438-3367
mailto: j oe .nadenicek@state. sd .us
Rick Boddicker (SBAP)
Department of Environment and
Natural Resources
Joe Foss Building
523 East Capitol
Pierre, SD 57501
(605) 773-6706
(605) 773-5286 (F)
(800) 438-3367
mailto:rick.boddicker@state.sd.us
TENNESSEE
Linda Sadler (SBO)
Small Business Environmental
Assistance Program
L&C Annex, 8th Floor
401 Church Street
Nashville, TN 37243-1551
(615)532-0779
(615) 532-8007 (F)
(800) 734-3619
mailto:linda.sadler@state.tn.us
TEXAS
Israel Anderson (SBO)
Small Business Advocate
TCEQ (Mail Code 112)
P.O. Box 13087
Austin, TX 78711-3087
(512)239-5319
(512) 239-3165 (F)
(800) 447-2827
mailto:ianderso@tceq.state.tx.us
Tamra ShaeOatman (SBAP)
Small Business and Local
Govt. Asst. Section Mgr.
TCEQ (Mail Code 106)
P.O. Box 13087
Austin, TX 78711-3087
(512)239-1066
(512) 239-1065 (F)
(800) 447-2827
mailto:toatman@tceq.state.tx.us
UTAH
Renette Anderson (SBO)
UT Dept. of Environmental Qlty.
Office of the Small Business
Ombudsman
168 North 1950 West
Salt Lake City, UT 84114-4810
(801)536-4478
(801) 536-4457 (F)
(800)458-0145
mailto: renetteanderson@utah .gov
Ron Reece (SBAP)
Environmental Engineer
UT Dept. of Environmental Qlty.
Division of Air Quality
150 North 1950 West
P.O. Box 144820
Salt Lake City, UT 84114-4820
(801)536-4091
(801) 536-4099 (F)
(800) 270-4440
mailto: rreece @utah .gov
VERMONT
Judy Mirro (SBAP)
SB Compliance Assistance
Program
VT DEC Environmental
Assistance Division
Laundry Building
103 South Main Street
Waterbury,VT 05671
(802)241-3745
(802) 241-3273 (F)
(800) 974-9559
mailto:junym@dec.anr.state.vt.us
VIRGINIA
John Daniel (SBO)
Programs Coordinator
VA Dept. of Environmental Qlty.
629 E. Main Street
P.O. Box 10009
Richmond, VA 23240
(804)698-4311
(804) 698-4510 (F)
(800) 592-5482
mailto:jmdaniel@deq.state.va.us
Richard Rasmussen (SBAP)
Director
Small Business Assistance Prog.
Air Division
VA Dept. of Environmental Qlty.
629 E. Main Street
P.O. Box 10009
Richmond, VA 23240
(804) 698-4394
(804) 698-4510 (F)
(800) 592-5482, Ext. 4394
mailto:rgrassmussen@deq.state.va.us
VIRGIN ISLANDS
MarylynA. Stapleton
(SBO/SBAP)
SBTAP Program Adm.
V.I. Department of Planning and
Natural Resources
Environmental Protection
Division, SBAP
Terminal Bldg, 2nd Floor
Cyril E. King Airport
St. Thomas, VI 00802
(340)774-3320, Ext. 5167
(340) 714-9528 or 9549 (F)
(340)714-9529
mailto: envprotj @viacce ss .net
WASHINGTON
Bernard Brady (SBO/SBAP)
WA Department of Ecology
Air Quality Program
P.O. Box 47600
Olympia,WA 98504-7600
(360) 407-6803
(360) 407-7534 (F)
mailto:bbra461@ecy.wa.gov
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WEST VIRGINIA
Terry L. Polen PE, QEP (SBO)
WV Department of Environmental
Protection
10 McJunkin Road
Nitro,WV 25143
(304)759-0510, Ext. 341
mailto:tpolen@dep.state.wv.us
Gene M. Coccari (SBAP)
Technical Specialist
Small Business Assistance
Program
WV DEP, Division of Air Quality
7012 MacCorkle Avenue, SW
Charleston, WV 25304
(304)926-3731
(304) 926-3637 (F)
(800) 982-2474
mailto:gcoccari@mail.dep.state.wv.us
WISCONSIN
Pam Christenson (SBO)
WI Small Business
Clean Air Assistance Program
P.O. Box 7970 6th Floor
201 West Washington Avenue
Madison, WI 53707-7970
(608) 267-9384
(608) 267-0436 (F)
(800) 435-7287
mailto:pchristenson@commeice.statE.wi.us
Renee Lesjak Bashel (SBAP)
WI Department of Commerce
PO Box 7970 6th Floor
201 West Washington Avenue
Madison, WI 53707-7970
(608)264-6153
(608) 267-0436 (F)
(800) 435-7287
mailto:rlesjakbashel@commerce.state.wi.us
WYOMING
Dan Clark (SBO/SBAP)
Dept. of Environmental Qlty.
Small Business Ombudsman
Herschler Building 4W
122 W. 25th Street
Cheyenne, WY 82002
(307) 777-7388
(307) 777-3610 (F)
mailto: dclark@state. wy.us
Brian Lovett (SBAP)
Dept. of Environmental Qlty.
Technical Assistance Program
Coordinator
Herschler Building 4W
122 W. 25th Street
Cheyenne, WY 82002
(307) 777-7347
(307) 777-3610 (F)
mailto: blovet@state .wy.us
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VI. General Pollution Prevention Resources
Check Lists
Environmental Self-Assessment for Health Care
Facilities
New York State Department of Environmental
Conservation Pollution Prevention Unit. February
2000. A checklist of pollution prevention measures
for health care facilities.
http://www.dec.state.ny.us/website/ppu/esahcf.pdf
Fact Sheets
Best Management Practices for Hospitals and
Medical Facilities
Palo Alto Regional Water Quality Control Plant. Ken
Torke. September 1994. These best management
practices encompass the metal pollutants of concern
in hospitals from the South San Francisco Bay Area.
http://www.city.palo-alto.ca.us/cleanbay/pdf/hosp.pdf
Case Studies in Hospital Solid Waste Reduction
and Recycling: Reusable Totes, Blue Bag Wrap
Recycling and Composting: Environmental Best
Practices for Health Care Facilities
Spring 2002. U.S. EPA. Contains three hospital case
studies, which cover reusable totes, blue sterile wrap
and plastic film recycling and composting.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/totes .pdf
Eliminating Mercury in Hospitals: Environmental
Best Practices for Health Care Facilities
Spring 2002. U.S. EPA fact sheet that outlines
sources of mercury in hospitals, efficiency and cost
data for mercury-free sphygmomanometers as well as
three case studies that summarize successes, costs
and lessons learned by hospitals accomplishing
mercury reduction.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/mercury.pdf
Right to Know Hazardous Substances Fact Sheets
New Jersey Department of Health and Senior
Services.
http ://www. state .ni .us/health/eoh/rtkweb/rtkhsfs .htm
Replacing Ethylene Oxide and Glutaraldehyde
with Environmentally Preferable Sterilants/
Disinfectants: Environmental Best Practices for
Health Care Facilities
Spring 2002. U.S. EPA. Contains case studies on
hospitals reducing use of ethylene oxide and
glutaraldehyde.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/glutareth.pdf
Using Microfiber Mops in Hospitals:
Environmental Best Practices for Health Care
Facilities
Spring 2002. U.S. EPA. Provides focus on an often
overlooked aspect of hospital pollution prevention:
janitorial cleaning products. Hospital case studies
provide cost data from water and chemical savings
associated with switching to microfiber mops in
hospitals. Labor savings included.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/mops.pdf
Guides
Environmental Management Guide for Small
Laboratories
U.S. EPA Small Business Division. Washington, DC.
May 2000.
http://www.epa.gov/sbo/smalllabguide_500.pdf
Guide to Mercury Assessment and Elimination in
Health Care Facilities
Medical Waste Management Program, Department of
Health Services: State of California. 2000.
http://www.getf.org/file/toolmanager/O16F8459.pdf
Guide to Pollution Prevention: Selected Hospital
Waste Streams; Risk Reduction Engineering
Laboratory. The Center for Environmental Research
Information, June 1990, EPA/625/7/-90/009.
http ://www.p2pavs .org/ref/02/01059 .pdf
Mercury Pollution Prevention in Health Care
National Wildlife Federation. Guy Williams. 1997.
A guide to help hospitals and their employees in their
effort to become mercury free.
http://www.nwf.org
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Guidebook for Hospital Waste Reduction
Planning and Program Implementation
American Society for Health Care Environmental
Services of the American Hospital Association.
Chicago, IL. 1996.
http://www.ahaonlinestore.com/
Rq]iicOisph^?Ra]iic^
H2E guide to EPP Guide for Hospital
Environmentally Preferable Purchasing
http://www.geocities.com/EPP_how_to_guide/
Mercury: In Your Community and the
Environment
Wisconsin Department of Natural Resources.
October 1998.
http://www.epa.gov/glnpo/bnsdocs/merccomm/
merccomm.pdf
NYC WasteLe$$: Hospital Waste Prevention and
Energy Conservation Guidance Document
City of New York Department of Sanitation, U.S.
EPA, New York State Energy Research and
Development Authority. February 2001.
http://www.nycwasteless.com/bus/businesstour/
healthcare.html
2000 PBT Program Accomplishments
Office of Pollution Prevention and Toxics. U.S.
EPA. EPA-742-R-01-003. November 2001.
http://www.epa.gov/pbt/PBT2000annualreport.pdf
Pollution Prevention Guide for Hospitals
(excluding medical wastes)
California Environmental Protection Agency,
Department of Toxic Substances Control, Office of
Pollution Prevention and Technology Development.
May 1998.
http://www.getf.org/file/toolmanager/O16F4754.pdf
Environmental Management Systems Managers
Guide
Office of the Federal Environmental Executive
document provides information on EMS
implementation at federal facilities. April 2004
http://www.ofee.gov/ems/training/manguide.pdf
Cleaning for Health: Products and Practices for
Safer Indoor Environment
Alicia Culver, Marian Feinberg, David Klebenov,
Judy Muskinow, Lara Sutherland
ISBN 0-918780-79-9. August 2002. Guide to
environmentally preferable cleaning products and
methods that have been effectively used in office
buildings, schools, hospitals and other facilities in
the United States and Canada. It describes pioneering
product evaluation programs and lists the brands that
were chosen based on environmental and
performance criteria. It also provides a model
specification, as well as manufacturer contacts and
other resources for those who want to develop a safer
cleaning program for their buildings.
http://www.informinc.org/cleanforhealth.php
Profile of the Health Care Industry
Includes information on various services provided by
the health care facilities and the pollutants and
environmental regulations associated with each.
Information about pollution prevention opportunities,
compliance history and related organizations and
initiatives also included. October 2004.
http: //www.epa. gov/compliance/
Manuals
An Organizational Guide to Pollution Prevention
CD-ROM. U.S. EPA. Office of Research and
Development. EPA/625/C-01/003. August 2001.
http: //www. epa.gov/ttbnrmrl
Code Green P2 Strategies for Health Care
This manual provides hospitals with an overview of
important pollution prevention areas based on
Canadian resources.
http ://www.cornet.nf.ca/web/acapha/proj ects/
documents/hospital_book.pdf
Greener Hospitals
Bristol-Meyers Squibb Company. ISBN 3-00-
012582-5. December 2002. This manual explains
how to implement Environmental Management
Systems for environmentally friendly activities in
hospitals, doctors' offices, clinics and other health
care facilities.
http://www.bms.com/static/ehs/sideba/data/
greenh.pdf
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U.S. EPA Buy Clean Training Manual for Eastern
Kentucky School Districts
Developed by the Kentucky Pollution Prevention
Center. October 2001.
http://www.epa.gov/oppt/buy_clean/docs/schools-
regional .htm#region4
Waste Management Strategies for Hospitals and
Clinical Laboratories
Pollution Prevention Program, North Carolina Dept.
of Environment, Health and Natural Resources. May
1992.
http://www.p2pays.org/
Reducing Mercury Use in Health Care:
Promoting a Healthier Environment A "How-to"
Manual
Monroe County Department of Health and the
Monroe County Department of Environmental
Services, NY. Manual addresses how to establish a
mercury pollution prevention program in hospitals.
http://www.epa.gov/glnpo/bnsdocs/merchealth/
Writing a Waste Reduction Plan for Health Care
Organization
The University of Tennessee Center for Industrial
Services. A handbook designed to help hospitals
comply with the Tennessee Hazardous Waste
Reduction Act of 1990, Resource Conservation and
Recovery Act (RCRA), and help identify and assess
pollution prevention and waste reduction options.
http://www.cis.utk.edu/EHSP/hospman.pdf
Reports
Scientific Report on APE Surfactants
Troubling Bubbles: The Case for Replacing
Alkylphenol Ethoxylate Surfactants.
Philip Dickey, Washington Toxics Coalition, 1997.
This report documents the scientific evidence that
APEs are poor environmental performers. Includes a
summary of research on biodegradability, endocrine
disruption and toxicity as well as recommendations
for replacing APEs with alternative surfactants.
Contains a list of 477 products found to contain one
or more APEs. Available by mail at Washington
Toxics Coalition Web site.
http://www.watoxics.org/pages/root.aspx
Greening Hospitals Report
A first of its kind environmental survey of 50 major
U.S. hospitals uncovered widespread failure on the
part of medical facilities to take steps to halt
contamination of milk, meats and fish by dioxins and
mercury, pollutants that cause a wide range of health
impacts.
http://www.ewg.org/reports/greening/greenpr.html
Healthy Hospitals: Controlling Pests without
Harmful Pesticides
This November 2003 survey, released by health
advocate groups Health Care Without Harm and
Beyond Pesticides, found that many major hospitals
regularly spray with toxic pesticides. The good news,
according to the report, is that some hospitals have
great success managing pests with no or few
hazardous pesticides by using proven, safer
integrated pest management (IPM) techniques. The
report concludes with tips and resources on how
hospitals can manage pests while also protecting the
health of people and the environment.
http: //www.noharm. org/
details.cfm?ID=864&type=document
Environmentally Preferable Purchasing
This report highlights the variety of approaches
organizations use to incorporate environmental and
social factors into procurement activities. Based on
interviews with representatives from 18 public and
private sector organizations, the report describes (1)
how the organizations choose product categories and
attributes for EPP initiatives, (2) how integrated EPP
is into everyday purchasing decisions, (3) common
challenges, and (4) the positive outcomes produced
by the organizations' EPP efforts. Synopses of the
participating organizations' EPP strategies and
programs are included.
http://www.pprc.org/pubs/pubslist.cfm
HealthSystem Minnesota Mercury Reduction
Holly J. Baron. Minnesota Technical Assistance
Program. 2000.
http://www.cleanmed.org/2002/presentations/
saturday/gonyon_tice/gonyon_tice_files/
frame .htm#slideOOO 1 .htm
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Compact Disc
Compliance Assistance & Pollution Prevention
Hospitals
Provided free of charge from the U.S. EPA - Region
2, 290 Broadway, 21 Floor, New York, NY 10007
(212) 637-4050. This CD includes presentations,
documents, resources and Web sites.
http://www.epa.gov/region02/healthcare/
Web sites
American Hospital Association
The American Hospital Association (AHA) provides
education for health care leaders and is a source of
information on health care issues and trends. AHA
leads, represents and serves health care provider
organizations that are accountable to the community
and committed to health improvement.
http://www.hospitalconnect.com/hospitalconnect/
index.jsp
California Department of Health Services,
Medical Waste Management Program
This Web page provides guidelines for proper
handling and disposal of medical waste in California.
http://www.dhs.ca. gov/ps/ddwem/environmental/
med_waste/default.htm
California Integrated Waste Management Board -
Waste Preventions Information Exchange Health
Care Waste
A comprehensive list of publications, fact sheets and
Web links to information on health care waste.
http://www.ciwmb.ca. gov/wpie/healthcare/
The Canadian Centre for Pollution Prevention,
Health Care Environet
Health Care Environet offers information on
management tools including audits, environmental
management systems, health and safety programs,
pollution prevention plans, emergency response
plans, numerous case studies as well as networks and
programs.
http://www.c2p2online.com/
PCB homepage Information on Polychlorinated
Biphenyls (PCBs)
http://www.epa.gov/opptintr/pcb/
The Canadian Coalition for Green Health Care
Includes case studies, an environmentally preferred
list of PVC-free and mercury suppliers and links to
additional green health care Web sites.
http: //www. greenhealthcare .ca/
EPP Database of Vendors
http ://www.epa. gov/oppt/epp/database .htm
EPP Update Newsletter
http://www.epa.gov/epp/pubs/updatel3_final_124.pdf
Center for New American Dream Green Cleaners
Product List
The Center for a New American Dream helps
Americans consume responsibly to protect the
environment, enhance quality of life and promote
social justice. The Center works with individuals,
institutions, communities and businesses to conserve
natural resources and promote positive changes in the
way goods are produced and consumed.
http://www.newdream.org/procure/products/
approved.html
Disinfection Best Management Practices
Using best management practices helps ensure proper
use of disinfectants. It illustrates only the amount of
disinfectant necessary to do the job. Ultimately, best
management practices protect patients, employees
and the environment.
http://www.mntap.umn.edu/health/disinfection.htm
Environmental Working Group
Environmental Working Group (EWG) is a nonprofit
environmental research organization dedicated to
improving public health and protecting the
environment by reducing pollution in air, water and
food.
http://www.ewg.org/
U.S. EPA Design for the Environment Program
The Design for the Environment (DfE) program is
one of the U.S. EPA's premier partnership programs,
working with individual industry sectors to compare
and improve the performance and human health and
environmental risks and costs of existing and
alternative products, processes and practices.
http: //www. epa. gov/opptintr/dfe/
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PBT/Mercury Reduction Resources
Resources are accessible under Technical Resource
Links P2 for Health Care Organizations.
http: //www.kppc .org/
Health Care Case Studies in Oregon
Several documented case studies of pollution
prevention and cost savings in Oregon.
http: //www. deq. state .or.us/wmc/solwaste/cwrc/
cstudy/healthcare .html
U.S. EPA Disinfectant Web site
A list of EPA registered disinfectants. These strong
disinfectants do not need to be used all the time, just
where cleaning blood or other bodily fluids. They
are strong disinfectants and are used in hospital
settings. For disinfectant needs other than in blood
and bodily fluids covered by OSHA's regulations, a
regular environmentally preferable disinfectant can
be used.
http://www.epa.gov/oppad001/chemregindex.htm
Health Care Without Harm
This Web site features new resources including
"Going Green: A Resource Kit for Pollution
Prevention in Health Care" and links to PVC and
mercury publications, videos and web resources.
http: //www.noharm .org/
Hospitals for a Healthy Environment
H2E is a voluntary partnership of the U.S. EPA,
American Hospital Association, Health Care Without
Harm and the American Nurses Association pledged
to eliminate mercury use by 2005 and reduce all
hospital waste by 50 percent by 2010. The Web site
offers resources to achieve these objectives including
lists of mercury-containing items, persistent
bioaccumulative toxins, green cleaning products and
links to pollution prevention providers, consultants,
mercury recyclers and many other resources.
http://www.h2e-online.org/
Hotlines and Clearinghouses
Request technical information, reports and
documents or ask questions about environmental
issues.
http://www.epa.gov/epahome/hotline.htm
Kentucky Hospital Association
The Kentucky Hospital Association provides
information for Kentucky Hospitals.
Medical and Scientific Community Organization
Mercury Work Group
http://www.kyha.com/
MASCO
MASCO has mercury management and mercury-free
resources including a mercury management
guidebook and a searchable database of mercury-free
products.
http://www.masco.org/mercury/index.htm
Minnesota Technical Assistance Program
Answers to questions regarding disposal of some
common medical-related waste streams.
http: //www.mntap .umn. edu/
Northwest Guide to Pollution Prevention by the
Health Care Sector
This Web site features a list of resources for pollution
prevention in hospitals.
http://www.pprc.org/pubs/healthcare.cfm
OSHA Basis of Carcinogen Listing of Individual
Chemicals
This table shows the specific bases for which the
individual chemical was designated as a known or
suspect carcinogen.
http: //www.epa. gov/tri/chemical/
appendixc 1999pdr.pdf
Pollution Prevention Tips for Health Care
Providers
This Montana Pollution Prevention Program lists
tips, additional resources and more information about
pollution prevention.
http://www.montana.edu/~wwwated/healthcare.htm
Rechargeable Battery Recycling Corporation
The Rechargeable Battery Recycling Corporation
(RBRC) offers information on how to recycle
portable rechargeable batteries.
http ://www.rbrc .org/
index.html?sp=true&h=400&w=275
U.S. EPA's Office of Solid Waste
Provides link to state solid waste programs.
http ://www.epa. gov/epaoswer/osw/stateweb .htm
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Small Business Assistance Programs
SBAPs provide free, nonregulatory environmental
compliance and pollution prevention assistance to
small businesses. This site provides a list of state
contacts for compliance assistance.
http://www.epa.gov/reg3ecej/compliance_assistance/
hospitals.htm
Sustainable Hospitals Project - Alternative
Cleaning Products
Provides technical support to the healthcare industry
for selecting products and work practices that reduce
occupational and environmental hazards, maintain
quality patient care, and contain costs.
http://www.sustainablehospitals.org/cgi-bin/
DB_Index.cgi
The Sustainable Hospitals Web site
Provides technical support to the health care industry
for selecting products and work practices that reduce
occupational and environmental hazards, maintain
quality patient care and contain costs.
http://www.sustainablehospitals.org/cgi-bin/
DB_Index.cgi
U.S. EPA - Information on Antimicrobial
Pesticide Products
Nearly 50 percent of antimicrobial products are
registered to control infectious microorganisms in
hospitals and other health care environments.
However, public health antimicrobial products tend
to be low-volume products, and thus constitute less
than 5 percent of the estimated total market for
antimicrobial products.
http://www.epa.gov/pesticides/factsheets/antimic.htm
U.S. EPA's Mercury Web site
This site provides background information and
agency actions taken on mercury, fish advisory
information, as well as downloadable research and
technical materials.
http://www.epa.gov/mercury/
U.S. EPA's Mercury in Medical Facilities
This is an interactive environmental education
software program that provides information on the
proper handling and disposal of mercury wastes
produced by medical facilities.
http://www.epa.gov/seahome/mercury/src/
outmerc.htm
Waste Reduction Activities for Hospitals
This Web site provides information on waste
reduction activities for hospitals as well as statistics
on hospitals' success in waste reduction.
http://www.ciwmb.ca.gov/BIZWASTE/factsheets/
hospital.htm
U.S. EPA's Office of Pollution Prevention and
Toxics (OPPT) PBT Web site
Information on U.S. EPA initiatives, goals, regulatory
activities, voluntary partnerships and links to
technical materials and environmental/health effects
associated with PBT's.
http: //www.epa. gov/pbt/
The U.S. EPA sponsors approximately 89 hotlines
and clearinghouses that provide free and convenient
avenues to obtain assistance with environmental
requirements. Key hotlines that may be of interest to
include the following:
RCRA/UST/CERCLAHotline: (800) 424-9346
Toxic Substances and Asbestos Information:
(202)554-1404
Stratospheric Ozone/CFC Information:
(800) 296-1996
Clean Air Technical Center: (919) 541-0800
The Waste Reduction Resource Center
Provides resources for hospitals and medical
facilities including Web sites, manuals, articles and
reports, fact sheets, videotapes and case studies.
http: //wrrc .p2pays. org/industry/hospital .htm
Waste Reduction Tips for Health Care/Medical
Provides waste reduction tips in the pharmacy, X-ray,
custodial, purchasing, supplies and cafeteria. There
are also recycling and composting tips.
http: //www. deq. state .or.us/wmc/solwaste/cwrc/
wrstrategy/healthcarestrategy.html
Pollution Prevention Information for Health Care
Facilities
Contains links that provide information on how to
comply with environmental regulations, apply P2
techniques and achieve better environmental
performance at a lower cost.
http://www.dec.state.nv.us/website/ppu/p2shlth.html
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VII. Hospital Water Permits/Effluent Limits
Memorandum
From: Carey A. Johnston, P.E.
USEPA/OW/OST
ph: (202) 566-1014
mailto:johnston.carey@epa.gov
To: Public Record for the Effluent Guidelines Program Plan for 2004/2005
DCN XXX, Section 2.2.3
EPA Docket Number OW20030074 (http://www.epa.gov/edockets/)
Date: December 30, 2003
Re: Factor 2 Screening Level Information on the Health Care Industry
Overview
Under the Clean Water Act (CWA), the U.S. EPA establishes technology-based national regulations,
termed "effluent guidelines," to reduce pollutant discharges from industrial facilities to waters of the United
States. Section 304(m) of the Clean Water Act (CWA) requires the U.S. EPA to publish an Effluent
Guidelines Program Plan every two years. CWA Section 304(m)(l)(A) also requires the U.S. EPA to
establish a schedule for the annual review and revision of all existing effluent guidelines. Additionally, CWA
Section 304(m)(l)(B) requires the U.S. EPA to identify categories of point sources discharging toxic or
nonconventional pollutants for which the U.S. EPA has not published effluent guidelines.
The preliminary Effluent Guidelines Program Plan for 2004/20051 describes the four factors the U.S.
EPA considered during its screening-level analyses. Factor 2 (Technology Advances and Process Changes)
considers applicable and demonstrated technologies, process changes or pollution prevention alternatives that
can effectively reduce the pollutants remaining in an industry category's wastewater and thereby substantially
reduce any identified risk to human health or the environment associated with those pollutants. This memo
summarizes the Factor 2 screening level information gathered on the health care industry. Sectors of this
industry were identified in the U.S. EPA's outreach activities, however, this industry was not identified for
further data collection in the current effluent guidelines planning cycle.2
Click here to return to start of Appendix B.
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Health Services Industry
The health services industry is one of the many service industries that have recently experienced a large
percent increase in revenue and value of receipts. Unlike many other service industries, the health services
industry discharges wastewaters that contain a variety of pollutants such as pathogenic microorganisms,
radioactive elements and other toxic chemicals such as mercury. The health services industry (SIC 80)
consists of the following eight segments: 1) hospitals, 2) nursing and personal care facilities, 3) offices and
clinics of physicians, 4) home health care services, 5) offices and clinics of dentists, 6) offices and clinics of
other practitioners, 7) health and allied services, and 8) medical and dental laboratories. However, hospitals
are the only segment of the health services industry currently subject to any effluent limitations guidelines
(ELGs). Direct discharges from hospitals are subject to the requirements of the ELG for the Hospital Point
Source Category (40 CFR 460) established in 1976. Most hospitals discharge to POTWs and are not subject
to these effluent guidelines.
Hospitals generate wastewater from food service operations, cleaning of exam and surgical suits,
equipment sterilization, laundries, sanitary waste (toilets, sinks and showers), medical laboratories, cooling
towers and heating systems (boiler blow-down). Approximately 242 gallons of wastewater are generated per
bed per day in the average hospital. Wastewater from hospitals is characterized by BOD5 (50 to 400 mg/L),
chemical oxygen demand (150 to 800 mg/L), total suspended solids (60 to 200 mg/L), and total organic
carbon (50 to 300 mg/L).
The current BPT effluent limits for hospitals are based on biological treatment with sludge handling
facilities. BPT effluent limits are based on multimedia filtration following biological treatment to remove
residual solids. Regulated pollutants include BOD5, TSS and pH. Sampling data from hospitals with
treatment systems indicate BOD5 and TSS removals are approximately 93 percent and 86 percent
respectively.
Other possible pollutants in hospital waste include solvents, radioisotopes and body fluids (considered
to be infectious). Solvents include alcohols, acetone, xylenes, formalin, some halogenated compounds and
toluene. The continued increase in the use of pharmaceuticals may also affect the composition of wastewater
from health service facilities. Drugs such as antibiotics, antidepressants, birth control pills, seizure
medication, cancer treatment, pain killers, tranquilizers and cholesterol-lowering compounds have been
detected in various water sources. These drugs can pass through conventional sewage treatment facilities
intact, and end up in waterways, lakes and even aquifers. For example, data from Tucson, Arizona, show
Click here to return to start of Appendix B. - 177 -
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approximately 3.4 mg/L of Ibuprofen and 6.3 mg/L Naproxen in effluent from the city's activated sludge
treatment plant.
Medical procedures as well as research utilize radioactive dyes. For example, radioactive sodium iodide
(Na 131-1) is a common compound used in medical treatment for thyroid disease. About 750,000 diagnostic
thyroid scans are performed each year in the United States. Each procedure utilizes about 0.01-0.1 millicuries
of I-131. Patients who have been inj ected with the iodine will eventually excrete the material in their urine or
feces mostly while in the hospital. Radioactive discharges from a hospital to a POTW may result in
radioactive particles suspended in effluent and entrapped in sewage sludge. These discharges are regulated by
the U.S. Nuclear Regulatory Commission.3
Recent studies have shown a variety of pathogenic pollutants present in hospital wastewater, including
bacteria, fungi and viruses. Ozonation has been shown to be a suitable treatment process for the control of
such pollutants prior to the discharge of wastewater from a hospital.
Internationally, high concentrations of AOX (halogenated organic compounds adsorbable on activated
carbon) have been detected in hospital wastewater. In Germany, iodized X-ray contrast media used for
medical applications have been linked to these high concentrations. Photochemical oxidation with hydrogen
peroxide was investigated as a method to reduce concentrations of AOX. Studies demonstrate that complete
removal of the organically bonded iodine and partial mineralization is feasible. The degradation in the UV
reactor was enhanced by adding hydrogen peroxide and by using a bubble column to remove the formed
elemental iodine from the solution by stripping.
The disposal of mercury, a persistent bioaccumulative toxin, is a problem for many health care facilities.
Mercury can accumulate in waste traps and discharge in small amounts each time water is used. Many
hospitals already take steps to reduce or eliminate mercury use. There are many mercury-free products (e.g.,
thermometers, sphygmomanometers) that can be used in place of the conventional mercury-containing
products. Mercury may also originate in laboratory reagents and laundry bleach. Hospitals have begun
testing these products and reagents to quantify the mercury content and investigate product substitution to
reduce mercury use.
The dental industry, which uses mercury amalgam fillings, has also been receiving pressure to reduce
their use of mercury and develop effective techniques for removing mercury from their liquid wastewater
streams. The larger particles of amalgam captured by the chair side dental vacuum system during the
placement or removal of amalgam fillings get caught in the chair side trap. This trap is periodically cleaned,
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and any pieces of amalgam are recycled. However, most of the vacuumed amalgam material is in smaller
particles or slurry, which passes through the chair side trap and enters the wastewater line which eventually
leads to the municipal sewage system. There are several different commercially available amalgam separators
that can remove more than 99 percent of amalgam from dental wastewater streams, however, in most states,
dentists are not required to use amalgam separators.
Composite resin fillings are becoming a popular alternative to conventional amalgam fillings. While the
number of new amalgam restorations is declining, there are still billions of amalgam restorations currently in
place, which will eventually need to be removed. Consequently, the process of removing amalgam
restorations will continue to serve as a source of mercury discharges for many years to come and may
necessitate the implementation of pollution prevention techniques to control the release of mercury from
dental offices.
'This preliminary Plan was signed by EPA
's Assistant Administrator for Water on December 23, 2003. It is expected to be published in the Federal Register on
December 31,2003.
2See "Description and Results of EPA Methodology to Synthesize Screening Level Results for the Effluent Guidelines
Program Plan for 2004/2005," DCN 548, Section 3.0.
3See http://www.nrc.gov/.
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science fora changing world
Pharmaceuticals, Hormones, and Other Organic Wastewater
Contaminants in U.S. Streams
A recent study by the Toxic Substances Hydrology Program of the U.S. Geological Survey (USGS) shows that a broad range
of chemicals found in residential, industrial, and agricultural wastewaters commonly occurs in mixtures at low concentrations
downstream from areas of intense urbanization and animal production. The chemicals include human and veterinary drugs
(including antibiotics), natural and synthetic hormones, detergent metabolites, plasticizers, insecticides, and fire retardants.
One or more of these chemicals were found in 80 percent of the streams sampled. Half of the streams contained 7 or more
of these chemicals, and about one-third of the streams contained 10 or more of these chemicals. This study is the first
national-scale examination of these organic wastewater contaminants in streams and supports the USGS mission to assess
the quantity and quality of the Nation's water resources. A more complete analysis of these and other emerging water-
quality issues is ongoing.
Background: Chemicals, used everyday in homes, industry
and agriculture, can enter the environment in wastewater.
These chemicals include human and veterinary drugs (including
antibiotics), hormones, detergents, disinfectants, plasticizers,
fire retardants, insecticides, and antioxidants. To assess whether
these chemicals are entering our Nation's streams, the Toxic
Substances Hydrology Program of the U.S. Geological Survey
(USGS) collected and analyzed water samples from 139 streams
Household chemicals can enter streams through wastewater
discharges. A wastewater treatment facility near Atlanta,
Georgia, is shown above. (Photograph by Daniel J. Hippe,
U.S. Geological Survey)
Pharmaceuticals, hormones, and other organic wastewater
contaminants were measured in 139 streams during 1999 and
2000.
in 30 states during 1999 and 2000. Streams were sampled that
were considered susceptible to contamination from various
wastewater sources, such as those downstream from intense
urbanization or livestock production. Thus, the results of this study
are not considered representative of all streams.
Although each of the 95 chemicals is used extensively, there
is little information about the extent or occurrence of many of
these compounds in the environment. Some may be indicators
of certain classes of contamination sources, such as livestock
or human waste, and some have human or environmental
health implications. The results of this study are a starting point
for investigation of the transport of a wide range of organic
wastewater contaminants in the Nation's waters.
New laboratory methods were developed in several USGS
research laboratories to provide the analytical capability to
measure concentrations of 95 wastewater-related organic
chemicals in water. Uniform sample-collection protocols and field
and laboratory quality-assurance programs were followed to
ensure that results are comparable and representative of actual
stream conditions.
U.S. Department of the Interior
U.S. Geological Survey
Click here to return to start of Appendix B.
- 180-
USGS Fact Sheet FS-027-02
June 2002
-------
Findings: One or more chemicals were detected in 80 percent of
the streams sampled, and 82 of the 95 chemicals were detected
at least once. Generally, these chemicals were found at very
low concentrations (in most cases, less than 1 part per billion).
Mixtures of the chemicals were common; 75 percent of the
streams had more than one, 50 percent had 7 or more, and 34
percent had 10 or more.
The most frequently detected chemicals (found in more than
half of the streams) were coprostanol (fecal steroid), cholesterol
(plant and animal steroid), N-N-diethyltoluamide (insect repellent),
caffeine (stimulant), triclosan (antimicrobial disinfectant), tri
(2-chloroethyl) phosphate (fire retardant), and 4-nonylphenol
(nonionic detergent metabolite). Steroids, nonprescription drugs,
and insect repellent were the chemical groups most frequently
detected. Detergent metabolites, steroids, and plasticizers
generally were measured at the highest concentrations.
Veterinary Pharmaceuticals used in animal agriculture can
enter streams through runoff or infiltration. A swine facility
near the South Fork Iowa River, Iowa, is shown above.
(Photograph by Doug Schnoebelen, U.S. Geological Survey)
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-------
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- APPENDIX C -
KENTUCKY POLLUTION PREVENTION CENTER
ENVIRONMENTAL MANAGEMENT SYSTEMS (EMS)
AUDITING TOOL
Kentucky
Pollution
Prevention
Center
This auditing tool is for the sole use of health care professionals and health care organizations. Further use,
duplication or distribution of this auditing tool without expressed written consent of the Kentucky Pollution
Prevention Center is unauthorized.
The Kentucky Pollution Prevention Center (KPPC) is the Commonwealth of Kentucky's primary resource for
pollution prevention technical assistance, training and applied research. The Center helps organizations
increase efficiency and profitability by identifying opportunities for waste reduction and other methods of
improving environmental management.
For more information, call toll-free at (800) 334-8635, extension 0965 or direct at (502) 852-0965.
Fax KPPC at (502) 852- 0964 or visit KPPC's Web site at http://www.kppc.org.
Click here to return to Table of Contents.
- 183-
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Kentucky
Pollution
Prevention
Center
Kentucky Pollution Prevention Center
Environmental Management Systems
(EMS) Auditing Tool
oo
Date:
Audit Team:
Lead Auditor:
. Facility Name:
. Facility Location:
_Facility Representative:
Opening meeting:
• Brief introduction and background of auditors
• Review scope (this plant)
• Intent is to collect objective evidence to assess whether organization has a EMS.
• Does the system conform to the ISO 14001 standard?
• Is the system documented where required?
• Does the work agree with the documented/undocumented system?
• Do records show the system works?
• Review audit plan and timetable. There will be a closing meeting each day of the audit to review the sections covered. At the end of the audit,
there will be a final closing meeting with a preliminary written report for the plant before the audit team leaves.
• Establish communication links between audit team and auditee.
• Confirm needed resources and facilities are available.
• Confirm date and time of closing meeting.
• Review relevant site safety and emergency procedures with audit team.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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ISO 14001 Section 4.2 - Environmental Policy: Top management shall define the organization's environmental policy and ensure that it:
a) is appropriate to the nature, scale and environmental impacts of its activities, products or services; b) includes a commitment to
continual improvement and prevention of pollution; c) includes a commitment to comply with relevant environmental legislation and
regulations, and with other requirements to which the organization subscribes; d) provides the framework for setting and reviewing
environmental objectives and targets; e) is documented, implemented, maintained and communicated to all employees; f) is available to
the public.
4.2 Environmental policy
This section requires the organization's top management to define, document, maintain, implement, and communicate an environmental policy that
includes a commitment to continual improvement, prevention of pollution, and a commitment to comply with legal and other requirements.
1.1 Has top management defined the organization's environmental policy?
Note(s) Observations and Recommendations Score
Who is top management? Has it been defined in system?
1 Objective evidence includes meeting minutes showing top
oo management attendees and policy review and approval.
^ Signature(s) by top manager(s) on written policy.
1.2 Is the policy appropriate to the nature and scale of the organization's activities, products, and services?
Note(s) Observations and Recommendations Score
Corporate policies handed down to the facility may not
be appropriate to organization's activities, products, or services.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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1.3 Check to ensure the policy includes:
a) A commitment to continual improvement.
b) A commitment to prevention of pollution.
c) A commitment to comply with relevant environmental legislation and regulations and other requirements to which the organization subscribes, that are
applicable to the environmental aspects of its activities, products, or services?
Note(s)
Observations and Recommendations
Score
1.4 Does the policy provide a framework for setting and reviewing the organization's environmental objectives and targets?
Note(s)
Observations and Recommendations
Score
Score 0=environmental policy does not guide setting
of objectives and targets. Policy written in a way that
leaves readers confused.
Score l=Policy is specific enough to guide setting of
environmental objectives and targets for most aspects;
^ most of policy understandable to interested parties
oo Score 2=policy clear and specific to guide setting of
, environmental objectives and targets; policy
understandable to interested parties.
1.5 Is the policy documented?
Note(s)
Observations and Recommendations
Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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1.6 Is the policy implemented and maintained?
Note(s) Observations and Recommendations Score
Is there evidence of discussion of possible need to change
policy? Organization may review policy and progress toward
objectives and targets annually as part of management
review (4.6). Review meetings may have documented
agendas and minutes indicating preventive and corrective
action.
1.7 Is the policy communicated to all employees?
Note(s) Observations and Recommendations Score
Objective evidence that the policy has been
communicated would include employee answers to
questions under 4.4.2 training, awareness, and
competence. Others include documented training
agendas and course materials, policy postings on bulletin
boards throughout production and common areas,
electronic access from workstations, publications, hardhat
stickers, policy on back of ID badges.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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1.8 How do you make the policy available to the public?
Note(s)
Observations and Recommendations
Score
oo
oo
Objective evidence would include policy posted in lobby,
on brochure in lobby, newspaper clippings, handouts at
community events, etc.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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ISO 14001 4.3 - Planning: Section 4.3.1 - Environmental Aspects: The organization shall establish and maintain (a) procedure(s) to
identify the environmental aspects of its activities, products or services that it can control and over which it can be expected to have an
influence, in order to determine those which have or can have significant impacts on the environment. The organization shall ensure that
the impacts related to these significant aspects are considered in setting its environmental objectives. The organization shall keep this
information up-to-date.
4.3.1 Environmental aspects
This section requires the organization to establish and maintain a procedure for the identification of environmental aspects that could have a
significant impact on the environment. Aspect information is required to be kept up-to-date.
2.1 Does the organization have a procedure to identify environmental aspects of plant's activities, products and services, which it can control
and have influence over?
Note(s)
Observations and Recommendations
Score
oo
VO
1) If no written procedure present, ask how organization
identifies its aspects and assess whether the process
could be duplicated in a controlled and consistent
manner.
2) Relevant records demonstrating application of
procedure include aspect identification worksheets,
meeting minutes from departmental teams identifying
environmental aspects, etc.
3) Are there design, procurement, distribution, product
use and end-of-life issues mentioned in the aspects
procedure?
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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2.2 How do you determine significance of aspects/impacts?
Note(s)
Observations and Recommendations
Score
Was significance of aspects determined in
conformance with the procedure?
2.3 Have environmental aspects which have significant environmental impacts been considered in setting objectives?
Note(s) Observations and Recommendations
Score
2.4 Is aspect information up-to-date?
Note(s)
Observations and Recommendations
Score
1) How frequently is it reviewed (at least annually)?
How are new activities, products, and services
handled within the EMS?
2) Look to see review is occurring as stated and as often
as stated. Examples of objective evidence includes
records of periodic review. This review is commonly
done by environmental staffer functional areas or
Management Review (4.6).
3) New activities, products, and services may be
handled through periodic reviews performed by
environmental staff or functional areas or
Management Review (4.6).
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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ISO 14001 4.3 Planning: Section 4.3.2 - Legal and other requirements: The organization shall establish and maintain a procedure to
identify and have access to legal and other requirements which the organization subscribes, that are applicable to the environmental
aspects of its activities, products or services.
4.3.2 Legal and other requirements
Section 4.3.2 requires the organization to have procedures in place to identify and have access to legal and "other" requirements to which the
organization subscribes. 'Other' requirements include industry codes of practice, voluntary waste minimization/pollution prevention programs
such as Project XL, and corporate policies.
3.1 Does the organization have a procedure to identify/have access to legal requirements that relate to environmental aspects of organization's
activities, products, and services?
Note(s)
Observations and Recommendations
Score
1) If no written procedure present, ask how organization
identifies its legal requirements and assess whether
the process could be duplicated in a controlled and
1 consistent manner.
vo 2) Choose a requirement that the organization
h]~' determined was not applicable. Ask them to show
how they made this determination.
3) Objective evidence that legal requirements have been
identified may include a list/matrix of applicable
regulatory requirements. Pick 2 or 3 legal
requirements and ask auditee to show regulatory text
that is applicable. Is it done how the procedure says
it would be done? Objective evidence for access to
legal requirements includes corporate counsel,
ongoing subscriptions to BNA, CD-ROM's, Internet
bookmarks, corporate headquarters legal staff, CFRs
present during audit, and EPA compliance audits and
results.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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3.2 Does the organization have a procedure to identify/have access to other requirements (relating to environmental aspects of activities,
products, services) to which the organization may subscribe?
Note(s)
Observations and Recommendations
Score
to
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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ISO 14001 Section 4.3.3 - Objectives and Targets: The organization shall establish and maintain documented environmental objectives
and targets, at each relevant function and level within the organization. When establishing and reviewing its objectives, an organization
shall consider the legal and other requirements, its significant environmental aspects, its technological options and its financial,
operational and business requirements, and the views of interested parties. The objectives and targets shall be consistent with the
environmental policy, including the commitment to prevention of pollution.
4.3.3 Objectives and targets
Section 4.3.3 specifies several factors that must be considered for setting objectives and targets. These include, significant environmental aspects,
legal and other requirements, views of stakeholders, technology, financial, operational and other business issues. ISO 14001 also requires the
objectives and targets to link to the environmental policy, and be established at every relevant function and level in the organization.
4.1 Does the organization have documented objectives and targets?
Note(s) Observations and Recommendations
Score
4.2 Are the objectives and targets established at each relevant function and level within the organization?
Note(s)
Observations and Recommendations
Score
This requirement is most commonly addressed in the
documentation through a statement indicating that
objectives and targets apply throughout the organization.
Objective evidence will come through questioning
employees on their knowledge.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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VO
4.3 How were each of the following considered in establishing and reviewing objectives:
a) Legal requirements?
b) Other requirements?
c) Significant environmental aspects?
d) Technological options?
e) Financial requirements?
f) Operational requirements?
g) Business requirements?
h) Views of interested parties?
Note(s) Observations and Recommendations Score
4.4 Who are the organization's external interested parties? How did you consider their views in setting your objectives and targets?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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4.5 Has responsibility for establishing and maintaining documented objectives and targets been assigned?
Note(s) Observations and Recommendations Score
1) Tell me how you review your objectives and targets.
How frequently are they reviewed? Who reviews and
approves the objectives and targets?
2) Look to see review is occurring as stated and as often
as stated. Examples of objective evidence includes
records of periodic review of the procedure. This
review is commonly done by environmental staffer
Management Review (4.6) but frequency of review
should be specified.
4.6 Are objectives and targets consistent with the environmental policy, including commitment to prevention of pollution?
Note(s) Observations and Recommendations Score
4.7 Is reasonable progress being made in accomplishing objectives and targets?
Note(s) Observations and Recommendations Score
1) Review quarterly or annual reports on objectives and
targets when auditing Management Review 4.6. Have
they been reviewed by management? Are corrective
actions being implemented that improve the chances
of meeting targets for the objectives?
2) Progress toward objectives and targets may provide
objective evidence of 4.2 Environmental Policy
continual improvement.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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4.8 As objectives and targets are met, are new ones established?
Note(s) Observations and Recommendations Score
1) As objectives and targets are achieved, are new ones
established? This would be objective evidence for
continual improvement under 4.2(b) and (d).
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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VO
ISO 14001 Section 4.3.4 - Environmental Management Program (s): The organization shall establish and maintain (a) program(s) for
achieving its objectives and targets. It shall include: a) designation of responsibility for achieving objectives and targets at each relevant
function and level of the organization; b) the means and time frame by which they are to be achieved. If a project relates to new
developments and new or modified activities, products or services, program(s) shall be amended where relevant to ensure that
environmental management applies to such projects.
4.3.4 Environmental management program(s)
This section requires the organization to establish programs for achieving its objectives and targets. The program requirement specifically includes
designation of responsibility at each relevant function and level in the organization, and the means and time frame by which these objectives are to
be achieved. The program is also required to address new activities, products, or services.
5.1 Has the organization established an environmental management program(s) for achieving its objectives and targets?
Note(s) Observations and Recommendations Score
5.2 Has responsibility for achieving objectives and targets at each relevant function and level of the organization been established in the BMP?
Note(s) Observations and Recommendations Score
Pick 2 or 3 objectives and ask auditee to describe which
plant areas are affected by each target/objective.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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VO
oo
5.3 Has the organization specified the time frames by which objectives and targets will be achieved?
Note(s) Observations and Recommendations Score
Do key personnel know relevant timeframes for achieving
objectives and targets? This can be objective evidence of
4.4.2 (d) and 4.4.3 (a).
5.4 Has the organization specified how objectives and targets will be achieved?
Note(s) Observations and Recommendations Score
Objective evidence can include work instructions.
Objective evidence of financial means would include
budgets for EMPs, line item in accounting budget for EMS
or EMP expenditures, staffing plans and vacancies in the
environmental programs.
5.5 How is progress toward objectives and targets measured?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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VO
VO
5.6 Does the organization maintain/review programs for achieving objectives and targets?
Note(s) Observations and Recommendations Score
This review may be mentioned under 4.3.3 Objectives and
targets. Examples of objective evidence include records
of periodic review. This review is commonly done by
environmental staffer Management Review (4.6). Look to
see how often review will be conducted.
5.7 When new or modified activities, products or services are implemented, how do you ensure that environmental management applies to these
projects?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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ISO 14001 4.4 Implementation and Operation: Section 4.4.1 - Structure and Responsibility: Roles, responsibilities and authorities shall
be defined, documented and communicated in order to facilitate effective environmental management. Management shall provide
resources essential to the implementation and control of the environmental management system. Resources include human resources and
specialized skills, technology and financial resources. The organization's top management shall appoint (a) specific management
representative(s) who, irrespective of other responsibilities, shall have defined roles, responsibilities and authorities for: a) ensuring that
environmental management system requirements are established, implemented and maintained in accordance with this standard; b)
reporting on the performance of the environmental management system to top management for review and as a basis for improvement of
the environmental management system.
4.4.1 Structure and responsibility
This section requires the organization to formally and clearly define, document, and communicate environmental responsibilities, and to assign a
management representative with responsibility for overseeing the overall implementation of the EMS.
6.1 Are environmental roles (what has to get done), responsibilities (who gets it done), and authorities (who sees that it gets done) documented?
If not documented, have environmental roles been defined?
g Note(s) Observations and Recommendations Score
o
6.2 Are environmental roles (what has to get done), responsibilities (who gets it done), and authorities (who sees that it gets done)
communicated?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
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6.3 Have adequate resources (human, skills, technology, and financial) been provided for the implementation and control of the EMS?
Note(s) Observations and Recommendations Score
How are human, financial, and technological resources
allocated/provided to the EMS? Objective evidence of
financial support would include line item in accounting
budget or an account number for EMS expenditures.
6.4 Has top management appointed an EMS management representative?
Note(s) Observations and Recommendations Score
Be sure to look for documentation/record of appointment
of top management representative (e.g., in a letter or
memo of commitment from President/General Manager or
an organization chart that shows roles and
responsibilities).
o 6.5 Do the roles and responsibilities of the management's representative(s) fulfill the duties described in Section 4.4.1 a) and b) of the Standard?
Note(s) Observations and Recommendations Score
Top management shall appoint representatives who ensure
EMS requirements are established, implemented, and
maintained" (a) and who report the performance of the EMS
to top management (b). See 6.4 above.
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ISO 14001 Section 4.4.2 - Training, Awareness and Competence: The organization shall identify training needs. It shall require that all
personnel, whose work may create a significant impact upon the environment, receive appropriate training. It shall establish and
maintain procedures to make its employees or members at all relevant levels aware of: a) the importance of conformance with the
environmental policy and procedures and with the requirements of the environmental management system; b) the significant
environmental impacts, actual or potential, of their work activities and the environmental benefits of improved personal performance; c)
their roles and responsibilities in achieving conformance with the environmental policy and procedures, and with the requirements of the
environmental management system including emergency preparedness and response requirements; d) the potential consequences of
departure from specific operating procedures.
Personnel performing tasks which can cause significant environmental impacts shall be competent on the basis of appropriate education,
training and/or experience.
4.4.2 Training, awareness, and competence
This section requires the organization to evaluate and implement specific training activities for those personnel at each relevant function and level,
whose job activities could have a significant impact on the environment. Training is required to include general environmental awareness, and job
i specific training.
o 7.1 Has the organization identified what job functions may have a significant impact on the environment? How does organization identify EMS
, training needs?
Note(s) Observations and Recommendations Score
1) Sample-check that personnel (preferably a key line
operator, manager, and supervisor) whose work can
have a significant impact on the environment have
been identified.
2) Objective evidence can include lists of positions
within the organization and associated training needs,
procedures for training, as well as organization charts.
3) Documentation should link personnel whose work can
have a significant impact on the environment to the
training they receive.
4) Was the training delivered? Look at training records
(4.5.3), agendas, class materials/training curricula to
verify what was covered in the training.
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7.2 Has the organization established a procedure to make its employees aware of the following?
a) The importance of conformance with the environmental policy, procedures, and requirements of the EMS.
b) The significant actual and potential impacts of their work and the benefits of improved personal performance.
c) Their roles and responsibilities in achieving conformance with the environmental policy, procedures, EMS, and emergency preparedness and
response procedures.
d) The potential consequences of departure from specified operating procedures.
Note(s) Observations and Recommendations Score
7.3 How does the organization assess competence of personnel whose work can cause significant environmental impacts?
Note(s) Observations and Recommendations Score
7.4 Have training needs for the EMS representative been determined?
Note(s) Observations and Recommendations Score
Verify whether the EMS representative received this
training? Ask for EMS representative's training records
(4.5.3).
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7.5 Who else provides training that is required? How were they trained or qualified to be a trainer?
Note(s) Observations and Recommendations Score
a) Ask to see objective evidence of training received and
competency.
b) If experience is called out as the basis of competency,
follow up with questions: how many years of
experience required? How do you decide 'how much'
experience is enough? What qualifies as experience?
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ISO 14001 Section 4.4.3 - Communication: With regard to its environmental aspects and environmental management system, the
organization shall establish and maintain procedures for: a) internal communication between various functions and levels of the
organization; b) receiving, documenting and responding to relevant communication from external interested parties.
The organization shall consider processes for external communication on its significant environmental aspects and record its decision.
4.4.3 Communication
This section requires the organization to establish and maintain procedures for communicating its aspects and elements of the environmental
management system to external interested parties. It also requires the organization to consider a process for communicating to external parties
about its significant aspects, and record its decision.
8.1 Is there a procedure for internal communication of the EMS and the environmental aspects between the various levels and functions of the
organization?
^j Note(s) Observations and Recommendations Score
o
, 1) If yes, is communication occurred as indicated in the
procedure?
2) Any of the following may be sample items that a
facility may point to as examples of how internal
communication occurs: training-related materials,
agendas, sign-up sheets, and overheads from
environmental meetings.
3) A common nonconformance is that documented
internal communications were required under the
Standard but transmitted verbally.
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8.2 Is there a procedure for receiving, documenting and responding to communications from external interested parties regarding the
organization's environmental aspects and EMS?
Note(s) Observations and Recommendations Score
1) There are three things to look for: how it receives,
documents, and responds to the request.
2) Have you received any external requests for
information? If yes, ask/look to see how these have
been handled in the system. Is it how they said it
would be handled? Was it documented? Responded
to in the required or reasonable period of time? One
test would be to call ahead to ask for significant
aspects. When on-site, verify that your request has
been handled within the system. A common example
of an external request is a sister facility calling for
information on the EMS.
8.3 Has the organization has documented a decision as to whether or not it will communicate information on its aspects and EMS to external
interested parties.
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.4.4 - Environmental Management System Documentation: The organization shall establish and maintain
information, in paper or electronic form, to: a) describe the requirements of the management system and their interaction, b) provide
direction to related documentation.
4.4.4 Environmental management system documentation
This section requires the organization to maintain documentation (electronically or written) which describes the core elements of the EMS, their
interaction, and directions to related documentation.
9.1 Is there documentation describing the core elements of the EMS and their interaction?
Note(s) Observations and Recommendations Score
There are a variety of ways to show interaction among the
elements: references within the procedures (probably
most common), flowcharts, procedural matrices, EMS
table of contents or Master Document Control List.
9.2 Does the scope of the EMS documentation and related documents cover all elements of the ISO 14001 standard? Does documentation
provide direction to related documents?
Note(s) Observations and Recommendations Score
Related documentation may include internal standards
and operational procedures, process information, site
emergency plans, etc.
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ISO 14001 Section 4.4.5 - Document Control: The organization shall establish and maintain procedures for controlling all documents
required by this standard to ensure that: a) they can be located; b) they are periodically reviewed, revised as necessary and approved for
adequacy by authorized personnel; c) the current versions of relevant documents are available at all locations where operations essential
to the effective functioning of the system are performed; d) obsolete documents are promptly removed from all points of issue and points
of use or otherwise assured against unintended use; e) any obsolete documents retained for legal and/or knowledge preservation purposes
are suitably identified. Documentation shall be legible, dated (with dates of revision) and readily identifiable, maintained in an orderly
manner and retained for a specified period. Procedures and responsibilities shall be established and maintained concerning the creation
and modification of the various types of documents.
4.4.5 Document control
This section requires the organization to establish and maintain procedures for controlling documentation related to the EMS.
This section is largely audited while looking at other system requirements.
Generally speaking, if a paper/reference is being used to answer an auditor question, to support the system or to communicate information
regarding the system, it should be in document control and meet document control requirements.
to
oo 10.1 Does the organization have a procedure for controlling documents required by ISO 14001?
Note(s) Observations and Recommendations Score
10.2 Does the procedure ensure that:
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a) Documents are locatable?
b) Documents are periodically reviewed, revised as necessary, and approved for adequacy by authorized personnel?
c) Current versions of relevant documents are available at all locations where operations essential to the effective functioning of the EMS are
performed?
d) Obsolete documents are promptly removed from all points of issue and use, or otherwise protected from unintended use?
e) Obsolete documents retained for legal and/or knowledge preservation purposes are suitably identified?
Note(s) Observations and Recommendations Score
10.3 Has responsibility for fulfilling document control responsibilities been assigned?
to
o Note(s) Observations and Recommendations Score
10.4 Is documentation legible?
Note(s) Observations and Recommendations Score
10.5 Does documentation have dates of revision?
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Note(s) Observations and Recommendations Score
10.6 Is documentation readily identifiable?
Note(s) Observations and Recommendations Score
10.7 Is documentation maintained in an orderly manner?
Note(s) Observations and Recommendations Score
10.8 Is documentation retained for a specific period?
Note(s) Observations and Recommendations Score
10.9 Are there assigned responsibilities for creating and modifying EMS documents?
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Note(s) Observations and Recommendations Score
10.10 Is there/are there procedure(s) for creating and modifying EMS documents?
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.4.6 - Operational Control: The organization shall identify those operations and activities that are associated with the
identified significant environmental aspects, in line with its policy, objectives and targets. The organization shall plan these activities,
including maintenance, to ensure that they are carried out under specified conditions by: a) establishing and maintaining documented
procedures to cover situations where their absence could lead to deviations from the environmental policy and the objectives and targets
b) stipulating operating criteria in the procedures; c) establishing and maintaining procedures related to the significant environmental
aspects of goods and services used by the organization and communicating relevant procedures and requirements to suppliers and
contractors.
4.4.6 Operational control
This section requires the organization to identify operations and activities that are associated with the significant aspects, then document
procedures whenever the absence of documented procedures could result in deviations from the environmental policy and objectives and targets.
All operational control procedures should have operating criteria spelled out. There should be procedure(s) for communicating applicable and
relevant operational procedures and requirements to suppliers and contractors.
11.1 Has the organization identified operations and activities associated with its identified significant environmental aspects?
Note(s) _ Observations and Recommendations _ Score _
11.2 Has the organization established documented work instructions and procedures to cover situations where their absence could lead to
deviations from the environmental policy, objectives and targets?
Note(s) Observations and Recommendations Score
Sample several operations and activities associated with
significant aspects. Verify that the procedures tell
"how-to".
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11.3 Has the organization established operating criteria in the work instructions and procedures?
Note(s) Observations and Recommendations Score
11.4 Are relevant documented procedures available at locations where these operations and activities are performed?
Note(s) Observations and Recommendations Score
Is maintenance crew on spill response team? Is
emergency preparedness and response procedure
available at this workstation?
11.5 Has responsibility for implementing these work instructions and procedures been assigned?
Note(s) Observations and Recommendations Score
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11.6 Has responsibility for periodically reviewing and updating these work instructions and procedures been assigned?
Note(s) Observations and Recommendations Score
Tell me how you maintain the procedure. How frequently
is it maintained/reviewed? Look to see review is
occurring as stated and as often as stated. Examples of
objective evidence include records of periodic review.
This review is commonly done by environmental staffer
Management Review (4.6) but frequency of review should
be specified.
11.7 Has the organization established and maintained procedure(s) related to the identifiable significant environmental aspects of goods and
services used by the organization? How are these communicated to suppliers and contractors?
Note(s) Observations and Recommendations Score
1) Show me some of the relevant procedures and
requirements you have for your suppliers and
contractors.
2) Organization should have a procedure that identifies
suppliers (i.e. those whose goods and services are
related to significant aspects) and provides for
communicating relevant procedures and requirements
to these suppliers.
3) Record of this training/external communication could
include mailing of aspect/impact/objectives and
targets/sheet with signed confirmation back to
organization.
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ISO 14001 Section 4.4.7 - Emergency Preparedness and Response: The organization shall establish and maintain procedures to identify
potential for and respond to accidents and emergency situations, and for preventing and mitigating the environmental impacts that may
be associated with them. The organization shall review and revise, where necessary, its emergency preparedness and response
procedures, in particular, after the occurrence of accidents or emergency situations. The organization shall also periodically test such
procedures where applicable.
4.4.7 Emergency preparedness and response
This section requires the organization to establish and maintain procedures for identifying and responding to potential accidents and emergency
situations; preventing and mitigating associated environmental impacts. The organization shall review procedures especially after accidents and
emergency, and revise procedures where necessary.
12.1 Has the organization established a procedure to identify the potential for accidents and emergency situations?
Note(s) Observations and Recommendations Score
Has the organization defined accidents and emergencies?
to
12.2 Does the procedure address how the organization will respond to accidents and emergency situations so as to prevent and mitigate the
associated environmental impacts?
Note(s) Observations and Recommendations Score
Objective evidence of how the organization would respond
include referenced SPCC Plans, RCRA Hazardous Waste
plans, Stormwater Pollution Prevention Plans, etc.
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12.3 Are emergency preparedness and response procedures available in applicable operational areas?
Note(s) Observations and Recommendations Score
Check during tour, while interviewing key employees.
12.4 Are the procedures maintained, reviewed and updated regularly and when necessary, particularly after the occurrence of accidents or
emergency situations?
Note(s) Observations and Recommendations Score
Have any accidents or emergencies occurred? If so, may
want to see if organization reviewed its procedures. What
would guide decision to review and update the procedure?
Look at incident investigation results and corrective
actions. If one of the potential accidents occurred, what
would be the steps that would be followed for reviewing
and revising the procedures.
12.5 Does the organization periodically test these procedures where practicable? Has responsibility been assigned in these circumstances?
Note(s) Observations and Recommendations Score
Some organizations say: "The organization shall
periodically test such procedures where practicable." How
do you determine if it is practicable to test the procedure?
If practicable, when were they last tested. Look for log of
last test date and time.
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ISO 14001 4.5 Checking and Corrective Action: Section 4.5.1 - Monitoring And Measurement: The organization shall establish and
maintain documented procedures to monitor and measure, on a regular basis, the key characteristics of its operations and activities that
can have a significant impact on the environment. This shall include the recording of information to track performance, relevant
operational controls and conformance with the organization's objectives and targets. Monitoring equipment shall be calibrated and
maintained, and records of this process shall be retained according to the organization's procedures. The organization shall establish and
maintain a documented procedure for periodically evaluating compliance with relevant environmental legislation and regulations.
4.5.1 Monitoring and measurement
This section requires the organization to establish and maintain documented procedures to monitor and measure the key characteristics of
operations and activities that are related to the significant aspects. This should include a requirement for documented procedures for compliance
auditing and monitoring equipment maintenance and calibration.
13.1 Has the organization established documented procedures to monitor and measure on a regular basis the key characteristics (as determined in
4.4.6) of its operations and activities that can have a significant impact on the environment?
, Note(s) Observations and Recommendations Score
to
^ How do you monitor and measure operations and activities
i that can have a significant impact on the environment?
What are the measurements you use that show you are
making progress toward your objectives and targets?
13.2 Does the procedure include requirements for recording information to track performance, relevant operational controls, and conformance
with the organization's objectives and targets?
Note(s) Observations and Recommendations Score
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13.3 Is there a procedure for calibrating and maintaining monitoring equipment?
Note(s) Observations and Recommendations Score
13.4 Are records of calibration and maintenance retained according to the organization's procedures?
Note(s) Observations and Recommendations Score
13.5 Has the organization established a documented procedure for periodically evaluating compliance with relevant environmental legislation and
regulations?
• Note(s) Observations and Recommendations Score
to
oo 1) Procedure should specify how and when compliance
1 will be evaluated.
2) Verify that compliance evaluations have been
performed as described and at specified time
intervals. Objective evidence includes internal and
external compliance audit reports.
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ISO 14001 Section 4.5.2 - Nonconformance, Corrective and Preventative Action: The organization shall establish and maintain
procedures for defining responsibility and authority, for handling and investigating nonconformance, taking action to mitigate any
impacts caused by non-conformances and for initiating and completing corrective and preventative action. Any corrective or
preventative action taken to eliminate the causes of actual and potential non-conformances shall be appropriate to the magnitude of
problems and commensurate with the environmental impact encountered.
4.5.2 Nonconformance and corrective and preventive action
This section of the ISO 14001 requires that the organization identify the causes of nonconformance, identify and implement the necessary
corrective action, implement or modify controls necessary to avoid repeating the nonconformance, and record any changes in written procedures
resulting from the corrective action.
14.1 Does the organization have a procedure that defines responsibility and authority for:
a) Handling and investigating nonconformance, including determining root cause of the nonconformance?
b) Taking action to mitigate impacts caused by non-conformances?
c) Initiating and completing corrective and preventive action?
Note(s) Observations and Recommendations Score
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14.2 Has corrective or preventive action (if any) taken been appropriate to the magnitude of the problem and commensurate with the
environmental impacts?
Note(s) Observations and Recommendations Score
If so, was the nonconformance/suggestion handled
according to procedure? Has the organization
implemented and recorded any changes in the
documented procedures resulting from the corrective and
preventive action?
14.3 Has the organization implemented and recorded any changes in the documented procedures resulting from the corrective and preventive
action?
Note(s) Observations and Recommendations Score
1) Have appropriate changes have been carried through
the system and made in documented procedures,
training, relevant work instructions/procedures, etc.
2) If no non-conformances, have there been any
suggestions brought forward to improve the system?
Is there a mechanism, perhaps as part of 4.4.3
Communication, whereby employees can bring
forward suggestions for the EMS? Suggestions
brought forward and handled appropriately in the
system can be objective evidence of a procedure in
place to handle corrective and preventive action. Ask
to see related forms and records. Related records
could include action request forms, action request
logs, etc.
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14.4 Has responsibility for the following been assigned?
a) Handling and investigating nonconformance's
b) Taking action to mitigate impacts of nonconformance's
c) Initiating and completing corrective and preventive action
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.5.3 - Records: The organization shall establish and maintain procedures for the identification, maintenance and
disposition of environmental records. These records shall include training records and the results of audits and reviews. Environmental
records shall be legible, identifiable and traceable to the activity, product or service involved. Environmental records shall be stored and
maintained in such a way that they are readily retrievable and protected against damage, deterioration or loss. Their retention times
shall be established and recorded. Records shall be maintained, as appropriate to the system and to the organization, to demonstrate
conformance to the requirements of this standard.
4.5.3 Records
This section requires the organization to establish and maintain procedures for handling environmental records. Records are used to show that the
organization is doing what procedures said would be done.
15.1 Has the organization established procedures to identify, maintain and dispose of environmental records?
Note(s) Observations and Recommendations Score
Training records, EMS audit records, and management
1 review records are the minimum system records that must
fo be kept. See that these are referenced from the
^ Record(s) procedure.
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15.2 Has responsibility for maintenance and disposition of records been assigned?
Note(s) Observations and Recommendations Score
1. Are records identified, maintained, and disposed of as
indicated in the procedure?
Note: Sample check records to verify that records
are being kept in accordance with the written
retention times.
2. How frequently is it maintained/reviewed? Look
to see review is occurring as stated and as often as
stated. Examples of objective evidence include
records of periodic. This review is commonly done
by environmental staffer Management Review (4.6)
but frequency of review should be specified.
15.3 Do environmental records in the procedure include training records and the results of audits and reviews?
Note(s) Observations and Recommendations Score
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15.4 Are environmental records:
a) Legible?
b) Identifiable?
c) Traceable to the activity, product, or service involved?
d) Readily retrievable?
e) Protected against damage, deterioration, or loss?
Note(s) Observations and Recommendations Score
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ISO 14001 Section 4.5.4 - Environmental Management System Audit: The organization shall establish and maintain programs and
procedures for periodic environmental management system audits to be carried out, in order to: (a) determine whether or not the
environmental management system: 1) conforms to planned arrangements for environmental management including the requirements of
this standard; 2) has been properly implemented and maintained; (b) provide information on the results of audits to management. The
audit program, including any schedule, shall be based on the environmental importance of the activity concerned and the results of
previous audits. In order to be comprehensive, the audit procedures shall cover the audit scope, frequency and methodologies, as well as
the responsibilities and requirements for conducting audits and reporting results.
4.5.4 Environmental management system audits
This section requires the organization to establish and maintain procedures and programs for periodic audits of the EMS.
16.1 Has the organization established a procedure/program for periodic EMS audits?
Note(s) Observations and Recommendations Score
16.2 Does the audit procedure/program:
a) Determine whether or not the EMS conforms to planned arrangements for environmental management including ISO 14001?
b) Determine whether the EMS has been properly implemented and maintained?
c) Address how audit information is provided to management?
Note(s) Observations and Recommendations Score
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16.3 Do audit procedures address the following:
a) Audit scope?
b) Audit frequency? (Note: Does the audit program and procedure provide for audit frequency and scope appropriate to the importance of the
activity concerned and results of previous audits? A follow-up question may ask how the organization takes importance of the activity and
results of previous audits into consideration when determining audit frequency.)
c) Audit methodologies?
d) Responsibilities and requirements for conducting and reporting audit results?
Note(s) Observations and Recommendations Score
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ISO 14001 4.6 Management Review: The organization's top management shall, at intervals it determines, review the environmental
management system, to ensure its continuing suitability, adequacy and effectiveness. The management review process shall ensure that
the necessary information is collected to allow management to carry out this evaluation. This review shall be documented. The
management review shall address the possible need for changes to policy, objectives and other elements of the EMS, in the light of
environmental management system audit results, changing circumstances and the commitment to continual improvement.
4.6 Management review
This section requires the organization's top management to periodically review the EMS for suitability and effectiveness, and to make changes to
the system where appropriate. This review must be documented.
17.1 Is there a procedure for top management review to ensure EMS suitability, adequacy, and effectiveness?
Note(s) Observations and Recommendations Score
17.2 Does the procedure address what will be reviewed?
Note(s) _ Observations and Recommendations _ Score
17.3 Has top management determined the frequency of the reviews?
Note(s) Observations and Recommendations Score
Look to see where top management determined how often
it meets for management review.
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17.4 Are EMS audit results reviewed during management review?
Note(s) Observations and Recommendations Score
17.5 Does management review address possible need for changes to the environmental policy, objectives, and other elements of the EMS?
Note(s) Observations and Recommendations Score
17.6 Has top management participated in the review?
Note(s) Observations and Recommendations Score
, Verify that all procedures to be reviewed during
to management review are in fact reviewed at this time.
oo Verify that possible need for changes to policy, objectives,
1 etc., have been considered. Make sure these are
documented as having been considered.
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Position/of person interviewed:
Department/work area;
1. What do you do? (What are your job responsibilities?)
Note(s) Observations and Recommendations Score
2. What is the environmental policy? What does policy mean to you?
Note(s) Observations and Recommendations Score
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3. How does your work impact the environment? What do you do to reduce these impacts, to protect the environment? Listen for mention of
significant impacts, objectives and targets and work instructions. How did you know to do this?
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence of 4.3.4 (a).
4. How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
follow?) Do you have to record any information? Ask to see.
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence for
4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
5. How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?
Note(s) Observations and Recommendations Score
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6. What environmental training have you had? When was it?
Note(s)
Observations and Recommendations
Score
7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
emergency? A spill? Have you had drills lately? When? (4.4.7)
Note(s)
Observations and Recommendations
Score
to
oo
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
Objective evidence of 4.4.5 (c) Reasonable for members
of emergency response/action team to have copy of plan
at their workstation. Competency (4.4.2) demonstrated
through question and answer acceptable.
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8. Can you provide example of something that's improved environmentally here over the last couple of years?
Note(s) Observations and Recommendations Score
9. What would you like to see improve environmentally here in the future?
Note(s) Observations and Recommendations Score
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Position/of person interviewed:
Department/work area;
1. What do you do? (What are your job responsibilities?)
Note(s) Observations and Recommendations Score
2. What is the environmental policy? What does policy mean to you?
Note(s) Observations and Recommendations Score
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3. How does your work impact the environment? What do you do to reduce these impacts, to protect the environment? Listen for mention of
significant impacts, objectives and targets and work instructions. How did you know to do this?
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence of 4.3.4 (a).
4. How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
follow?) Do you have to record any information? Ask to see.
Note(s) Observations and Recommendations Score
^ Answers to this can provide objective evidence for
<->-> 4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
5. How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
6. What environmental training have you had? When was it?
Note(s)
Observations and Recommendations
Score
7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
emergency? A spill? Have you had drills lately? When? (4.4.7)
Note(s)
Observations and Recommendations
Score
to
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
Objective evidence of 4.4.5 (c) Reasonable for members
of emergency response/action team to have copy of plan
at their workstation. Competency (4.4.2) demonstrated
through question and answer acceptable.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
8. Can you provide example of something that's improved environmentally here over the last couple of years?
Note(s) Observations and Recommendations Score
9. What would you like to see improve environmentally here in the future?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
Position/of person interviewed:
Department/work area;
1. What do you do? (What are your job responsibilities?)
Note(s) Observations and Recommendations Score
2. What is the environmental policy? What does policy mean to you?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
oo
oo
3. How does your work impact the environment? What do you do to reduce these impacts, to protect the environment? Listen for mention of
significant impacts, objectives and targets and work instructions. How did you know to do this?
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence of 4.3.4 (a).
4. How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
follow?) Do you have to record any information? Ask to see.
Note(s) Observations and Recommendations Score
Answers to this can provide objective evidence for
4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
5. How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?
Note(s) Observations and Recommendations Score
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
6. What environmental training have you had? When was it?
Note(s)
Observations and Recommendations
Score
7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
emergency? A spill? Have you had drills lately? When? (4.4.7)
Note(s)
Observations and Recommendations
Score
to
oo
VO
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
Objective evidence of 4.4.5 (c) Reasonable for members
of emergency response/action team to have copy of plan
at their workstation. Competency (4.4.2) demonstrated
through question and answer acceptable.
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
8. Can you provide example of something that's improved environmentally here over the last couple of years?
Note(s) Observations and Recommendations Score
9. What would you like to see improve environmentally here in the future?
Note(s) Observations and Recommendations Score
to
j^.
o
KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
- APPENDIX D -
U.S. EPA REGION 1
COMPLIANCE AUDITING TOOL
United States
Environmental Protection
Agency
Click here to return to Table of Contents. - 241 -
-------
&EPA
EPA New England- Hospital Environmental Assessment Template
An amirownsntal compliance and pollution pvpvennon tool
Introduction
This tool was developed fci an Office of Environmental Compliance and .Assistance (GEC'A) grant which was given to the University
3f New Hampshire Pollution Prevention Program. The lool was modified into three state specific took for CT. RI mid NH, The
intetiu collected and compiled information from i total of 25 hospitxls in flic three sates. A copy of the £nil report can be found si
http: '\\iv\v.uah.edu'ij2'i;iapi3C'i-2CK}3 jitml This tool is not aJl-iadiMive and it doe* not include all Federal hospital requirements or
preferable practices. If you are a VA there ate additional requirements that TV til apply to you that are not covered m this template in
addition. TOO should al»o atwav^ chest: with wur state for any additional state requirements- If you would lite a word version of thii
document to customize for your state or EPA Region, please email Janet Bowen of EPA Region I at Bowen.JanettjJ-epa .gov or coll hej
directly at <617)91S-t 795 "
Section I; General Facility
1.1 Number of Hotpi lal Beds
1.2 What sate are you located in*1
' 5-200
200
1.3 Whar departments ) are ne-:-poasible for eavircmnfttital coinpJiaiice at youi- hospnal1 (Check ill that apply)
_ Health and Safety _ MainreiiauceTaciiity _ Industrial Hygienic
_ Environments!
Nursing
1.4 lias Y3oi hospital used t?A technics! retonrces1' (Check ali that apply)
Otber
Accessed H2E website
Participate H2E teleconferences
H2E fact sheets
j-21'01 Hospital workshop in CT
Accessed Region I website
SPCC Amendment fact sheet
Participate on Hit Lht^err
PamcipaTe EnergrStar mferaet trmminE
H2E Assessment
EPA presemsiion
11/6'02 SPCCtraimnsinCT
EPCRA fact siieei
Telephcne a^siifance from tPA
Infoyamion from EPA at event
Accessed EPA website
EnergvStaf Beuchmarfcuis, ia£oiinaitou
Mercr.r," Challenge Partneiar du'ector,'
Other (Specify)
1,3 Whai changes or actions (if any) have you nude as a result of EFA/H2E a «i stance11 (Check all that apply)
Filed notification Became IDE Partnet Improved'evalnated water
Obtained penuit Inventoried mercury use-'equipment efficiency
Provided employee training Benchmaiked-increase energy efficiency Reduced'replaced mercury items
Submitted documentation to EPA, Stats Minimized infectious u'sste __In«atuted'increased recycling tew
Adopted fonml purchasing policy Came into compliance Othei (S
Section II: Compliance Self Assessment
1,0 Resource Conservation and Recover}- Act (RCRA) (40 CFR 261. 262, 165)
1 1
1 2
15
1 4
! 5
What is vow hospital'^ Eenerafor itatusT' (Pleaie check)
No Hazardous w>ae CESQGJ SQGJ LQGJ Doa'tKnow (DKj
Does your hospital have in EPA hazaidoa? waste eenerator number?
Storage
Is all hazardous waste stored in either a satellite acciiaailalion area and,1 or a -itpirafe hazardous iTaste
storage arean
Aie the satellite accumulation area^ clearly identified!*
Are ali liazardons wa«« containers kept closed except when filling or adding waste1*
i -
i
N
Ssice
DK
KA
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1.0 Resource Conservation and Recovery Act (RCRA) (40 CFR 261, 262, 265)
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
Are all hazardous waste containers in good condition0
Is there a secondary containment system in the hazardous waste storage area0'
Does the storage area have an impervious surface and no floor drain?
Does your hospital maintain emergency and safety equipment within the hazardous waste storage
area? (spill kits, eve ivash, personal protective equipment (PPE). etc.)
Does your hazardous waste storage area have a communication device11 (telephone, alarm, etc.)
Labeling
Are hazardous wastes stored in labeled containers with:
the words ""Hazardous Waste"
the name of waste.
the EPA waste code
the date container was placed in storage9
Inspections
Is the hazardous waste storage area inspected weekly for signs of spills or container deterioration'1
Are the inspections documented11
Is there a hazardous waste determination on file for all wastes9
Contingency Plan
Is there an updated RCRA Contingency Plasi including accurate phone numbers'1
Was a copy of the RCRA Contingency Plan sent to the local fire department?
Training
Do employees receive hazardous waste management training related to their job duties?
Are these training records maintained':'
Manifests
Does the hospital maintain its manifests for at least three years?
Does the hospital maintain Land Disposal Restriction notices with the manifests that they are
providing the Notice for*1
Y
N
Some
DK
KA
2.0 Universal Waste' (40 CFR 273)
2.1
1 ~>
2.3
2.4
Does your hospital handle Universal Waste separately from your other hazardous waste?
Tip: For more information on Universal Waire visit
hnp:wv^\epa.KO\?epaoswer/hazYiasie>'idfimi\\(ast.ktn\
If yes to 2.1, does your hospital label its Universal Waste and specify type (e.g.. lamps, batteries)?
If yes to 2.1. does your hospital store Universal Waste in appropriate containers that prevent releases
to the environment?
If yes to 2.1, does your hospital have a system to document the length of time that the Universal Waste
has been accumulating?
Y
N
DK
NA
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3.0 Spill Prevention Control Countermeasure Plans (SPCC) (40 CFR 112)
3.1
3.2
3.3
3.4
Is oil of any kind stored above ground in containers or equipment that Lave a capacity of 55 gallons or
greater and a total aggregate capacity of over 1.320' gallons?
Tip: For more information visit EPA 's Oil Program website at kttp: >H-H-M eua.ser 'oikpiil'wdex.'Mm
Does your hospital store oil below ground 111 any size tank (s) with a total aggregate volume over
42,000 gallons not including Underground Storage Tanks regulated under 40 CFR 2SO and 281?
(Note: USTs containing heating fuels for on-sife heating purposes are exempted from 40 CFR 2SO and
281)
Does your hospital have a Spill Prevention. Control Countermeasuie plan {SPCC}9
If yes to 3.3, is it certified by a licensed Professional Engineer?
Y
N
DK
NA
4.0 Integrated Contingency Plan ("One Plan")
4.1
Has your hospital consolidated your various planning requirements into an Integrated Contingency
Plan ("One Plan") which encompasses various planning requirements including but not limited to
SPCC, RCRA Contingency Plan. OSHA HAZWOPER. OSHA Chemical Hygiene Plan. etc.
Y
N
DK
NA
5.0 Underground Storage Tanks (UST) (40 CFR 280 & 281)
5.1
5.2
5.3
5.4
5.5
Does your hospital store motor fuels, waste oils and/or hazardous substances irs USTs? ("Note: USTs
containing heating fuels for on-site heating purposes are exempted from RCRA UST.)
If yes to 5.1. are USTs registered with the State11
If yes to 5.1, are records available for showing registration*7
If yes to 5. 1, is there some form of leak detection in use for UST system's tank and associated piping^1
If yes to 5.1, are there records showing monthly leak detection along with yearly UST system tightness
test9
Tip: Use EPA 's Basic Checklist for USTs found at 'iitp ~n-n^i .eua.pov "^erusrl atiDlasTC C'lekiisr^itm
as a help/ill, comprehensive tool to identify compliance lapses
Y
N
DK
NA
6.0 Community Right to Know SARA Title III - EPCRA (Sections 302-304, 31 land 312)
6.1
6.2
63
6.4
Does the hospital have on-site. at any time during the calendar year, a listed Extremely Hazardous
Substance (EHS) in an amount over the threshold reporting quantity?
Tip: Find this list ai k tip: •••'! osem ire. spa pw.'oru ei • cevpoeks ns f FHS Pi -ofils ? open form
If yes to 6.1, has your hospital submitted a notification letter identifying the EHS and facility
emergency coordinator to the Local Emergency Planning Committee (LEPC)'State Emergency
Response Committee (SERC)?
Does the hospital have on-site at any time during the calendar year lO.OOOlbs of anv product-'material
requiring a Material Safety Data Sheet (MSDS)"
If yes to 6.1 or 63, have Tier II chemical inventory forms (Tier 2 Submit for electronic submissions)
been filed annually with the local fire department. LEPC and SERC?
Tip: For electronic Tier II Submit go to
>} *fp " 1 'CTfij.i! its. eua.?.o~\ "cswet'-'CepDO FT V b. > is f 'con te> \ t 'rie>'2. knr. =rJ forms
Y
N
DK
NA
7.0 Clean Air Act (CAA)
7.1
7 "*
7.4
Does your hospital ha\"e a Title V operating permit9
If no to 7.1 , does your hospital have a State air permit?
Hospitali'Medical/Infectioiis Waste Incinerators - 40 CFR Part 62 Subpart HHH
Does your hospital operate a medical waste incinerator en-site?
Y
N
DK
NA
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7.0 Clean Air Act (CAA)
7 ^
7.6
-7 -7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16
7.17
7.18
Tip: For more information visit EPA '; Air Toxic website,
hnp: 'H'H-H1 eu$. FCV rrf! 'ar-<."l 29 hmr-ii rikmw ;, Imnl
If yes to 7.4. has EPA/ State been notified and the incinerator tested?
New Source Performance Standards - JO CFR Part 60
Does your hospital have boilers constructed (manufactured) or modified after June 9, 1989 with heat
input between 10-100 MMBTU/hr or larger?
If yes to 7.6, did your hospital notify EPA and.'or the State that you are subject to the New Source
Performance Standard (NSPS)?
Chlorofluorocarbon (CFC)
Does your hospital use a certified technician to service your refrigeration units with freon?
If your hospital uses in-house certified technicians, is vour recovery'recycling equipment registered
with EPA9
Are annual CFC leak rate records and maintenance and repair records maintained for the refrigeration
and air conditioning system having over 50 Ibs of CFC normal refrigerant charge for a period of three
years?
Mobile Sources
Does your hospital have vehicle gasoline dispensing units on-site?
Specify annual throughput sal/vr
If yes to 7.11, are these units equipped with Stage 2 vapor recovery equipment"1
Does your hospital prohibit hospital operated vehicles from idling?
Asbestos - 48 CFR Part 61
Has your hospital undergone any demolition ''renovation within the last 18 months'
Tip: For more information asbestos, visit http:/?www.epa.gQ\'/asbesto5i
Has the hospital removed any asbestos from any facility components within the last 18 months?
If yes to either 7.14 or 7.15. was notification for the project provided to yoiir State asbestos regulatory
agency?
If yes to 7.15 and 7.16, was the area where the renovation/demolition occurred "thoroughly inspected""
for the presence of asbestos prior to commencement of the renovation/demolition activity?
Other
If you have a helicopter landing site, is exhaust prevented from entering the hospital?
Y
N
DK
NA
8.0 Federal Insecticide, Fungicide & Rodenticide Act (FIFRA)
8.1
8.2
8.3
8.4
8.5
Does your hospital mix/blend your own pesticides? (Pesticides include: disinfectants, sterilants. germicides.
aigicides. virucides. swimming pool compounds, insecticides, fungicides, herbicides, etc.)
If your hospital uses your OWE janitorial employees to apply disinfectants and other pesticides, do you
offer/provide training as to the proper use of pesticides'
Does your hospital use any "Restricted Use" pesticides' (Note: Refer to the label)
If yes to 8.3. is the pesticide applied by a certified applicator or under direct supervision of a certified
applicator11
Are your hospital pest control operators licensed/certified by the state to apply pesticides'
Y
N
DK
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9.0 Clean Water Act (OVA)
9.1
9.2
9.3
Have all the wastewater discharges been identified and evaluated to determine whether they are being properly
managed? (Note: If the hospital discharges, wastewater into a municipal server system you should check with
local publicly owned treatment works (POTW) for regulatory requirements.)
Is your hospital's wastewater directly discharged into 'surface water or groundwater?
If yes to 9.2. does your hospital have a National Pollutant Discharge Elimination System (XPDES) permit1?'
Y
N
DK
10.0 Toxic Substances Control Act (TSCA) (40 CFR 761) - Potychlortnated Biphenyl (PCB)
10.1
10.2
10.3
Does the hospital have any PCB-coutaining electrical equipment ou-site?
If yes to 10.1. is the PCB- containing equipment properly identified0
If yes to 10.1, does your hospital inspect PCB-contairung equipment regularly for leaks and keep records of
the inspections?
Y
N
DK
11.0 Lead Paint
11.1
11.2
11.3
11.4
Has your hospital sold or leased housing built before 1978?
If yes to 11.1. did your hospital disclose potential and known lead-based paint and lead-based paint
hazardous?
If yes to 11.1. did your hospital give buyers/renters the pamphlet titled "Protect Your Family from
Lead in Your Home".
If yes to 11.2. are disclosures documented and the records kept for three years?
V
•£,
N
DK
KA
Section III: Pollution Prevention
Tins section includes additional voluntary actions your facility can consider that may reduce environmental
liability, waste disposal costs, and worker exposure.
Tip: H2E or Hospitals for a Healthy Environment is national vohmraiy program, which has set goals for mercitn' roxics elimination and
solid waste reductions specifically for the healthcare industiy. This program provides technical support and recognition for the indusny.
Read more about H2E or join as an H2E partner by reading more at 'tttp. tr.r.i . k2e-cnli?n
1.0 Resource Conservation and Recovery Act (RCRA) (40 CFR 261, 262, 265)
1.1
1.2
1.3
1.4
1.5
1.6
1.7
Have you conducted a mercury audit of your hospital, including an inventory of all mercury
devices'sources?
Tip. Can von virhiallv eliminate mercun- ai vour facilitv? Find out how at htrz. \r,-.-v.-. h2e-
onl'Jis. or?' toe-is 'wet'ciii'i .ht»i
Have vou replaced mercury thermometers (If Yes. specify alternatives in the notes section)
"in lab?
hospital patients'1
in dispensing to outpatients including newboms?
Have vou replaced mercury blood pressure units? If Yes. specify alternative
Have you replaced other mercury containing cantor tubes, dilators, etc?
Have you identified which lab chemicals you use that contain mercury?
Have you replaced lab chemicals containing mercury?
Do you still purchase any equipment containing mercury?
Y
N
Some
DK
NA
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2.0 Solid Waste
Tip: For more information Q?I Waste Reduction visit http:SAvww.h2e-online.oi'gstools'M.-aste.htm
2.1 Do YOU donate/compost any of the following (Check all that apply)?
_Food scrap/plate waste
_Landsc:ape waste
_ Edible food
Medical device/equipment
_ Office equipment
Linen
2.2 Do you recycle any of the following materials? (Check all that apply)
Paper, white
Paper, color
Cardboard
Newspaper
Boxboard
Batteries
_ Nickel cadmium
_ Alkaline
_ Mercury
Lead acid
Tyvek
Mattresses
Lead aprons
Plastics
rflPET
S4LDPE
rf5 Polyproplene
£6 PS"
_Toner cartridges
_Infc jet cartridges
_Printer ribbons
_Computers
_!ce packs/coolers
_Flucrescent lamps
_Scrap metal
_Motor oil Expired pharmaceutical^ (reverse
_ Construction/demolition waste distribution)
_Other (Please specify)
_Xray films
_Silver recovery
_Solveuts.''fixers
_Foam peanuts
jShnrik wrap
_Mercury
_Sliaips
_Wood
_Pallets
jTooking oil
_GIa»s
_Steel cans.
_Alumiiiiirn cans
Grass.-' leaves
2.3 Does your hospital reuse any of the following materials'1'
If you do nor reuse enter 0; otherwise specifi eiiker < 50H, 50%, >50% or 100%. Write DK if you do nor h\ow and NA if not applicable.
Dietary
Dishware. patient
Dishware, employee
Glassware
Cutler)'
Baking pans
Metal travs
Other
Reusable
(?-i)
Patient care
Bath basmi
Mattress overlays
Water pitchers
Bedpans
Urinals
Pillows
Towels
Underpads (Chux)
Exani gowns,
Linens
Other
Reusable
(%)
Surgery
Instrument pans
Splash basins
Medicine cups
Gowns
Towels
Drapes
Other
Reusable
(%}
Equipment
Ventilator tubing
Ambu bags
Pulse oximeters
Suture removal kit
Vaginal speculums
Other
Reusable
(%)
2.4 How much solsd waste does your hospital generate per year (tons/year)?
2.5 How many tons.'year did your hospital recycle? for calendar vear
2.6 What percentage of your hospital's waste is medical red bag waste?
for calendar year
% for calendar rear
2.7 How does your hospital dispose of your medical red bag waste? (Please check)
incinerate (offsite) incinerate (onsite) autoclave (offsite) autoclave (onsite)
Other( specify)
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3.0 Purcliasing
Tip: To read more about green purchasing visit ktTp^^ww.t^e-online.orgnools/grnpifrck/epp.kim
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
Has your hospital instituted purchasing policies in any of the following areas9 (Check all that apply)
"Green" Product Low VOC product-? PVC products and DEHP products
EaergyStar products Latex Specifying recycled content in pro ducts
Less toxic materials Mercury Other (Specifv)
Has your hospital called upon vendors and your Group Purchasing Organization (GPO) to identify and
develop alternatives for harmful and/or wasteful products and materials'1
Has your hospital worked with suppliers to minimize wasteful packaging?
Does your hospital receive -supplies in reusable shipping containers?
Does your hospital use office paper with at least 30°-o recycled content0
Has your hospital evaluated alternatives to Polyvinyl Chloride (PVC) aad DEHP containing products?
Does your hospital purchase tiou-to sic/less toxic alternatives for janitorial chemicals'1
Do you use Ethylene Oxide at your hospital11
If yes to 3.8. have you evaluated alternatives?
Does your hospital have a central system in place for tracking and quantifying the amount of chemicals
purchased, dispensed and disposed of
Does your hospital track the quantity or amount of green products and services used?
Y
N
DK
4.0 Energy/Water Conservation
Tip: To view Energy-Star information for Healthcare visit htip:<'.':208.254.22.6/index.cfh\?c=kealthca)'e. bus healthcare
4.1
4.2
4.3
4.4
4.5
4.6
4.1
Have you created a baseline of energy performance for your hospital using the EPA's benchmarking tool?
Tip: To view the Energy-Star hospital benchmarking tool visit
http:/f20S.254.22.6^ndex.cfm"c-eligibniti\busjor^lyliomanager_eligibilii)'_kosp!tah
Has your hospital done an energy management review within the last 3 years'1
Has your hospital implemented within the last three years any of the following? (Check all that apply)
Heating /ventilation upgrades Control ventilation rales to minimum requirements
Air side cooling economizer cvcle Enersv efficient lighting upgrades
Proaramable thermostats Lighting occupancy sensors
Does your hospital purchase EnergyStar equipment11 (Check all that apply)
Computers Fax machines Roofing Products
Monitors Printers Transformers
Copiers TVs Dishwashers
Scanners Exit signs Commercial refrigerator/freezei's
Multifunction devices Water coolers Other (Specify)
Has your hospital assessed its water usage?
Tip to read about water conservation visii http://www.h2e-online.org/toolz--'\vaTer.ktm
Have you implemented a water conservation program?
Does your hospital use any of the following water-efficient equipment or practices? (Check all that apply)
Low flow toilets Flow control mechanisms Regular inspection and repair of leaks
Low flow faucets Recirculating cooling water Landscaping/irrigation
Automatic faucet shut off Recirculate sterilizer water Low water Xray process
Low flow showerfaeads Kitchen Other (Specify)
Y
N
DK
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Section IV: General
4.1 Does your hospital have an Integrated Pest Management (IPM) program''
Yes
Don't Know
4.2 What environmental topics would you like more training in? (Check all that apply)
Solid waste recycling
CAA Solid waste recycling Energy Management Systems
SPCC Red bag waste reduction Energy conservation
EPA Audit Program Resource management Green buildings
Mercury Wafer conservation Environmental Management System
Integrated Pest Management Green purchasing Other (Specify)
_General compliance
_RCRA - hazardous waste
_Universal Waste
EPCRA
4.3 What are your top three training needs?
Priority 1 Priority 2
Priority 3
4.4 Has your hospital taken any action not covered above to improve environmental performance? Please specify.
Notes on any questions above:
Question number
Comments
Conditionally Exempt Small Quantity Generator (CESQG) is a generator who generates les? thaa 100 kg.'month (about 220 Ibs.inanth) and never
accumulates more than 1000 kg (22001bs) or more. (Note220Ibs is about half a 55 gallon drum)
""Small Quantity Generator (SQG) is a generator who generates more than 100 kg/month (2201b-i/inonii) but less than lOOO kg/month (2200 Ibs-'month))
" Large Quantity Generator (LQG) K a generator who generates more than 1000 kg'inontfa (2200 Ibs/rnontk) or generates 1 kg (2.2 Ibs) or more of an
acutely hazardous or severely toxic waste.
Federal definition includes batteries( eg. nickel cadmium), pesticides, tamps and thermostats
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-------
- APPENDIX E -
COMPLIANCE: A SUPPLEMENT TO
LEGAL AND OTHER REQUIREMENTS
This resource compendium provides a starting point for identifying and maintaining compliance
requirements. Be sure to check with state and local regulators to determine final requirements.*
Federal Regulation of Medical Waste
Each federal agency develops regulations related to its direct responsibilities. For example, the U.S.
Environmental Protection Agency (US. EPA) is charged with protecting the air, land and water from improper
management practices while the Department of Transportation is responsible for the safe transport of
infectious and hazardous waste over the nation's roadways.
Regulation of hazardous waste is the responsibility of multiple, separate agencies of the federal
government including the following:
U.S. Environmental Protection Agency (http://www.epa.gov)
National Institutes of Health, Centers for Disease Control (http://www.cdc.gov)
U.S. Department of Health and Human Services (http://www.hhs.gov)
U.S. Food and Drug Administration (http://www.fda.gov)
U.S. Department of Labor, Occupational Safety and Health Administration (http://www.osha.gov)
U.S. Department of Transportation (http://www.dot.gov)
U.S. Coast Guard (http://www.uscg.mil/USCG.shtm)
U.S. Postal Service (http://www.usps.com)
U.S. Department of Energy, Nuclear Regulatory Commission (http://www.energy.gov)
* While the U.S EPA has made every effort to ensure the accuracy of this information, a regulated entity's legal obligations are
also determined by the terms of its applicable environmental facility-specific permits, underlying statutes and applicable state and
local law. States and local regulating bodies may impose more stringent requirements than those established by the U.S. EPA and
other federal agencies. It is beyond the scope of this compliance chapter to list the requirements of all federal, state and local
regulatory bodies.
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Code of Federal Regulations (CFR) and the Federal Register
The Code of Federal Regulations (CFR) is referenced throughout this compliance chapter at the end of
each act. To search the CFR, go to the Electronic Code of Federal Regulations (e-CFR) at
http://www.gpoaccess.gov/ecfr/. The e-CFR consists of two linked databases: the "current code" and
"amendment files." The Office of Federal Register updates the current code database according to the
effective dates of amendments published in the Federal Register. The Federal Register is the official daily
publication of rules, proposed rules and notices of federal agencies and organizations as well as executive
orders and other presidential documents. The Federal Register is available online at
http://www.gpoaccess.gov/fr/index.html.
Clean Air Act
Through the enforcement of the Clean Air Act (CAA), the U.S. EPA protects and enhances the quality of
the nation's air to promote public health and the environment. The CAA addresses permitting programs,
criteria pollutants, hazardous air pollutants, mobile sources, acid rain control and stratospheric ozone
protection.
Common CAA violations and problems found at hospitals:
• Failure to use properly trained and accredited asbestos personnel
• Failure to notify U.S. EPA of asbestos removal projects and to keep required documentation/record
keeping
• Failure to properly dispose of asbestos debris
• Failure to have CFC leak rate records for chillers and air conditioning units more than 50 pounds of
charge
• Failure to have U.S. EPA certified technicians for CFC containing air conditioning and refrigeration
systems
• Failure to get boilers permitted with the state agency
• Failure to apply for Title V operating permit
The U.S. EPA Region 2 health care Web site lists common violations/problems found at hospitals and
fact sheets on environmental requirements for hospitals, http://www.epa.gov/region02/healthcare/
CAA Common Areas for Inspections
For the most part, a U.S. EPA air inspector will primarily be interested in five areas of a hospital: air
conditioning and refrigeration, asbestos, boilers, Title V operating permit and medical waste incinerators.
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Air Conditioning and Refrigeration Service
Under Section 608 of the Clean Air Act, the U.S. EPA has developed regulations to reduce the emissions
of environmentally harmful refrigerants into the environment to the "lowest achievable level" during the
servicing and disposal of air conditioning and refrigeration equipment. This site also contains CAA Section
608 fact sheets, http://www.epa.gov/region02/cfc/
Asbestos
A hospital that performs demolition and renovation operations will be subject to the CAA National
Emission Standards for Hazardous Air Pollution (NESHAP) for asbestos. Asbestos must be removed prior to
demolition or renovation and proper precautions must be made, such as wetting down the materials to keep it
intact. No asbestos is to be striped, removed or otherwise handled or disturbed unless at least one authorized
representative trained in NESHAP asbestos regulations is present. A written notice of intention to demolish
or renovate must be submitted to the U.S. EPA at least 10 working days prior to start of construction.
Also the Toxic Substance Control Act (TSCA) comes into play with asbestos removal under the
Asbestos Hazardous Emergency Response Act (AHERA) and the Asbestos Model Accreditation Plan (MAP),
which expands AHERA's training requirements to include not only schools but all public and commercial
buildings, including hospitals. Under AHERA, a facility must have personnel, trained by the U.S. EPA or
state approved instructors, conducting the asbestos removal..
"Public and commercial building" means the interior space of any building which is not a school
building, except that the term does not include any residential apartment building of fewer than 10 units or
detached single-family homes. The term includes, but is not limited to: industrial and office buildings,
residential apartment buildings and condominiums of 10 or more dwelling units, government-owned
buildings, colleges, museums, airports, hospitals, churches, preschools, stores, warehouses and factories.
Interior space includes exterior hallways connecting buildings, porticos and mechanical systems used to
condition interior space.
http://www.epa.gov/asbestos/
http://www.epa.gov/region02/ahera/
Boilers
Most hospital boilers are subject to the Federal New Source Performance Standards (NSPS) regulations.
The applicable regulations can be found at 40 CFR Part 60 Subparts Db and DC. Subpart Db applies to the
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larger boilers (greater than 100 million BTU/hr), which were constructed after June 19, 1984, whereas
Subpart DC applies to the smaller boilers (between 10 and 100 million BTU/hr), which were built after June
8, 1989. Depending on the type of fuel combusted, the regulations have emission standards for sulfur
dioxide, nitrogen oxide and particulate matter. The NSPS also have requirements for monitoring and record
keeping.
http://www.epa.gov/ttn/atw/boiler/boilerpg.html
CAA Title V Operating Permit
Existing major industrial sources (including hospitals) are required to obtain a legally enforceable Title
V operating permit. The operating permit program is a national permitting system that consolidates all of the
air pollution control requirements into a single, comprehensive "operating permit" that covers all aspects of a
source's yearly air pollution activities after the source has begun to operate. A Title V operating permit grants
a source permission to operate. The permit includes all air pollution requirements that apply to the source,
including emissions limits and monitoring, record keeping and reporting requirements. State and local
permitting authorities issue most of the permits required by Title V of the Clean Air Act. (40 CFR part 70
permits). However, the U.S. EPA issues Title V permits (40 CFR part 71 permits) to sources in Indian country
and in other situations as needed.
http://www.epa.gov/air/oaqps/permits/whogets.html
http://www.epa.gov/air/oaqps/permjmp.html
Medical Waste Incinerators
Under the CAA, the U.S. EPA regulates air emissions from hospital and/or medical/infectious wastes
incinerators (HMIWI). When burned, medical waste may emit air pollutants, including hydrochloric acid
(HC1), dioxins and furans and metals, such as lead (Pb), cadmium (Cd) and mercury (Hg). Therefore, the
U.S. EPA has developed emission standards that apply to incinerators used by hospitals and health care
facilities as well as those used by commercial waste treatment and disposal companies to treat medical waste.
The emission guidelines are intended to meet the requirements of the CAA, and states must establish
standards that are at least as protective. These standards will result in reductions in the air emissions of
concern from HMIWI.
http: //www. epa.gov/ttn/atw/129/hmiwi/rihmiwi .html
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Clean Air Technology Center (CATC)
The Clean Air Technology Center (CATC) serves as a resource for all areas of emerging and existing air
pollution prevention and control technologies and provides public access to data and information on use,
effectiveness and cost. In addition, the CATC provides technical support, including access to the U.S. EPA's
knowledge base, government agencies and others, as resources allow, related to the technical and economic
feasibility, operation and maintenance of these technologies. Go to http://www.epa.gov/ttn/catc/ or call (919)
541-0800. For publications, call (919) 541-2777.
For more information on the CAA visit the Web links below.
CAAhttp://www.epa.gov/oar/oaq_caa.html
CAA http://www.epa.gov/region5/defs/html/caa.htm
CAA http://www.epa.gov/ebtpages/air.html
Federal CAA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Part 50-99
* Also look at the Federal TSCA regulations under Appendix C to Subpart E of Part 763 Asbestos Model
Accreditation Plan, (http://www.epa.gov/compliance/civil/programs/tsca/tscaenfprog.html)
Clean Water Act
The Clean Water Act (CWA) is the primary federal statute regulating the protection of the nation's
waters. The CWA established national programs for prevention, reduction and elimination of pollution in
navigable water and groundwater, including a water quality standards program, a permit program for
discharge and treatment of wastewater and stormwater and an oil pollution prevention program.
The U.S. EPA protects water resources primarily through the National Pollution Discharge Elimination
System (NPDES), the regulatory program reinforcing the CWA, which restores and maintains the chemical,
physical and biological integrity of the nation's waters. The CWA eliminates the discharge of pollutants,
including contaminated stormwater, solid waste, biological materials, sewage, chemical wastes and
radioactive materials to surface waters through dredge and fill prohibitions and end-of-the-pipe effluent
limits.
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Common CWA violations and problems found at hospitals:
• No permit for or noncompliance with wastewater discharges
• Failure to know about local treatment plant sewer use regulations and possible prohibited discharges
for indirect dischargers
• No or inadequate secondary containment of storage tanks
• Improper disposal down floor drains
• Failure to have a Spill Prevention Control Countermeasure (SPCC) plan in place
CWA common areas for inspections
Generally, a U.S. EPA water inspector will primarily be interested in three areas of a hospital:
wastewater discharges, stormwater discharges and any aboveground or underground oil storage containers.
Wastewater Discharges
The water regulations establish two different permitting programs for wastewater discharges. Facilities
that discharge directly to waters (e.g., rivers, lakes, oceans) of the United States are covered by the National
Pollutant Discharge Elimination System (NPDES) Permit Program. These facilities are known as direct
dischargers. Facilities that discharge to municipal wastewater treatment plants are covered by the
Pretreatment Program. These facilities are known as indirect dischargers. Most hospitals are indirect
dischargers.
Indirect Dischargers
Hospitals, which are indirect dischargers, are subject to regulations by the local sewer authority.
Currently, about 1,500 of the nation's largest municipalities are required to implement industrial pretreatment
programs, which include issuing industrial user permits to significant industrial users. Some municipalities
have determined hospitals to be significant industrial users.
Most municipalities have established local prohibitions that apply specifically to medical waste
discharges. For example, some municipalities have set a prohibition on "all medical waste." Other
prohibitions include, for example, no discharge of discernible body parts, no human remains greater than 0.5
inches in diameter, and/or no radioactive wastes. The ability of municipalities to establish prohibitions to
meet their specific needs/interests is very flexible.
Federal pretreatment regulations prohibit discharges of fire or explosion hazards; corrosive discharges
(pH < 5.0); solid or viscous pollutants; heat (in amounts that cause the treatment plant influent to exceed 104
degrees F); pollutants that cause toxic gases, fumes or vapors; and any other pollutant (including oil and
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grease) that will interfere with or pass through the treatment plant.
Direct Dischargers
Hospitals, which are direct dischargers of process and sewer wastes, must be permitted (e.g., obtain a
permit) for any point source discharge of pollutants to waters of the United States. These permits are issued
either by the U.S. EPA or the state, where the state has been authorized to implement the NPDES Permit
Program. The federal regulations establish the permit application and permit requirements. Specific numeric
limitations that apply to a medical facility depend on the receiving stream of the discharge. For detailed
information on numeric limitations, contact your U.S. EPA Regional pretreatment coordinator. Contact
information can be found at the following Web site:
http ://cfpub .epa.gov/npdes/contacts .cfm?program_id=3 &type=REGION.
Stormwater Discharges
U.S. EPA's NPDES Web site, http://cfpub.epa.gov/npdes, provides technical and regulatory information
about the National Pollutant Discharge Elimination System (NPDES) Permit Program, which controls water
pollution by regulating point sources (e.g. pipe, ditch) that discharge pollutants into waters of the United
States. The stormwater program is part of the NPDES Permit Program and is designed to prevent the
discharge of contaminated stormwater into navigable waters.
http://cfpub.epa.gov/npdes/home.cfm?program_id=6
Phase I of the stormwater program was promulgated in 1990 and applied to medium and large municipal
separate storm sewer systems (MS4), certain industrial facilities (not hospitals) and any construction activity
disturbing greater than five acres (large construction sites).
Phase II of the stormwater program was promulgated in 1999 and applies to small municipal separate
storm sewer systems (MS4) and construction activity greater than one acre and less than five acres (small
construction sites). Public hospitals located in urbanized areas are regulated under this new rule. Any
hospital located in urbanized or rural areas that plan construction activities should look into obtaining a
stormwater NPDES permit for construction.
The term MS4 does not solely refer to municipally owned storm sewer systems, but rather is a term with
a much broader application that can include, in addition to local jurisdictions, state departments of
transportation, universities, local sewer districts, hospitals, military bases and prisons. An MS4 is not always
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just a system of underground pipes; it can also include roads with drainage systems, gutters and ditches.
Hospitals in urbanized areas should consult with the state NPDES authority to evaluate whether a permit
authorization is required.
The regulatory definition of an MS4 is provided in 40 CFR 122.26(b)(8). General stormwater
information can be found at http://cfpub.epa.gov/npdes/home.cfm?program_id=6, and the Stormwater Phase
II Compliance Assistance Guide at http://www.epa.gov/npdes/pubs/comguide.pdf.
Aboveground or Underground Oil Storage Containers
The U.S. EPA's oil spill program (http://www.epa.gov/oilspill/) provides information about the U.S.
EPA's program for preventing, preparing for and responding to oil spills that occur in and around inland
waters of the United States. If a hospital uses or stores oil, it may be subject to the Spill Prevention Control
Countermeasure (SPCC) rule. Hospitals with an aboveground oil storage capacity of greater than 1,320
gallons, or total completely buried oil storage capacity greater than 42,000 gallons must prepare and
implement a SPCC Plan to prevent any discharge of oil into or upon navigable waters of the United States or
adjoining shorelines.
On July 16, 2002, the U.S. EPA promulgated a revised final SPCC regulation, which became effective
August 17, 2002. The U.S. EPA subsequently extended the regulatory compliance schedule included in the
new SPCC rule. The current compliance dates for the new rule are as follows:
• August 17, 2004: Facilities must prepare and P.E. (professional engineer) certify an SPCC Plan in
accordance with the new SPCC rule by this date;
• February 18, 2005: The revised SPCC Plan must be implemented.
In the interim, facilities are required to maintain the existing SPCC Plans and amend in accordance with
40 CFR §112.5.
Typical records that a U.S. EPA inspector may ask to review under the CWA are:
Industrial User permit (IU permit) for discharges to the local municipality (indirect discharge). Most
hospitals are indirect dischargers.
Spill Prevention, Control and Countermeasure (SPCC) Plan. The plan is to prevent any discharge of
oil into or upon navigable waters of the United States or adjoining shorelines.
• Phase II stormwater permits under the National Pollution Discharge Elimination System (NPDES)
program for public hospitals located in an urbanized area.
• NPDES construction stormwater permits (Phase I and Phase II) are also required for any construction
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activity greater than one acre for any hospital located in urban or rural areas.
• National Pollution Discharge Elimination System (NPDES) general permit for discharging directly to
a water body (direct discharge).
For more information on the CWA, visit the following Web site: http://www.epa.gov/r5water/cwa.htm
Federal CWA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts:
100-136
140
230-233
401-471
501-503
Emergency Planning and
Community Right to Know Act (EPCRA)
This act, also known as Superfund Amendments and Reauthorization Act (SARA) Title III, was
designed to promote emergency planning and preparedness at both the state and local levels. It provides
citizens, local governments and local response authorities with information regarding the potential hazards in
their community. EPCRA requires the use of emergency planning and designates state and local governments
as recipients of information regarding certain chemicals used in the community. SARA Title III, better known
as EPCRA, originated from the Comprehensive Environmental Response, Compensation and Liability Act
(CERCLA, or better known as the Superfund Law). Like EPCRA Section 304, CERCLA also has hazardous
substance release reporting regulations under CERCLA Section 103; 40 CFR Part 302. Under CERCLA, the
person in charge of a facility is required to report to the National Response Center (800-424-8802 or http://
www.nrc.uscg.mil) "immediately upon knowledge of a reportable release," any environmental release of a
listed hazardous substance that equals or exceeds a reportable quantity.
EPCRA has four major components:
Emergency planning (EPCRA Sections 301-303 corresponds to 40 CFR 355.30)
Emergency release notification (EPCRA Section 304 corresponds to 40 CFR 355.40 and CERCLA
Section 103 corresponds to 40 CFR 302)
• Community right-to-know reporting (EPCRA Sections 311-312)
Material Safety Data Sheet reporting (40 CFR 370.21)
Inventory reporting (40 CFR 370.25; 370.40; 370.41)
• Report hazardous chemicals above 10,000 Ibs. and/or extremely hazardous
substances present at amounts 500 Ibs. or the threshold planning quantity whichever
is lower. Reporting mechanism is the annual emergency and hazardous chemical
inventory forms, Tier I and Tier II forms. Submit to state emergency response
commission and local emergency planning committee and local fire department. Tier
I includes chemical categories, quantities and locations of hazardous chemicals on
site. For a Tier I form, call the hotline at (800) 424-9346. Tier II is a more detailed
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list and is recommended over Tier I by the U.S. EPA. The Tier II form can be
downloaded at: http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/tier2.htm/.
Hospitals will typically have more than 10,000 pounds of heating fuel and/or
gasoline for vehicles; also look at lab quantities (e.g., formaldehyde).
Toxic chemical release reporting (EPCRA Section 313 corresponds to 40 CFR 372)
• Toxic Release Inventory Form R only applies to federal facilities (e.g., Veterans
Administration hospitals; military health care units). Public and private hospitals are exempt
from EPCRA Section 313 reporting.
Common EPCRA violations and problems found at hospitals:
• Failure to report certain accidental chemical releases that occur.
• Chemicals are stored on-site above threshold [hazardous chemicals above 10,000 Ibs. and/or
extremely hazardous substances present at amounts 500 Ibs. or the threshold planning quantity,
whichever is lower (e.g., heating oil, gasoline)].
Typical records a U.S. EPA inspector may ask to review under the EPCRA:
Proof of notification for all environmental releases of a listed hazardous substance. "Failure to
notify" violation will be sited if the National Response Center, state hotline and Local Emergency
Planning Committee are not notified in a timely fashion.
• Emergency Response Plans
Material Safety Data Sheets (MSDS)
• Tier I or Tier II inventory reporting forms. This inspection is done together with the MSDS. The
inspector will look at what materials are stored and in what quantity and if subject to reporting
requirements. The federal government prefers the more detailed Tier II inventory form.
• U.S. EPA Toxic Release Inventory Form R for federal health care facilities report on every chemical
manufactured, processed or used. Form R contains facility identification information and chemical
specific information (toxic chemical identity; mixture component; activity and uses; maximum
amount of chemical on site during calendar year; quantity; transfers; discharges; on-site waste
treatment; on-site energy recovery; on-site recycling; source reduction/recycling).
Several compliance assistance tools that can help medical facilities comply with EPCRA:
U.S. EPA Call Center RCRA, Superfund, EPCRA http://www.epa.gov/epaoswer/hotline/ (800) 424-
9346 or D.C. area local (703) 412-9810, TDD (800) 553-7672 or TDD D.C. area (703) 412-
3323 Monday - Friday 9:00 a.m. - 5:00 p.m. Eastern time. Closed federal holidays.
mail to:epacallcenter@bah.com. Note that the call center cannot provide regulatory interpretations.
• U.S. EPA Document Protocol for Conducting Environmental Compliance Audits under the
Emergency Planning and Community Right-to-Know Act and CERCLA Section 103 at
http://www.epa.gov/compliance/resources/policies/incentives/auditing/epcra.pdf
• U.S. EPA Toxic Release Inventory Web site: http://www.epa.gov/tri/. The Toxic Release Inventory
(TRI) is a publicly available U.S. EPA database that contains information on toxic chemical releases
and other waste management activities reported annually by certain covered industry groups as well
as federal facilities.
• U.S. EPA Superfund Web site: http://www.epa.gov/superfund/ Links to tools such as Enviromapper,
which maps hazardous waste sites in your community, guidance documents, current news events,
success stories and more.
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For more information on EPCRA visit the following Web sites:
• http://www4.law.cornell.edu/uscode/42/chl 16.html
http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/epcraOverview.htm
• http://yosemite.epa.gov/oswer/ceppoweb .nsf/content/result.htm?OpenDocument&list%20of%201ists
http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/epcra_law.htm
• http://www.epa.gov/region5/defs/html/epcra.htm
"List of Lists" - Consolidated list of chemicals subject to EPCRA and CAA Section 112(r). Used to help
facilities handling chemicals determine whether they need to submit reports under sections 302, 304, 311,
312, or 313 of EPCRA and, for a specific chemical, what reports may need to be submitted. It will also help
facilities determine whether they will be subject to accident prevention regulations under CAA section 112(r)
and lists "unlisted hazardous wastes" under RCRA: http://www.epa.gov/ceppo/pubs/title3.pdf
Federal EPCRA regulations are set forth in the Code of Federal Regulations (CFR) in 40 CFR Parts:
302
55
370
372
Federal Insecticide, Fungicide and Rodenticide Act (FIFRA)
The U.S. EPA has established requirements under the Federal Insecticide, Fungicide and Rodenticide
Act (FIFRA) for medical waste treatment technologies that use chemicals for treating waste. In hospitals,
chemical pest control helps contain the spread of infection, reduces infestations with vermin and is used in
kitchens, cafeterias, patient rooms, public areas and offices. Under FIFRA, alternative medical waste
treatments that use chemicals are considered pesticides and require registration by the U.S. EPA. Cleaning
disinfectants are also considered pesticides under FIFRA and require registration. Check labels to make sure
they have a U.S. EPA registration number and are used properly as the label indicates. Registration is a
scientific, legal and administrative process where the chemical ingredients are carefully examined to
determine the amount, frequency and timing of use, storage and disposal practices. The U.S. EPA assesses a
wide variety of potential environmental and human health effects associated with use of the product including
adverse effects on humans, wildlife, fish and plants, as well as possible contamination of surface water or
groundwater.
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Common violations and problems found at hospitals for FIFRA issues include:
• Misuse of a registered pesticide product
• Use of an unregistered product
• Lack of proper records concerning pest control application within the hospital and/or on the hospital
grounds
• Failure to report pesticide poisonings incidents either occurring within the hospital or of admitted
patients.
Typical physical features to inspect for under FIFRA include:
• Personnel protection equipment
• Pesticide application equipment
• Pesticide storage areas, including storage containers
• Cleaning disinfectants and labels
Typical records a U.S. EPA inspector may ask to review under the FIFRA include:
• Records of pesticides purchased (purchase orders, inventory)
• Pesticide application records
• Description of the pest control program
• Certification status of pesticide applicators
• Pesticide disposal manifests
• Contract files
• Recent ventilation rating for pesticide fume hood and pesticide mixing/storage areas
FIFRA compliance assistance tools include the following:
• U.S. EPA Office of Pesticides Programs Web site provides information and resources to help
facilities comply with regulations regarding pesticide use and implement safer means of pest control.
http://www.epa.gov/pesticides/
• Registering pesticides for use in the United States at
http://www.epa.gov/pesticides/regulating/index.htm
• Pesticides Consumer Alert U.S. EPA fact sheet for all pesticide industry organizations, facilities and
handlers as a precaution during this heightened state of security awareness. This alert highlights
some general security areas that companies may want to review to ensure that appropriate measures
are being implemented. http://www.epa.gov/pesticides/factsheets/pest_secu_alert.htm
• National Pesticide Information Center (NPIC) is a cooperative effort of Oregon State University and
the U.S. EPA. NPIC provides objective, science-based information about a variety of pesticide
related subjects, including pesticide products, recognition and management of pesticide poisonings,
toxicology and environmental chemistry. NPIC also lists state pesticide regulatory agencies and
provides links to their Web sites, http://www.npic.orst.edu/
• U.S. EPA Document Protocol for Conduction Environmental Compliance Audits under Federal
Insecticide, Fungicide and Rodenticide Act was developed by the U.S. EPA to provide guidance to
regulated entities conducting a review of facility conditions to determine their compliance with
FIFRA. http://www.epa.gov/compliance/resources/policies/incentives/auditing/fifra.pdf
• Pest Management in New York State Hospitals, Risk Reduction and Health Promotion: The major
finding from this report is that pesticides are used widely in New York's hospitals. More than 30
different pesticide preparations are currently applied in hospitals across the state. They are used as
fogs, sprays and powders. They are applied in virtually all areas of hospitals, including areas that
contain patients, http://www.oag.state.ny.us/environment/hospital95.html
• Healthy Hospitals-Controlling Pests Without Harmful Pesticides report by Healthcare Without Harm
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and Beyond Pesticides. http://www.noharm.org/details.cfin?ID=864&type=document
For more information on FIFRA, go to http://www.epa.gov/region5/defs/html/fifra.htm.
Federal pesticide regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts 150-189
Resource Conservation Recovery Act (RCRA)
The regulation of land-based waste management activity is achieved primarily through the federal
Resource Conservation and Recovery Act (RCRA). The primary goals of RCRA are to protect the
environment and human health from the potential hazards of waste disposal, to conserve energy and natural
resources, to reduce the amount of waste generated and to ensure that wastes are managed in an
environmentally sound manner. RCRA regulates the management of solid waste, hazardous waste and
underground storage tanks holding petroleum products or certain chemicals. Of concern for health care
facilities is the hazard associated with the land disposal of untreated, infectious or hazardous wastes.
RCRA Subtitle D regulations focus on state and local governments as the primary planning, regulating
and implementing entities for the management of nonhazardous solid waste, such as household garbage and
nonhazardous industrial solid waste. The U.S. EPA provides state and local agencies with information,
guidance, policy and regulations to help them and the regulated community make sound decisions concerning
waste issues. To promote the use of safer units for solid waste disposal, the U.S. EPA developed federal
criteria for the proper design and operation of municipal solid waste landfills and other solid waste disposal
facilities. Many states have adopted these criteria and have required upgrading or closure of all
environmentally unsound disposal units.
RCRA Subtitle C regulations first identify the criteria to determine which solid wastes are hazardous.
They then establish various requirements for the three categories of hazardous waste handlers: 1) generators,
2) transporters and 3) treatment, storage and disposal facilities (TSDFs). In addition, Subtitle C regulations
set technical standards for the design and safe operation of TSDFs. These standards are designed to minimize
the release of hazardous waste into the environment. Furthermore, the regulations for TSDFs serve as a basis
for developing and issuing the permits required by the RCRA for each facility. Permits are essential to
making the Subtitle C regulatory program work, since it is through the permitting process that the U.S. EPA or
the state applies standards to TSDFs. The U.S. EPA conducts compliance evaluation inspections to ensure
that hazardous waste is managed in accordance with applicable laws, regulations and safe handling practices;
works with state agencies to enforce hazardous waste laws where violations are observed; and helps state and
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local agencies develop and administer hazardous waste management programs.
Common violations and problems found at hospitals for RCRA issues include:
• Failure to comply with hazardous waste generator regulations and lack of documentation
• Failure to comply with underground storage tank regulations and lack of documentation
• Improper or lack of hazardous waste labeling
• Failure to have waste batteries/fluorescent lamps stored in proper universal waste containers and
labeled
• Infrequent or no weekly inspections of hazardous wastes storage/satellite areas
• Open containers of hazardous wastes
• Improper disposal of chemotherapy drugs
• Failure to have hazardous waste determinations on file for all wastes (e.g., some pharmaceutical
wastes are classified as RCRA hazardous wastes)
• No or inadequate hazardous waste manifests
• Throwing hazardous wastes down the drain
• Failure to have procedure in place to ensure spent aerosol containers are empty before disposal as
solid waste
• Improper management of expired pharmaceuticals, paints, etc.
• Lack of hazardous waste contingency plan
• Lack of or inadequate training of employees in hazardous waste management, handling and
emergency preparedness
• Failure to ensure that hazardous waste meets land disposal restrictions
• Failure to upgrade or close underground storage tanks (USTs) by 12/22/98
• Malfunctioning leak detection systems on underground storage tanks
• Improper consolidation of wastes from nearby facilities
Typical physical features to inspect under RCRA:
• Universal waste storage area
• Used oil storage areas
• Vehicle maintenance facilities
• Battery storage areas
• Building maintenance and repair shops
• Laboratories
• Bulk storage tank farms
• Transfer terminals
• Secondary containment structures
• Tank peripheral piping, manifolds, filling and dispensing areas
• Dispenser pumps and check valves
• Tank sumps, manway areas
• Leak detection equipment
• Overflow alarms or other audible and visual alarms, sight gauges
• Fill ports, catchment basins
• Oil/water separators
• Clean-up equipment (e.g., absorbent materials, fuel recovery pumps, personal protective gear)
• Hazardous waste generation sites (e.g., x-ray, chemotherapy, morgue, pathology, etc.)
• Waste storage areas
• Satellite accumulation points
• Vehicles used for transport
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• Container storage areas
• Shop activities
Typical records an inspector may ask to review under RCRA:
Notification of Hazardous Waste Activity (U.S. EPA ID No.)
• Hazardous waste manifests
• Manifest exception reports
• Biennial reports
• Inspection logs
• Land disposal restriction certifications
• Employee training documentation
• Hazardous substance spill control and contingency plan
Material Safety Data Sheets (MSDSs)
• Inventory records
• Spill records - Spill Prevention Control and Countermeasure (SPCC) plans
• Emergency plan documents
• Placarding of hazardous waste and hazardous materials
• Permits, if issued
• Waste analysis plan(s)
• Operating record
• Universal waste transportation/shipping records
• Used oil analysis records
• Used oil transportation related documentation
• Underground Storage Tanks (UST) regarding leak detection performance and maintenance including
the following:
• Monitoring results over the last 12 months
• Most recent tank tightness test(s)
• Manual tank gauging records
• Copies of performance claims provided by leak detection equipment manufacturers
• Records of recent maintenance, repair and calibration of on-site leak detection equipment
• Records of required inspections and test of corrosion protection systems
• Records of repairs or upgrades of UST systems
• Site assessment results of closed USTs
• Results of AST integrity assessments, sampling, monitoring, inspection and repair work
• Notification forms and registration records for all in-service, temporarily out-of service and
permanently closed tanks
• Waste determinations
Several compliance assistance tools that can help medical facilities comply with RCRA:
• U.S. EPA's RCRA Web site enables users to locate documents, including publications and other
outreach materials, that cover a wide range of RCRA issues and topics.
http: //www. epa.gov/rcraonline/
• The U.S. EPA RCRA, Superfund and EPCRA call center, http://www.epa.gov/epaoswer/hotline/
(800) 424 9346 or DC Area Local (703) 412-9810 or TDD (800) 553-7672 or TDD D.C. area local
(703) 412 3323 Monday - Friday 9:00 a.m. - 5:00 p.m. Eastern time. Closed Federal Holidays.
mailto:epacallcenter@bah.com. Note that the call center cannot provide regulatory interpretations.
• RCRA wastes A-Z. http://www.epa.gov/osw/topics.htm
• Nuclear Regulatory Commission radioactive wastes Web site, http://www.nrc.gov/waste.html
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• U.S. EPA Document Protocol for Conducting Environmental Compliance Audits of Hazardous Waste
Generators Under RCRA.
http://www.epa.gov/compliance/resources/policies/incentives/auditing/hazardous.pdf
• U.S. EPA Document Protocol for Conducting Environmental Compliance Audits of Treatment
Storage and Disposal Facilities Under RCRA.
http://www.epa.gov/compliance/resources/policiesincentives/auditing/rcra.pdf
• U.S. EPA Document Protocol for Conducting Environmental Compliance Audits for Used Oil and
Universal Waste Generators Under RCRA.
http://www.epa.gov/compliance/resources/policies/incentives/auditing/oil.pdf
• U.S. EPA Document Protocol for Conducting Environmental Compliance Audits of Storage Tanks
Under RCRA.
http://www.epa.gov/Compliance/resources/policies/civil/rcra/audstankrcra-rpt.pdf
• Expired pharmaceuticals and reverse distribution concept. One way of handling outdated
Pharmaceuticals is by sending them back to their place of origin. There are more than 40
organizations that will take outdated pharmaceuticals, reprocess them when possible, and properly
discard them if they cannot be used. More information is available at the Returns Industry
Association Web site at http://www.returnsindustry.com.
For more information on RCRA:
• RCRA: http://www.epa.gov/region5/defs/html/rcra.htm
• RCRA Subtitle D: http://www.epa.gov/epaoswer/osw/non7hw.htm
• RCRA Subtitle C: http://www.epa.gov/epaoswer/osw/hazwaste.htm
"List of Lists" - Consolidated list of chemicals subject to EPCRA and CAA Section 112(r). Used to help
facilities that handle chemicals determine whether they need to submit reports under sections 302, 304, 311,
312 or 313 of EPCRA and, for a specific chemical, what reports may need to be submitted. It also helps
facilities determine whether they will be subject to accident prevention regulations under CAA Section 112(r)
and lists "unlisted hazardous wastes" under RCRA at http://www.epa.gov/ceppo/pubs/title3.pdfRCRA.
Federal RCRA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts: 240-282
Safe Drinking Water Act (SDWA)
The Safe Drinking Water Act (SDWA) protects public health by requiring public water systems to
monitor for specified contaminants on a periodic basis and by mandating underground injection requirements
for waste disposal into underground injection wells. It does this by directing the U.S. EPA to set maximum
contaminant levels for regulated contaminants found in public water supply systems, establishing
underground injection control and sole-source aquifer/wellhead protection programs and prohibiting the use
of lead pipes, solder or flux in the installation and repair of any public water systems or any plumbing in a
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residential or nonresidential facility providing water for human consumption.
The SDWA established the Underground Injection Control (UIC) Program to provide safeguards so that
injection wells do not endanger current and future underground sources of drinking water. The most
accessible fresh water is stored in shallow geological formations called aquifers and is the most vulnerable to
contamination. Aquifers feed our lakes; provide recharge to our streams and rivers, particularly during dry
periods; and serve as resources for 92 percent of public water systems in the United States. To assure that
underground injection will not endanger drinking water sources, the SDWA provides that all underground
injections are authorized by a permit. For a hospital an injection well can constitute any bored, drilled or
driven shaft or a dug hole, where the depth is greater than the largest surface dimension that is used to
discharge fluids underground as well as any on-site drainage systems, such as septic systems, cesspools and
stormwater wells, that discharge fluids only a few feet underground. Hospitals and doctors' offices must make
sure that what they pour down a drain goes to a sewer, not a drywell or septic system.
A hospital would be considered a non-transient noncommunity water system (e.g., a public water
system) if it regularly serves at least 25 of the same people six months per year from its own water source.
The hospital would thus be required to comply with SDWA monitoring and reporting requirements.
Typical physical features to inspect under SDWA:
• Safe drinking water inspectors will primarily be concerned with any underground injection control
wells at the hospital.
Several compliance assistance tools that can help medical facilities comply with SDWA:
• U.S. EPA Safe Drinking Water Hotline provides up-to-date information on recently promulgated
standards and regulations that have appeared in the Federal Register and answers questions.
(800) 426-4791 or http://www.epa.gov/OGWDW/drinklink.html
• U.S. EPA's Groundwater and Drinking Water Web site provides information and resources that help
facilities ensure safe drinking water and protect ground water, http://www.epa.gov/ogwdw/
• Safe Drinking Water Academy/The Drinking Water Academy (DWA) provides training and
information to help U.S. EPA, states, tribes and others increase their capability to implement the
1996 Safe Drinking Water Act amendments. Training will, in turn, promote better compliance and
encourage greater public health protection. The academy will develop courses designed to meet the
training needs of the Public Water System Supervision, Underground Injection Control and Drinking
Water Source Water Protection programs, http://www.epa.gov/safewater/dwa/
• Safe Drinking Water Academy Underground Injection Control on-line training module.
http://www.epa.gov/safewater/dwa/electronic/uic.html
For more information on SDWA:
• http://www.epa.gov/region5/defs/html/sdwa.htm
• Underground Injection Control general information, http://www.epa.gov/safewater/uic.html
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Federal SDWA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts 141-149
Also look at Underground Injection Control Program: Part C of the SDWA, 40 CFR Part 144-148
Toxic Substances Control Act (TSCA)
The Toxic Substances Control Act (TSCA) protects human health and the environment by requiring the
testing of certain potentially hazardous chemicals and establishing regulations that restrict the manufacturing,
processing and use of such chemicals. Health care facilities may be subject to TSCA through the lead hazard
reduction regulations in the event of lead-based paint issues possibly at staff residential units, especially those
built before 1980 Note: Use of lead-based paint was outlawed in 1978. However, lead-based paint was still in
circulation and used after 1978.
Common violations and problems found at hospitals for TSCA issues:
TSCA inspectors will primarily be interested in any PCBs and lead-based paint at the hospital.
Typical staff residential area lead paint violations/issues:
• Failure to notify residents of lead-based paint in the building or lack of knowledge of any lead hazard.
• Failure to provide the U.S. EPA's pamphlet, "Protect Your Family from Lead in Your Home" as
required under 40 CFR Part 745.107(a)(l). http://www.epa.gov/opptintr/lead/leadpdfe.pdf
Typical physical features to inspect for PCB 's, asbestos and lead-based paint under TSCA.
• PCB storage areas
• Equipment, fluids, and other items used or stored at the facility containing PCBs. PCBs are most
likely to be found in electrical equipment such as transformers, capacitors, and possibly fluorescent
light ballasts in older (pre-1980s) fixtures.
• Pipe, spray-on, duct, and troweled cementitious insulation and boiler lagging
• Ceiling and floor tiles
Several compliance assistance tools that can help medical facilities comply with TSCA:
• TSCA Hotline provides up-to-date technical assistance and information about programs implemented
under TSCA, the Asbestos School Hazard Abatement Reauthorization Act, the Residential Lead-
Based Paint Hazard Reduction Act and the Pollution Prevention Act. In addition, the hotline
provides a variety of documents, including Federal Register notices, reports, brochures and booklets.
The hotline is a free service available to the public, state and local governments, federal agencies,
environmental and public interest groups, and members of the United States Congress.
Call (202) 554-1404 or mailto:tsca-hotline@epa.gov.
• National Lead Information Center (NLIC) provides the general public and professionals with
information about lead hazards and their prevention. NLIC operates under a contract with funding
from the U.S. EPA, the Centers for Disease Control and Prevention and the Department of Housing
and Urban Development, http://www.epa.gov/opptintr/lead/nlic.htm
• U.S. EPA's Lead Program Web site provides information and documents on how to comply with
U.S. EPA's lead regulations and reduce residential lead hazards, http://www.epa.gov/opptintr/lead/
• U.S. EPA's Asbestos Web site provides information and resources to help facilities comply with the
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asbestos regulations under the Clean Air Act and the Toxic Substances Control Act.
http://www.epa.gov/asbestos/
• U.S. EPA's PCB Web site provides information on the federal program for regulating
polychlorinated biphenyls (PCBs). http://www.epa.gov/opptintr/pcb/
• U.S. EPA Regional PCB Program contacts, http://www.epa.gov/opptintr/pcb/coordin.html
• U.S. EPA document protocol for conduction environmental compliance audits of facilities with
PCB's, asbestos, and lead-based paint under TSCA.
http://www.epa.gov/compliance/resources/policies/index.html
For more information on TSCA:
• http://www.epa.gov/region5/defs/html/tsca.htm.
Federal TSCA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts 700-799
• Lead hazard reduction regulations can be found at 40CFR Part 745.
• Management requirements for polychlorinated biphenyls (PCBs) is found at 40CFR Part 761.
U.S. EPA Voluntary Audit Policy
The U.S. Environmental Protection Agency (U.S. EPA) is responsible for ensuring that businesses and
organizations comply with federal laws that protect the public health and the environment. The U.S. EPA's
Office of Enforcement and Compliance (OEC) combines traditional enforcement activities with more
innovative compliance approaches including the provision of compliance assistance to the general public.
The OEC was established in 1994 to focus on compliance assistance-related activities. The U.S. EPA also
encourages the development of self-assessment programs at individual facilities. Voluntary audit programs
play an important role in helping companies meet their obligation to comply with environmental
requirements. Such assessments can be a critical link, not only to improved compliance, but also to
improvements in other aspects of an organization's performance. For example, environmental audits may
identify pollution prevention opportunities that can substantially reduce an organization's operating costs.
Environmental audits can also serve as an important diagnostic tool in evaluating a facility's overall
environmental management system or EMS.
Reasons to consider the voluntary audit program include the following:
• Take proactive measures to find and address compliance problems before the U.S. EPA discovers
them.
• Take advantage of the penalty mitigation incentives under the audit policy.
Conduct and publicize disclosures as evidence of good corporate citizenship and awareness of
need to protect public health and the environment.
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• Obtain certainty by relying on predictable enforcement response under the audit policy.
Obtain assurance from EPA that the violation(s) is being properly corrected and/or damage is
properly remediated.
Take advantage of the incentives regarding no recommendation for criminal prosecution under the
audit policy.
Incentives for Self-Policing Under the Audit:
No gravity-based penalties for disclosing entities that meet all nine policy conditions, including
"systematic discovery" of the violation through an environmental audit or a compliance management
system. Gravity-based penalties are that portion of the penalty over and above the economic benefit.
In general, civil penalties that U.S. EPA assesses are comprised of two elements: the economic benefit
component and the gravity-based component. The economic benefit component reflects the economic
gain derived from a violator's illegal competitive advantage. Gravity-based penalties are that portion
of the penalty over and above the economic benefit. They reflect the egregiousness of the violator's
behavior and constitute the punitive portion of the penalty. The U.S. EPA retains its discretion to
collect any economic benefit that may have been realized as a result of noncompliance.
• Reduction of gravity-based penalties by 75 percent may be granted to entities that meet all of the
conditions except for "systematic discovery" of the violation through an environmental audit or a
compliance management system.
• No recommendation for criminal prosecution for entities that disclose violations of criminal law and
meet all applicable conditions under the policy. "Systematic discovery" is not required to be eligible
for this incentive, although the entity must act in good faith and adopt a systematic approach to
preventing recurring violations. The U.S. EPA generally does not focus its criminal enforcement
resources on entities that voluntarily discover, promptly disclose and expeditiously correct violations,
unless there is potentially culpable behavior that merits criminal investigation. When a disclosure that
meets the terms and conditions under the audit policy results in a criminal investigation, the U.S. EPA
generally will not recommend criminal prosecution for the disclosing entity, although the agency may
recommend prosecution for culpable individuals and other entities.
• No routine requests for audit reports from entities who disclose under the audit policy. In general, the
U.S. EPA will refrain from routine requests for audit reports. However, if the U.S. EPA has
independent evidence of a violation, it may seek the information it needs to establish the extent and
nature of the violation and the degree of culpability.
Under the audit program, the hospital can typically audit compliance with the following federal
regulatory programs:
Air Programs (CAA)
40 CFR Part 52 Section 21 (40 CFR 52.21)
Prevention of Significant Deterioration of Air Quality
40 CFR Part 60
Standards of Performance for New Stationary Sources
40 CFR Part 61
National Emission Standards for Hazardous Air Pollutants, Subpart M, National Emission Standard
for Asbestos
40 CFR Part 62 Subpart HHH
Federal Plan Requirements for Hospital/Medical/Infectious Waste Incinerators
40 CFR Part 63
National Emission Standards for Hazardous Air Pollutants for Source Categories (all applicable
provisions)
40 CFR Part 68
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Chemical Accident Prevention Provisions
40 CFR Part 70
State Operating Permit Programs
40 CFR Part 82
Protection of Stratospheric Ozone
All applicable provisions of the State Implementation Plan Regulations (promulgated pursuant to
Section 110 of the Clean Air Act) including the New Source Review regulations.
Water Programs (CWA)
40 CFR Part 112
Oil Pollution Prevention
40 CFR Part 122
EPA Administered Permit Programs: The National Pollutant Discharge Elimination System
40 CFR Part 141
National Primary Drinking Water Regulations
40 CFR Part 142
National Primary Drinking Water Regulations Implementation
40 CFR Part 143
National Secondary Drinking Water Regulations
40 CFR Part 144
Underground Injection Control ("UIC") Program
40 CFR Part 145
State UIC Program Requirements
40 CFR Part 146
UIC Program: Criteria and Standards
40 CFR Part 147
State UIC Programs
40 CFR Part 148
Hazardous Waste Injection Restrictions
40 CFR Part 403
General Pretreatment Regulations for Existing and New Sources of Pollution
Pesticide Programs (FIFRA)
40 CFR Part 160
Good Laboratory Practice Standards
40 CFR Part 162
State Registration of Pesticide Products
40 CFR Part 170
Worker Protection Standard
40 CFR Part 171
Certification of Pesticide Applicators
40 CFR Part 172
Experimental Use Permits
Solid and Hazardous Wastes (RCRA)
40 CFR Part 260
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Hazardous Waste Management System: General (Part 370, 6 New York Code of Rules and
Regulations)
40 CFR Part 261
Identification and Listing of Hazardous Waste
40 CFR Part 262
Standards Applicable to Generators of Hazardous Waste
40 CFR Part 263
Standards Applicable to Transporters of Hazardous Waste
40 CFR Part 264
Standards for Owners and Operators of Hazardous Waste Treatment, Storage and Disposal Facilities
40 CFR Part 265
Interim Status Standards for Owners and Operators of Hazardous Waste Treatment, Storage and
Disposal Facilities
40 CFR Part 266
Standards for the Management of Specific Hazardous Wastes and Specific Types of Hazardous Waste
Management Facilities
40 CFR Part 268
Land Disposal Restrictions
40 CFR Part 273
Standards for Universal Waste Management
40 CFR Part 279
Standards for the Management of Used Oil
40 CFR Part 280
Technical Standards and Corrective Action Requirements for Owners and Operators of Underground
Storage Tanks ("USTs")
Hazardous Substances and Chemicals, Environmental Response, Emergency Planning and Community
Right-to-Know Programs (EPCRA)
40 CFR Part 3 02
Designation, Reportable Quantities and Notification
40 CFR Part 355
Emergency Planning and Notification
40 CFR Part 3 70
Hazardous Chemical Reporting: Community Right-to-Know
40 CFR Part 3 72
Toxic Chemical Release Reporting: Community Right-to-Know
Toxic Substances (TSCA)
40 CFR Part 745
Lead-Based Paint Poisoning Prevention in Certain Residential Structures
40 CFR Part 761
Polychlorinated Biphenyls (PCBs) Manufacturing, Processing, Distribution in Commerce and Use
Prohibitions
40 CFR Part 763
Asbestos
To learn more about the policy: http://www.epa.gov/compliance/incentives/auditing/auditpolicy.html
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U.S. EPA National Environmental Performance Track Program
www.epa.gov/performancetrack
(888) 339-PTRK (7875)
Performance Track is a voluntary program in which the U.S. EPA rewards public and private facilities
that consistently exceed regulatory requirements, work closely with their communities, and excel in
protecting the environment and public health. A core principle of Performance Track is that companies with
a history of dedication to continuous improvement should be treated differently than other facilities. To foster
continuous improvement at member facilities, Performance Track offers incentives, such as recognition on
local and national levels, low inspection status, and regulatory changes, to help ease reporting requirements
and reduce administrative costs.
Standard Criteria for Program Eligibility
1. Implementation of an Environmental Management System (EMS)
2. Commitment to Continuous Improvement
3. Community Outreach
4. Sustained Compliance
5. Standard Criteria for "Small Business" Applicants
Environmental Management System (EMS)
During the application process, Performance Track organizations certify that they have adopted and
implemented an Environmental Management System (EMS). An EMS is an organization's systematic effort
to meet its environmental requirements and improve its overall performance. To participate, applicants must
complete at least one full cycle of implementation (NOTE: This "full cycle of implementation" could be one
year, less than one year or more than one year. The duration of the implementation cycle is best determined
by the originator/implementer of the individual EMS). Organizations that have adopted ISO 14001 or other
systems with a Plan-Do-Check-Act framework likely meet most of these elements.
Because each organization is unique, the scope and formality of its EMS will vary according to its size,
sector and complexity.
A qualifying EMS for Performance Track includes the following elements:
1. Policy
2. Planning
3. Implementation and Operation
4. Checking and Corrective Action
5. Management Review
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Continuous Improvement Performance Criteria
To submit a successful application, organizations must demonstrate past environmental achievement
and commit to continued improvement in their performance. Past achievements and future commitments are
in specific aspects of environmental categories. The categories are as follows:
Energy Use
• Water Use
Materials Use
• Air Emissions
Waste Generation
• Water Discharges
Accidental Releases
• Preservation and Restoration
Product Performance
Aspects are specific environmental impacts within these categories (e.g., discharge of heavy metals).
The Performance Track Application Instructions on the United States Environmental Protection Agency's
(U.S. EPA's) Web site (http://www.epa.gov/performancetrack/index.htm) lists the categories and their
associated aspects and measures.
Performance Track program applicants must demonstrate achievement in at least two environmental
aspects in any of the categories in the current and preceding year. Applicants must also commit to future
improvements in at least four environmental aspects, drawn from two or more categories. Two of these
aspects may be in the same category, and they may be the same as those used to demonstrate past
performance.
Organizations are encouraged to commit to more than the minimum. Aspects are chosen by the
organization, not by the U.S. EPA. Commitments for improvement should relate to the organization's
significant environmental aspects identified in the EMS and should take into account local environmental
priorities and pollution prevention opportunities. In documenting past achievements and committing to
continued improvement, organizations should not rely on any actions that represent compliance with existing
legal requirements at the federal, state, tribal or local levels. Improvements should represent actions beyond
existing legal requirements.
Community Outreach
Performance Track members demonstrate their commitment to public outreach and report periodically
on their performance in the program. In addition, the U.S. EPA expects that applicants will already have
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established a public outreach program (e.g., newsletters, sponsorship of community activities, performance
reporting) prior to submitting their applications. Public outreach activities may vary across organizations
depending on their size, setting and type of operation, but should include the following:
Identifying and responding to community concerns. An organization should be able to
demonstrate that it has established mechanisms for identifying and responding to local concerns
regarding the environmental effects of its operations (e.g., emissions, odor).
• Informing the community of important matters that affect it. Appropriate to an organization's size,
operation and setting, each applicant should describe the mechanisms it uses to inform the
community of important issues that relate to its environmental performance.
Reporting on the organization's EMS and performance commitments. Whatever means an
organization employs for community outreach, it should explain specifically how it provides the
public with the environmental performance information that it is committed to reporting (e.g.,
open houses, community meetings).
Finally, organizations must provide a short list of community/local references that are familiar with the
facility and to list any ongoing citizen lawsuits against the facility.
Sustained Compliance
Performance Track members have a record of compliance with environmental laws and are in
compliance with all applicable environmental requirements. They also commit to maintaining the level of
compliance necessary to qualify for the program.
The U.S. EPA screens all applications consistent with U.S. EPA Compliance Screening Policy for U.S.
EPA Partnership Programs. See http://www.epa.gov/performancetrack/program/sustain.htm. In evaluating an
applicant's compliance record, the U.S. EPA and its state partners will consult available databases and
enforcement information sources. The U.S. EPA encourages applicants to assess their own compliance record
as they make decisions regarding participation in this program. Participation in the Performance Track is not
appropriate if the compliance screen shows any of the following, under federal or state law:
Criminal Activity
• Corporate criminal conviction or plea for environmentally-related violations involving the
corporation or a corporate officer within the past five years.
• Criminal conviction or plea of employee at the same facility for environmentally-related violations
within the past five years.
• Ongoing criminal investigation/prosecution of corporation, corporate officer or employee at the same
facility for violations of environmental law.
Civil Activity
Three or more significant violations at the organization in the past three years.
• Unresolved, unaddressed Significant Noncompliance (SNC) or Significant Violations (SV) at the
facility.
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Planned but not yet filed judicial or administrative action at the organization.
• Ongoing U.S. EPA- or state-initiated litigation at the organization.
Situation where a facility is not in compliance with the schedule and terms of an order or decree.
"Small Business" Criteria (for Performance Track Eligibility)
For the purposes of this program, an organization is considered to be a "small" organization if the
company as a whole is a small business as defined by the Small Business Administration [see "National
Environmental Performance Track Program: Final Program Changes for 2004" May 15, 2000 (http://
www.epa.gov/performancetrack/events/program_changes_web_version.pdf)] and if the organization itself
employs fewer than 50 full-time employees.
Small businesses are active participants in innovative programs such as the U.S. EPA Sustainable
Industries Program, Design for the Environment, voluntary partnership programs and EMS projects with local
governments. Qualified small businesses, organizations and local governments are encouraged to participate
in the National Environmental Performance Track as well.
Based on input from small business representatives, certain provisions were designed to meet their
special needs:
• Environmental Management Systems. The scope and level of formality of the EMS will vary,
depending on the nature, size and complexity of the facility. U.S. EPA's experience with a variety
of programs suggests that these EMS elements are within the capability of small organizations
and can be met through different approaches. To help small organizations implement an EMS, the
U.S. EPA makes guidance documents and assistance materials available.
• Continuous Improvement. Small businesses have the option of documenting improvement for at
least one environmental aspect from any category. In making future performance commitments,
small organizations should select at least two aspects from two or more categories.
Community Outreach and Reporting. There is no standard set of outreach activities beyond the
Annual Performance Report (APR). Each organization's approach to community reporting
beyond the annual performance report will depend on its size, scale of operations and setting. At a
minimum, a small organization should be able to document that it has designated a point of
contact with direct access to facility management and has adopted procedures for responding to
local residents' questions or concerns.
Sustained Compliance. Small organizations must have a record of sustained compliance in the
same manner as other organizations participating in Performance Track.
• Annual Performance Reporting to EPA. EPA is considering providing specialized assistance in
this area for small organizations. A facility should maintain onsite the supporting documentation
used to prepare its Annual Performance Report and make this documentation available to EPA
upon EPA's request.
EPA has held numerous discussions with representatives of small business interests and is encouraging
participation by qualified small businesses and their organizations. In addition, EPA may create a more active
and focused development program for small businesses and other small entities with the goal of helping to
expand their capacities for participation in Performance Track.
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Other Organizations
American Hospital Association (AHA)
In the United States, private businesses including health care facilities and health care providers joined
together to form an organization that represents their interests and assists their efforts to work with the
government on a variety of health care issues. The American Hospital Association (AHA) is a national trade
organization that represents all types of hospitals, health care networks, their patients and the communities
they serve. As many as 5,000 institutions and 40,000 individuals belong to the AHA. The AHA's mission is
to advance the health of individuals and communities.
AHA provides representation and advocacy activities to ensure that members' perspectives are addressed
in national health policy development, legislative and regulatory debates and judicial matters. In addition,
AHA provides resources to help health care leaders implement change at the community level. The AHA
helps hospitals and other health care providers form networks for patient care. They conduct research and
demonstration projects; provide educational programs; perform data gathering and information analysis to
support policy development and track trends and keep members informed of national developments and
trends and their impact on local communities.
The AHA works for its membership to track international and federal rule-making to educate members of
the health care community on the potential impact of new legislation and regulatory initiatives.
http://www.aha.org
Hospitals for a Healthy Environment (H2E)
The Hospitals for a Healthy Environment (H2E) is a voluntary program, which was formed as a result of
the American Hospital Association and the U.S. EPA's Memorandum of Understanding (MOU) dated June
24, 1998.
This landmark agreement calls for:
Elimination of mercury-containing waste from health care facilities' waste streams by 2005.
• Reduction of the overall volume of waste (both regulated and nonregulated waste) by 33 percent by
2005 and by 50 percent by 2010.
• Identification of hazardous substances for pollution prevention and waste reduction opportunities,
including hazardous chemicals and persistent, bioaccumulative and toxic pollutants (PBT).
The Hospitals for a Healthy Environment program helps health care facilities enhance workplace
safety, reduce waste and waste disposal costs and become better environmental stewards and neighbors. This
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is done by educating health care professionals about pollution prevention opportunities in hospitals and
health care systems.
Through activities, such as the development of best practices, model plans for total waste management,
resource directories and case studies, H2E provides hospitals and health care systems with enhanced tools
for minimizing the volumes of waste generated and the use of persistent, bioaccumulative and toxic
chemicals (PBT). Such reductions are beneficial to the environment and health of our communities.
Furthermore, improved waste management practices will reduce the waste disposal costs incurred by the
health care industry.
To take advantage of the opportunities the H2E program offers, visit the H2E Web site www.h2e-
online.org and/or participate in one of the H2E programs as either a partner or champion.
Partners are health care facilities who commit to making changes in their facilities that protect
community and environmental health. Champions are organizations that encourage and aid health care
facilities to participate as H2E partners and/or who make changes in their own institutions that support the
goals of the H2E program. Partners and champions receive local and national recognition for the work they
do to reduce waste and protect the environment through the H2E recognition and awards program.
Visit the H2E Web site for a complete list of current partners and champions; tools and resources
including many items such as mercury, green buildings and green purchasing; Environmental Management
Systems; technical resources with links to mercury recyclers and consultants and vendors; news and events;
videos and much more.
www.h2e-online .org
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO "jayco" or Joint
Commission) is an independent, not-for-profit organization, and a leading health care standards-setting and
accrediting body. The Joint Commission strives to improve the safety and quality of care provided to the
public. The Joint Commission evaluates and accredits more than 19,500 health care organizations in the
United States, including hospitals and health care organizations that provide home care, long term care,
behavioral health care, laboratory and ambulatory care services.
JCAHO enforces seven (7) standards. The environment of care standard will be the focus for
connecting Environmental Management Systems to related JCAHO requirements. The seven JCAHO
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standards are:
• Environment of Care
• Improving Organizational Performance
• Leadership
Governance
• Human Resource
• Management of Information
• Surveillance, Prevention and Control of Infection
http://www.icaho.org
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Environmental Management
Systems for Healthcare
Organizations
US Environmental Protection Agency,
Region 2
Welcome to attendees:
We'd like to thank you for attending this workshop today. We realize you are here because
you want to make your hospital a better place environmentally, learn how to go beyond
compliance, and possibly save resources in the process. As you know, the EMS is a
voluntary program for non-federal facilities and we commend you for taking the time out of
your busy day to be here. For those of you who are federal facilities, we commend you too.
The Executive Order that mandates all federal facilities implement an EMS has been a
daunting task and we know first hand how challenging it can be and the fact that you are
here today shows your are committed to the effort.
We encourage the audience to be interactive. You should feel free to ask questions and offer
your own experiences developing EMSs both good and bad so we can learn from each
other. Every now and then we will stop for group exercises to improve understanding of
new terms and concepts.
I will be go over a lot of information in this presentation and while you do have a place to
take notes, you may not quite catch everything. Enclosed in your binder you will find a
CD-ROM that contains today's presentation with detailed speaker notes so you can go back
and read if you missed something. Other presentations and guides are found on the CD as
well.
We would like to recognize Russell F. Mankes of Albany Medical Center and Marvin R.
Stillman of Strong Memorial Hospital for their photographs.
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Topics to be covered in this module
• Desired workshop outcomes - what we hope you will get out of this course today
• What an EMS is and is not and the benefits of an EMS
Similarities between JCAHO and EMS
• How you can get top management support for an EMS at your hospital
• Choosing a fenceline for your EMS - you don't have to do the whole hospital all at
once
• Provide an overview of ISO 14001 - the international standard for an EMS
• Environmental policy
• Resources, roles, and responsibilities
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Workshop Outcomes
Better understanding of what an EMS is and
the benefits of an EMS
Armed with tools to help with EMS
implementation, such as:
• Examples of policies; SOPs; action plans
• Lessons learned from real-life healthcare facilities
• Websites; manuals; contacts
Be familiar with ISO 14001 terms (This is not
an ISO course, however)
Our goal today is threefold.
• First, we hope to give you a better understanding of what an environmental
management system is and the benefits of an EMS.
• Second, we will provide you with tools to help you implement an EMS at your
facilities, such as examples of policies, standard operation procedures (SOP), and
action plans; success stories and lessons learned from real life healthcare facilities
that can help you save time and resources in the early stages of implementation; and
websites, manuals, and points of contact that are available to assist you when you
reach an impasse in the development of your EMS.
• Third, by the end of day, you should be familiar enough with ISO 14001 terms that
if you hear someone talking about environmental aspects at a wedding you can jump
right into the conversation. (International Organization for Standardization 14001 is
the EMS standard).
However, we do want to make clear upfront that even though the international EMS
standard - ISO 14001 - underlies much of this workshop, it is not intended to be an ISO
course. Facilities may wish to consider obtaining formal ISO training for key personnel.
The range of ISO training available ranges from a basic orientation session (1-day) to
internal auditor training (3-day) to lead auditor training (5-days).
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What is an Environmenta
and review mechanisms used by an
organization to achieve its
environmental objectives.
You already have an EMS
Your EMS probably doesn't meet the
requirements of a formal standard
(e.g. ISO 14001)
An EMS, like any management system, consists of numerous elements (staff,
documentation, and procedures) all of which must be present for the system to
function. What makes one management system different from another is the reason
for the system's existence. The purpose of an EMS is to enable the organization to
integrate environmental considerations into day-to-day decisions and practices in
order to at a minimum maintain compliance with environmental regulations and
ideally continually improve its environmental performance by implementing
pollution prevention and best management practices wherever feasible.
On the positive side, since healthcare facilities are subject to environmental
requirements and regularly expend personnel and financial resources to address
these requirements (e.g., red bag waste, hazardous waste, air permits), your facility
must already have some form of an EMS in place. Unfortunately, this EMS, unless
your facility has formally attempted to do so, more than likely, does not fulfill all
the requirements of a recognized EMS standard (e.g., ISO 14001).
Why, you may ask, do we need such a formal EMS? Well, judging from the high
number of violations being found at healthcare facilities, a case can be made that
most of the "informal" EMSs at hospitals are not very effective. By modifying your
existing EMS to meet the requirements of a recognized standard, you will
significantly increase your chances of having a system that works.
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An EMS is Environmental
Reviews environmental aspects of all relevant
activities
Targets significant environmental impacts
Places responsibility for environmental
performance with staff performing the activity
Enhances communication
Establishes oversigl
records
documents and
liance
Now, regardless of what standard you choose, all EMSs have three things in
common. First, they are environmental systems. As such, they consider every part
of a facility's operations that can potentially affect the environment — not just the
regulated ones - and then focuses on the most significant impacts.
Accountability is critical to an EMS - employees who are in a position to affect the
environment bear primary responsibility for assuring that they carry out their duties
so as to minimize potential adverse environmental impacts. Everyone is a part of
the EMS, from the Director of the facility to the most recently hired part-time
employee. Effective communication of environmental issues among all staff
ensures that the EMS is not isolated to the "environmental department."
Comprehensive documentation and document control promotes continuity and helps
eliminate personality-driven EMSs. An EMS maintains compliance in several
ways:
• Ensuring that employees are properly trained;
• Maintaining and disseminating up-to-date information on compliance
requirements;
• Establishing formal procedures and oversight mechanisms; and
• Eliminating compliance requirements through pollution prevention
strategies.
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An EMS is Management
Based on commitment and increased
involvement of top management
Alignment of environmental anc
mission objectives
Transition of responsibility for
managing environmental programs
Second, an EMS is a management system. Without a demonstrated commitment (i.e., time
and resources) on the part of top management, the EMS will ultimately fail. Although it is
possible for organizations to adopt ideas that originate at the grassroots level, it is more
likely that such ideas will be dismissed unless they have a champion with sufficient
organizational clout to advance them. If management commitment is seen as lacking,
environmental concerns will not receive the priority they deserve. Top management is
involved at various phases of EMS implementation, including policy development, approval
of objectives and targets, and management review of EMS performance.
An effective EMS supports the mission of a healthcare facility - promoting patient and
community health and well-being.
Management of environmental programs is assigned across the organization, and at the most
appropriate level - staff outside of the "environmental" department have environmental
responsibilities.
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Finally, an EMS is a system and to be a system, environmentally-related activities must be
repeatable, independent of the person who is conducting the activity. If a key
environmental staff person retires, transfers, or otherwise leaves the facility, other staff must
assume these key roles and responsibilities. To ensure this occurs, informal elements of an
EMS must be made formal.
Formal elements of an EMS include:
• Documented roles and responsibilities;
• Mandatory training;
• Documented policies and operating procedures;
• Document and record control systems; and
• Regular internal and external review and oversight.
An EMS builds upon the progress made in preceding years and on a regular basis, sets new
environmental goals and refines established policies and procedures to bring about a "cycle"
of continuous improvement.
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Benefits of an EM
Reducing or eliminating the potential
>atient and worker exnosure tn
hazardous chernicals/waste;
Decreasing compliance costs and risks;
Saving resources;
Improving relationships with external
and internal stakeholders.
The following represent a few examples of medical facilities experiencing real cost savings
from implementing EMSs:
•Thomas Jefferson Hospital in Philadelphia implemented a recycling program that
cut the volume of solid waste generated by 50 percent, resulting in $150,000 per
year in disposal cost savings;
•Houston Shriners Hospital reduced utility costs by 40 percent relative to 1997 since
implementing energy conservation strategies as part of its EMS; and
•Cambridge Memorial Hospital reduced biomedical waste generation and disposal
costs by 20 percent in each of the first two years of its EMS implementation process.
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As we mentioned before, an EMS will not succeed without top management support and
commitment. Top management allocates staffing and other resources necessary to
implement the EMS. Management also plays a key role in defining and enforcing staff
responsibilities and in communicating the importance of the EMS to staff. Lastly, top
management periodically reviews the performance of the EMS relative to the environmental
objectives and targets and redefines these objectives and targets as necessary.
Obtaining top management commitment generally involves the following actions:
• Describing what an EMS is and how it benefits a healthcare facility;
• Identifying the environmental issues, particularly compliance-related, that the
facility faces;
• Estimating the resources and time requirements for the initial development and
implementation; and
• Defining top management's roles and responsibilities.
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Management Buy-in
Cost savings
Improved compliance with
environmental requirements
Increased staff ownership
Management needs to buy into the idea of an EMS and its benefits in order for the system to
work. They need to understand the benefits of the EMS, why it will be good for the hospital
and how it will save the hospital money. Keep in mind that cost savings from pollution-
prevention projects (including energy efficiency) is just one benefit to communicate to
management. EMSs also provides improved operational efficiencies that can lead towards
improved compliance with environmental laws which can ultimately increase staff
ownership of environmental performance. And lastly, a hospital is a place to go to get
better and improve your health. In this regard, an EMS offers an opportunity for enhanced
hospital image in the community.
Ask the audience: Does anyone have any lessons learned from management
commitment and management buy-in?
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Senior Management: Senior management consists of the president, chief executive officer and vice
presidents, directors, program managers from various functional centers throughout the hospital.
These managers plan present and future hospital programs and operations and ensures that they
remain efficient, effective and fiscally responsible. The decision to implement an EMS should first
be presented to and approved at the senior management level prior to going to the Board of Trustees
for comments and final approval. Senior management is the first line of communication to the Board
of Trustees and is often aware of agenda items and topics to be reviewed at monthly board meetings.
The hospital's senior management team also approves and allocates funds for the hospital's
upcoming operating budget.
Board of Trustees: This governing body is often comprised of hospital staff as well as community
and health care professionals. Board members are responsible for the overall direction and planning
of the hospital. Trustees approve corporate programs, make significant hospital decisions and discuss
current and future hospital initiatives. Look to board members as potential environmental allies.
Board members may live in the local community and share the same environmental concerns as staff
and local residents. Tap into these influential and professional resources for EMS implementation
support.
Middle Management: Hospital middle management includes program/department managers,
supervisors and coordinators that oversee the day-to-day management of such hospital programs as
patient services, support services and facility management. Middle management plays a significant
role in the EMS, particularly in the follow through stages associated with staff environmental
training, awareness activities and standard operating procedures.
Hospital employees: Excluding management, hospital employees include physicians/doctors, nurses,
specialists, technologists, support staff and all other union and nonunion staff.
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The "fenceline" defines the scope of the EMS at a healthcare facility. Think of a fence around the area you'd
like to concentrate with the EMS. There are a range of options from a large grand scale to a smaller more
manageable scale. Larger fencelines include:
All healthcare facility operations and property, including outpatient clinics and supported operations;
The healthcare facility and immediately surrounding property;
The healthcare facility and surrounding property, excluding that leased to another entity for other
purposes (e.g., golf course, veterans service organization);
Smaller fencelines can include:
The operational or non-patient care portion of healthcare facility (e.g. purchasing, landscaping);
A single functional area (e.g., laboratory) or set of functional areas within a healthcare facility; or
A specific environmental activity or issue (e.g. waste management, purchasing, energy efficiency).
In the case of the smaller fencelines, healthcare facilities will elect to implement their EMS using a phased
approach. These facilities may start with a particularly high risk area or areas, or with an area that has a
potential to demonstrate immediate results, and then building upon initial success, the facility will expand the
EMS to encompass more and more operations. Whatever fenceline is chosen, it is essential that this choice be
clearly stated within the EMS documentation and procedures.
One thing to make sure with regards to a small fenceline is to choose an area where you know there are
environmental problems of concern so that you can take these lessons learned and more proactively expand the
EMS later on. This will also show results to upper management that the EMS can help your facility with
potential compliance issues. For example, a small fenceline focusing on universal wastes will provide more
public perception and upper management support than one that focuses on Styrofoam cups and recycling in the
cafeteria.
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There are many small fenceline areas within a healthcare facility, and we've chosen a few to
illustrate where you might start.
Laboratories are a single function, high-risk area. You do not need environmental training
to know that these products are an accident waiting to happen. However, when we find
items such as these in healthcare facilities, it is clear that no EMS is in place or functioning.
Here we see a bottle marked "waste everything." The other photos are some examples of
materials that were still considered to be products; not wastes. You can see how well these
economically valuable materials were maintained. You can only imagine how well they
might handle waste materials for which they had no use. The bottle on the top right is
sodium which must be kept under oil since it is both water and air reactive. You can see
that the oil level has not been maintained. For the bottles on the bottom, you can see that
the labels are unreadable. This is not a good situation for a material that you want to use
again since you cannot tell what is in these bottles. The bearded bottles in the top center
photo are never an indication of good storage practices.
Do the handlers of these products at your facility know how to use and dispose of them
properly?
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Another fenceline area is red-bag waste. This specific environmental activity would reach
many employees throughout the facility. Here, we see a clean, orderly red-bag waste
collection area.
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Maintenance, housekeeping or an operational function is yet another place to start. Here we
see a cluttered storage or disposal area. Maintenance equipment, housekeeping materials,
recyclables and universal waste (fluorescent bulbs) are improperly stored together. An
EMS implemented for this area would likely yield immediate, effective results.
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In contrast with previous clutter, this universal-waste collection area maintains proper
storage (examples: cardboard, original boxes, and dot plastic 1 gallon shipping containers)
and labeling. Depending on your facilities problem areas, a single waste management
activity such as this may be an excellent initial phase to your EMS.
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4001)
Policy
Planning
Implementation
Checking and Corrective Action
Management Revi
There are five basic requirements or steps within an EMS:
• Policy;
• Planning;
• Implementation;
• Checking and corrective action; and
• Management review.
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Checking &
Corrective
ction
The requirements of an EMS are intended to be part of a "continual improvement" cycle
(i.e., plan-do-check-act). These steps are repeated over and over again so that the last step,
conducting management review, leads to new ideas and recommendations that then become
the starting point for renewed management commitment to the environmental policy.
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Environmental Policy
Environmental
Aspects
Legal and Othe
Requirements
Objectives & Targets
Environmental
Management
Programs
Structure and
Responsibility
Training: Awareness
& Competence
Communication
A
OR
^
EMS Documentation
Document Control
Operational Control
Emergency Preparedm
and Response
Monitoring and
Measurement
Nonconformance &
Corrective and Preventative
Action
Records
EMS Audit
Management Review
Within the five basic ISO requirements, there are 17 elements. Most of these are
not unique to an EMS, but are a part of any management system.
The challenge for a healthcare facility in developing an EMS is to build upon
existing management system elements, modify them or develop new ones as
appropriate, and then dedicate sufficient resources to enable the EMS to become
fully functional and integrated within the facility's day-to-day operations.
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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires
healthcare facilities to engage in many of the same or analogous activities that are a part of
an EMS. For example, one of the Environment of Care (EOC) program areas within the
JCAHO standard deals specifically with hazardous materials and waste management, while
another deals with emergency preparedness - both are part of an EMS.
In addition, JCAHO terminology - design-implement-monitor-measure - is very similar to
the EMS model - plan-do-check-act.
Other similarities between JCAHO and EMS include:
• Formal policy statements;
• Regularly scheduled third-party program reviews;
• Annual internal program audits (e.g., Annual Workplace Evaluations);
• Documented operating instructions;
• Mandatory annual training requirements;
• Corrective action tracking; and
• Root-cause analyses.
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invironmental Policy
Signed by top management
Appropriate to the nature, scale, and
environmental impacts of activities,
products or services
Includes commitments to continual
improvement, prevention of pollution,
and compliance
At a minimum, the environmental policy should be reviewed and signed by the director of the healthcare
facility. This represents a tangible demonstration of commitment by top management. Whenever a new
director is appointed, the policy should be reviewed and re-issued or otherwise formally re-affirmed. At some
facilities, the policy is signed by the top tier of management to emphasize its applicability to all operations.
Appropriateness of the environmental policy:
The wording should reflect those operations within the defined fenceline - no more, no less;
The wording should reflect the environmental impacts that are most relevant to healthcare facilities -
avoid generic language; and
The wording should reflect that the EMS supports the primary mission of the facility.
The policy must contain specific commitments to compliance, continual improvement, and prevention of
pollution. Note that prevention of pollution is not the same as pollution prevention:
"Prevention of pollution," as defined under ISO 14001, includes processes, practices, materials, or
products that avoid, reduce or control pollution, including recycling, treatment, process changes,
control mechanisms, efficient use of resources, and material substitution.
"Pollution prevention" as defined under the Pollution Prevention Act, is any practice that reduces the
amount of any hazardous substance, pollutant, or contaminant entering any waste stream or released
into the environment prior to recycling, treatment, or disposal.
Pollution prevention is potentially a much more rigorous standard than prevention of pollution because it is
possible for a healthcare facility to adhere to the prevention of pollution standard simply by "controlling"
pollution. Depending on how the facility defines control, this could involve fairly passive strategies (e.g.,
maintaining current emission/discharge levels and simply avoiding fines or notices of violations). Pollution
prevention strategies tend to look beyond compliance and it is pollution prevention not prevention of pollution
that EPA encourages healthcare facilities to consider in the development of their EMPs. This is one of our
major disagreements with the ISO standard which only requires prevention of pollution.
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invironmental Policy
Provides a framework for setting and
reviewing objectives and targets
Documented
Implemented and maintained
Communicated to all employees
Available to the public
With respect to the environmental policy, the term "framework" means:
• Wording that states the facility will set environmental objectives and targets and
formulate plans to achieve them;
• Wording that states the facility will monitor progress towards achieving objectives
and targets and update them as necessary; and
• Wording that defines who is responsible for setting objectives and targets or, at a
minimum, refers to another document that defines these responsibilities.
The policy must be documented.
The policy should be regularly reviewed and changed, as necessary, to reflect changes in
activities or services.
The policy should be concise, clearly written, and actively distributed to all employees
(preferably through multiple mechanisms). Many healthcare facilities develop two versions
of the policy - a standard version and an abbreviated version that can be readily posted
throughout the facility, incorporated onto business cards or ID cards, or included within
position descriptions or professional development plans. The policy should be publicized in
newsletters; discussed in mandatory employee orientation training; and included on the
agenda of staff meetings, as appropriate.
The policy should be made available to the public (e.g., via bulletin boards, public
websites).
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Samples are located in the back of your binder, in the resource section.
Ask the audience if they have experience in drafting their own EMS Policy Statement. As a
group, we can take a closer look at one example and see if all major elements are included:
signed by top management; appropriate; continual improvement; prevention of pollution;
and compliance.
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One of the earliest and most critical steps in the process of getting an EMS started is the
designation of an EMS Management Representative. In most instances, designation of the
MR precedes even the development of an environmental policy.
The next step is the formation of an EMS implementation team. The team provides a forum
in which most of the key EMS decisions are identified, discussed, and resolved.
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EMS Management
Representati
Designation
Roles and responsibilitie;
Management Representative vs. EMS
Specialist
In practice, many healthcare facilities elect to divide EMS leadership among two staff- one
drawn from senior management (the Management Representative) and another from middle
management (the Environmental Coordinator/EMS Specialist).
The role of the Management Representative is to coordinate. The Management
Representative is not responsible for every aspect of the EMS. The Management
Representative is responsible for:
• Ensuring that EMS requirements are established, implemented, and maintained;
• Reporting on the performance of the EMS to top management;
• Providing EMS leadership;
• Ensuring adequate resources;
• Defining and reviewing employee EMS responsibilities; and
• Approving EMS-related initiatives
The role of the Environmental Coordinator/EMS Specialist is more towards implementing
the EMS
• provide training;
• respond to questions;
• assure compliance with environmental requirements; and
conduct internal inspections
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The EMS implementation team is composed of individuals from across the facility.
Represented departments traditionally have environmental issues (e.g., laboratories,
custodial services, facility management) or have influence over the decision-making process
for environmental programs (e.g., purchasing, infection control). If at all possible, try to get
doctors, and nurses involved as well since they tend to have the most pull at healthcare
facilities. If doctors, for instance, insist on using mercury thermometers because they
believe the alternatives are not accurate you will have a hard time setting up a mercury
reduction program. The implementation team plays many key roles, including:
Identifying environmental aspects and impacts;
• Establishing and monitoring objectives and targets;
• Identifying training needs;
• Supporting the communication of environmental messages throughout the facility;
• Assisting in the development of EMS documentation;
Assigning responsibility for corrective actions;
Identifying root causes for EMS deficiencies;
• Participating in internal reviews; and
• Making recommendations for improving the EMS.
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Team Membe
Purchasing;
Housekeeping;
Surgery;
Cafeteria;
Infections control;
Nursing;
Doctors;
Finance;
• Laborato]
• Facilities
management;
• Safety and health
coordinator
The Implementation Team should represent key departments in the hospital - especially
those that deal firsthand with environmental issues.
Exercise #1: Please turn to the last section of your binder to find a hypothetical
organization chart for a hospital. Ask the participants to identify functions/personnel
within the various service lines that would be good candidates to serve on the EMS
Implementation Team and explain why they should be included.
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Resources, Roles, Responsibility
Ensure availability ot resources to
establish, implement, maintain and
improve the EMS
Define and EMS roles,
responsibilities and authorities from top
fo bottom
After designating the Management Representative and forming the Implementation Team,
management must continue to devote sufficient personnel, technological, administrative,
and financial resources to ensure that implementation of the EMS does not falter.
Management also plays an important role in communicating the relevance of the EMS to all
staff. With the assistance and expertise of the Implementation Team, management should
identify appropriate EMS roles, responsibilities, and authorities for all staff and incorporate
them into written position descriptions and performance plans.
• Operations managers should be responsible and accountable for effective
implementation of EMS and environmental performance.
• Staff at all levels should be accountable, within the scope of their responsibilities,
for environmental performance in support of the overall environmental management
system.
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Topics to be covered in this module
• Environmental requirements that potentially affect healthcare facilities and how to
stay abreast of changing requirements.
• Understanding which operations and activities interact with the environment
(aspects) and their potential effects (impacts).
- Determining which aspects and impacts are significant.
Tips on setting environmental objectives and targets, as well as action plans for
achieving them.
• Pollution prevention strategies, such as
- Environmentally preferable purchasing, and
- Energy efficiency.
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There are an abundance of regulatory requirements that one must be aware of in planning an
effective EMS. In a moment, we will discuss strategies to tackle these. To get you
thinking, here are a few examples. These are mercury-containing healthcare devices
(fluorescent bulbs, mercury-containing lamp (package), various thermometers). Is your
facility up-to-date with current legal and regulatory requirements in handling these items?
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Can everyone see what is wrong with this picture?
Someone at this facility thought it was a good idea to keep apple cider in the chemical
storage cabinet so that their co-workers didn't drink it. Maybe we don't need environmental
requirements to know that this is a bad idea.
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In comparison, good environmental practices include clear labels and organization to guide
employees in their activities, as well as indicate storage contents an unfamiliar individual.
Note: "NO FOOD" on fridge, safety data poster and other labels.
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More examples of poor practices that fail to meet certain legal and regulatory requirements.
On the right we see chemicals and clutter in unmarked storage boxes. On the left,
flammable liquids storage cabinets are left open. It's also a bad idea to store compressed
explosive gas next to a flammable liquids storage cabinet.
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FLAMMABLE
KKP
Here is the proper flammable storage cabinet with adequate labeling, in an orderly
laboratory.
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Legal and Other Requirements
» Establish and maintain a procedure
»Identify and gain access to updates
r i i 1.1 • .
Applies to environmental aspects
of the facility
There are many legal requirements that can apply to healthcare facility operations,
including: federal, state, and local laws and regulations, Executive Orders, and ordinances.
There are also other requirements that may not involve an external regulatory authority, yet
they are still relevant to facility operations. These include: internal agency/corporate
policies and orders, JCAHO requirements, professional association standards, and any other
"voluntary" provisions to which the facility subscribes, such as, Hospitals for a Healthy
Environment, WasteWise, and Leadership in Energy and Environmental Design.
Establishing and maintaining a procedure for identifying applicable requirements is critical
to ensure continuity of operations. A highly knowledgeable or motivated individual can
provide a healthcare facility with all the information it needs regarding applicable
environmental requirements; however, if that person retires or takes another position,
his/her knowledge is likely to be lost to the institution. And this applies to all elements of
the EMS. The need for written procedures is critical to a successful EMS. We'll talk more
about this later today. But bear in mind as we proceed, most elements of the EMS will
require some documentation.
The Legal and Other Requirements procedure should describe how the facility identified its
baseline of applicable requirements, as well as how it stays abreast of changing
requirements. This baseline is defined by the environmental aspects of the facility.
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keeping up with Requirements
Prepare a requirements matrix
Sponsor a third-party audit
Subscribe to a service
Role of HQ
Role of ENT
Peers
Write a description o^]
List of contacts
List of permits
List of websites (e-CFR =
Resources in Appendix E (in the Healthcare EMS Guide)
Practical suggestions on establishing a procedure include:
Prepare a matrix of requirements that lists the regulatory authority, citation/reference, and general nature of the
requirements on one axis, and the affected organizations, activities, operations, and responsible parties on the
other axis. Update the matrix regularly to reflect changes in personnel, operations, or requirements. Enclosed in
your three-ring binder under the Resources tab, you'll find an example blank matrix you can take back to
work with you.
Consider obtaining the services of an independent third-party to conduct a multi-media environmental
compliance audit of the facility. The results of this audit can be used in identifying aspects/impacts, as well as in
establishing objectives and targets.
• Depending on resources and staff availability, a healthcare facility might elect to subscribe to a commercial
service (e.g., Bureau of National Affairs), or contract with a local law firm to obtain periodic updates and
interpretations on regulatory requirements.
Federal and some private healthcare facilities may receive some regulatory guidance and interpretations from
their respective headquarters organizations.
• The EMS Management Representative should be involved in the procurement process for any new products,
contracts, or activities the facility is contemplating. Ideally, this involvement would consist of formal approval
authority.
Selected staff (e.g., industrial hygienists, environmental professionals) should attempt to leverage their resources
by forming or participating on regular conference calls or e-mail listserves within their peer groups or
professional associations. These groups can defray the costs of conducting regulatory research and serve to
disseminate information on changing requirements to the most appropriate personnel.
• Regardless of how you choose to keep up with your requirements, remember that you need to formally document
your procedure for obtaining and maintaining information for environmental requirements, including list of
contacts permits, websites, and other resources used. Healthcare facilities should formally document their
procedure for obtaining and maintaining information of environmental requirements.
There are many resources available on websites, listed in the resource section, as well as guides on your CD-
ROM for more information
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Healthcare Environmental
Resource Center (HERC)
The HERC website is sponsored by Hospitals
for a Healthy Environment (H2E)
Provides pollution prevention and
compliance assistance information for the
healthcare sector
Compiled from a wide variety of resources
and is not complete yet
Address is http://www.hercenter.org/
One helpful website that we would like to especially point out today is HERC.
HERC website is sponsored by Hospitals for a Healthy Environment (H2E) is a voluntary
program designed to help health care facilities enhance work place safety, reduce waste and
waste disposal costs and become better environmental stewards and neighbors.
Assistance areas on the website include, or will include:
• Hazardous materials;
• Regulated medical waste;
• Waste reduction;
• Facilities management; and
• Regulations and standards.
Log on and you can submit comments/suggestions to the developing web site.
38
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Illustra
iremen
CAA
- Asbestos
- Boilers
- Medical waste incinerators
CWA
- Storm water discharges
- SPCC
EPCRA
- Release reporting
- Chemical inventories
FIFRA
JCAHO
RCRA
- Hazardous waste disposal
- Fluorescent bulbs
- Batteries
- Solid waste
- Underground storage tanks
SDWA
TSCA
Agency initiatives
- Mercury reduction (VA)
Healthcare facilities potentially face a wide variety of environmental requirements, some of
which are presented above. The applicability of these requirements depends on a number of
factors. For example, the existence of certain types of facilities (e.g., wastewater treatment
plants, boilers) or specific activities (e.g., research involving hazardous chemicals, major
construction projects) clearly triggers environmental requirements. Other requirements are
affected by the location of the facility (e.g., proximity to wetlands or watersheds). On the
other hand, and more hidden at times, are when some states or localities have more or
sometimes less stringent requirements than others (e.g., used oil, spent fluorescent tubes).
Lastly, other requirements are based on material or other thresholds (e.g., TRI reporting,
SPCC plans, hazardous waste generator status).
The diversity and complexity of these requirements poses many challenges; however, once
the initial identification has occurred, and appropriate procedures have been established,
most facilities will find that staying abreast of these requirements is much less cumbersome
and resource intensive.
Understanding these requirements also assists in identifying and prioritizing environmental
aspects and impacts.
CAA = Clean Air Act
CWA = Clean Water Act
EPCRA = Emergency Planning & Community Right to Know Act
FIFRA = Federal Insecticide, Fungicide & Rodenticide Act
JCAHO = Joint Commission on Accreditation of Healthcare Organizations
RCRA = Resource Conservation & Recovery Act
SDWA = Safe Drinking Water Act
TSCA = Toxic Substances Control Act
39
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Related Elements of an EMS
Many EMS elements are directly related to
one another especially with regards to
significant aspects and their associated
impacts:
J Objectives and Targets
• Environmental Management Programs
• Training/Awarenes
' Operational Control
Identifying environmental aspects and impacts is probably the most influential part of the
development of an EMS because so many EMS elements are directly related with significant
aspects and their associated impacts.
Because significant aspects and impacts are central to the design of the EMS, healthcare
facility personnel should be prepared to spend a considerable amount of time and effort
identifying and prioritizing them.
Once the aspect/impact identification procedure is in place, periodic updates will be
relatively easy.
Careful identification of significant environmental aspects and impacts will make
subsequent steps easier and more meaningful.
The connection is simple, but can be hard to follow at times. Significant aspects have
associated impacts and in order to make improvements, you need clear goals (objectives).
Targets are in place to help you find a way to reach the goals. To manage all this, the
Environmental Management Program identifies responsible parties (who), what needs to be
done (what), where records are kept (where), and a schedule for implementation (when).
Training/Awareness is needed so all staff understand why the aspect is considered
significant and can better provide input for improvements. Operational controls, such as a
hospital policy on red bag use, might already be in place for the significant aspect that needs
to be documented and identify where it can be found and who's responsible for this control
(red bag policy). Lastly, monitoring and measurement are important so that you know you
are going in the right direction regarding your significant aspect (e.g. pound of red bag
waste reduced; results of periodic compliance audits).
40
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Environmental Aspects
Impacts
Environmental aspect
• Element of an organization's activities,
products, or services that car
le environment.
t with
Environmental impact
• Any change to the environment resulting
from an organization's activities, products,
or services
An environmental aspect is:
• An element of an organization's activities, products, or services that can interact with
the environment.
• An aspect is analogous to a cause or to an input
- For example, gasoline use associated with groundskeeping activities
An environmental impact is:
• Any change to the environment whether adverse or beneficial, wholly or partially
resulting from an organization's activities, products, or services.
• An impact is analogous to an effect or to an output
- For example, soil and water contamination from gasoline spills, worker
exposure to harmful vapors, air emissions from combustion of gasoline
41
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A single activity will often be associated with multiple aspects.
A single aspect will often generate multiple impacts.
A single impact can result from more than one aspect.
42
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Purpose and Implications
Determining the environmental
aspects and associated impacts allows a
facility to focus its time and resources on
those issues with the
environmental impact.
Basing an EMS on significant environmental aspects and impacts provides the
greatest assurance that the environment will be protected and also encourages an
efficient and cost-effective use of resources.
A hospital may have 100's of aspects and through cross examination and ranking
(which we'll discuss in a few minutes) you may find that 50 of them are significant.
The EMS can focus on 3 of the 50 to start and make room for the remaining 47
through continual improvement over time. This will also allow for lessons learned
in the whole EMS process.
43
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To provide you with an example, let's consider the typical lab bench. The occupational
health and safety issues are immediately obvious, but impacts also extend beyond the walls
of the laboratory.
44
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We can guess that this most likely has less-severe environmental concerns in comparison,
but just what are the aspects and impacts of clinical laboratory operations to consider for an
EMS?
45
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Aspects and Impacts Examp
Activity,
Product,
Service
Clinical
Laboratory
Operations
Aspects
Medical waste
generation
Hazardous waste
generation
Impacts
Human health, air pollution, waste,
resource depletion
Human health, air pollution, waste,
resource depletion
Chemical spills
Raw material usage
Energy consumption
Water consumption^
Wastewater discharges
Human health, air pollution
[uman health, resource depletion
Air, water & land pollution from
combustion, resource depletion
Resource depletion
Water pollution, resource depletion
This represents an example, not a definitive analysis of clinical laboratory operations at a
facility. The specific aspects and impacts identified will depend upon the particular
laboratory, processes, equipment, and method of chemical waste disposal.
Other activities associated with the laboratory (e.g., flammables storage, chemical
recycling) also need to be evaluated as part of the overall analysis for the facility.
More examples like this can be found in the Healthcare Guide to Pollution Prevention
Implementation Through Environmental Management Systems (EPA Guidance found on
your CD ROM).
46
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ects a
EMS implementation te
Data call
Methodologies
• Process flows
• Interviews
• Peer evaluation
• Independent aud
Document the process
r >?<
The EMS implementation team is the most appropriate forum in which to identify aspects and impacts because
its members are drawn from across the organization and will therefore be familiar with all of the facility' s
activities and services.
Gathering data to support the analysis might involve circulating a questionnaire or matrix for staff to complete.
Alternatively, members of the implementation team might hold meetings or informal discussions with staff and
managers across the service lines. In general, the more familiar staff are with EMS concepts, the greater the
number of staff who will provide their input.
Using process flow diagrams can help prevent the team from overlooking any potential aspects.
Interviews are useful when members of the team are attempting to gather data from staff who have little or no
familiarity with EMS concepts.
Do not hesitate to use the results of other healthcare facilities' efforts or reference materials (e.g., EPA and
Veterans Administration guidance) as templates. Also consider non-healthcare templates if they have similar
activities, such as, colleges, facility maintenance (a boiler is a boiler is a boiler), fleet maintenance, research
laboratory templates.
Some facilities elect to have a contractor or other third party conduct the initial identification of aspects and
impacts. While this approach makes sense if time is a major constraint, using an external party to conduct the
analysis could make it more difficult to maintain and integrate the EMS into daily operations - staff may not
accept that the EMS is truly a part of the facility's operations. Also, hiring a third party is not free. The more
you can do on your own (with staff input) the more you can save the hospital money and the greater
management support which can equate to keeping the EMS alive.
Again, regardless of the method you choose to identify your aspects and impacts, you will need to document
the process to ensure continuity.
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Updating Aspects and Impacts
When is it necessary?
• Changes in the facility
• Regular management review
• Change management
' Continued improvements (Plan-Do-Check-
Aspects should be updated or reviewed periodically, especially when there are changes to the way the facility
operates, or simply when you're ready for continual improvements in the EMS
Updating the aspect/impact analysis should occur when:
The facility plans or institutes changes that will significantly alter its activities, products, or services,
such as:
Engaging in new construction, major renovation, or demolition projects;
Providing new or expanded services or discontinuing services; or
Changing processes or materials used.
When changes are imposed on the facility, such as:
New or amended laws, regulations, or ordinances; or
New internal agency policies or initiatives.
Senior management conducts a regular review of the EMS and its progress towards achieving
environmental objectives and targets.
When there's new management on board they need to be kept abreast of the EMS, and he/she may
even have new priorities that could effect the current significant aspects or could create new aspects.
Continual improvements is the nature of the EMS. The EMS is run on a continuous cycle of Plan-
Do-Check-Act. The "Plan" part is related to planning for new aspects.
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List the environmental aspects
associated with your assigned activity
Determine the environmental impacts
of these aspects
Exercise #2: Please find the three-column matrix worksheet under the Exercise tab in
your binder (see Slide #46). Spend 5-10 minutes listing the aspects and impacts from the
following list of potential activities:
• Cafeteria operations;
• Janitorial services;
Sterilizer operations; and
• Landscaping and grounds maintenance.
Review the examples and using a flip chart, list the aspects and impacts identified by the
attendees. Identify/discuss any potential omissions.
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termine Significance
Determine what criteria you will use
to determine significance
• Should involve input from top management
• Should involve input from activity managers
• Could involve input from "interested parties"
T-> . i i • i i • __i__.___r_._ii____
criteria
Identifying aspects and impacts helps the healthcare facility define the potential scope of the EMS -
identifying significant aspects and impacts brings the EMS into focus.
The choice of criteria for determining significance is entirely up to the facility.
It is possible for a healthcare facility to have numerous environmental aspects, only a few of which
are significant.
The implementation team should take the lead on determining significance, however:
It is important for top management to be involved because they will commit the resources
necessary to address significant aspects and impacts.
Activity managers should be involved because they will be responsible for implementing
and overseeing EMS components.
Other potential interested parties include: employees, patients, local community
representatives, and veterans groups (VA).
Developing and documenting a consistent rating scheme ensures consistency across aspects and
continuity over time.
We can't stress it enough ~ document, document, document. The agreed upon rating system must be
written into a procedure so that one year later you (and others) know how the aspects were rated the
last time and you can repeat the process.
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Factors to Consider
Environmental concerns such as:
The size of the impact
The frequency of the impact
Legal and other requirements
Business concerns such as:
• Feasibility and cost of changing the impact
• Effect of change on other activities and
processes
f^nnrfrTic of ititf>rc>ctc>c[ parties
There are many factors for the team to consider when developing the criteria of
what is considered significant, both in terms of the environment and business
operations.
Concerns of interested parties may be included as criteria:
• Worker health and safety;
• Potential risks/benefits to patients; and
• Effects on surrounding community/public image of the facility.
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Sample Rating Scheme
Significance Criteria
Legal Liabilities: Is the
impact regulated?
Public Concern: Has the
Public ever expressed concern
about the impact?
Frequency: What is the
probability of the impact?
Severity: What is the overall
severity of the impact?
Degree of Control: Does the
facility have the ability to
influence the impact?
Rating
Low (1): Not regulated
Medium (2): Regulated by internal policy or
voluntary undertaking
High (3): Regulated by agency (EPA, JCAHO, State)
Low (1): Never
Medium (2): Sometimes
High (3): Often
Low (1): Less than once a year
Medium (2): Between 1/mn and 1/yr
High (3): Occurs monthly or more freq.
Low (1): Impacts aesthetic, amenity
Medium (2): Impacts water, air, soil quality
High (3): Detrimental to humans, flora, fauna
Low (1): Primarily controlled by external forces
Medium (2): Some internal control
High (3): Primarily controlled by the facility
Once the team has identified that factors or criteria it will need to develop a rating
scheme that defines for the team member when to apply a specific value or indicator
to the aspect and associated impact.
The precise format for the rating scheme is entirely up to the facility. Most
facilities use some form of numerical scoring, although it is not absolutely
necessary to do so.
A sample rating scheme is shown on this slide, other rating examples are provided
in the Healthcare Guide to Pollution Prevention Implementation Through
Environmental Management Systems on your CD ROM.
Just because a healthcare facility has a low degree of control over an aspect, does
not necessarily mean that it can't establish an objective to address a related or
contributing factor. For example, a facility may be required by it's parent
organization to use a particular disinfecting agent containing hazardous
constituents. Or there may be no currently available non-hazardous substitutes that
provide the same level of infection control. In such a circumstance, the facility
may not be able to set an objective of eliminating use of the disinfectant; however,
there may be opportunities for practice changes or other operational controls that
can reduce the frequency of use or quantity used.
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After evaluating all your aspects and impacts relative to the significance criteria, the
implementation team must identify which are significant. Most facilities elect to use some
sort of scoring matrix (similar to that displayed above).
Typically, individual scores for each impact are added or multiplied to arrive at a composite
score. This score is then compared to a significance threshold. Any impact with a score
above the threshold is defined as significant. Note, however, some facilities:
• Use weighting factors for individual criteria to account for special concerns. For
example, a facility with a recent history of compliance problem or public perception
issues might double or triple that particular score.
Combine numerical with qualitative criteria that automatically trigger significance.
For example, if a potential impact has any regulatory compliance implications, a
facility may classify it as significant irrespective of how it scores relative to other
criteria.
• Define significance in a relative sense rather than with respect to a threshold (e.g.,
highest x% of impacts are significant).
Aspects associated with significant impacts are considered significant. Significant
aspects/impacts are the basis for a medical facility's environmental objectives and targets.
Exercise #3: Take one example from Exercise #2 and complete this table as a group
(find the blank matrix in your binder)
-------
To repeat: aspects associated with significant impacts are considered significant.
Significant aspects/impacts are the basis for a medical facility's environmental objectives
and targets.
For each significant aspect, try to come up with a handful of objective and targets and assess
which are most feasible and realistic.
There is no required number of objectives and targets, but you will need at least one for the
whole system. Over time you can add or change objective/targets depending on results.
Remember: Plan-Do-Check-Act.
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Now we can start talking in more detail about objectives and targets and how we're going to implement them.
An objective is an overall environmental goal.
Objective = end of journey. Think about the ultimate and feasible end product. For example:
Mishandling red bag waste was determined to be significant aspect in your ranking scheme. One
objective could be reduction in red bag waste generated or better management for red bag waste.
A target is a detailed performance guideline, quantifiable where possible, that is established as part of the
objective.
Target = milestone. Think about how you can achieve the end product. For example, train all staff
on proper red bag management, or quantifiable, by 2008 all reduce the amount of red bag waste by
20%.
Other examples of objectives and targets:
Objective: Eliminate all mercury containing devices
Target: Complete inventory of mercury-containing instruments
Target: Replace mercury sphygmomanometers
Target: Replace mercury gauges and thermometers
Objective: Maintain compliance with all applicable environmental requirements
Target: Submit required reports on time
Target: Maintain all required shipping and training records
Target: Conduct annual audit and correct deficiencies
Objective: Minimize hazardous waste generation from laboratory operations
Target: Purchase and install xylene and ethanol recycling units
Target: Implement formaldehyde neutralization
Target: Switch to non-hazardous or less hazardous cleaning and disinfection agents
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When talking about "quantifiable" objective and targets we think of performance-based.
Performance-based objectives and targets focus on results, not on processes. For example:
The facility will increase the volume of recycled materials by 100 percent within 2 years - a
performance-based objective.
The facility will conduct monthly inspections of solid waste accumulation areas to ensure proper
waste/recyclable segregation - not a performance-based objective.
The more measurable the objectives and targets, the easier it will be for a facility to track its performance;
however, measurable does not necessarily mean quantifiable. While many objectives and targets are
readily quantifiable (e.g., reduce medical waste by 10 percent), others are less so (e.g., maintain
compliance with all applicable environmental requirements).
Factors to consider when setting objectives and targets:
They should be tied to significant environmental aspects; however, it is not necessary to set an
objective for every significant aspect. An example of this is when EPA did a review of a National
Guard base and they were storing over a million gallons of oil so it was a significant aspect but they
had it under control, they were in compliance, and given that it was war time they were not likely to
reduce the amount of oil. Thus, no objective and target for improvement were possible for that aspect.
Compliance is the minimum acceptable standard - don't aim too low;
Most of what healthcare facilities do involves serving external parties (e.g., patients, visitors,
community representatives) - their views and priorities should be considered;
Current technological constraints may inhibit a facility from pursuing some objectives, at least
initially;
Pursue objectives and targets that make financial sense; and
Top management will be more supportive if environmental objectives and targets can operate in line
with or otherwise compliment other operational and business priorities.
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Focus on Pollution Prevention-based objectives and targets because they eliminate waste
before it's created.
Objectives and targets should be challenging, yet attainable. Initially, it may be most
practical to focus on relatively high payback, low cost objectives and targets in order to
maintain top management support (e.g. move trash receptacle away from red bag container
to make it harder for mistakes with regards to trash. Trash should go in trash can and not
red bag bin). And it's also important to remind top management that such payoffs may not
always be possible.
Start with a few objectives and targets, and build on your successes. Try to keep objectives
and targets S.M.A.R.T. (Specific, Measurable, Achievable, Results-oriented, and Time-
dependent).
Objectives and targets do not necessarily have to involve the entire facility, they can address
specific departments or processes.
Consider ways to measure and consider sources of measurement data when setting
objectives and targets - it may save you time and resources.
Provide regular status reports on progress towards meeting objectives and targets to both top
management and those personnel most responsible for achieving them and to all staff so
they know that the EMS is more than a paper exercise. Maybe have progress updates by
water coolers/luncheon areas or at regular briefings.
Document objectives and targets and progress towards meeting them. Again, a written
procedure is needed for the process involved in deciding on objectives and targets.
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With significant aspects and objectives/targets in place you will need a plan of action that will help show who is responsible for achieving
the objectives and targets, when the objectives and targets need to be met, and how they will be met. The environmental management
program (EMP) is what ISO 14001 calls this written plan of action to achieve a facility's objectives and targets. I tend to prefer the term
"action plan" since I think it is less confusing but the correct ISO term is EMP. In any case, at a minimum, the written plan of action
should include:
• Who is responsible for achieving each target and objective, for example:
The Director of Facilities shall identify mercury containing switches and gauges and oversee their replacement;
• When each target and objective will be achieved, for example:
All fluorescent light ballasts will be inventoried and any potentially containing PCBs will be replaced by December
31 of2006;and
• How each target and objective will be achieved, for example:
Based on manifests and chemical inventories, identify quantities of hazardous waste generated in the laboratory;
Identify potential recycling technologies and vendors;
Meet with laboratory manager to identify potential alternatives and existing chemical handling and disposal
procedures;
Institute and provide training on new chemical ordering, storage and disposal procedures.
Example EMPs include:
Biomedical Waste Reduction EMP - for some hospitals "red bag" waste and disposal could be considered a
significant aspect. A Program (EMP) for biomedical waste reduction could start with tasks to identify risks, costs,
and compliance associated with disposal. A biomedical waste audit of emergency room, operating room, and
laboratories might show misuse of "red bag" waste (garbage in the red bag when it should be in the trash)
Recycling and Reuse EMP - improved "red bag" management might increase garbage because now trash is going
in the proper receptacle, so you can have a Program (EMP) in place for improved recycling. Join forces with other
regional hospitals and negotiate services with the recycling contractor.
Spill Response and Emergency Preparedness EMP - on-site laboratories have lots of chemicals that have the
potential to spill.
Landscaping Practice EMP - pesticide usage and lawn mower emissions could be considered a significant aspect
at your facility. The EMP could be to develop a "green landscaping policy" and for future landscaping plans, use
native land cover to reduce the need to mow and pesticide use.
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There is no required format for any EMP - only guidelines on the required elements. The
matrix format above represents one potential template that could be used to prepare an EMP
for a facility.
Note that the numbering scheme for objectives and targets will assist in tracking, reporting,
and document control issues.
Exercise #4: Based on the objective presented above, suggest potential targets to
complete the EMP matrix(please find a blank matrix in the Exercise section of your
binder).
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are
Pollution Prevention
Opp
Pollution prevention vs. prevention of
pollution
Important area of financial return from
an EMS
Useful in identifying aspects and
impacts and in setting objectives and
targets
Since EPA encourages facilities to take advantage of pollution prevention opportunities when developing their
action plans; we will digress for a second and talk about pollution prevention opportunities in the healthcare
sector. As discussed earlier in the first module, "pollution prevention" is not the same as "prevention of
pollution."
Because EPA prefers the concept of pollution prevention over prevention of pollution, from this point on,
whenever the term pollution prevention appears, EPA is using the Pollution Prevention Act (PPA) definition,
not the ISO 14001 definition.
An EMS is designed to achieve improvements in environmental performance. Pollution prevention is an
excellent way to achieve these results, both compliance and beyond compliance results. Healthcare facilities
use numerous products and services, therefore, they present many opportunities to save materials, energy,
time, and financial resources.
Pollution prevention also provides both indirect and direct compliance benefits. For example, reducing the
quantity of hazardous chemicals on site decreases the likelihood of violations associated with chemical spills
or releases. Reducing the quantity of hazardous waste generated also has more immediate compliance
implications. For example, RCRA large quantity generators must have a program in place to reduce the
volume or quantity and toxicity of hazardous waste generated; whereas small quantity generators need only
certify on their hazardous waste manifests that they have made a good faith effort to minimize their waste
generation.
Healthcare facilities should give careful consideration of potential pollution prevention strategies and
opportunities when setting objectives and targets.
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EPA ranks options for managing waste in descending order of preference.
Source reduction is assigned the highest priority because it emphasizes elimination or reduction of
wastes at the point of generation. Source reduction is typically less expensive then collecting,
treating, and disposing of waste. It also reduces risks for workers, patients, the community, and the
environment.
Reuse of products and packages for their original purpose reduces purchasing costs and packaging
wastes, as well as wastes for some patient care activities (e.g., food service). Reuse of patient care
items is generally preferable to disposal, although there are costs associated with cleaning or
sterilizing items for reuse.
Recycling encourages regeneration of materials into usable items. Paper and paper products, such as
corrugated cardboard, glass food and beverage containers, metals and certain plastics may be
recyclable. However, important factors in evaluating recycling options include the local
environmental and economic consequences associated with the collection and processing of materials
for recycling, as well as the associated energy and resource costs.
Treatment to reduce the volume or the potentially harmful environmental impacts of the waste is
ranked at the lowest end of the spectrum. Medical waste treatment technologies include autoclaving,
hydropulping, pyrolysis, microwave, incineration, chemical treatment and irradiation.
Treatment precedes disposal, the least favored option. Ultimately, however, some wastes and medical
waste treatment residues require land disposal. The costs of treatment and disposal are significant,
and both have inherent environmental impacts, including emissions to air and water.
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ironmentally Preferable
Purchasing
Definition
Best practices
Information resources
Useful web sites include:
• Hospitals for a Healthy Environment
• The Massachusetts Office of Technical Assistance
• Nightingale Institute for Health and the
Environment
1 HealthCare Purchasing; News Online
Environmentally preferable purchasing is the purchase of products or services that have a lesser or reduced
effect on human health and the environment when compared with competing products or services. It includes
the total effect of the product including packaging, disposal, quality, and cost.
Environmentally preferable purchasing best practices include:
Forming group purchasing organizations to leverage volume to achieve volume discounts. Creating
preferred vendor programs.
Purchasing products in bulk, totes, or in recyclable containers. Reusing packaging when possible.
Avoiding custom packs; although they contain less waste than the same set of items obtained
individually, waste from unused supplies can generate more waste. Consider negotiating to exclude
items in patient care kits that are repeatedly not used.
Monitoring requests for chemicals and implement policies to reduce over-purchasing that result in
waste generation. Procuring chemicals through a central department or person. Purchasing smaller
quantities of chemicals and supplies not frequently used. Controlling acquisition and use of reagents
that have limited shelf life.
Encouraging suppliers to become responsible partners by providing quick delivery of small orders
and accepting the return of unopened stock such as sealed bottles of stable chemicals.
A listing of all websites can be found in the back of the binder
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The healthcare industry is one of the most energy-intensive in the United States annually spending $6 billion
on energy costs and using an average 228 kBtu energy usage per square foot per year - more than twice the
energy as a typical office space. Hospitals run continuously, and certain uses, such as diagnostic equipment,
large air-handling systems and technical equipment are particularly energy-intensive. Consequently, energy
efficiency presents a great cost savings opportunity. Some examples of the cost savings associated with
energy conservation include:
Saint Joseph's Medical Center in Yonkers, New York, achieved savings of more than $250,000 a
year through energy conservation efforts.
Mercy Hospital in Pittsburgh instituted a comprehensive energy plan including retrofitting lighting;
expanding its energy monitoring and control systems; installing variable speed drives on chilled water
pumps; and replacing chillers and cooling towers. Their efforts resulted in operational and cost
savings of more than $ 1 million.
Houston Shriners Hospital implemented changes to lighting, fans, and HVAC systems that decreased
utility costs by 40 percent.
Energy Star is an EPA program that works to make energy efficiency easy by recognizing the best performing
products, homes, buildings and organizations. Energy Star's approach, tools, and resources give health care
facility managers an easy way to gauge the facility's progress. More than 875 hospitals and health systems
across the country have partnered with the U.S. EPA Energy Star. Energy Star Buildings and Green Lights
Health Care Partners have experienced an average annual savings of $0.63 per square foot.
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Energy Star Tools and Online
Resource*
Energy Performance Rating System
Target Finder
Delta Score Estimator
Financial Value Calculator
Products
Training
Energy Star provides the tools and resources needed to implement a successful energy management strategy.
Technical guidance, procurement policies, demonstrated best practices, communications resources and awards
can distinguish the organization as an environmental leader.
The Energy Performance Rating System is a free Internet-based system designed to help businesses
track and objectively compare energy use on a continual basis for both individual and large groups of
buildings, www.energystar.gov/benchmark
Target Finder is an Internet-based tool that helps manage energy during the design of a new building.
It allows selection of an aggressive energy performance target for a building design and compares
estimated energy consumption to the established target.
www.energystar.gov/index.cfm?c=target_finder.bus_target_finder
The Delta Score Estimator provides a quick way to identify the relationship between the percent
energy saved in a building and the energy performance rating score of a building using Energy Star.
www.energystar.gov/index.cfm?c=delta.index
The Financial Value Calculator analyzes portfolio-wide or single building opportunities using a
variety of metrics that range from simple payback to increased earnings per share based on various
levels of energy reductions.
www.energystar.gov/index.cfm?c=assess_value.bus_financial_value_calculator&layout=print
Energy Star qualified products such as TVs, VCRs, computers and other office equipment use 25 to
50 percent less energy without compromising quality or performance, www.energystar.gov and select
the "Products" link
Free online training sessions help establish the partnership with Energy Star, educate staff on the use
of Energy Star tools and provide further education to staff about the depth of Energy Star's tools and
resources, www.es.netspoke.com/attendee/default.asp
In your binder, you will find a fact sheet listing the web links listed above.
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Federal Electronics Challen
What is it?
Why electronics?
Why the federal government?
To join the FEC, log on to
w ww .f ederalelectrnni rsrh a 11 PT
in fec.htm
The Federal Electronics Challenge (FEC) is a voluntary partnership program that
encourages federal facilities and agencies to:
• Purchase greener electronic products;
• Reduce impacts of electronic products during use; and
• Manage obsolete electronics in an environmentally safe way.
Used and obsolete electronics, such as computers, printers, mobile phones, and fax
machines, are part of an increasing and complex waste stream that poses challenging
environmental management problems. Cathode ray tubes, circuit boards, batteries, and
other electronic components often contain significant quantities of toxic materials such as
lead, mercury, and cadmium.
The federal government purchases more than $60 billion worth of electronic equipment and
services annually, and has the opportunity to provide leadership in the environmentally
sound and cost effective management of electronic assets.
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The Hospitals for a Healthy Environment (H2E) website (http://www.h2e-online.org/)
provides information on pollution prevention opportunities, as well as links to pollution
prevention guidance documents and websites.
The FedCenter website (http://www.fedcenter.gov) contains compliance assistance and
pollution prevention links, guidance documents, and other reference materials.
The Healthcare Guide to Pollution Prevention Implementation through Environmental
Management Systems (EPA/625/C-05/003) provides customized guidance and real world
examples of EMS implementation at healthcare facilities.
All websites can be found in your resources section
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Topics to be covered in this module include:
• How to identify, delegate, and reinforce EMS roles and responsibilities across the
facility.
• The importance of identifying training needs for various staff and developing a
documented environmental training program that designs, delivers, and tracks
appropriate training content.
• Methods for communicating EMS messages within and outside of the facility.
• How to establish operational controls for activities that potentially affect the
environment.
• Emergency preparedness and response plans and procedures.
• EMS documentation and document control systems.
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In a moment, we will see that it is vital for every employee, no matter function at your
facility, to know their EMS responsibilities. For example, it is not merely the responsibility
of a lab supervisors to assure proper laboratory maintenance, but every individual working
in the lab.
Here's a lab hood. There is no segregation of potentially incompatible materials and
anything spilled can leak directly into the lab.
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In contrast, a successful EMS will train and communicate good practices to every worker,
such as this worker in a an orderly, disaster-free chemo preparation hood.
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Here is a different functional area within the facility, yet employees must be aware of
requirements and responsibilities. Here we see a cluttered dumpster with electronics,
cardboard, equipment, material and all!
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Comparatively, this facility hosts an organized recyclable waste area.
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Again, every employee must be aware of EMS requirements. Delivery, maintenance,
housekeeping, service providers and contractors may all play a role in the laboratory
environment and must collaborate to understand regulations. Here we see a sign on the
hood warning of toxic fumes, but can also find a disconnected ventilation system and an
installed pipe and wood-block that prevented the hood from closing.
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Spill response
equipment.
Emergency preparedness represents one environmental aspect that cross-cuts an entire
facility. This is a well-prepared facility with an emergency response area. Do all
employees of your facility know where products such as these are located and have
emergency preparedness training?
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For an EMS to be effective, one needs to lay out the organizational structure and lines of
responsibility for the system. Without a clear structure showing who is in charge and who is
accountable for getting things done, the system will ultimately fail. EMS roles and
responsibilities need to be clearly articulated — in writing — to ensure that staff not only
understand them, but realize that their performance will be evaluated, in part, based on
them. This is key. At a minimum, evaluations and performance measures need to include
EMS responsibilities for key environmental personnel; those who duties may have a
significant impact on the environment; and those responsible for achieving EMS objectives
and targets.
Remember, don't just confine environmental responsibilities to an environmental office.
The point of an EMS is that environmental responsibilities are a primary responsibility of
all employees, including management. Also, you should outline - in writing - the potential
consequences for departing from standard operating procedures (which we will talk about
later), especially if doing so will result in non-compliance or a significant impact on the
environment.
Also, don't forget your on-site service providers and contractors. What are their roles and
responsibilities in your EMS? Many compliance and environmental disasters have resulted
from the actions of contractors. On a positive side, you should consider creating incentive
programs to reward and recognize employees for excellent environmental performance.
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Clearly document EMS roles
and responsibilities
Annual performance plans
Position descriptions
Committee charters
The following are types of documentation the auditors commonly look for under this EMS element.
• Annual performance plans for key EMS personnel may initially include milestones in
developing an EMS (e.g., establishing environmental objectives and targets) and later, as the
EMS is developed, may include achieving objectives and targets. An EMS by its very nature
is continuously changing and improving so the annual performance plans will have to change
with it. Again, the key here is that annual performance plans with EMS criteria should not be
limited to just the EMS committee but should be expanded to include all personnel that can
impact the effectiveness of your EMS.
• Position descriptions for key personnel with environmental responsibilities should include
specific EMS duties. At a minimum, the EMS Coordinator and EMS Committee members
should have EMS requirements in their position descriptions An example is included in
the Resource section of your binder.
• Formal committee charters demonstrate management commitment and provide mission
clarity and authority to those committees charged with EMS implementation.
Organization charts illustrate the system and can help staff understand their roles and
responsibilities and how these roles relate to other parts of the EMS. Organization charts
also help auditors and other external parties gain a clearer understanding of how an EMS is
structured. At a minimum, organizational charts should identify units, management, and
other individuals having environmental performance and regulatory compliance
responsibilities.
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Identifying Training Need
• Prepare a training requirements
matrix
EMS implementation team can help
• General awareness versus specialized
training
Training employees about environmental management is important for two reasons. First,
every employee can have an impact on the environment. Therefore, they need to understand
how their actions affect environmental performance and how to do their jobs so as to avoid
or mitigate the occurrence of environmental incidents. Second, any employee can have
good ideas about how to improve the EMS. Trained personnel are better able to understand
the processes for which they are responsible and are more likely to offer suggestions to
improve those processes. As a result, an EMS should establish procedures to ensure that all
personnel (including employees, on-site service providers, and contractors) whose job
responsibilities affect the ability of the organization to achieve its EMS goals have been
trained and are capable of carrying out these responsibilities.
One way to help visualize training needs is to prepare a training requirements matrix. This
matrix can help clarify training needs and schedules. The matrix should be based on a
training needs assessment that considers mandatory training, desirable training, and
available training resources. A sample matrix is included in the Resources section of
your binder.
The EMS implementation team is probably the most appropriate forum for completing this
exercise. Because team members are drawn from service lines across the facility, they
should have a good idea of the sorts of job-specific training requirements that apply to
various positions.
All employees should receive general environmental awareness training that outlines their
responsibilities within the EMS, but more specialized jobs (e.g., industrial hygienist, HVAC
technician, waste management personnel) will require more specialized work area training.
Some training (e.g., RCRA training) may be State-required, while other training may be
discretionary and represent best management practices. Senior management may need
additional training to address their EMS roles and responsibilities.
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ypes of Training
Environmental awareness
• Employees and resid —A-
• Contractors
• Suppliers
• Visitors
Post EMS information
Regulatory compliance
Advanced EMS training
All employees, and residents if housing is available at the facility, should undergo general
environmental awareness training so they can understand their role in the EMS and how they can
impact the environment. Some facilities use computer-based training to accomplish this. It has been
my experience that most people just keep hitting "next slide" and don't really read or comprehend
what is being said; however, you know your employees, so if that works for you ~ great. I have a
preference, at least initially, for in-house face-to-face EMS awareness sessions with top management
present.
Also, employees and new residents should receive a presentation on environmental issues at the
hospital and their EMS responsibilities as part of new employee/new resident orientation. A Coast
Guard facility in the Caribbean requires all residents and employees to visit the environmental office
as part of the regular documented check-in process and they can not start work until this is done.
The facility should consider methods for making contractors, suppliers, and visitors aware of the
EMS. We cannot emphasize this enough. To the extent possible, the facility should write EMS
requirements into contracts with contractors and vendors. Procurement requirements may include
materials with minimum recycled content and "green" products. Contractors working on site should
be aware of their EMS responsibilities, including requirements for waste disposal and types of
materials and chemicals (e.g., pesticides, herbicides, paint products) used on-site. Facility personnel
should meet with contractors prior to work start to cover environment, safety, and health
requirements.
The facility should post information about its EMS (including its environmental policy) on its public
web site and also in areas accessible to patients and visitors (e.g., lobby bulletin boards).
In addition to general environmental awareness training, your training needs assessment must also
consider a range of specialized environmental training options for compliance with various State and
Federal regulations including air, water, and solid and hazardous waste regulations. The EMS
Coordinator should receive advanced EMS training, often referred to as lead auditor training. Lead
auditor training is a 36-hour course that covers the ISO 14001 standard in-depth.
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raining Program
Already existing training
Tracking, scheduling, delivery, and
documentation
Software package^
Once a facility has determined who needs what training, a formal environmental training program should be
developed that tracks and maintains employee training records, notifies employees (or their supervisors) when
training is due, and provides information to employees when training is available. The facility may also
choose to highlight its training opportunities through bulletin board displays and e-mail announcements.
The facility's existing training program can often be adapted to accommodate environmental training contents.
In fact, some of the training that is already provided to meet JACHO standards (e.g., hazardous materials
management), is directly applicable to EMS training. In addition general EMS awareness training sessions
have already been developed by other facilities so consider borrowing their slides. It is also very likely that
the facility's existing training infrastructure will support the necessary tracking, scheduling, and documentation
requirements. Do not reinvent the wheel. However, if needed, there are commercial software packages
available to track, schedule, and document training. Examples that we have encountered during EMS reviews
include Synquest and EnviroManager - and there are undoubtedly others. Hospitals should contact other
medical facilities and organizations to obtain their assessments as to the effectiveness of these packages before
contacting software vendors.
Finally, remember to train employees on a continuous basis to keep them abreast of new regulations,
procedures, and technological developments.
Exercise #5: Please find Exercise 5 in the exercise section of your binder. Identify potentially applicable
environmental training for the following job descriptions:
Director
Lab Technician
Purchasing Official
Construction Contractor
Cook
Mechanic
Physician
Pharmacist
Oncology Nurse
Groundskeeper
Volunteer
These requirements could be listed on a flip chart based on audience response or on a check box matrix with
requirements on one axis and job titles on the other axis.
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Internal Communication
Procedure for communicating
information about the EMS internally
- Vertical communication - up and down the
chain
• Horizontal communication
In addition to training, another key element of an EMS is the establishment of a system for
communicating environmental issues and information internally to all employees, on-site
service providers, and contractors. Thus, a facility should ensure that it has in place an
appropriate system of communicating environmental policies and procedures internally
across all functions and levels of the organization. Again, do not reinvent the wheel. E-mail
and existing staff meetings already provide ready means for communicating this
information to personnel. This need for internal communication highlights the importance
of representation from all hospital services and senior management on the EMS Committee.
EMS Committee members can provide environmental management information directly to
their services.
Also, please note that effective internal communications require mechanisms for
information to flow top-down and bottom-up. Since employees are on the front lines, they
are often an excellent source of information, and ideas on how to improve the organization's
environmental performance, such as identifying pollution prevention opportunities. Thus,
the hospital should have a program that allows employees to provide input on the EMS and
environmental management, including process improvement ideas and nonconformance
with the EMS and legal/regulatory violations. This program may be as simple as a
suggestion box. A formal awards program for process improvement ideas that the hospital
adopts provides extra incentive for employees to provide input. Awards may be monetary
or time-off. However, remember to choose a method of receiving information and
suggestions from employees that will protect them from negative repercussions.
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nal Communication
Procedure for communicating
information about environmental
management and the EMS with:
• Local community
• Regulators
• Suppliers
• Customers
• Other interested t
The surrounding community and other external stakeholders will no doubt be interested in knowing how you
manage hazardous waste, or that your hospital has a green cleaning policy. Therefore, your facility should
have a formal procedure for responding to inquiries from the general public about your EMS. The procedure
should document who made the contact, the date, the nature of the request and response, and what, if any,
materials were sent. Maintaining general information about the facility's EMS (including the environmental
policy) on the hospital's public web site is one easy way of making information available to patients, the
public, and other interested parties.
The hospital should also communicate information about its EMS and environmental management practices to
suppliers, contractors, and vendors to make them aware of their responsibilities under the EMS and also to
prompt them to provide products and services that are consistent with the EMS. A potential cleaning products
supplier may begin to carry green cleaners if they know the hospital requires use of these products.
As for regulators, at a minimum, you will need to have procedures in place for interacting with them in regards
to environmental issues and regulatory compliance, including required reporting. However, EPA and many
states have or are developing programs that provide special benefits, such as low inspection priority, to those
facilities that have an EMS. EPA's Performance Track program is one such program. Thus, you may want to
proactively reach out to EPA and other regulatory agencies to see what incentives they are offering and what
they are looking for in an EMS.
This brings up an important point about external communication. Most of what we discussed during the last
few minutes has been passive or required communication with outside parties. If someone asks you an
environmental question, you respond. If you have a spill, you report it. Yet some organizations have found
that a more proactive external communications strategy can be beneficial even though it may require more
resources. For example, reporting on your environmental performance may give you an edge over your
competition. It may also improve your relationship with the surrounding community. In addition, external
stakeholders bring useful perspectives to identifying environmental issues, often identifying issues that might
otherwise have been overlooked, thereby improving the EMS.
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Operational Controls
Tied to significant aspects
What is an operational control?
• Engineering
• Non-engineering
Application to suppliers and
contractors
Another EMS element is operational controls. To ensure that an organization's environmental policy is followed and that
it's objectives are achieved, certain activities must be controlled. Where these activities are complex and/or their potential
environmental impacts are significant, these controls should take the form of documented procedures. These documented
procedures will help an organization ensure regulatory compliance and consistent environmental performance. Thus, an
EMS must include a process for identifying activities were documented standard operating procedures (SOPs) are needed
and it should define a uniform process for developing, approving, and implementing these SOPs. Operational controls may
include:
• Engineering controls such as sensors that automatically turn off lights in a room when empty or printers/copies
that print double-sided documents by default;
• Non-engineering controls such as requiring new employees to check in with the EMS Coordinator to receive a
briefing on their specific responsibilities within the EMS or posting signs that remind employees not to co-
mingle red bag and solid waste.
When the term "operational control" is used in the EMS context, it usually refers to work instructions or SOPs, but it can
also include work area training, equipment test results, and "control points" such as those located at air or water discharge
points (e.g., backflow inhibitors on utility sinks).
Whenever possible, operational controls should also be extended to include services rendered by suppliers and contractors.
This is especially important because these companies may not subscribe to EMS principles, yet their actions can result in
significant impacts at the healthcare facility. For example, contractors have been involved in the following incidents at
federal healthcare facilities:
Disposal of oil-based paint in a hospital dumpster;
Discharge of waste solvents down a hospital drain; and
Discharge of surplus pesticide down a storm sewer.
To ensure appropriate operational controls are implemented by suppliers and contractors, the facility must clearly
communicate these requirements prior to their providing services to the facility.
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The facility should consider the following three steps to identify and maintain operational controls associated
with each significant environmental aspect:
Annually, review each significant impact in conjunction with its activities, products or services to
determine whether operational controls are needed for those activities, products or services.
Where applicable, document the operational controls to specify operating criteria, maintenance plans,
and the actions to be taken when operational controls fail. Any documentation associated with
operational controls should kept current and accessible to appropriate personnel.
Annually, or whenever significant aspects are reviewed, the EMS Coordinator should review the
operational controls to determine if they are adequate.
Exercise #6: Please find Exercise 6 in the Exercise section of your binder. For each of the
activities/processes listed on the left, provide an example of an operational control from the list on the right
that could address a significant environmental impact associated with each activity/process:
Activity/Process
Administration of antineoplastics
Operation and maintenance of refrigerators
Autopsy/morgue operations
Operational Control
Monitoring equipment
Inspection checklists
Tracking procedures
Sampling and testing protocols
Equipment settings
Routine maintenance
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Plan-Do-Check-Act cycle
• Plan for emergencies
• Take action to prevent
• Respond to problems
• Fix anything not in order
Documentation
JCAHO
Despite an organization's best efforts and the operational controls that they have put in
place, the possibility of accidents and other emergency situations still exists. Thus,
establishing an emergency preparedness and response plan is a critical part of any EMS and
merits special attention. Emergency preparedness, like an EMS, functions most efficiently
under a Plan-Do-Check-Act cycle to achieve continual improvement.
The facility should plan for potential incidents by conducting a multidisciplinary
vulnerability assessment. The facility may find it useful to appoint an emergency
preparedness and response team to plan and conduct drills. The facility should ensure that
emergency preparedness and response drills occasionally include environmental incidents
(e.g., chemical spills). The facility should coordinate with local response authorities (e.g.,
fire departments, hazardous materials teams) on disaster drills, including inviting them to
participate and providing information on the location and inventory of hazardous materials.
The facility should review the results of the drills to determine areas for improvement and
change and revise emergency preparedness plans accordingly. Also, in the case of real
emergencies, the facility should investigate the root cause of the emergency and modify the
EMS so that similar incidents are avoided.
Again do not reinvent the wheel. Existing emergency preparedness and response documents
(e.g., SPCC, hazardous materials) should be organized as part of the EMS and referenced in
EMS document control procedures. JCAHO, for instance, requires healthcare facilities to
develop and maintain a written emergency management plan that includes specific
procedures for preparedness, response, and mitigation. JCAHO also requires healthcare
facilities to conduct at least two emergency preparedness and response drills annually with
at least one of these drills involving the local community.
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Required Documentation
Environmental policy
Objectives and targets
Description of the "fenceline"
Formal plans (e.g., emergency response,
SPCC, waste minimization)
Standard operating procedures and
* 1 • • * • i
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controls
So far today we've talked about various elements of the EMS and one area that keeps
coming up again and again is documentation. One of the most important components of the
EMS is the ability to track your progress towards meeting environmental objectives and
targets, as well as to describe to management, potential auditors, and other interested parties
what the main elements of your EMS are and how they interact with each other. It is also
essential to show that your EMS is effective in improving the environmental performance of
your facility. This can only be done through proper documentation.
Documentation also has the added benefit of promoting continuity as staff turns over. If
your environmental coordinator were to leave, would his or her replacement know what
regulations your facility is subject to and what to do in the case of an emergency? Listed on
this slide are some, but certainly not all, of the EMS elements that are required to be
documented under ISO 14001.
You should consider developing a separate EMS manual that describes the main elements of
the EMS, clearly delineates the scope (i.e., its "fenceline"), and contains or references
relevant EMS documents such as standard operating procedures and emergency response
plans. Again, you do not need to and I would not recommend putting every document that
is part of your EMS into this manual, but it should include at least a reference to all EMS-
related documents, including the document's purpose (what), location (where), and the
person(s) responsible for maintaining it (who). This will make it easier for internal and
external auditors to evaluate your EMS.
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EMS documentation can be in paper or electronic format, but should be centrally referenced
and controlled to ensure that it is current.
EMS documentation should be reviewed regularly and revised as necessary to ensure that it
is consistent with significant aspects, objectives and targets, and operational controls.
The EMS coordinator may be a good choice to oversee control of EMS documentation.
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Document Contro
Approve documents for adequacy prior to
issue
Current versions are available at points of use
Documents are periodically reviewed,
revised, and approved
Changes and current revision status are
identified in documents
Obsolete versions are promptly removed
If retained, obsolete versions are clearly
identified
Where possible, the Director should approve EMS documents. The Director's signature
demonstrates management commitment to the EMS, a critical element for EMS success. At
a minimum, the EMS coordinator should review for adequacy and approve EMS documents
prior to issuance.
Existing EMS documents should be reviewed and, if necessary, revised on a set schedule to
reflect changing circumstances such as new facilities, changes in activities, new scientific
data, new stakeholder concerns, new management, unanticipated results of internal and
external audits and exercises/drills. Existing hospital document review schedules may be
sufficient for EMS documents.
When significant updates are made to documents, affected employees should be notified via
e-mail. Obsolete or outdated documents should be quickly removed from circulation and
current versions made available at points of use. If older versions of EMS documents need
to be retained in accordance with the facility's regular records management procedures,
they should be clearly identified as such and placed in an outdated file. The EMS
coordinator should also authorize uploading of the new documents to the website to replace
existing content to prevent obsolete documents from being downloaded and mistakenly
followed.
As a safeguard, all documents should be dated and marked to ensure the most up-to-date
version is in use. A revision history should be kept for all documents. Files posted on the
internet should be automatically dated when posted.
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• Distribution to offices on as-needed
basis
• Central file cabinet
Microsoft Outlook "Public Folders"
• Use of software version control
properties
• Web site with Adobe Acrobat .pdf files
• Proprietary software packages
Document control systems can include a variety of mechanisms from a simple file cabinet
to a complex software package. Whichever system or combination of systems the
healthcare facility chooses, it should ensure that EMS documents are centrally referenced
for easy retrieval. EMS documents should also include records indicating revision dates and
disposition.
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Topics to be covered in this module
• Measuring EMS performance to determine how effectively it is meeting its
objectives and targets
• Identifying instances in which the EMS fails to meet desired performance standards
• Developing tools for preventing such failures and addressing them as they do occur
• Managing essential EMS records
• Providing senior management review of the EMS and adjusting the system to
promote continuous improvement
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Monitoring and Measurement
measures
Identify key indicators of operations
and activities
Tie measures to objectives and targets
as well as significant impacts
Choose measures carefully
An EMS without an effective monitoring and measurement program is like driving at night without
the headlights on - you know you're moving, but you don't know where you're going. Monitoring
and measurement enables an organization to assess how well the EMS is working and to identify
steps to improve the system. At a minimum, a monitoring and measurement program should
include:
• Monitoring key characteristics of operations and activities that can have significant
environmental impacts;
• Tracking environmental and system performance (including how well an organization is
meeting its environmental goals, objectives, and targets);
Assessing relevant operational controls; and
Evaluating compliance with environmental requirements (including periodic compliance
audits by an independent auditor(s)).
The EMS implementation team should choose measures carefully. Too many create information
overload and an ineffective system - too few do not provide enough information to make good
decisions. Information gathered through monitoring and measurement should be used strategically to
detect overall performance trends. This allows for identification and correction of declining
performance before it becomes a major problem. Also, the measures should be quantifiable and
verifiable.
As an example, St. Mary's General Hospital in Kitchener, Ontario used shipping data from its
contracted biomedical waste hauler to measure waste flows and quantities. After conducting a
comprehensive waste audit and implementing control measures, the hospital experienced a 38
percent reduction (by weight) in biomedical waste since 1998.
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Monitoring and Measurement
Ensure that monitoring equipment is
calibrated and maintained
Keep good records
Collect data according to procedures
Some measures are obtained through observation (e.g., inspection reports, workplace
evaluations), while others are derived from external records (e.g., utility bills, invoices,
manifests). To the extent EMS measures are obtained directly from monitoring equipment
(e.g., air emissions monitors, scales), it is essential that healthcare facilities calibrate and
maintain this equipment, and ensure that any records are kept.
Information collected as part of the monitoring and measuring process may also be useful in
determining future improvement goals.
Your facility should develop a written procedure that identifies personnel responsible for:
• Reviewing and reporting on environmental performance indicators;
• Identifying and assuring necessary equipment is calibrated; and
• Assessing compliance with environmental regulations.
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Monitoring and Measurement
Examples of different measures:
• Amounts of waste generated (solid, hazardous,
red bag, radiological)
• Amounts and types of chemicals used (e.g.,
cleaning products, solvents, pesticides)
• Amount of electricity used
• Amount and types of materials recycled
• Number of employees trained on an EMS topic
_ TV T 1 r • 1 • • f 11- • . 1
compliance audits
Because monitoring and measurement is directly connected to objectives and targets, your
facility should consider possible metrics when establishing objectives and targets. An
objective and target may be as simple as reducing hazardous waste generation (the
objective) by 20 percent over the previous year's baseline (the target). The facility can
easily determine how effectively it is meeting these goals by comparing hazardous waste
manifests.
For programs that are not already established, identifying an "original" baseline may not be
possible, simply because data were not collected, therefore, the effective baseline becomes
the year in which the program is established. In such an instance, a facility might choose to
set a target of establishing a computer recycling program by the end of the first year and
then collect data from that point forward.
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ecords Management
Definition: record vs. document
Types of environmental records
Record control and retention
• Build upon existing procedures
Centralized retention vs. dissemination
The value of records management is fairly obvious - an organization needs to be able to prove that it is
actually implementing its EMS as designed. Basic records management requires an organization to decide:
What records will be kept;
• Who maintains them and where;
How long they are kept, taking into account record retention requirements in applicable
environmental regulations;
How they are accessed (some records may require additional security); and
How they are disposed.
"Records" show evidence that an activity has already occurred (e.g., internal memoranda, procedural forms,
plans, monitoring data, maintenance logs). "Documents" describe how current or planned activities are
conducted. Good management of records can provide your healthcare facility with a history of environmental
performance and improvements. Examples of environmental records include:
Aspect/impact inventory and significance rankings;
EMS roles and responsibilities;
• Monitoring records;
Training records;
Corrective action logs; and
Compliance inspection and management audit/review reports.
The facility should write a procedure describing how records are identified, maintained, and disposed. It is also
important to identify who is responsible for maintaining records. Your facility probably has a procedure in
place upon which to build an EMS records procedure. Records kept in separate locations should be centrally
referenced. Reasonable precautions should be taken to protect records from damage or loss such as from fire
or flood.
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EMS Audi
Compliance audits
Gap analyses
Internal EMS audits
• Not necessarily all-inclusive
• Role of HQ and peer groups
• Scope
• Frequency
• Practical recommendations
Just as a person should have periodic medical exams, an EMS must be periodically audited and reviewed by management
to stay "healthy." Audits establish whether your facility is meeting its regulatory requirements, addressing its EMS
elements, and meeting its EMS goals. There are three types of audits that your facility should conduct, either internally or
with the assistance of a third-party:
Environmental Compliance Audit — determines Federal, state, and possibly, local legal requirements for your
facility and identifies areas where there may be compliance issues. It is often helpful to have a third-party
conduct the compliance audit. Professional compliance specialists will know what to look for and may discover
operations or activities that are subject to regulatory requirements that you may not have considered. Some states
have environmental agencies that will perform compliance audits for free. At a minimum, your facility should
conduct a baseline environmental compliance audit and review its regulatory requirements annually. Your
facility should also ensure that it addresses new compliance requirements as changes to its operations warrant.
To encourage organizations to conduct compliance audits, EPA has agreed to eliminate or substantially reduce
monetary penalties for violations that are voluntarily discovered and disclosed to us, provided that certain
conditions are met. These conditions are outlined in our Voluntary Audit Policy and are designed to ensure that
human health and the environment are not compromised. To aid in conducting environmental compliance audits,
EPA Region 1 has developed a compliance-focused audit tool especially designed for healthcare facilities. A
copy is in the Resources section of your binder. Also, on page 41 of Resources you will find a list of
common violations.
EMS Gap Analysis — is a self-evaluation, usually a series of questions or a checklist, that helps your facility
compare its current environmental management practices against a standard EMS model. By making this
comparison, the facility can identify EMS elements it needs to develop or enhance and the steps to get there. A
gap analysis is not an audit - your facility can not "fail" a gap analysis. Steps in a gap analysis usually include
EMS document review, staff interviews, and a facility walk-through to identify and document "gaps" between
the existing EMS and the selected EMS standard.
Internal EMS Audit — It is important to periodically evaluate - or audit - how well your EMS is performing.
Internal EMS audits are usually performed annually. You can audit the entire EMS at one time or break it down
into different areas and audit a few areas at a time. The results of these audits should be presented to top
management. Information collected assists in determining overall EMS effectiveness and ongoing suitability. On
page 29 of Resources, you'll find an EMS Audit Checklist.
Your facility should write a procedure that describes how the EMS will be audited and identifies personnel responsible and
the timeframe for conducting the auditing. The procedure should define appropriate training for internal auditors, define
guidelines for completing internal EMS audits, and describe methods for reporting results to top management.
95
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dentifyine Non-conf ormance
Definition
Non-conf ormance vs. non-
compliance
Sources
• Internal audits
• Second-party auui
• Third-party audits
• Employee self-disclosure
The main purpose of all these audits is to identify npnconformance. Nonconformance is a deficiency
where implementation of an EMS is inconsistent with its description, or the system does not meet
EMS criteria. It should be noted that nonconformance is not the same as non-compliance. Non-
compliance refers to a violation of an environmental law or regulation. Nonconformance relates
specifically to the EMS. So an EMS may have nonconformances, but no regulatory compliance
issues. For example, your EMS policy may not be available to the public, which is not a violation of
the law but is a nonconformance with the EMS 14001 standard. Of course, it goes without saying
that any noncompliance issue is also a nonconformance since it is typically caused by a breakdown
in the EMS. Nonconformances can be major (should be corrected immediately), minor (should be
corrected before the next audit), or observational (optional).
A healthcare facility should establish and maintain procedures for:
Handling and investigating nonconformance, including conducting a root cause analysis;
Taking action to reduce potential impacts; and
Initiating and completing corrective and preventive actions.
There are four main sources for identifying EMS nonconformance:
Internal or first-party audits are conducted by participants in the EMS being audited (could
be employees or consultants as agents of the hospital).
Second-party audits are conducted by auditors from outside the hospital being audited, but
could be from the same organization or parent company. The army for instance every three
years has their environmental office in Aberdeen Maryland audit their facilities in New
York, New Jersey, and the Caribbean. Any VA hospitals in the room should consider
having their VISN audit them for nonconformance with GEMS. Other hospitals, consider
having another hospital audit your facility and then return the favor.
Third party audits are conducted by independent registrars and are generally done for
hospitals seeking EMS certification (e.g., ISO 14001).
Employee reporting is a less formal way of identifying nonconformance. The hospital
should encourage employees to report possible nonconformance and have procedures in
place that allow them to disclose this information anonymously.
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Action
Corrective and preventive actions
should:
• Resolve the immediate problem
• Consider whether the same or similar
problems exist elsewhere
Prevent the problem from recurring
Regardless of how you identified the nonconformance, one needs to resolve it and
then take steps to prevent it from happening in the future. Remember just
correcting the immediate problem is not enough; you need to investigate why the
nonconformance occurred in order to prevent the problem from recurring and apply
controls so that the preventive actions are effective. For example, if your drums are
not labeled properly, don't just label them and walk away; find out if the improper
labeling was do to failure to follow procedures; lack of oversight; insufficient
training, or some other reason and then respond appropriately. Corrective and
preventive action allow for ongoing improvement of the EMS and improved
environmental performance.
97
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Your facility should develop a clear written procedure for initiating and completing
corrective and preventive action so that authorities and responsibilities are clearly
defined. The procedure should at a minimum document:
• Authority for reporting actual or potential nonconformance (The process
will of course be most successful when employees are encouraged to report
any problems they see that might result in a negative environmental impact);
• Responsibility and methodology for investigating, recording, and reporting
corrective and preventive actions; and
• Responsibility for recording changes to EMS documentation such as written
SOPs that resulted from the corrective action.
We recommend that you implement a tracking log or corrective action report form
that notes the nonconformance, the suggested fix, and closure of the action when
completed. As mentioned earlier, the procedure should include a root cause
analysis to determine where the system was compromised to ensure that the
nonconformance does not re-occur.
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Reasons for Non-conformance
Poor communicatior,
Insufficient training
Lack of EMS understanding
Procedures not followed
Equipment malfunctions or is not
properly maintained
Nonconformance with your facility's environmental policy, SOPs, and standards, or non-compliance with
applicable laws and regulations may occur for a number of reasons. These reasons need to be identified
promptly so that corrective action can be taken.
Examples of reasons for nonconformance include:
• Failure to communicate to employees their EMS roles and responsibilities;
Failure by management to demonstrate commitment through their actions or by not allocating
sufficient resources to the EMS;
• Failure of staff to follow procedures because no procedures exist, staff are not aware of these
procedures or trained in their application;
• Equipment failure due to improper or inadequate maintenance or not replacing obsolete components.
Identifying the root cause of the nonconformance is crucial. This often demands more intense time and focus to
determine why the problem occurred or could have occurred, but it is worth the investment.
If you are following a written standard operating procedure (SOP) that leads to non-compliance would
that be a non-conformance with an EMS since you are following the EMS procedure? For example, your
SOP says to label the drum "waste oil", but RCRA requires the term "used oil". This would be a non-
compliance with RCRA but it would not be a non-conformance with EMS because it's written in the SOP.
How would the ISO auditors view this?
Answer: In this case, there would be a non-conformance; although it is not related to adherence to the SOP, but
rather to a failure to identify or stay abreast of regulatory requirements (4.3.2); and to a lesser extent, a failure to
maintain documented operational controls to address situations in which there absence could lead to deviations
from the environmental policy (i.e., compliance) (4.4.6).
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Management Review
Purpose
"ustainability
Cost-effectiveness
• Progress made towards achieving
objectives and targets
• Continual improv
The final but certainly not the least (in fact it is the most important) component of any EMS
is management review. To maintain continual improvement and effectiveness of the EMS,
top management must review and evaluate the EMS periodically at an interval to be
determined by the hospital, although annual reviews are strongly encouraged. Management
review subjects may include:
• Results from audits and assessments;
• The continuing suitability and adequacy of the EMS in relation to changing
conditions and information such as new facilities, changes in activities, new
scientific data, new stakeholders concerns, new regulations, etc ;
• EMS resources and costs (or savings);
• Progress in meeting objectives and targets; and
• Changes to the EMS to ensure its continued effectiveness and improvement.
Healthcare facilities should involve two kinds of people in the management review process:
people who have the EMS knowledge (e.g., the EMS coordinator, EMS committee
members) and people who can make decisions about the organization and its resources (i.e.,
top management).
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Management Review
Typical questions asked during management review:
1 Is our environmental policy still relevant to what we do?
j Are we meeting our objectives and targets?
• Can we set new objectives and targets?
•> Are roles and responsibilities clear and do they make sense?
1 Are we applying resources appropriately?
1 Are we meeting our regulatory obligations?
1 Do changes in laws or regulations impact our operations?
1 Are our procedures clear and adequate? Do we need others?
1 What effects have changes in services had on our EMS?
• How effective are our monitoring and measurement systems?
The key question that a management review seeks to answer is, "Is the system working (i.e., is it suitable,
adequate, and effective)?" Management review questions should:
Provide a means of confirming that the EMS policy is understood and is being implemented;
Enable management to determine whether the system is being implemented in the manner prescribed
and resources are being used efficiently;
Provide a structured means of identifying deficiencies in the system, agreeing on corrective action,
and following up to confirm effectiveness;
Identify system weaknesses before the related potential problems are reflected in environmental
performance; and
• Provide a framework for determining where the EMS needs improvement so top management can
authorize the necessary changes.
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Second Edition
Environmental Management Systems:
An Implementation Guide for
Small and Medium-Sized Organizations
Environmental
Policy
Management
Review
Continual
Improvement
Planning
Checking /
Corrective Action
Implementation,
-------
Second Edition
Environmental Management Systems:
An Implementation Guide for Small and Medium-Sized Organizations
Written by:
Philip J. Stapleton, Principal
Margaret A. Glover, Principal
Glover-Stapleton Associates, Inc.
3 Bunkers Court
Grasonville, MD 21638
410-827-7232
and
S. Petie Davis, Project Manager
NSF ISR
789 N. Dixboro Road
Ann Arbor, Ml 48158
1-888-NSF-9000
Copyright © NSF 2001
All rights reserved
This work has been copyrighted by NSF to preserve all rights under U.S. Copyright law and
Copyright laws of Foreign Nations. It is not the intent of NSF to limit by this Copyright the fair
use of these materials. Fair use shall not include the preparation of derivative works.
Published by NSF International: E-mail: information@nsf-isr.org Web: www.nsf-isr.org
©2001 NSF I
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Acknowledgments
When the first edition of this Guide was published in November 1996, the use of environmental
management systems (EMS) was a relatively new, but rapidly expanding phenomenon. Considerable
experience in EMS design and implementation has been gained since the first edition of this Guide was
published. The authors' primary goal in preparing this second edition of the Guide was to take
advantage of the many new developments in the EMS field as well as the insights and experiences of
many organizations that have implemented EMS over the past few years.
The second edition was prepared by NSF International with funding through a cooperative agreement
with the U.S. Environmental Protection Agency's Office of Wastewater Management; Office of
Enforcement and Compliance Assistance; Office of Pesticides, Prevention and Toxic Substances; and
Office of Policy Economics - Innovation.
In preparing the second edition, the authors solicited input from a variety of organizations that used the
Guide in EMS planning and implementation activities. Feedback from the user community was very
helpful in framing the changes that are reflected in this second edition. In particular, the authors would
like to thank the following individuals for sharing experiences and insights on their use of the first edition
of the Guide.
• Sue Mills, Champion International,
• Charles Tellas, Milan Screw Products, Inc.,
• Ronda Moore, Zexel Corporation
• Susan Briggs, Brookhaven National Laboratory
NSF International also would like to acknowledge the following individuals for their many contributions
to the first edition of this Guide:
• Jeffrey R. Adrian, The John Roberts Company
• Lemuel D. Amen, Washtenaw County Department of Environment & Infrastructure Services
• Stephen P. Ashkin, Rochester Midland
• Christine A. Branson, Industrial Technology Institute
• Ken Burzelius, Midwest Assistance Programs, LeSueur County
• Marci Carter, Iowa Waste Reduction Center, University of Northern Iowa
• John Dombrowski, U. S. Environmental Protection Agency (Office of Compliance)
• David Fiedler, Michigan Department of Environmental Quality (Environmental Assistance Div.)
• Wendy Miller, U. S. Environmental Protection Agency (Office of Compliance)
• Charles Tellas, Milan Screw Products, Inc.
• Bryant Winterholer, K. J. Quinn & Co., Inc.
Finally, the authors of this Guide would like to thank Jim Home of the U. S. Environmental Protection
Agency (Office of Wastewater Management) for his significant contributions to the development of this
Guide.
©2001 NSF
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Second Edition
Environmental Management Systems:
An Implementation Guide for Small and Medium-Sized Organizations
CONTENTS
Introduction to Second Edition 1
Section 1: Why Your Organization Should Have an EMS 4
Section 2: Key EMS Concepts 8
Section 3: READY! (Initial EMS Planning) 10
Section 4: SET! (Key Elements of an EMS) 14
Environmental Policy 16
Identifying Environmental Aspects 20
Legal and Other Requirements 25
Objectives and Targets 28
Environmental Management Program(s) 32
Structure and Responsibility 35
Training, Awareness and Competency 39
Com munications 43
EMS Documentation 47
Document Control 50
Operational Control 53
Emergency Preparedness and Response 57
Monitoring and Measurement 60
Nonconformance and Corrective / Preventive Action 65
Records 69
EMS Auditing 71
Management Review 75
Section 5: GO! (Roadmap for EMS Development) 78
Creating Your EMS: Step by Step 80
Appendix A: TOOLKIT 88
Sample Environmental Policies 89
Environmental Impact Identification and Evaluation: Techniques and Data Sources...96
Sample Procedure: Instructions for Environmental Aspects Identification Form 98
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Sample Procedure: Instructions for Environmental Aspects Identification Form 103
Environmental Aspects Identification 106
Sample Environmental Aspect Evaluation and Scoring Tools 108
Resources for Tracking Environmental Laws and Regulations 111
Sample Process Tool: Setting Objectives & Targets 113
Sample Procedure: Setting Objectives & Targets 117
Sample Tools: Environmental Management Program 120
Sample Responsibility Matrix 123
Sample Environmental Training Log 125
Sample Procedure: Communications with External Parties 127
Sample Document Index 130
Outline of Sample EMS Manual and Other EMS Documents 132
Sample Records Management Form (supplied courtesy of 134
General Oil Company) 134
Sample Procedure: Corrective and Preventive Action 136
(includes tracking log) 136
Sample Environmental Records Organizer 141
Sample Procedure: EMS Audits 143
Sample EMS Audit Forms 149
Sample EMS Audit Questions 152
Sample Procedure: Management Review 157
Appendix B: EPA's Performance Track and Other Government EMS Initiatives 159
Appendix C: Information on Process Mapping and Design for Environment 169
Appendix D: Registration of Environmental Management Systems 178
Appendix E: Integration of Environmental Management Systems and Quality
Management Systems 182
Appendix F: Additional Sources of Information and Contacts 186
Glossary of Acronyms 195
Bibliography 196
©2001 NSF
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Introduction to Second Edition
The first edition of this Guide was published in November 1996. Like its predecessor, this second
edition is designed to explain environmental management system (EMS) concepts and to support and
facilitate the development of EMS among small and medium-sized organizations. Implementation of an
EMS is a voluntary approach to improving environmental performance. Over the past several years,
many public and private sector organizations have implemented EMS and their numbers grow daily.
These organizations report a number of important EMS benefits, as described in this Guide.
Many changes were made in this edition of the Guide to improve its usefulness and to reflect EMS
experience gained over the last four years The changes were based on feedback solicited from
selected users of the first edition of the Guide, lessons learned and implementation examples from the
NSF/EPA projects, the Multi-State Working Group, Guide users, and Technical Committee 207-Small
and Medium-Sized Enterprise efforts. In particular, the authors have provided additional information on
certain EMS elements that many organizations have found to be particularly challenging - including
environmental aspects, communications and operational controls, among others. Sections 3 through 5
have been reconfigured into a new "Ready-Set-Go" format. The new Section 5 (GO!) has been added
to provide a "roadmap" or logical sequence for implementing the key elements of an EMS. In addition,
pollution prevention success stories and examples of EMS implementation practices from public sector
and service based-organizations have been added to help demonstrate the value of EMS.
This Guide is designed primarily for use by EMS implementers — the people in a small or medium-
sized organization that lead the EMS development effort. The heart of the Guide is found in Section 4,
"Key Elements of an EMS." For each of the key EMS elements, this section describes the importance of
the element, how to get started on implementation, and other key suggestions. In this edition,
worksheets have been added to help users "capture their learning" as they progress from one EMS
element to the next. Readers of the Guide can use these worksheets to summarize and evaluate their
existing management processes, to initiate needed improvements and to help maintain implementation
momentum.
The Guide continues to use the ISO 14001 standard as one important EMS model. ISO 14001,
published in November 1996, is the most widely accepted international standard for EMS. EPA, as part
of its effort to promote the use of EMS's that can help organizations improve environmental performance
(including compliance) and make greater use of pollution prevention approaches, is implementing
several EMS initiatives that might be useful to some organizations. These include the National
Environmental Performance Track, the EMS Initiative for Local Governments and the Design for
Environment EMS Guide. Information on the National Environmental Performance Track program and
other Federal and state-level EMS initiatives can be found in Appendix B and other relevant sections of
this Guide.
While this Guide is intended primarily for organizations outside the Federal government, some Federal
agencies are developing EMS's at their facilities. These agencies may wish to use this Guide to support
their EMS efforts.
This Guide is not intended for use by registrars (or others) for registration purposes, nor is it intended to
provide specific interpretations of the ISO 14001 Standard.
©2001 NSF
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How this Guide is Organized
Section 1:
Why Your Organization
Should Have an EMS
Section 2:
Key EMS Concepts
Section 3:
Initial EMS Planning
Section 4:
Key Elements
of an EMS
Section 5:
Roadmap for
EMS Development
Appendices
Describes the many benefits of an EMS and how such a system can
help your organization to compete and prosper in today's global
marketplace.
Summarizes overall management systems concepts. This section
explains what a management system is and what must be in place for
a successful EMS.
Describes the initial process for planning an EMS and recommends
some steps in the overall EMS planning effort.
Provides detailed guidance on how each element of your EMS could
be designed and implemented. Discusses each of the key elements of
an EMS and suggests how to put them in place.
Describes a sequence of events or "roadmap" for implementing the
key elements of an EMS and explains why the implementation of
certain elements might precede others.
Describe sources of EMS information and related EPA and state
programs. Also describe the process for registering an EMS and
selecting and working with a registrar. The Tool Kit (Appendix A)
provides sample EMS policies, procedures and other tools that your
organization can tailor to fit its EMS needs. The sample procedures
are adapted from actual EMS procedures used by organizations that
have implemented EMS.
Use of Icons
A variety of icons are used in this Guide to highlight key concepts and suggestions for the reader. The
most frequently used icons include:
4^%
^f (" y|^ The light bulb is used to highlight EMS examples and experiences from various
\^~ organizations.
The hand is used to point out hints for implementing EMS elements.
The key is used to indicate keys to successful EMS implementation, as identified by
various organizations.
©2001 NSF
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The speech balloon is used to indicate quotes from representatives of organizations that
have implemented an EMS, as well as definitions from various sources (such as ISO
14001).
The Tool Box icon is used to highlight references to useful examples and other tools
that are found in Appendix A (the Tool Kit).
The Links icon is used to summarize critical linkages among EMS elements.
©2001 NSF
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Section 1: Why Your Organization Should Have an EMS
A systematic approach to achieve your environmental and other organizational goals
Key EMS Benefits
improved
environmental
performance
reduced liability
competitive advantage
improved compliance
reduced costs
fewer accidents
employee involvement
improved public image
enhanced customer
trust
more favorable credit
terms
meet customer
requirements
Does your organization need an EMS? Well, ask
yourself the following questions:
"We view the
establishment of an
EMS as a process
that forces us to
better organize our
priorities and
projects and to
identify problems
and exposures
before they occur."
- K.J. Quinn &Co.,
a small specialty
chemical company
Is your organization required to comply
environmental laws and regulations?
with
• Are you looking for ways to improve your
environmental performance?
• Is the state of your organization's environmental
affairs a significant liability?
• Does a lack of time or resources prevent your
organization from managing its environmental
obligations effectively?
• Is the relationship between your organization's
environmental goals and other goals unclear?
If you answered YES to one or more of the above
questions, an EMS can help your organization —
and so will this Guide!
As one of your organization's leaders, you probably
know that interest in environmental protection and
sustainable development is growing each year. You
might hear about these issues from customers, the
public or others. Like many, your organization may
be increasingly challenged to demonstrate its
commitment to the environment. Implementing an
EMS can help you meet this challenge in several
important ways.
First, an effective EMS makes good sense, whether
your organization is in the public or private sector.
By helping to identify the causes of environmental
problems and then eliminate them, an EMS can help
you save money. Think of it this way:
> Is it better to make a product (or provide a
service) right the first time or to fix it later?
> Is it cheaper to prevent a spill in the first place or
to clean it up afterwards?
> Is it more cost-effective to prevent pollution or to
manage it after it has been generated?
©2001 NSF
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"We found that an
EMS could improve
employee retention,
new hire selection,
working conditions,
and the perceptions
of our customers,
suppliers, lenders,
neighbors, and
regulators."
Milan Screw Products,
a 32-person manufacturer
of precision fittings
Some reasons that
municipalities have
implemented an EMS:
0 Improved compliance
performance
0 Enhanced
management
confidence
0 Increased efficiency
0 Public image concerns
0 Growth management
0 Desire to be seen as
leaders and innovators
Second, an EMS can be an investment in long-
term viability of your organization. An EMS can
help you to be more effective in achieving
environmental goals. And, by helping businesses to
keep existing customers and attract new ones, an
EMS adds value.
Here's some good news: Much of what you need for
an EMS may already be in place! The management
system framework described in this Guide includes
many elements that are common to managing many
organizational processes, such as quality, health &
safety, finance, or human resources. As you review
this Guide, you will probably find that your
organization has many EMS processes in place,
even though they may have been designed for other
purposes. Integrating environmental management
with other key organizational processes can improve
financial, quality and environmental performance.
The key to effective environmental management is
the use of a systematic approach to planning,
controlling, measuring and improving an
organization's environmental performance.
Potentially significant environmental improvements
(and cost savings) can be achieved by assessing and
improving your organization's management
processes. Many environmental "problems" can be
solved without installing expensive pollution control
equipment.
Of course, there is some work involved in planning,
implementing and maintaining an EMS. But many
organizations have found that the development of an
EMS can be a vehicle for positive change. Many
organizations have seen that the benefits of an EMS
far outweigh the potential costs. And while these
EMS concepts certainly apply to the private sector, a
number of public sector organizations (including
municipalities) have found that they can benefit from
an EMS.
In the Total Quality Management (TQM) world, they
say that "quality is free" — as long as you are willing
to make the investments that will let you reap the
rewards. The same holds true for environmental
management.
Want to know more about EMS costs and benefits?
Then read on ...
©2001 NSF
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EPA encourages the use
of EMS that improve
compliance, pollution
prevention and other
forms of environmental
performance. The
Agency is assessing how
EMS can be used to
strengthen environmental
programs and policies.
"We needed a system
to manage things that
came up in a consistent
way. Our area is
growing and an EMS
will help us handle
development issues
such as controlling soil
erosion and preserving
the natural features of
the area. An EMS is a
way to control
environmental
problems in a rapidly
growing community."
Steve Daut, Council Trustee
Village of Chelsea, Michigan
Frequently Asked Questions about EMS
1. We already have a compliance program - why do
we need an EMS?
An EMS can help you to comply with regulations more
consistently and effectively. It also can help you identify
and capitalize on environmental opportunities that go
beyond compliance.
2. How big does an organization need to be to
successfully implement an EMS?
EMS have been implemented by organizations ranging in
size from a couple of dozen employees to many thousands
of employees. The elements of an EMS (as described in
this Guide) are flexible by design to accommodate a wide
range of organizational types and sizes.
3. Will an EMS help us to prevent pollution?
A commitment to preventing pollution is a cornerstone of an
effective EMS and should be reflected in an organization's
policy, objectives and other EMS elements. Examples
throughout this Guide show how organizations have used
an EMS to prevent pollution.
4. To implement an EMS, do we have to start from
scratch?
Much of what you have in place now for environmental
management probably can be incorporated into the EMS.
There is no need to "start over".
5. How will an EMS affect my existing compliance
obligations?
An EMS will not result in more or less stringent legal
compliance obligations. But an EMS should improve your
efforts to comply with legal obligations, and, in some cases,
may lead to more flexible compliance requirements. (See
discussion of Performance Track in Appendix B.)
6. Do we need to be in 100% compliance in order to
have an EMS?
No. The concept of continual improvement assumes that
no organization is perfect. While an EMS should help your
organization to improve compliance and other measures of
performance, this does not mean that problems will never
occur. However, an effective EMS should help you find and
fix these problems and prevent their recurrence.
©2001 NSF
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EMS Costs and Benefits
POTENTIAL COSTS
Internal
• Staff (manager) time
• Other employee time
(Note: Internal labor costs represent the
bulk of the EMS resources expended
by most organizations)
External
• Potential consulting assistance
• Outside training of personnel
POTENTIAL BENEFITS
Improved environmental performance
Enhanced compliance
Prevention of pollution/resource conservation
New customers / markets
Increased efficiency / reduced costs
Enhanced employee morale
Enhanced image with public, regulators, lenders,
investors
Employee awareness of environmental issues and
responsibilities
If your organization already has or is
considering a quality management system
(based on ISO 9001, for example), you will
find significant synergy between what you
need for quality management and for
environmental management (see below).
Some Common Aspects of Quality and Environmental Management Systems
QMS
Quality Policy
Adequate Resources
Responsibilities and Authorities
Training
System Documentation
Process Controls
Document Control
System Audits
Management Review
EMS
Environmental Policy
Adequate Resources
Responsibilities and Authorities
Training
System Documentation
Operational Controls
Document Control
System Audits
Management Review
One final note: Small and medium-sized
organizations often have certain advantages
over larger organizations in ensuring effective
environmental management. In smaller
organizations, lines of communication are
generally shorter, organizational structures are
less complex, people often perform multiple
functions, processes are generally well
understood, and access to management is
simpler. These can be real advantages for
effective environmental management.
Are you interested in learning more about how
an EMS can help your organization? If so, let's
look at some key management systems concepts
and how they are applied in the environmental
area.
©2001 NSF
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Section 2: Key EMS Concepts
The focus on quality principles
An EMS is:
A continual cycle of planning,
implementing, reviewing and
improving the processes and
actions that an organization
undertakes to meet its
environmental obligations.
You have probably heard of Total Quality Management
(TQM). Your organization may apply TQM principles to
some of its operations and activities.
An effective EMS is built on TQM concepts. To improve
environmental management, your organization needs to
focus not only on what things happen but also on why
they happen. Over time, the systematic identification
and correction of system deficiencies leads to better
environmental (and overall organizational) performance.
Most EMS models (including the ISO 14001 standard,
which is described later) are built on the "Plan, Do,
Check, Act" model introduced by Shewart and Deming.
This model endorses the concept of continual
improvement.
Continual
Improvement:
Enhancing your EMS
to better your overall
environmental
performance
Figure 1
An effective EMS doesn't just
happen. An effective EMS
needs ongoing and visible
management support
Top management" is the
person or group with
executive responsibility for the
organization"
In the EMS model described in this Guide, the "Plan, Do,
Check, Act" steps have been expanded into seventeen
elements that are linked together. These EMS
elements and their linkages are discussed in Section 4.
Some of the keys to a successful EMS include:
Top Management Commitment
Applying TQM principles to the environmental area and
providing adequate resources are the job of top
management. To initiate and sustain the EMS effort,
top management must communicate to all employees
the importance of:
• making the environment an organizational priority
(thinking of effective environmental management as
fundamental to the organization's survival)
• integrating environmental management
throughout the organization
(thinking about the environment as part of
product/service and process development and
delivery, among other activities)
©2001 NSF
8
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Flexible & Simple =
Adaptable &
Understandable
Some organizations have
found that an effective EMS
allows them to design pollution
and other environmental
impacts out of their products,
services and operations. This
can save money and reduce
liability.
Employee involvement is
crucial. An effective
implementation team is
pivotal to the success of
many organizations.
An EMS should integrate
]^- environmental
^ management into day-to-
day operations as well as
strategic decisions. It can
make the environment the
responsibiity of every
employee.
• looking at problems as opportunities
(identifying problems, determining root causes
preventing problem recurrence)
and
Focus on Continual Improvement
No organization is perfect. The concept of continual
improvement recognizes that problems will occur. A
committed organization learns from its mistakes and
prevents similar problems from recurring.
Flexibility
An effective EMS must be dynamic to allow your
organization to adapt to a quickly changing
environment. For this reason, you should keep your
EMS flexible and simple. This also helps make your
EMS understandable for the people who must
implement it — your organization's managers and
other employees.
Compatibility with Organizational Culture
The EMS approach and an organization's culture
should be compatible. For some organizations, this
involves a choice: (1) tailoring the EMS to the culture,
or (2) changing the culture to be compatible with the
EMS approach. Bear in mind that changing an
organization's culture can be a long-term process.
Keeping this compatibility issue in mind will help you
ensure that the EMS meets your organization's
needs.
Employee Awareness and Involvement
As you design and implement an EMS, roadblocks
may be encountered. Some people may view an
EMS as bureaucracy or extra expense. There also
may be resistance to change or fear of new
responsibilities. To overcome potential roadblocks,
make sure that everyone understands why the
organization needs an effective EMS, what their role
is and how an EMS will help to control environmental
impacts in a cost-effective manner. Employee
involvement helps to demonstrate the organization's
commitment to the environment and helps to ensure
that the EMS is realistic, practical and adds value.
Building or improving an EMS (with the help of this
Guide) provides an opportunity to assess how your
organization manages environmental obligations and
to find better (and more cost-effective) solutions.
While you will probably identify some areas where
your current EMS can be improved, this does not
mean that you should change things that are working
well! By reviewing what your organization does and
how well it works, you can ensure that your EMS will
be viable and effective, both now and in the future.
Don't get discouraged if your system has some bugs
at first — the focus is on continual improvement!
©2001 NSF
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V
Section 3: READY! (Initial EMS Planning)
Putting the theory of EMS into practice
Building an EMS might sound like an overwhelming task
for a smaller organization, but it need not be. Since time
and other resources are limited in any organization, it is
important that you use resources wisely. One way to do
this is by preparing and following a simple, effective plan.
Fortunately, you can build on the experiences of other
organizations that have already implemented an EMS.
Examples are provided throughout this Guide.
Milan Screw Products found
that the use of a cross-
functional team (the
environmental task group)
was the key to progress in
evaluating and implementing
their EMS. Participation of
line managers and
employees is essential in
successfully implementing
an EMS.
Appendix F has
information on EMS
resources
K.J.Quinn & Company found
that it could perform an initial
assessment of its
environmental programs in
20-25 hours
Preliminary Review Tools:
See the "NSF ISO 14001
Self Assessment Tool"
(at www.nsf-isr.org) or
"Incorporating Design for
Environment into your Gap
Analysis"
(at www.epa.gov/dfe)
Figure 2 illustrates the initial steps in the EMS planning
process. The importance of careful planning cannot be
overemphasized. Taking the time to figure out what you
need to do, how you will do it, and who must be involved
will pay big dividends down the road.
Experience shows that using a team approach to
planning and building an EMS is an excellent way to
promote commitment and ensure that your objectives,
procedures and other system elements are realistic,
achievable, and cost-effective. Ideas for using a team
and involving employees are discussed in this section.
A few hints to keep in mind as you build your EMS:
• Help is available — don't hesitate to use it.
(See Appendix F for information on resources.)
• Pace yourself. Move quickly enough that employees
stay interested and engaged, but not so fast that
those involved are overloaded or that the effort
becomes superficial.
Don't re-invent the wheel - existinc
practices should help you to meet EMS
management
requirements.
Consultants can help you evaluate your EMS and
suggest approaches used successfully elsewhere.
Explore ways to hold consulting costs down. You
may be able to join forces with other organizations to
hire a consultant or sponsor a training course.
Some Thoughts on Using Consultants
Assess your own in-house resources first.
Ensure both parties understand the scope
of work.
Get references and check them. Look for
consultants with experience in small
organizations and your specific industry.
Use consultants to gain insights on approaches
used by other organizations.
An EMS developed by consultants "in isolation"
will not work. Your own people need to be
involved in the EMS development process.
©2001 NSF
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FIGURE 2: INITIAL EMS PLANNING STEPS
Define Organization's Goals
Secure
Management
Commitment
Select
EMS
Champion
Hold
Kick-off
Meeting
Conduct
Preliminary
Review
Secure
Resources,
Assistance
Initiate
Employee
Involvement
READY!
Build
Implementation
Team
Develop
Project
Plan,
Schedule
Monitor &
Communicate
Progress
©2001 NSF
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Laying the Groundwork for an EMS: Key Steps
Define
Organization's
Goals for EMS
Secure Top
Management
Commitment
Select
EMS
Champion
Build
Implementation
Team
Hold
Kick-Off
Meeting
more...
A first step in EMS planning is to decide why you are
pursuing the development of an EMS. Are you
trying to improve your environmental performance (for
example, compliance with regulations or prevent
pollution)? Are you trying to promote involvement
throughout the organization? Write your goals down
and refer back to them frequently as you move
forward. As you design and implement the EMS, ask:
How is this task going to help us achieve our goals?
This also is a good time to define the project scope or
"fenceline" (i.e., what is the "organization" that the
EMS will cover? One location? Multiple locations?
Should we "pilot" the EMS at one location then
implement the system at other locations later?).
One of the most critical steps in the planning process is
gaining top management's commitment to support
EMS development and implementation. Management
must first understand the benefits of an EMS and what
it will take to put an EMS in place. Explain the
strengths and limitations of your current approach and
how those limitations can affect the organization's
financial and other performance. Management also
has a role in ensuring that the goals for the EMS (see
above) are clear and consistent with other
organizational goals. Management's commitment
should be communicated across the organization.
Not all small- or medium-sized organizations have the
luxury of choosing among multiple candidates, but your
choice of project champion is critical. The champion
should have the necessary authority, an understanding
of the organization, and project management skills.
The champion should be a "systems thinker" (ISO
9000 experience can be a plus, but is not necessary),
should have the time to commit to the EMS-building
process and must have top management support.
A team with representatives from key management
functions (such as engineering, finance, human
resources, production and/or service) can identify and
assess issues, opportunities, and existing processes.
Consider including contractors, suppliers or other
external parties as part of the project team, where
appropriate. The team will need to meet regularly,
especially in the early stages of the project. A cross-
functional team can help to ensure that procedures are
practical and effective and can build commitment to
and "ownership" of the EMS.
Once the team has been selected, hold a kick-off
meeting to discuss the organization's objectives in
implementing an EMS, the steps that need to be taken
initially, and the roles of team members, among other
topics. If possible, get top management to describe its
mitment to the EMS at this meeting. The kick-off
©2001 NSF
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Conduct
Preliminary
Review
Prepare
Budget and
Schedule
Secure
Resources,
Monitor and
Communicate
Advertise your successes to
keep management and
employees aware of your
EMS efforts. Document
benefits, no matter how
small they may seem at the
time. As this list grows, so
will EMS support.
Creating Your Own EMS (cont'd.)
meeting also is a good opportunity to provide some
EMS training for team members. Follow-up this
meeting with a communication to all employees.
The next step is for the team to conduct a preliminary
review of your current compliance and other
environmental programs/systems and to compare
these against the criteria for your EMS (such as ISO
14001). Evaluate your organization's structure,
procedures, policies, environmental impacts, training
programs and other factors. Determine which parts of
your current EMS are in good shape and which need
additional work. See the "NSF ISO 14001 Self-
Assessment Tool" (www.nsf-isr.org) or "Incorporating
Design for the Environment into Your Gap Analysis"
(www.epa.gov/dfe) for gap analysis tools.
Based on the results of the preliminary review, prepare
a project plan and budget. The plan should describe
in detail what key actions are needed, who will be
responsible, what resources are needed, and when the
work will be completed. Keep the plan flexible, but set
some stretch goals. Think about how you will maintain
project focus and momentum over time. Look for
potential "early successes" that can help to build
momentum and reinforce the benefits of the EMS.
The plan and budget should be reviewed and
approved by top management. In some cases, there
may be outside funding or other types of
assistance that you can use (from a trade association,
a state technical assistance office, etc.). See
Appendix F for more ideas on possible sources of help.
Employees are a great source of knowledge on
environmental and health & safety issues related to
their work areas as well as on the effectiveness of
current processes and procedures. They can help the
project team in drafting procedures. Ownership of the
EMS will be greatly enhanced by meaningful employee
involvement in the EMS development process.
As you build the EMS, be sure to regularly monitor
your progress against the project plan and
communicate this progress within the organization.
Be sure to communicate the accomplishments that
have been made and describe what happens next.
Build on small successes. Be sure to keep top
management informed and engaged, especially if
additional resources might be required.
©2001 NSF
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Section 4: SET! (Key Elements of an EMS)
What does an EMS consist of? How are the elements linked together?
As mentioned earlier, your EMS should be built on the "Plan, Do, Check, Act" model to ensure that
environmental matters are systematically identified, controlled, and monitored. Using this approach
will help to ensure that performance of your EMS improves over time and that you meet your goals for
implementing an EMS in the first place.
This section describes seventeen EMS elements that are common to most EMS models. This section
also notes the key linkages among these elements. While there are several good EMS models
available, this Guide generally uses the ISO 14001 Standard as a starting point for describing EMS
elements. This has been done for several reasons:
ISO 14001 is a widely accepted international standard for EMS that focuses on
continual improvement;
Companies may be asked to demonstrate conformance with ISO 14001 as a
condition of doing business in some markets; and
• The Standard is consistent with the key elements found in many EMS models,
including the European Union's Eco-Management and Audit Scheme, EPA's
Performance Track and the Code of Environmental Management Principles for
Federal Agencies, among others.
Figure 3: EMS Model
Management
Review
Environmental
Policy
Checking /
Corrective Action
Monitoring & Measurement
Nonconformance & Corrective &
Preventive Action
• Records
• EMS Audits
Continual
Improvement!
Planning
Environmental Aspects
Legal & Other Requirements
• Objectives & Targets
Environmental Management,
Program
©2001 NSF
Implementation
Structure & Responsibility
Training, Awareness, Competence
• Communication
• EMS Documentation
• Document Control
• Operational Control
Emergency Preparedness /
Response
-------
Key Elements of an EMS: A Snapshot
• Environmental policy — Develop a statement of your organization's commitment to the
environment. Use this policy as a framework for planning and action.
• Environmental aspects — Identify environmental attributes of your products, activities
and services. Determine those that could have significant impacts on the
environment.
• Legal and other requirements — Identify and ensure access to relevant laws and
regulations, as well as other requirements to which your organization adheres.
• Objectives and targets — Establish environmental goals for your organization, in line
with your policy, environmental impacts, the views of interested parties and other
factors.
• Environmental management program — Plan actions necessary to achieve your
objectives and targets.
• Structure and responsibility — Establish roles and responsibilities for environmental
management and provide appropriate resources.
• Training, awareness and competence — Ensure that your employees are trained and
capable of carrying out their environmental responsibilities.
• Communication — Establish processes for internal and external communications on
environmental management issues.
• EMS documentation — Maintain information on your EMS and related documents.
• Document control — Ensure effective management of procedures and other system
documents.
• Operational control — Identify, plan and manage your operations and activities in line
with your policy, objectives and targets.
• Emergency preparedness and response — Identify potential emergencies and develop
procedures for preventing and responding to them.
• Monitoring and measurement — Monitor key activities and track performance.
Conduct periodic assessments of compliance with legal requirements.
• Nonconformance and corrective and preventive action — Identify and correct problems
and prevent their recurrence.
• Records — Maintain and manage records of EMS performance.
• EMS audit — Periodically verify that your EMS is operating as intended.
• Management review — Periodically review your EMS with an eye to continual
improvement.
©2001 NSF 15
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Environmental Policy
Communicating your environmental vision
Key Policy Commitments: *
0 Continual improvement
0 Pollution prevention
0 Compliance with
relevant laws and
reaulations
Sample environmental
policies are provided in the
Tool Kit (see Appendix A).
An environmental policy is top management's
declaration of its commitment to the environment. This
policy should serve as the foundation for your EMS
and provide a unifying vision of environmental concern
by the entire organization. Given its importance, your
policy should be more than just flowery prose.
Since it serves as the framework for setting
environmental objectives and targets, the policy should
be brought to life in your plans and deeds. Everyone
in the organization should understand the policy and
what is expected of them in order to achieve the
organization's objectives and targets.
Your policy should reflect three key commitments (see
box), including a commitment to continual
improvement. While this does not mean that you must
improve in all areas at once, the policy should drive your
organization's efforts to continually improve
environmental management (and the improved
performance that results from these efforts).
Continual Improvement:
"Process of enhancing the
environmental management
system to achieve
improvements in overall
environmental performance
in line with the organization's
environmental policy."
ISO U001
Hints:
• Your organization probably has some type of
environmental policy now, even if it's not written
down. For example, your organization probably is
committed to complying with the law and avoiding
major environmental problems, at a minimum.
Document existing commitments and goals as a
starting point.
• The policy should relate to your products and
services, as well as supporting activities. Consider
the results of your preliminary review (see Section
3) and your analysis of the environmental aspects
of your products, services and activities before
finalizing the policy. These two steps can provide
insight as to how your organization interacts with the
environment and how well it is meeting its
challenges. For example, information obtained
during the preliminary review might help you define
specific policy commitments.
• Keep your policy simple and understandable. Ask
yourself: What are we trying to achieve? How can we
best communicate this to the rest of the organization?
One test to use: Could our employees describe the
intent of our policy in twenty words or less?
©2001 NSF
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Environmental
Policy
^
c
o
M
P
L
1
A
N
C
1 E
1
M
P
R
O
V
E
M
E
N
T
i j
P
R
E
V
E
N
T
1
O
( N ,
Figure 4:
Three Pillars of an
Environmental Policy
Environmental Aspects
Objectives & Targets
Training & Awareness
Communication
Management Review
The environmental policy should be explicit enough
to be audited. If you choose to use phrases such as
"We are committed to excellence and leadership in
protecting the environment", consider how you would
demonstrate that such a commitment is being met.
The environmental policy can be a stand-alone
document or it can be integrated with your health &
safety, quality, or other organizational policies.
Consider who should be involved in developing the
policy and the best process for writing it. Input from a
range of people within your organization should
increase commitment and ownership.
Make sure that your employees understand the
policy. Options for communicating your policy
internally include posting it around work sites (e.g., in
lunchrooms), using paycheck stuffers, incorporating
the policy into training classes and materials, and
referring to the policy at staff or all-hands meetings.
Test awareness and understanding from time to time
by asking employees what the policy means to them
and how it affects their work.
The policy also should be communicated externally.
Some options for external communications include
placing the policy on business cards, in newspaper
advertisements and in annual reports, among other
options. You might choose to communicate the policy
proactively or in response to external requests (or
both). This decision should be factored into your
overall strategy for external communication (see later
discussion under "Communications").
Consider how you would demonstrate that you are
living by the commitments laid out in the policy. This
is a good test of whether or not the policy is a "living
document".
For EPA's Performance Track program, an organization's policy must
include:
compliance with legal requirements and voluntary commitments;
pollution prevention (see Figure 5);
continuous improvement in environmental performance, including
areas not subject to regulation, and
sharing information on environmental performance and their operation
of the EMS with the community.
For more information see Appendix B.
©2001 NSF
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Commitments to Compliance with Legal Requirements and Pollution Prevention
Compliance with legal requirements is a critical consideration in EMS development and
implementation. EMS implementation requires an organization, among other things, to:
• develop and communicate an environmental policy that includes a commitment to compliance;
• develop and implement a procedure to identify, analyze and have access to environmental
laws and regulations;
• set objectives and targets in line with its environmental policy, which includes a commitment to
compliance;
• establish management programs to achieve its objectives;
• train employees and communicate relevant EMS requirements to them;
• establish and implement operational control procedures;
• establish and implement a procedure for periodically evaluating compliance; and
• establish and implement a procedure to carry out corrective and preventive actions.
While the requirements noted above relate directly to an organization's management of legal
requirements, each of the seventeen EMS elements described in this Guide can contribute to
enhanced compliance (including communication, documentation and document control, records
management, EMS audits, and management review). An EMS that includes the elements described
in this Guide will help your organization improve or maintain its compliance performance and facilitate
the establishment of objectives and targets that go "beyond compliance."
Figure 5
Prevention of Pollution Hierarchy
Source Reduction
In-Process Recycling
Other Recycling
Treatment &
Recovery
EMS design and implementation also
should take into account the Pollution
Prevention (P2) hierarchy. In
evaluating P2 opportunities,
organizations should start at the top of
the pyramid (i.e., source reduction)
and work their way down as needed to
define the most appropriate methods
for preventing pollution. Examples
and best practices of P2 in operation
are provided throughout this Guide.
©2001 NSF
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Capture the Learning: Environmental Policy Worksheet
Do we have an existing policy?
If yes, how was the policy developed?
When was the policy last reviewed?
Does the policy reflect the three key
commitments (commitments to
compliance, prevention of pollution and
continual improvement?)
What other commitments does or
should our policy contain?
How does our policy take into account
the environmental attributes of our
products, activities and services?
How would we demonstrate
conformance to our policy?
How is the policy communicated to
our employees? Do our employees
understand the critical elements of our
policy? How do we know?
What feedback have we received on
the policy (from employees, contractors
or other interested parties)?
What happens when we receive
feedback on the policy?
How do we make our policy available
to external parties? Is this process
effective?
Our next step on environmental
policy is to ...
©2001 NSF
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Identifying Environmental Aspects
How an organization interfaces with the environment
/Environmental Aspect:
"Element of an
organization's
activities, products, or
services that can
interact with the
environment."
ISO 14001
Environmental Impact :'
"Any change to the
environment, whether
adverse or beneficial,
wholly or partially
resulting from an
organization's activities,
products, or services."
efme
environmental
aspects
Decide if under
your control and
influence
dentify relate
environmental
impacts
ecide if th
impacts are
significant
To plan for and control its environmental impacts, an
organization must know what these impacts are. But
knowing what the impacts are is only part of the challenge
— you also should know where these impacts come
from. Stated another way, how does your organization
(i.e., your products, services and activities) interact with the
environment?
If your organization has undertaken pollution prevention
projects, you are probably familiar with this concept — that
is, you must know how and where a waste is generated in
order to minimize or eliminate it. And like pollution
prevention, the identification and management of
environmental aspects can (1) have positive impacts on the
bottom line and (2) provide significant environmental
improvements.
So, an EMS should include a procedure to identify and
assess environmental aspects that the organization:
• can control, and
• over which it can have an influence.
Your organization is not expected to manage issues
outside its sphere of influence or control. For example,
while your organization probably has control over how
much electricity it buys from a supplier, it likely does not
control or influence the way in which that electricity is
generated. Similarly, if your organization manufactures a
product that is subsequently incorporated into another
product (for example, a bumper that becomes part of an
automobile), your organization does not control the
environmental aspects of that "finished" product (the
automobile). Thus, your focus should be on the
environmental aspects of your products or services.
The relationship between aspects and impacts is often one
of cause and effect. The term "aspects" (see definition
above) is neutral, so keep in mind that your environmental
aspects can be either positive (such as making a product
out of recycled materials) or negative (such as discharging
toxic materials to a stream). Aspects may result from past
activities, such as spills.
Once you have identified the environmental aspects of your
products, activities, and services, you should determine
which aspects could have significant impacts on the
environment. Aspects that have one or more significant
impact should be considered significant environmental
aspects. These significant aspects should be considered
when you establish environmental objectives, define
operational controls and consider other actions, as
discussed later.
©2001 NSF
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A multi-step process can be used to make this evaluation.
Keep the resulting information up-to-date, so that potential
aspects of new products, services, and activities are
factored into your objectives and controls.
' US Postal Service Assesses \
Its Environmental Aspects
The US Postal Service examined
environmental aspects related to the
vehicles it operates, the chemicals it
uses to maintain equipment, the solid
wastes it generates, and the products
(stamps) that it sells.
"Products" are tangible
results of a process that
transforms inputs into
outputs (for example, cars
or computers). "Services"
also result from processes,
but are intangible in that you
cannot "hold" them (such as
dry cleaning or equipment
maintenance at a customer
site). "Activities" may relate
directly or indirectly to the
provision of products or
services to customers (such
as purchasing or product
design).
V
Milan Screw Products set up
an internal task group to
identify environmental
aspects. As part of this
process, external
stakeholders were identified
and interviewed to
understand their
environmental concerns.
These stakeholder concerns
were added to the list of
environmental aspects.
Hints:
• In identifying aspects and impacts, look beyond
activities covered by laws and regulations. But
because many of your aspects/impacts may be
addressed by legal requirements, your compliance
program might yield some valuable information. Permits,
audit reports, and monitoring records can be useful
inputs. Beyond regulated aspects, consider land,
energy, and natural resource use, for example.
• Once you have identified environmental aspects and
related significant impacts, use this information in setting
your objectives and targets. This does not mean that
you need to address all of your impacts at once.
There may be good reasons (such as cost, availability of
technology or scientific uncertainty) for addressing some
impacts now while deferring action on others. Keep in
mind that managing environmental aspects can have
positive impacts on the organization.
• Remember to look at services as well as products.
While the need to examine on-site operations might be
obvious, you also should consider the potential impacts
of what you might do "off-site" (such as servicing
equipment at customer sites). Similarly, the
environmental aspects of the products, vendors, and
contractors you use may be less obvious, but should still
be considered.
• Identifying significant environmental aspects is one of
the most critical steps in EMS implementation. It can be
one of the most challenging - as well as one of the
most rewarding. Decisions you make in this step can
affect many other system elements (such as, setting
objectives and targets, establishing operational controls
and defining monitoring needs). Careful planning of this
activity will pay dividends in later steps.
Getting Started
• To understand your environmental aspects, it helps to
understand the processes by which you generate
products and services. Flow charting your major
processes can help you understand the process inputs
and outputs as well as how materials are used. A sample
flow chart is provided in the Tool Kit (see Appendix C).
You might also want to consider the views of interested
parties (e.g., neighbors, civic groups, regulators, etc.) in
this process. Some organizations have found external
parties to be a good resource in identifying environmental
aspects.
©2001 NSF
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In evaluating your
environmental
aspects and impacts,
consider both normal
and abnormal (such
as start-up and
shutdown) operating
conditions.
Use visual tools. As a
starting point, some
organizations prepare
maps of their site and
building(s), along with
surrounding land uses.
The implementation
team uses these maps
to "audit" the site and
identify potential
environmental aspects.
Objectives & Targets
Training & Awareness
Communications
Operational Controls
Monitoring & Measurement
You can use many sources of information to help you
identify and assess your environmental aspects. For
starters, look at your permits, the regulations that apply
to your operations, EPCRA reports, Material Safety
Data Sheets and monitoring records. Trade
associations, regulatory agencies, customers and
suppliers also might provide useful information to
support the assessment
Your team should define the criteria that will be used to
determine significance. Such criteria often include the
types of impact; the magnitude, frequency and duration
of the impact; regulatory status, and other factors.
Consider the questions on the following page for
identifying and characterizing aspects and impacts.
Various approaches exist for evaluating environmental
aspects and impacts. Select one that can be readily
adapted for your use and that makes sense for your
organization. Examples of approaches for evaluating
environmental aspects and impacts can be found in the
Tool Kit (see Appendix A).
Once you've found a process that works for your
organization, describe the process in the form of a
written procedure. A sample procedure for performing
the assessment is provided in the Tool Kit.
You can start out with a simple process for identifying
aspects and impacts, then refine the process in the
future as needed. You also can identify and consider
more obvious environmental impacts or "low hanging
fruit" first, then enhance the assessment process to
consider more complex environmental impacts later. As
with any element of the EMS, there is virtue in
considering how your process for identifying aspects
and impacts might be improved over time. Ask yourself:
Is there additional information we should consider in this
process? Do we have the right people involved? Are
we using the results in a meaningful way?
Use the worksheet at the end of this section to capture
some of your ideas. Using this worksheet will give you
a "jump start" on implementing this EMS element.
©2001 NSF
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Identifying Aspects and Impacts: Some Questions to Consider:
Identifying Aspects
Which operations and activities interface with
the environment in a way that could result (or
has resulted) in environmental impacts?
What materials, energy sources and other
resources do we use in our work?
Do we have emissions to the air, water or
land?
Do we generate wastes, scrap or off-spec
materials? If so, does the treatment of
disposal of these materials have potential
environmental impacts?
Which characteristics or attributes of our
products or services could result in impact the
environment (through their intended use, end-
of-life management, etc.)?
Does our land or infrastructure (e.g.,
buildings) interact with the environment?
Which activities (for example, chemical
storage) might lead to accidental releases?
Evaluating Impacts
Are the impacts actual or potential?
Are the impacts beneficial or damaging to the
environment?
What is the magnitude or degree of these
impacts?
What is the freguency or likelihood of these
impacts?
What is the duration and geographic area of
these impacts?
Which parts of the environment might be
affected (e.g., air, water, land, flora, fauna)?
Is the impact regulated in some manner?
Have our interested parties expressed
concerns about these impacts?
The Link Between Aspects and Impacts (some examples from a real company)
Aspects
Emissions of volatile organic
compounds
Discharges to stream
Spills and leaks
Electricity use
Use of recycled paper
Potential Impacts
Increase in ground level ozone
Degradation of aquatic habitat and drinking
water supply
Soil and groundwater contamination
Air pollution, global warming
Conservation of natural resources
Air Emissions
• Solid and Hazardous Wastes
• Contamination of Land
Some Potential Environmental Aspect Categories:
• Water Discharges
• Energy Use
• Local Issues
(e.g. noise, odor, dust, traffic, etc.)
Raw Material and Resource Use
(water, energy, etc.)
Hazardous Material Storage and Handling
©2001 NSF
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Capture the Learning: Environmental Aspects Worksheet
Do we have an existing process for
identifying aspects and/or impacts?
If yes, does that process need to be
revised? In what way?
Who needs to be involved in this
process within our organization?
Should any outside parties be
involved?
When is the best time for us to
implement this process? Can it be
linked to an existing organizational
process (such as our budget, annual
planning or auditing cycles?)
What are some obvious
environmental aspects of our:
^ Operations and activities?
^ Products?
^ Services?
What sources of information can we
use to identify environmental aspects?
What sources of information can be
used to determine the environmental
impacts of these aspects?
What significance criteria might make
sense for our organization?
How will we keep this information up-
to-date?
Our next step on environmental
aspects is to ...
©2001 NSF
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Legal and Other Requirements
Setting the legal framework for your EMS
Legal requirements include:
• Federal requirements
• State and local requirements
• Standards in locations where
you sell products/services
• Permit conditions
Other requirements might
include (for example):
• Company-specific codes
• International Chamber of
Commerce (ICC) Charter
for Sustainable
Development
• American Chemistry
Council's (ACC)
Responsible Care
• American Petroleum
Institute's Strategies for
Today's Environmental
Partnership (API STEP)
• Other industry codes or
programs to which your
organization voluntarily
subscribes.
KEY STEPS
Identify
Requirements
Analyze Impacts
Communicate
Act
In order to comply with laws and regulations that apply to
your organization, you must first know what the rules
are and how they affect what you do. As discussed
earlier, compliance with legal requirements is one of the
"three pillars" upon which your environmental policy
should be based. The potential costs of non-compliance
(possible damage to the environment, revenue loss and
impact on public image, for example) can be very high.
Thus, an effective EMS should includes processes to:
• identify and communicate applicable legal and
other requirements, and:
• ensure that these requirements are factored into the
organization's management efforts.
New or revised legal requirements might require
modification of your environmental objectives or other
EMS elements. By anticipating new requirements and
making changes to your operations, you might avoid
some future compliance obligations and their costs.
Getting Started
Your EMS should include a procedure for identifying,
having access to and analyzing applicable legal and
other requirements. "Other requirements" might include
industry codes of practice or similar requirements to
which your organization might subscribe.
Identifying applicable regulations, interpreting them, and
determining their impacts on your operations can be a
time-consuming task. Fortunately, there are many
methods for obtaining information about applicable laws
or regulations. These methods include:
commercial services (with updates offered on-line, on
CD-ROM or in paper form);
regulatory agencies (federal, state and local);
trade groups / associations;
the Internet (see USEPA web site at www.epa.gov);
public libraries;
seminars and courses;
newsletters / magazines;
consultants and attorneys; and
customers, vendors and other companies.
Small business assistance programs exist in every state.
Under the Clean Air Amendments of 1990, each state
environmental regulatory agency has established
©2001 NSF
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For more information on EMS
and compliance, see "Improving
Environmental Performance and
Compliance: Ten Elements of
Effective Environmental
Management Systems" (see
Appendix F for details)
Environmental Policy
Objectives & Targets
Training & Awareness
Communication
Operational Controls
See Appendix A for information
on resources for tracking
environmental laws and
regulations.
technical and compliance assistance programs to help
companies comply with air quality rules. In some cases,
these programs have expanded into other environmental
"media", such as water and waste management. In
addition, National Compliance Assistance Centers can
provide compliance assistance for certain industry
sectors (see Appendix F for more information).
Once applicable requirements have been identified and
analyzed for potential impacts, communicate these
requirements (and plans for complying with them) to
employees, on-site contractors and others, as needed.
Communicating "other applicable requirements" (as well
as their impacts on the organization) is an important but
often overlooked step. Keep in mind that different people
may have different information needs.
As with many EMS elements, this is not a "one time"
activity. Since legal and other requirements change
over time, your process should ensure that you are
working with up-to-date information.
Resources to identify and track environmental laws and
regulations are described in the Tool Kit (Appendix A).
Commonly Applicable Federal Environmental Laws in the US
Clean Air Act (CAA)
[40 CFR Parts 50-99]
Clean Water Act (CWA)
[40 CFR Parts 100-145, 220-232, 410-471]
Federal Insecticide, Fungicide and
Rodenticide Act (FIFRA)
[40 CFR Parts 150-1 89]
Resource Conservation and Recovery
Act (RCRA)
[40 CFR Parts 240-299]
Toxic Substances Control Act (TSCA)
[40 CFR Parts 700-799]
Comprehensive Environmental
Response, Compensation and Liability
Act (CERCLA, also known as "Superfund")
[40 CFR Parts 300-311]
Emergency Planning and Community
Right-To-Know Act (EPCRA)
[40 CFR Parts 350-374]
Hazardous Materials Transportation Act
(HMTA) [49 CFR Parts 100-1 80]
Establishes ambient and source emission standards and permit
requirements for conventional and hazardous air pollutants.
Establishes ambient and point source effluent standards and
permit requirements for water pollutants, including sources that
discharge directly to a waterbody or to a public sewer system.
Establishes a program for Federal review of, registration and
control of pesticides.
Establishes regulations and permit requirements for hazardous
waste management. Also, creates standards for underground
storage tanks that hold oil or hazardous substances.
Regulates the use, development, manufacture, distribution and
disposal of chemicals. Certain chemicals (such as PCB's) are
subject to specific management standards.
Establishes a program for cleaning up contaminated waste sites
and establishes liability for clean-up costs. Also, provides
reporting requirements for releases of hazardous substances
Establishes a program (also known as the "Toxic Release
Inventory") to inform the public about releases of hazardous and
toxic chemicals. Reporting requirements apply to companies that
use, process or store specific chemicals over specified quantities.
Establishes standards for the safe transportation of hazardous
materials.
©2001 NSF
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Capture the Learning: Legal & Other Requirements Worksheet
Do we have an existing process for
identifying applicable legal and other
requirements?
If yes, does that process need to be
revised? In what way?
Who needs to be involved in this
process within our organization? What
should their responsibilities be?
What sources of information do we
use to identify applicable legal and
other requirements?
Are these sources adequate and
effective? How often do we review
these sources for possible changes?
How do we ensure that we have
access to legal and other
requirements? (List any methods
used, such as on-site library, use of
web sites, commercial services, etc.)
How do we communicate information
on legal and other requirements to
people within the organization who
need such information?
Who is responsible for analyzing new
or modified legal requirements to
determine how we might be affected?
How will we keep information on legal
and other requirements up-to-date?
Our next step on legal and other
requirements is to ...
©2001 NSF
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Objectives and Targets
Establishing goals for environmental management
Environmental Objective:
"Overall environmental
goal, arising from the
environmental policy,
that an organization sets
itself to achieve, and
which is quantified
where practicable."
ISO 14001
Objectives and targets help an organization translate
purpose into action. These environmental goals
should be factored into your strategic plans. This can
facilitate the integration of environmental
management with your organization's other
management processes.
You determine what objectives and targets are
appropriate for your organization. These goals can
be applied organization-wide or to individual units,
departments or functions -- depending on where the
implementing actions will be needed.
In setting objectives, keep in mind your
environmental policy, including its three "pillars."
You should also consider your significant
environmental aspects, applicable legal and other
requirements, the views of interested parties, your
technological options, and financial, operational,
and other organizational considerations.
Environmental Target:
"Detailed performance
requirement, quantified
where practicable,
applicable to the
organization or parts
thereof, that arises from
the environmental
objectives and that
needs to be set and met
in order to achieve
those objectives?
Figure 6
Policy
Environmental
Aspects
Legal / Other
Requirements
Views of
Interested Parties
[ Technology 1 I Finance 1 [Operations]
There are no "standard" environmental objectives that
make sense for all organizations. Your objectives and
targets should reflect what your organization does,
how well it is performing and what it wants to achieve.
©2001 NSF
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Factors to consider
in setting objectives
and targets
0 ability to control
0 ability to track /
measure
0 cosf to track /
measure
progress reporting
links to policy
commitments
J
A sample process tool and
procedure for setting
objectives and targets are
included in the Tool Kit
(Appendix A).
• Environmental Policy
• Environmental Aspects
• Legal & Other
Requirements
• Structure &
Responsibility
• Operational Control
• Monitoring &
Measurement
• Management Review
Hints:
• Setting objectives and targets should involve people in
the relevant functional area(s). These people should be
well positioned to establish, plan for, and achieve these
goals. Involving people helps to build commitment.
• Get top management buy-in for your objectives. This
should help to ensure that adequate resources are applied
and that the objectives are integrated with other
organizational goals.
• In communicating objectives to employees, try to link
the objectives to the actual environmental
improvements being sought. This should give people
something tangible to work towards.
• Objectives should be consistent with your overall mission
and plan and the key commitments established in your
policy (pollution prevention, continual improvement, and
compliance). Targets should be sufficiently clear to
answer the question: "Did we achieve our objectives?"
• Be flexible in your objectives. Define a desired result,
then let the people responsible determine how to achieve
the result.
• Objectives can be established to maintain current levels
of performance as well as to improve performance. For
some environmental aspects you might have both
maintenance and improvement objectives.
• Communicate your progress in achieving objectives and
targets across the organization. Consider a regular report
on this progress at staff meetings.
• To obtain the views of interested parties, consider
holding an open house or establishing a focus group with
people in the community. These activities can have other
payoffs as well.
• How many objectives and targets should an organization
have? Various EMS implementation projects for small and
medium-sized organizations indicate that it is best to start
with a limited number of objectives (say, three to five) and
then expand the list over time. Keep your objectives
simple initially, gain some early successes, and then build
on them.
• Make sure your objectives and targets are realistic.
Determine how you will measure progress towards
achieving them.
• Keep in mind that your suppliers (of service or materials)
can help you in meeting your objectives and targets (e.g.,
by providing more "environmentally friendly" products).
©2001 NSF
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Comparing Objectives and Targets - Some Examples
Objectives
Reduce energy usage
Reduce usage of hazardous chemicals
Improve employee awareness of
environmental issues
Improve compliance with wastewater
discharge permit limits
Targets
• Reduce electricity use by 10% in 2001
• Reduce natural gas use by 15% in 2001
• Eliminate use of CFCs by 2002
• Reduce use of high-VOC paints by 25%
• Hold monthly awareness training courses
• Train 100% of employees by end of year
• Zero permit limit violations by the end of
2001
POLLUTION PREVENTION
Pfizer Global Research & Development (formerly Warner-Lambert Parke-Davis) has
a pollution prevention program that shows that improving the environment and the
bottom line can go hand-in-hand. For example:
By replacing chillers and redesigning chilling systems to be more efficient, the
company has realized $250,000 in energy savings. Also, because the company is
more energy efficient, it has reduced emissions from its local power supplier.
By redesigning and modifying its dust collection system, the company replaced its
100-hp motors with 40 hp motors, without compromising the effectiveness of the
dust collection system. This project lowered the company's operating costs and
reduced emissions at the local power plant.
POLLUTION PREVENTION
Some Motorola manufacturing sites have reduced their water consumption and
wastewater discharges by greater than 95% by installing ion exchange technology
and employing better operating techniques. These changes have lowered usage of
water treatment chemicals and have resulted in considerable cost savings.
EPA's Performance Track program requires organizations to consider the
following factors in setting measurable objectives and targets:
• Prevention of noncompliance,
• Prevention of pollution at the source
• Minimization of cross-media pollutant transfers, and
• Environmental performance improvement.
Participating organizations also must show continued improvement in specific
environmental categories, such as energy use, water discharges, or waste
generation, among others.
See Appendix B for more information.
©2001 NSF
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Capture the Learning: Objectives and Targets Worksheet
Do we have an existing process for
setting and reviewing environmental
objectives and targets?
If so, does that process need to be
revised? In whatway(s)?
Who needs to be involved in this
process within our organization?
Should any outside parties be
involved?
When is the best time for us to
implement this process? Can it be
linked to another existing
organizational process (like our annual
or strategic planning process?)
What are our existing environmental
goals? How were these developed?
Who was involved?
What factors were considered in
setting these goals?
Who are our interested parties?
How do we obtain their views?
How effective has our process been?
How can we effectively and efficiently
track our progress and communicate
the results?
Who is in the best position to do this?
Our next step on environmental
objectives and targets is to ...
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Environmental Management Program(s)
A road map for achieving environmental goals
Objectives and
Targets
Established
T
Environmental
Management Program
Defined
T
Monitoring and
Measurement
V
At St. Joseph's Mercy
Hospital (in Michigan),
mercury was in widespread
use. The Hospital had a
contract with a professional
environmental response
company to clean up and
dispose of any discarded
equipment and waste that
resulted from mercury spills.
Mercury was identified as
an environmental aspect
during EMS implementation,
leading to the development
of a Mercury Reduction
Initiative. This Initiative is
expected to save the
Hospital as much as
$20,000 per year.
So far, this Guide has focused on the foundations of an
EMS - the planning elements. An important part of this
planning effort is defining what your organization intends to
achieve in the environmental area. To achieve your
objectives and targets, you need an action plan - also
known as an environmental management program.
Your environmental management program should be linked
directly to your objectives and targets — that is, the
program should describe how the organization will translate
its goals and policy commitments into concrete actions
so that environmental objectives and targets are achieved.
To ensure its effectiveness, your environmental
management program should define:
• the responsibilities for achieving goals (who will do it?)
• the means for achieving goals (how will they do it?)
• the time frame for achieving those goals (when?)
Keep in mind that your program should be a dynamic one.
For example, consider modifying your program when:
• objectives and targets are modified or added;
• relevant legal requirements are introduced or changed;
• substantial progress in achieving your objectives and
targets has been made (or has not been made); or
• your products, services, processes, or facilities change
or other issues arise.
Your action plan need not be compiled into a single
document. A "road map" to several action plans is an
acceptable alternative, as long as the key responsibilities,
tactical steps, resource needs and schedules are defined
adequately in these other documents.
This program should not be developed in a vacuum — it
should be coordinated or integrated with other
organizational plans, strategies, and budgets. For
example, if you are planning for a major expansion in one of
your service operations, then it makes sense to look at the
possible environmental issues associated with this
operational expansion at the same time.
Hints:
• Build on the plans and programs you have now for
compliance, health & safety or quality management.
• Involve your employees early in establishing and
carrying out the program.
• Clearly communicate the expectations and
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"Before, we focused on
compliance issues without
the benefit of an EMS.
Now, we have a strategic
plan in place to look beyond
legal requirements and save
money. It makes my job
easier when I can prove my
department does not have
to be a cost center."
Charlie Saunders, EMS Manager,
Pfizer Global Research &
Development
Objectives & Targets
Structure &
Responsibility
Communication
Operational Control
Monitoring &
Measurement
responsibilities defined in the program to those who need
to know.
• In some cases, your environmental management
program may encompass a number of existing
operating procedures or work instructions for
particular operations or activities. In other cases, new
operating procedures or work instructions might be
required to implement the program.
• Re-evaluate your action plan when you are considering
changes to your products, processes, facilities or
materials. Make this re-evaluation part of your change
management process.
• Keep it simple (see sample tool, below) and focus on
continual improvement of the program overtime.
• There may be real opportunities here! Coordinating
your environmental program with your overall plans and
strategies may position your organization to exploit some
significant cost-saving opportunities.
Figure 7: Environmental Management Program (Sample Form)
A full-size copy of
this form and
another sample
form are provided in
the Tool Kit (see
Appendix A).
Objective / Tar
Action
Items
Priority
Responsibilities
aet #1 :
Schedule
Resources
Needed
Comments
POLLUTION PREVENTION
March Coatings operated a de-ionization unit to purify water for its coating process.
While effective, the unit required 39,000 pounds of hydrochloric acid to operate.
Concerns about potential spills and worker health & safety impacts led the company
to replace the de-ionizer with a reverse osmosis unit, which completely eliminated the
use of hydrochloric acid.
©2001 NSF
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Capture the Learning: Environmental Management Programs Worksheet
Do we have an existing process for
establishing environmental
management programs?
If yes, does that process need to be
revised? In what way?
What environmental management
programs do we have in place now?
What is the basis for our
environmental management programs
(for example, do they consider our
environmental objectives, our
environmental policy commitments and
other organizational priorities)?
Who needs to be involved in the
design and implementation of these
programs within our organization?
When is the best time for us to
establish and review such programs?
Can this effort be linked to an existing
organization process (such as our
budget, planning or auditing cycles?)
How do we ensure that changes to
products, processes, equipment and
infrastructure are considered in our
programs?
How will we otherwise keep our
programs up-to-date?
Our next step on environmental
management programs is to ...
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Structure and Responsibility
Aligning your resources to succeed
"Resources include human
resources and specialized
skills, technology, and
financial resources."
- ISO 14001
Characteristics of a
good management
representative:
• Knowledgeable
• Assertive
• Independent
For an EMS to be effective, roles and responsibilities
must be clearly defined and communicated. The
commitment of all employees is needed for an EMS to
live up to its full potential.
Top management plays a key role by providing
resources needed to implement the EMS. This is one of
the most important jobs of top management (see "Finding
Resources" on next page). In some organizations, "top
management" might be a single individual, while in others
it might be a group of people (such as a board of
directors).
An effective management system needs an advocate.
Thus, top management should appoint a management
representative. This representative (1) ensures that
the EMS is established and implemented; (2) reports on
its performance over time; and (3) works with others to
modify the EMS as needed. The management
representative can be the same person who serves as
the project champion (as discussed in Section 3), but
this is not mandatory. A business owner, plant or shop
manager, or any number of other people might serve as
an effective EMS management representative.
/ More organizational \
advantages of small business:
0 shorter lines of
communication
0 less complex organization
0 limited delegation
0 simpler access to
management
Getting Started
Look at:
0 Program Scope
0 Environmental
Aspects
0 Objectives
0 Previous audits
0 Other systems
Small and medium-sized organizations may have
advantages over larger ones in structuring their
resources for environmental management. Because
personnel and other resources are generally more
limited in smaller organizations, people often "wear more
than one hat" and have experience in performing
multiple functions. An individual responsible for
environmental management in a smaller organization
also might be responsible for quality, health & safety,
facilities, or other functions. In such cases, integrating
environmental responsibilities with other functions can
be greatly simplified.
Getting Started:
The following questions can help you determine the right
organizational structure for environmental management:
• What is the scope of our environmental
management program? What capabilities do we
need? Who will help to make the EMS effective?
What training or other resources do we need?
• What are pur significant environmental aspects
and compliance needs? What operations / activities
need to be controlled? Who needs to be involved to
ensure that controls are implemented?
©2001 NSF
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Consider integrating EMS
with your existing:
0 information systems
0 purchasing controls
0 quality procedures
0 work instructions
0 training programs
0 communication efforts
0 reporting systems
0 recruitment, appraisal
and disciplinary
processes
See Appendix C for information
on process mapping
What are the results of previous audits or other
assessments? What does this information tell us
about the effectiveness of our organizational structure
and how it might be improved?
• What are the current responsibilities for
environmental management? How can we
enhance ownership of environmental management
across the organization? How can other functions
support the EMS? (See next page.)
• What are our objectives and targets, including
those related to compliance and pollution
prevention? How will the organizational structure
help up achieve these goals?
• What quality management and / or other existing
management systems exist? What roles and
responsibilities exist in these management systems?
Do opportunities for system integration exist?
Consider flow charting your existing environmental
management activities. This can help you understand
how these processes work and the final product can be
a great communication and training tool. Flow charts
also can be useful to look at processes such as
chemical purchasing and distribution, employee
training, and preventive maintenance, among others.
Appendix C provides information on process mapping.
Hints:
Appendix A provides a sample
responsibility matrix
More information on resources
is found in Appendix F of this
Guide
Objectives & Targets
Training & Awareness
Communication
Management Review
Build flexibility into your organizational structure.
Recognize that environmental (and other)
management needs will change over time.
Communicate to people what their roles are (as well
as the roles of others). One tool for communicating
these responsibilities is a responsibility matrix.
(See the Tool Kit in Appendix A for an example of
such a matrix.)
Finding Resources
In most cases, developing and maintaining an EMS will
not require large capital outlays. What an EMS will
require is time. Many smaller organizations find they
can make effective use of interns or temporary
employees to perform potentially time-consuming EMS
development tasks (such as collecting data, drafting
procedures, etc.). This allows in-house personnel to
focus on more complex EMS development tasks. Also,
look for areas where environmental management can
support other organizational functions (and vice-versa —
see next page).
©2001 NSF
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How Various Functions Can Support Your EMS
Functions
Purchasing
Human Resources
Maintenance
Finance
Engineering
Top Management
Quality
Line Workers
How They Can Help (Possible Roles)
• Develop and implement controls for chemical / other material
purchases
• Define competency requirements and job descriptions for
various EMS roles
• Train temporary workers and contractors; maintain training
records
• Integrate environmental management into reward, discipline
and appraisal systems
• Implement preventive maintenance program for key
equipment
• Support identification of environmental aspects
• Track data on environmental-related costs (such as
resource, material and energy costs, waste disposal costs,
etc.)
• Prepare budgets for environmental management program
• Evaluate economic feasibility of environmental projects
• Consider environmental impacts of new or modified products
and processes
• Identify pollution prevention opportunities
• Communicate importance of EMS throughout organization
• Provide necessary resources
• Track and review EMS performance
• Support document control, records management and
employee training efforts
• Support integration of environmental and quality
management systems
• Provide first-hand knowledge of environmental aspects of
their operations
• Support training for new employees
For EPA's Performance Track program, organizations must provide
appropriate incentives for personnel to meet EMS requirements.
See Appendix B for more information.
See the EPA/NSF project report, Implementing an EMS in Community-Based
Organizations for more ideas on how organizations with limited resources can
implement an EMS. Download the report free of charge at www.nsf-isr.org or
www.epa.gov.
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Capture the Learning: Structure & Responsibility Worksheet
How do we define roles,
responsibilities and authorities for
environmental management now?
Is this process effective?
Who is / should be our EMS
Management Representative? Does
this individual have the necessary
authority to carry out the
responsibilities of this job?
Are our key roles and responsibilities
for environmental management
documented in some manner? If so,
how (e.g., job descriptions,
organizational charts, responsibility
matrix, etc.)?
How are EMS roles and responsibilities
communicated within our
organization?
How do we ensure that adequate
resources have been allocated for
environmental management? How is
this process integrated with our overall
budgeting process?
How are environmental expenditures
tracked?
How will we keep this information up-
to-date?
Our next step on structure and
responsibility is to ...
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Training, Awareness and Competency
Building internal capabilities
Implementing and
maintaining an EMS
involves everyone
Reasons for
Training:
motivation
awareness
commitment
skills/
capability
compliance
performance
An example of a trainin log
is provided in the Tool Kit
(see Appendix A)
Environmental Aspects
Legal/Other
Requirements
Structure &
Responsibility
Operational Control
Records
Here are two excellent reasons for training employees
about environmental management and your EMS:
• Every employee can have potential impacts on the
environment, and
• Any employee can have good ideas about how to
improve environmental management efforts.
Each person and function within your organization can
play a role in environmental management. For this
reason, your training program should cast a wide net.
Every employee and manager should be aware of the
environmental policy, the significant environmental
impacts of their work activities, key EMS roles and
responsibilities, procedures that apply to their work and
the importance of conformance with EMS requirements.
Employees also should understand the potential
consequences of not following EMS requirements
(such as spill, releases, fines or other penalties).
All personnel should receive appropriate training. Such
training should be tailored to the different needs of
various levels or functions in the organization.
However, training is just one element of establishing
competence, which is typically based on a combination
of education, training, and experience. For certain jobs
(particularly tasks that can cause significant
environmental impacts), you should establish criteria to
measure the competence of individuals performing
those tasks.
Getting Started:
• A critical first step in developing your training
program is assessing your training and skill
needs. In assessing these needs, you should
consider both general and specific needs (e.g.,
"What EMS procedures affect Joe's daily work and
what happens if they aren't followed?" "What
environmental impacts might Joe's work cause?"
"What broader understanding of environmental
issues and our EMS does Joe need?")
• Look at the training you conduct already, for
compliance with environmental and health and
safety regulations and other purposes. You may
find that your existing training efforts go a long way
towards satisfying the requirements for the EMS.
Competence might be established on the basis of
regulatory-required training, in some instances.
©2001 NSF
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Milan Screw Products found
that it could provide a great
deal of its training during
"brown bag" lunches, during
which employees bring their
lunches, participate in a
training session, and remain
"on the clock" for the lunch
period.
Key Steps in Developing a Training Program
Step 1: Assess training needs & requirements
Step 2: Define training objectives
Step 3: Select suitable methods and materials
Step 4: Prepare training plan (who, what, when,
where, how)
Step 5: Conduct training
Step 6: Track training (and maintain records)
Step 7: Evaluate training effectiveness
Step 8: Improve training program (as needed)
Training Resources:
internal trainers / experts
consultants
community colleges
vendors /suppliers
customers
technical / trade /
business associations
self-study or study
groups
training consortia
(teaming with other local
companies)
computer-based training
Hints:
• Because of the level of effort involved in training, this
is one EMS element where you don't want to start
from scratch. Many employees may be qualified on
the basis of their experience and previous training.
(Keep in mind that all training should be
documented.) Since some employees might require
training on how to operate equipment safely, on-the-
job training certainly can play an important role.
Computer-based training also may be an option,
especially for employees who spend much of their
time in the field.
• Plan and schedule training opportunities carefully.
While finding enough time for training can be a
challenge, you might find creative ways to make
"more time" (see "tip", above left). Use safety
meetings, staff meetings, and tool box meetings to
provide training and reinforce key messages.
• New employees can pose a significant training
challenge. Consider developing an EMS training
package for new employee orientation. Even
better, videotape one of your current EMS training
courses to show to new employees.
• In reviewing training needs, don't forget to consider
the qualifications and training needs of your
environmental manager and your trainers.
Professional certification programs may be
appropriate for certain functions.
• If the organization uses temporary or contract
workers, assess their training needs as well.
• Factor EMS skills requirements into your recruiting,
selection, and new employee orientation
processes.
©2001 NSF
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When Training
Might Be Needed:
New employee is hired
Employee is transferred to a
new job
Individual doesn't follow
procedure / instruction
Procedures are changed
New process, material or
equipment is introduces
Company changes objectives
and/or targets
New regulation affects
organization's activities
Job performance must be
improved
Establishing competency for various tasks can be a
challenge. Competency criteria for jobs that can
cause significant environmental impacts should be as
objective as possible.
One informal method for assessing competency is to
question employees in critical functions as to how
they perform various aspects of their jobs (e.g.,
"Show me how you..."). Use responses to determine
whether they have the requisite skills and
understanding to perform the job safely. This can
help you gauge whether additional training might be
needed.
Consider visual "job aids" to supplement training or
help establish competence. Examples of job aids
include written or pictorial job procedures, decision
tables or flow charts posted at the workstation.
Finally, some organizations have been successful in
blending environmental awareness training into
existing safety training programs. This can be
particularly effective where safety training is
mandated (i.e., by regulation or other organizational
requirements) and has strong management support.
A Few Thoughts About Adult Learning
Adults need the opportunity to integrate new ideas with what they already know.
Information that conflicts sharply with existing beliefs or has little conceptual
overlap with what is already known is acquired more slowly.
Adults prefer self-directed learning and want to have a hand in shaping the
training program.
Adults have expectations. It is important to clarify these up-front.
Adults prefer active participation to straight lecture.
- Adapted from "Adults Learning: What Do We Know For Sure"
(Training Magazine, June 1995)
For EPA's Performance Track, organizations must provide specific training for
employees whose responsibilities relate directly to achieving objectives and targets
and legal compliance.
See Appendix B for more information.
©2001 NSF
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Capture the Learning: Training, Awareness & Competence Worksheet
Do we have an existing process for
environmental training?
If so, does that process need to be
revised? In whatway(s)?
What types of training do we provide
now (e.g., new employee orientation,
contractor training, safety training)?
How would EMS-related training fit with
our existing training program?
Who is responsible for training
now? Who else might need to be
involved within our organization?
How do we determine training needs
now? (List methods used) Are these
processes effective?
Who is responsible for ensuring that
employees receive appropriate
training? How do we track training to
ensure we are on target?
How do we evaluate training
effectiveness? (List methods used,
such as course evaluation, post-
training testing, behavior observation)
How do we establish competency,
where needed? (List methods used,
such as professional certifications)
What are the key job functions and
activities where we need to ensure
environmental competency?
Our next step on training,
awareness & competence is to
©2001 NSF
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Communications
Maintaining the flow of information
Consider
communication
strategies for:
0 neighbors
0 community groups
0 other interest groups
0 local officials
0 regulatory agencies
emergency
responders
Pfizer Global Research &
Development (formerly
Warner-Lambert Parke-
Davis) has hosted local
community leaders, state
agencies, and federal
agencies, to share its
environmental activities and
programs and to obtain
feedback.
The importance of employee involvement in developing
and implementing your EMS has been discussed earlier.
In addition, there may be parties with an interest in your
environmental performance and management efforts
outside the organization. Effective environmental
management requires effective communications, both
internally and externally.
Effective communications will help you:
• motivate your workforce;
• gain acceptance for your plans and efforts;
• explain your environmental policy and EMS and how
they relate to the overall organizational vision;
• ensure understanding of roles and expectations;
• demonstrate management commitment;
• monitor and evaluate performance; and,
• identify potential system improvements.
Effective internal communication requires mechanisms for
information to flow top-down, bottom-up and across
functional lines. Since employees are on the "front lines,"
they can be an excellent source of information, issues,
concerns and ideas.
Proactive, two way communication with external parties is
also important for an effective environmental management
system. Taking steps to obtain the views of these
stakeholders, which can include neighbors, customers,
community groups, and regulators, will help you better
understand how your organization is perceived by others.
These stakeholders can also bring important
environmental issues to your attention that should be
addressed in your EMS. Your should also condiser ways
to get specific advice from these stakeholders when
developing critical elements of your EMS such as setting
objectives and targets. Involving these parties, however,
does not mean you should cede control of your EMS to
them, but rather use their input to make your EMS
stronger and more responsive to community concerns.
Doing so will usually provide long-term benefits to your
organization.
Thus, an effective EMS should include procedures for:
• communicating internally (between levels and
functions within the organization), and
• soliciting, receiving, documenting and responding to
external communications.
©2001 NSF
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Milan Screw Products' staff
interviewed neighbors,
customers, suppliers, and
employees' family members to
obtain the views of external
parties.
Getting Started:
The first step in designing a communications program is
determining your key audiences. Make a list of internal
and external audiences.
Once you have identified the audiences, determine what
you need to communicate to them. (What do they need to
know about your products, operations or management
efforts? What are their concerns?)
A sample procedure for
external communication is
provided in the Tool Kit (see
Appendix A)
Next, decide how you can best reach them. Appropriate
communication methods might vary from audience to
audience. Start by looking at your existing methods for
communicating, both internally and externally. These
might include:
Environmental Policy
Environmental
Aspects
Objectives & Targets
Structure &
Responsibility
Monitoring &
Measurement
Management Review
Internal Methods
• newsletters
• intranet
• staff meetings
• employee meetings
• bulletin boards
• brown bag lunches
• training
External Methods
• open houses
• focus or advisory groups
• web site or e-mail list
• press releases
• annual reports
• advertising
• informal discussions
Hints:
• Determine how proactive your external communications strategy
should be. Select an approach that fits your organization's
culture and strategy. Consider, for example, whether reporting
on environmental performance and progress might give you a
competitive edge.
• While a proactive external communications program may require
some resources, many organizations find that a proactive
communication strategy can be beneficial. Weigh the costs and
benefits for yourself, but keep in mind that you might have many
interested audiences.
• In communicating with employees, it is helpful to explain not only
what they need to do but also why they need to do it. For
example, when describing a requirement based on a regulation,
explain the purpose behind the rule and why it is important. Also,
make a clear connection between the requirement and how it
applies to each person's job.
• Keep the message simple, clear, concise, and accurate.
• Managing responses to external inquiries does not have to be
burdensome. Use a simple method, such as stapling an inquiry
to its written response and then filing them together. The key is
to be able to demonstrate that the organization has a process for
gathering and responding to external inquiries.
©2001 NSF
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** POLLUTION PREVENTION **
and Public Involvement
Motorola has conducted Household Waste Electronics Recycling Days for local residents.
Working in collaboration with local solid waste authorities, the Company has collected for
recycle a variety of home electronic and entertainment equipment, small appliances and other
products. At one of these events, over 21 tons of materials were collected and over 95% of
these materials were recycled.
For EPA's Performance Track, organizations must commit to public outreach and
performance reporting. Specifically, participating organizations must prepare an
annual report on their EMS, a summary of progress on performance commitments,
and of their public outreach activities.
See Appendix B for more information.
>\ /^
== The community as part of the solution....
In an effort to involve stakeholders in the EMS process the Town of Londonderry, NH and
the City of Lowell, MA engaged residents to collect information pertaining to environmental
issues that affect their communities. For example, the Town of Londonderry, NH in
conjunction with its household hazardous waste collection day, asked residents to complete
a survey to prioritize community related environmental issues. The residents identified the
fast pace at which the small community is growing as their top-priority issue. The City of
Lowell, MA's wastewater treatment plant asked local residents to assist with efforts to
address the plant's odor issues. A number of residents throughout the surrounding area
recorded weather information on days the odor was prevalent. This information identified
odor patterns which would aid the City's efforts to identify a solution to this problem.
©2001 NSF 45
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Capture the Learning: Communications Worksheet
Who are our key external
stakeholders?
How were these stakeholders
identified?
With regard to our organization, what
are the key concerns of these
stakeholders?
How do we know this?
What community outreach efforts
are we making now (or have we made
in the recent past)?
How successful have these efforts
been?
What methods do we use for external
communications? Which appear to be
the most effective?
Who has primary responsibility for
external communications?
How do we gather and analyze
information to be communicated?
Who has responsibility for this?
How do we communicate internally
(as well as with our suppliers and
contractors)? What processes do we
have to respond to internal inquiries,
concerns and suggestions?
How effective are these methods?
Our next step on communication
is to ...
©2001 NSF
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EMS Documentation
Describing the EMS and how the pieces fit together
' Rule of thumb:
Try to keep the EMS
description
document (or
manual) to no more
than one page per
EMS element
Easy to read and understand
equals
easy to implement
To ensure that your EMS is well understood and operating
as designed, you must provide adequate information to the
people doing the work. There also may be external parties
that want to understand how your EMS is designed and
implemented, such as customers, regulators, lending
institutions, registrars and the public. For these reasons,
the various processes that make up your EMS should be
documented.
The EMS Manual (or description document)
A "road map" or description that summarizes how the
pieces of the EMS fit together can be a very useful tool.
This roadmap generally takes the form of an EMS manual.
An EMS manual is a series of explanations of the
processes your organization implements to conform to the
EMS criteria (such as the elements discussed in the
Guide). While you don't need to maintain a single
"manual" that contains all of your EMS documentation, you
should maintain a summary of the EMS that:
• describes the system's core elements (and how the
elements relate to each other), and
• provides direction to related documentation.
Figure 8:
Hierarchy of EMS
Documentation
EMS Manual
Procedures
Forms, Drawings, etc.
Other EMS Documentation
In addition to the EMS manual, your organization should
maintain other documentation of its EMS.
First, you should document the processes used to meet
the EMS criteria. (For example, "How do we identify
environmental aspects?" "How do we implement
corrective actions?") This documentation generally takes
the form of system procedures. In addition, you might
maintain area-or activity-specific documentation (such as
work instructions) that instructs employees on how to carry
out certain operations or activities.
EMS documentation is related to (but not the same as)
EMS records. EMS documentation describes what
your system consists of (i.e., what you do and how you do
it), while EMS records demonstrate that you are doing
what the documentation said you would do. Document
control and records management are discussed later in
this Guide.
One way to think about your EMS documentation is to use
the figure shown at left, which also can be applied to
quality or other management system documents.
©2001 NSF
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V
Use flow charts or other
graphics where they help
explain the linkages from one
system element to another
Environmental Policy
Environmental
Management
Programs
Document Control
Operational Control
You can maintain EMS documentation either on paper or
electronically. There may be some advantages to
maintaining documents electronically, such as ease of
updating, controlling access, and ensuring that all readers
are using the most up-to-date versions of documents.
Hints:
• Keep EMS documentation simple. Choose a format
that works best for your organization. Your manual
does not need to describe every detail of your EMS.
Instead, the manual can provide references to other
documents or procedures.
• Use the results of your preliminary assessment to
prepare your EMS documentation. In the course of
conducting this assessment, you should have collected
or prepared useful material on how your organization
satisfies the selected EMS criteria. The box below
illustrates what constitutes EMS documentation.
• The usefulness of your EMS manual can be improved
by including the organization's mission statement, vision
or guiding principles (if these exist). These will improve
understanding of the organization and how the EMS
supports its overall goals.
• An EMS manual can be a useful tool for explaining your
EMS to new employees, customers and others. A
sample outline for an EMS manual is provided in the
Tool Kit (see Appendix A).
• EMS documentation should be updated as needed,
based on any system improvements you put in place.
However, if you put too much detail in an EMS manual,
you might need to update the manual frequently (see
first hint, above).
What Constitutes EMS Documentation? Consider the following:
your environmental policy
your organizational structure and key responsibilities
a description or summary of how your organization satisfies EMS requirements
(e.g., "How do we identify environmental aspects?". "How do we control
documents?" How do we comply with legal requirements?")
system-level procedures (e.g., procedure for corrective action)
activity- or process-specific procedures / work instructions
other EMS-related documents (such as emergency response plans, training
plans, etc.)
©2001 NSF
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Capture the Learning: EMS Documentation Worksheet
Do we have existing documentation
of our EMS?
If yes, how is this EMS documentation
maintained (electronically? In paper
form?)
Who is responsible for maintaining
EMS documentation within our
organization?
Do we have an EMS manual or other
summary document that describes the
key elements of the EMS?
If so, does this document describe the
linkages among system elements?
What does our EMS documentation
consist of? (List components such as
environmental policy, EMS manual,
activity-level procedures or work
instructions, emergency plans, etc.)
Is our EMS documentation integrated
with other organizational
documentation (such as human
resource plans or quality procedures)?
If so, how do we ensure proper
coordination between environmental
and these other functions?
How will we keep our EMS
documentation up-to-date?
Our next step on EMS
documentation is to ...
©2001 NSF
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Document Control
Ensuring that everyone works with the right tools
Suggested elements
of document control
0 issue / revision date
0 effective date
0 approval
(i.e., signature)
0 revision number
0 document number
(or other identifier
0 copy number
0 cross references
oe Document control
should address:
Preparation
Issuance / distribution
Revision
Periodic review
Disposition of obsolete
documents
People in your organization probably use various
documents (procedures, work instructions, forms,
drawings and the like) as they perform their duties. To
ensure that personnel are consistently performing their
jobs in the right way, the organization must provide them
with the proper tools. In the context of an EMS, the "tools"
needed are correct and up-to-date procedures,
instructions and other documents. Without a mechanism
to manage these EMS documents, the organization cannot
be sure that people are working with the right tools.
To ensure that everyone is working with the proper EMS
documents, your organization should have a procedure
that describes how such documents are controlled.
Implementation of this procedure should ensure that:
• EMS documents can be located (we know where to
find them),
• they are periodically reviewed (we check to make sure
they are still valid),
• current versions are available where needed (we make
sure the right people have access to them), and
• obsolete documents are removed (people don't use the
wrong documents by mistake).
Your procedure should designate responsibility and
authority for preparing documents, making changes to
them and keeping them up-to-date. In other words, you
need to make it clear who can actually generate and
change documents and the process for doing so.
' Key Questions:
Is everyone working with
the same set of
documents?
Do people who need
access have access?
Getting Started:
• EMS document control requirements are almost a
mirror image of the ISO 9001 requirements.
Organizations that have or are developing an ISO 9001
management system can enjoy some advantages here.
• Even if your organization doesn't have an ISO 9001
system, you might be better off than you think. Your
organization probably has document controls in place
for other purposes (such as finance, human resources
or purchasing). Assess how well these controls work
and if they can be adapted for your EMS.
©2001 NSF
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EMS Documentation
Operational Control
Records
The Tool Kit contains a sample
index of EMS-controlled
documents (see Appendix A).
Hints:
• Don't make your procedure more complicated than it
needs to be. While larger organizations often have
complex processes for document control, smaller
organizations can use simpler processes.
• Limiting distribution can make the job easier. Cpuld
everyone have access to one or a few copies?
Determine how many copies you really need and
where they should be maintained for ease of access.
• If the people that need access to documents are
connected to a local area network or have access to
the organization's internal web site, consider using a
paperless system. Such systems can facilitate control
and revision of documents considerably. There also
are a number of commercial software packages that
can simplify the document control effort.
• Prepare a document control index that shows all of
your EMS documents and the history of their revision.
Include this index in your manual. Also, if multiple
paper copies of documents are available at the facility,
prepare a distribution list, showing who has each copy
and where the copies are located.
• As your procedures or other documents are revised,
highlight the changes (by underlining, boldface, etc.).
This will make it easier for readers to find the changes.
What EMS documents should be controlled?
Consider the following:
Environmental policy
Objectives and targets
Roles, responsibilities and authorities
EMS description document ("manual")
System-level procedures
Process- or activity-level procedures / work instructions
Related plans (such as emergency response plans)
©2001 NSF
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Capture the Learning: Document Control Worksheet
Do we have an existing process for
controlling EMS documents?
If yes, does that process need to be
revised? In what way?
Who needs to be involved in this
process within our organization?
Who needs access to controlled
copies of EMS documents? How do
we ensure that they have access?
How do we ensure that EMS
documents are periodically reviewed
and updated as necessary?
Who has authority to generate new
documents or modify existing ones?
How is this process managed?
How are users alerted to the
existence of new EMS documents or
revisions to existing ones?
How do we ensure that obsolete
documents are not used?
Is our EMS document control process
integrated with other organizational
functions (such as quality)?
If so, how do we ensure proper
coordination between environmental
and other functions?
Our next step on document
control is to ...
©2001 NSF
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Operational Control
Building environmental performance into operations and activities
Figure 9
f N
Environmental
Policy
V J.
/•• N
Significant
Environmental
Aspects
V. , ,/f
^^
^\
f Operational \
V Controls j
^^^^ ^*<^.- '
\
Objectives &
Targets
Legal & Other
Requirements
To ensure that you satisfy the commitments in your
environmental policy, certain operations and activities
must be controlled. Where operations or activities are
complex and/or the potential environmental impacts are
significant, controls should include documented
procedures. Procedures can help your organization to
manage its significant environmental aspects, ensure
regulatory compliance and achieve environmental
objectives. Procedures can also play a prominent role in
employee training.
Documented procedures should be established where the
absence of procedures could lead to deviations from the
environmental policy (including the commitments to
compliance and pollution prevention) or from your
objectives and targets. Determining which operations
should be covered by documented procedures and how
those operations should be controlled is a critical step in
designing an effective EMS. Keep in mind that you might
need operational controls in order to manage significant
aspects or legal requirements, regardless of whether you
established objectives and targets for each of them.
In determining which operations and activities need to be
controlled, look beyond routine production or service.
Activities such as equipment maintenance, management
of on-site contractors, and services provided by
suppliers or vendors could affect your organization's
environmental performance significantly.
Examples of activities and
operations that might require
operational controls:
0 management / disposal of
wastes
0 approval of new chemicals
0 storage & handling of raw
materials and chemicals
0 equipment servicing
0 wastewater treatment
0 operation of paint line
0 operation of plating system
0 management of contractors
Getting Started:
• Start by looking at the environmental aspects and
legal requirements that you identified earlier. Identify
the operations and other activities that are related to
these significant impacts and legal requirements, then
consider what types of controls might be needed to
manage these aspects and compliance requirements. If
you have flow charts of these processes (or can
develop them), this may simplify the identification of the
process steps where some type of control might be
appropriate.
• Prepare draft procedures and review them with the
people who will need to implement them. This will help
to ensure that the procedures are appropriate, realistic
and practical. Don't be surprised if reviewers come up
with a simpler way to achieve the same results!
©2001 NSF
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Hints:
• Review procedures you already have in place to comply
with environmental and health & safety regulations.
Some of these may be adequate to control significant
impacts (or could be modified to do so). Develop a chart
to keep track of what controls are needed, such as:
Operation or
Activity
1
2
3
4
Procedure is
needed (none
exists)
X
Procedure
exists, but is not
documented
X
X
Procedure
exists and is
documented
X
No procedure
is needed
Rules of Thumb: In general, the more highly skilled and trained
your employees are, the less critical documented work instructions
become. As work becomes more complex or as the potential
impact on the environment increases, the more important these
documented work instruction will be.
Once you have identified operations that require control, consider
what kinds of maintenance and calibration may be appropriate.
Maintenance of equipment that could have significant
environmental impacts or result in non-compliance should be
considered, and the need for a plan to manage such maintenance
should not be overlooked. An elaborate preventive or predictive
maintenance program is not needed in all cases. Assess your
existing maintenance program and its effectiveness before making
significant changes.
' Factors that could affect
the need for documented
procedures
0 risk of activity
0 complexity of activity /
methods
0 degree of supervision
0 skills /training of
workforce
Hints on Writing Procedures
Understand the existing process. Start with a flow
chart, if one is available. Build on informal procedures
where possible.
Focus on steps needed for consistent implementation.
Use a consistent format and approach.
Review draft procedures with employees that will have
to implement them. (Better yet, enlist employees to
help write them.)
Keep procedures simple and concise. Excessive detail
does not provide better control and can confuse the
user.
©2001 NSF
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Some of your identified environmental aspects may relate
to the chemicals, raw materials, or other goods and
services you obtain from vendors/suppliers. Likewise,
the activities of your contractors can affect your
environmental performance. Communicate your
expectations (including any relevant procedures) to these
business partners.
Policy
Environmental
Aspects
Legal/Other
Requirements
Objectives &
Targets
Training
Monitoring &
Measurement
While the development of procedures can be time-
consuming, organizations have come up with creative
ways to reduce the burden. For example, consider using a
college intern or temporary employee to interview
employees "on the line", collecting information on what
employees do and how they do it.
If your organization uses a "work team" concept, ask the
work teams to draft procedures for their work areas (or to
modify existing procedures for EMS purposes).
POLLUTION PREVENTION
Rochester Midland Corporation, a manufacturer of cleaning and
other chemical products, formed a partnership with a cleaning
contractor that uses Rochester Midland's products, the owners of a
building where the products are used, and building tenants, to lessen
the risks associated with cleaning products. The partners began by
developing common goals, identifying alternative cleaning products and
processes, and identifying opportunities to reduce risks to building
occupants and cleaning staff. Over a two-month period, they were able
to: reduce chemical exposures; improve tenant satisfaction; improve
communication, awareness, and training; achieve a 50% reduction in
cleaning products; and achieve measurable cost savings.
For EPA's Performance Track program, organizations must have operation and
maintenance programs for equipment and operations that relate to legal compliance
and significant environmental aspects.
See Appendix B for more information.
©2001 NSF
55
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Capture the Learning: Operational Controls Worksheet
Have we identified operations and
activities associated with significant
environmental aspects, legal
requirements and environmental
objectives?
If not how will this be accomplished?
Who should be involved?
What operations and activities are
associated with significant
environmental aspects?
What operations and activities are
associated with legal requirements?
What operations and activities are
associated with environmental
objectives and targets?
How are the above operations and
activities controlled? (list methods)
How do we know whether these
controls are adequate (i.e., to
manage significant aspects, to ensure
compliance, to achieve objectives?
How do we train employees and
contractors on relevant operating
controls?
If new controls are needed (or
existing ones need to be revised),
what is our process for doing so?
Who needs to be involved in this
process?
Our next step on operational
control is to ...
©2001 NSF
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Emergency Preparedness and Response
Minimizing the impacts of uncontrolled events
Don't think only about
response - focus on how
to prevent accidents in the
first place
Review prior accidents
and incidents as one
guide to where future
incidents may occur.
Despite an organization's best efforts, the possibility of
accidents and other emergency situations still exists.
Effective preparation and response can reduce
injuries, prevent or minimize environmental impacts,
protect employees and neighbors, reduce asset losses
and minimize downtime.
An effective emergency preparedness and response
program should include provisions for:
• assessing the potential for accidents and
emergencies;
• preventing incidents and their associated
environmental impacts;
• plans / procedures for responding to incidents;
• periodic testing of emergency plans / procedures;
and,
• mitigating impacts associated with these incidents.
Consistent with the focus on continual improvement, it
is important to review your emergency response
performance after an incident has occurred. Use this
review to determine if more training is needed or if
emergency plans / procedures should be revised.
USEFUL INFORMATION
SOURCES:
• Material safety data sheets
• Plant layout
• Process flow diagrams
• Engineering drawings
• Design codes and
standards
• Specifications on safety
systems (alarms,
sprinklers, etc.)
V
Getting Started:
• This is another area where you should not have to start
from scratch. Several environmental and health and
safety regulatory programs require emergency plans
and/or procedures. Look at what you have now and
assess how well it satisfies the items discussed above.
• Two planning components that many organizations
overlook are how they identify the potential for
accidents and emergencies and how they mitigate
the impacts of such incidents. A cross-functional
team (with representatives from engineering,
maintenance and environmental health & safety, for
example) can identify most potential emergencies by
asking a series of "what if" questions related to
hazardous materials, activities, and processes
employed at the site. In addition to normal operations,
the team should consider start-up and shutdown of
process equipment, and other abnormal operating
conditions.
©2001 NSF
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Environmental Aspects
Legal/Other
Requirements
Training & Awareness
Communication
Document Control
Ask yourself: Does everyone (including new
employees) know what to do in an emergency? How
would contractors or site visitors know what to do in an
emergency situation?
Communicate with local officials (fire department,
hospital, etc.) about potential emergencies at your site
and how they can support your response efforts.
Hints:
Mock drills can be an excellent way to reinforce
training and get feedback on the effectiveness of your
plans / procedures.
Post copies of the plan (or at least critical contact
names and phone numbers) around the site and
especially in areas where high hazards exist. Include
phone numbers for your on-site emergency
coordinator, local fire department, local police, hospital,
rescue squad, and others as appropriate.
Revise and improve your plan as you learn from
mock drills, training or actual emergencies.
Checklist for Emergency Preparedness and Response Plans
Does your plan describe the following:
0 potential emergency situations (such as fires, explosions, spills or releases of hazardous
materials, and natural disasters)?
0 hazardous materials used on-site (and their locations)?
0 key organizational responsibilities (including emergency coordinator)?
0 arrangements with local emergency support providers?
0 emergency response procedures, including emergency communication procedures?
0 locations and types of emergency response equipment?
0 maintenance of emergency response equipment?
0 training / testing of personnel, including the on-site emergency response team (if
applicable)?
0 testing of alarm / public address systems?
0 evacuation routes and exits (map), and assembly points?
©2001 NSF
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Capture the Learning: Emergency Preparedness & Response Worksheet
Have we reviewed our operations
and activities for potential emergency
situations?
If not how will this be accomplished?
Who should be involved?
Do our existing emergency plans
describe how we will prevent incidents
and associated environmental
impacts?
If not how will this be accomplished?
Who should be involved?
Have we trained personnel on their
roles and responsibilities during
emergencies?
What emergency equipment do we
maintain? How do we know that this
equipment is adequate for our needs?
How do contractors and other
visitors know what to do in an
emergency situation?
When was our last emergency drill? Is
there a plan / schedule for conducting
future drills?
Have we established a feedback loop
so we can learn from our experiences?
Our next step on emergency
preparedness & response is to ...
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Monitoring and Measurement
Assessing how well the system is performing
"If you can't
measure it, you
can't manage it."
Peter Drucker
Management Expert
Which operations and
activities can have
significant environmental
impacts?
What are the key
characteristics of these
operations and activities?
How do we measure
these characteristics?
Attributes of effective
measurement programs
3 simple
3 flexible
3 consistent
3 ongoing
3 produce reliable data
3 communicate results
An EMS without effective monitoring and measurement
processes is like driving at night without the headlights on
—you know that you are moving but you can't tell where
you are going! Monitoring and measurement enables an
organization to:
• evaluate environmental performance;
• analyze root causes of problems;
• assess compliance with legal requirements;
• identify areas requiring corrective action, and,
• improve performance and increase efficiency.
In short, monitoring helps you manage your
organization better. Pollution prevention and other
strategic opportunities are identified more readily when
current and reliable data is available.
Your organization should develop procedures to:
• monitor key characteristics of operations and
activities that can have significant environmental
impacts and/or compliance consequences;
• track performance (including your progress in
achieving objectives and targets);
• calibrate and maintain monitoring equipment; and,
• through internal audits, periodically evaluate your
compliance with applicable laws and regulations.
Getting Started:
• Monitoring and measuring can be a resource-intensive
effort. One of the most important steps you can take is
to clearly define your needs. While collecting
meaningful information is clearly important, resist the
urge to collect data "for data's sake."
• Review the kinds of monitoring you do now for
regulatory compliance and other purposes (such as
quality or health and safety management). How well
does this serve your EMS purposes? What additional
monitoring or measuring might be needed?
• You can start with a relatively simple monitoring and
measurement process, then build on it as you gain
experience with your EMS.
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EPA policies provide
incentives for effective
compliance management
programs. See "Incentives for
Self-Policing: Discovery,
Disclosure, Correction and
Prevention of Violations"
(http://es. epa. gov/oeca/finalpo
lstate.pdf) and "Small
Business Compliance Policy"
(http://es. epa. gov/oeca/sbcp
2000.pdf)
Employees should have a
mechanism to report
regulatory violations (or other
EMS issues) without fear of
retaliation by their employer
Focus on things that you
can do something about
Hints:
• Monitoring key process characteristics: Many
management theorists endorse the concept of the "vital
few" — that is, that a limited number of factors can have
a substantial impact on the outcome of a process. The
key is to figure out what those factors are and how to
measure them. Process mapping can help you
determine what those factors might be.
• Most effective environmental measurement systems
use a combination of process and outcome measures.
Outcome measures look at results of a process or
activity, such as the amount of waste generated or the
number of spills that took place. Process measures
look at "upstream" factors, such as the amount of paint
used per unit of product or the number of employees
trained on a topic. Select a combination of process and
outcome measures that are right for your organization.
• Equipment calibration: Identify process equipment
and activities that truly affect your environmental
performance. As a starting point, look at those key
process characteristics you identified earlier. Some
organizations place critical monitoring equipment under
a special calibration and preventive maintenance
program. This can help to ensure accurate monitoring
and make employees aware of which instruments are
most critical for environmental monitoring purposes.
Some organizations find it is more cost-effective to
subcontract calibration and maintenance of monitoring
equipment than to perform these functions internally.
• Regulatory compliance: Determining your compliance
status on a regular basis is very important. You should
have a procedure to systematically identify, correct,
and prevent violations. Effectiveness of the
compliance assessment process should be considered
during EMS management review. EPA encourages
"systematic discovery" of regulatory violations, which
means detecting potential violations through
environmental audits or compliance management
systems that show due diligence in preventing,
detecting and correcting violations.
. Operational performance: Consider what information
you will need to determine if the company is
implementing operational controls as intended. The
example on Page 62 illustrates the relationship among
monitoring and measurement, operational controls and
significant environmental aspects.
. Progress on meeting objectives: You should measure
progress on achieving objectives and targets on a
regular basis and communicate the results of such
measurement to top management. To measure
progress in meeting objectives, select appropriate
performance indicators (see below).
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Environmental Aspects
Legal/Other
Requirements
Objectives & Targets
Operational Control
Corrective Action
Management Review
The value of periodic monitoring:
St. Joseph's Mercy Hospital
noticed an increase in its
discharge of silver to the local
wastewater treatment plant. They
investigated what had changed at
the Hospital and found that a new
x-ray processor had been installed
without a silver recovery system.
Once the recovery system was
installed, silver discharge levels
returned to permitted levels.
Selecting performance indicators: Performance
indicators can help you to understand how well your
EMS is working. Start by identifying a few performance
indicators that are:
- simple and understandable;
- objective;
- measurable; and
- relevant to what your organization is trying to
achieve (i.e., its objectives and targets)
Data collected on performance indicators can be quite
helpful during management reviews. So, select
indicators that will provide top management with the
information it needs to make decisions about the EMS.
Make sure you can commit the necessary resources
to track performance information over time. It is OK to
start small and build overtime as you gain experience
in evaluating your performance. Keep in mind that no
single measurement will tell your organization how it
is doing in the environmental area.
Communicating performance: People respond best
to information that is meaningful to "their world."
Putting environmental information in a form that is
relevant to their function increases the likelihood
they will act on the information. Be sure to link your
measurement program with your communications
program and other elements of the EMS (such as
management reviews, as discussed later).
Compliance auditing guidance: The USEPA has
prepared guidance documents and protocols for
conducting environmental compliance audits under a
number of its regulatory programs. For more
information, check the EPA web site at
www.epa.gov/oeca/index.html.
POLLUTION PREVENTION
A Pitney Bowes Inc. facility formed a Zero Discharge Task Team to design
projects to reduce emissions over a five-year period. Wastes were ranked
ordered in terms of their potential risks to the environment and employee
safety. Those with high rankings were evaluated on a priority basis.
Through the implementation of many projects, the facility has reduced
hazardous waste generation by 69%, EPCRA 313 air emissions by 98%
and treated wastewater by 93%. Projects included finding substitutes for
parts cleaning and degreasing, replacement of all cyanide processes, and
installation of fume scrubbers on plating lines, among others.
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Figure 10:
Linking Monitoring Processes to Operational Controls: One Example
Operation with
Significant
Environmental
Aspect
Surface
Coating
Operation
(significant
aspect is VOC
emissions)
Liquid
Waste
Storage
(significant
aspect is
potential for
spills)
Operational
Controls
• Approved list ^.
of coatings
• Coating work — ^
instruction
— ^
• Permit report — ^
procedure
• Generator — ^
• procedure
— ^
• Storage — ^
area procedure
-------
Capture the Learning: Monitoring and Measurement Worksheet
Have we identified operations and
activities associated with significant
environmental aspects, legal
requirements and environmental
objectives? If, not how will this be
accomplished?
What type(s) of monitoring and
measurement do we need to ensure
that operational controls are being
implemented correctly?
What type(s) of monitoring and
measurement do we need to ensure
that we are complying with applicable
legal requirements?
What type(s) of monitoring and
measurement do we need to ensure
that we are achieving our
environmental objectives & targets?
How do we identify the equipment
used for any of the monitoring or
measurement listed above? If not how
will this be accomplished?
How will we ensure that monitoring and
measurement equipment is properly
calibrated and maintained?
What process do we have to
periodically evaluate compliance with
legal requirements? How effective is
this process?
Our next step on monitoring and
measurement is to ...
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Nonconformance and Corrective / Preventive Action
Fixing EMS problems - and avoiding them in the future
Key Steps
identify the problem
investigate to identify
the root cause
come up with solution
implement solution
document solution
communicate solution
evaluate effectiveness
of solution
Nonconformance"
means...
• system does not meel
the EMS criteria
~ or -
• implementation is not
consistent with the
EMS description
No EMS is perfect. You will probably identify problems
with your system (especially in the early phases) through
audits, measurement, or other activities. In addition, your
EMS will need to change as your organization changes
and grows. To deal with system deficiencies, your
organization needs a process to ensure that:
• problems (including nonconformities) are identified
and investigated;
• root causes are identified;
• corrective and preventive actions are identified and
implemented; and,
• actions are tracked and their effectiveness is
verified.
EMS nonconformities and other system deficiencies
(such as legal noncompliance) should be analyzed to
detect patterns or trends. Identifying trends allows you
to anticipate and prevent future problems.
Focus on correcting and preventing problems.
Preventing problems is generally cheaper than fixing
them after they occur (or after they reoccur). Start
thinking about problems as opportunities to improve!
Management
Review
Figure 11:
= System Improvement
Hints:
• If your organization has an ISO 9001 management
system, you should already have a corrective and
preventive action process for quality purposes. Use
this as a model (or integrate with it) for EMS purposes.
• Some organizations find that they can combine some
elements of their management review and corrective
action processes. These organizations use a portion of
their management review meetings to review
noncomformities, discuss causes and trends, identify
corrective actions and assign responsibilities.
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Why do EMS problems
occur?
Typical causes include:
0 poor communication
0 faulty or missing procedures
0 equipment malfunction
(or lack of maintenance)
0 lack or training
0 lack of understanding
(of requirements)
0 failure to enforce rules
0 corrective actions fail to
address root causes of
problems
Legal & Other
Requirements
Operational
Control
Monitoring &
Measurement
EMS Audits
Management Review
The amount of planning and documentation needed for
corrective & preventive actions will vary with the
severity of the problem and its potential environmental
impacts. Don't go overboard with bureaucracy —
simple methods often work quite effectively.
Once you document a problem, the organization must
be committed to resolving it in a timely manner. Be
sure that your corrective & preventive action process
specifies responsibilities and schedules for
completion. Review your progress regularly and follow
up to ensure that actions taken are effective.
Make sure your actions are based on good information
and analysis of causes. While many corrective actions
may be "common sense," you need to look beneath
the surface to determine why problems occur. Many
organizations use the term "root cause" in their
corrective and preventive action processes. While this
term can be used to describe a very formal analysis
process, it can also mean something simpler - looking
past the obvious or immediate reason for a
nonconformance to determine why the nonconformance
occurred.
Rule of thumb: Corrective actions should (1) resolve
the immediate problem (2) consider whether the same
or similar problems exist elsewhere in the organization,
and (3) prevent the problem from recurring. The
corrective action process also should define the
responsibilities and schedules associated with these
three steps.
Initially, most EMS problems may be identified by your
internal auditors. However, over the long run, many
problems and good ideas may be identified by the
people doing the work. This should be encouraged.
Find ways to get employees involved in the system
improvement process (for example, via suggestion
boxes, contests or incentive programs).
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People doing the
work are often in
the best position
to see problems
and suggest
solutions
The Tool Kit
contains a sample
corrective action
procedure and
tracking log
(see Appendix A)
Sources
of change
Investigate and
recommend
solutions
Institutionalize
Change
Corrective
Action
Process
Figure 12
POLLUTION PREVENTION
By switching from a solvent-based paint that contained lead to a no
lead, low-solvent, water-based paint, March Coatings dramatically
decreased its volatile organic compound (VOC) air emissions from over
19 tons in 1995 to less than 6 tons in 1999 while simultaneously
increasing production. The company went from being a large quantity
generator of hazardous waste to small quantity generator status under
RCRA. March Coatings accomplished this by working closely with its
paint supplier to find a formula that met their needs.
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Capture the Learning: Corrective & Preventive Action Worksheet
Do we have an existing process for
corrective and preventive action?
If yes, does that process need to be
revised? In what way?
Who needs to be involved in this
process within our organization?
How are nonconformities and other
potential system deficiencies
identified? (List methods such as
audits, employee suggestions, ongoing
monitoring, etc.)
How do we determine the causes of
nonconformities and other system
deficiencies? How is this information
used?
How do we track the status of our
corrective and preventive actions?
How is / can information on
nonconformities and corrective actions
be used within the EMS (for example,
in management review meetings, in
employee training sessions, in review
of procedures, etc.)
How do we ensure the effectiveness
of our corrective and preventive
actions?
Our next step on corrective and
preventive action is to ...
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Records
Evidence that the EMS is working as intended
What are "records"?
Records provide evidence
that the processes that
make up your EMS are
being implemented as
described.
The value of records management is fairly simple — you
should be able to demonstrate that your organization is
actually implementing the EMS as designed. While
records have value internally, over time you may need to
provide evidence of EMS implementation to external
parties (such as customers, a registrar, or the public).
Records management is sometimes seen as
bureaucratic, but it is difficult to imagine a system
operating consistently without accurate records.
The basics of records management are straightforward:
you need to decide what records you will keep, how you
will keep them and for how long. You should also think
about how you will dispose of records once you no
longer need them.
If your organization has an ISO 9001 (or other)
management system, you should have a process in place
for managing records. This process could be adapted for
EMS purposes.
Records should be
important to the operation
of the EMS, including your
regulatory compliance
efforts.
Hints:
• Start by identifying what EMS records are required. Look
at your other procedures and work instructions to determine
what evidence is needed to demonstrate implementation.
Also consider records that are required by various legal
requirements.
• Focus on records that add value — avoid bureaucracy. If
records have no value or are not specifically required, don't
collect them. The records you choose to keep should be
accurate and complete.
• You may need to generate certain forms in order to
implement your EMS. When these forms are filled out, they
become records. Forms should be simple and
understandable for the users.
• Establish a records retention policy and stick to it. Make sure
that your policy takes into account records retention
requirements specified in applicable environmental
regulations.
• In designing your records management process, be sure to
consider:
- who needs access?
- to what records?
- in what circumstances?
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Key Questions
what records are kept?
who keeps them?
where are they kept?
how are they kept?
how long are they kept?
how are they accessed?
how are they disposed? /
.„ r-—!?>•*'
Virtually every element
of an EMS can result in
the generation of
records
The Tool Kit contains a tool
for organizing your filing
system (see Appendix A).
You can copy the pages, cut
out the tabs, and use them to
set up your filing system.
If your organization uses computers extensively,
consider using an electronic EMS records management
system. Maintaining records electronically can provide
an excellent means for rapid retrieval of records as well
as controlling access to sensitive records.
Think about which records might require additional
security. Do you need to restrict access to certain
records? Should a back-up copy of critical records be
maintained at another location?
Types of Records You Might Maintain (Examples):
• legal, regulatory and other code requirements
• results of environmental aspects identification
• reports of progress towards meeting objectives and
targets
• permits, licenses and other approvals
• job descriptions and performance evaluations
• training records
• EMS audit and regulatory compliance audit reports
• reports of identified nonconformities, corrective
action plans and corrective action tracking data
• hazardous material spill / other incident reports
• communications with customers, suppliers,
contractors and other external parties
• results of management reviews
• sampling and monitoring data
• maintenance records
• equipment calibration records
Capture the Learning: Records Management Worksheet
Have we identified what records
need to be maintained? Where is this
defined?
Have we determined records retention
times? Where is this defined?
Have we established an effective
storage and retrieval system?
Our next step on records is to
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EMS Auditing
Objective evidence of conformance with EMS requirements
Once your organization has established its EMS, verifying
the implementation of the system will be critical. To
identify and resolve EMS deficiencies you must actively
seek them out.
In a smaller organization, periodic audits can be
particularly valuable. Managers are often so close to the
work performed that they may not see problems or bad
habits that have developed. Periodic EMS audits will
help determine whether all of the requirements of the
EMS are being carried out in the specified manner.
Audits are vital to
continual
improvement
( EMS Audit
"A systematic and
documented verification
process of objectively
obtaining and evaluating
evidence to determine
whether an organization's
environmental
management system
conforms to the
environmental
management system
audit criteria set by the
organization, and for
communication of the
results of this process to
management.
- ISO 14001
For your EMS audit program to be effective, you should:
• develop audit procedures and protocols;
• determine an appropriate audit frequency;
• select and train your auditors; and,
• maintain audit records.
Results of your EMS audits should be linked to the
corrective and preventive action process, as described
earlier.
While they can be time-consuming, EMS audits are
critical to EMS effectiveness. Systematic identification
and reporting of EMS deficiencies to management
provides a great opportunity to:
• maintain management focus on the environment,
• improve the EMS and its performance, and
• ensure the system's cost-effectiveness.
Getting Started:
• How frequently do we need to audit?
To determine an appropriate frequency of your EMS
audits, consider the following factors:
- the nature of your operations and activities,
- your significant environmental aspects / impacts
(which you identified earlier),
- the results of your monitoring processes, and
- the results of previous audits.
As a rule of thumb, all parts of the EMS should be audited
at least annually. You can audit the entire EMS at one
time or break it down into discrete elements for more
frequent audits. (There may be advantages to
conducting frequent audits, but the decision is up to you).
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Audit procedures should
describe:
3 audit planning
3 audit scope (areas and
activities covered)
3 audit frequency
3 audit methods
3 key responsibilities
3 reporting mechanisms
3 recordkeeping
Traits of a good
auditor:
1 Independent
(of the activity
being audited
] Objective
1 Impartial
1 Tactful
] Attentive to detail
Who will perform the audits? You should select and
train EMS auditors. Auditor training should be both
initial and ongoing. Commercial EMS auditor training
is available, but it might be more cost-effective to link up
with businesses or other organizations in your area
(perhaps through a trade association) to sponsor an
auditor training course. Some local community colleges
also offer EMS auditor training courses.
Auditors should be trained in auditing techniques and
management system concepts. Familiarity with
environmental regulations, facility operations, and
environmental science can be a big plus, and in some
cases may be essential to adequately assess the EMS.
Some auditor training can be obtained on-the-job.
Your organization's first few EMS audits can be
considered part of auditor training, but make sure that
an experienced auditor leads or takes part in those
"training" audits.
Auditors should be independent of the activities
being audited. This can be a challenge for small
organizations. See the box on next page for ideas.
If your company is registered under ISO 9001, consider
using your internal quality auditors as EMS auditors.
While some additional training might be needed for
EMS auditing, many of the required skills are the same.
How should management use audit results?
Management can use EMS audit results to identify
trends or patterns in EMS deficiencies. The
organization also should ensure that identified system
gaps or deficiencies are corrected in a timely fashion
and that corrective actions are documented.
Hints:
Sources of Evidence
0 interviews
0 document review
0 observation of
work practices
Your EMS audits should focus on objective evidence
of conformance. During an audit, auditors should
resist the temptation to evaluate, for example, why a
procedure was not followed — that step comes later.
During an audit, auditors should review identified
deficiencies with people who work in the relevant
area(s). This will help the auditors verify that their
audit findings are correct. This also can reinforce
employee awareness of EMS requirements.
If possible, train at least two people as internal
auditors. This will allow your auditors to work as a
team. It also allows audits to take place when one
auditor has a schedule conflict, which is often
unavoidable in a smaller organization!
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V
Results of regulatory
compliance audits are often
good indicators of EMS
deficiencies. Use
compliance audit findings to
guide your EMS efforts
The Tool Kit includes a sample
EMS audit procedure, sample
EMS audit questions, and a
number of sample audit forms
(see Appendix A)
Structure & Responsibility
Training & Awareness
Corrective Action
Management Review
Options for Auditor Independence
Barter for audit services with other small organizations
in your area
Use external auditors
Have office personnel audit production areas
(and vice versa)
Before you start an audit, be sure to communicate
the audit scope, criteria, schedule, and other pertinent
information to the people in the affected area(s). This
helps to avoid confusion and facilitate the audit
process.
Consider integrating your EMS and regulatory
compliance audit processes, but keep in mind that
these audit processes have different purposes. While
you might want to communicate the results of EMS
audits widely within your organization, the results of
compliance audits might need to be communicated in a
more limited fashion.
Final thought: An EMS audit is a check on how well
your system meets your own established EMS
requirements. An EMS audit is not an assessment of
how well employees do their jobs. Auditors should
avoid the "gotcha" mentality. Audits should be judged
on the quality of findings, rather than on the number of
findings.
Figure 13:
Linkages among EMS audits, corrective action and
management reviews
Even if you have an
effective internal audit
program, consider periodic
external audits to ensure
objectivity
Periodic
EMS Audits
EMS
Established
Corrective Action
Process
Management
Reviews
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Capture the Learning: EMS Auditing Worksheet
Have we developed an EMS audit
program? If not, how will this be
accomplished?
Who need to be involved in the audit
process?
Is there another audit program with
which our EMS audits could be linked
(for example, our quality or health &
safety management system audits)?
Have we determined an appropriate
audit frequency? What is the basis
for the existing frequency? Should the
frequency of audits be modified?
Have we selected EMS auditors?
What are the qualifications of our
auditors?
What training has been conducted or
is planned for our EMS auditors?
Have we conducted EMS audits as
described in the audit program?
Where are the results of such audits
described?
How are the results of EMS audits
communicated to top management?
How are the records of these audits
maintained?
Our next step on EMS auditing
is to ...
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/ An effective EMS \
is one that:
ZI meets the
organization's
needs
produces results
conforms to EMS
criteria
has staying power
Management Review
Closing the continual improvement loop
Just as a person should have periodic physical exams,
your EMS must be reviewed periodically by top
management to stay "healthy". Management reviews are
one key to continual improvement and for ensuring that
the EMS will continue to meet your organization's needs
over time.
Management reviews also offer a great opportunity to
keep your EMS efficient and cost-effective. For
example, some organizations have found that certain
procedures and processes initially put in place were not
needed to achieve their environmental objectives or to
control key processes. If EMS procedures and other
activities don't add value, eliminate them.
The key question that a management review seeks to
answer:
"Is the system working?" (i.e., is it suitable,
adequate and effective, given our needs?)
"Many of the benefits
of an EMS cannot be
anticipated
beforehand. You will
have to discover them
as pleasant surprises
at some point after
implementation. They
will be there.
Milan
^roducts
The Tool Kit contains a
sample Management Review
procedure.
(See Appendix A)
Hints:
• Two kinds of people should be involved in the
management review process:
- people who have the right information / knowledge,
- people who can make decisions about the
organization and its resources (top management).
• Determine management review frequency that will
work best for your organization. Some organizations
combine these reviews with other meetings (such as
director meetings). Other organizations hold "stand-
alone" reviews. At a minimum, consider conducting
management reviews at least once per year.
• During management review meetings, make sure that
someone records what issues were discussed, what
decisions were arrived at, and what action items were
selected. Results of management reviews should be
documented.
• Management reviews should assess how changing
circumstances might influence the suitability,
effectiveness or adequacy of your EMS. Changing
circumstances might be internal to your organization
(such as new facilities, new raw materials, changes in
products or services, new customers, etc.) or might be
external factors (such as new laws, new scientific
information or changes in adjacent land use).
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Information sources to
consider:
3 Audit results
3 Internal suggestions
3 External communications
3 Progress on objectives
and targets
3 Other environmental
performance measures
3 Reports of emergencies,
spills, other incidents
3 New or modified
legislation and
regulations
3 New scientific / technical
data on materials and
processes used by the
organization
Consider holding
management review meetings
"after hours" to minimize
disruption of work.
All elements of the
EMS should be
considered as part
of Management
Review
After documenting the action items arising from your
management review, be sure that someone follows-up.
Progress on action items should be tracked to
completion.
As you assess potential changes to your EMS, consider
other organizational plans and goals. In this way,
environmental decision-making can be integrated into
your overall management and strategy.
Management Review: Questions to Ponder
Did we achieve our objectives and targets? If not,
why not? Should we modify our objectives?
Is our environmental policy still relevant to what we do?
Are roles and responsibilities clear, do they make
sense and are they communicated effectively?
Are we applying resources appropriately?
Are our procedures clear and adequate? Do we need
other controls? Should we eliminate some of them?
Are we fixing problems when we find them?
Are we monitoring our EMS (e.g., via system audits)?
What do the results of those audits tell us?
What effects have changes in materials, products, or
services had on our EMS and its effectiveness?
Do changes in laws or regulations require us to
change some of our approaches?
What other changes are coming in the near term?
What impacts (if any) will these have on our EMS?
What stakeholder concerns have been raised since
our last review? How are concerns being addressed?
Is there a better way? What can we do to improve?
Smaller organizations often favor employee experience overwritten procedures and
documented systems. However, personnel turnover without documented systems can
stall progress. When the manager of the Washtenaw County Home Toxics Reduction
Program took over his position, there had been a six-month gap since his predecessor
had left and very little in place to tell him what to do, whom to contact, or what the
history of the program was. Having an EMS can facilitate a smooth transfer of
responsibilities for environmental management.
YOU SHOULD NOW UNDERSTAND ALL OF
THE ELEMENTS OF AN EFFECTIVE EMS !!
NOW YOU'RE READY TO "GO"! (See next section)
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Capture the Learning: Management Review Worksheet
Do we have an existing process for
conducting management reviews?
If yes, does that process need to be
revised? In what way?
Who needs to be involved in this
process within our organization?
When is the best time for us to
implement this process? Can this
effort be linked to an existing
organization process (such as our
budget, annual planning or auditing
cycles?)
How frequently are management
reviews? What is the basis for this
frequency?
Should we conduct reviews more or
less frequently?
Who is responsible for gathering the
information needed to conduct
management reviews? Who is
responsible for presenting this
information?
How do we ensure that changing
circumstances (both internal and
external to the organization) are
considered I this process?
How do we ensure that the
recommendations of management
reviews are tracked and acted upon?
Our next step on management
review is to ...
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Section 5 : GO! (Roadmap for EMS Development)
A sequence of activities for building an EMS from the ground up
Once you gain an understanding the individual elements of
an EMS, you can begin the process of putting these
elements in place. Each of the individual EMS elements
is described in detail in Section 4. Also, several "up front"
EMS planning tasks (such as gaining top management
commitment) were described in Section 3.
Ford Motor Company
^ conducted ISO 14001
~"~ implementation
workshops for its
suppliers. Part of these
workshops was devoted
to a discussion of how to
"launch" the EMS effort
through a set of
implementation steps.
The Washtenaw County
^ Home Toxics Reduction
^ Program (HTRP)
successfully linked its
management review
process with its new
Business Improvement
Process (BIP). HTRP used
its environmental objectives
as input to the BIP and
reviewed progress annually
to determine what worked
and to make adjustments,
where needed. The output
of BIP will feed into the
County's budgeting
process.
Experience of many organizations shows that the order in
which EMS implementation activities should take place is
not always obvious or intuitive. Further, the optimal
sequence of implementation activities does not
necessarily follow the order in which elements are
described in various EMS models, such as ISO 14001.
Using a logical sequence can save time and money and
minimize the "false starts" an organization might make.
This section provides a step by step action plan for
developing and implementing the elements of an EMS. It
describes a logical sequence or "roadmap" for planning
and implementing EMS elements and explains how this
sequence can be important in building an effective EMS.
Keep in mind that this is just one way to do the job- you
might find other approaches that work just as well.
Figure 14 illustrates the suggested implementation
process flow. Each of the steps (and a rationale for their
sequence) is discussed below.
A few hints to keep in mind as you build your EMS:
• You may already have some EMS elements in
place, as indicated by the preliminary review that
you performed earlier (see Section 3 for more
details).
• Make sure to build in the links between elements.
Refer back to Section 4 for information on the key
links. The effectiveness of your EMS depends as
much on the strength of its links as it does on the
strength of the individual elements themselves.
• For many EMS elements, you will need to design
and implement a process. In these cases, you
also should consider documenting the process in
the form of a procedure.
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Identify
Legal & Other
Requirements
Identify & Evaluate
Environmental
Aspects, Related
Operations & Activities
Define Views
of Interested
Parties
Prepare
Environmental
Policy
Define Key
Roles and
Responsibilities
Establish
Objectives
& Targets
Establish
Operational
Controls &
Monitoring
Processes
Establish
Procedures for
Corrective/
Preventive
Action,
Document
Control &
Records
Management
Environmental
Management
Programs
Identify
Monitoring &
Measurement
Needs
Identify
Operational
Controls
_\Sec. £
Define
Job-Specific
Roles and
Responsibilities
Initial
Employee
Awareness
Establish
Other
System-Level
Procedures
Prepare
EMS
Documentation
(manual)
Conduct Specific
Employee Training
Conduct
Internal
EMS Audits
Conduct
Management
Reviews
Figure 14: GO!
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Identify
Legal and
Other
Requirements
Identify
Environmental
Aspects and
Related Products,
Operations and
Activities
Creating Your EMS: Step by Step
A first step in the EMS-building process is understanding the
legal and other requirements that apply to what you do (i.e.,
that apply to your products, activities and services). This step is
important for understanding compliance obligations and how
these obligations affect the overall EMS design. For example,
you might have an operation that is covered by an air quality
permit or might provide a service that results in the generation
of regulated wastes. Your EMS should include processes to
ensure that such legal requirements are addressed when you
conduct these operations (or when they are modified).
Your EMS should be designed to help you accomplish more that
just compliance with applicable laws and regulations, but these
compliance requirements should be a major consideration.
Performing this step first allows you to understand how legal
requirements might relate to the environmental aspects and
impacts of your products, activities and services, as discussed
next.
Once you understand what "rules" apply, you should assess
how your organization interacts with the environment. This
is accomplished by identifying your environmental aspects and
impacts and determining which of them are significant. Some
of your environmental aspects may be regulated, while others
may not be.
As you identify and assess your aspects, you also should
identify specific products, operations and activities from
which these aspects / impacts arise. Likewise, you can identify
any monitoring that is performed of these operations or
activities for environmental purposes. For example, if you
identify the generation of a particular air emission as a
significant environmental aspect, it would help to know which
operation(s) generate such air emissions. It might also help to
know whether these air emissions are monitored or otherwise
measured in some manner.
Collecting this information at an early stage will help you
implement subsequent EMS elements. You can use a form
(such as Figure 15) to capture this information. One caveat -
just because you identify an existing control and/or monitoring
activity related to a particular operation or activity, don't
automatically assume that these controls are adequate for
EMS purposes. The adequacy of these controls will depend on
several factors, including your objectives and targets.
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Figure 15: Linking Operations, Aspects, Controls and Monitoring (example)
Source
Operations
Parts painting
Parts plating
Other A ctivities
Raw material
storage
Fleet maintenance
Products
Pumps
Services
Equipment servicing
at customer sites
Significant Aspect(s)
• Air emissions
(VOCs)
• Solvent waste
generation
• Waste generation
• Water discharges
• Potential spills
• Waste oil generation
• Potential spills
• Energy Use
• Chromium content
• Waste generation
• Fuel use
Regulated?
• Yes
• Yes
• Yes
• Yes
• Yes
• Yes
• Yes
• A/o
• A/o
• A/o
• A/o
Associated Controls
• Limits on VOC
content in paints
and operating hours
• SOP for HW
generation
• SOP for HW
generation
• Notification to site
effluent treatment
plant
• Stormwater
Pollution Prevention
Plan
• SOP for HW
generation
• Stormwater
Pollution Prevention
Plan
• None
• None
• SOP for equipment
service
• None
Associated
Monitoring
or Measurement
• Paint use records,
log of operating
hours
• Waste tracking
sheet
• Waste tracking
sheet
• Pre-discharge
sampling
• Weekly
inspections of
storage area
• Waste tracking
sheet
• Weekly
inspections of
storage area
• None
• None
• Waste tracking
sheet
• Fuel dispensing
records
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Define
Views of
Interested
Parties
Armed with information on applicable legal and other
requirements as well as the environmental attributes of your
products, activities and services, you should gather
information of the views of your "stakeholders" (or
interested parties). Stakeholders might include, for example,
your neighbors, interest groups, regulators and others. Their
views might address how your organization affects the
environment, how well you are meeting your environmental
obligations, and whether your organization is a "good neighbor",
among other topics. There are many ways to collect information
on stakeholder views, as discussed in Section 4 (See
"Communication").
Gathering this information now allows you to consider
stakeholder input in the development of your environmental
policy. Since you have already assessed your legal and other
requirements and your environmental aspects, you should be in
a good position to have meaningful dialogues with these
stakeholders.
Prepare
Environmental
Policy
At this point, you should have a sound basis for developing (or
possibly amending) your environmental policy. Using the
information developed in the previous three steps allows your
organization to prepare a policy that is relevant to the
organization and the key issues that it faces. For example, you
will have information on the views of your stakeholders that
might be valuable in developing an environmental policy.
Keep in mind that you evaluated your current environmental
programs when you performed the preliminary review (see
Section 3), so you should understand how (and how well) you
are currently managing these key issues.
Define
Key Roles
and
Responsibilities
Once the environmental policy has been written, you can begin
to define key roles and responsibilities within the EMS. At
this stage of implementation, focus on "higher-level"
responsibilities, such as the roles and responsibilities of senior
management, key functional leaders and environmental staff (if
one exists). EMS responsibilities for other specific jobs or
functions will be identified in a later step. Once the key roles
and responsibilities have been defined, obtain the input of these
individuals in the next step of the process - establishing
objectives and targets.
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Establish
Objectives
And
Targets
Figure 16
Develop
Environmental
Management
Programs
Identify
Monitoring and
Measurement
Needs
Identify
Operational
Controls
At this point you are ready to establish environmental
objectives and targets for your organization. These objectives
should be consistent with your environmental policy. Each of
your objectives also should reflect the analyses you carried out
on legal and other requirements, environmental aspects and
impacts, and the views of interested parties (as well as the other
factors discussed in Section 4).
You identified the operations and activities related to your
significant aspects and impacts in an earlier step. Also, you
defined certain key roles and responsibilities. This information
will help you to determine the relevant levels and functions
within the organization for achieving objectives and targets. For
example, if you set an objective to reduce hazardous waste
generation by 10% this year, you also should know which parts
of the organization must be involved in order to meet this
objective.
This brings us to one of the most challenging (and
potentially most valuable) steps in the overall process.
Armed with an understanding of legal requirements,
your significant environmental aspects and impacts,
and your objectives and targets, your are ready to
tackle several EMS elements simultaneously.
These elements include the design of environmental
management programs, the initial identification of
necessary operational controls, and the initial
identification of monitoring and measurement needs.
One reason combining these steps is that they can
often overlap significantly. For example, your
environmental management program for achieving a
certain objective (such as maintaining compliance with
regulations) might consist of a number of existing
operational controls (procedures) and monitoring
activities. Similarly, achieving an objective might
require a feasibility study or the implementation of
certain "new" operational controls. Likewise,
determining progress on achieving objectives often
requires some form of monitoring or measurement.
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An example of a form for
describing environmental
management programs that
shows the links between
programs and operational
controls is provided in the
Tool Kit (Appendix A)
One important caveat: Keep in mind that operational
controls and monitoring / measurement processes might
be needed even if no objective (or corresponding
management program) exists for a particular operation or
activity. For example, controls might be needed for
certain operations to ensure compliance with legal
requirements or to control a significant environmental
aspect, even where no specific objective has been set.
The initial identification of operational control needs at this
point in the process should be supplemented by a more
detailed design of operational controls and monitoring
processes, as described in a subsequent process step.
Also keep in mind that this process is usually iterative.
That is, you might need to "re-visit" your management
programs, operational controls and monitoring processes
over time to ensure they are consistent and up-to-date.
You should already have a head start on this step, since
you identified operations and activities related to your
significant environmental aspects (as well as existing
control and monitoring processes) several steps ago.
Remember how we said this was a good idea?
Your don't need to fully develop these operational
controls and monitoring activities yet - that step comes
later (see "Design Operational Controls & Monitoring
Processes"). What you need to do now is compile a list
of your operational control and monitoring needs. As
you develop your environmental management programs,
ask yourself the following questions:
• How do we control this operation or activity now?
• Are these controls adequate to meet our objectives
and to ensure compliance?
• If additional controls are needed, what types of
controls make sense?
• What type of monitoring / measurement is needed to
track our progress in achieving objectives and to
ensure that operational controls are implemented as
designed?
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Establish
Corrective Action,
Document Control &
Records Management
Processes
At this stage of implementation, your EMS will begin to
generate some documents (such as procedures and
forms) and records (that demonstrate that various
processes are being carried out). For this reason, it is a
good time to establish procedures for
corrective/preventive action, document control, and
records management. These three processes are
essentially "system maintenance" functions. As you
develop and implement other system-level procedures,
work instructions for various activities, and other EMS
documents, you need a process for controlling the
generation and modification of these documents.
Likewise, you will need a process to ensure that you can
fix (or correct) problems when they occur. In addition,
many of these processes (such as monitoring activities)
will generate records, so you need an effective way to
manage the records that your EMS generates.
Establish
Operational
Controls &
Monitoring
Once the system maintenance functions are in place, you
can start in earnest the establishment of activity- or
area-specific operational controls and monitoring
processes. As a starting point, refer back to the list of
operational control and monitoring needs that you
generated in preparing your environmental management
programs (see earlier step). Also, you should have a
template for the development of these work instructions
(or standard operating procedures), since your document
control process was established in the prior step.
Remember that you might need operational controls and
monitoring processes to meet your policy commitments
and control significant environmental aspects, even
where no specific objectives or environmental
management programs have been established.
Employees that work in relevant operations or activities
can provide a lot of support here. Also, note that these
operational controls and monitoring processes can play
an important role in employee training, as discussed later.
Also keep in mind that you also need a procedure for
conducting periodic compliance evaluations.
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Define
Job-Specific
Roles and
Responsibilities
Plan and
Conduct
Initial
Employee
Awareness
Establish
Other
System-Level
Procedures
Prepare
EMS
Documentation
(manual)
As part of the process described above, you should
define job-specific roles and responsibilities. Such
roles and responsibilities should address the specific
operational controls and monitoring processes discussed
above. You might want to document these
responsibilities in a responsibility matrix or in some
other form that is easily communicated to employees.
Initial employee awareness training should be
conducted to promote understanding of the organization's
EMS efforts and the progress made to-date. As a first
step, train employees on the environmental policy and
other elements of the EMS. Discuss the environmental
impacts of their activities, any new / modified procedures,
the organization's objectives and targets, as well as their
EMS responsibilities. If you have contractors or others at
your site who are not employees of your organization,
consider whether these other individuals should be
included in these EMS awareness sessions.
Some system-level procedures (such as the procedures
for identification of environmental aspects and access to
legal and other requirements) were developed at earlier
stages of the process. At this point, you can establish
any other procedures required for the EMS. These
other system-level procedures might include, for example:
• employee training and awareness,
• internal and external communication,
• emergency preparedness and response,
• EMS auditing, and
• management review.
Once you have established roles and responsibilities and
defined all of your system-level procedures, preparing
the EMS manual should be a relatively simple matter.
The manual should summarize the results of your efforts
so far (that is, it should describe the processes you have
developed, the roles and responsibilities you have defined
as well as other EMS elements). Also, it is important to
describe the links among system elements and provide
direction to other system documents. Keep the manual
simple - there is no need to provide great detail on any
particular system process. Readers can be referred to
the detailed procedures if more information is needed.
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Plan and
Conduct
Specific
Employee
Training
Once the procedures and other system documentation
have been prepared, you are ready to conduct specific
employee EMS training. As a first step, identify specific
training needs. Employee training should be designed to
ensure understanding of:
• key system processes,
• operational controls related to their specific jobs, and
• any monitoring or measurement for which they are
responsible.
Job-specific training should also cover topics such as
EMS auditing for those employees that will conduct
internal EMS audits.
Conduct
Internal
EMS
Audits
Once internal auditors have been selected and trained,
you should design and initiate the internal auditing
process. At this point, you should have sufficient EMS
processes in place to conduct meaningful audits. Many
organizations find that it is easier to start with smaller,
more frequent audits that to audit the entire EMS at once.
These early audits can serve as a learning tool for the
auditors.
Once the audit results are known, use the corrective and
preventive action process you developed earlier to
address any identified problems. Audit records should be
managed in accordance with the records management
process.
Conduct
Management
Reviews
Use the results of your internal audits (along with other
information on the EMS) to conduct management
reviews. Management should consider the need for any
changes to the EMS and make assignments for any
changes needed. Such assignments should be
consistent with the roles and responsibilities established
previously.
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Appendix A: TOOLKIT
Sample Environmental Policies 89
Environmental Impact Identification and Evaluation: Techniques and Data Sources..96
Sample Procedure: Instructions for Environmental Aspects Identification Form 98
Environmental Aspects Identification Form 103
Sample Environmental Aspect Evaluation and Scoring Tools 104
Resources for Tracking Environmental Laws and Regulations 106
Sample Process Tool: Setting Objectives & Targets 108
Sample Procedure: Setting Objectives & Targets 111
Sample Tools: Environmental Management Program 113
Sample Responsibility Matrix 117
Sample Environmental Training Log 120
Sample Procedure: Communications with External Parties 123
Sample Document Index 125
Outline of Sample EMS Manual and Other EMS Documents 127
Sample Records Management Form (supplied courtesy of 130
General Oil Company) 132
Sample Procedure: Corrective and Preventive Action 134
(includes tracking log) 134
Sample Environmental Records Organizer 136
Sample Procedure: EMS Audits 136
Sample EMS Audit Forms 141
Sample EMS Audit Questions 143
Sample Procedure: Management Review 149
Note: The examples in the Tool Kit are drawn from many different sources. They are not
designed to be used together in EMS development.
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X
Sample
Environmental
Policies
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Sample policy - Actual policy reproduced with permission. Policy is not in original format.
NEO INDUSTRIES
HEALTH, SAFETY AND ENVIRONMENTAL POLICY
Neo Industries is committed to managing health, safety and environmental (HS&E) matters as an
integral part of our business. In particular, it is our policy to assure the HS&E integrity of our processes
and facilities at all times and at all places. We will do so by adhering to the following principles:
Compliance
We will comply with all applicable laws and regulations and will implement programs and procedures
to assure compliance. Strict compliance with HS&E standards will be a key ingredient in the training,
performance reviews and incentives of all employees.
Where existing laws and regulations are not adequate to assure protection of human health, safety
and the environment, we will establish and meet our own HS&E quality standards.
Prevention
We will employ management systems and procedures specifically designed to prevent activities and /
or conditions that pose a threat to human health, safety or the environment. We will minimize risk and
protect our employees and the communities in which we operate by employing safe technologies and
operating procedures, as well as being prepared for emergencies.
We will strive to prevent releases to the atmosphere, land or water. We will minimize the amount and
toxicity of waste generated and will ensure the safe treatment and disposal of waste.
Communication
We will communicate our commitment to HS&E quality to our employees, vendors and customers. We
will solicit their input in meeting our HS&E goals and in turn will offer assistance to meet their goals.
Continuous Improvement
We will continuously seek opportunities to improve our adherence to these principles, and will
periodically report progress to our stakeholders.
{Signature}
Neil K. Holt
President
March 1995
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Sample policy - Actual policy reproduced with permission. Policy is not in original format.
Pacific Gas and Electric Company
Environmental Quality
statement
PG&E is committed to a
clean, healthy environment.
We will provide our
customers with safe,
reliable, and responsive
utility service in an
environmentally sensitive
and responsible manner
We believe that sound
environmental policy
contributes to our
competitive strength and
benefits our customers,
shareholders, and
employees by contributing
to the overall well-being
and economic health of the
communities we serve.
September 1995
(Actual policy is printed on recycled paper)
We will:
Comply fully with the letter and spirit of
environmental laws and regulations, and
strive to secure fundamental reforms that will
improve their environmental effectiveness
and reduce the cost of compliance.
Consider environmental factors and the full
acquisition, use, and disposal costs when
making planning, purchasing, and operating
decisions.
Work continuously to improve the
effectiveness of our environmental
management.
Provide appropriate environmental training
and educate employees to be environmentally
responsible on the job and at home.
Monitor our environmental performance
regularly through rigorous evaluations.
Seek to prevent pollution before it is
produced, reduce the amount of waste at our
facilities, and support pollution prevention by
our customers and suppliers.
Manage land, water, wildlife, and timber
resources in an environmentally sensitive
manner.
Use energy efficiently throughout our
operations, and support the efficient use of
gas and electricity by our customers and
suppliers.
Re-use and recycle whenever possible.
Use environmentally preferred materials.
Clean up residual pollution from past
operations in a cost-effective manner.
Work cooperatively with others to further
common environmental objectives.
Communicate and reinforce this policy
throughout the company.
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Sample policy - Actual policy reproduced with permission. Policy is not in original format.
CAMPBELL & CO. ENVIRONMENTAL POLICY
Campbell & Go's commitment to improve the
environment is an expression of our Guiding
Principles, and a demonstration of "think
globally and act locally" sensibilities.
We strengthen this commitment by
employing Quality Operating System
methodology as the framework to identify
objectives and targets for addressing areas
of environmental significance.
Campbell & Co. is improving the condition of
our environment by preventing pollution,
specifically through the reduction of natural
resource usage. We are also helping to
preserve the environment by promoting
recycling as well as continuing to make
responsible environmental choices when
purchasing products.
Campbell & Co. will comply with all federal,
state and local legislation and regulatory
requirements, as well as those requirements
adopted through the Michigan Business
Pollution Prevention Partnership Policy.
Above all, Campbell & Co. employees will
strive to continuously improve our efforts to
create a cleaner and safer environment.
David Scheinberg, President & CEO
Created: June 6, 2000
Revised: October 6, 2000
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Sample policy - Actual policy reproduced with permission. Policy is not in original format.
Village Of Chelsea, Michigan
Statement Of Environmental Policy
The Village of Chelsea is committed to continual improvement of its Environmental
Management System and is in compliance with all relevant federal, state, and local
environmental legislation and regulations. The Village of Chelsea will meet and
strive to exceed all environmental requirements and will seek to prevent pollution
before it is produced. To sustain this commitment, the requirements of the
Environmental Management System described in this Manual apply to all activities
and employees. The Village's Department Superintendents are the Village's
Management Representatives who have the responsibility and authority to plan,
enforce, and maintain the Village's Environmental Management System. This
responsibility also includes stoppage of activities that deviate from the
requirements of this Manual. The EMS Management Representative may
delegate some of this authority downward through the organization in order to
implement the system effectively. We will continuously seek opportunities to
improve our adherence to the principles of environmental management.
Policy adopted by Village Council on March 11, 1997.
Village President
Village Clerk
[Signatures included in original policy.]
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Sample policy - Actual policy reproduced with permission. Policy is not in original format.
Saint Joseph Mercy Hospital (in Michigan) demonstrated that an environmental policy can
be written in the form of a procedure. One advantage of this approach is that hospital staff can
make a direct connection between the policy and their departmental responsibilities for
implementing the policy. The hospital includes its policy in the Administrative Policy Manual
because that manual was already well established and widely distributed. Integrating EMS
requirements with existing manuals, procedures, training, and responsibilities was a key
implementation strategy for the hospital.
Saint Joseph Mercy Hospital
Administrative Policy and Procedure
Subject: Environmental Compliance Policy
Effective Date: September 14, 1998
Revised Date:
Approved By: President and CEO
POLICY
It is the policy of St. Joseph Mercy Hospital (SJMH), which includes all SJMH owned and
operated buildings and services, to conduct all of its operations in an environmentally
responsible and sensitive manner. St. Joseph Mercy Hospital will fully comply with both
the letter and the spirit of all applicable federal, state and local regulatory requirements
governing hazardous materials and wastes, pollution prevention and environmental
protection. It is recognized that the health and well being of the environment contributes to
the health and well being of the communities and populations we serve. St. Joseph Mercy
Hospital will strive to continuously improve its systems and procedures related to
environmental protection and pollution prevention activities. St. Joseph Mercy Hospital will
manage its facilities and properties in an environmentally responsible manner. St. Joseph
Mercy Hospital will participate as appropriate in community, industry, and/or governmental
sponsored groups addressing environmental issues affecting the communities we serve.
NARRATIVE
Environmental protection is the responsibility of all SJMH departments and employees. As a
health care organization, SJMH must handle and manage a wide variety of potentially
hazardous or polluting materials including medical wastes, radioactive materials and
hazardous chemicals and wastes. Many of our processes present potential water and air
quality issues that demand continuous monitoring and control. Proper and responsible
handling of these materials and processes is imperative to prevent pollution, reduce waste
and protect our environment. A host of federal, state and local regulatory requirements are in
place to guide this organization in achieving environmental compliance.
PROCEDURE
I. Each department will continuously assess its operations to identify potential safety
hazards and pollution risks. Each department is responsible for establishing and
maintaining department specific policies and procedures designed to reduce or
eliminate environmental hazards and minimize any negative environmental impact
when applicable.
A. Potential risks will be minimized to the extent possible by seeking out less
environmentally hazardous products, equipment or procedures.
B. Appropriate engineering controls will be implemented when it is not
possible to eliminate an environmentally hazardous material or
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Sample policy - Actual policy reproduced with permission. Policy is not in original format.
procedure.
C. All departments and employees will strive to reduce all types of wastes
through identifying and eliminating wasteful practices and products and
participate in organizational recycling and waste reduction programs.
D. Departments will educate and communicate organizational and
department specific environmental policies, goals and objectives to
employees as required.
E. Departments will consider using products that have recycled content
taking economic and quality factors into account.
II- The Safety Steering Committee is responsible for monitoring environmental
compliance issues recommending and assuring that corrective action is
implemented as warranted to correct deficiencies.
A. Objectives and targets will be established to assure continuous
improvement in organizational environmental performance. Safety
Committee structure is responsible for establishing goals and
implementing programs to meet targets. The Safety Steering Committee
is responsible for monitoring progress and reporting activities to
Executive Management.
REFERENCES
• Safety Steering Committee
• Hazardous Material and Waste Committee
• Product Value Analysis Committee
• Safety Policy Manual Section lll_300 - "Hazardous Materials and Waste"
• Departmental Specific Hazardous Material/Pollution Prevention Policies and Procedures
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X
Environmental Impact
Identification and Evaluation:
Techniques and
Data Sources
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SOME TECHNIQUES AND DATA SOURCES FOR IDENTIFYING AND
EVALUATING ENVIRONMENTAL IMPACTS
Process Hazard
Analyses
Used to identify and assess potential impacts associated
with unplanned releases of hazardous materials.
Methodology in common use due to OSHA Process Safety
Management regulations. Typically employs team approach
to identify and rank hazards.
Failure Mode and
Effects Analyses
Commonly used in quality field to identify and prioritize
potential equipment and process failures as well as to
identify potential corrective actions. Often used as a
precursor to formal root cause analyses.
Process Mapping
See Appendix C for details of this technique.
Environmental Impact
Assessments
Used to satisfy requirements of National Environmental
Policy Act (NEPA) regarding the evaluation of environmental
impacts associated with proposed projects. Methodology in
common use, but not typically used to assess environmental
impacts associated with existing operations.
Life Cycle
Assessments
Used to assess full range of impacts from products, from
raw material procurement through product disposal.
Methodologies somewhat subjective and can be resource
intensive. Described in ISO 14040-14048.
Risk Assessments
Used to assess potential health and/or environment risks
typically associated with chemical exposure. Variety of
qualitative and quantitative methodologies in common use.
Project Safety / Hazard
Reviews
Used to assess and mitigate potential safety hazards
associated with new or modified projects. Methodologies in
common use. Typically do not focus on environmental
issues.
Used to quantify emissions of pollutants to the air. Some
data may already by available to the organization, based on
EPCRA requirements and CAA Title V permitting program.
Emission Inventories
Pollution Prevention
or Waste Minimization
Audits
Used to identify opportunities to reduce or eliminate pollution
at the source and to identify recycling options. Requires
fairly rigorous assessment of facility operations. Typically
does not examine off-site impacts.
Environmental
Property Assessments
Used to assess potential environmental liabilities associated
with facility or business acquisitions or divestitures. Scope
and level of detail is variable. Typically do not assess
impacts associated with products or services.
Environmental Cost
Accounting
Used to assess full environmental costs associated with
activities and/or products. Emerging protocols require
comprehensive assessment to quantify costs.
Environmental
Compliance Audits
Used to assess compliance with federal, state and local
environmental regulations. Methodologies in common use.
Scope and detail vary. Not typically directed at examining
environmental impacts (particularly for products).
©2001 NSF
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Sample Procedure:
Instructions for Environmental Aspects
Identification Form
(courtesy ofZEXEL Corporation)
©2001 NSF 98
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OPERATIONAL PROCEDURE
Number:
Title:
1 Author:
Ronda Moore
Environmental Aspects & Impacts
Issue Date:
August 04, 2000
Approval:
Vice President Operations
Reviewed By:
Waste Water Group Leader
1.0 Purpose
The purpose of this procedure is to provide a system and instructions to identify
environmental aspects of ZEXEL's activities, products, and services in order to
determine those which may have a significant impact on the environment.
2.0 Scope
This procedure covers all activities, products, and services associated with ZEXEL. For
purposes of evaluation, activities, products, and services with similar characteristics may
be grouped together.
Document Number
3.0 Reference Documents
Document Name
Objectives and Targets OP-EV0103
Management Review OP-ZX006
Aspect/Impact Evaluation Form WF-ES002
Aspect/Impact Listing - Decatur WF-ES008
Aspect/Impact Listing - Arcola WF-ES058
Initial Production Control OP-ZX001
Contract Review OP-SA001
4.0 Procedure
4.1 The procedure consists of an initial screening of activities, products, and services, based
on data submitted to the ISO 14000 Task Force by the Area Managers. The Task Force
assesses the aspects, determines associated impacts, and assigns an impact rating.
The Task Force will review the evaluation results, and up-date as needed.
4.2 Area Managers are responsible for developing a flowchart for their department(s)
showing all inputs and outputs to their processes. Inputs into the process may include
supplies, raw materials, chemicals, packaging, and energy consumption. Outputs from
the process may include products, solid wastes, liquid wastes, emissions, noise, and
odor. The flowcharts shall also include the current method of handling generated
wastes.
4.3 The Task Force shall evaluate the information submitted on the flowcharts. The Task
Force may call upon other ZEXEL Team Members to assist, as needed. Each activity,
product, and service shall be evaluated from the time the material is accepted on site
through the time of sale, at the sale location. If a waste is being evaluated, the timeline
to consider is the time the material is accepted on site through ultimate disposal, as
displayed by the diagram below.
©2001 NSF
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Accept Material
-Product-
-Waste—
Sale Location
I Ultimate Disposal
4.4 The Task Force shall assign an impact rating according to the scales described below,
while considering each of the following stages: raw material storage, production
(accidents, start up, and normal operation), product and waste storage, transportation,
and ultimate disposal.
4.5 The Task Force shall ask for each aspect / impact evaluation:
a) Is it in our permits / permittable?
b) Is it regulated by law?
c) Do we have control over it?
If the answer to a and/or b is "yes", the impact must be included on the list of significant
impacts. If the answer to c is "no", the impact shall not be included on the list of significant
impacts. The following table explains the different possible answers.
Possible Answer
yes
No
Permitted /
Permittable
must include
may include
Regulated by Law
must include
may include
Do we have
Control
may include
shall not include
4.6 When evaluating the "frequency", the number shall be determined from the following
scale, based on documented evidence, by asking the following questions to determine
frequency of use and of accidents: (1). How often does the process occur? and (2).
How often has a problem occurred?
Frequency
Continuously
once per shift
once per day
Weekly
Monthly
Quarterly
semi-annually
Annually
once every 1 to 5 years
over 5 years
Never
Scale
10
9
8
7
6
5
4
3
2
1
0
©2001 NSF
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4.7
4.8
4.9
When evaluating the "severity" the task force shall assign an impact number by selecting
the highest evaluated rate from the scale below, based on documented evidence. When
considering human impact, it is important to include contractors, neighbors, customers,
etc., as well as team members.
Severity
Scale
10
9
8
7
6
5
4
3
2
1
Human Impact
multiple deaths
single death
disabling injury
long term health
effects
lost time
Injury/Illness
restricted duty
medical only
first aid treatment
Discomfort
None
Animal /Plant
Effect
widespread
permanent
destruction
on-site permanent
destruction
widespread genetic
impact
on site genetic
impact
wide spread
disfigurement
on-site disfigurement
wide spread
appearance
reduction of natural
beauty
on-site appearance
none
Public Relations
plant closure
permanent public
disfavor
interrupted
operations
loss of historical
assets
state or national
protest
city or county protest
employee protest
public inconvenience
public disfavor
none
4.10
Impact ratings shall be determined by multiplying the frequency and severity numbers.
The Task Force shall determine an appropriate cutoff level for significant impacts.
The Environmental Manager shall work closely with ZEXEL's Plant Management to
ensure that the identified significant environmental aspects are considered in
establishing environmental objectives and targets for ZEXEL, as stated in the Objectives
and Targets OP.
The results of the most recent environment aspect / impact identification is reviewed as
part of the Management Review process, as specified in the Management Review OP.
From this review ZEXEL Management determines the need to update the environmental
impact evaluation. Factors considered in the determination to update the assessment
include improved methodologies, and major changes in ZEXEL's policies, products, or
processes. Aspect reviews may also be triggered from the Initial Production Control
(I PC) and Contract Review process. Environmental impact evaluations shall be
conducted at least, on an annual basis, by the end of each calendar year, even if none
of the factors listed above dictate a review.
©2001 NSF
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ASPECT / IMPACT EVALUATION
Aspect/Impact/Activity:
Date:
Category
Air Quality
Water
Quality
Land Quality
Consumption
Stages
Raw Material
Storage
Production
(Start-Up)
Production
(Normal)
Product/
Waste Storage
Transportation
Ultimate
Disposal
Freq
Use
uency
Incident
Severity
Human
Impact
Animal/Plant
Public
Impact
Rating
Overall Rating \ \
Please note. Significant Impact if
- permittable
- required by law
- over the establish cut off
Frequency
continuously
1 per shift
1 per day
weekly
monthly
quarterly
semi-annually
annually
1 every 1 - 5 yrs
over 5 yrs
never (Use Only)
Severity
Human Impact
multiple deaths
single death
disabling injury
long term health
effects
lost time injury/
illness
restricted duty
medical only
first aid
treatment
discomfort
none
Animal/ Plant Effect
widespread perm.
destruction
on-site permanent
destruction
widespread genetic
impact
on-site genetic impact
widespread
disfigurement
on-site disfigurement
widespread appearance
reduction of natural
beauty
on-site appearance
none
Public Relations
plant closure
permanent public
disfavor
interrupted
operations
loss of historical
assets
state or national
protest
city or county
protest
employee protest
public
inconvenience
public disfavor
none
Scale
10
9
8
7
6
5
4
3
2
1
0
©2001 NSF
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Environmental Aspects Identification Form
(courtesy of Johnson Controls, Inc. -
Automotive Systems Group)
Note: The instructions and form were developed within the context of a comprehensive
EMS. References are made to processes outside of the instructions.
This is intended as an example, not a stand-alone document.
©2001 NSF 103
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Provided courtesy of Johnson Controls, Inc., Automotive Systems Group
Instructions for Environmental Aspect Identification Form
Responsibilities
The facility Cross Functional Team (CFT) led by the Management Representative (MR) is
responsible for completing this form for each Core Process and Supporting Activity within a
facility. If possible, members of the CFT must conduct a physical inspection when completing
this form. The completed form is a material balance of a process or activity and is used to
identify Environmental Aspects. The facility CFT compares the resulting material balance and
list of facility-specific aspects to any information available in the form of generic "HSE Process
Profiles" produced for similar type processes or activities.
At a minimum, the CFT will review and revise the completed forms, by means of physical
inspection, as necessary at issuance, annually, prior to and immediately following
implementation of new or modified processes/activities.
All environmental aspects are evaluated for significance and managed as defined in the
Environmental Aspects Control Plan form.
Conducting a Material Balance
The material balance consists of identifying all raw materials, chemicals, and utilities used as
input along with their relative usage rates, and all output as product and by-products produced.
The latter is all wastes produced, all recycled materials, water discharges, and air emissions
known for the process(es), and any available rates of production.
1.0 Record the Plant Name, Process/Activity Name, and Location.
2.0 Provide a description of the process/activity.
3.0 Determine and record if the Process/Activity is a Contracted Process/Activity.
4.0 Record Material Inputs and Outputs. If the Process/Activity is installed or in place,
conduct the identification by means of physical inspection.
Raw material inputs
• Parts: Enter the major, non-chemical parts/supplies used in the process.
• Chemical: Enter any chemical materials used in the process.
• Energy: Enter energy type and usage. (Levels are relative to the facility.)
• Other Input: Enter inputs that are not covered clearly in other categories, (e.g.
packaging, containers)
• Water Use: Enter water type (e.g. city, well, storm, process, chilled) and usage.
(Levels are relative to the facility.)
©2001 NSF 104
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Provided courtesy of Johnson Controls, Inc., Automotive Systems Group
Process Output
• List all products produced by the process specifically produced for sale.
Recyclable and Chemical By-Product (e.g. Rebond) outputs are entered in the
waste section.
• List all air emissions whether they are drawn directly through a stack or are
discharged into the room and escape as fugitive emissions. Include noise and
odor as an air emission if potentially noticeable outside the facility.
• Enter wastes. Wastes are any materials intended to be discarded or disposed of,
whether regulated or not, and include liquids, solids, and gases. Also include
recycled materials, returnable containers and chemical by-products under this
category
• Check the recycled box if the material is currently recycled, internally or
externally. It does not include materials that go directly back into the process
(i.e., Calibration shots returned to day tanks, etc.)
• Include containerized wastewater transported off-site.
• Enter all wastewater streams that discharge directly to storm or sanitary sewer
systems or surface waters. Containerized wastewater should be included in the
waste section. In the bottom portion of the wastewater section, list any treatment
that occurs before the water is discharged.
5.0 Compare the completed form to any information available in the form of generic "HSE
Process Profiles" produced for similar type processes or activities.
6.0 Sign and date the form with the date the form was completed or revised.
7.0 Collect all completed Aspect Identification forms and enter data into the supporting
Environmental Aspect Control Plan form.
©2001 NSF 105
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X
Environmental Aspects Identification
Process Overview
Establish Cross
Functional Team
(CFT)
Determine Core
Processes and
Supporting Activities
Inspect each
Process/Activity and
conduct material
blanace
Identify and record
aspects
Compare to available
profiles
Proceed to
Environmental
Aspects
Analysis and
Control Form
©2001 NSF
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Plant
ENVIRONMENTAL ASPECTS IDENTIFICATION
Process/Activity:
Contracted?
Process/Activity Location:
RAWMflTERIAl UIPUTS
PARTS
CHEMICAL MftTEPW
Natural 0«
Pr^«n«
Steam
Compressed A*
HydraUic;
E1IE.RGV L
USAGt
MHfiUTI
LOW
OTHER IMPUT:
TVPfe
WAIIBJIg:
USAGt
H^h t*lKhUTi
LOW
•1
MATER
5te(cti drawing, deiaierf descr frfion
^
WAIEH DISCHARGES
•'vr,!f [ie«rri-^'i rvriei
PHOOIICT OUTWTS
Jfe
AlfttMSSJOIB
WASTfj* BYPRODUCTS)
ISOU CL Lk)UK]|
_D
©2001 NSF
107
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X
Sample Environmental
Aspect Evaluation and
Scoring Tools
©2001 NSF 108
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Sample 1: Environmental Aspect/Impact Scoring Worksheet
A company identified "Spills from Unloading Trucks" as an environmental aspect of its
operations. The company used the following worksheet and rating criteria to determine
whether the environmental impacts (on water quality and/or soil contamination) of this
aspect should be considered significant.
First, the company determined that the LIKELIHOOD of a spill was low, since it had not
experienced any spills of this type in the prior three years. Second, they determined that the
MAGNITUDE (or SEVERITY) of the environmental impact would be moderate for most of
the types of materials that they unload from trucks at the loading dock. The company noted,
however, that certain chemicals are regulated and that spills of such materials in reportable
quantities would require an appropriate response to regulatory agencies.
Using the "Key to Impact Rating" (see below), an environmental impact with a Low
Likelihood and a Moderate Magnitude received an overall score of "low impact
significance". Thus, "spills from unloading trucks" was not considered a significant
environmental aspect.
Area or
Activity
Shipping
Dock
Aspect
Spills from
Unloading
Trucks
Impacts
Water Quality
and
Soil
Contamination
Impact Scoring
(see below)
Likelihood is
low
Magnitude
is moderate
A
OVERALL \
IMPACT / \
SCORE IS / \
LOW \
Significance
Not
Significant
(Note: spills
of
reportable
quantities of
certain
chemicals
\must be
\ Yeported)
Key to Impact Rating
Likelihood of
Occurrence
or Impact(s)
High
Medium
Low
Magnitude
(severity of impacts, actual or pc/
Severe
High
Significance
High
Significance
Medium
Significance
Moderate /
High
Significance
Medium
Significance
Low
Significance
r^ I
t
/
ential
Low
Medium
Significance
Low
Significance
Low
Significance
Excerpted from "Environmental Management Systems: A Guide for Metal Finishers"
(NSF International), available for free download at www.nsf-isr.org.
©2001 NSF
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Sample 2: Environmental Aspect/Impact Scoring Worksheet
Approach
For each product, service or activity (or group of products, services or activities), each
element in the table is assigned two scores, based on (1) the degree of impact and (2)
frequency or likelihood of the associated environmental impacts.
Degree of Impact
4 = serious (likely to result in severe or widespread damage to human health or the
environment)
3 = moderate
2 = minor
1 = no impact (unlikely to have an adverse impact on human health or the environment)
Frequency/Likelihood of Impact
4 = continuous (impact occurs on an on-going basis)
3 = frequent (impact occurs more than once / month)
2 = infrequent (impact occurs more than once / year but less than once / month)
1 = improbable / never (impact has never occurred or is highly unlikely to occur)
Scores are added for each indicator across the relevant life cycle stages (as shown in the
example below) to generate a total impact score.
Category
Human Health
Environment
Resource Use
Indicator
Employees
Surrounding
Community
Global
Air Quality
Surface
Water
Ground
Water
Land / Soil
Ecosystem
Effects
Noise
Fuels
Water
Raw
Materials
Pre-
Production
3/2
2/2
1/2
Manufact- Production/ Use / Waste
uring Distribution Service Mgt
2/2
2/3
1/2
2/1
2/2
1/3
4/2
1/2
1/2
2/2
2/2
1/3
TOTAL
SCORE
22
20
17
©2001 NSF
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X
Resources for Tracking Environmental
Laws and Regulations
©2001 NSF 111
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Resources for Tracking Environmental Laws and Regulations
Over the last few years, the Internet has emerged as a tremendous tool for tracking and
obtaining information on environmental laws and regulations. For example, the USEPA
home page (see address below) in one quite useful Internet source. See Appendix F for
additional information on resources.
This table describes a variety of commercial and non-commercial sources of information on
federal and state environmental laws and regulations. This list is not intended to be
comprehensive. Appearance on this list should not be construed as an endorsement by
EPA or NSF of any commercial products listed here.
Source
USEPA
Small Business Ombudsman
(1-800-368-5888)
USEPA Web Site
Small Business Assistance
Programs (various states)
US Small Business
Administration
US Government Printing Office
(202-512-1800)
Trade and Professional
Associations (various)
Counterpoint Publishing
(1-800-998-4515)
Bureau of National Affairs
(1-800-372-1033)
Thompson Publishing Group
(1-800-677-3789)
Business & Legal Reports, Inc.
(1-800-727-5257)
Aspen Law and Business
(1-800-638-8437)
Description
Regulatory explanations and guidance, research, case
studies, contacts for additional information. Variety of hotlines
available for particular statutes (such as RCRA). Internet
access also available (http://www.epa.gov).
Provides a variety of information of environmental laws and
regulations as well as tools and compliance guidance.
(http://www.epa.gov).
Guidance on regulations and compliance issues. Initially
focused on clean Air Act requirements, but expanding into
other environmental media.
Various services available to small businesses in the US.
Federal Register published daily with all federal proposed and
final rules. (Also available on line via GPO Access)
Provide a variety of services related to environmental laws
and regulations, including regulatory updates and training.
Contact individual associations for details.
CD-ROM and Internet dial-up access to legal / regulatory
information for federal government and all 50 states, updated
daily.
Information on EHS laws, regulations and activities at
international, national and state level. Paper and electronic
access available.
Manuals on a variety of federal and state environmental
programs with monthly updates and newsletters.
Access to federal and state regulations with monthly, updates
on available on CD-ROM.
Publishes compliance manuals with regular update service for
RCRA and Clean Air Act.
©2001 NSF
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X
Sample Process Tool:
Setting Objectives & Targets
©2001 NSF 113
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Sample Process Tool for Setting Objectives & Targets
Step 1: A cross-functional team is a good way for your organization to set realistic objectives
and targets. List here who needs to be involved on the team:
Name
Contacted?
Step 2: Think about what information sources your team will need to establish objectives and
targets. Pull together information sources such as:
Information Sources
process maps
waste, and emission data
site maps
compliance audit reports
list of identified environmental aspects and
impacts
communications from interested parties
others??
(you may also want to do a plant tour or "walk
through" to identify other issues)
How they will help
e.g.,
• identify process steps with environmental
aspects
• determine current wastes and sources
• etc.
Step 3: Is there other information that might be helpful to the team?
Other Information Needed
Where we will get it
©2001 NSF
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Step 4: List the significant environmental impacts (you identified these earlier). You can
categorize these impacts by type:
Energy
Use
Raw
Materials
Air
Impacts
Water
Impacts
Waste
Impacts
Land
Issues
Other
(specify)
Step 5: Look at processes (such as plating or assembly) and activities (such as shipping or
purchasing). Are there any other issues the team should consider, in addition to those
listed above as significant impacts? (For example, you might want to establish an
objective to reduce spills of hazardous materials at the loading dock, even if this was not
identified as a potentially significant environmental impact.)
Process or activity
Issues
Possible Objectives & Targets
Step 6: List any new regulatory requirements that affect the facility (or other regulations for
which the need for additional actions has been identified).
Regulations, other requirements
Possible Objectives & Targets
Step 7: Consider inputs from interested parties. Any need for additional objectives related to
views of neighbors, community groups or other parties?
Inputs from Interested Parties
Possible Objectives & Targets
©2001 NSF
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Step 8: Look at the lists of possible objectives developed in Steps 4 -7. Brainstorm
with the team on whether these objectives are:
• reasonable,
• technologically feasible,
• consistent with other organizational plans/goals, and
• affordable.
List preliminary objectives and targets based on this exercise:
Selected Preliminary Objectives
Step 9: Determine how you will measure each of the selected preliminary objectives. (If you
cannot establish an effective way to measure it, put that objective "on-hold" for later
consideration).
Selected Objectives
Performance Indicator(s)
Step 10: For each objective that you selected, determine who is going to develop the action plan
(who, what, when, where, how). List these names below:
Selected Objectives
Responsibility for Action Plan
©2001 NSF
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Sample Procedure:
Setting Objectives & Targets
©2001 NSF 117
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EMS PROCEDURE: SETTING AND TRACKING OF ENVIRONMENTAL
OBJECTIVES AND TARGETS
I. Purpose
The purpose of this procedure is to ensure that the organization establishes and maintains
documented environmental objectives and targets.
II Scope
This procedure applies to environmental objectives and targets set at all relevant levels
within the organization.
III. Definitions
Environmental (or environmental) objective- A site goal that is consistent with the
environmental policies and considers significant environmental impacts and applicable laws
and regulations. Objectives are quantified wherever practicable.
Environmental (environmental) target- A detailed performance requirement (quantified
wherever practicable) based on an environmental objective. A target should be met in order
for the underlying objective to be achieved.
IV. General
The organization establishes environmental objectives and targets in order to implement the
environmental policies. Objectives and targets also provide a means for the organization to
measure the effectiveness of its environmental efforts and improve the performance of the
environmental management system. In establishing environmental objectives, the
organization considers:
• applicable laws and regulations (and requirements of other programs, such as ...);
• environmental aspects of the organization's activities and products;
• technological, financial, operational, and other organizational requirements; and,
• the views of employees and other interested parties.
Based on the organization 's environmental objectives, targets are established for different
functions within the organization and for different areas of the plant. For example, the
organization may establish an environmental objective to "reduce waste generation by 10%
per year". Based on this objective, different areas of the plant might set targets for reducing
individual waste streams in order to ensure that the organization's objective was achieved.
An organization-wide environmental objective might also be translated into individual
projects (such as changes in production processes, materials or pollution control equipment)
in different plant areas.
©2001 NSF 118
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V. Procedure
A. The organization's top management is responsible for establishing environmental
objectives on an annual basis. To initiate the process, the Plant Manager holds a
meeting of all staff members to discuss the development of environmental objectives.
B. Objectives are action- and prevention-oriented and are intended to result in meaningful
improvements in the organization 's environmental performance.
C. Each plant area or functional manager is responsible for providing input from his / her
own function (Finance, Engineering, etc.) or shop area (Fabrication, Assembly, Shipping /
Receiving, etc.). The organization's environmental manager is responsible for providing
input on applicable laws and regulations, significant site environmental impacts, and the
views of interested parties. (These inputs are obtained from the separate analyses
required by Procedure #'s).
D. As a starting point, the organization's management evaluates its performance against
environmental objectives for the current year. As part of this effort, management
examines the results of its environmental performance evaluations.
E. Preliminary environmental objectives are developed for further discussion and evaluation.
Each manager is responsible for evaluating the potential impacts within his / her
functional or shop area (if any) of the proposed environmental objectives. The
organization's environmental manager reviews proposed objectives to ensure
consistency with the overall environmental policy.
F. Environmental objectives are finalized, based on review comments from site managers
and employees. Each manager identifies the impacts of the objectives in his / her
function or shop area, establishes targets to achieve the objectives, and develops
appropriate measures to track progress towards meeting the objectives and targets.
G. Each manager is responsible for communicating objectives and targets (and the means
for achieving them) to others in his / her part of the organization.
H. Progress towards the objectives and targets is reviewed on a regular basis at
management meetings. The progress is also communicated to plant employees via
bulletin boards and other similar means.
I. At the end of each calendar year, the organization's management reviews its performance
with regard to achieving the objectives and targets. This information is used as input to
setting objectives and targets for the succeeding year.
©2001 NSF 119
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X
Sample Tools:
Environmental Management Program
©2001 NSF 120
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Sample Environmental Management Program Form
(Note: Use one form per objective)
Date Individual Responsible:
I I I )
Environmental Objective:
Related Target(s):
Related Significant Environmental Aspect(s):
Specific Function and/or Department:
Target Date (Month/Year): (_
Environmental Management Program: Action Plan
How will this objective be met? (attach additional pages as necessary)
What operational controls might support the achievement of this objective?
How will this objective be tracked? (attach additional pages as necessary)
What resources will be required to achieve this objective? (attach additional
pages as necessary)
Adapted from the EPA/NSF guide "Environmental Management Systems: A Guide for Metal
Finishers" (December 1998). Available for free download at www.nsf-isr.org.
©2001 NSF 121
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Environmental Management Program - Sample Tool
Objective / Target #1
Action Items
Priority
Respon-
sibilities
•
•
Schedule
Resources
Needed
Comments
©2001 NSF
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X
Sample Responsibility Matrix
©2001 NSF 123
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Legend:
L = Lead Role
S = Supporting Role
Responsibility Matrix
Communicate importance of
environmental management
Coordinate auditing efforts
Track / analyze new
regulations (and maintain
library)
Obtain permits and develop
compliance plans
Prepare reports required by
regulations
Coordinate communications
with interested parties
Train employees
Integrate environmental into
recruiting practices
Integrate environmental into
performance appraisal
process
Communicate with
contractors on
environmental expectations
Comply with applicable
regulatory requirements
Conform with organization's
EMS requirements
Maintain equipment /tools
to control environmental
impact
Monitor key processes
Coordinate emergency
response efforts
Identify environmental
aspects of products,
activities, or services
Establish environmental
objectives and targets
Develop budget for
environmental management
Maintain EMS records
(training, etc.)
Coordinate EMS document
control efforts
Plant
M'gr
L
L
L
L
S
L
EHS
M'gr
S
L
L
L
L
S
L
L
S
S
L
S
S
L
HR
M'gr
L
L
L
S
S
S
Maintenance
S
S
S
L
S
Purchasing /
Materials
L
S
S
S
S
Engineering
S
S
S
S
Production
Supervisor(s)
S
S
L
S
S
L
S
S
Finance
S
S
S
L
EMS
Mg't Rep.
S
S
S
L
Employees
S
S
©2001 NSF
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X
Sample Environmental Training Log
©2001 NSF 125
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EMS Training Log (Sample)
Training Topic
EMS Awareness
Supervisor EHS Training
Hazardous Waste
Management
Hazardous Waste
Operations
Spill Prevention &
Response
Chemical Management
Emergency Response
Accident Investigation
Hazardous Materials
Transport
Hazard Communication
Personal Protective
Equipment
Fire Safety
Electrical Safety
Hearing Conservation
Confined Space Entry
Lock-out/Tag-out
Bloodborne Pathogens
Job-Specific Training (list)
Attendees*
Frequency
Course Length
Course
Method
Comments
Date
Completed
Attendees Code
1: All Employees
2: Supervisors / Managers
3: Operators
4: Maintenance
5: Material Handlers
6: Engineering
©2001 NSF
126
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X
Sample Procedure:
Communications with External
Parties
©2001 NSF 127
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EMS PROCEDURE: COMMUNICATIONS
WITH EXTERNAL PARTIES
I. Purpose
This procedure is intended to establish a process for outreach and communication
with external parties regarding the organization's environmental management system
(Note: the organization should also consider external communication regarding its
significant environmental aspects).
II. Scope
This procedure describes how the organization receives, documents, and responds to
communications from external parties. In addition, it discusses proactive steps that
the organization takes to maintain a meaningful dialogue with external parties on
environmental matters.
III. Definitions
Interested Parties- Individuals or groups with an interest in the environmental impacts
of the organization's products, activities or services. These parties include regulators,
local residents, employees, stockholders, insurers, customers, environmental groups
and the general public (adapted from ISO 14001).
IV. General
The organization uses a number of mechanisms to ensure effective communication
with interested parties. These mechanisms include regulatory filings (such as permit
applications and reports), open houses, the media, and informal discussions with
regulators, community representatives, and local business leaders.
To solicit the views of interested parties, the organization may use additional
techniques, including (but not limited to) surveys, community advisory panels,
newsletters, or informal meetings with representatives of external groups.
General rules for external communications require that the information provided by the
organization:
• be understandable and adequately explained to the recipient(s); and
• present an accurate and verifiable picture of the organization and its
environmental management system, its environmental performance, or other
related matters.
©2001 NSF 128
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V. Procedure
A. Management of Communications from External Parties
1. Inquiries and other communications (received by mail, fax, telephone, or in
person) from external parties concerning the organization's EMS or
environmental performance may be received by a number of the
organization's representatives, including the Plant Manager, the
environmental manager, and the human resources manager, among others.
All such communications are reviewed by the Plant Manager or his / her
designee to determine the appropriate response.
2. Communication with representatives of regulatory agencies is delegated to
the organization's environmental manager, who maintains records of all
such communications (both incoming and outgoing). In the absence of the
environmental manager, communications with regulatory officials are
delegated to the human resources manager.
3. Copies of all other written communications on environmental matters are
maintained by the human resources manager. All non-written
communications from external parties are documented using telephone logs
or similar means. All records of external communications are maintained as
discussed in Procedure # (Records Management).
4. A record of the responses to all communications from external parties is
maintained by the human resources manager in files designated for that
purpose.
B. Outreach to Interested Parties
1. The organization solicits the views of interested parties on its environmental
management system, its environmental performance, and other related
matters. In particular, such outreach is conducted when significant changes
at the facility are being considered, such as facility expansion or other
actions that might affect the actual or potential environmental impacts of the
organization's products, activities, or services.
2. As part of the Management Review process, the team designated to
conduct the Review evaluates proactive efforts to communicate with
external parties. Based on this evaluation and other factors, the
organization's management determines the need for outreach with external
parties in the coming year and how such communications can be carried
out most effectively.
External Hazard and Emergency Communication
Note: All external communications regarding emergency response are addressed in
Procedure #.
©2001 NSF 129
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X
Sample Document Index
©2001 NSF 130
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Sample Document Index
(sample indicates individual that revised document, his/her Dosition/deoartment and date(s) of
revision) Revision Number
Document
Environmental Policy
Environmental Manual
Procedure 1 :
Environmental Aspects
Identification
Procedure 2: Access to
Laws and Regulations
Procedure 3: Setting
Objectives & Targets
Procedure 4:
Environmental Training
Procedure 5: External
Communications
Procedure 6: Internal
Communications
Procedure 7: Document
Control
Procedure 8:
Emergency
Preparedness
Procedure 9: Corrective
Action
Procedure 10: Records
Management
Procedure 1 1 : EMS
Audits
Procedure 12:
Management Reviews
Procedures 13-X(list
individually)
EMS Audit Checklist
Other plans &
documents related to
above procedures (list
separately, e.g. SPCC
Plan, Emergency
Response Plan, etc.).
Other forms and
checklists (list)
1
John Smith
Plant Manager
1/1/98
2
John Smith
Plant Manager
1/1/99
3
4
5
6
©2001 NSF
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X
Outline of Sample
EMS Manual and
Other EMS Documents
©2001 NSF 132
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Outline of Sample EMS Manual and Other EMS Documents
Basic EMS Manual
• Index / Revision History / Distribution List
• Environmental Policy
• Description of How Our EMS Addresses Each of the EMS Elements (and linkages
among these elements)
- How We Identify Significant Environmental Aspects
- How We Access and Analyze Legal and Other Requirements
- How We Establish and Maintain Objectives and Targets
- How the Organizational Structure Supports EMS (organization charts, key
responsibilities)
- How We Train our Employees and Ensure Competence
- How We Communicate (internally and externally)
- How We Control EMS Documents
- How We Identify Key Processes and Develop Controls for them
- How We Prepare for and Respond to Emergencies
- How We Monitor Key Characteristics of Operations and Activities
- How We Identify, Investigate and Correct Nonconformance
- etc.
Environmental Management Program Description
• Annual Objectives and Targets
• Action Plans (to achieve objectives and targets)
• Tracking and Measuring Progress
EMS Procedures
• Index / Revision History / Distribution List
• Organization-wide Procedures (for some EMS elements there might be more than
one procedure)
- Environmental Aspects Identification
- Access to Legal and Other Requirements
- Training, Awareness and Competence
- Internal Communication
- External Communication
- Document Control
- Change Management Process(es)
- Management of Suppliers / Vendors
- Emergency Preparedness and Response
- Monitoring and Measurement
- Calibration and Maintenance of Monitoring Equipment
- Compliance Evaluation
- Corrective and Preventive Action
- Records Management
- EMS Auditing
- Management Review
• Procedures /Work Instructions for Specific Operations or Activities
- Waste Management
- Wastewater Treatment (These are examples only)
- Operation of the Paint Line
Other EMS Documentation (Emergency Response Plans, etc.)
©2001 NSF 133
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X
Sample Records Management Form
(supplied courtesy of
General Oil Company)
©2001 NSF 134
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Title: EMS RECORDS MANAGEMENT TABLE
Revision Date: November 7, 2000
Print Date: February 15, 2001 (Uncontrolled document if
printed)
Doc. No.: EMF-4.5.3
Approval by:
Page 135 of 1
EMS Records Management Table
The following table lists records related to the Environmental Management System, in
accordance with EMP-4.5.3 (Record keeping procedure).
Record Type
ADMINISTRATION
Records on costs - purchasing,
operations, and disposal
Utility bills
Record of annual waste quantity
received
Certificates of Insurance
Waste Analysis Sheets
Waste Manifests - outgoing
ENVIRONMENTAL
Incident Reports
Complaint Reports
EMS Communications with external
parties
Decision regarding external
communication of significant
environmental aspects
Major Source Determination Records
Title V Permit Exemption
Correspondence regarding Air Notices
Odor Control System Permit
Air Emission Reports
Records on waste disposal sites used
EMS Monitoring Inspection reports
Person Responsible
Office Manager
Office Manager
Office Manager
Office Manager
Office Manager
Office Manager
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Env. Dept.
Location
Admin. Office
Admin. Office
Admin. Office
Admin. Office
Admin. Office
Admin. Office
Env. Office
Env. Office
Env. Office
Env. Office
Env. Office
Env. Office
Env. Office
Env. Office
Env. Office
Env. Office
Env. Office
File
Method
Date order
Date order
Date order
Date order
Customer
name
Date order
Date order
Date order
Issue
Date order
Date order
Date order
Date order
Date order
Date order
Site name
Date order
Retention
minimum
3 years
3 years
Life of Co.
Life of
Company
3 years
3 years
3 years
3 years
3 years
3 years
Life of Co.
Life of
Company
5 years
5 years or
per Permit
5 years
Life of Co.
5 years
©2001 NSF
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X
Sample Procedure:
Corrective and Preventive Action
(includes tracking log)
©2001 NSF 136
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EMS PROCEDURE: PREVENTIVE AND CORRECTIVE ACTION
I. Purpose
The purpose of this procedure is to establish and outline the process for identifying,
documenting, analyzing, and implementing preventive and corrective actions.
II. Scope
Preventive or corrective actions may be initiated using this procedure for any environmental
problem affecting the organization.
III. General
A. Corrective action is generally a reactive process used to address problems after they
have occurred. Corrective action is initiated using the Corrective Action Notice (CAN)
document as the primary vehicle for communication. Corrective action may be triggered
by a variety of events, including internal audits and management reviews. Other items
that might result in a CAN include neighbor complaints or results of monitoring and
measurement.
B. Preventive action is generally a proactive process intended to prevent potential problems
before they occur or become more severe. Preventive action is initiated using the
Preventive Action Notice (PAN). Preventive action focuses on identifying negative trends
and addressing them before they become significant. Events that might trigger a PAN
include monitoring and measurement, trends analysis, tracking of progress on achieving
objectives and targets, response to emergencies and near misses, and customer or
neighbor complaints, among other events.
C. Preventive and corrective action notices are prepared, managed and tracked using the
preventive and corrective action database.
D. The ISO Management Representative (or designee) is responsible for reviewing issues
affecting the EMS, the application and maintenance of this procedure, and any updates to
EMS documents affected by the preventive and corrective actions.
E. The ISO Management Representative is responsible for logging the PAN or CAN into the
database, and tracking and recording submission of solutions in the database. The
requester and recipient of the CAN or PAN are responsible for verifying the effectiveness
of the solution. The ISO Management Representative is responsible for overall tracking
and reporting on preventive and corrective actions.
F. Personnel receiving PAN's and CAN'S are responsible for instituting the required
corrective or preventive action, reporting completion of the required action to the ISO
Management Representative, and assuring sustained effectiveness.
©2001 NSF 137
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///. General (cont'd.)
G. Completed records of PAN's and CAN'S are maintained in the database for at least two
years after completion of the corrective or preventive action.
IV. Procedure
A. Issuing a CAN or PAN
1. Any employee may request a CAN or PAN. The employee requesting the CAN or
PAN is responsible for bringing the problem to the attention of the ISO Management
Representative. The ISO Management Representative is responsible for
determining whether a CAN or PAN is appropriate and enters the appropriate
information into the corrective and preventive action database. Responsibility for
resolving the problem is assigned to a specific individual ("the recipient").
2. The ISO Management Representative, working with the recipient, determines an
appropriate due date for resolving the CAN or PAN.
B. Determining and Implementing Corrective and Preventive Actions
1. The CAN or PAN is issued to the recipient, who is responsible for investigation and
resolution of the problem. The recipient is also responsible for communicating the
corrective or preventive action taken.
2. If the recipient cannot resolve the problem by the specified due date, he / she is
responsible for determining an acceptable alternate due date with the ISO
Management Representative.
C. Tracking CAN'S and PAN's
1. CAN'S or PAN's whose resolution dates are overdue appear on the Overdue
Solutions report. The ISO Management Representative is responsible for issuing
this report on a weekly basis to the Plant Manager and the recipients of any
overdue CANs or PANs.
2. Records of PANs and CANs are maintained in the database for at least two years
after completion of the corrective or preventive action.
D. Tracking Effectiveness of Solutions
1. The recipient of a CAN or PAN, in conjunction with the requester, are responsible for
verifying the effectiveness of the solution. If the solution is deemed not effective, the
CAN or PAN will be reissued to the original recipient.
©2001 NSF 138
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SAMPLE CORRECTIVE ACTION NOTICE
CAN Number: Issue Date: Solution Due Date:
Name Location Phone:
Requested By:
Issued To:
Problem Statement (completed by ISO Management Representative):
Most Likely Causes (completed by ISO Management Representative):
Implemented Solutions (completed by recipient- include dates as applicable):
Results (confirming effectiveness):
Closed by: Closing Date:
©2001 NSF 139
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CORRECTIVE ACTION TRACKING LOG
CAN
Number
Requested
By
Issued
To
Plan
Due
(Date)
Plan
Completed
(Date)
Corrective
Action
Completed
(Date)
Effectiveness
Verified
(Date)
CAN
Closed
(Date)
©2001 NSF
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X
Sample Environmental
Records Organizer
©2001 NSF 141
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Environmental Records Organizer (SAMPLE)
Air Emissions Regulations
Air Emissions Fees
Air Emissions Inventories
Air Emissions Permits
Air Permit Applications
Air Permit(s): Historical
Annual Licenses & Fees
Compliance Reporting
Compliance Plans
Community Right-to-Know
EPCRA Regulations
EPCRA Reporting
Hazardous Waste Regulations
Hazardous Waste Permit/ID Number
Hazardous Waste Fees
Hazardous Waste Biennial Report
Hazardous Waste: Open Manifests
Hazardous Waste: Closed Manifests
Historical Data
Indoor Air Quality
Loss Prevention Information
Other Permits & Permit Applications
Pollution Prevention (P2) Regulations
Pollution Prevention Fees
Pollution Prevention Reporting
Recycling Information
Recycling Projects
Special Wastes
Solid Waste Permit
Solid Waste Fees
Spill Reports
Spill Response Actions
Stormwater Regulations
Stormwater Permit
VOC/HAPs Reporting
VOC Annual Analysis
Wastewater Regulations
Wastewater Fees
Wastewater Permit
Wastewater: Semi-Annual Reporting
©2001 NSF
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X
Sample Procedure: EMS Audits
©2001 NSF 143
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EMS Procedure: Environmental Management System Audits
I. Purpose
To define the process for conducting periodic audits of the environmental management
system (EMS). The procedure defines the process for scheduling, conducting, and
reporting of EMS audits.
II. Scope
This procedure applies to all internal EMS audits conducted at the site.
The scope of EMS audits may cover all activities and processes comprising the EMS or
selected elements thereof.
III. General
Internal EMS audits help to ensure the proper implementation and maintenance of the EMS
by verifying that activities conform with documented procedures and that corrective actions
are undertaken and are effective.
All audits are conducted by trained auditors. Auditor training is defined by Procedure #.
Records of auditor training are maintained in accordance with Procedure #.
When a candidate for EMS auditor is assigned to an audit team, the Lead Auditor will
prepare an evaluation of the candidate auditor's performance following the audit.
The ISO Management Representative is responsible for maintaining EMS audit records,
including a list of trained auditors, auditor training records, audit schedules and protocols,
and audit reports.
EMS audits are scheduled to ensure that all EMS elements and plant functions are audited
at least once each year.
The ISO Management Representative is responsible for notifying EMS auditors of any
upcoming audits a reasonable time prior to the scheduled audit date. Plant areas and
functions subject to the EMS audit will also be notified a reasonable time prior to the audit.
The Lead Auditor is responsible for ensuring that the audit, audit report and any feedback to
the plant areas or functions covered by the audit is completed per the audit schedule.
The ISO Management Representative, in conjunction with the Lead Auditor, is responsible
for ensuring that Corrective Action Notices are prepared for audit findings, as appropriate.
©2001 NSF 144
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IV. Procedure
A. Audit Team Selection - One or more auditors comprise an audit team. When the team
consists of more than one auditor, a Lead Auditor will be designated. The Lead Auditor is
responsible for audit team orientation, coordinating the audit process, and coordinating
the preparation of the audit report.
B. Audit Team Orientation - The Lead Auditor will assure that the team is adequately
prepared to initiate the audit. Pertinent policies, procedures, standards, regulatory
requirements and prior audit reports are made available for review by the audit team.
Each auditor will have appropriate audit training, as defined by Procedure #.
C. Written Audit Plan - The Lead Auditor is responsible for ensuring the preparation of a
written plan for the audit. The Internal EMS Audit Checklist may be used as a guide for
this plan.
D. Prior Notification - The plant areas and / or functions to be audited are to be notified a
reasonable time prior to the audit.
E. Conducting the Audit
1. A pre-audit conference is held with appropriate personnel to review the scope, plan
and schedule for the audit.
2. Auditors are at liberty to modify the audit scope and plan if conditions warrant.
3. Objective evidence is examined to verify conformance to EMS requirements,
including operating procedures. All audit findings must be documented.
4. Specific attention is given to corrective actions for audit findings from previous audits.
5. A post-audit conference is held to present audit findings, clarify any
misunderstandings, and summarize the audit results.
F. Reporting Audit Results
1. The Team Leader prepares the audit report, which summarizes the audit scope,
identifies the audit team, describes sources of evidence used, and summarizes the
audit results.
2. Findings requiring corrective action are entered into the corrective action database.
©2001 NSF 145
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IV. Procedure (cont'd.)
G. Audit Report Distribution
1. The ISO Management Representative is responsible for communicating the audit
results to responsible area and / or functional management. Copies of the audit
report are made available by the ISO Management Representative.
2. The ISO Management Representative is responsible for ensuring availability of audit
reports for purposes of the annual Management review (see Procedure #).
H. Audit Follow-up
1. Management in the affected areas and / or functions is responsible for any follow-up
actions needed as a result of the audit.
2. The ISO Management Representative is responsible for tracking the completion and
effectiveness of corrective actions.
I. Record keeping
1. Audit reports are retained for at least two years from the date of audit completion.
The ISO Management Representative is responsible for maintaining such records.
©2001 NSF 146
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Audit Plan
Area or
Function to be
Audited
Purchasing
•
•
•
•
•
•
Lead
Auditor
• Jim H.
•
•
•
•
•
•
Audit Team
Members
• Linda B.
• Joe S.
•
•
•
•
•
•
Target
Date
• 11/10/00
•
•
•
•
•
•
Special Instructions
- Verify corrective actions
from previous audit
- Interview new employee
in department
•
•
•
•
•
•
©2001 NSF
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Sample Communications to Audit Team
ENVIRONMENTAL MANAGEMENT SYSTEM AUDIT
Lead Auditor:
Audit Team Members:
Audit Area:
Target Due Date:
Listed above is the area to be audited. The due date given is the target to have the entire audit
completed, including the report and follow-up meeting with the responsible area management. Listed
below are the areas of environmental management systems criteria that you are to assess. If you
have any questions, please call me. Special instructions, if any, are listed below. Thank you for your
help. Effective audits help make an effective environmental management system.
Policy
Environmental Aspect identification
Environmental Management Program
Training, Awareness, Competence
EMS Documentation
Operational Controls
Monitoring and Measurement
Records
Management Review
Legal and Other Requirements
Objectives and Targets
Structure and Responsibility
Communication
Document Control
Emergency Preparedness
Nonconformance / Corrective Action
Management System Audits
Special Instructions:
ISO Representative (signature)
©2001 NSF
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X
Sample EMS Audit Forms
©2001 NSF 149
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EMS AUDIT SUMMARY SHEET
Organization Audited:,
Lead Auditor:
Date:
ELEMENT NUMBER AND DESCRIPTION
4.2
4.3
Environmental Policy
Planning
AUDIT RESULTS
No. of Majors / No. of Minors
4.3.1 || Environmental Aspects ||
4.3.2
4.3.3
4.3.4
4.4
4.4.1
4.4.2
4.4.3
4.4.4
4.4.5
4.4.6
Legal and Other Requirements
Objectives and Targets
Environmental Management Program(s)
Implementation and Operation
Structure and Responsibility
Training, Awareness, and Competence
Communication
EMS Documentation
Document Control
Operational Control
A, N, orX*
II
«
II
«
4.4.7 || Emergency Preparedness and Response ||
4.5
4.5.1
4.5.2
4.5.3
4.5.4
4.6
Checking and
Corrective Action
Monitoring and Measurement
Corrective and Preventive Action
Records
EMS Audit
Management Review
TOTAL
Legend:
A = Acceptable: Interviews and other objective
evidence indicate that the EMS meets all the
requirements of that section of the standard.
N = Not Acceptable: The auditor has made
the judgment that, based on the number and
type of nonconformances, the requirements
of that the section of the standard are not
being met.
X= Not Audited
©2001 NSF
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EMS AUDIT FINDINGS FORM
Type of Finding (circle one):
Nonconformance: Major Minor Positive Practice Recommendation
Description (include where in the organization the finding was identified):
ISO 14001 (or other EMS criteria)
Reference:
Date:
Finding Number:
Auditor:
Auditee's Rep.
Corrective Action Plan (including time frames):
Preventive Action Taken:
Individual Responsible for Completion of the
Corrective Action:
Date Corrective Action Completed:
Corrective Action Verified By:
Date:
©2001 NSF
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Sample EMS Audit Questions
(by organizational function)
The following questions are excerpted from a
comprehensive list of EMS audit questions contained in
the NSF-ISR project report, "Implementing Environmental
Management Systems in Community-Based
Organizations: Part 2".
For a complete list of EMS audit questions by function,
download Part 2 of the project report from the NSF web
site (www.nsf-isr.org)
©2001 NSF 152
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Function: TOP MANAGEMENT
4.2 Environmental Policy
Top Management
a. Describe your role in the development of the
environmental policy.
b. How do you know that your policy is
appropriate for your activities, products, and
services?
c. What is management's role in the review and
revision of the policy?
d. How does management ensure continued
adherence to the policy throughout the
company?
e. How does the policy help guide organizational
decisions?
f. How are employees made aware of the
environmental policy?
g. How is the policy made available to the public?
[Auditor Note: Is there evidence that the policy was
issued by top management? (e.g., Is the policy signed?
By whom? At what level in the organization are they?)]
Objective Evidence
Notes:
©2001 NSF
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Function: TOP MANAGEMENT
4.3.3 Objectives and targets
Top Management
a. What are the environmental objectives and
targets for your organization? What is your role
in approving them?
What are the relevant functions and levels within
your organization that support the attainment
each of the objectives and targets?
b. How are the environmental objectives linked to
other organizational goals (and vice versa)?
c. Are the objectives/targets consistent with the
goals of the environmental policy for prevention
of pollution and continual improvement?
d. How were the objectives and targets developed
by or communicated to management?
e. How does management keep up with progress
in meeting their objectives and targets
throughout the year?
f. How often are you informed of the status of the
objectives and targets?
g. On what basis are the objectives and targets
reviewed and modified?
Objective Evidence
Notes:
©2001 NSF
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Function: TOP MANAGEMENT
4.4.1 Structure and responsibility
Top Management
a. At what level within the organization is the
designated EMS representative placed?
Auditor Note: Is the EMS representative at a level within
the organization to effectively implement an EMS for
his/her organization?]
b. What authority does the EMS representative
have to carry out his/her responsibilities?
c. How does the organization assess its resource
needs for environmental management? How
are these factored into operating and strategic
plans (and vice-versa)?
d. What resources (financial, technical personnel)
has management provided to develop or
maintain the EMS?
e. How are you informed on the performance of
the EMS? Do you receive routine reports?
f. Are responsibilities for the environmental
management of the organization documented?
If so, where?
Is an integrated structure in place in which
accountability and responsibility are defined,
understood, and carried out?
g. How are these responsibilities communicated to
all employees (including managers)?
Objective Evidence
Notes:
©2001 NSF
155
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Function: TOP MANAGEMENT
4.4.3 Communication
Top Management
Objective Evidence
a. How are you informed of the environmental
issues within your organization? How often
does this take place? Does this include
compliance issues?
b. How are you kept up to date with progress in
meeting your organization's environmental
objectives and targets?
How is this information passed on to your
managers?
c. How do you communicate with the
organization on environmental issues?
How is this done? How frequently?
d. How does the organization handle inquiries
from interested parties (e.g., the public,
regulators, other organizations) on
environmental matters?
Who has responsibility for responding to such
inquiries?
4.6 Management review
Top Management
a. Describe the organization's management
review process.
b. How often are management reviews
performed? How was this frequency
determined?
c. Who is involved in the management review
process? What are their roles in this process?
d. What changes have been made to the EMS as a
result of the last review?
Objective Evidence
Notes:
©2001 NSF
156
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X
Sample Procedure:
Management Review
©2001 NSF 157
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EMS PROCEDURE: MANAGEMENT REVIEW
I. Purpose
The purpose of this procedure is to document the process and primary agenda of issues to
be included in the Management Review meetings for evaluating the status of the
organization's environmental management system (EMS).
II. Scope
This procedure applies to all Management Review meetings conducted by the organization.
III. General
The Management Review process is intended to provide a forum for discussion and
improvement of the EMS and to provide management with a vehicle for making any
changes to the EMS necessary to achieve the organization's goals.
IV. Procedure
A. The ISO Management Representative is responsible for scheduling and conducting a
minimum of two Management Review meetings during each 12-month period. The ISO
Management Representative is also responsible for ensuring that the necessary data and
other information are collected prior to the meeting.
B. At a minimum, each Management Review meeting will consider the following:
• suitability, adequacy and effectiveness of the environmental policy;
• suitability, adequacy and effectiveness of the environmental objectives (as well as
the organization's current status in achieving these objectives);
• overall suitability, adequacy and effectiveness of the EMS;
• status of corrective and preventive actions;
• results of any EMS audits conducted since the last Management Review meeting;
• suitability, adequacy and effectiveness of training efforts; and,
• results of any action items from the previous Management Review meeting.
C. Minutes of the Management Reviews will be documented and will include, at a minimum
the list of attendees, a summary of key issues discussed and any actions items arising
from the meeting.
D. A copy of the meeting minutes will be distributed to attendees and any individuals
assigned action items. A copy of the meeting minutes will also be retained on file.
©2001 NSF 158
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X
Appendix B:
EPA's National Environmental Performance
Track and Other Government EMS Initiatives
©2001 NSF 159
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National Environmental Performance Track Program
The National Environmental Performance Track is designed to recognize and encourage top
environmental performers - those who go beyond compliance with regulatory requirements
to attain levels of environmental performance and management that benefit people,
communities, and the environment. As top environmental performers, participants earn
access to a unique reward package that includes recognition, better information, and
administrative streamlining.
The Performance Track consists of two levels. The first level, the National Environmental
Achievement Track, is available now and is open to facilities of all types, sizes, and
complexity, public or private, manufacturing or service-oriented. It is designed to recognize
facilities that consistently meet their legal requirements and have implemented high-quality
environmental management systems, as well as encourage them to even better
achievement by continuously improving their environmental performance and informing and
involving the public. The second level, the National Environmental Stewardship Track, is
designed to recognize and encourage broader and higher levels of voluntary environmental
performance than those expected under the Achievement Track. The Stewardship Track is
still under development, and EPA plans to have it available by May 2001.
Any program for improving environmental performance must aim for participation by small
businesses and other small entities, such as local governments. EPA is making every effort
to make the Achievement Track accessible for small entities. This effort is reflected in
several aspects of the design. For example, depending on the nature and extent of a
facility's operations, the EMS for a small facility may be simpler than one for a larger, more
complex facility. For the same reason, a small facility may have fewer environmental
aspects. In addition, a small facility is not asked to make as many performance
commitments as other participants.
Environmental Management System (EMS) Requirements
Facilities wanting to participate in the Performance Track must meet several requirements.
A facility will certify that it has an EMS in place.1 The EMS will include the elements listed
below and will have gone through at least one full cycle of implementation (i.e., planning,
setting performance objectives, EMS program implementation, performance evaluation, and
management review). A facility that has adopted systems based on EMS models with a
Plan-Do-Check-Act framework would meet most of these elements.
EPA recognizes that the scope and level of formality of the EMS will vary, depending on the
nature, size, and complexity of the facility. EPA's experience with a variety of programs
suggests that these EMS elements are within the capability of small facilities and can be met
through a variety of approaches. To help small facilities implement an EMS, EPA will make
guidance documents and assistance materials available.
A facility will certify that it has implemented an EMS that includes these elements:
1 For purposes of the Achievement Track, an EMS represents an organization's systematic
efforts to meet its environmental requirements, including maintaining compliance and
achieving performance objectives that may be related to unregulated aspects of the
organization's activities.
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Policy
A written environmental policy, defined by top facility management, that includes
commitments to: (1) compliance with both legal requirements and voluntary
commitments; (2) pollution prevention (based on a pollution prevention hierarchy
where source reduction is the first choice); (3) continuous improvement in
environmental performance, including areas not subject to regulations; and (4)
sharing information about environmental performance and the operation of the EMS
with the community.
Planning
• Identification of significant environmental aspects2 and legal requirements, including
procedures for integrating anticipated changes to the facility's requirements or
commitments into the EMS.
• Measurable objectives and targets to meet policy commitments and legal
requirements, to reduce the facility's significant environmental impacts, and to
meet the performance commitments made as part of the facility's participation in
the program. In setting objectives and targets, the facility should consider the
following criteria: preventing non-compliance, preventing pollution at its source,
minimizing cross-media pollutant transfers, and improving environmental
performance.
• Active, documented programs to achieve the objectives, targets, and
commitments in the EMS, including the means and time-frames for their
completion
Implementation and Operation
• Established roles and responsibilities for meeting objectives and targets of the
overall EMS and compliance with legal requirements, including a top
management representative with authority and responsibility for the EMS.
• Defined procedures for: (1) achieving and maintaining compliance and meeting
performance objectives; (2) communicating relevant information regarding the
EMS, including the facility's environmental performance, throughout the
organization; (3) providing appropriate incentives for personnel to meet the EMS
requirements; and (4) document control, including where documents related to
the EMS will be located and who will maintain them.
• General environmental training programs for all employees, and specific training
2 An "environmental aspect" is defined as an "element of an organization's activities,
products, or services that can interact with the environment." Facilities are asked to use their
list of significant environmental aspects in selecting performance commitments under this
program.
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for those whose jobs and responsibilities involve activities directly related to
achieving objectives and targets and to compliance with legal requirements.
• Documentation of the key EMS elements, including the environmental policy,
significant environmental aspects, objectives and targets, a top management
representative, compliance audit program, EMS audit program, and overall EMS
authority.
• Operation and maintenance programs for equipment and for other operations
that are related to legal compliance and other significant environmental aspects.
• An emergency preparedness program.
Checking and Corrective Action
• An active program for assessing performance and preventing and detecting non-
conformance with legal and other requirements of the EMS, including an
established compliance audit program and an EMS audit program.
• An active program for prompt, corrective action of any non-conformance with
legal requirements and other EMS requirements.
Management Review
• Documented management review of performance against the established
objectives and targets and the effectiveness of the EMS in meeting policy
commitments.
Although a third-party audit of the EMS is not necessary to qualify for the Achievement
Track, a facility is asked in the application form if it has undergone such an audit. If it has
not, it will have conducted a self-assessment. A facility will retain EMS documentation and
provide a summary of its performance, including performance against objectives and
targets, and a summary of the results of compliance and EMS audits, in its Annual
Performance Report.
For more information about the National Environmental Performance Track, contact the EPA
via:
Web: www.epa.gov/performance track
E-Mail: ptrack@indecon.com
Phone: 888-339-PTRK
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The Multi-State Working Group on Environmental Management
Systems Overview of Organizational and State Activities
MSWG is an organization that convenes government, non-government, business and
academic interests to conduct research, promote dialogue, create networks and establish
partnerships that improve the state of the environment, economy and community through
systems-based public and private policy innovation. Its quarterly meetings move around the
US to accommodate participation. Meetings are open; everyone is welcome. All have a right
to speak. Decisions are by consensus. The Council of State Governments (CSG) handles
administration and to accommodate gifts has 501(c)(3) status. Voluntary dues support
MSWG. NGOs do not pay dues. New members are welcome, especially businesses and
NGOs. All 50 states are enrolled in MSWG and linked by e-mail. About 25 states regularly
participate at quarterly meetings and 30-40 states attend the annual meeting and workshop.
Check www.mswg.org for information.
What activities does MSWG sponsor?
• Pilot projects: In partnership with the U.S. EPA, the Environmental Law Institute, and
University of North Carolina-Chapel Hill, MSWG states sponsor about 75 EMS pilot
projects that produce data for a national database project funded by the EPA's Office of
Water. The purpose of the pilots is to evaluate the ability of environmental management
systems to improve the environment. Information is at: www.eli.org/isopilots.htm
• EMS Research: MSWG held six EMS research roundtables at major universities that led
to a Research Summit, held in 1999 at The Brookings Institution in cooperation with
CSG and the National Academy of Public Administration. The Summit produced an EMS
research agenda. Summit papers are included in a textbook, edited by Harvard
University and the Massachusetts Institute of Technology, published in 2001 by
Resources for the Future. Plans are being made for a second summit.
• EMS Policy Academy: Wth funding from The Joyce Foundation to CSG and support of
business, MSWG has a design team of business, government, academic and NGO
appointees preparing recommendations fora national EMS Policy Academy. The
"virtual" Academy will focus on learning about public policy EMSs, not those within the
confines of a private organization and will complement and not compete with existing
services. Public policy EMSs have designed to have credibility with business,
government, NGO, consumer and enlightened shareholder interests.
• Workshops: Each June or July, MSWG sponsors, with support from EPA and
businesses, an annual EMS workshop. It is a "hands-on" event that hosts EMS
practitioners from the US and abroad. It has grown from 75 participants in Gary, NC
1998 to nearly 300 in San Diego, CA in 1999.
• Networking: MSWG provides a networking function between states and EMS support
functions, especially those focused on EMSs that fit into a public policy strategy.
Technical assistance centers in Florida, Georgia, Iowa, Kentucky, Massachusetts and
South Carolina help MSWG participants.
• Other activities: MSWG members contribute to numerous public policy-related
environmental initiatives and discussions including EPA's Performance Track, ISO
14001 revisions; Environmental Council of States forums; Global Environmental
Management Initiative meetings; professional and trade association programs and
Commission for Environmental Cooperation.
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MSWG is state-driven. Several states sponsor EMS pilot projects and contribute data to the
UNC-ELI database. They are: AZ, CA, IL, IN, NC, NH, OR, PA VT and Wl. These states
have or are developing public-policy-related EMS policies, programs, internal EMSs or
environmental laws that recognize EMSs: AZ, CA, CT, FL, IA, IL, IN, LA, MA, ME, MN, NC,
NH, OH, OR, PA, SC, TX, VA, WA, VT and Wl. Contact Marci Carter, carterm@uni.edu for
state contact information or questions. Many MSWG states participate in EPA's performance
track program, whose businesses use EMSs for public policy purposes.
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Implementing Environmental Management Systems
In Government Entities
Fourteen government entities were selected from an applicant pool of 50 to participate in a
pilot project designed to assist public-sector organizations develop and implement an
environmental management system (EMS) based on the ISO 14001 protocol. The U.S.
Environmental Protection Agency's (U.S. EPA) Office of Water, Office of Compliance, and
Office of Air and Radiation, including Regions I and IX, jointly sponsor this initiative which
runs from April 2000 to January 2002.
Each participating organization has selected a facility/organization ("fenceline") in which to
implement the EMS, as noted below.
Public Entity
City of Berkeley, CA
City of San Diego, CA
City of Detroit, Ml
Florida Gulf Coast University - Fort Myers, FL
Port of Houston, TX
Jefferson County, AL
Little Blue Valley Sewer District - Independence, MO
Louisville and Jefferson County Metropolitan Sewer
District Louisville, KY
Wisconsin Department of Natural Resources -
Madison, Wl
Tri-County Metropolitan Transportation District
Portland, OR
King County Solid Waste Division - Seattle, WA
Massachusetts Department of Environmental
Protection Lawrence, MA
University of Massachusetts - Lowell, MA
New Hampshire Department of Transportation
Concord, NH
Fenceline
Solid Waste Management Division
Refuse Disposal Division
Department of Recreation & Public
Lighting
Solid Waste Activities and Services
Container Terminal and the Central
Maintenance Department
General Services Department
Wastewater Treatment Facility
All operations
Wastewater Treatment Facility and
Purchasing Department
Air Management Bureau
Maintenance Facilities
Entire Division - Eight Transfer Stations &
one Regional Landfill
Wall Experiment Station
Analytical Laboratory
Olney Science Building - Laboratory
Bureau of Traffic
In 1997, U.S. EPA sponsored the first two-year EMS project for nine local governments.
Participants experienced compelling environmental and economic benefits over the two-year
project period:
• Improved Environmental Awareness - "There's a much better understanding of
environmental issues in every department of the fenceline, not just in the environmental
department. We are recognizing simple internal "housekeeping" measures that are
having a positive effect on our environmental performance. We have self-imposed
additional requirements to help prevent pollution, reduce energy use, manage our
contractors, and expand environmental education for our citizens. Employees are
bringing ideas for reducing our waste streams, for less toxic products. There has been a
definite improvement in involvement and morale."
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• Improved Efficiency - "Systematically analyzing compliance issues revealed an
opportunity for cost savings. Fifteen departments were responsible for obtaining their
own air quality permits - 23 altogether. The implementation team consolidated these
permits into eight, saving the city $16,000 per year."
• A Positive Effect on Environmental Compliance and Performance - "With regards to
environmental compliance, we have a better understanding of our legal requirements.
We have better-trained employees whose competence in their work area is critical to the
environment. We expect that our EMS efforts will increase our ability to stay in
compliance."
For case study information, see the final report atwww.getf.org/projects/muni.cfm.
THE SECOND GOVERNMENT EMS INITIATIVE
Due to the overwhelming success of the first program and local governments' growing
interest in EMSs, U.S. EPA decided to conduct a second EMS initiative to gather additional
data about the value of EMS tools in government organizations. The Global Environment &
Technology Foundation (GETF) was again selected to lead the effort, providing in-depth
training, coaching and on-site technical assistance to help participants design and
implement their EMS's.
Jim Home, the National Project Manager, from U.S. EPA's Office of Water said,
"The U.S. EPA team was extremely gratified by the level of interest shown by local
governments for this second initiative and the level of sophistication of the applications. It is
clear that public-sector organizations are rapidly becoming aware of the value of
implementing EMS's and the value of working with U.S. EPA. We are delighted with the
diverse range of organizations that were selected and expect great things from each of
them."
During the two-year project, participants attend five comprehensive workshops. At each they
receive training, materials, and technical assistance to help them accomplish EMS
milestones in each of the four implementation phases.
The Houston Port Authority, TX had the following to say about the project:
"This will be an interesting two-year process, learning with and from other organizations who
share our interest in protecting the environment while providing public services. We plan to
convey all that we learn to our tenants, the city and county, and other port authorities so that
we can all do a better job as stewards of the environment."
For more information on the Local Government EMS Initiative, please contact Craig Ruberti
(cruberti@getf.org) at 703-750-6401, Faith Leavitt (fleavitt@earthvision.net) at 941-489-
1647, or Jim Home (horne.james@epa.gov) at 202-260-5802 or visit the project web site
(http://www.getf.org/projects/muni.cfm) for regular updates on the project.
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NEIC Compliance-Focused Environmental Management System
Since the late 1980s, civil multimedia compliance investigations conducted by the EPA
National Enforcement Investigations Center (NEIC) have increasingly involved identifying
causes of observed noncompliance. In a significant number of cases, the causes arise from
inadequate environmental management systems (EMSs). NEIC, in response, developed
key elements for a compliance-focused EMS (CFEMS) model, which have been used as the
basis for EMS requirements in several settlement agreements. The CFEMS, which includes
a guide for using it in settlement agreements, was published in August 1997 and revised in
January 2000.3
The CFEMS elements are as follows:
1. Environmental Policy
2. Organization, Personnel, and
Oversight of EMS
3. Responsibility and Accountability
4. Environmental Requirements
5. Assessment, Prevention and Control
6. Environmental Incident and
Noncompliance Investigations
7. Environmental Training, Awareness,
and Competence
8.
Environmental Planning and
Organizational Decision-Making
Maintenance of Records and
Documentation
Pollution Prevention Program
Continuing Program Evaluation and
Improvement
12. Public Involvement/Community
Outreach
9.
10
11
To achieve maximum benefit from the CFEMS elements, the overall EMS in which they are
incorporated should embody the "plan, do, check, and act" model for continuous
improvement. Consequently, the compliance-focused EMS model described here is
intended to supplement, not replace, EMS models developed by voluntary consensus
standards bodies, such as the ISO 14001 EMS standard developed by the International
Organization for Standardization.
Settlement agreements that require an EMS typically include a requirement that the
organization conduct an initial review of its current EMS, followed by development of a
comprehensive CFEMS that must be documented in a manual. The EMS manual must
contain policies, procedures, and standards for the 12 key elements, at a minimum, and
should also identify other, more detailed procedures and processes (e.g., inspections and
self-monitoring) that may be located elsewhere at the facility. After the organization has
had sufficient time to implement and refine the EMS (usually 2 to 3 years), the agreement
should require at least one EMS audit by an independent third-party auditor, with results
reported to both the organization and EPA. However, additional audits may be required, as
individual circumstances dictate
3The document is available on NEIC's website.
http://es.epa.gov/oeca/oceft/neic/12elmenr.pdf
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The intended result of this approach is twofold: first, to have the organization develop an
EMS that will both improve its compliance with applicable environmental requirements and,
second, to improve its environmental performance by achieving the organization's
environmental targets and objectives.
The January 2000 revision involved enhancing several of the elements and more completely
incorporating the due diligence provisions of the EPA audit policy. Refinement continues
through settlement negotiations, and discussions with EPA staff, EMS consultants, and
environmental personnel from several companies with medium-size and large facilities.
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X
Appendix C:
Information on Process Mapping and Design
for Environment
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Introduction to Process Mapping
Organizations operate using a collection of processes. A process can be defined as a
method of doing something, generally involving a number of steps or actions. An EMS is
one example of linked organizational processes that are directed at a specific purpose.
Most organizations employ a variety of processes to carry out their core functions, such as
manufacturing a product or providing a service.
A process typically has four components. Two of these are inputs (the items to which action
is done) outputs (the results of those actions). In addition, a process has controls (which
direct the action) and mechanisms (which are the resources that actually perform the
action). Mechanisms can be people or machines that change the inputs to the outputs.
Other concepts that are important to process mapping are process boundaries (which define
the limits of a particular process from its larger environment), suppliers (who provide the
process inputs) and customers (whoever receives the output of the process).
Process mapping is a tool that allows an organization to visualize and understand how work
gets accomplished and how its work processes can be improved. It is a simple but powerful
tool through which an organization can focus its efforts where they matter most and
eliminate process inefficiencies. Used properly, process mapping can help an organization
understand its environmental aspects and reduce wastes and pollution. It also can help an
organization to reduce operating costs by identifying and eliminating unnecessary activities.
As an EMS tool, process mapping can help an organization to:
• improve its understanding of existing processes, including the key inputs
(such as chemicals, raw materials and other resources used), outputs (including
products, wastes, air emissions, etc.) and interactions with other processes.
• identify areas for process improvement that can result in environmental
performance improvements (such as pollution prevention opportunities)
Over time, processes are often modified many times in seemingly small ways. Over time,
these process modifications can result in a process that is ineffective. This is one of the
bases for the concept of "re-engineering" which seeks to examine processes in a holistic
manner to ensure they are effective and necessary to achieve an organization's mission.
Getting Started on Process Mapping
• Select a process (or set of related processes) to examine. Processes might be
prioritized for review based on a number of criteria, such as relevance or importance to
the organization, prior assessments of the process, existing knowledge of the
environmental significance of the process, or history of problems with the process,
among others. Define the process boundaries.
• Use a team to understand and map how these existing process(es) work. At a
minimum, the team should include the process "owner" as well as individuals that are
actively involved in carrying out the process. Many organizations use a facilitator that is
independent of the process under review to manage team meetings. Don't be surprised
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if a diversity of opinions exists among team member exist regarding how the existing
process works.
• Clarify the objectives of the process under review. Each process should have a
primary customer and a primary performer, although additional (secondary) customers
and performers also might exist.
• As a team, determine the level of detail needed to accurately map your processes.
Initially, you might map at a fairly high level, then get into more detail as improvement
opportunities as identified.
• Decide on a set of symbols that the team will use to visually describe the process. For
example, use one symbol for work steps, another symbol for process inputs, a third
symbol for process outputs, a fourth symbol for decision points, a fifth symbol for
measurement points, etc.
• Identify the key steps (or "unit operations") in the process first, then go back and
analyze each of these steps in more detail. Use lines or arrows to show the
relationships among individual process steps. Use brainstorming and/or storyboarding
techniques to identify the process steps, then agree upon the sequence of these steps.
• Start with the preparation of an "as is" map that describes how the process works
now, including key process inputs to and outputs. For environmental purposes, key
inputs might include energy and other resources consumed, and raw materials and
chemicals used. Outputs might include products or services, air emissions, wastewater
discharges, solid and hazardous wastes. This "as is" map can be analyzed to identify
environmental aspects and key opportunities for improvement.
• Some processes can be extremely complex and might consist of numerous sub-
processes. If the team gets bogged down, it might examine and map some of the key
sub-processes first, rather than trying to tackle the entire process at once. As a rule of
thumb: If the process is so complex that it cannot be shown on a single page, then it
might be a good candidate for re-engineering.
• Depending on the purpose of the process mapping exercise, the analysis of the "as is"
map can lead to the preparation of a modified map that defines how the re-engineered
process is intended to function.
• A variety of tools and materials can be used to prepare process maps. For example, a
number of commercial software packages exist. However, you can also employ simpler
methods, such as self-sticking removable ("Post-It") note pads. These are particularly
useful for moving individual process steps around on a board.
A sample process map for a printing operation is shown at the end of this section.
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Conclusion
Process mapping can provide a solid foundation for understanding and continually
improving an organization's processes.
Viewing processes graphically helps an organization to see things that otherwise might not
be apparent. Once a process map has been prepared, it can be used as training tools as
well as for internal and external communications.
Process mapping has several important benefits for an EMS. First, it allows an organization
to understand its current environmental aspects and impacts as well as the specific
operations and activities from which they arise. Second, it provides a basis for enhancing
an organization's processes in a manner that can improve both environmental and financial
performance.
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Sample Process Map for Printing Operation
Packaging
- skids & pallets
kraft wraps
PRODUCTS
brochures
catalogs
art prints
annuals
waste paper
recycled |
fugitive air
emissions
3
[ atmosphere |
Supplies
- spray powder
- shop towels
Raw
Materials
- plates
- paper & ink
- water
; Chemicals
- cleaning
solvents
ink preservers
plate gums
PRINTING PRESS
web dryer
emissions
thermal
oxidizer
atmosphere
waste ink
waste solvents
waste solutions
waste plates
waste packaging
waste oil & antifreeze
recycled~|
fuel blencT|
recycled~|
sewer ~|
recycled~|
recycled~|
trash
recycled |
1
r
spun shop
towels
secondary use in
parts washers
commercial laundry
recycled back to company
sewer
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Information on Design for Environment
Every product or service has some impact on the environment. Such impacts can occur at
many stages of the product or service's life cycle, from raw material acquisition to ultimate
disposal or reuse. Just as the quality and performance characteristics of a product are
significantly affected by decisions made at the development stage, so are the product's
environment attributes. Consideration of potential environmental impacts throughout the
product or service development process can improve both environmental and financial
performance. By looking at each stage of a product or service life cycle, an organization
can better understand and control the potential environmental impacts.
Design for Environment (DFE) is based on techniques for integrating environmental
considerations into an organization's decisions concerning its products and services, as well
as manner in which these products and services are generated. In involves an
understanding of materials flows (and the environmental effects of such material flows) as
well as the comparison of alternative approaches to producing a product or service.
DFE is grounded in the use of life cycle assessment to evaluate the full range of impacts
associated with a product or service. Such life cycle assessments allow an organization to
evaluate potential environmental impacts and identify opportunities to make improvements.
DFE is based on an assessment of the performance, costs and risks associated with
alternatives. The technique seeks to encourage front-end innovation through product or
service redesign, rather than reliance on "end of pipe" controls in order to manage risks to
the environment. As such, use of the technique might result in redesign of a product
formulation, a manufacturing process, or a management practice, among other possibilities.
In general, the earlier that environmental considerations are taken into account in the
product or service development process, the more effective the results will be with respect to
environmental performance. Organizations can use an approach that includes:
• Evaluating information on the environmental attributes of a product or service,
• Designing specific measures to reduce associated environmental impacts.
• Testing alternatives that seek to reduce impacts, while considering other importance
product characteristics (such as quality and performance), and
• Applying the resulting "lessons learned" to subsequent product or service
development.
While it might be simpler to implement DFE practices on new products or services, an
organization also might find opportunities to apply DFE in their existing products or services.
In conducting such evaluations, an organization could consider a number of goals, such as:
Minimizing the use of toxic materials
Minimizing compliance costs
Avoiding chemicals that are banned or
restricted by customers / other parties
Minimizing packaging
• Minimizing energy use
• Minimizing use of water, other resources
Maximizing reuse potential
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A product or service's environmental impacts are largely based on the inputs used to make
the product (or provide the service) and the outputs generated at various stages of its life
cycle. An organization can start to apply DFE concepts by using a simple matrix to assess
the environmental impacts associated with a product, such as shown below (1).
Potential Environmental Issues
Product Life
Cycle Stages
Premanufacture
(Product design)
Product
Manufacturing
Product
Packaging &
Delivery
Product
Use
Product Disposal
or Reuse
Material
Selection
Energy
Use
Air
Emissions
Water
Discharges
Solid
Wastes
For many organizations, the effective application of DFE concepts involves working closely
with their suppliers and customers. Effective communications with supply chain partners
can be critical in ensuring that an organization's products or services satisfy all their
performance needs (i.e., performance, durability, environmental, safety, cost, etc.)
More information on DFE can be obtained from a variety of sources (see Appendix F for
additional information sources). In particular, organizations can access information on DFE
tools and projects on EPA's DFE web site at www.epa.gov/opptintr/dfe.
(1) Adapted from "Best Current Practices: Design for Environment", Lucent Technologies,
February 1997.
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US. EM
Integrated Environmental Management Systems
What is EPA's DIE Program?
EPA's Design for the Environment Program partners with stakeholders to help businesses
help the environment. DfE projects help businesses design products, processes, and
management systems that are cost-effective, cleaner, and safer for workers and the public.
The DfE goals are to
*• Encourage businesses to incorporate environmental information into their decision
criteria, and
*• Effect behavior change to facilitate continuous environmental improvement.
To accomplish these goals DfE and its partners use several approaches including cleaner
technology and life-cycle assessments, environmental management systems (EMS),
formulation improvement, best practices, and green supply chain initiatives.
To date, the DfE Program has brought environmental leadership to over 2 million workers at
over 170,000 facilities. Small- and medium-sized businesses recognize DfE as a unique
source of reliable environmental (as well as performance and cost) information.
DIE'S Approach to EMSs
EPA's Design for the Environment (DfE) Program has developed an enhanced EMS
approach called Integrated Environmental Management Systems (IEMS) to help companies
achieve continuous environmental improvement. I EMSs emphasize reducing risk to
humans and the environment, pollution prevention, and wise resource management. DfE's
IEMS combines continuous improvement principles and tools with proven environmental
assessment methodologies.
Key IEMS components that might not be included in traditional EMSs are
* Paying close attention to process and material flows,
* Obtaining knowledge of chemicals used and their hazards and exposures,
* Conducting substitutes assessments that can include full-cost accounting, and
* Considering and selecting cleaner technologies.
I EMSs assist companies in making sound environmental decisions as part of daily business
practices. As a result, I EMSs help companies to
* Reduce cross-media impacts and Use energy and other resources efficiently,
* Better manage the risk associated with using hazardous chemicals (both regulated
and unregulated),
* Practice extended product and process responsibility, and
* Integrate environmental and worker safety and health requirements.
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DfE's I EMS approach was piloted with several small and large screen printing companies
and the Screenprinting & Graphic Imaging Association International. The pilots
demonstrated that both small and large companies can develop and implement
sophisticated, action-oriented lEMSs. Several of the pilot companies are applying for ISO
14001 certification.
What IEMS Materials Are Available?
To help organizations create and document their own lEMSs, DfE has developed an IEMS
Implementation Guide (EPA 744-R-00-011), an IEMS Company Manual Template (EPA
744-R-00-012), and a website. The Implementation Guide walks an organization through
the steps of developing an IEMS. It provides simple, thorough directions that are clear even
to those unfamiliar with environmental management planning. The Guide includes
worksheets, examples, and step-by-step guidance on process mapping, environmental
policy development, risk assessment, and evaluating cleaner alternatives.
IEMS information and materials may be obtained by visiting the DfE website at
www.epa.gov/dfe or by contacting EPA's Pollution Prevention Information Clearinghouse via
email (ppic@epa.gov) or phone (202-260-1023).
Possible IEMS Roles for Lead Organizations, Associations, Technical Assistance
Providers, and Large Companies
A lead organization such as an association, a technical assistance provider, or a large
company can greatly facilitate development of lEMSs among its members, clients, or small
suppliers. DfE's IEMS experience shows that the IEMS development process can be much
more cost- and time-efficient and more fun if a lead organization takes on common
activities, such as developing a basic process map or providing group training, that each
company would otherwise do separately. Some additional ways in which a lead
organization could help companies with lEMSs include
* Adapt the IEMS Implementation Guide and other tools to reflect a given industry
sector's unique conditions,
* Organize and lead participating companies to develop an IEMS,
* Develop sector-specific pollution prevention and regulatory information,
* Help establish environmental improvement targets and evaluate results, and
* Recognize or certify companies that participate and demonstrate results.
Opportunities For IEMS Partnerships With DfE. If you are interested in becoming an
IEMS partner and in leading IEMS efforts for an industry group or supply chain call DfE at
202-260-1678.
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Appendix D:
Registration of Environmental
Management Systems
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Registration of Environmental Management Systems
1st Party Audit
Internal Audit
2nd Party Audit
Customer audit of a
supplier
3rd Party Audit
Audit by another party
independent of a
supplier and its
customer
Registration
vs.
Certification
Both terms refer to
describe the third-
party audit process.
Technically speaking,
"registration" applies
to management
systems, while
"certification" applies
to products.
However, in common
usage, they are
synonymous.
Scope of
Registration....
..is the activities and
organizations that are
included within the
EMS.
The scope should be
discussed with your
registrar before
Stage 1.
EMS registration in this appendix refers to the process
whereby a non-biased third-party attests that an
organization's EMS conforms with the requirements of the
ISO 14001 Standard. ISO 14001 was written to describe the
requirements for registration/self declaration and is the only
one of the ISO series of environmental standards (such as
environmental labeling or environmental performance
evaluation) to which an organization may register. The third-
party organization that performs the registration services is
called the "registrar," and is selected by the organization that
desires registration services.
An accredited registrar is one whose competence is
evaluated by an independent third-party. Each country of the
world has its own accreditation body established either
nationally or by their government. In the United States, the
accrediting body for both ISO 9000 and ISO 14001 is the
American National Standards Institute/Registrar
Accreditation Board (ANSI/RAB). ANSI/RAB has
established criteria which registrars must meet in order to
achieve accreditation. Accreditation is not a legal
requirement. However, accreditation provides organizations
assurance that their registrar has met ANSI/RAB
requirements for things such as impartiality, confidentiality, a
documented registration system, quality assurance, and
policies to handle complaints and appeals.
The Registration Process
ANSI/RAB has established a two-stage registration approach
for accredited registrars. Registrars may have different
registration processes but must follow the basic two stage
process:
Stage 1 Planning for the Audit
The purpose of Stage 1 is to determine the organization's
preparedness for the registration audit. This stage includes a
document review as well as on-site visit. A review of the EMS
in light of the possible significant environmental aspects is a
primary objective of Stage 1.
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Stage 2: Evaluating Implementation
What does registration
really mean?
Registration to ISO 14001
does not mean that your
organization is a "green"
facility, is environmentally
friendly or that you have
demonstrated superior
environmental
performance.
It means that your
organization can claim it
has a documented EMS
that is fully implemented
and consistently followed.
Major Nonconformance
occurs when
One or more of the
numbered requirements
of ISO 14001 have not
been addressed and/or;
One or more of the
numbered requirements
of ISO 14001 have not
been implemented
and/or;
Several
nonconformances taken
together lead a
reasonable auditor to
conclude that one or
more of the numbered
requirements of ISO
14001 have not been
addressed or
implemented
Stage 2 always takes place at the organization's location.
An audit team conducts an on-site audit to evaluate and
verify through objective evidence (interviews, procedures,
records, etc.) that the EMS conforms to the requirements in
the ISO 14001 Standard and is implemented and maintained.
Once you achieve registration, regular surveillance audits by
the registrar are required by ANSI/RAB. These may be
conducted once per year (with a re-audit after three years) or
at least twice per year with all 17 elements audited in a three
year period.
To what do you conform?
The answer may surprise you. Naturally you have to conform
to ISO 14001 Standard requirements but you also have to
conform to:
• Your own organization's policies and procedures: The
EMS an organization designs often goes above and
beyond ISO 14001 requirements. Did your environmental
policy say your organization would promote sustainable
development? Be an environmental leader? Continually
improve environmental performance? During a
registration audit, your policies and procedures become
criteria to which you will be audited.
• The policies and procedures of the registrar: You will not
be audited to the registrar's policies and procedures but
they will include your responsibilities (such as timeframes
for corrective actions) and rights within the registration
process (such as auditor approval), and processes you
should be aware of (such as confidentiality and dispute
resolution).
Why Register?
The ISO 14001 Standard does not require third-party
registration. However, for some industries such as
automotive, a registered EMS is a mandated requirement for
thousands of suppliers to the major auto makers. In addition,
organizations that sell their goods or services internationally
may find that EMS registration is a strong selling point in the
global marketplace and may enable them to obtain preferred
supplier status.
Where registration is not a direct market driver, organizations
may pursue registration for many reasons including:
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"Sufficient data on an
organization's
compliance with
relevant legislation
and regulations,
gathered during the
registration review
and surveillance, are
relevant and
necessary to
determine whether or
the organization's
systems conform to
the standard."
-ANSI/RAB Criteria for
Bodies Operating
Registration of
Environmental
Management Systems
(E3.2)
"...while compliance is
part of the
management system,
the registration audit
is not an audit of full
compliance with all
applicable regulatory
requirements."
- ANSI/RAB Criteria
for Bodies Operating
Registration of
Environmental
Management Systems
(E3.2).
• Maintenance of current market position;
• Opportunities for a competitive advantage;
• Help ensure regulatory compliance;
• Improve relationships with regulators and/or the
surrounding community; and
• Support state and Federal regulatory incentive programs.
There are also important but often unrecognized internal
benefits to registration. Registration is a way to protect the
investment your organization has made in your EMS.
Knowing that you will be audited regularly by an outside party
helps to keep management's attention on the EMS and
ensure that it has the resources it needs to improve over
time.
Registration and Compliance
A registration audit is not a compliance audit. Difference in
the two types of audits are highlighted in Table 1. An EMS
auditor will not perform a detailed compliance inspection but
the will gather data on how your organization manages its
compliance program. Pertinent questions may include; How
do you stay informed of new requirements? How are these
communicated to employees? How do you evaluate
compliance with regulations? What process do you have for
resolving any noncompliances identified?
Occasionally, an EMS auditor may identify a regulatory
noncompliance during the registration audit. Does this mean
you automatically fail the audit? No, it does not. The registrar
must verify that the EMS is set up to handle noncompliances
and that taken together, the noncompliances do not indicate
a major nonconformance.
Accredited registrars are required to have a method for
handling and reporting regulatory noncompliance identified
during a registration audit. Ask your registrar for their policy
or procedure for handling this situation.
Table 1. Difference between EMS and Compliance Audits
EMS Audit
• Focus is on systems
• Information gathered
largely through interviews
and document review
• Corrective action involves
individuals outside of the
environmental staff
Compliance Audit
• Focus is on details of
regulations
• Observation of activities
is important
• Corrective actions
involve only
environmental staff
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Appendix E:
Integration of Environmental Management
Systems and Quality Management Systems
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Integration of Management Systems
Integrating management systems has become an increasingly important competitive issue. A
growing body of information indicates that organizations that integrate their EMS and quality
management systems (QMS) can realize significant benefits, such as streamlined operations and
decision-making, simplified employee training, more efficient of resources and reduction in audit
costs. Systems for managing health & safety and other organizational functions can be similarly
integrated.
The two most common models for QMS and EMS (ISO 9001 and ISO 14001, respectively) share
many common elements. This should be no great surprise, since ISO 9001 was one of the source
documents used by the drafters of ISO 14001. The two standards are very compatible in their
current forms. The ISO committees responsible for the development and maintenance of these two
standards continue to examine potential opportunities to increase the compatibility or alignment of
the two standards.
Organizations that choose to implement both of these standards generally find that they can use
many common processes to conform. In general, the elements of a QMS and an EMS can be
categorized as either (1) essentially the same, (2) similar or (3) unique (see table below). System
elements in both the "essentially the same" and "similar" categories can often be addressed by a
common procedure (or parallel procedures), although some customization may be needed to
address the differing overall purposes of these systems. Unique elements are typically dealt with in
separate (EMS or QMS) procedures. Some of the typical elements for integration include:
document control, corrective/preventive action, training, records management and management
review. However, some organizations have gone much further - for example, some have
developed common (quality and environmental) policies. The degree of system integration varies
widely from organization to organization.
While an EMS can be readily integrated with an existing QMS, the overall purposes of these two
systems must be kept in mind. A QMS is intended primarily to ensure that an organization satisfies
its customers by assuring the quality of its products. An EMS generally has a broader context - the
relationship between an organization and the environment in which it operates. Also, an EMS often
concerns itself with a broader range of stakeholders, such as neighboring communities, customers
and regulatory agencies.
System integration can have environmental benefits. By linking environmental management more
closely with day-to-day planning and operation, some organizations have been able to raise the
visibility of environmental management as a core organizational issue. In addition, these
organizations enhance their abilities to address environmental issues when making modifications to
products or processes for quality purposes.
Organizations that have a QMS in place generally are better off when implementing an EMS for
several reasons. First, employees typically are already familiar with management system concepts
and are involved in making the system work. Second, many of the processes needed for the EMS
might already be in place. Finally (and perhaps most importantly), top management has committed
the use of management systems to achieve organizational goals.
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A Few Tips on System Integration
For organizations that have an existing QMS and wish to integrate an EMS with it, some
suggestions are provided below.
®° Understand the existing QMS, its effectiveness and how the workforce perceives the
system. Is the existing QMS documentation clear and workable? Do employees
believe that the system is helping the organization to achieve desired results?
®° Ensure that the scope of the two systems will be consistent (i.e., that the systems will
cover the same facilities, products, activities and/or services). In particular, this will be
an important issue if third-party registration will be sought.
®° Establish a cross-functional team (including, at a minimum, representatives from the
environmental and quality functions) to determine the optimal approach to system
integration.
®° As needed, manage resistance to change. Some employees and managers may be
reluctant to change a system that they are already familiar with and/or in which they
have important roles.
®° Understand how QMS and EMS differ in purpose. While there are many common
management system elements, there are elements of each system that are unique (see
below). In the case of EMS, these include for example, environmental aspects,
communications, emergency preparedness and response. These differences must be
acknowledged and accommodated within the integrated management system.
Relationship of EMS Elements to QMS (based on ISO 9001: 1994)
Elements that are Essentially the Same Elements that are Similar
®° Training, Awareness & Competence ®° Environmental Policy
®° Document Control ^ Structure and Responsibility
®° Nonconformance, Corrective & Preventive ®° EMS Documentation
Action ®° Operational Control
^ Calibration (part of the Monitoring & ^ Monitoring & Measurement
Measurement element) ®° EMS Audit
®° Records ^ Management Review
Elements that are Unique
Environmental Aspects
Legal and Other Requirements
Objectives & Targets
Environmental Management Program(s)
Communications
Emergency Preparedness & Response
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• Modify system documentation as required. Keep procedures simple and clear for
users. Review proposed changes with affected managers and employees.
• On a procedure-by-procedure basis, consider whether to integrate procedures or keep
them separate. While integration can reduce the total number of procedures or work
instructions, it also can confuse the overall purpose of such procedures in some cases.
• Once the integrated system documentation has been prepared, train managers and
employees on the integrated system.
• Audit the integrated system and take actions as necessary.
A few final thoughts on system integration:
• Can your organization afford to have two or more separate systems?
• Are there compelling reasons to keep these systems separate?
• What is the optimal approach from a strategic and operational standpoint?
• What approach is best suited for the organization's change and growth?
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Appendix F:
Additional Sources of Information and
Contacts
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Appendix F: Additional Sources of Assistance
There are many resources available to help your organization develop and implement an EMS that are
free of charge or relatively inexpensive. The following is a description of some of these resources.
Federal Government Agencies
The U.S. Environmental Protection Agency (USEPA) provides information on a number of topics
that can be useful in the development and implementation of an EMS. Some of these resources
include: assistance with interpretation of environmental laws and regulations; information on pollution
prevention technologies (case studies and fact sheets); and hotlines to answer questions about
environmental issues. The Agency also has web sites for information on EMS's and Design for
Environment. The USEPA's Office of Compliance has established national Compliance Assistance
Centers for various industry sectors.
The Small Business Administration (SBA) provides assistance to small and medium-sized
organizations. The SBA can provide information and assistance related to: operation and
management of a business; sources of financial assistance; international trade; as well as laws and
regulations.
State Agencies
Your state environmental regulatory agency can provide assistance with the development of an EMS.
Contact your state environmental agency and inquire about education and outreach programs for
organizations that are developing an EMS. Many state environmental agencies also can provide
publications, pamphlets, and on-line help related to state environmental laws, innovative pollution
prevention technologies, waste reduction, and permitting. Some states (such as North Carolina,
Wisconsin and Virginia) have developed programs to help organizations implement and EMS and/or
seek ISO 14001 registration. Recently, several states (including Texas and Virginia) established
"EnviroMentor" programs within their Small Business Assistance Offices. These mentoring programs
are intended to help small companies comply with regulations.
Associations
Industry trade associations can provide assistance with the development of an EMS. These
organizations can provide information on industry-specific environmental management issues, and can
put you in contact with other organizations that can share their experience and expertise in EMS
implementation.
Colleges and Universities
Some colleges and universities provide EMS-related training or manage EMS demonstration projects.
Chambers of Commerce
Your local or state chamber of commerce might be helpful in providing information about legislative
and regulatory issues that affect environmental management for small and medium- sized
organizations. Other services that are commonly offered include handbooks, workshops, conferences
and seminars.
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Non-Profit Organizations
Another resource to consider is the Manufacturing Extension Partnership (MEP), which is a growing
nationwide system of services that provide technical support to businesses interested in assessing and
improving their current manufacturing processes. The MEP is a partnership of local manufacturing
extension centers which typically involve federal, state, and local governments, educational
institutions, and other sources of information and funding support. The MEP can also often provide
assistance with quality management, development of training programs and business systems.
The Industrial Technology Institute (ITI) is a non-profit organization dedicated to expanding technology
access and technology management among U.S. manufacturers. ITI provides technical assistance to
small and medium-sized organizations through the Michigan Manufacturing Technology Center. ITI
also has experience with the development of business performance tools and provides services for
energy, environment, and manufacturing assessments; as well as, QS 9000 and ISO 14000 training
and implementation.
Other Organizations
Another recommended source of information and expertise is the organizations with which you do
business. It is likely that your suppliers and customers have experience with many of the aspects of
an EMS, and might be willing to share their experiences and provide advice to your organization.
On-line Resources
There is a wealth of information related to EMS implementation available electronically via the Internet.
Many state, federal, and local agencies have home pages on the Internet containing information that
can be useful to your organization. Numerous non-governmental organizations have home pages that
contain information on topics such as ISO 14000, pollution prevention, recycling and waste
minimization, environmental laws and regulations, innovative manufacturing technologies, and
materials substitution. If your organization does not have Internet access, contact your local library to
see if it provides Internet access to users.
Additional EMS resources and contacts are described on the following table.
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Appendix F (cont'd.)
Additional Sources of Information and Contacts
Note: This list is not intended to be comprehensive. Appearance on this list should not be construed as an endorsement by NSF of any products/service.
FEDERAL AGENCIES
Organization
US Environmental
Protection Agency
Resource
Small Business Compliance
Assistance Centers:
Design for Environment Guide,
Fact Sheets and DFE EMS
Template
Small Business Compliance
Policy
Compliance-Focused EMS •
Enforcement Agreement
Guidance
Environmental Compliance
Auditing Protocols
Code of Environmental
Management Principles
Pollution Prevention
Clearinghouse
Telephone Number / Internet Address
202/564-7066 (general information)
www.epa.gov/opptintr/dfe/tools/ems/
ems.html
202/564-7072
www.epa.gov/oeca/smbusi.html
http://es.epa.gov/oeca/oceft/neic/
12elemnr.pdf
EPA National Service Center
1-800-490-9198
www.epa.gov/oeca/ccsmd/profile.html
www.epa.gov/oeca/cemp/cemptoc.html
202/260-1023
Description
Centers are Internet Web Sites with
comprehensive environmental compliance,
technical assistance, & pollution prevention
information for various industry sectors.
Website contains information on EMS and
how to incorporate DFE into an EMS.
Provides a how-to manual for implementing
a DFE-based EMS and a set of integration
tools for companies that already have an
EMS.
Effective May 11, 2000, this policy
supercedes the June 1996 version.
Published in the Federal Register on April
11, 2000 (65FR19630).
Presents the key elements of a compliance
focused EMS model.
These protocols are intended to guide
regulated entities in the conduct of
compliance audits and to ensure that audits
are conducted in a thorough manner.
Collection of five broad principles and
performance objectives that provide a basis
for environmental management among
Federal agencies.
Technical Information on materials and
processes, including publications related to
waste minimization and pollution prevention.
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Office of Wastewater
Management
Public Information Center
RCRA / Superfund Hotline
FEDERAL AGENCIES
www.epa.gov/owm/iso2/htm
202/260-7751
800/424-9346
202/382-3000
Provides information on various EPA-
sponsored EMS projects.
General information about EPA programs.
Provides information about hazardous waste
regulations and handles requests for federal
documents and laws.
Small Business and Asbestos 800/368-5888
Ombudsman 202/557-1938
Information and advice on compliance
issues for small quantity generators of
hazardous waste.
U.S. Small Business
Administration
Technology Transfer and
Support Division
TSCA Hotline
Enviro$en$e
US EPA Home Page
SBA Answer Desk
SBA Home Page
513/569-7562
202/554-1404
http://es.inel.gov
http://www.epa.gov
1-800-8-ASK-SBA
http://www.sbaonline.sba.gov
Access to the ORD research information and
publications.
Assistance and guidance on TSCA
regulations.
Solvent alternatives, international, federal
and state programs, other research and
development. Also, environmental profiles
of various industrial categories.
Information about EPA regulations,
initiatives, and links to the home pages of
other agencies and EPA regional offices.
Information about SBA programs, and
telephone numbers for local offices.
Information about business services
available to your organization, with links to
other related sites.
Government Printing GPO Superintendent of
Office Documents
202/512-1800
US Department of Pollution Prevention Information http://www.er.doe.gov/production/esh/
Energy Clearinghouse epic.html
Information about available documents and
instructions on ordering GPO publications.
Pollution prevention and environmental
design information.
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Organization
State Environmental
Protection Agencies
Resource
Environmental Assistance
Programs
Small Business Assistance
Programs (Mandated under Title
V of the Federal Clean Air Act).
STATE AGENCIES
Telephone Number / Internet Address
Contact your state's Environmental
Protection Agency
Call the EPA Small Business
Ombudsman (800/368-5888) for the
phone number and address of the Small
Business Assistance Program in your
state.
Description
Many state environmental protection
agencies provide publications, technical
assistance, and information on pollution
prevention technologies, waste reduction,
and regulatory compliance, at little or no
charge.
Provides information and technical
assistance to small businesses regulated
under the Clean Air Act.
State Environmental
Protection Agencies
(cont'd)
State and Local Pollution
Prevention Programs
Michigan Department of
Environmental Quality
Contact the National Pollution Prevention
Roundtable (202/466-7272) for the phone
number and address of the pollution
prevention program in your state.
http://www.deq.state.mi.us
Provides information and technical
assistance on pollution prevention.
Fact sheets, training, and technical
assistance.
Minnesota Technical Assistance
Program
Ohio Department of
Environmental Protection
Wisconsin Department of
Natural Resources
http://es.inel.gov/techinfo/facts/mpca/mpc
a.html
http://arcboy.epa.ohio.gov
http://es.inel.gov/techinfo/facts
Fact sheets on pollution prevention,
materials substitution.
Fact sheets on pollution prevention,
materials substitution.
Fact sheets on pollution prevention,
materials substitution.
Note: The list shown above represents only a sample of the resources that may be available from state agencies. Contact your state
agency for details of existing programs and other forms of assistance available
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EMS SOFTWARE PACKAGES
Organization
Greenware
EMSoft2000
ISOXpert
ISOSoft 14001
Contact Info
1-800-474-0627
www.greenware.com
1-800-241-3618
www.rmtinc.com
1-800-ISO-EASY
416-679-0119
www.isogroup.simplenet.com/soft14k
Description
Provides ISO 14001 assessment, implementation and audit
software
Software package based on LotusNotes to support EMS
implementation
Built on LotusNotes platform. Customizable document formats.
Provides ISO 14001 assessment, implementation and audit
software. Co-developed with BSI.
Organization
Industrial Technology Institute (ITI)
Manufacturing Extension Partnership
(MEP)
NON-PROFIT ORGANIZATIONS
Address Phone Number
2901 Hubbard Road
P.O. Box 1485
Ann Arbor, Michigan 48106-1485
Building 301, Room C121
National Institute of Standards and
Technology
Gaithersburg, Maryland 20899-
0001
1-800-292-4484
Fax: 1-313-769-
4064
1-301-975-5020
1-800-MEP-4MFG
Fax: 1-301-963-
6556
Description
Technical assistance to small and mid-sized
manufacturers. Energy, environment, and
manufacturing assessments, as well as
performance benchmarking, and QS 9000
and ISO 14000 implementation assistance.
Assists manufacturers with assessing
technological needs, and works to help small
manufacturers solve environmental problems
with cost-effective solutions.
North American Commission on
Environmental Cooperation
"Improving Environmental Performance
and Compliance: 10 Elements of Effective
Environmental Management Systems"
www.cec.org/pubs_info_resources/
publications/enforce_coop_law/ems
.cfm?varlan=english
514/350-4334 Joint expression from three North American
(Commission) governments regarding how voluntary EMS's
designed for internal management purposes
202/564-7048 can also serve broader public policy goals,
(USEPA) such as compliance assurance and improved
environmental performance.
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Resource
ANSI Online
Business Resource Center
Canadian Standards Association
INTERNET RESOURCES
Internet Address
http://www.ansi.org
http://www.kciLink.com/brc
http://www.csa.ca/isotcs
Clean Technologies Center (UCLA) http://cct.seas.ucla.edu
Consortium on Green Design and Manufacturing (DC-Berkeley) http://euler.berkeley.edu/green/cgdm.html
Environmental Technology Gateway http://iridium.nttc.edu/environmental.html
International Corporate Environmental Reporting Site
Industrial Technology Institute Home Page
International Network for Environmental Management
www.enviroreporting.com
http://www.iti.org
www.inem.org
ISO 14000 Information Center
http://www.iso14000.com
Description
Contains information related to the
American National Standards
Institute, including meetings, events,
and standards information databases.
Provides information on a variety of
topics, including tips on management,
recycling, and financing.
A center for information and services
related to ISO 9000 and ISO 14000,
maintained by the Canadian
Standards Association.
Innovative technologies for pollution
prevention.
Environmental design and
sustainable develooment.
Access to other environmental links
and information, environmental
technologies.
International news about
environmental issues and resources
for environmental reporting.
Information about ITI, how to find
environmental information on the
Internet, and links to other
organizations.
Case studies, publications and how-
to information on environmental
management. Interactive tools for
assessing environmental policies and
reports.
Answers to questions on ISO 14000
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Resource
ISO 14000 Integrated Solutions (ANSI/GETF)
ISO Online
INTERNET RESOURCES
Internet Address
http://www.gnet.org
http://www.iso.ch
Multi-State Working Group www.mswg.org
National Environmental Information Resources Center (NEIRC) http://www.gwu.edu/~greenu/
NSF-ISR Home Page
Description
standards.
http://www.nsf-isr.org
AUTHORIZED SOURCES OF THE ISO 14000 STANDARDS
Will provide training, conferencing,
on-line information services and
publications on a fee basis.
The ISO homepage provides
information on ISO, its structure,
members, technical committees,
meetings, and events.
Describes the activities of this group
regarding EMS and ISO 14001.
Provides access to a wide variety of
information about environmental
matters, with links to hundreds of
organizations.
Contains information on NSF
International and its pilot projects in
EMS implementation.
NSF International (NSF)
American National Standards Institute (ANSI)
American Society for Quality (ASQ)
American Society for Testing and Materials (ASTM)
Phone: 1-888-NSF-9000
Fax: 1-734-827-6801
Phone: 1-212-642-4900
Fax: 1-212-398-0023
Phone: 1-414-272-8575
Fax: 1-414-272-1734
Phone: 1-610-832-9585
Fax: 1-610-832-9555
789 N. Dixboro Road
Ann Arbor, Ml 48105
11 West 42nd Street
New York, NY 10036
Milwaukee, Wl
West Conshohocken, PA
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Glossary of Acronyms
ACC American Chemistry Council
ANSI American National Standards Institute
API STEP American Petroleum Institute's "Strategies for Today's Environmental Partnership"
CAA Clean Air Act
CEC Commission for Environmental Cooperation
CERCLA Comprehensive Environmental Response, Compensation and Liability Act
CERES Coalition for Environmentally Responsible Economies
CFCs Chlorofluorocarbons
CMA Chemical Manufacturers Association
CWA Clean Water Act
DFE Design for Environment
EHS Environment, Health and Safety
EMAS Eco-Management and Audit Scheme
EMS Environmental Management System
EPA (Also USEPA) U.S. Environmental Protection Agency
EPCRA Emergency Planning and Community Right-to-Know Act
FIFRA Federal Insecticide, Fungicide and Rodenticide Act
HMTA Hazardous Materials Transportation Act
ICC International Chamber of Commerce
ISO International Organization for Standardization
ITI Industrial Technology Institute
MEP Manufacturing Extension Partnership
OSHA Occupational Safety and Health Administration
PCBs Polychlorinated Biphenyls
P2 Pollution Prevention
QMS Quality Management System
RCRA Resource Conservation and Recovery Act
SBA U.S. Small Business Administration
SPCC Spill Prevention Control and Countermeasure
TC 207 Technical Committee 207 (of ISO)
TSCA Toxic Substances Control Act
TQM Total Quality Management
USTAG U.S. Technical Advisory Group (to TC 207)
VOCs Volatile Organic Compounds
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Bibliography
• Canadian Standards Association, Competing Leaner, Keener and Greener: A Small
Business Guide to ISO 14000, 1995.
• Cascio, Joseph, editor. The ISO 14000 Handbook. CEEM Information Services with ASQC
Quality Press, 1996.
• Diamond, Craig P., "Voluntary Environmental Management System Standards: Case
Studies in Implementation." Total Quality Environmental Management, (Winter 1995/1996),
pp. 9-23.
• GETF, The USEPA Environmental Management System Pilot Program for Local
Government Entities, January 2000.
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