1. Welcome

2. Disclaimer The opinions presented do not necessarily reflect the opinions or practices of AHE.

3. Hospital waste: how to properly implement and maintain a successful program

4. Today’s speakers Gary Zuckerman Vice President, Supply Chain & Facility Operations University of Pittsburgh Medical Center (UPMC) Altoona

5. About Gary Over 35 years of experience in the healthcare industry Served 28 years as a medical service corps officer in the Navy including positions as executive officer and commanding officer of Navy hospitals and clinics throughout the United States, Europe, and Southeast Asia Responsibilities include contracting, material management, engineering, environmental services, and biomedical engineering Received bachelor’s degree in Health Planning and Administration from Penn State University and MBA in Hospital Administration from the University of Florida

6. Today’s speakers Ed Barr Program Manager, Waste Stream Management Stericycle

7. About Ed Over 25 years of recycling and medical waste management experience and has lead recycling initiatives recognized by EPA, AHA, Practice Greenhealth, and the Greater Philadelphia Recycling Council Oversees waste stream solutions in Pennsylvania, New Jersey, and Delaware 12 years as President of the Greater Philadelphia Commercial Recycling Council 13 years as the Greater Philadelphia AHE President

8. All about: University of Pittsburgh Medical Center Altoona, PA 380-bed facility governed by a volunteer community board of directors Offers more than 130 years of health care experience with over 300 physicians, over 2,000 caregivers and 500 volunteers Serves more than 20 counties throughout Central Pennsylvania A top-three employer in Blair County

9. Learning objectives: Outline and discuss the top waste stream management efforts to minimize waste generated to protect the environment and your bottom line; to stay ahead of the compliance curve, which can include civil and criminal penalties that directly affect hospital leaders and practitioners. Detail implementation and management methods to outline an approach that you can customize to your own facility to create a facility-wide culture of sustainability that permeates business practices and drives your healthcare model. Educate hospital leaders and staff on the most effective methods for implementing and managing a sustainable program and how to best manage waste streams through collaboration, communication and a shared vision.

10. To be covered today: Methods for a hospital to diminish environmental footprint Potential human health risks associated with improper waste disposal Relevant regulations and legislation On-boarding tactics for developing a leadership team Educational and training methods for implementing a hospital-wide waste stream sustainability solution at your facility

11. Current issues facing leadership

12. Healthcare impacts our environment. Healthcare accounts for 8% of the U.S. Carbon Footprint (JAMA, 2009) (JAMA, 2009) Organic Wastewater Contaminants (OWCs) were found in 80% of streams tested (U.S. Geological Survey) (U.S. Geological Survey) 13.2M pounds of hospital-generated waste go to the landfill each day (Building Operating Management)Building Operating Management Healthcare facilities are 2.5x more energy intensive than other facilities due to 24/7 operation (Department of Energy) (Department of Energy) Hospitals manage up to 12 regulated waste streams (Stericycle) (Stericycle)

13. Hospitals face numerous pressures. Going Green 8%8% The average hospital today is recycling only 8% of its waste. Industry leaders recycle 35%. Reduce, reuse and recycle. Financial Pressure 90% The percentage of hospitals that could NOT readily pull together cost and weight data for their waste streams. Compliance Issues15 The average number of regulatory compliance issues uncovered during a typical hospital compliance review.

14. Waste streams are interconnected. No single department is responsible for managing all hospital waste streams. Waste affects everyone.

15. Understanding regulations and compliance issues

16. Managing waste has many layers. Regulations have led to hospital leaders to focus on the various waste streams and their complexities in order to manage appropriately: Municipal Solid Waste (MSW) Regulated Medical Waste (RMW), including trace chemotherapy Pharmaceutical (RCRA and Non-RCRA) Sharps waste (syringes, scalpels, needles, blades) Universal Waste (oils, batteries, bulbs, mercury) E-Waste Confidential documents that must be disposed without violating HIPAA Radioactive waste

17. Understand the regulatory factors. Regulatory Standards set by: Resource Conservation & Recovery Act (RCRA) Clean Water Act (40 CFR Parts 122 and 403) Safe Drug Disposal Act of 2009 (HB 5809) Hospital Medical Infectious Waste Incinerator Rule The Joint Commission Department of Transportation EPA OSHA/NIOSH DEA Failure to comply and properly manage issues leads to higher risk for the hospital and its employees.

18. Play an active role in managing your waste stream sustainably. Visit EPA, DEA, DOT, TJC, OSHA, EPA and other sites to know when updates come out Share the new information with peers and leadership Be knowledgeable about your facility’s current practices to stay ahead of the compliance curve

19. It is important to know the risks. Financial Risk: Penalties incurred (fines, civil & criminal charges, etc.) Hospital leaders do not “know” Decreased customer satisfaction, hospital ratings Environmental Risk: Non-compliant disposal of waste (Rx, Hazardous, MSW, RMW) can pollute and damage watersheds, ecosystems, communities Community Risk: Increased chance of workplace injury (i.e. sharps sticks) Can negatively impact perception in the surrounding areas

20. Proper management benefits the bottom line. Integrating the process hospital-wide results in: Implementing systems to track and document waste stream management You can’t change what you can’t measure Determine processing and transportation timelines Decreased disposal costs Regular waste ends up in red bag resulting in higher disposal costs Only 20% of waste streams are actually regulated and < 5% of Rx streams are hazardous Strive for a cleaner, safer environment

21. Understanding your impact on the community

22. Identify ways to reduce your waste. (% total waste) AVERAGE HOSPITAL TOP GREEN HOSPITAL Recycled27%35% MSW68%56% RMW (of MSW) 15%8% Other5%9% Question your vendors and analyze your supply chain for environmentally preferred purchasing (less mercury, silver in products, better packaging, air, land and water quality services). Explore Practice Greenhealth’s Environmentally Preferred Purchasing initiativePractice Greenhealth’s Environmentally Preferred Purchasing initiative

23. Redirect your waste. Waste diversion drives better economics and sustainability. RMW Solid Waste Recycling

24. A case study analysis: UPMC Altoona

25. UPMC Altoona Throughout the system: Reusable pharmaceutical waste containers have helped manage 39,160 pounds of drugs from January 2011 to July 2014 Reusable sharps containers result in: 70,826 lbs. of CO 2 emissions prevented 3,647 gallons of gas not burned 1,340 BBQ propane tanks not used

26. By using the Sharps Management Service & reusable sharps containers annual emissions are prevented from: 121,440 pounds of plastic kept out of landfills 5,311 pounds of cardboard kept out of landfills Carbon emissions savings

27. Recycling at UPMC Altoona <10% of total waste recycled before 2010 24% of total waste recycled in 2013 28% of total waste recycled in year- to-date June 2014 35% of total waste recycled is a best practice according to Practice Greenhealth

28. Waste reduction efforts at UPMC Altoona 40% of total waste was RMW at end-of-year 2010 9% of total waste was RMW at end- of-year 2013 as a result of recycling more

29. Training & education Understand the importance of ongoing training: Competency fairs held annually to train all staff and review materials Utilize online training: Net Learning Keep training records for OSHA, especially for regulated and hazardous waste Specialists must be trained on DOT; OSHA, RCRA standards and proper handling of shipping manifests 2260 hospital staff trained including examples such as 12 trained on DOT manifests

30. Sustainability & green initiatives Green Team committee includes cross-functional departments (nursing, staffing, medical, clinical, OR, ER, housekeeping etc.) Meets quarterly to discuss upcoming initiatives Includes community representative, member of the Intermunicipal Relations Council, which represents the four communities of Altoona Is part of Earth Day celebration with community-based presentations Includes a uniform initiative to clean/disperse used uniforms for those seeking employment in the healthcare industry ‘Clean Out Your Files Day’ every six months to recycle paper An on-site Farmer’s Market supports local/sustainable food and healthier lifestyles Outsourced waste management Removed on-sight autoclave, redesigned dock

31. Sustainability & green initiatives Community-based presentations during Earth Day Green Team member Drew Appleman with Gary and Ed

32. Operational effectiveness Removed autoclave in order to create more efficient, sustainable practices Nearly all waste prior to waste stream management system went into the red bags and was treated as RMW Through training and awareness, the amount of RMW has decreased 31% since we started the program Waste no longer needs to be handled twice by the hospital (once for treating the waste in the autoclave and then again for the transportation to a landfill) Outsourcing the waste allows for a more efficient handling of the waste and reduces the carbon footprint for the hospital The redesigned dock provides a much better working environment for those who handle trash and use the dock

33. Redesigned hospital dock Left: autoclave used prior to implementation of waste stream management system Above: Redesigned dock without autoclave

34. Have an education plan to get hospital teams on board for proper segregation and proactive disposal.

35. Include all key stakeholders. Process Improvement Team Full Participation Leads To Compliance Senior Leadership Education Pharmacy Nursing / Patient Care Service Provider Infection Control Materials Management Program Champion Safety / Environment Services Hospital-wide Green Team Risk Management (Clinical and Enterprise) Quality Compliance

36. Properly segregating waste is critical. Non-RCRA Pharmaceutical Waste RCRA Pharmaceutical Waste Syringes with Medication

37. Identifying disposal options can reduce cost and increase compliance.

38. Implementing sustainable waste stream practices at your facility

39. Step 8: Facility Executive Leadership Communicate across entire organization Celebrate big wins Step 7: Performance vs. expected outcome Is there additional room for improvement Lessons learned Step 6: Are we on track? What adjustments need to be made? Communicate back to key department directors Step 5: Complete regular walk throughs Seek feedback Solve problems Step 4: Place equipment Communicate in advance Ensure SOPs are in place Complete training Step 3: Key departments directors Seek their ideas Customize to meet their needs Get their team involved Step 2: Program Design SOPs Required assets Implementation schedule Expected outcome Step 1: Prioritize based on facility input Coordinate with other initiatives Continuous Improvement Continuous ImprovementCycle 1. Identify improvement opportunity 2. Present opportunity to leadership/ sustainability team 3. Gain Unit Leadership Buy-in 4. Launch Initiative 6. Measure Results 7. Review results with leadership 8. Publish results & recognize key contributors 5. Monitor Progress

40. Assess your facility’s current efforts. Visualize from your floors to your dock the flow of managing waste streams and then determine where to start Evaluate current green team initiatives Understand what waste is currently being generated and assess current practices Examine all waste-related invoices from all vendors Assess practices in relation to compliance, regulatory standards and legal requirements

41. Consider what it will cost. Direct Costs Staff Dock pick-up Transport / waste hauling Equipment Training Fines Data collection / record retention Infrastructure / IT Insurance Regulatory Compliance Staff Training Indirect Costs Cost containment Cost of improper segregation Potential risk costs (exposure, spills, etc.) Increased labor costs Increased time to manage multiple steams / vendors Workers compensation costs Community Image

42. Make sustainable practices part of daily life. Create a culture for change; rethink how you view waste Make it part of the culture and establish a Green Team Educate all departments and establish a point of contact Implement hospital-wide initiatives that involve streamlining waste Coordinate all communications (Internal & External) Track, manage & measure all waste streams

43. Integrate the “3 Rs.” Start by reducing waste Appropriate segregation and diversion of waste streams decreases cost & waste Reduce waste that goes to landfills Educate employees on proper waste disposal practices High efficiency transportation fleet LEED certification and other high efficiency projects

44. Then reuse & recycle where possible. Switch to reusable products Reusable containers (disposable sharps containers are each reused 600x) Minimizes use of virgin materials to make new products Use reusable products in the OR (can reduce RMW generated by 65%) Start and increase your recycling efforts Implement a comprehensive recycling program & educate staff Be creative on what can be recycled (blue wrap, etc.)

45. Know where to look for more resources and information. Environmental Protection Agency - www.epa.gov The Joint Commission - www.jointcommission.org Healthcare Plastics Recycling Council - http://www.hprc.org Commission on Air & Water Quality - www.glc.org/airwater.html Practice Green Health (green teams / greening supply chains) http://practicegreenhealth.org/ Product Stewardship Institute - http://www.productstewardship.us/ Local and State regulations - http://www.envcap.org/statetools Office of Inspector General - https://oig.hhs.gov/compliance/compliance-guidance/index.asp

46. Questions?