Annual Performance Evaluation for <<Year>>
Environment of Care (EC) Program:
Hazardous Materials and Waste
Reviewer:
Review Date:
<<Date>>
Review of Program Scope
The review of the scope is based on a comparison of actual operating experience to the program
intent. The scope defines the areas the program includes for management, and the kinds of
services provided.
SCOPE
The Hazardous Materials and Waste Management Program is designed to address the risks the
variety of substances addressed in this plan pose to the environment of <<Facility Name>> and to
the patients, staff, and visitors of the organization. The program is also designed to assure
compliance with applicable codes and regulations.
The program is applied to <<Facility Name>.
Evaluation:
No changes to the facilities served or the programs provided were made during the past years.
The scope still accurately reflects the intent of the program.
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Review of Program Objectives
Each management objective is listed in the following table. Each objective is marked as met or not met. If
an objective is not met, the appropriate EC program manager(s) review the objective to determine what
needs to be done to meet it during the next year. Objectives can be added, deleted, or modified. The
action required to address each change is indicated in the last column of the table.
Objectives
A. The processes used to select, transport, store,
use and dispose of hazardous materials, and to
separate, segregate, transport, store, package
and dispose of hazardous wastes are defined in
written procedures.
Met
√
The written criteria for
hazardous materials should
be reviewed to be current
by the new MSDS Vendor.
They will conduct a full
inventory during
<<Year>>.
√
D. Monitoring of gases and vapors, including:
formaldehyde, gluteraldehyde, waste anesthetic
gases, and ethylene oxide are performed at least
annually where used, and the results reported to
affected departments, and the EC Committee at
least annually
E. Inspections are conducted at least annually to
assure that areas used to store and handle
hazardous wastes have adequate space, are
separated from clean and sterile goods and
foodstuffs; and hazardous chemicals are stored
appropriately to their hazards.
Adjusted Objective /
Action Plan
√
B. Written criteria are used as part of the process
to identify and inventory hazardous chemical
materials; and are used to identify, evaluate and
define hazardous waste and waste handling
practices.
C. The Hazardous waste programs includes
 Chemical wastes
 Chemotherapeutic wastes, where present
 Radioactive wastes, where present
 Biohazardous wastes, and
 Sharps and other physical hazards
and each have been reviewed in the past
year.
Not Met
√
Monitoring was performed,
and the results will be
summarized for the Safety
Committee during
<<Year>>.
√
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F. Incidents involving spills, releases, and
exposures to hazardous chemicals and wastes
are reported, in aggregate, to the EC
Committee at least quarterly.
G. Staff who handle hazardous chemical materials
and/or hazardous wastes are trained about the
hazardous of the materials they handle,
protective methods, and responses to spills, and
exposures. Staff knowledge about personal
protection and procedures is conducted at least
quarterly, and reported to the EC Committee.
H. The performance monitor for hazardous
materials and waste is evaluated and reported
to the EC Committee at least quarterly.
I. Staff who may discover or be part of emergency
spills are provided with appropriate training to
recognize spills that may exceed the ability to
respond at that site, and their knowledge is
evaluated at least annually.
J. Annual evaluations are conducted of the scope,
and objectives of this plan, the effectiveness of
the programs defined, and the performance
indicators.
√
√
√
√
√
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Review of Performance
The review of performance evaluates the effectiveness of the current performance measures in providing
EC managers with information that can be used to adjust program activities to maintain performance or to
identify opportunities for improvement. The review also evaluates the effectiveness of any performance
improvement projects related to the program.
*
Current Performance Measure(s) (list)
1.
2.
*
Percentage of completed Air and gas testing and analysis in high risk areas
Percentage of eyewash stations tested
Summary of performance reports for the last 12 months. (Attach copies of reports):
Performance reports indicate:
1.
2.
100% completion for all air / gas testing
100% completion rate for all eyewash testing
1.
Performance is stable, sustainable, and acceptable: __√__
2.
Performance is stable, sustainable, and unacceptable: ____
3.
Performance is unstable:
Review of Program Effectiveness
Program effectiveness is evaluated by comparing the review of the program to current needs and stated
objectives of the program with measurements made related to stated performance measures.
Effectiveness is determined based on how well the scope fits current organizational needs and the degree
to which current performance met those stated objectives.
This program was generally considered to be fully effective.
Planning Objectives for <<Year>>
1.
Continue programs to reduce total amount of hazardous waste
2.
Improve recycling efforts
3.
Reevaluate current measures of performance to determine new indicators for <<Year>>
3.
Increase staff education safe handling of HAZMAT.
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