Does the RMW vendor know the regulations?

Knowing and adhering to the regulations surrounding disposal of RMW is vital for healthcare facilities to avoid fines, loss of licenses, and avoid negative publicity. In addition to complying with the federal, state and local regulations, many hospitals receive their accreditation from Joint Commission and follow their standards for patient environment of care (EOC).  Understand and ask how your RMW Vendor ensures compliance with these authorities.

The myriad of regulations can make it difficult for hospital personnel to stay on top of the requirements.

If you look to your RMW vendor to provide expertise on regulations, how can you be certain that they have knowledge of this area? First, ask if they have staff dedicated to regulatory and environmental regulations. Second, ask them for a listing of all the regulations that impact your facility and impact their ability to service your facility. Expect the list to cover federal, state and local regulations.

Although there are additional regulations depending on the location, the following are a few of the mandatory elements: Federal Motor Carrier Safety (ensures safety of highways and drivers through roadside inspections, truck and driver monitoring), OSHA bloodborne pathogen training on an annual basis for your employees, and DOT training for all employees handling hazardous materials including regulated medical waste.

Check for evidence that your regulated medical waste vendor knows the regulations, including their drivers. Ask the driver who services your account what waste stream they are transporting and what safety protocols they have on the truck to contain any spill (i.e. spill control kits). Chances are that if they cannot answer basic questions concerning the waste they are handling, then they are not properly trained to service your facility.

Be wary of vendors who don’t emphasize the regulations regarding training. Often, when facilities are inspected, the easiest way for a regulator to evaluate compliance at a facility is to ask them for their training records. Without full knowledge and understanding of often- changing regulations, many facilities find themselves out of compliance. Don’t let your vendor put you in this vulnerable position.

According to Rhett Belser, Safety Specialist at Shawnee Mission Medical Center in Kansas, "You can’t think of RMW as out of the door and out of mind because the hospital has a cradle-to-grave responsibility. That’s why you want a vendor you have confidence in. A compliance problem at the landfill is still your responsibility."

Does your vendor stay current with the regulations and assure a trained compliance-focused workforce?

Does your regulated medical waste disposal vendor have Environmental Health and Safety (EHS) staff dedicated to regulations? Not just the sales person, but a team of regulatory experts studying the laws at local, state and national levels and who anticipate emerging changes that could impact your facility? It’s important to know the current regulations, and be prepared to anticipate and comply to changes as they emerge. The regulations are confusing, continually changing, they differ by state, and in many cases, require the generator (the hospital) to have responsibility for the waste they generate until it is treated and is finally disposed of at a landfill. Generators often have questions about how to properly manage their waste. While it may be the hospital staff producing the waste, it may be another party or entity within the hospital that has to manage the waste and maintain compliance. It is important to partner with a waste disposal company which will provide the right tools at all the right levels to help manage the varying aspects of medical waste disposal, including training.

In addition to having staff dedicated to understanding regulations and anticipating changes as they emerge, a waste vendor should have staff with industry and regulatory relationships. Leveraging these relationships can provide a voice from your facility to the ears of the regulators.

Does your RMW vendor help your facility remain compliant?

Partnering with a RMW vendor who helps you stay on track with training requirements will help keep the regulators satisfied and most importantly decrease your employee risk.

Does your waste vendor have the capability to provide training programs such as OSHA blood borne pathogen training? Do they provide training for waste packaging, proper labeling on containers, proper shipping documents, and proper closure of containers? Look for regulated medical waste vendors that provide compliance audits, waste segregation training, waste packaging training, and a variety of posters to their clients to assist in the educational efforts to stay compliant.

Training pays off and keeps hospitals in compliance. Kirsi Aryan-Edwardson, Director of Environmental and Nutrition Services at Littleton Adventist Hospital in Colorado said that keeping compliant is more important than ever with the increased focus that regulators have. She said, "Regulatory agencies are focusing more on healthcare. The benefit is that hospitals are learning to be more compliant."

Everyone can agree that staying compliant is the best course of action for hospitals. Healthcare organizations are better served by focusing on patient care than by focusing their efforts on corrective action required to address noncompliance. Non-compliance is more than just a waste of hospital effort; it also can bring citations, fines, and negative publicity. On a monthly basis, the DOT posts enforcement actions. Recently the DOT fined a healthcare facility $5,600 for RMW containers which were not properly closed. Another institution received a fine of $5,950 for RMW containers that were not secure and leak proof. See the following website for enforcement actions from the DOT, http://hazmat.dot.gov/enforce/
hmenforce.htm.

How much does your RMW vendor outsource waste treatment/disposal?

Because the responsibility for RMW remains with the facility even after the vendor hauls it away, it’s important for the vendor to be compliant through the entire process of pickup, transportation, treatment and final disposal of the regulated medical waste. Healthcare facilities need to feel secure that the RMW vendor they chose is handling the entire waste process and is fully integrated. Some small waste companies are merely waste haulers who subcontract waste treatment and disposal. When you increase the number of companies who handle the waste, you increase the risk and it becomes more difficult to determine the responsibility. At the end of the day, you need to know where your waste is going. When you sign your name on a shipping document the DOT specifically holds you, the generator, responsible for identifying, classifying and packaging the waste.

If your RMW transporter does not own the disposal facility, make sure the transporter has done a thorough job of due diligence, an agreement and a good working relationship with the disposal facility are important. Do not let a problem between the disposal facility and transporter become your problem.

Besides outsourcing part of your regulated medical waste, some RMW companies may lack the insurance required by your healthcare institution. Hospitals should require proof of general liability insurance, workers compensation, transportation permits and financial assurance documents from their RMW providers. Many small companies don’t have the knowledge or the financial ability to carry such insurance.

In addition to fines and the tarnished scorecard with regulators, the hospitals have been left with a public relations disaster as they struggle to keep noncompliance off the front-page news. Current and prospective patients wonder about the quality of hospital care when their healthcare organization (or the hospital’s waste vendor) is found to be non-compliant.

Healthcare facilities need to audit their waste disposal company from collection to transportation, treatment and final disposal. (Tips are available at hpnonline.com.) Healthcare facilities need to ask if their waste company outsource any of the waste processing to another vendor, and they should make sure that all companies touching their waste are properly licensed and insured. Additionally, ask how long they have been in business and ask for references to ensure that your selected vendor is experienced in working with healthcare institutions of your size.

Does your regulated medical waste disposal service offer compliance audits and training?

Where your Regulated Medical Waste should not end up.

How do you know if your healthcare facility has gaps in Joint Commission’s EOC standards, Joint Commission’s performance improvement requirements, OSHA, EPA, DOT, and state/local regulations? Ask if your regulated medical waste vendor provides on-going consulting and compliance audits to customers. Do they have dedicated consultants to provide these audits?

A healthcare compliance specialist, not the sales representative should perform a compliance or waste survey and audit report. Does your auditor have a PDA/laptop, a camera, and years of knowledge, compliance training and certification? The auditor should observe current practices, identify safety issues and identify best demonstrated practices as well as gaps from best-demonstrated practices. Not all compliance audits are created equal. Seek vendors who have the ability to go the extra mile with the technical expertise and proven, documented results.

After identifying top deficiencies and potential violations, the compliance audit identifies corrective action such as training and changes in processes like ensuring the right containers are in the right locations. Your RMW provider should be able to provide training materials and coach departments through needed changes in the way they do their jobs. Recognizing the audit is simply a snapshot of that day; these changes need to be monitored time and time again.

Does the regulated medical waste company have the ability to provide educational in-services and training materials on various subjects? Training should be considered for nurses, clinical staff and housekeeping employees who are responsible for RMW disposal. Training might also be available to the lab. Extensive training is usually provided with environmental services staff who package the RMW. Ask if your vendor offers certified US DOT Hazardous Material training as well as bloodborne pathogen OSHA training for your personnel. Ask if your vendor has the capability to provide this training for personnel every three years, a requirement of the DOT. The DOT requires the training to be facilitated by an instructor, requires attendees to pass a certifying test and requires attendees to receive certificates. All of these requirements should be available through the RMW disposal vendor for the employees that handle the regulated medical waste at the healthcare facility.

Aryan-Edwardson commented on her RMW reps, "They are patient and non-judgmental. They evaluate our processes and advise us what needs to get done, but leave the follow through up to us, as we prioritize our next steps. This approach works well to engage us without making us feel defensive."

Education is necessary at the management level as well. Belser remembers being new in his position at Shawnee Mission Medical and being thrown into the regulations. "Our waste vendor helped me by providing education on EPA and DOT. That was really useful when we had a surprise EPA inspection recently."

Does your RMW vendor provide training on waste stream segregation and departmental tracking of RMW generated?

Does your RMW vendor have the depth to provide departmental tracking which identifies the specific amount hospital departments generate? Does your waste vendor identify which departments need training on waste stream segregation? Your vendor should be targeting their training and educational in-services to the departments which are in need. Hospitals should take advantage of all the training that’s offered by their vendors whether it is posters, in-services, etc. Additionally, hospitals should make sure to train all the shifts.

Does your RMW vendor provide consultation on waste stream minimization?

Properly segregating waste is the first step in an overall program to minimize RMW. Hospitals for a Healthy Environment (H2E) have set a goal to reduce RMW to 15% of the total hospital waste stream. Does your vendor offer consulting services and on-going reporting to help hospitals reduce total waste? Does your vendor offer other options which provide incentive for the facility to reduce waste and costs?

On the surface, it might appear like a conflict of interest to entrust RMW minimization to the RMW vendor. However, it is in the vendor’s best interest to have optimally packaged, heavier containers that are truly RMW, which result in fewer hauls, more efficient use of space on the trucks, and less costs to treat the waste. Reducing the amount of red bag waste is good for the hospital and more efficient for the vendor. Kathy Lockamy in IC at Cape Fear Valley Hospital System in North Carolina, agrees, "Our RMW rep is helpful and supportive in reducing our RMW. She has helped us to get control and reduce the waste stream. She saw where containers were located and made some recommendations to make the tubs less available in certain areas of the hospital to cut down on the non-RMW in the biohazard containers."

Does your RMW vendor provide reports that you really use?

Does your vendor periodically report on the amount of RMW collected, the billings, and the key issues with the hospital’s waste program? Does the report trace waste back to the individual generating department? This would enable the facility to have the option to charge the department back for their service utilization. This also helps the hospital target departments where additional training or efforts may be needed.

Does your vendor offer reports? Are the reports available on-line? Do the reports track regulated medical waste from collection through documented disposal? Not only should you be able to see which departments are generating what amounts and types of waste, but you should be able to benchmark your total waste streams against H2E goals. See Figure 1 for an example. For hospitals that are focusing on environmental, Green Team efforts and possibly winning the coveted H2E award, on-going reporting is an invaluable feedback tool.

Your RMW vendor should provide reports, which analyze the waste stream, show the breakdown of the types of waste collected, and the associated costs. Some facilities use their waste stream reports as a basis for periodic review meetings between the RMW disposal company and key hospital stakeholders. These meetings are an ideal forum to discuss waste education, training and efforts to meet the hospital’s ongoing RMW goals. Some hospitals use their waste reduction goal as part of their Joint Commission performance improvement initiatives.

Does your RMW vendor provide shipping documents or manifests? Are these documents available on-line?

What do you show the regulator who asks to see the paper trail on your RMW shipments? RMW disposal companies should provide hospitals with on-line manifests, eliminating the need to keep big ring binders of shipping documents. Federal DOT requires documents be kept by the shipper for two years. State requirements can sometimes be even longer. Having on-line documents helps the hospital provide the required documentation for any regulator request without burdening staff with reams of paper. This archive system makes life easier for EVS personnel and reduces labor costs while ensuring a proper electronic paper trail.

Does your RMW vendor provide disaster and emergency preparedness?

In the light of Katrina and other emergencies and natural disasters many hospitals are requiring that their RMW vendors have disaster recovery and contingency plans. Many purchasing departments are requiring vendors to have back-up plans for inclement weather and other emergencies. They need to know the waste vendor’s back-up location will service their account to ensure that waste doesn’t pile up at the hospital. Healthcare facilities need to know that additional trucks can be diverted to pick up waste. Ask your waste vendor if they own their back-up facility. If not, ask if there is a contractual relationship requiring the back-up to accept their waste. Healthcare facilities need proof that the back-up will provide service during an emergency. These contingency plans need to be determined between the hospital and the vendor in advance of the emergency. During a crisis is not the time to negotiate back-up plans with your RMW vendor.

Healthcare facilities should list their vendors on the Disaster & Emergency Plan so they will be permitted on-site if needed. The solid waste vendor, the hazardous waste vendor and the RMW vendor should all be listed.

Does your RMW vendor offer full and flexible services?

RMW vendors should be able to be flexible to changing hospital needs. For example, ask the vendor what happens if you want to switch the day of pick up or add an additional pick up during the week. Hospitals need vendors with the bandwidth to accommodate such changes so they can be responsive to changing patient loads.

According to Lockamy, "Expertise and cost and reliability are the most important attributes of a good vendor. We don’t have any problems with our vendor because they carry their end of responsibilities."

RMW vendors should provide compliant containers and tubs to hospitals in shapes and sizes that best meet their needs. Containers should be strategically placed and appropriately labeled for solid waste, infectious waste, hazardous waste, recycling and universal waste. The vendor may also provide transport carts to move the waste to the hospital storage areas.

A full service vendor offers one stop shopping for regulated medical waste.

Summary

In today’s competitive, cost-driven, environmentally-focused economy, hospitals deserve value for the regulated medical waste services they are purchasing. This means not only efficient RMW removal, but also exemplary service that smoothly integrates with the rest of the hospital operations.

The risk of utilizing a low cost/pound RMW vendor can put your healthcare facility at risk due to cutting corners or simply lacking regulatory awareness. Identifying a high-value RMW vendor requires due diligence on the part of the facility.