Healthcare Waste Policy

Reference No:

IC003

Version:

3.1

Ratified by:

LPCT Trust Board

Date ratified:

November 2007

Name of originator/author:

Janine Rayfield, Raymond Wright

Name of responsible committee/individual:

Infection Control Committee

Date issued:

November 2007

Review date:

31 March 2013

Target audience:

All staff with healthcare waste responsibilities and their managers; risk managers; environmental managers; managers with responsibility for transport

Distributed via:

myMail Email Website

NHS Lincolnshire Healthcare Waste Policy Version Control Sheet Versio n

Section/Para/ Appendix

Version/Description of Amendments

Date

1

Minor revisions, for approval by Director: (1) Target audience, review and issue dates added to front page; (2) Version Control Sheet added

2

Review date extended to July April 2010 2010 to enable review to take place in line with the newly created web page

4 March 2009

Author/Amended by

Amended by Anny Jones, as agreed with Janine Rayfield and Raymond Wright S Barnes on behalf of Janine Rayfield

3

Entire Policy

Policy extended to enable full review by newly appointed Infection Control Nurse and full consultation and approval process to be applied

August 2011

Janine Rayfield

3.1

Front cover and version control sheet

Extended to March 2013 to enable full review incorporating future working requirements

5 September 2012

S Barnes

4 5 6 7 8 9 10 11 12 13 14 15

Improving Health, Improving Services Page 2 of 7

Lincolnshire Teaching Primary Care Trust

NHS Lincolnshire Healthcare Waste Policy 1.

Policy statement

The Board of the Lincolnshire teaching Primary Care Trust is committed to implementing the guidance provided in the Department of Health Environment and Sustainability Health Technical Memorandum 07-01: Safe management of healthcare waste (HTM 07-01)1. Implementation of this guidance will ensure the Trust complies with the regulatory requirements of relevant health and safety, environmental and transport legislation with respect to its management of wastes2,3,4,5. The Trust will encourage its partners and other stakeholders to adopt this Waste Policy.

2.

Policy aims

The aim of this Policy, and its associated summary guidance and procedure notes, is to ensure Trust waste is appropriately managed from the time of production to its place of final recovery or disposal. This “cradle to grave” approach will require waste producers to assess wastes at the point of production and segregate them accordingly using the Policy’s assessment and segregation procedures in the Standard Operational Procedures (SOPs). These procedures are based on the “unified” segregation approach outlined in HTM 07-01 (see Appendix 1). The Trust has also to demonstrate compliance with the duties placed on all NHS organisations under the Health Act (2006) and the relevant Core Standard: C4e6.

3.

Legal and statutory obligations

These obligations are accounted for in HTM 07-01, implementation of this guidance will fulfil these obligations. Future obligations will be highlighted by the waste management system incorporated into this policy.

4.

Waste management arrangements

The Trusts assessment and segregation procedures and guidance will ensure healthcare wastes generated are appropriately segregated, described, packaged and securely stored whilst awaiting collection and disposal. Each waste will then be consigned to an appropriately licensed waste contractor for suitable disposal. Similar segregation protocols will be generated for non-healthcare municipal waste-streams requiring segregation and separate collection. 1

Department of Health (2006) Environment and Sustainability: Health Technical Memorandum 07-01: Safe Management of Healthcare Waste. 2 Great Britain (2005) The Hazardous Waste (England and Wales) Regulations, 2005. S12005 No 894. 3 Environment Agency (2005) Technical Guidance WM2: Hazardous Waste: Interpretation of the definition and classification of hazardous waste (Second Edition. Version 2.1). 4 Great Britain (2004) The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004. 5 Great Britain (1990) The Environment Protection Act 1990 (c.43). The Stationery Office, London www.opsi.gov.uk 6 Department of Health (2006) The Health Act 2006; Code of Practice for the Prevention and Control of Health Care Associated Infections. 1st October 2006. Core Standard C4(e): The Stationery Office www.dh.gov.uk. Improving Health, Improving Services Page 3 of 7

Lincolnshire Teaching Primary Care Trust

Waste audits will be undertaken by appropriately trained senior staff members to verify waste segregation protocols are being adopted by waste producers and that wastes are being appropriately packaged and stored prior to collection by waste contractors. Audits will also be undertaken to ensure wastes are being described, characterised and consigned to waste contractors according to relevant waste legislation.

5. Process for identify improvement programmes and monitoring progress The person with responsibilities for waste management within the Trust (The Waste Manager) will develop a waste management system to examine Trust premises waste audit records, and report back to the Trust Waste Group. This Waste Group will review the Trust’s performance, respond to issues and plan improvements to the Trust’s waste management system. The Waste Group will report to the Board, via the Infection Control Committee, recommending changes to waste policy and procedures. The Waste Manager will conduct; inspections at Trust premises, duty of care audits of waste contractors and cradle-to-grave audits of the waste-streams generated by the Trust. The Waste Manager will identify any relevant forthcoming legislation to the Trust Waste Group so necessary changes can be made to the Trust’s Waste Policy and procedures (see Diagram 1 below). Diagram 1 The Waste Management Cycle

Assess Current & Future Legislation

Review Policy Systems & Procedures

Respond to Problems Identified

Write Waste Policy, Guidance & Procedures

WASTE MANAGEMENT SYSTEM

Review Performance against Policy & Procedures

Arrange Training & Instruction for Staff Audit Procedures & Monitor Progress

Improving Health, Improving Services Page 4 of 7

Lincolnshire Teaching Primary Care Trust

6. Waste management responsibilities and lines of accountability 

It is the duty of those who produce waste to follow the assessment and segregation protocols, and deposit their waste into the appropriate colour coded waste receptacle.



It is the duty of all waste handlers to follow waste handling procedures and place colour coded waste receptacles into the appropriate bulk storage bins.



It is the duty of the premises/clinical/general manager to audit staff under their control to ensure they understand and follow assessment and segregation protocols.



It is the duty of premises/clinical/general managers to ensure wastes are described and characterised according to the site Duty of Care Manual.



It is the duty of the premises/clinical/general managers to ensure that waste assessment and segregation / duty of care audits are completed as Policy protocol. This may be allocated to other appropriate personal to undertake.



It is the Trust’s Waste Manager’s duty to advise the Waste Group regarding current and forthcoming legislation and to audit premises for compliance with waste legislation.



It is LtPCT’s Waste Manager’s duty to conduct duty of care audits of waste contractors and cradle-to-grave audits of the waste-streams generated by the Trust.



It is the duty of the Waste Group to report progress to the Board via the Infection Control Committee.



The Waste Group will be representative of the organisations across Lincolnshire and be fit for purpose. As a sub-group of the Infection Control Committee minutes and reports will be made available to the Committee at the quarterly meetings; terms and reference will also be available.



The Trust’s Waste Manager will develop a Summary of Guidance Notes which will clearly identify the legal obligations set out in waste, health and safety, and transport legislation in relation to healthcare waste.

7. Arrangements for implementation Waste producers will be trained regarding segregation protocols. This will be via a cascade method that has been discussed at various meetings across the Trust and other stakeholder areas. All areas generating healthcare waste will be involved. The Trust’s Waste Manager will advise, oversee preparation of the training packages and assist in the training events. The packs will contain different training levels to meet the needs of different staff cohorts and agencies. The following list is an example:  

Dental staff require specific knowledge for hazardous chemicals e.g. x-ray medium, mercury; Clinical staff guidance involves the segregation in treatment areas of infectious wastes, sharps and cytotoxic / cytostatic waste streams;

Improving Health, Improving Services Page 5 of 7

Lincolnshire Teaching Primary Care Trust

  

Domestic staff need specific training regarding the handling and storage of waste relevant to their area of work which may include keeping an accurate waste log Some Managers will have need of instruction on the maintenance of the waste management system (verifying audit trails to the waste group) Particular emphasis will be placed on auditing waste segregation, handling, storage and waste transfer records for all senior staff/managers

It is intended that the training given to senior staff will include segregation protocol training, regulatory definitions and classifications of waste, consignment note procedures and audits at the premises / areas they are responsible for as a standard. Packs will be given to these managers/senior staff and they will be encouraged to cascade the information to staff in their area of responsibility. Other training events will be scheduled; these events will give all managers and senior staff the option to send other strategic personnel for training so that several cascade training sessions can be organised across the same vicinity. This takes account of the geographical area and the numbers of agencies requiring the information. The Standard Operational Procedures (SOPs) will provide clearly written instructions on the way waste should be managed.

8. Tools and Guidance This document is the over arching Policy underpinned by other documents that will be updated and developed to meet service need. These documents will not be presented to the Board but they will be passed to the Infection Control Committee for ratification. This will ensure that all support documents and training tools remain up-to-date to guide staff in their responsibilities. The following is not an exhaustive list of the documents that support this Healthcare Waste Policy:      

    

Standard Operational Procedures Range of training packages Summary Guidance for completing hazardous waste consignment notes. Summary Guidance for Duty of Care transfer notes. Duty of Care manual for all Trust healthcare premises, including Waste audit forms for: o waste assessment and segregation practice, o waste transfer notes and record keeping, o waste handling and storage. Assessment and segregation procedure notes for all healthcare premises based on HTM 07-01 and what can be achieved within space constraints of treatment areas. Assessment and segregation procedure note for healthcare workers in patients homes based on HTM 07-01. Standard Operational Procedures for community nurses transporting small quantities of medicinal or infectious waste from patient’s homes to healthcare base. Audit Procedure for assessing healthcare premises compliance with waste legislation (based on Environment Agency inspection and audit protocols). Audit Procedure for assessing waste contractors (based on Environment Agency inspection and audit protocols).

Improving Health, Improving Services Page 6 of 7

Lincolnshire Teaching Primary Care Trust

APPENDIX 1

This Waste Policy is based on the above (Chapter 3 Health Technical Memorandum 07-01 Safe management of healthcare waste - HTM 07-01)

Improving Health, Improving Services Page 7 of 7

Lincolnshire Teaching Primary Care Trust