1. Region 2 Healthcare Compliance Initiative 1 Region 2's Healthcare Compliance Initiative: Environmental Results From An Integrated Strategy Leveraging Limited Resources To Obtain Better Compliance

2. Region 2 Healthcare Compliance Initiative2 Goals For Compliance Initiative Improve environmental compliance and safety at main and off-site healthcare facilities. Improve environmental compliance and safety at main and off-site healthcare facilities. Change the culture to one in which environmental compliance is a priority. Change the culture to one in which environmental compliance is a priority. Ensure compliance of entire sector; not just those reached through inspections. Ensure compliance of entire sector; not just those reached through inspections. Ensure continued compliance by implementing permanent changes. Ensure continued compliance by implementing permanent changes.

3. Region 2 Healthcare Compliance Initiative3Approach Region 2 combined the following strategies to address compliance issues in these sectors: Region 2 combined the following strategies to address compliance issues in these sectors: –Compliance assistance –Compliance incentives (voluntary audit/disclosure) –Compliance monitoring –Enforcement –Pollution prevention –Environmental management systems (EMS)

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5. 5 Results: Compliance Monitoring & Incentives Programs Hospitals Universe 480 Inspections 45 Enforcement Actions33 Formal Enforcement Actions10 ($1,523,613) Settlements8 ($642,612) Audit Agreements37 Voluntary Disclosures 129 covering 496 facilities ($12,648,521 for 68 resolved) Violations Corrected1100+

6. Region 2 Healthcare Compliance Initiative6 Results: Environmental Protection From Audits Hospitals Number of Beds 34,453 Number of Inpatients1,112,914 Number of Outpatients19.158,153 Number of Staff150,613

7. Region 2 Healthcare Compliance Initiative7 Results: Environmental Benefits ProgramEnvironmental Benefits from FY04 Disclosures RCRAMore than 42,576 lbs/year of hazardous waste is now being managed properly because hospitals have self-disclosed violations and corrected mismanagement. SPCCAt least 349,733 gallons of oil is now being managed properly. TSCAAt least 305 residential units now in compliance with lead-based paint rules. CAAAt least 153,850 pounds of chlorofluorocarbons now being appropriately managed.

8. Region 2 Healthcare Compliance Initiative8 Root Causes Of Noncompliance Systemic violations appear to stem from: Inadequate resources for people, equipment and training to carry out environmental activities; Inadequate resources for people, equipment and training to carry out environmental activities; Limited or no environmental compliance accountability for individual departments, laboratories, and staff; Limited or no environmental compliance accountability for individual departments, laboratories, and staff; Limited authority vested in environmental compliance officials; Limited authority vested in environmental compliance officials;

9. Region 2 Healthcare Compliance Initiative9 Root Causes Of Noncompliance No clear environmental compliance chain- of-command; No clear environmental compliance chain- of-command; Scattered, incomplete, and missing environmental compliance documentation; Scattered, incomplete, and missing environmental compliance documentation; Incomplete institutional knowledge regarding environmental regulatory requirements; and Incomplete institutional knowledge regarding environmental regulatory requirements; and Broad use of hazardous materials when effective substitutes exist Broad use of hazardous materials when effective substitutes exist

10. Region 2 Healthcare Compliance Initiative10 Healthcare Violations

11. Region 2 Healthcare Compliance Initiative11 Healthcare RCRA Violations

12. Region 2 Healthcare Compliance Initiative12 Common Hazardous Waste Violations Laboratories Laboratories Dental clinics Dental clinics X-rays units X-rays units Nuclear medicine areas Nuclear medicine areas Pharmacy Pharmacy Maintenance areas Maintenance areas Physical therapy Physical therapy Underground storage tanks Underground storage tanks Laundry Laundry Morgue Morgue Operating rooms Operating rooms Nursing units Nursing units Hazardous waste storage areas Hazardous waste storage areas Medical technology unit Medical technology unit Construction areas Construction areas Satellite accumulation points Satellite accumulation points

13. Region 2 Healthcare Compliance Initiative13 Healthcare CAA Violations

14. Region 2 Healthcare Compliance Initiative14 Healthcare CWA Violations

15. Region 2 Healthcare Compliance Initiative15 Healthcare TSCA Violations

16. Region 2 Healthcare Compliance Initiative16 Healthcare EPCRA Violations

17. Region 2 Healthcare Compliance Initiative17 Top 15 Violations From 68 Resolved Voluntary Disclosures RankViolationStatuteFrequency 1 ID of HW RCRA146 2 Universal Waste RCRA111 3LabelingRCRA80 4 SIP Requirements CAA61 5 CFC Leak Detection Records CAA58

18. Region 2 Healthcare Compliance Initiative18 Top 15 Violations From 68 Resolved Voluntary Disclosures RankViolationStatuteFrequency 6 Chemical Inventory EPCRA53 7SPCCCWA49 8 Container Management RCRA46 9ManifestsRCRA35 10 Personnel Training RCRA33

19. Region 2 Healthcare Compliance Initiative19 Top 15 Violations From 68 Resolved Voluntary Disclosures RankViolationStatuteFrequency 11 MSDS Records EPCRA31 12 CESQG Requirements RCRA27 13 Empty Containers RCRA24 14 Lead Paint Disclosure TSCA23 15 CFCs – Use Certified Technicians CAA22

20. Region 2 Healthcare Compliance Initiative20 Survey Overview 38 hospitals completed and returned the audit survey 38 hospitals completed and returned the audit survey 65,279 staff are reported to be working at these 38 hospitals 65,279 staff are reported to be working at these 38 hospitals 10,691 beds are reported to be within these 38 hospitals 10,691 beds are reported to be within these 38 hospitals 282 facilities are reported to compose these 38 hospitals 282 facilities are reported to compose these 38 hospitals

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26. Region 2 Healthcare Compliance Initiative26 Understanding Of Waste Management Regulations Before And After Compliance Initiative (24% - 92%)

27. Region 2 Healthcare Compliance Initiative27 Understanding Of Above Ground Storage Tank Regulations Before And After Compliance Initiative (9% - 75%)

28. Region 2 Healthcare Compliance Initiative28 Understanding Of Under Ground Storage Tank Regulations Before And After Compliance Initiative (34% - 88%)

29. Region 2 Healthcare Compliance Initiative29 Understanding Of Clean Air Act Regulations Before And After Compliance Initiative (27% - 76%)

30. Region 2 Healthcare Compliance Initiative30 Understanding Of Wastewater Discharge Regulations Before And After Compliance Initiative (24% - 70%)

31. Region 2 Healthcare Compliance Initiative31 Understanding Of Spill Prevention Control Countermeasure Plans Before And After Compliance Initiative (14% - 83%)

32. Region 2 Healthcare Compliance Initiative32 Understanding Of Toxic Substances Control Act Before And After Compliance Initiative (14% - 61)

33. Region 2 Healthcare Compliance Initiative33 Understanding Of Pesticide Regulations Before And After Compliance Initiative (36% - 76%)

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36. Region 2 Healthcare Compliance Initiative36 Top Five $ Saving Activities RMW management/segregation $350,000 Chemical, electronics, battery & HW recycling/exchange programs $250,000 Installed high-efficiency motors, up-graded light fixtures to t-8’s, and new electronic ballasts $136,000 Disposable RMW containers/bulb crushers $114,000 Changed to reusable sharps containers $30,000

37. Region 2 Healthcare Compliance Initiative37 Top Five Pollutant Reductions Battery Recycling 15 tons RMW Segregation 475 tons Electronics-EDP equipment recycling 75 tons Sharps containers 10,500 units Integrated pest management 80% reduction in pesticides

38. Region 2 Healthcare Compliance Initiative38 Five Simple Waste Reduction Activities Five Simple Waste Reduction Activities Install automatic light sensors Install automatic light sensors Install water saver plumbing fixtures Install water saver plumbing fixtures Send kitchen grease to a reclamation facility Send kitchen grease to a reclamation facility Switch from disposable to reusable plates, eating utensils, and cups for cafeteria services Switch from disposable to reusable plates, eating utensils, and cups for cafeteria services Reduce the use of disposable cleaning materials Reduce the use of disposable cleaning materials

39. Region 2 Healthcare Compliance Initiative39 Most Common Mercury Reduction Activities Upgraded light fixtures to t-8’s and installed new electronic ballasts Upgraded light fixtures to t-8’s and installed new electronic ballasts Replaced mercury monometers & thermometers Replaced mercury monometers & thermometers Implemented computer monitor and electronics recycling program Implemented computer monitor and electronics recycling program Collected and recycled amalgam at dentist and silver reclaimer installed at cancer treatment center Collected and recycled amalgam at dentist and silver reclaimer installed at cancer treatment center Initiated a hospital-wide mercury reduction and recycling program Initiated a hospital-wide mercury reduction and recycling program

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52. Region 2 Healthcare Compliance Initiative52 Reported Hospital Audit Costs Average cost of audit is approximately $10,200 Average cost of audit is approximately $10,200 Average cost of compliance is approximately $29,300 Average cost of compliance is approximately $29,300 Average cost of compliance without two most expensive (>$100,000) is approximately $16,600 Average cost of compliance without two most expensive (>$100,000) is approximately $16,600

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59. Region 2 Healthcare Compliance Initiative59 Goals For Compliance Initiative Improve environmental compliance and safety at main and off-site healthcare facilities. Improve environmental compliance and safety at main and off-site healthcare facilities. Change the culture to one in which environmental compliance is a priority. Change the culture to one in which environmental compliance is a priority. Ensure compliance of entire sector; not just those reached through inspections. Ensure compliance of entire sector; not just those reached through inspections. Ensure continued compliance by implementing permanent changes. Ensure continued compliance by implementing permanent changes.