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Legal Update
Is Your Facility Environmentally Compliant?
Edward Callaway
Publish Date: April 3, 2008

You may not see your facility as a waste generator, but if you have an incinerator or lab on site, discharge fluid waste into the municipal sewer or ship out red bag waste, you are — and you likely face regulation by local, state or federal authorities over these and other processes.

The EPA's 2002 Hospital and Healthcare Initiative urges prompt self-reporting of environmental violations and warns of imminent inspections. It also encourages healthcare facilities to implement an environmental management system (EMS). Here's how to build an EMS that will keep you compliant.

Identify and analyze requirements
The first step in developing your EMS is identifying and documenting your facility's current and future environmental requirements. You'll either need to enlist internal resources, such as your operations manager or biomedical engineer, or hire a consultant. Walk through your facility's operations, taking into account which processes need permitting, monitoring or reporting, until you've compiled a comprehensive inventory of regulatory requirements. This self-audit establishes what you'll need to verify later.

Second, define the roles and duties of the personnel who'll implement and maintain the EMS through oversight and communication. While there are no regulations mandating what those positions should be and who should fill them, more specific planning will result in more effective efforts and better compliance.

Finally, determine who'll be responsible for monitoring additions and updates to requirements and for changing the facility's policies as needed. The sooner you figure out who'll handle this task — whether it's a staff member looking to take on more responsibility or a full- or part-time external hire — the better, as this person can and should help you in completing the document described in the first step.

Establish an effective communication system
A successful EMS will accurately reflect your facility's current operations and up-to-date environmental policies. Since the laws and regulations change frequently, it should also include a mechanism for communicating those changes identified and interpreted to affect your facility. Specify how and when this information will be disseminated to the rank and file: management, department heads, staff, on-site providers, contractors and even vendors.

You should also institute protocols for the communication of internal and external concerns. Internally, communication and information should be able to flow from the bottom up as well as from the top down, with personnel protected from any potential negative repercussions. Administrators need to establish that the EMS is a priority and ensure that staff can raise issues, report concerns and speak their minds without fear of professional retaliation.

Externally, protocols should establish how you'll respond to inquiries and requests from authorities, and perhaps even from patients, regarding environmental issues and how reporting and compliance will be communicated to regulatory agencies. Much of the information and protocol required to develop an effective communication system may already exist at your facility — your safety reporting mechanism, for example, may serve as a model — but an EMS should be tailored to specifically address environmental issues.

Standard operating procedures
You'll need to establish standard operating procedures that draw up methods for preventing violations, responding to accidents or emergencies and otherwise achieving the EMS's goals of proper waste collection, storage, handling and disposal. Be sure to document the potential consequences for departing from those procedures: not just your facility's liability for violations, but also the administrative penalties imposed against staff's failure to comply. Don't neglect the steps for developing, approving and implementing new standard operating procedures as needed.

Ensuring compliance isn't just about writing the rules. Your EMS should also include standard educational procedures to train and re-train personnel, including on-site service providers, contractors and anyone whose job responsibilities affect your facility's ability to successfully manage materials potentially hazardous to the environment. Document the personnel who've been trained and pay particular attention to those whose tasks and compliance responsibilities can have significant environmental impacts. This includes personnel responsible for your emergency response and corrective action programs.

To gauge how well your EMS is working, monitor activities that can have significant environmental impact and evaluate your actual compliance with regulatory requirements. In conjunction with written targets, objectives and action plans, taking these steps can help you identify areas for improvement.

Another essential component in judging your system's efficiency is hiring an independent auditor to regularly review your EMS's performance and your staff's compliance. These independent compliance audits are integral to success, as they can identify opportunities for improvement and help you to ensure that your environmental compliance efforts remain cost-effective and tied to your organization's overall mission. If conducted by outside counsel, the findings will remain confidential under attorney-client privilege. You might also consider a corporate audit agreement with the EPA, which lets regulated facilities that have compliance concerns communicate directly with the EPA for assistance, with reduced fines if violations are discovered. If you don't take advantage of this option at the present time, perhaps your EMS should provide a plan for determining when and if your facility should enter into the agency's corporate audit agreement or voluntary audit policy.

Committed to compliance
A well-planned and well-implemented EMS can save you the costs of enforcement- or compliance-related fines by providing a framework for the systematic management of environmental responsibilities. Overall, your system should reflect a commitment to providing adequate personnel, technology and financial resources, and to performing any public outreach or community involvement necessary to making the system work.

Web Resources

Environmental management system information by the EPA

EMS initiatives, by region

Additional EMS resources

The University of Louisville / Kentucky Pollution Prevention Center EMS manual (available under "KPPC E2 Training Manuals and Publications" subheading)