Request title: Information Governance and Environmental Impact Policies
Reference Number: F2344 Date of Response: 03/01/2020
Further to your Freedom of Information Act request, please find the Trust’s response, in blue bold text below:
Request and Royal Devon and Exeter NHS Foundation Trust Response
Dear Royal Devon and Exeter NHS Foundation Trust,
1) Please can you send me a copy of the current subject access request acknowledgment AND response letter that you use. Please find attached a copy of an acknowledgment letter (document 1) and response letter (document 2).
2) a copy of the last 5 dpias completed. Section 21(1) of the Freedom of Information Act 2000 provides that information which is reasonably accessible to members of the public otherwise than under section 1 is exempt information. This is an absolute exemption. The Trust publishes basic details of completed DPIAs at https://www.rdehospital.nhs.uk/trust/information- governance/accessing-information/freedom-of-information/data-protection- impact-assessments.html
3) a copy of any internal mandatory information governance training that you give to staff which was written in the last 2 years including presentation slides and videos and any other media Please see attached (document 3 and 4).
4) a copy of any instructions given to staff members to reduce data security breaches, for example double checking work which was written in the last 5 years. To undertake this piece of work would take in excess of the appropriate limit set by the Freedom of Information Act 2000 (section 12 (1)) and defined in the Freedom of Information and Data Protection (Appropriate Limit and Fees) Regulations 2004. The appropriate limit of £450 represents the estimated cost of one person spending two and a half days in determining whether the Trust holds the information, and locating, retrieving and extracting the information. Consequently, the Trust is not obliged by the Freedom of Information Act 2000 to retrieve the above information. This is an absolute exemption. Under Section 16 of the FOI Act we have a duty to provide advice and assistance, therefore please find attached staff guidance created to reduce data security breaches as an example of instructions given to staff in the last five years.
5) a list of any policies implemented in the last 2 years within the organisation to help reduce the environmental impact that the organisation has? Please see attached (document 5 and 6). Royal Devon & Exeter 0 Hospital Wonford 0 Area Q1, Room C 0 Barrack Road 0 Exeter 0 EX2 5DW
Information Governance Team IM&T
16 December 2019 Our Ref: 0 Your Ref:
Re: 0
Dear 0
Thank you for your request for access to personal data.
We have received everything that we require from you and will now proceed with processing your request. To confirm, the start date of your request is: 00 January 1900
In accordance with Article 12 of the General Data Protection Regulation, we are required to respond to your request within one month, however this can be extended by two further months when necessary.
To enable us to respond to everyone as quickly as possible, we respectfully ask that you do not contact us about the progress of your application within the first month.
Yours Sincerely
Information Governance Team Royal Devon & Exeter 0 Hospital Wonford 0 Area Q1, Room C 0 Barrack Road 0 Exeter 0 EX2 5DW
Information Governance Team IM&T
16 December 2019 Our Ref: 0 Your Ref:
Re: 0
Dear 0
Further to your request for access to the personal data of the above individual, I am pleased to be able to offer you the Trust’s response, enclosed. In order to locate the information you requested, I undertook the following searches:
• • If you are in any way dissatisfied with how your request has been handled or responded to, please outline your concerns in writing to [email protected] or to:
Information Governance Team Area Q1, Room C Royal Devon & Exeter Hospital Barrack Road Exeter EX2 5DW
I hope that this information is of assistance to you.
Yours Sincerely
Information Governance Team
Data Security Protection Training v2.2
2. Untitled Scene
2.1 Untitled Slide
2.2 MODULE DURATION
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2.3 SPECIAL INSTRUCTION
Guidance (Slide Layer)
2.4 MENU
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2.5 DATA SECURITY AND PROTECTION
2.6 NHS IG OPERATING FRAMEWORK
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2.7 KEY AREAS
2.8 CONFIDENTIALITY
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2.9 EU LAW - GENERAL DATA PROTECTION
LEGISLATION 2016
2.10 UK LAW - THE DATA PROTECTION ACT
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2.11 PERSONAL INFORMATION
2.12 SPECIAL CATEGORY DATA
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2.13 CONFIDENTIAL INFORMATION
2.14 DISCLOSING INFORMATION
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2.15 INDIVIDUAL’S RIGHTS
2.16 SUBJECT ACCESS REQUESTS
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2.17 CALDICOTT GUARDIAN
2.18 CALDICOTT PRINCIPLES
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2.19 NDG DATA SECURITY STANDARDS
2.20 10 DATA SECURITY STANDARDS
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2.21 INFORMATION ASSET OWNERS
2.22 UK LAW - THE FREEDOM OF
INFORMATION ACT
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2.23 THE INFORMATION COMMISSIONER'S
OFFICE
2.24 RECORDS MANAGEMENT
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Records Man (Slide Layer)
Public Records (Slide Layer)
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Personal Information (Slide Layer)
2.25 INFORMATION QUALITY
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2.26 INFORMATION QUALITY
High (Slide Layer)
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Poor (Slide Layer)
2.27 INFORMATION ASSURANCE
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2.28 INFORMATION SECURITY IS EVERYONE'S
RESPONSIBILITY
2.29 TOP TIPS FOR CYBER SECURITY
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2.30 TOPS TIPS FOR CYBER SECURITY
2.31 REPORTING INCIDENTS AND SECURITY
WEAKNESSES
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2.32 DATA SECURITY RISKS - SCENARIO
The Situation (Slide Layer)
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The Organisation's reaction (Slide Layer)
Consequences (Slide Layer)
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Actions (Slide Layer)
2.33 EMAIL BREACH- SCENARIO
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The Situation (Slide Layer)
The Organisation's reaction (Slide Layer)
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Consequences (Slide Layer)
Actions P1 (Slide Layer)
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Actions P2 (Slide Layer)
2.34 SECURITY MEASURES
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Transportation (Slide Layer)
Telephone (Slide Layer)
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Fax (Slide Layer)
Post (Slide Layer)
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Email (Slide Layer)
Eavesdropping (Slide Layer)
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Incidents (Slide Layer)
Encryption (Slide Layer)
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2.35 MANAGING INFORMATION RISKS
Published by Articulate® Storyline www.articulate.com Follow the 10 Commandments to avoid Information Security breaches
1. Avoid gossip and use of inappropriate venues for discussion of patient care/confidential information.
2. Do not look up or handle your own or family/friend(s) information (either electronic or paper) – you do not need to know this information in order to do your job. All systems are audited.
3. Check identity before giving out details and only provide information if the person asking has a right to know. If in doubt pass to a senior member of staff or refer to the Information Governance Team.
Information Governance Follow the 10 Commandments to avoid Information Security breaches 4. Do not save information on your desktop – use the Trust’s Network Drive.
5. Anonymise information wherever possible before sending electronically and follow the Trust’s Faxing / Email procedures.
6. Do not share passwords or leave yourself logged on, always remember you are personally responsible for any unauthorised access to systems.
7. Only use USB sticks ordered through the Trust (they are encrypted.)
Information Governance Follow the 10 Commandments to avoid Information Security breaches
8. Confidential / personally identifiable information must be destroyed securely and should be placed in white confidential waste bags which should be stored securely. Blue Bins (CWO) are now placed at Trust exits.
9. Close doors, lock cabinets and don’t let people tail gate behind you into secure areas. All staff should wear their ID badge at all times. Do not be afraid to ask someone before allowing entry.
10. When leaving your desk please ensure that you LOCK your computer and do not leave documents unattended on your desk!!!!!!!!!
Information Governance SUSTAINABLE DEVELOPMENT MANAGEMENT PLAN 2019/2020
Foreword Sustainability is no longer the preserve of niche organisations; some of the largest and most profitable businesses in the world have identified that sustainable business practice is common sense and integral to their ongoing success. All organisations are required to make changes to ensure the well- being of society, to maintain and improve the quality of our environment and to be financially stable.
Social, environmental and economic sustainability are concepts which are well understood; there is clear evidence available as to the benefits of sustainable practices a mature body of guidance available on how to make the NHS more sustainable and firm scientific evidence of the risks present if it does not change. In addition to this, the recent protests seen across various schools and within city centres show that there is now a strong social movement behind tackling climate change that the government and public sector must respond to.
As a public sector healthcare provider, the RD&E has a conspicuous obligation to society to deliver its services in a fair and sustainable way. The RD&E will lead in making sustainability focused changes and has developed this Sustainable Development Management Plan to record our successes and set out ambitions for the future. Working together we will deliver positive change for the RD&E and its stakeholders and fulfil our obligations under the NHS Standard Contract and the NHS Constitution.
This plan identifies that by meeting the NHS Sustainable Development Unit (SDU) targets, there is a Left blank for potential for the RD&E to achieve annual savings of £800,000, reduce annual carbon dioxide image emissions by 2,200 tonnes, improve the patient environment and demonstrate environmental responsibility and leadership in the Devon area.
Contents Foreword ...... 0 1. Introduction ...... 1 2. Drivers for Change ...... 2 3. Our Vision ...... 3 4. Governance ...... 4 5. Communications and Engagement ...... 5 6. Sustainable Development Assessment Tool ...... 6 7. Key Areas of Focus ...... 7 7.1 Carbon Emissions ...... 8 7.2 Corporate Approach ...... 11 7.3 Asset Management and Utilities ...... 12 7.4 Travel and Logistics ...... 13 7.5 Adaptation ...... 14 7.6 Capital Projects ...... 15 7.7 Green Space and Biodiversity ...... 16 7.8 Sustainable Models of Care ...... 17 7.9 Our People ...... 18 7.10 Sustainable Use of Resources...... 19 7.10.1 Energy Consumption ...... 20 7.10.2 Waste and Recycling ...... 21 7.10.3 Anaesthetic Gases, Pharmaceuticals and Medical Devices ...... 22 7.10.4 Water...... 23 7.10.5 Fuel Consumption ...... 24 8. Reporting ...... 25 9. Risks and Opportunities ...... 26 10. Finance ...... 27 11. Key Performance Indicators ...... 29 12. Contact Us ...... 30
1. Introduction The Healthcare industry operates in a way that is currently paradoxical: it exists solely to improve people’s wellbeing however, as a consequence of its resource intensive nature, where services are not delivered in a sustainable way there may be significant negative impacts on the local and wider society it exists to serve. This Sustainable Development Management Plan (SDMP) is an emergent plan that starts to direct the RD&E towards a sustainable way of working that will make every patient contact a net positive gain for the individual being treated and for every link in the supply chain that supports that care pathway. The RD&E is the largest healthcare provider in Devon, serving a population of 460,000, and employing over 8,000 staff to deal with 766,000 patient contacts every year. Operating expenditure was £517 million in 2018-19 with non-pay spend of £189 million, £4.5 million of which was spent on energy and water. This level of activity resulted in 82,600 tonnes of carbon dioxide (CO2e) emissions. Climate change, driven by fossil fuel emissions of CO2e, has been identified by the World Health Organisation (WHO) as a risk to the healthcare sector. The UK Climate Change Risk Assessment 2017 predicts increases in the number of heat related illness and deaths; an increased incidence of flooding and coastal change; and it warns about the impact on mental health. As well as the environmental consequences of
CO2e emissions there are societal issues brought about from delivery of healthcare. For example specifying that goods and services are procured sustainably helps ensure that the people in the supply chain are fairly treated and reducing business mileage will assist in reducing the 40,000 deaths caused per year by air pollution. In 2017/18, through the Transforming Community Services (TCS) project, the RD&E saw a number of community sites and staff join the RD&E acute services to form a single organisation that provides seamless care across the whole of Devon. Measurements and targets in this plan have been developed with the best available information that mainly consists of data from the acute side; as management processes from the Acute and Community services continue to integrate the targets and data will be updated appropriately. Another once in a lifetime opportunity has arisen with the RD&E developing MY CARE, a transformation that moves away from paper based working and aims to connect people using technology. In conjunction with TCS this is an opportunity to revolutionise the way patient care is delivered across Devon and dramatically improve efficiency. The impact of the RD&E is clearly far reaching and immediate, the responsibility of delivering healthcare in a way that maximises positive outcomes is something that the RD&E is keen to continually address and improve upon. This year’s sustainability assessment score was 25%, acute Trusts of similar size average 50%. The RD&E recognises that this score needs to improve and is aiming to increase this score to at least 50% over the next year. Exeter is an ideal place to develop this goal and it is a perfect time as this year various institutions around the city have committed to making Exeter a carbon neutral city by 2030. The RD&E will work with local organisations including: Exeter City Council, Devon County Council, Exeter City Futures and the University of Exeter to achieve this ambition.
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2. Drivers for Change The importance of addressing climate change and global inequalities mean that there is an international consensus on the direction of travel to fix the problems that are facing us. At the time of writing, the UK Parliament has declared a “Climate and environment emergency” and set a target of making the UK “Net zero carbon” by 2050. The World Health Organisation (WHO) and the Intergovernmental Panel on Climate Change (IPCC) have provided information and strategic targets that have been developed into National regulations and targets. These flow through to local implementation measures, the legal framework below shows what must be addressed for the RD&E to be compliant.
At the simplest level, the NHS Standard Contract requires the RD&E to have a Board of Directors approved SDMP, HM Treasury and the NHS Estates Return Information Collection specify mandatory annual reporting on key areas. This means that delivering the SDMP is not something that “should” be done, it is a task that must be done.
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In addition to the contractual requirement; the need for the NHS to make better use of resources was identified as a key area for improvement by the Carter Report (2016). This highlighted areas of wastage and shows how conducting business with the principles of sustainable development in mind is simply good business sense.
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3. Our Vision The RD&E will embrace the ethos of sustainable development and be a leader in the healthcare field, with sustainability driven continual improvement integrated into its normal business practices.
Following this vision will:
Protect and enhance the health and wellbeing of the local community and beyond Improve the environment in which the RD&E delivers care, for service users and staff Embed sustainability into individual departments and empower staff to make changes Ensure robust governance arrangements are in place to monitor progress Align sustainable development requirements with the RD&E strategic objectives Demonstrate leadership in the field Fulfil the requirements of the NHS standard contract, with regards to clause 18 Save money through increased efficiency and resilience
We are committed to embedding sustainable development across our sites and services. Left blank for This will be detailed out within a Sustainability Policy, to be created in 2019. image
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4. Governance Sustainability at the RD&E is championed by the RD&E’s Chief Financial Officer who will chair the Sustainability Steering Group, the members of the group will be responsible for delivering the SDMP. Members will consist of representatives from relevant departments in the hospital, including clinical, procurement, estates and facilities disciplines. The group will meet quarterly to: Create a detailed delivery action plan Monitor SDMP delivery progress and drive forward improvements Review what good practice already exists within the Trust and document it. Set continual improvement objectives and create appropriate performance metrics Ensure that effective governance and policy support is in place
Actively raise awareness of reducing CO2e emissions at every level of the Trust Create an environment where staff are empowered to make change
The SDMP will be reviewed and approved by the Board of Directors on an annual basis, supported by a progress report submitted halfway through the year. The Energy and Sustainability Manager will be responsible for providing guidance to members, monitoring and reporting on progress and integrating sustainability practices into the Trust.
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RDE Trust Board Strategic Development Group
Hospital Operations Board Sustainablity Steering Group
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5. Communications and Engagement Communicating successes and aspirations is key to delivering the objectives of this plan. The multifaceted nature of the RD&E means that there is no one size fits all communications method. A variety of channels will be used dependent on the task in hand, these will include:
Hub is the primary repository for communications and information at the RD&E. Upcoming events and information will be posted here @sustainableRDE is the RD&E’s Twitter feed, dedicated to providing up to the minute information on our sustainability themed features and events Each month, a different sustainability theme is focused on by the sustainability team. Posters and information on the subject are made available and a sustainability representative visits departments to promote the feature and collect feedback The RD&E publishes a sustainability section in its annual report Estates Returns Information Collection (ERIC) is an annual data collection exercise for all NHS Trusts, the resulting data is made publicly available A calendar of Health and Wellbeing events is made available to all staff, along with a regular newsletter. The Green Team competition, this is an annual RD&E event run by the Centre for Sustainable Healthcare that encourages staff to deliver sustainability themed quality improvement projects in their area
In addition, the RD&E will host and support roadshow type events throughout the year, such as NHS Sustainability Day and Cycle to Work Week. One of the SDMP aims is to make more use of social media to promote its aims and to inform staff.
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6. Sustainable Development Assessment Tool The Sustainable Development Assessment Tool (SDAT) is a self-assessment tool, provided by the NHS Sustainable Development Unit (SDU), to help healthcare organisations: measure sustainability progress, understand their performance and direct plans for the future.
The assessment determines progress against the implementation and delivery of sustainable development goals across the health and care system. SDAT replaces the Good Corporate Citizen Assessment (GCCA) with a more streamlined system aligned to the United Nations (UN) and WHO Sustainable Development Goals (SDGs).
The SDAT assesses ten modules with four cross cutting themes. Modules include: Asset Management & Utilities, Travel and Logistics, Green Space & Biodiversity, Sustainable Care Models. It works as a national benchmarking system on behalf of Public Health England and NHS England and allows dissimilar organisations to be compared in the field of sustainability.
The RD&E will conduct an annual SDAT assessment in order to:
1. Identify the focus of the SDMP Left blank for 2. Measure progress year on year by evaluating sustainability across the board in image financial, social and environmental terms 3. Determine how well RD&E activities support sustainability within the organisation and within the community.
The RD&E’s 2019 overall SDAT score was 25%. The national average score for a large acute hospital is currently 50%. The RD&E is aiming to achieve 50% in the 2020 assessment and will adopt a rigorous approach to evidencing its scores. A breakdown of performance is shown below
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7. Key Areas of Focus This section outlines the RD&E's progress against the key areas of the SDAT referred to in the previous section in more detail. Each area is allocated a percentage score which is provided in the top right hand corner of the page, shown above right is the RD&E’s overall SDAT score. Achieving at least a 50% overall score by 2020 is a firm goal for the RD&E.
As previously mentioned there are ten areas of focus. Trusts are assessed against how well they are delivering progress in these areas against four cross cutting themes.
Modules Cross Cutting Themes
Adaptation
Asset Management & Utilities
Capital Projects
Carbon / GHGs
Corporate Approach Chain Supply Green Space & Biodiversity
Our People Sustainable Care Models Sustainable use of
Resources
Governance and Policy and Governance and Procurement and Patients Staff with Working Community Travel and Logistics Responsibilities Core
This system is aligned with the WHO’s Sustainable Development Goals (SDGs) and include metrics for how well Trusts are delivering improvements in carbon hotspot areas such as Energy, Procurement, Pharmaceuticals, Waste, Anaesthetic Gases and Travel.
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7.1 Carbon Emissions
NHS England has set a goal to reduce carbon dioxide equivalent (CO2e) emissions by 28% by 2020. The RD&E is working towards this goal which also compliments and supports
Exeter City Council’s aim to be a carbon-neutral city by 2030. The RD&E sees CO2e emissions as a key metric for monitoring sustainability performance.
CO2e emissions related to energy use across the estate have been falling steadily and are expected to fall further due to significant investment in building energy reduction measures and grid decarbonisation. However, this represents a small element of the RD&E’s carbon footprint. Emissions from transport, waste, anaesthetic gases and building energy account for just 24% of the footprint, the majority is procurement related. Ongoing work in relation to staff engagement should see carbon emissions fall further, through continuation of an estate- wide energy and sustainability awareness campaign, and through the roll out of improvements, including those generated through the annual Green Team Competition.
Overleaf is data showing a more detailed breakdown of RD&E CO2e emissions and performance. Organisation Carbon Profile 2018-19 2% Procurement
24% Left blank for Core Emissions image Energy/Waste/Water/Travel/Gases
Commisioning 74%
We Have We Will
Appointed a Director to the Board of Work alongside City stakeholders to plan Exeter City Futures CIC, committing to and deliver a carbon-neutral Exeter. the delivery of a healthier Exeter. Commit resource to developing a strategy Procured a partner to deliver Estate wide for the RD&E operations to meet NHS
building CO2e reductions England CO2e reduction target
Set utilities CO2e emissions reduction Identify immediate opportunities and targets in line with the Climate Change crucial first steps such as a carbon Act 2008 reduction strategy. Appoint a full time member of staff to lead staff engagement work Develop carbon efficiency metrics for
relative performance (eg t/CO2 per patient), as well as performance against an absolute target. 8 #SustainableRDE
Emissions have been calculated using the NHS SDU reporting tool and shown in tonnes of
CO2e. The SDU uses actual data to generate emissions figures or, where specific data is unavailable, emissions are estimated based on benchmark data and assumptions derived from the RD&E’s operating and capital expenditure. Therefore emissions in 2017-18 and 2018-19 were heavily influenced by the increase in RD&E scope of operations through TCS and the deployment of capital for MYCARE and a new Oncology bunker. Core emissions and freight transport have been calculated based on actual consumption/usage and are therefore very accurate.
Whole organisation annual carbon profile - generated using SDU tool 2015-16 2016-17 2017-18 2018-19 Patient and visitor travel - Data not available - - - - Staff commute - Data not available - - - - Business services 6,977 6,942 7,594 7,906 Capital spending 2,360 1,661 2,636 8,127 Construction 2,435 2,423 2,650 2,760 Food and catering 5,106 5,080 5,558 5,786 Freight transport 2,696 2,682 2,934 3,055 Information and communication technologies 1,072 1,067 1,167 1,215 Manufactured fuels, chemicals and gases 2,874 2,859 3,128 3,257
Medical instruments / equipment Procurement 14,908 14,832 16,226 16,894 Other manufactured goods 2,466 2,453 2,684 2,794 Left blank for Paper products 2,027 2,017 2,206 2,297 image Pharmaceuticals 5,894 5,864 6,415 6,680 Electricity (net of any exports) 7,933 6,853 5,525 4,842 Gas 11,089 12,095 12,032 11,904 Oil 158 144 174 171
Business travel and fleet Core 1,412 1,451 1,731 1,981 Anaesthetic Gases 271 258 211 453 Waste and Water 616 537 548 690 Commissioning 1,583 1,575 1,723 1,794 Total 71,877 70,793 75,142 82,606 Organisational Carbon Footprint Against Climate Change Act 90,000 Target 80,000
70,000 Core 60,000
50,000 Commissioning
40,000 Supply chain
30,000 Climate Change
Carbon Emission (tCO2e) 20,000 Act Target
10,000
- 2015-16 2016-17 2017-18 2018-19 2019-20 2020-21
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Further work is required to develop an emissions target that contributes to the Climate Change Act Target (CCAT) and incorporates the new scope of RD&E operations. The CCAT is an absolute, highly ambitious target based on a 1990 baseline and will require current procurement emissions to reduce by some 10-20,000t/CO2e by 2020 and further dramatic reductions by 2050. There is no allowance made for increases in organisations size, because for climate change goals to be realised global CO2e emissions need to reduce absolutely. A key part of the RD&E’s journey to contribute to this target is to develop an appropriate strategy and policy support that sets manageable CO2e targets which are measured in both absolute reductions and relative performance, eg t/CO2e per patient. The newly formed Sustainability Steering Group will be tasked with developing this framework for improvement.
Building emissions have been targeted using HTM guidance. This involves taking 2013 as a baseline year and targeting: Electricity, Gas, Fuel Oil and Waste emissions to be reduced by 28% by 2020.
2013 Baseline Carbon Emissions (tCO2e)
Consumption tCO2e 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 Scope 1 Gas 20,764,290 kWh 9,592 9,795 11,115 11,089 12,095 11,979 11,871 Oil 3,122,047 kWh 1,085 652 152 145 144 173 163 Scope 2/3 Electricity 20,764,290 kWh 11,626 10,949 8,728 7,933 7,304 6,174 4,217 Scope 3 Waste 1959 t 479 482 475 468 517 530 729
Total emissions: 22,782 21,878 20,470 19,635 20,060 18,856 16,980 Target 2020 emissions: 16,403
target tCO2e reduction of: 6,379
tCO2e reduction to date against 2013: 5,802 % reduction to date against 2013: 25.5% Meeting our 2020 target requires a further reduction in 2018/19 emissions of: 3.4% This target is a reduction in annual tCO2e emissions of: 641
Progress against this target has been effective and with the implementation of capital projects planned for 2018-19, this target will be reached and hopefully exceeded by circa
1,000t/CO2e per year. However the majority of the current reduction in electricity derived emissions is due to the dramatic reduction in coal fired power stations contributing to the National Grid (NG). This is a double edged sword in terms of the RD&E’s energy strategy, which is to increase reliance on Combined generation of Heat and Power (CHP) on-site using natural gas. It is currently economical and more carbon efficient to do this than by buying from the grid. Over time the NG will decarbonise, meaning that on-site natural gas fuelled CHP will result in higher CO2e emissions than purchasing electricity from the NG. To combat this, further strategic improvements will be required including: investment in efficiency measures, further deployment of renewables, purchasing renewable energy and considering CO2e offsetting.
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7.2 Corporate Approach
Our Corporate Strategy defines how we will work together to build a health and care system which delivers for all, both now and into the future.
The RD&E is now delivering services across acute and community settings throughout Devon, so a clear and defined path is needed to ensure that all staff know what is expected of them and patients know what to expect.
The NHS Long Term Plan identifies that the NHS has challenging environmental targets to meet and key to the RD&E delivering on these goals is establishing a strong governance structure with a nominated Non-Executive Director lead.
We Have We Will
An Executive Director sustainability lead Appoint a Non-Executive Board of Directors (Chief Financial Officer) lead for sustainability.
An operational sustainability lead Create a Sustainability Policy.
Reported sustainability performance via Approve ambitious targets to reduce the our annual report, and our wider supply RD&E’s environmental impacts, including chain emissions are recorded and aligning carbon emissions to those detailed submitted via the SDU reporting tool. in the Climate Change Act. Approval of this plan will achieve this Benchmarked our energy, waste, water and cost of production (WAU) against Ensure that sustainable development and other Trusts within the same STP region. social value are a material consideration in all business cases. Created a dedicated sustainability Twitter feed, email contact point and have an Develop an evaluation process for our active engagement campaign to promote organisation's engagement and sustainable development internally. communication plan, to allow improvement to the process to be developed and Run a sustainability quality improvement implemented. competition that has resulted in one of the teams winning a National award Develop a clear sustainability action plan with SMART targets and named Reviewed our sustainability impacts and responsible leads aligned with other developed an SDMP to reduce negative organisational policies and plans (e.g. Cost impacts of carbon emissions and maximise Improvement Plan, Estates Strategy). benefits
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7.3 Asset Management and Utilities
Through improvements to our existing operational assets, buildings, critical infrastructure and the equipment which is essential to the smooth running of the hospital, and through carefully considering the sustainability credentials of assets and utilities yet to be procured, the RD&E has numerous opportunities to increase sustainability across the estate.
In 2018-19 the RD&E spent £1.7m on electricity, £1.5m on gas £.03m on oil and £.9m on water. This year the RD&E contracted Centrica Business Solutions to deliver a £7m capital improvement scheme that will reduce these annual costs by £800,000 and reduce annual emissions from these sources by 2,200t/CO2e based on 2017 emissions factors. This is being carried out as an Energy Performance Contract (EPC), whereby CBS guarantees to deliver financial savings.
As highlighted throughout this plan, these improvements and opportunities can stem from relatively large capital investment, or from individuals identifying simple changes which can be implemented across similar departments, or indeed the estate as a whole.
The development and implementation of relevant plans and strategies will see sustainable development integrated into all departments and activities within the RD&E.
We Have We Will
Set targets to reduce our energy and Implement plans to reduce our energy and water demand across the RD&E in line water demand, as well as building CO2 with the NHS Sustainable Development emissions across the RD&E. Strategy and 2008 Climate Change Act. Continue to improve metering of our Designated a Utilities and Sustainability energy and water consumption. lead. Include sustainability ambitions in our Across our major sites we have Estates Site Master Plan. implemented significant sub metering for utilities to better help the management of Review building stock and develop a demand. sustainable buildings action plan.
Purchased a digital property management Embed sustainable design into capital solution that will reduce paper use, save projects and major refurbishments time and improve information available to the Estates Department Purchase certified low carbon/renewable energy
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7.4 Travel and Logistics
Active travel plays a significant part in reducing traffic on the roads whilst also promoting health and wellbeing through exercise and improving local air quality. While it is challenging to attempt to reduce single occupancy car travel and acknowledged that to some this is an essential form of travel, the RD&E is committed to supporting alternative travel methods.
A Green Travel Management Plan (GTMP) is being prepared, which includes the following:
Targets and methods for moving away from single occupancy car journeys Improving pedestrian access around sites Increase bus usage Encourage cycling by providing better storage and changing facilities Increase uptake of car sharing Pursue opportunities for low emission fleet vehicles
In the last ten years, around £750,000 worth of bikes were sold via the RD&E cycle to work scheme, the majority of which were bought from local shops. Regular engagement events are held to encourage sustainable travel, and since 2016, RD&E staff have logged 110,453 miles on the Love to Ride website - the equivalent of over four laps of the circumference of Left blank for the Earth. With the increase of cycle to work scope to include electric bikes it is hoped that image this will increase further.
We Have We Will
Undertaken a transport survey. Develop and implement a Board approved Green (healthy/active) Travel Plan, Installed staff-only secure bike shelters developed in conjunction with onsite; there are now 152 secure bike stakeholders including staff and patients. storage spaces on the Wonford campus. Appoint a lead to manage sustainable Promoted video teleconferencing through travel for the RD&E, including conducting our engagement campaign. an annual travel survey.
Promoted cycle commuting via Continue to introduce facilities to Cycle2Work scheme, and Love2Ride encourage active travel and install electric bikes. 33% discount offered on Stagecoach commuting and signed up to Car Share Further promote cost savings and Devon. personal benefits of sustainable travel.
Promoted car share permit only parking spaces.
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7.5 Adaptation
In addition to reducing the RD&E’s contribution to climate change, we also need to ensure our resilience to its effects. These include the direct effects upon health and communities and also secondary impacts such as the effects of severe weather on our infrastructure and supply chain.
A 2015 report by Public Health England, NHS England, and the NHS Sustainable Development Unit1 set two objectives designed to ensure that the health system is resilient and adapted to climate change, these are to:
reduce mortality and morbidity associated with severe weather events and climate change; and to promote resilience and service continuity to ensure sound service delivery.
The RD&E already has a number of plans in place to support these objectives. For example, heat wave and severe weather plans help to prepare and respond to severe weather events. These are managed by the RD&E Planning and Preparedness Manager, with input from relevant departments. The frequency and significance of these extreme weather events is predicted to increase, and it is also expected that average temperatures will rise.
We Have We Will
Developed a heat wave plan and monitor Embed the effects of climate change into potential extreme events. our risk register, including detailed assessments for extreme weather events, Emergency Preparedness and Business and develop a Board approved adaptation Continuity Service Manager attends plan informed by our Climate Change Risk exercises with local emergency services Assessment (CCRA). to develop emergency action plans and procedures. Review our building portfolio and risk assesses them for climate risks and Ensured back up energy supplies for adaptation requirements. heating and power and have tanked water available. Ensure contingencies for supply chain failures, to include an understanding of resilience and contingencies within our major suppliers’ supply chains also.
1 Adaptation Report for the Healthcare System, Public Health England, NHS England and the NHS Sustainable Development Unit, 2015 14 #SustainableRDE
7.6 Capital Projects
The RD&E has a significant level of capital projects planned to upgrade the estate in order to keep providing world class healthcare. These include new developments and major alterations of existing buildings. Ensuring that the environmental impacts of these developments are kept to a minimum is imperative to ensure a sustainable future.
The RD&E’s Estates department has procured an energy partner to develop and deliver £7m of estate wide energy and water demand reduction measures and low carbon energy generation measures. Whilst this scheme will result in significant financial and CO2e savings of over £800k and 2,200t/CO2e from the current baseline, the RD&E needs to plan for the future by committing to improve the way that capital schemes are specified and delivered. The capital costs of many common pieces of equipment are dwarfed by the ongoing revenue costs required to run them over the course of their life. This means that there is scope to improve financial performance and reduce carbon emissions by ensuring that the most resource efficient products are purchased.
We Have We Will
Appointed the RD&E Energy and Develop a sustainable capital projects Sustainability Manager as lead for process to ensure sustainability is sustainable capital and refurbishment designed into all new builds and major projects. refurbishments at the outset, taking into account whole life costing. Installed solar photovoltaic panels (PV) on both the RILD and Aseptic buildings Set clear sustainability plans and on the Wonford site. objectives to be achieved by all capital projects, to include embodied and Commissioned a £7m capital project to operational carbon, access to greenspace, reduce utilities impacts use of natural capital and resilience to climate change.
Monitor and report on the sustainable performance of capital projects.
Ensure that Capital staff are appropriately trained in terms of sustainable building design
Install further solar PV across sites
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7.7 Green Space and Biodiversity
The RD&E has a wide ranging estate and the opportunities for conserving and enhancing biodiversity are significant.
There is clear evidence that the natural environment plays a key role in our health: improving patient recovery rates and patient experience, and offering opportunities and health benefits to staff. Making the best use of the green space on the RD&E estate is therefore a valuable resource to be enhanced and made use of.
Well managed greenspaces across our estate can also:
improve air quality provide noise reduction provide shading reduce local surface water flooding contribute to a coherent ecological network, improving Exeter’s wider biodiversity.
In addition to considering greenspace and biodiversity, it is essential that we recognise different classes of pollutants, to include lighting and noise.
Left blank for image
We Have We Will
Commenced development of a Obtain Board approval of our biodiversity biodiversity plan. plan. This will be publicly available and easy to understand. Grounds and greenspaces managed with minimal use of pesticides. Assess the impacts of our services on local biodiversity and put in place Green waste used on site where possible, adequate mitigation. including composting or mulching of grass cuttings. Actively and systematically maintain and enhance biodiversity on our estate. Some courtyards are maintained by staff. Provide green and natural areas even Ensured our catering and food contracts where land is constrained. demonstrate sustainability credentials by exceeding government guidelines, to Minimise use of timber and paper include external accreditation such as products, and source to government Food for Life or Red Tractor. guidelines as minimum.
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7.8 Sustainable Models of Care
The RD&E’s corporate vision is to become a leader in transforming the health and care system, working in partnership to connect people, services, communities and voluntary groups to meet the needs of the communities it serves.
Key to realising this vision is improving the experience of patients and staff by joining up care and connecting people through MY CARE. MY CARE is a new, clinically led transformation programme, across the acute and community settings, which is enabled by new technology. MY CARE is supported by the introduction of a new state-of-the-art Electronic Patient Record (EPR). The programme will be implemented by June 2020, with the RD&E taking a major step forward in establishing the future care model. Benefits to be realised from the delivery of MY CARE include: removing delays reduce administration time and paperwork increase speed of decision making improve management of theatre and outpatient demand enable the RD&E to deliver care in a very different way
With MY CARE and the TCS project, the RD&E is leading the country in changing the way that care is delivered in a seamless way across acute and community settings
We Have We Will
Educated patients about the importance Embed the principle of getting it right first of a diet which can benefit their own time (GIRFT) into a system approach for health where our nutritionists have the best use of all resources, such as deemed it appropriate. financial, staff, patients, infrastructure and natural. Invested in MY CARE, a technology driven means to improve patient care by Continue to promote an engagement connecting people and removing paper campaign to promote GIRFT and monitor based patient records progress.
Calculate the environmental impact of a specific care model to help identify hotspots where impacts can be minimised.
Deliver MY CARE by June 2020
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7.9 Our People
Engaging our workforce and increasing their awareness and knowledge of sustainability is key. Equipping staff with appropriate knowledge will enable them to act sustainably as an individual as well as a collective; they are in a position to shift towards sustainable behaviour within both their work and personal lives, and will be able to spot opportunities that can be implemented from the bottom up as well as the top down.
There are 8,000 RDE staff who are in a position to introduce simple, efficient changes to daily routines which are essential in supplementing the larger, shift changes. Every single staff member has an important role to play in helping us to improve our sustainability.
The Green Team competition provides a platform for various departmental teams to locally deliver sustainability actions to improve: health and well-being, the patient environment and experience, and avoid unnecessary resource consumption. A Green Team project from the RD&E Housekeepers recently went on to win the Waste category at the 2019 NHS Sustainability Awards. This kind of result is achievable across the RD&E and the SDMP aims to empower staff to keep delivering sustainability successes.
We Have We Will
Implemented an Equality and Diversity Develop and implement a clear and Policy and a Health and Wellbeing publicly available Modern Slavery Strategy. The latter produces an Annual Statement. Staff Surveys and an annual Health & Wellbeing survey. Complete development of our staff carers policy. Introduced a Talent Model and Succession approach into our PDR skills Continue to participate in national training. sustainability campaigns through collaboration between departments. An action plan to promote positive health choices, including formation of a Stop Provide all staff with information about the Smoking group. The estate is smokefree. RD&E’s sustainability at induction.
Established an engagement campaign to Enhance training and awareness to raise awareness of sustainability. increase knowledge of sustainability in all staff.
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7.10 Sustainable Use of Resources
The RD&E spends £189 million each year on non-pay spend to deliver services.
Whilst our demand for resources increases with the number of patient contact, we can try to minimise consumption and costs through more efficient practice; social value (environmental improvements, local social capital and economic value) can be ensured during the procurement process. By procuring carefully and considerately, we can influence our suppliers to adopt sustainable practices for the products and services which they provide.
The majority of the RD&E’s CO2e emissions arise from procurement processes and a key goal to reduce these is to prepare a sustainable procurement policy and an accompanying management plan that will reduce the impact of procuring goods and services.
In the sections below, arrows have been placed on graphs to indicate the direction of the trend and how it is contributing to corporate targets: positive (green) or negative (red).
We Have We Will
Departmental management and recording Introduce concrete sustainability of hazardous substance and chemical outcomes from our higher-value suppliers usage and a COSSH Policy. to make the most contribution to the Trust’s Sustainable Development Plan. Monitored waste outputs and their Expand to a more comprehensive system associated costs. of converting “waste” into resources.
Identified several routes by which “waste” Work with departments to incorporate can be converted into a resource, e.g. sustainable requirements in major medical electronics are sold and IT waste procurements is sold as seconds or scrap. Focus procurement capacity on the greatest sustainability benefits Introduced targets to increase healthy and sustainable food choices for patients, Strive to develop more efficient ways of staff and the wider public. working that reduce waste and minimise consumption Procured a partner to deliver utility Create a sustainable procurement policy
consumption reduction measures and action plan with CO2e emissions reduction at its heart
Set clear, long term resource/impact
reduction targets and report progress to the Sustainability Steering Group
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7.10.1 Energy Consumption
The RD&E has been regularly investing in energy efficiency projects and this year stepped up its game by partnering with Centrica Business Solutions, to deliver £7m of capital improvement works that are guaranteed to achieve savings of £800k and 2,200 t/CO2e emissions per year.
The graphs below show the RD&E’s energy consumption, as reported in the annual report. Progress is shown against the year on year reduction target of 1.5% per energy supply
Electricity Consumption Grid 30,000 Grid - Green
20,000 Tarriff
On-site MWh 10,000 generated (renewable) On-site - generated 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 (fossil fuel)
Oil Consumption 4,000,000 Left blank for image
3,000,000
2,000,000 kWh 1,000,000
0
Gas Consumption 70,000,000 60,000,000 50,000,000 40,000,000
kWh 30,000,000 20,000,000 10,000,000 0
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7.10.2 Waste and Recycling
Waste management within the RD&E is driven by a ‘Waste Hierarchy’ which gives sequential priority to Reducing, Reusing, and Recycling waste. Non-avoidable waste is managed towards recycling or other less financially and environmentally costly waste streams.
A new waste contract is being procured by the Facilities team which will offer better value for money and improved environmental performance.
The RD&E Waste Management Group have developed targets to reduce waste, and various initiatives to improve waste management have also been investigated and implemented on an ad hoc basis with the following successes:
Increasing dry mixed recycling bins (DMR) Segregation of wood waste On site garden waste composting Reusable theatre gowns RD&E-bay an online reuse forum where staff can share equipment and furniture Unrequired medical, engineering and IT equipment is sold via contractors.
Incineration Landfill Disposal Left blank for 900 1,000 image 800 900
700 800 600 700 500 600 400 300 500 200 400 Weight(Tonnes) 100 300 0 Weight (Tonnes) 200 100 0
Recycling Other Waste Recovery
700 500
600 400 500 300 400 200 300
200 Weight (Tonnes) 100 Weight Weight (Tonnes) 100 0 0
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7.10.3 Anaesthetic Gases, Pharmaceuticals and Medical Devices
Anaesthetic gases have extremely high global warming potential, for example 1 litre of
Desflurarane has the equivalent CO2 emissions of driving a diesel car from Lands’ End to John O’Groats and back 7 times. In addition to this issue: less than 5% of inhalational anaesthetic gases are metabolised by the body. This means that 95% of the administered gas goes into the atmosphere. The RD&E Anaesthetic Department are working on several fronts to reduce this impact. The RD&E is working with Sage Tech Medical to develop a revolutionary system that recovers the exhaled anaesthetic gas for reuse. In addition, as part of the 2019 Green team competition, significantly reducing the use of Nitrous Oxide through behavioural and practice change is being planned.
700 600 500
400 Sevoflurane - liquid
Litres 300 Isoflurane - liquid 200 Desflurane - liquid 100
0
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2007/08
600,000
500,000
400,000
300,000
Litres Nitrous oxide 200,000
100,000
- 2017/18 2018/19
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7.10.4 Water
The RD&E has been steadily improving the water infrastructure across the estate. This has involved replacing pipework, installing better valve controls and monitoring equipment to enable leak detection.
There is now comprehensive water monitoring in place across the RD&E, including throughout Wonford, Heavitree, South Devon Satellite Kidney Unit (SDSKU), Exeter Mobility Centre and Mardon House. This provides accurate consumption data to alert the Estates Department to leaks or unwarranted increases in consumption.
The water mains on the RD&E Wonford site have undergone substantial upgrades which, along with repairs to major leaks identified on both Wonford and Heavitree campuses, have contributed to financial savings of circa £30k per year. We have set a target of reducing water usage to 25% of 2007 consumption (base year data normalised for changes in organisation size). The EPC project is expected to reduce consumption by 20,000m3 of water per year, enough to fill 8 Olympic sized swimming pools.
Left blank for image RD&E Water Consumption 300,000
250,000
) 3 200,000
150,000
100,000 Volume Volume (m
50,000
0
Year
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7.10.5 Fuel Consumption
The graphs below show annual business mileage completed by non-RD&E owned grey fleet and RD&E owned fleet, respectively. The former saw a large increase in annual mileage from 2016/17 onwards, primarily due to the RD&E taking on community sites and staff through the TCS project.
Business Mileage: non-RD&E Owned Grey Fleet 3,000,000
2,500,000
2,000,000
Miles 1,500,000
1,000,000
500,000
0 2014/15 2015/16 2016/17 2017/18 2018/19 Left blank for image Business Mileage: RD&E Owned Fleet 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000
Miles 800,000 600,000 400,000 200,000 0 2014/15 2015/16 2016/17 2017/18 2018/19
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8. Reporting The NHS Standard Contract requires the RD&E to take all reasonable steps to minimise adverse impacts on the environment. The contract specifies that we must demonstrate progress on climate change adaptation, mitigation and sustainable development and that we must provide a summary of that progress in our annual report.
In addition to the Standard Contract requirements, NHS Trusts have an obligation to complete the HM Treasury sustainability reporting template on behalf of NHS England and Public Health England. This is completed annually using the Sustainable Development Unit’s
standardised reporting tool.
The Department of Health requires NHS Trusts to report data in the annual Estates Return Information Collection (ERIC). This data includes statistics on energy, waste and water from Estates and Facilities. Since 2017/18, more detailed data collection has been required, encompassing information relating to fleet mileage and electric vehicle usage.
The RD&E is proactive in using ERIC data to benchmark between peers and to drive change within its Sustainability and Transformation Plan (STP) region. During 2018-19 the RD&E hosted a utilities working group with members of the STP region, with a goal of standardising process and identifying regional saving opportunities. Against local and national peers, the RD&E scores well on NHS Improvement’s Model Hospital tool for performance in energy costs and there is a savings opportunity identified with regard to water costs.
The national Sustainability Strategy requires Trusts to report on their sustainable development progress in a Board approved SDMP. Progress against the SDMP will be reported quarterly to the Steering Group and six monthly to the Trust Board. Following Board approval, the SDMP will be publicly available on the RD&E website.
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9. Risks and Opportunities A management process dealing with risks and opportunities which have the potential to arise from the RD&E’s transition to increased sustainable development will be developed.
Any significant risks and opportunities which may arise specific to compliance obligations, objectives and targets and project delivery will be reported to the Sustainable Development Steering Group and to the RD&E Trust Board twice a year.
The RD&E’s heat wave plan and severe weather policy are currently recorded on our risk register. The RD&E will now embed the various anticipated effects of climate change into our risk register, develop a Climate Change Risk Assessment (CCRA) specific to these effects, and subsequently develop a Board approved adaptation plan which will also feed into the risk register. Other perceived risks which may arise through our transition towards increased sustainable development will also be included on the risk register.
Regarding opportunities, the RD&E has been working with a number of local public sector organisations to develop a district heating network that will provide Exeter with low carbon heat. This work continues and will align with the Exeter City Council’s goal of a Carbon Neutral City by 2030.
In January 2019 the RD&E appointed a Director to Exeter City Futures Community Interest Company (ECF CIC) alongside Exeter City Council, Global City Futures, Devon County Council, Exeter College, and the University of Exeter. ECF CIC’s goal is to establish a city plan for delivery of a carbon neutral City by 2030. This strong collaborative governance structure will identify and implement programmes of innovation and investment to achieve a carbon neutral City linking to the UN sustainable development goals of health, clean energy, cities and communities, and sustainable consumption and production (SDGs 3, 7, 11, and 12, respectively).
All ECF CIC Member organisations, including RD&E are mobilising resource to develop internal plans to address their own operational emissions and play a role in delivering the target.
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10. Finance Sustainable development offers opportunity to see long term cost savings through avenues such as reduced energy and water consumption, reduced waste production, increased resilience to the effects of climate change both on the RD&E itself and on the wider community. The current financial cost of the RD&E’s energy, waste and water is documented overleaf.
A further 12.8% (2,404 tCO2e) reduction on the RD&E’s 2017/18 building energy and waste emissions is required by close of financial year 2020/21. Achieving these CO2e reductions was projected to bring an estimated £540k recurring annual saving, with the successful delivery of the EPC this figure will be higher.
Over the last two years, the RD&E has invested £400,000 capital funding into CO2e emission reduction projects The RD&E is open to using various routes to finance our transition towards a more sustainable future, for example an interest-free Salix loan has been used to fund the majority of the £7m EPC.
All utilities have undergone contract reviews to ensure best value is being achieved and waste contracts are currently being retendered.
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Total Energy Cost 4,500,000 4,000,000 3,500,000
3,000,000 2,500,000
2,000,000 Cost Cost (£) 1,500,000 1,000,000 500,000 0
Water and Sewerage Cost 1,200,000
1,000,000
800,000
600,000 Cost Cost (£) 400,000
200,000
0
Total Waste Disposal Cost 600,000
500,000
400,000
300,000 Cost Cost (£) 200,000
100,000
-
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11. Key Performance Indicators Indicator KPI Metric 2015/16 2016/17 2017/18 2018/19 Trend Organisational Tonnes Carbon 70,294 69,218 73,418 80,812 Footprint (CO2e)
Electricity Standard Energy kWh - 13,260,810 12,395,909 13,726,718 Tariff
Electricity Green kWh 3,797,853 883,946 859,055 - Tariff
On-site generated kWh 59,388 55,023 53,189 53,291 (renewable)
On-site generated kWh 7,856,817 7,571,765 7,373,798 7,738,800 (fossil fuel)
Gas kWh 52,984,297 57,875,056 56,752,987 56,046,481 NA
Heating Oil kWh 494,308 453,814 533,889 534,667
Water Volume m3 225,480 218,598 220,245 232,140
Left blank for Transport Business Travel Miles 1,532,340 1,257,762 1,297,137 1,487,276 image
Grey Fleet Miles 839,150 1,499,335 2,262,820 2,398,895
Recycling Recycling2 Tonnes 462 449 330 618
Waste Recovery Tonnes 32 332 450 30
Landfill Tonnes 882 420 428 475
Incineration Tonnes 816 840 805 795
Food Local (< 50 miles) % NA NA NA NA
Organic % NA NA NA NA % NA NA NA NA Fairtrade
2 Dry Mixed Recycling, WEEE, scrap metal, gypsum, wood. 29 #SustainableRDE
12. Contact Us
Inclusion and collaboration are key to the RD&E’s continual success. Your views are welcome on how we can continually improve.
Please send any comments, ideas, suggestions or feedback you may have to:
[email protected] @sustainableRDE
Think before you print, and please 01392 403105 recycle after use
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Waste Management Policy
Post holder responsible for Policy Martin Conabeer, Facilities Operational Manager
Author of Policy Martin Conabeer, Facilities Operational Manager
Division responsible for Procedural Operations Support Division/Post & Waste Document Department
Contact details x6069
Date of original document September 2004
Impact Assessment performed Yes/ No Health and Safety Group: 22 September Ratifying body and date ratified 2016. Version 7 (addition of links to North Devon policy): H&SG Chair approval: 9th June 2017. Review date and (frequency of further April 2021 (every 5 years) reviews) Expiry date September 2021
Date document becomes live 12 June 2017
Please specify standard/criterion numbers and tick other boxes as appropriate
Monitoring Information Strategic Directions – Key Milestones Patient Experience Maintain Operational Service Delivery
Assurance Framework Integrated Community Pathways Monitor/Finance/Performance Develop Acute Services Infection Control CQC Fundamental Standards, Regulations: 15 Other (please specify): HTM 07-01 Note: This policy has been assessed for any equality, diversity or human rights implications
Controlled document This document has been created following the Royal Devon and Exeter NHS Foundation Trust Development, Ratification & Management of Procedural Documents Policy. It should not be altered in any way without the express permission of the author or their representative.
Waste Management Policy Ratified by: Health and Safety Group Chair approval 9th June 2017 (addition of links to North Devon policy). Review date: April 2021 Page 1 of 35
Full History: Status: Final
Version Date Author (Title not name) Reason September 1.0 Post and Waste Manager New policy 2004 Post and Waste Manager 2.0 January 2005 Review & minor amendments
Post and Waste Manager 3.0 March 2009 Updated in line with legislation
Post and Waste Manager 4.0 March 2012 Updated in line with legislation
Post and Waste Manager 5.0 April 2014 Updated in line with legislation
Facilities Operational 6.0 July 2016 Review & Minor amendments Manager Facilities Operational Addition of links to North Devon 7.0 February 2017 Manager Healthcare Trust waste policy
Associated Trust Cleaning Policy Policies/ procedural Confidentiality Policy (this is the Information Governance Policy) documents: Control of Substances Hazardous to Health (COSHH) Policy Decontamination Policy & Procedures Disposal of Waste IT Equipment Policy Incident Reporting, Analysing, Investigating and Learning Policy Infection Prevention & Control Policy Inoculation Injury Policy Radiation Safety Policy Risk Assessment Policy and Procedure
Associated Community Services procedural documents: Waste Management Policy (North Devon Healthcare Trust) Waste Management Manual (North Devon Healthcare Trust)
Key Words Waste In consultation with and date: Senior Matrons- by e-mail: 25 August 2016 Matrons- by e-mail: 25 August 2016 Waste Management Group- by e-mail: 25 August 2016 Infection Prevention and Control Team - by e-mail: 25 August 2016 Divisional Directors - by e-mail: 25 August 2016 Lead Nurses - by e-mail: 25 August 2016 Head of Governance - by e-mail: 25 August 2016 Safety & Risk Manager - by e-mail: 25 August 2016 Equality & Diversity Manager - by e-mail: 25 August 2016 Governance Leads - by e-mail: 25 August 2016 Policy Expert Panel (PEP): 15 September 2016 Health and Safety Group: 22 September 2016 Health and Safety Group Chair: 09 June 2017 (approval for minor amendments)
Contact for Review: Operational Support Manager W aste Management Policy Ratified by: Health and Safety Group Chair approval 9th June 2017 (addition of links to North Devon policy). Re view date: April 2021 Page 2 of 35
Executive Lead Signature:
Director of Nursing and Patient Care
Waste Management Policy Ratified by: Health and Safety Group Chair approval 9th June 2017 (addition of links to North Devon policy). Review date: April 2021 Page 3 of 35
CONTENTS
1. INTRODUCTION ...... 5 2. PURPOSE ...... 5 3. DEFINITIONS ...... 6 4. DUTIES AND RESPONSIBILITIES OF STAFF ...... 7 5. AUDITS ...... 11 6. TRAINING ...... 12 7. ARCHIVING ARRANGEMENTS ...... 12 8. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY ...... 12 9. REFERENCES ...... 13 APPENDIX 1: WASTE STREAMS ...... 15 APPENDIX 2: PROCEDURES TO COMPLY WITH WASTE LEGISLATION ...... 17 APPENDIX 3: WASTE HIERARCHY ...... 22 APPENDIX 4: PROCEDURES FOR REMOVING/HANDLING OF WASTE...... 23 APPENDIX 5: CHARTS OF COMMON TYPES OF HEALTHCARE WASTE AND RECEPTACLES ...... 25 APPENDIX 6: STANDARD COLOUR CODING SYSTEM ADOPTED BY THE TRUST ...... 30 APPENDIX 7: SEGREGATION FLOW CHART FOR HEALTHCARE WASTE ...... 31 APPENDIX 8: STORAGE OF WASTE ON SITE ...... 32 APPENDIX 9: COMMUNICATION PLAN ...... 33 APPENDIX 10: EQUALITY IMPACT ASSESSMENT TOOL ...... 34
Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 4 of 35
1. INTRODUCTION
1.1 The Royal Devon and Exeter NHS Foundation Trust (hereafter referred to as the Trust) in the provision of healthcare activities and associated support functions, produces a wide and diverse range of waste. These waste streams are set out in Appendix 1
1.2 It is the legal responsibility of all employees who dispose of waste within the Trust to ensure that risks relating to that waste are minimised for staff, patients, visitors, others and the environment.
1.3 A failure to comply with this policy could result in disciplinary action being taken against an individual or individuals(s). It should also be noted that any breach of this policy could also lead to prosecution of individuals and/or the Trust which could result in substantial fines, possible imprisonment, adverse publicity and loss of reputation. For the procedure for the disposal of healthcare waste, see Appendix 2
2. PURPOSE
2.1 The Trust is committed to disposing of its waste streams in compliance with relevant legislation and good practice guidance documents. It also aims to minimise and prevent significant risks to the health and safety of its staff, patients, public, waste contractors and the environment when disposing of that waste.
2.2 This policy applies to all Trust employees and non-Trust staff.
2.3 This policy adopts the unified colour coding policy suggested within the following Guidance on the safe management of healthcare waste (DoH, 2013) in relation to clinical waste derived from medical, nursing, dental, pharmaceutical and other clinical services, and applies the principles of assessment, segregation, packaging, and the required detailed documentation including the use of European waste codes Environmental Protection Agency (2002) European Waste Catalogue and Hazardous Waste List (EWC). Environmental Protection Agency. Available at: http://www.nwcpo.ie/forms/EWC_code_book.pdf
2.4 Waste Regulations require that the Trust and individuals working for it adhere to the Waste Hierarchy as shown in Appendix 3, where possible. The Trust is committed to reducing its environmental impact and ensuring services remain financially sustainable. When considering projects and services it is essential to review the waste hierarchy and identify how it can be implemented.
2.5 Versions of the North Devon Healthcare Trust (NDHT) Waste Management Policy and NDHT Waste Management Manual can be accessed on the Trust intranet, HUB, via the following links: Waste Management Policy (North Devon Healthcare Trust [NDHT]) Waste Management Manual (North Devon Healthcare Trust [NDHT])
Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 5 of 35
3. DEFINITIONS
3.1 Clinical waste is defined in the Controlled Waste Regulations 2012 as:
(a) any waste which consists wholly or partly of human or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, or syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it; (b) any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of blood for transfusion, being waste which may cause infection to any person coming into contact with it
3.2 Clinical waste can be divided into three groups of materials:
(a) Any healthcare waste which poses a risk of infection. (Technical Guidance H9) (Environment Agency, 2013b)
(b) Healthcare wastes which pose a chemical risk (Technical Guidance H1 to H8, H10 to H15) (Environment Agency, 2013b)
(c) Medicines and medically contaminated waste containing a pharmaceutically active ingredient
3.3 Clinical Waste (Yellow Stream) Poses a known or suspected risk of infection
Anatomical waste Chemically contaminated waste Medically contaminated infectious waste Category A Pathogens (Health and Safety Executive [2013])
3.4 Infectious / Potentially Infectious Waste (Orange Stream) This is waste known or suspected to contain pathogens classified in Category B as specified in the Carriage of Dangerous Goods Regulations (2009)
Category B Pathogens Blood Semen Vaginal secretion Cerebrospinal fluid Synovial Pleural Peritoneal Pericardial Amniotic
3.5 Offensive waste (Tiger Stripe) This is non-infectious waste, which is unpleasant and may cause offence to those coming into contact with it. It includes:
Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 6 of 35
outer dressings and protective clothing, e.g. masks, gowns and gloves that are not contaminated with body fluids hygiene waste and sanitary protection, e.g. nappies and incontinence pads auto-claved laboratory waste.
3.6 Pharmaceutical Waste (Blue) There are two Classes of Medicine:
Pharmaceutically active, (not Cytotoxic or Cytostatic) and Not pharmaceutically active and possessing no hazardous properties (e.g. saline solution and glucose).
3.7 Cytotoxic and Cytostatic medicines are classified as being hazardous and they display the following hazardous properties:
H6 Toxic H7 Carcinogenic H10 Toxic for reproduction H11 Mutagenic
Additionally, if medicines are deemed not to be Cytotoxic and Cytostatic then they may still be classed as hazardous based on the following properties:
H3B Flammable H4 Irritant H5 Harmful H14 Eco toxic
3.8 Radioactive waste contains radioactivity above levels defined in legislation. Radioactive waste generated in this hospital is low level waste and is usually also clinical waste. It must be held according to the permit granted by the Environment Agency. For advice on radioactive waste, please contact the radioactive waste adviser via Medical Physics. There is advice on handling radioactive waste from in-patients on the Nuclear Medicine page on the Hub.
Radiation Safety Policy (Ionising Radiation)
4. DUTIES AND RESPONSIBILITIES OF STAFF
4.1 Chief Executive
4.1.1 The Chief Executive has overall responsibility for ensuring safe and effective waste management systems are in place and is responsible for ensuring that employees are aware of and carry out the responsibilities identified in this policy.
4.1.2 The Chief Executive has delegated this responsibility to the Head of Facilities Management of the Operations Support Division and the Deputy Director of Capital and Estates
4.2 Head of Facilities Management Operations and Support Unit & Deputy Director of Capital and Estates Will ensure compliance with this Policy and delegate day to day responsibilities for maintaining that compliance to:
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4.3 Service Manager Facilities (who on behalf of the Head of Facilities Management, Operations Support Division) and the Head of Estates (who on behalf of the Deputy Director of Capital and Estates) - Operational management responsibilities are currently divided between Operations Support unit and Estates. A breakdown of the day to day area of responsibilities can be seen on the waste streams table (Appendix 1).
4.3.1 Will be responsible for the day to day management of this policy and be jointly responsible for ensuring compliance of the policy through the Operations Support Management /Specialties Governance Group (OSM/SGG), thus ensuring that Managers with specific responsibilities comply with this policy.
4.3.2 Maintaining a current knowledge base of relevant legislation, codes of practice and issued guidance.
4.3.3 Ensuring the correct registration and licensing of the site are in place and ensuring that such registrations are known to all department heads who may dispose of waste.
4.3.4 Ensuring a training programme is in place to allow staff to have the knowledge and information required to comply with the requirements of this policy.
4.3.5 Ensuring that any amendments/alterations/additions to this policy are accurately communicated and implemented along with supporting evidence on why the changes were instigated, thus providing a pedigree of information, in case of investigation by the Environment Agency or any other investigatory body.
4.3.6 Ensuring that suitable internal and external audits (where applicable) are in place to test and verify compliance with this policy.
4.3.7 Facilities Service Manager, will submit a report from the annual work plan to the Health & Safety Group outlining the performance of the Trust against this policy, the report will detail the Trusts waste recycling position, current rates/costs of waste disposal and the environmental considerations relating thereto as well as any remedial actions taken to ensure that this policy remains effective.
4.3.8 Ensuring that suitable waste disposal and recycling contracts are in place via Procurement and that all such contracts are controlled, monitored and audited.
4.3.9 Representing the Trust in liaison with Waste Regulatory Authorities, Local Authorities and other bodies having responsibilities under environmental and waste regulations.
4.3.10 Ensure that storage and disposal areas are appropriate and maintained in a satisfactory condition.
4.3.11 Monitoring and recording the levels and types of waste produced and making necessary reports to bring trends as well as variances to the attention of relevant managers.
4.3.12 Identifying opportunities to improve adherence to the Waste Hierarchy (see Appendix 3) and implementing them where appropriate.
4.3.13 Implementing improvements in waste management, in line with guidance from the NHS Sustainable Development Unit.
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4.4 Trust Waste Manager (Operations and Support Unit)
4.4.1 The Trust Waste Manager is responsible for maintaining a current knowledge of relevant legislation, Codes of Practice and issued guidance and advising how it may affect the Trust, as well as monitoring all waste arrangements: also to identify opportunities to improve Trust adherence to the waste hierarchy.
4.4.2 Working with the Trust Estates Manager to ensure that safe and suitable management systems are in place for all the Trust’s waste streams.
4.4.3 Being responsible, together with relevant heads of departments as required, and/or other safety advisors, to investigate any major waste related incident and to act on the findings of that investigation in line with the incident, investigation, analysing and learning policy and procedure.
4.4.4 Carrying out an annual internal overview audit, in conjunction with the department head or representative and/or an Infection Control Team member, of all premises/departments whose waste is disposed of by the Trust to verify compliance with this policy and providing a report to the Head of Facilities.
4.4.5 Conducting duty of care audits/visits to all contractors involved in the removal of clinical waste, and an annual check on controlled waste disposers to provide cradle-to-grave audits of the waste streams generated by the Trust, involving as appropriate representatives of the waste producer areas.
4.4.6 Ensuring that appropriate waste transfer and consignment notes throughout the Trust are completed in a correct manner and a record of such notes are, stored for at least 3 years.
4.4.7 Monitoring and recording the levels and types of waste produced and making necessary reports to bring trends as well as variances to the attention of relevant managers.
4.4.8 Providing advice, guidance and support to managers who have day to day duties on the identification, collection, internal movement, storage of waste and its consignment.
4.4.9 The Trust Waste Manager will generate quarterly Trust Datix reports identifying breaches to the Waste Management Group,
4.4.10 Undertake annual pre-acceptance audits to ensure that the Trust meets legal requirements for compliance against waste legislation.
4.5 Energy and Sustainability Manager Will be responsible for: providing assistance and guidance to improve environmental performance, setting waste environmental improvement targets and assist in implementing schemes to achieve them. Also to support adherence to the waste hierarchy, ensuring Estates Department waste is managed appropriately, formulating and controlling the Estates waste disposal budget, and managing contractors employed under the Estates waste budget.
4.6 Dangerous Goods Safety Advisor Has the responsibility to advise on storage, package and movement on and off site, and to final disposal.
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4.7 The Non Ionising Radiation and Nuclear Medicine Clinical Scientist Has the responsibility for radioactive waste.
4.8 Head of IT Infrastructure Delivery Has the responsibility for the Disposal of Waste IT Equipment Policy.
4.9 Information Governance Manager Has the responsibility for the Confidentiality Policy (Information Governance Policy).
4.10 Head of Department / Ward Manager 4.10.1 Have the responsibility for implementing and monitoring this policy within their specific area of responsibility.
4.10.2 Ensure that waste management procedures and safe working practices resulting from them are produced, documented and implemented for their area.
4.10.3 Ensure that an adequate number of waste containers and receptacles for waste are provided and are readily accessible.
4.10.4 Is responsible for risk assessments being undertaken within their department/ward concerning waste disposal. The Waste Manager can provide guidance on risk assessments.
4.10.5 Ensure that all staff are properly trained and are competent for their duties.
4.10.6 Ensure that arrangements with regard to waste are included in the induction training of new employees.
4.10.7 Ensure all staff under their control are aware of the correct procedures for waste management, and receive appropriate on-going waste training.
4.10.8 Ensure that disposal areas are kept clean and tidy and well maintained.
4.10.9 Ensure that any personal protective equipment deemed by risk assessment to be necessary is provided and used appropriately.
4.10.10 Ensure that appropriate waste signage and instructions regarding waste streams are displayed.
4.11 Domestic Services Manager Has the responsibility for the Cleaning Policy
4.12 The Infection Control Team
4.12.1 Assist the Divisions and departments to ensure that the staff are aware of the Trust’s control of infection/BBV (Blood borne viruses, e.g. Infection Prevention & Control Policy - also the Inoculation Injury Policy detailing how to deal with a sharps injury and how the safe and correct segregation of health care related waste will reduce the risk to other groups of staff within the waste chain.
4.12.2 Provide advice on the day-to-day management of infection control operational issues with other named officers within this policy to ensure a coordinated approach to the safe storage, transport and management of waste. Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 10 of 35
4.12.3 Along with the Operations Support Division Management and other staff with a direct responsibility for waste management monitor compliance with the policy through a process of audit and exception reporting.
4.12.4 Assist with or instigate investigations into incidents and/or injuries related to waste or sharps as necessary. Sharps related injuries caused within waste should be reported via Datix and monitored by the Health and Safety Group.
4.13 The Procurement Department Has the responsibility to develop standard contract clauses and tender criteria which improve adherence to the waste hierarchy with the aim of aiding the Trust in reducing waste disposal costs and improving its sustainability (this will be supported by the sustainable procurement policy which they are preparing).
4.14 The Health and Safety Group Has the responsibility for endorsing this policy.
4.15 The Waste Management Group This Group will monitor and oversee all aspects of waste management within the organisation (IMT and MEM are responsible for looking after their own elements of waste) and ensure compliance with relevant legislation and standards providing assurance to the Health and Safety Group.
4.16 Operations Support Division Audit Team and the Ward Housekeepers Carry out waste audits in all areas to ensure compliance with the Guidance on the safe management of healthcare waste (DoH, 2013) and Hazardous Waste: Interpretation of the definition and classification of hazardous waste (Environment Agency, 2013b)
4.17 All Staff 4.17.1 Although the Trust Management has primary responsibility for the safe management and disposal of waste, each employee has an individual and legal responsibility to:
1. Attend Waste training. 2. Comply with the Trust Management in the implementation of this policy. 3. Ensure that their waste is segregated and properly secured.
4.17.2 Ensure their compliance where a requirement for the wearing /use of Personal Protective Equipment (PPE) has been established for the handling of waste (see Appendix 4.)
4.17.3 Report any problems that arise regarding waste disposal to their supervisor/manager and complete a Datix incident form as per the Trust Incident Reporting, Analysing, Investigating and Learning Policy and Procedure.
5. AUDITS 5.1 Waste auditing is a legal requirement and is an essential tool in assessing that waste contractors are registered and approved, assessing composition of waste streams for the purpose of compliance: and ensuring that duty of care visits are undertaken.
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5.2 Waste audits will be carried out to monitor the effectiveness of waste segregation and minimisation to demonstrate compliance.
5.3 Audit reports are issued via the CCW (Cleaning Catering & Waste) software. Feedback will be given to wards/departments on outcomes of audits.
5.4 Respective managers or Ward Housekeepers on non-compliant wards/departments will be responsible for any follow-up action required to rectify non-compliance.
6. TRAINING Training will be given at local induction, refresher training by use of E-learning, paper version and face to face sessions are available to meet the requirements of all staff levels. This training has been added to the list of essential training reported monthly and compliance measured, minimum compliance figure Trust wide is 75% Training updates are required two yearly, for all staff.
7. ARCHIVING ARRANGEMENTS The original of this policy will remain with the author, the Post and Waste Manager, Operations Support Unit. An electronic copy will be maintained on the Trust intranet (A-Z) – P – Policies (Trust-wide) – W – Waste Management. Archived electronic copies will be stored on the Trust's “archived policies” shared drive, and will be held indefinitely. A paper copy (where one exists) will be retained for 10 years.
8. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY 8.1 In order to monitor compliance with this policy, the auditable standards will be monitored as follows:
No Minimum Requirements Evidenced by
1. Operations Support Division Audit Team Weekly Audit Log CCW report 2. Departmental Waste Reports Quarterly Datix Breach Figures Report 3. Service Manager Annual Audit Annual Report
Waste Management Annual Pre-acceptance Annual Report 4. Audits Journey & waste facility Duty of Care Inspections 5. observation documentation 6. External Auditor (HTM07-01) Annual Report 7. Monitor for trends in waste related incidents Datix reports quarterly Monitor Trust compliance with waste essential 8. Monthly ESR Reports training
8.2 Frequency In each financial year, the Operations Support Division Service Manager will present the annual waste audit to ensure that this policy has been adhered to and a formal report will be written and presented at Operations Support Management / Specialties Governance Group (OSM/SGG). 8.3 Undertaken by Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 12 of 35
Operations Support Division Service Manager
8.4 Dissemination of Results The Waste Management Group is held quarterly. Any resulting actions will be disseminated to OSM/SGG (if operational) or Health & Safety Group if related to legislation compliance.
8.5 Recommendations/ Action Plans Implementation of the recommendations and action plan will be monitored by the Waste Management Group, which meets quarterly
8.6 Any barriers to implementation will be risk-assessed and added to the risk register.
8.7 Any changes in practice needed will be highlighted to Trust staff via the Governance Managers cascade system.
9. REFERENCES
Environmental Protection Act 1990 (c.43). (Duty of Care – Para 34(1). London: Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/1990/43/section/34
The Environmental Protection (Duty of Care) Regulations 1991.London Stationary Office. Available at: http:/www.opsi.gov.uk/SI/si1991/UKsi_19912839_en_1.htm Regulations 1991
The Controlled Waste (Registration of Carriers & Seizure of Vehicles) Regulations 2012. (SI 2012/811). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2012/811/contents/made
Environment Agency (2013a). Hazardous Waste – Interpretation of the definitions and classification of hazardous waste. Available at: https://brand.environment- agency.gov.uk/mb/CVSM33
Environment Agency (2013b) Hazardous Waste: Interpretation of the definition and classification of hazardous waste. Environment Agency. (Technical Guidance H1 to H8, H10 to H15) Available at: http://a0768b4a8a31e106d8b0- 50dc802554eb38a24458b98ff72d550b.r19.cf3.rackcdn.com/LIT_5426_acd22f.pdf
Environment Agency (2013c). Duty of Care regulations. Available at: http://www.environment-agency.gov.uk/business/topics/waste/40047.aspx Environment Agency (2013d) European Waste Catalogue (EWC) Available at: http://www.environment-agency.gov.uk/business/topics/waste/31873.aspx
Environmental Protection Agency (2002) European Waste Catalogue and Hazardous Waste List (EWC). Environmental Protection Agency. Available at: http://www.nwcpo.ie/forms/EWC_code_book.pdf
The Hazardous Waste (England and Wales) Regulations 2005 as amended 2009. (SI 2009/507). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2009/507/contents/made
The Waste Electrical and Electronic Equipment (Amendment) Regulations 2010. (SI 2010/1155) London: Stationary Office. Available at: Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 13 of 35
http://www.legislation.gov.uk/uksi/2010/1155/note/made
The Waste (England and Wales) Regulations 2011. (SI 2011/988). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2011/988/made
The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004 (SI 2004/568). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2004/568/contents/made
The Control of Substances Hazardous to Health Regulations 2002 (SI 2002/2677). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2002/2677/contents/made
Health and Safety at Work Act 1974. (c.34). London: Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/1974/37
Radioactive Substances Act 1993. (c.12). London: Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/1993/12/contents
The List of Wastes (England) Regulations 2005. (SI 2005/895). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2005/895/contents/made
Department of Health (2013): Guidance on the safe management of healthcare waste Publications. London: Department of Health Publications. Available at: https://www.gov.uk/government/publications/guidance-on-the-safe-management-of- healthcare-waste
NHS (2016). And next available NHS Sustainability Day. Available at: http://www.nhssustainabilityday.co.uk/toolkits/
The Controlled Waste Regulations 1992 (SI 1992/588). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2012/811/contents/made
The Environmental Permitting (England and Wales) (Amendment) Regulations 2012. (SI 2012/630). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2012/630/contents/made
Health and Safety Executive (2009) Chemical warehousing: The storage of packaged dangerous substances. London: HSE. Available at: http://www.hse.gov.uk/pubns/books/hsg71.htm
The Health and Safety Executive (2013). The Approved List of biological agents. 3rd Edition, 2013. London: HSE. Advisory Committee on Dangerous Pathogens. Available at: http://www.hse.gov.uk/pubns/misc208.pdf
WasteCare (2011). The Waste (England and Wales) Regulations 2011. WasteCare. Available at: http://www.wastecare.co.uk/regulations/the-waste-regulations-2011/
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APPENDIX 1: WASTE STREAMS
Waste Contractual Specialist Description Physical Is waste Method of Operational Handlers of Waste Responsibilities Advisor/Key (Alphabetical Form Hazardous? Disposal Responsibilities Stakeholder order) Service Manager Aerosols Mixed Yes / No Recycled/Recovery Waste Team Waste Manager Head of Estates Facilities Service Manager Amalgam Solid Yes Recovery/recycling Waste Team Waste Manager Head of Estates Facilities, Inf. Control Service Manager Anatomical Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control Service Manager Batteries Solid No Recycled Waste Team Waste Manager Head of Estates Facilities Builders Solid No Landfill/recycled Estates Estates Head of Estates Cardboard Service Manager Solid No Landfill Waste Team / Estates Waste manager Head of Estates (black bag) Facilities Service Manager Cardboard Solid No Recycled Waste Team Waste Manager Head of Estates Facilities Cartridges Waste Team & Service Manager Solid Yes Recycled/Recovery Waste Manager Head of Estates (Toner) - empty Contractors Facilities Service Manager Chemicals Mixed Yes Reprocessed Waste Team Waste Manager Head of Estates Facilities Service Manager Clinical Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control Information Confidential Solid No Recycled Waste Team Waste Manager Head of Estates Governance Lead Service Manager Cytotoxic Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control Fluorescent Service Manager Solid Yes Recycled Estates Estates Head of Estates Lamps Facilities Waste Team / Service Manager Food waste Solid No Landfill Waste manager Head of Estates Catering Facilities Furniture Service Manager broken or re- Solid No Recycled Waste Team Waste Manager Head of Estates Facilities usable Service Manager Glass Solid No Recycled Waste Team Waste Manager Head of Estates Facilities Grounds Solid No Mulched Estates Estates Head of Estates Grounds (green Solid No Composted Estates Estates Head of Estates waste) Gypsum Reused, Recycled Solid No Estates Estates Head of Estates (Builders) other disposal Gypsum Service Manager Solid Yes Incinerated Waste Team Waste Manager Head of Estates (Clinical) Facilities Service Manager Offensive Waste Solid No Incineration Waste Team Waste Manager Head of Estates Facilities Energy & Recycled or Catering Oils (cooking) Solid No Catering Department Head of Estates Sustainability reprocessed Manager Manager Oils (non-edible Solid Yes Recycled Estates Estates Head of Estates machine) Service Manager Service Manager Paper Solid No Landfill Waste Team / Estates Waste manager Facilities Facilities Service Manager Paper (Office) Solid No Recycled Contractor Waste Manager Head of Estates Facilities Pathology Head of Solid Yes Reprocessed Contractor Path Lab Head of Pathology chemicals Pathology Service Manager Service Manager Pharmaceutical Mixed Yes Incineration Pharmacy Manager Waste Manager Facilities, Pharmacy Facilities Manager, Inf. Control Plastics Solid No Landfill Waste Team Waste manager Head of Estates (black bag) Plastics Service Manager Solid No Recycled Waste Team Waste Manager Head of Estates (clear bag) Facilities Service Manager Radiation Radioactive Solid Yes Incineration Waste Team Head of Estates Facilities, Medical Advisor Physics, Inf. Control Porters & Waste Service Manager Scrap Metals Solid No Recycled Porters, Waste Team Head of Estates Team Facilities Service Manager Sharps Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control
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Waste Contractual Specialist Description Physical Is waste Method of Operational Handlers of Waste Responsibilities Advisor/Key (Alphabetical Form Hazardous? Disposal Responsibilities Stakeholder order) WEEE 1 Service Manager Solid Yes Recycled Waste Team Waste Manager Head of Estates (General) Facilities WEEE 2 (large Service Manager Solid Yes Recycled Waste Team Waste Manager Head of Estates Appliances) Facilities WEEE 3 Reused or Medical (Medical Solid Yes Medical Electronics Head of MEM Head of MEM Recycled Electronics Electronics) Reused or WEEE 4 (IMT) Solid Yes IM&T IM&T Head of IT Head of IT Recycled
Estates are responsible for waste they generate in their activities; Facilities are responsible for waste generated by all other activities.
Estates do not handle furniture unless it is part of a specific project.
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APPENDIX 2: PROCEDURES TO COMPLY WITH WASTE LEGISLATION
1. PROCEDURES TO COMPLY WITH WASTE LEGISLATION
Managers and departments heads will comply with the following procedures and guidance, developing local procedures where required.. Whilst many of the examples quoted are for healthcare waste (clinical) the same procedures/principles apply to all waste types.
1.1 Segregation
1.1.1 The correct segregation of waste at point of production into suitable packaging, colour coded for healthcare waste is vital to good waste management. Health and safety, carriage and waste regulations require that waste is handled, transported and disposed of in a safe and effective manner. Waste may be basically divided into the three streams:
1.2 Waste from Direct Patient related care
1.2.1 Will be segregated as shown by Appendix 5, Appendix 6 and Appendix 7 which incorporates the Safe Management of Healthcare Waste unified colour coding policy.
1.2.2 If the waste does not match any of these categories, a risk assessment must be carried out to establish the appropriate disposal treatment. If this is a re-occurring waste, a copy of the assessment and the codes used, will be sent to the Waste Manager to ensure it is added to the relevant Appendix., see:- Guidance on the safe management of healthcare waste (DoH, 2013) pages 75 -112). The Department Manager must check with the Waste Manager that there is not already a Trust approved disposal route before committing to a waste contractor.
1.3 Waste from Non-direct patient related care
1.3.1 Waste which may be derived from activities not associated with direct patient care will be segregated as shown by Appendix 7
1.4 Waste not identified in Appendix(s)
1.4.1 This policy and associated documents cannot cover every single waste stream. Any wastes which are not shown must be correctly assessed for their hazards and correct means of disposal by referring to either:
1.4.2 Guidance on the safe management of healthcare waste (DoH, 2013) pages 75 - 112,
Or 1.4.3 List of Waste codes which provide information on how to code waste correctly for anyone producing, carrying or managing waste in England and Wales
Or 1.4.4 Seeking the advice of a specialized disposer qualified in that waste disposal.
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1.4.5 Notes of any conversation and arrangements agreed to this unidentified waste shall be recorded. The manager shall ensure that any arrangements relating to the waste are written into any local procedures and made known to staff including any safe handling and storage criteria. If this is a re-occurring waste, a copy of the assessment and the codes used and consignment notes arising from that waste will be sent to the Waste Manager.
2. Handling
2.1 See Appendix 4
3. Primary storage Waste will be collected in the following primary receptacles:
3.2 Waste Sacks
3.2.1 Only those waste sacks supplied by the Supplies Department or Domestic Services will be used for the collection of material. These will be to the relevant NHS specification for the waste concerned. In addition infectious waste sacks will be UN 3291 approved
3.2.2 They shall be tied and identified in accordance with the waste sack handling advice. (See Appendix 4)
3.3 Sharps Containers
3.3.1 Shall be BS 7320 and UN 3291 approved: European Waste Catalogue and Hazardous Waste List (EWC). http://www.nwcpo.ie/forms/EWC_code_book.pdf (Environmental Protection Agency [2002])
3.3.2 They shall be assembled, used and identified in accordance with the Inoculation Policy (Sharps) and manufacturer’s instructions.
3.3.3 Sharps containers are not leak proof and should contain no more than 5% of free liquid.
3.4 Rigid Containers (Leak-proof)
3.4.1 Shall be BS 7320 and UN 3291 approved. European Waste Catalogue and Hazardous Waste List (EWC). http://www.nwcpo.ie/forms/EWC_code_book.pdf (Environmental Protection Agency [2002])
3.4.2 They shall be assembled, used and identified in accordance with the manufacturer’s instructions.
3.4.3 The receptacles shall carry the following information in the form of a label or written in indelible black ink on the receptacle: the department name, date, and name of person dispatching the waste, the waste type and European Waste Catalogue
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http://www.nwcpo.ie/forms/EWC_code_book.pdf (Environmental Protection Agency [2002]) code and associated hazards.
3.5 Other Containers
3.5.1 Waste shall be stored in original containers prior to collection by disposal companies. The final packaging shall meet all the requirements for safe packaging and storage as directed by the Trust‟s Dangerous Goods Safety Advisor. For further information contact The Waste Management Team on ext 6056
3.5.2 Chemical storage on site awaiting disposal shall comply with the requirements of safe separation as required by the Control of Substances Hazardous to Health Regulations 2002.
4 Internal (intermediate) storage (See Appendix 8)
4.1 Are those classed as belonging to the ward/department generating the waste, e.g. dirty utility/ward sluice rooms.
4.2 The Hazardous Waste Regulations 2005, List of Wastes Regulations 2005, EPR 5.07 Environment permit (Clinical Waste) and Duty of Care regulations, (Environment Agency, 2013c) places several obligations on producers of waste namely that:
4.3 Waste must not be mixed – Mixing hazardous and non-hazardous waste is illegal. Keep waste(s) as separate as possible and do not place sharps containers on top of sacked waste within sluices. Internally transport differing waste types separately. Hazardous wastes cannot be mixed and any hazardous waste placed within non- hazardous waste renders all that consignment/load as hazardous waste. E.G. one sack of Infectious waste placed with sacks of domestic waste within a 5 tonne load of domestic waste from the Trust renders all that waste infectious.
4.4 The Trust or the individual concerned may be prosecuted or fined, in addition to the Trust having to remove all the consignment and dispose of it as infectious waste.
4.5 Waste must be secure – All rooms/areas where waste is kept should be secure and not accessible to members of the public. 770 litre collection containers (large yellow wheelie bins on the corridors) are deemed suitably secure provided that they are locked when not attended. They will only be left within agreed areas, internally to the hospital, at agreed times.
4.7 Loose waste, in sacks or sharps boxes must not be stored, kept or allowed to accumulate within corridors and public areas.
5 Main Storage (see Appendix 8)
5.1 The majority of waste, apart from those wastes who Department Heads retain responsibility for and consign separately, e.g. IT equipment, Pharmacy chemicals, pathology chemicals, Estates oils, will be removed to the Facilities waste recycling area, where:
5.2 All waste streams will be identified, kept separate and secure.
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6. Transport
6.1 All waste must be removed from the Trust premises by an approved and registered carrier; the Trust has a duty of care to ensure that the carrier is properly registered/licensed to transport waste and that the waste is transferred to a proper registered/licensed site. Registration is undertaken by the Environment Agency. Checks on carriers/sites may be undertaken at the Environment Agency public register website.
6.2 The Carriage of Dangerous Goods Regulations (2011) covers the movement of all dangerous (hazardous) goods not just waste. The appropriate UN number should appear on the waste consignment note. The relevant UN numbers for clinical waste types are:
Dangerous Goods (UN Number) Description Category A; UN 2814 (Highly) Infectious substance, affecting humans Category B; UN 3291 Infectious Clinical waste N.O.S UN1851 Medicines, liquid, toxic, N.O.S UN 3248 Medicines, liquid, flammable, toxic, N.O.S UN 3249 Medicine, solid, toxic, N.O.S UN 2025 (Dental amalgam) Mercury compound, solid, N.O.S
6.3 It is the responsibility of the waste producer to ensure that waste is packaged safely and securely and conforms to “The Carriage of Dangerous Goods” (2011).
6.4 If the waste is outside the definitions of clinical waste, specialist advice should be sought from an accredited and authorised waste disposal company and/or the Trusts Dangerous Goods Advisor.
7. Documentation
7.1 Apart from knowing that the person who removes the waste is authorized to carry it and that it must go to a proper site, documentation which gives an accurate description of what is being carried, has to be passed to the carrier, and others within the waste chain. This documentation follows a set form and is more onerous for hazardous waste than controlled wastes.
7.2 These notes are:
Hazardous waste consignment notes – where the waste is hazardous. It is a requirement that each and every transfer of waste from the Trust is covered by either of the above, as appropriate. These must be retained for 3 years minimum by the department who authorised the transfer of the waste.
Waste transfer notes When waste, not hazardous waste, is transferred from one party to another, the person handing it on (the “transferor‟) must complete a Waste Transfer Note. These are retained for 2 years.
The transferee and the recipient (the “transferee‟) sign the note and both keep a copy. To save on administration, it is possible to have a Waste Transfer Note issued annually. This is for regular and similar non-hazardous collections. Waste Management Policy Approved by Health and Safety Group Page 20 of 35 Re view date: September 2016
Hazardous waste consignment notes These notes must be completed for every transfer of waste which is hazardous. There is a requirement to give a full description of the waste, its EWC code, along with its associated hazards.
It is the producer’s responsibility to fill in the section of this note, but in many cases the specialist disposer will assist on your behalf.
This enables the carrier of the waste to appropriate measures to ensure the wastes are packaged, labelled and handled correctly and that the person who receives the waste for final disposal (the “consignee‟) is able to take it.
The Environment Agency have a fully descriptive website concerning the standard procedure required for hazardous waste consignment notes.
Where possible for clinical waste, notes are pre-printed by the disposer and filled in at every visit. (This may not be possible at SDRU and in the case of community sites).
7.3 Returns
The waste collection company is required to send back a return each quarter, or a copy of the consignment note with “Part E” filled in. This return is a record of what has happened to your waste and must be placed with the other waste records.
These vary company to company, but they must describe the quantity, nature, origin, destination, and frequency of collection, mode of transport, waste carrier and the disposal or recovery operation applied, to the waste received.
The Estate’s Energy & Sustainability Manager will request each disposal company to provide a quarterly waste return.
Copies of the returns should be sent to the Operational Support Division
8 EWC Code
European Waste Catalogue (EWC) (Environment Agency, 2013d) codes must be
included on the waste transfer note and the hazardous waste consignment notes. The European waste codes have been translated into domestic legislation and are called “List of Waste codes”. Environmental Protection Agency (2002) European Waste Catalogue and Hazardous Waste List (EWC). Environmental Protection Agency.
Available at: http://www.nwcpo.ie/forms/EWC_code_book.pdf
9 Premises Registration Code
9.1 There is a generic ROYALD code across all trust sites.
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APPENDIX 3: WASTE HIERARCHY
Waste Hierarchy
The Trust is endeavouring to adhere to the waste hierarchy. To assist in this please consider how you can follow this structure when disposing of your waste.
1.1 Try not to procure items which result in lots of waste
1.2 Identify where items can be reused, especially furniture
1.3 The Trust is increasing the amount of waste it sends for recycling, look for recycling bins and contacts the Waste department if you have a waste stream that can be recycled.
What is the waste Hierarchy
The waste hierarchy refers to the "3 R’s" reduce, reuse and recycle, which classify waste management strategies according to their desirability. The 3 R’s are meant to be a hierarchy, in order of importance.
The revised Waste Framework Directive introduced a changed hierarchy of options for managing wastes. It gives top priority to preventing waste in the first place. When waste is created, it gives priority to preparing it for re-use, then recycling, then other recovery such as energy recovery, and last of all disposal.
The Waste (England and Wales) Regulations 2011 (WasteCare, 2011) apply the requirements for the waste hierarchy. Regulation 12 says that businesses that import or produce, collect, transport, recover or dispose of waste, or who operate as dealers and brokers, must take all reasonable measures to apply the waste hierarchy when the waste is transferred.
Also, if you hold or require an environmental permit for an operation that generates waste, you will have to comply with a permit condition concerning the application of the waste hierarchy. Waste Management Policy Approved by Senior Operational Group: 16 April 2014 Page 22 of 35 Re view date: September 2016
APPENDIX 4: PROCEDURES FOR REMOVING/HANDLING OF WASTE
1. All waste containers/receptacles will be clearly marked with the source of the waste.
2. All personal protection equipment provided for the task, as identified within risk assessments will be maintained and worn by the operative. Any defective equipment will be brought to the attention of the operative’s line manager.
3. When the waste sacks are two thirds full or not exceeding 11 kilos, twist the neck of the sack firmly, double it back to form a “swan neck”. Secure with the correct black numerical tag. The use of a black numerical tag ensures that the Trust maintains a clear and auditable waste trail in the event of investigations or incidents around clinical waste.
4. Sacks shall be held away from the body; they shall not be thrown or compressed within any containers
5. If a sack splits, place the split sack and contents inside another of a same colour.
6. Differing waste types, sacks and containerised must not be stored or transported together. This applies from the point of primary storage onwards.
7. Sharps containers, must be fully labelled and the aperture housing closed and locked. They should be stored in the waste disposal room on the Ward/department awaiting collection by the waste staff. They should not to be placed within sacks or on top of sacks. They will be moved by the handle and not by being clasped around the container body.
8. Waste collection staff are obliged to return the container for labelling if sacks or containers have not been labelled correctly, and an incident reported on Datix.
9. Sharps containers, when being transported, shall be placed in an upright position to prevent any loss of free liquid.
10. Any spillages noted before collection will be brought to the attention of manager for that area.
11. Only those containers and cages authorised for the transportation of waste shall be used. Any defects found shall be reported to the line manager for rectification.
12. All spillages in transportation, within the container or floor, will be promptly cleaned in accordance with the spillage procedure, which is part of the Decontamination Policy and procedures (unless it is a COSHH spill, which falls within the COSHH Policy).
13. Any incident or accident shall be brought to the attention of the line manager and Trust in accordance with the Trust Incident and Reporting Policy. (See Appendix 1)
14. Any containers/cages used in the movement of waste shall not be used for transportation of food, clean linen, etc.
15. All transportation containers used for the internal transport of waste shall be kept clean and must be pressured washed every 3 months or sooner if a spillage occurs. This will be undertaken/organised by the department who transfer the waste.
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16. Training
16.1 All staff required to handle and / or move waste must be adequately trained in safe procedures of dealing with all types of waste. The level of training will be dependent on the staff’s involvement with waste. Specific staff, i.e. general services, housekeeping, nurses, doctors, will require greater depths of training.
16.2 Employees required to handle clinical waste will be trained in:
Manual Handling Training Risks associated with clinical waste Waste segregation Spillages Accidents / incidents
16.3 Specific training for General Services (Waste) staff would include:
Clinical waste handling procedures Electric tow vehicle training (licensed) Procedure for dealing with mercury spillages
17. Personal Protective Equipment (PPE)
17.1 Staff involved in the collection of waste will wear personal protective clothing at all times.
17.2 Where personal protective equipment / clothing are provided, employees are obliged to wear it. Any damage / defects must be reported as soon as possible.
17.3 Waste Collections Staff whom handle waste constantly throughout their working day will be provided with:
Protective turtle skin gloves (anti needle stick) Ballistic trousers (anti needle stick) Safety shoes Polo shirts (green) Sweatshirt (green) Light weight jacket (green) Water proof clothing
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APPENDIX 5: CHARTS OF COMMON TYPES OF HEALTHCARE WASTE AND RECEPTACLES
CHARTS OF COMMON TYPES OF HEALTHCARE WASTE AND RECEPTACLES
SHEET 1 SACKED HEALTHCARE WASTE
SHEET 2 CHART OF (SHARPS) CONTAINERS FOR HEALTHCARE WASTE
SHEET 3 CHART OF OTHER CONTAINERS FOR HEALTHCARE RELATED WASTE
SHEET 4 SHEET 4 – CHART OF OTHER WASTE STREAMS ASSOCIATED WITH HEALTHCARE ACTIVITIES
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SHEET 1 – CHART OF SACKED HEALTHCARE WASTE APPENDIX 5
BLACK TIGER STRIPE (YELLOW/BLACK) ORANGE YELLOW PURPLE
Use Use Use Use Use General Household/municipal waste Offensive waste – does not meet the Low Risk Infectious waste (such as For Recognizable tissue, For the disposal of soft items including: Food Soiled newspaper, definition of infectious waste or MRSA, HIV, C. Diff) including items diagnostic specimens etc. which contaminated with Cytotoxic and flowers, including plastic drinks bottles possess any hazardous properties such as dressings, gloves, aprons and require incineration. Also Cytostatic medicinal products only and Tins. Any tin which has sharp edges but may cause offence due to plasters, contaminated with blood or chemically contaminated clinical and their residues, or items must be wrapped in newspaper, to presence of recognizable healthcare other bodily fluids and teeth without waste such as Pathology slides. contaminated by them. prevent injuries during transport, before waste items. fillings, empty blood sacks. being placed within the sack Used for: nappies, plaster casts, incontinence pads, stoma sacks, empty. Special notes Special notes Special notes Special notes Special notes Closure: secure a knot at top No infectious waste or waste Large metallic objects should not be This waste stream is NOT for Category Sharps waste must be placed in to a rigid contaminated with medicines placed within this waste stream. A infectious waste, as listed within sharps bin – soft waste only No anatomical waste or medicines Appendix 4 Closure: secure a knot at top or liquid waste Closure: secure a knot a top with Closure: secure a knot a top with Closure: secure a knot a top with numerical tag numerical tag numerical tag
Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Landfill/ materials reclamation Deep Landfill Alternative Treatment Incineration at 850⁰C Incineration at 1150⁰C EWC Code EWC Code EWC Code EWC Code EWC Code 20 01 01 18 01 04 18 01 03* 18 01 03* 18 01 03* & 18 01 09* Hazard code Hazard code Hazard code Hazard code Hazard code N/A N/A HP9 HP9 HP9
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SHEET 2 – CHART OF (SHARPS) CONTAINERS FOR HEALTHCARE WASTE APPENDIX 5
ORANGE LID YELLOW LID PURPLE LID BLUE LIDDED YELLOW BODY YELLOW YELLOW BODY YELLOW BODY BODY (Pharmi-bin)
Used for Used Used for Used for For the disposal of sharps, excluding Sharps waste contaminated with medifcorine s. For the disposal of partially or fully For the disposal of sharps Pharmacy Use Only those contaminated with any discharged sharps contaminated with medicinal products and their residues. contaminated with Cytotoxic and medicinal products and their Medicine Blister packs, Medicine Bottles Cytostatic medicinal products only residues. Phlebotomy Use Only No Cytotoxic and/or Cytostatic medicines and their residues, or items contaminated by them.
Special notes Special Special notes Special notes No pharmaceutical Do not inject flnouidst esinto bin or sewer. Extremely hazardous due to dermal Use rigid leak proof contaminated items to be Use granules to absorb any liquids. absorption. container if free liquid placed within this 5% free fluid maximum. content may be above 5% container. Treat needle and syringe as one unit. Closure: secure by closing lid (See Sheet 4, Appendix 5) Do not inject fluids into bin Do not dispose of or sewer. Closure: secure by closing lid medicines in sinks/sluices. Treat needle and syringe Closure: secure by closing lid as one unit. Closure: secure by closing lid Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Alternative Treatment, Incineration at 850⁰C Incineration at 1150⁰C Incineration at 850⁰C Non-Incineration EWC Code EWC EWC Code EWC Code 18 01 03* C18o de01 18 01 03* 18 01 09 03* 18 01 08* Hazard code H18az 0ard1 Hazard code Hazard code HP9 HP3, HP4c,o0 HP5,d9e HP9, HP6,HP7,HP9,HP10,HP11 HP4, HP14 HP14 Waste Management Policy Approved by Senior Operational Group: 16 April 2014 Page 27 of 35 Review date: September 2016
SHEET 3 – CHART OF CONTAINERS FOR HEALTHCARE RELATED WASTE APPENDIX 5
RED LIDDED YELLOW LID YELLOW PHARMACY PHARMACY DENTAL YELLOW YELLOW LIDDED PURPLE PACKAGING AMALGAM BODY BODY YELLOW LIDDED IV PRODUCTS RED LIDDED LEAK PROOF BODY YELLOW BODY
ANATOMICAL LEAK WASTE PROOF
Used for Used for Used for Used for Used for Used for For the disposal of placentas. Rigid 60ltr containers (Griff Rigid 30ltr containers (Griff Wiva For the disposal of cytotoxic Giving sets with IV’s Rigid screw top containers Limb bins) for the disposal of bin for the disposal of all IV fluid and Cytostatic medicines, tablets, Medicate & non medicated for the disposal of anatomical waste – recognizable sacks. medicine bottles, within Pharmacy IV’s Dental Amalgam & teeth human body parts, internal organs Whether pharmaceutically active or Pharmacy Use Only Blood Sacks containing Amalgam Large Syringes 50ml and body tissue or to prevent leakage not and other potentially infectious waste. Glass Medicine bottl’s Blister packs Pharmacy packaging
Special notes Special notes Special notes Special notes Special notes Special notes Label to be attached: Label to be attached: For All IV fluid sacks and To be disposed of with No sharp items Approved disposal Contact “ Anatomical waste for “ Anatomical waste for incineration” giving sets Cytotoxic sharps stream waste department for collection incineration” Not for specimens soaked in Closure: secure by tying when full Must be refrigerated before formaldehyde Closure: secure by closing lid Closure: secure by closing lid a knot in plastic sack and disposal. Closure: secure by closing lid folding cardboard into Closure: secure by place (forming a box) Closure: secure by closing lid closing lid Final Disposal Method Final Disposal Method Final Disposal Method Final Disposal Method Final Disposal Method Final Disposal Method Incineration at 850⁰C Incineration at 850⁰C Incineration at 850⁰C Incineration at 1150⁰C Incineration at 1150⁰C Recovery/Recycling EWC CODE EWC Code EWC Code EW1150C8 C50o⁰deC EWC Code 18 01 02 18 01 02 18 01 09 18 01 08* 18 01 09 18 01 10* 18 01 03* 18 01 03* Hazard code Hazards Code Hazard codes Hazard codes Hazard codes Hazard codes HP9 HP9 HP4, HP9, HP14 HP6,HP7,HP10,HP11 HP4,HP9,HP14 HP6 HP9
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SHEET 4 – CHART OF OTHER WASTE STREAMS ASSOCIATED WITH HEALTHCARE ACTIVITIES APPENDIX 5
WHITE PLASTIC CONFIDENTIAL WHITE PAPER SACK CLEAR CARDBOARD SACK
Used for Used for Used for Used for Confidential waste to be shredded within the Non-Confidential paper or locally Glass Bottles (non Pharmaceutical) Packaging material recycling area. shredded paper and broken Crockery Also used for other recycling Special notes Special notes Special notes Special Notes Sacked must be secured with tie- Paper Chain replenish & dispose of the paper To be flat packed by producer. wrap before internal transportation If contaminated by blood or infectious waste to be treated as “Clinical” See Appendix 10 & 11 Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Pulping and re-use Pulping and re-use Recycling if appropriate Recycling EWC Code EWC Code EWC Code EWC Code 20 01 01 20 01 01 20 01 01 if remerged with domestic 20 01 01 waste 20 01 99 if separate collect waste stream
Hazard code Hazard code Hazard code Hazard code NR NR NR NR
* Any waste marked with an asterisk (*) is considered to be a Hazardous waste and an Absolute entry on a consignment note
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APPENDIX 6: STANDARD COLOUR CODING SYSTEM ADOPTED BY THE TRUST
The Trust has adopted the unified colour coding system advocated within Safe Management of Healthcare Waste, to aid healthcare professionals to segregate the waste and as listed below:
This colour coding system has been standardized throughout the Trust for sacks and receptacles and is shown in: * Offensive / hygiene waste sacks will be introduced to the Trust in a staged approach, with each area being risk assessed for suitability Appendix 5 – Sheet 1 Chart of sacked healthcare waste. Appendix 5 – Sheet 2 to 4 Charts of (sharps) containers for healthcare waste
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APPENDIX 7: SEGREGATION FLOW CHART FOR HEALTHCARE WASTE
PURPLE LID
Is the waste sharp i.e. SHARPS WASTE Cytotoxic / cytostatic can it cause a cut or a YES contaminated sharps YELLOW LID
puncture wound? Scalpel / Razor Needles Stitch cutters Syringes and needle Medicinally contaminated must be disposed of as one Sharps (un-discharged / partially
NO unit discharged / fully discharged syringe) Broken glass ampoules
Infusion sets (the sharp part) YELLOW LID NO Is the waste a medicinal tablet, Is it a Cytotoxic medicine in a bottle etc., which YES or cytostatic is not required to be returned to medicine? YES PURPLE LID Pharmacy?
Offensive Waste
NO NO incontinence pads, catheter and stoma sacks, nappies, sanitary waste, nasal secretions, sputum, condoms, urine, vomit and soiled human bedding from a non-infectious source;
Is the waste INFECTIOUS WASTE Is the waste contaminated YES likely to pose a Dressings (heavily blood stained or from infected wounds) with a body fluid? risk of YES Any soiled waste from a patient in isolation in bedded areas infection? Any waste item soiled with an infected body fluid (i.e. continence pad from patient with a known UTI or infected diarrhoea) Used disposable instruments (non sharp)
NO
Is the waste contaminated with a disease Does the waste have to be incinerated causing pathogen included within category NO because it is recognizable e.g. limbs, A. anatomical waste etc.
RECYCLING DOMESTIC WASTE
YES Cardboard Paper towels YES Glass Packaging (no medical details) NO Plastics Food Waste Paper Flowers Metals Magazines Refer to: SEEK FURTHER HAZARDOUS INFECTIOUS Place in INFECTIOUS WASTE GUIDANCE FROM INFECTION yellow sack & rigid yellow bin OR Refer to Place in Orange sack CONTROL TEAM Local Pathology Policies
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APPENDIX 8: STORAGE OF WASTE ON SITE
STORAGE OF WASTE ON SITE
1. All bins in clinical areas should be lidded and foot or sensor operated and must be rigid sided, to reduce the risk of infection. All new bins purchased should be of a hands free type, for further information contact the procurement team on ext. 5412.
2. All waste within the organisational areas shall be stored in secure strategic locations away from food preparation and general storage areas, and from routes used by the public.
3. The external storage areas should be large enough to ensure that different types of waste can be stored separately i.e. domestic, offensive, infectious and sharps. This should be in separate steel containers, pallets, cages, trunks or wheelie bins. The area shall be well-lit and ventilated and sited on well drained, impervious hard standing. The employees will be provided with washing facilities and showering facilities.
4. The internal ward / department disposal rooms are the responsibility of each ward / department and are to be clean and tidy. They are to be well maintained, any faults or damages are to be reported to Estates, preferable by using the online tool or via the Hotline on Ext 3113.
5. The collection containers and areas will be kept secure from unauthorised persons and entry by animals and free from infestation by rodents and insects. The containers must be kept locked at all times, and wheeled containers must be kept secure. Keys will be kept by the Waste Manager and the operatives within the Waste Recycling area.
6. All clinical waste sacks must be sealed by swan necking and identified with the area location tape. Sacks shall be no more than two thirds full or 11 kilos in weight.
7. All sharps containers shall have the aperture housing closed and locked. All details on the container shall be completed regarding area, date closed off etc.
8. All rigid bins shall have the appropriate label attached indicating the nature of the waste and any associated hazards.
9. Bulk waste 770 litre containers (large yellow wheelie bins) must be kept secure and locked at all times when in use.
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APPENDIX 9: COMMUNICATION PLAN
COMMUNICATION PLAN
The following action plan will be enacted once the document has gone live.
Staff groups that need to have All staff knowledge of the strategy/policy
The key changes if a revised More waste streams. policy/strategy Colour coding changes in many areas.
The key objectives To make staff aware of all aspects of waste management.
How new staff will be made aware of Cascade by email from manager, induction the policy and manager action process
Specific Issues to be raised with staff All staff should be made aware of the policy/strategy. Particular attention should be drawn to the waste streams and colour coding.
Training available to staff Support available from O.S.U. Waste Management Department.
Any other requirements
Issues following Equality Impact No negative impacts. Assessment (if any)
Location of hard / electronic copy of Appendix of the policy/ procedural document on the document etc. the Trust intranet
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APPENDIX 10: EQUALITY IMPACT ASSESSMENT TOOL
Name of document Waste Management Policy
Division/Directorate and service area Operations Support Division / Trust Wide
Name, job title and contact details of Martin Conabeer person completing the assessment Facilities Operational Manager
Date completed: 27th July 2016
The purpose of this tool is to:
identify the equality issues related to a policy, procedure or strategy summarise the work done during the development of the document to reduce negative impacts or to maximise benefit highlight unresolved issues with the policy/procedure/strategy which cannot be removed but which will be monitored, and set out how this will be done.
1. What is the main purpose of this document? This policy ensures the Trust is committed to disposing of its waste streams in compliance with relevant legislation and good practice guidance documents. It also aims to minimize and prevent significant risks to the health and safety of its staff, patients, public, waste contractors and the environment when disposing of that waste
2. Who does it mainly affect?
Carers ☒ Staff ☒ Patients ☒ Other (please specify) Visitors / Environment
3. Who might the policy have a ‘differential’ effect on, considering the “protected characteristics” below? The policy is assessed as having a neutral impact on the protected characteristics below
Protected characteristic Relevant Not relevant
Age ☐ ☒
Disability ☐ ☒
Sex - including: Transgender, ☐ ☒
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and Pregnancy / Maternity
Race ☐ ☒
Religion / belief ☐ ☒
Sexual orientation – including: ☐ ☒ Marriage / Civil Partnership
4. Apart from those with protected characteristics, which other groups in society might this document be particularly relevant to… (e.g. those affected by homelessness, bariatric patients, end of life patients, those with carers etc.)?
None
5. Do you think the document meets our human rights obligations? ☒
Feel free to expand on any human rights considerations in question 6 below.
A quick guide to human rights: Fairness – how have you made sure it treat everyone justly? Respect – how have you made sure it respects everyone as a person? Equality – how does it give everyone an equal chance to get whatever it is offering? Dignity – have you made sure it treats everyone with dignity? Autonomy – Does it enable people to make decisions for themselves?
6. Looking back at questions 3, 4 and 5, can you summarise what has been done during the production of this document and your consultation process to support our equality / human rights / inclusion commitments? We are aware that people with the disability of colour blindness might have difficulty in discerning the colour of the disposal bags. We ensure, therefore, that bags have text on them, in as much as this is legally permissible, to indicate the type of waste to be placed in them and that, as of September 2016, the bins will have text on them, to indicate the types of waste which can be placed in them.
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