1. MODULE 5: HCWM Planning in a Healthcare Facility
The training modules are part of the United Nations Development Programme-supported, Global Environment Facility-funded Project on Healthcare Waste, in cooperation with the World Health Organization and Health Care Without Harm. The modules were completed in 2012 by Preethi Pratap, PhD, and Leslie Nickels, PhD, of the University of Illinois at Chicago School of Public Health, and Jorge Emmanuel, PhD, Chief Technical Advisor of the UNDP GEF Project, with input from Yves Chartier (WHO), Mohammad-Ali Hamandi, MPH, Ashley Iwanaga, MPH, Glenn McRae, PhD, Megha Rathi, PhD, Ruth Stringer (Health Care Without Harm), and Emily Warren, MSES.
This module may be used as a resource to improve healthcare waste management. The module is copyrighted but may be reproduced in its original unaltered form without permission for advocacy, campaigning and teaching purposes. Reproduction and distribution for commercial resale is strictly prohibited. UNDP GEF does not warrant that the information contained in this document is complete and correct and shall not be liable for any damages incurred as a result of its use.

2. Module Overview
Describe the principles and framework for management of healthcare waste
Describe the steps for developing a waste management plan
Identify key members of a waste management team and their associated tasks
Describe how to conduct a healthcare waste assessment in your facility
Discuss potential obstacles to implementing a healthcare waste management plan and how to overcome them
Instructor:
Unlike Module 4 which deals on national waste management planning, Module 5 focuses on local/hospital/facility-based waste management planning.
Resources:
Chapter 5 of Blue Book

3. Learning Objectives List the steps for developing a HCWM Plan
Understand how to conduct a waste assessment
Describe the contents of a HCWM Plan
List the responsibilities of key members of a HCWM team
Describe some tools used in HCWM planning
Identify barriers to implementing an effective healthcare waste management system and strategies to overcome them

4. General Principles
Planning for HCWM at the facility level should take into consideration the World Health Organization (WHO) core principles for achieving safe and sustainable management of healthcare waste
The right investment of resources will result in a substantive reduction of disease and corresponding savings in health expenditures
Planning for health care waste management at national, regional and local levels should take into consideration the WHO core principles for achieving safe and sustainable management of health care waste. The core principles state that the right investment of resources and commitment will result in a substantive reduction of disease burden and corresponding savings in health expenditures. The core principles provide guidance on a clear delineation of responsibilities and funding which takes place chiefly at the planning stage, and are attached as an annex to this guideline.
Planning for health care waste management at national, regional and local levels should cover the six objectives (reference preparation of national health care waste management plans in sub-Saharan countries, WHO/Basel convention/UNEP, 2005) that are listed below. As HCWM is an evolving field, planning should allow for periodic updates to policies, practices, improved packaging and technology as it becomes available:
Develop the legal and regulatory framework for HCWM
Rationalize the HCWM practices within health care facilities
Develop specific financial investment and operation resources dedicated to HCWM
Launch capacity building and training measures
Set up monitoring plan
Reduce the pollution associated to HCWM.

5. General Principles
The effective management of health care waste depends on:
good administration and organization
adequate legislation and financing
active participation by trained and informed staff
Monitoring and continuous improvement
The end result is to :
decrease the burden of disease
reduce the pollution associated with healthcare waste and its attendant effects on healthcare workers and the community
The trainer presents the step
The effective management of health care waste with the aim to control infections depends on good administration and organization. It also requires adequate legislation and financing, active participation by trained and informed staff.
for developing a facility HCWM plan, bringing together all the concepts presented in the course so far.

6. Framework for the Management of Healthcare Waste
HCWM is inextricably linked to infection control & prevention, occupational health & safety, patient safety, and environmental protection.
National and local laws and regulations establish minimum requirements for HCWM; international laws and standards complement national and local laws.
HCWM plans are roadmaps towards creating and sustaining good HCWM systems in healthcare facilities.
Participatory planning promotes stakeholder ownership.
Funding and human resources allocated to HCWM are essential for sustainability.
Commitment by the administration, fostering environmental champions among staff, and capacity building can bring success.
Planning is an adaptive process with periodic review and updating.

7. Planning is an Evolving and Adaptive Process
Leadership
Policy & Guidelines
Human Resources
Financial Resources
Capacity Building
Networks & Partnerships
Evaluation
Planning
Implemen-
tation
Monitoring

8. Preparing for HCWM Planning
Obtain top-level administrative support
Rationale include regulatory compliance, cost reduction, worker safety, patient safety, enhanced infection control, community relations
Form a HCWM planning committee
Representation from management, heads of departments generating waste, medical and nursing officers, infection control officer, safety officer
Other key members: training coordinator, purchasing manager, head of facility engineering, housekeeping manager, head of central sterile supply

9. Preparing for HCWM Planning
Review regulatory requirements and existing standards
Become knowledgeable about applicable national and local laws and regulations, accreditation requirements, and standards on waste management, worker safety, environmental pollution, etc.
Be aware of any applicable international laws and guidelines
Be familiar with WHO policies and recommendations on HCWM and related issues such as infection control
Establish the committee’s mission, goals and specific objectives

10. Steps for Developing a HCWM Plan
Establish the baseline
Develop detailed mapping of waste flows in the healthcare facility
Conduct a waste assessment
Data collection for a period of a few days provides limited information and may not reflect accurately weekly or seasonal variations. Data collection for a month or longer and repeated at different times in the year provide a more accurate picture and a better understanding of the quantities of waste generated in individual parts of a facility. For waste minimization, a breakdown of the amounts of recyclable materials is needed. In addition to calculating average rates, information regarding the spread of the data (data range or standard deviation) is important. Instructions to data collectors should include worker safety, such as using personal protection equipment (PPE) and avoiding physical contact with infectious items.

11. Example of a Waste Flow Map
Ward 1
Stairs
Reception
Medical Records
X-ray
Pharmacy
Cafeteria & Kitchen
Outpatient Department
Waiting Area
Waste Storage
Infectious
Entrance
Chemical
Infectious Waste
Chemical Waste
Regular Waste
GROUND FLOOR

12. Conducting a Healthcare Waste Assessment
Examples of data obtained during a healthcare waste assessment:
Basic facility data
Rapid assessment score (using the I-RAT tool)
Information on waste management practices
Waste generation
Waste generation rates per department
Breakdown of waste generation according to classification
Evaluation of the levels of segregation
Average waste generation rate (kilograms per bed per day) and average bulk densities (kg per liter)
Inventory of containers, sizes and locations; collection frequency and routing
Information on HCWM training
Occupational safety data
Cost data on HCWM
Estimate of dioxin releases (for facilities using incinerators) and mercury usage data
Trainer/Participant Activities
The trainer presents the fundamentals and tools for conducting a healthcare waste assessment.
1. 0 Basic facility data: any general information that relates to healthcare waste, such as if the facility is a small health station or a tertiary care medical center. Examples of “hospital services offered” are pediatrics, maternity, surgery, pharmacy, laboratory, radiology, emergency services, etc. The “types of hospitals” are private or public (government-run); and for-profit or non-profit. The “levels of hospitals” can be urban or rural; national/central, provincial, district, city, primary health station, etc. Attach copies of any existing hospital policies related to healthcare waste management.
2.0 Baseline rapid assessment: Use the Individualized Rapid Assessment Tool (I-RAT) to obtain a final score for the model facility. Follow the instructions found in the I-RAT.
3.0 Information on waste management practices: This section lists the baseline data needed on procurement, hospital inventory control, waste management equipment, placement of waste containers, storage areas, segregation practices, labeling, color-coding, signage and educational posters, collection and internal transport, external transport, treatment technology, final disposal, waste spill response, and chemical waste management. Keep in mind that the purpose of this data is to set an initial reference point for comparison at a later time. In some cases, data obtained using the I-RAT can be copied into this section.   
4.0 Waste generation data: An important part of the baseline assessment is obtaining waste generation data. A one-month waste assessment should be conducted.
5.0 Information on training: The baseline assessment focuses on three main issues: training policy, training content and methodology, and how many personnel were trained.
6.0 Occupational safety data: The baseline assessment on occupational safety and health focuses on policy, training, personal protection equipment, vaccinations, post-exposure prophylaxis procedures, blood-borne pathogen exposure and needle-stick injury related to healthcare waste, nosocomial infections and infection control.
7.0 Cost data: track the costs associated with healthcare waste management for the next three years. During the baseline assessment period, obtain (1) capital and operating costs associated with treatment and disposal, including any on-site treatment system; (2) one-time costs for capital equipment purchased in the last year; and (3) a monthly breakdown of all recurrent (operating) costs for the last 12 months or the last fiscal year.
8.0 Dioxin estimation
9.0 Mercury usage: focuses on annual past purchases of mercury thermometers and sphygmomanometers (blood pressure devices), spill clean-up and disposal procedures, and other sources of mercury. For facilities that still use mercury thermometers and sphygmomanometers, a one-month assessment of breakage and costs of mercury thermometers and sphygmomanometers is also required.

13. Sample Sheet for Waste Generation Assessment
From the WHO Blue Book: Chapter 5 Table 5.1 Adapted from Christen (1996),
bInfectious waste, pathological waste, sharps, pharmaceutical waste, cytotoxic waste, waste with
high heavy-metal content, radioactive waste.
or use the WHO assessment tool:

14. Conducting a Healthcare Waste Assessment
A baseline provides information on the initial condition of the facility to:
determine what best practices and techniques should be introduced
develop and monitor performance indicators
be used as the initial reference point
be used as a starting point for future assessments
be used as a basis for future evaluations
collect written and photographic documentation
decide what technologies should be used
decide what waste storage and treatment capacity is needed
In order to develop a waste management plan, the waste management team needs to make an assessment of all waste generated in the hospital.
To determine what best practices and techniques should be introduced to the facility;
To develop performance indicators and compare with existing national or international indicators and averages;
To be used as the initial reference point for later ascertaining and quantifying waste reduction, changes in waste management practices and techniques, decreases in dioxin and mercury releases, training improvements, improved occupational safety, cost-effectiveness, and cost savings, if any;
To be used as a starting point for future assessments of whether or not goals are being met, milestones are being reached in keeping with the timeline, and other indicators to gauge progress;
To be used as a basis for future evaluations of the success or shortcomings of the model facility component of the project;
To collect written and photographic documentation that can be used for developing tools and educational materials;
To compile data for technical and academic publications.

15. Steps for Developing a HCWM Plan
Review the baseline data
Identify problems in HCWM practices
Consider practices in training, segregation, handling of sharps, waste collection, transport, storage, cleaning of bins and storage areas, spill response, etc.
Identify problems in HCWM equipment
Consider the size, quantity and quality of bins, sharps containers, and carts; container colors and markings; treatment technology; availability and condition of PPE; transport vehicles; etc.

16. Steps for Developing a HCWM Plan
Prioritize issues and targets for improvement
Priorities should be based on stated goals and objectives.
Management of sharps, blood & body fluids, and lab culture waste is generally a high priority.
Worker protection and waste minimization are also important priorities.

17. Steps for Developing a HCWM Plan
Establish proper HCWM practices
Develop a set of written procedures based on existing regulations, WHO guidelines and international standards for best practices
Review technology options, conduct technical and economic evaluations, and select technologies
A technical evaluation determines if a proposed option meets minimum standards and will work for the specific application.
An economic evaluation looks at investment and operating costs of proposed equipment and determines the most cost-effective option.

18. Steps for Developing a HCWM Plan
Employ a participatory approach to HCWM planning
Organize consultation meetings with the staff of each department and other stakeholders (waste workers, cleaners, outside waste collectors, municipal officials, etc.)
Raise awareness about the need for good HCWM and generate interest and participation in the planning process
Ask for their input on proposed new practices and technologies
Obtain information on the steps, resources and time needed to transition to the proposed waste management system
Identify potential environmental champions and members of a HCWM organization from among the staff of each department

19. Steps for Developing a HCWM Plan
Draft the HCWM Plan – contents:
Rationale for HCWM
Review of the present situation and data from the waste assessment
HCWM organization
Organizational structure
Roles and responsibilities of managers and staff
Linkages with infection control, safety, quality and other committees

20. Typical Waste Management Structure
Officer
(WMO)
Head of Hospital
Hospital attendants, ancillary workers and waste handlers
Support Staff
Ward sisters, nurses and medical assistants
Department Heads
Medical and Dental
Engineering
Pharmacy
Radiology
Laboratory
Blood Bank
Catering
Housekeeping
Internal transportation system
Administration
Finance
Hospital Engineer
Head of Environmental Services
Advisors
Infection control
Pharmaceutical
Matron and Hospital Manager
Liaison paths
Line management paths
Instructor:
Based on the country specific status, please focus on what structure works in your setting. Many countries have one or two of these positions and people wearing multiple hats. This is an ideal team…..what works in your country should be encouraged.
Ask participants what the structure is in their facility?

21. Waste Management Team Typical members of the Waste Management Team
Head of Hospital
Heads of Hospital Departments
Infection Control Officer
Chief Pharmacist
Radiation Officer
Matron/Senior Nursing Officer
Housekeeping In-charge
Hospital Manager
Hospital Engineer
Supplies officer: supply chain management
Financial Controller
Waste Management Officer and
waste management handlers
The individual responsibilities of members of the waste management team will be covered in the next series of slides. Instructors are encouraged to first focus on the WMT structure in the facility. Remember very often one person may wear many hats and have multiple responsibilities.
Responsibilities
1. Definitions of responsibilities, duties, and codes of practice for each of the different
categories of personnel of the hospital who, through their daily work, will generate waste
and be involved in the segregation, storage, and handling of the waste.
2. A definition of the responsibilities of hospital attendants and ancillary staff in collecting
and handling wastes, for each ward and department; where special practices are required,
e.g. for radioactive waste or hazardous chemical waste, the stage at which attendants or
ancillary staff become involved in waste handling shall be clearly defined.

22. Roles and Responsibilities
Head of Hospital or Establishment
Formalizes the waste management team
Works with the team to develop the waste management plan
Designates the waste management officer (WMO)
Allocates financial resources and manpower
Ensures monitoring procedures are followed
Ensures adequate training of key staff
Ensures that agreed practices are carried out and practices are corrected
Ensures safety of staff through vaccination, PPE, access to hand-washing facilities for staff
Head of Hospital
The Head of Hospital is responsible for the following tasks:
Forming a waste management team to develop a written waste management plan for the hospital. The team should consist of representatives from clinical and non clinical areas of the organization in addition to those who are involved in the removal and management of waste.
The plan should clearly define the duties and responsibilities of all members of staff, both clinical and non-clinical, in respect of the handling of health care waste, and establish lines of accountability.
Development of waste management plan.
Designating a WMO to supervise and coordinate the waste
management plan. The Head of Hospital retains overall responsibility for ensuring that health care and other wastes are disposed of in accordance with national guidelines.
Keeping the management plan up to date by setting regular review dates.
Allocating sufficient financial and personnel resources to ensure efficient operation of the plan. For example, sufficient staff should be assigned to the Waste Management Officer to ensure efficient operation of the waste management plan.
Ensuring that monitoring procedures are incorporated in the plan. The efficiency and
effectiveness of the treatment and disposal system should be monitored so that the system can be updated and improved when necessary. Any changes should be incorporated in to the reviewed management plan.
Immediately appointing a successor in the event of personnel leaving key positions in the waste management team (or temporarily assigning responsibility to another staff member until a successor can be appointed).
Ensuring adequate training for key staff members and designating the staff responsible for
coordinating and implementing training courses.

23. Roles and Responsibilities
Waste Management Officer
Has overall responsibilities for:
development of the HCWM Plan
subsequent day-to-day operation and monitoring of the HCWM system
incident management and control
HCWM training
This waste management officer may be the infection control officer/nurse or the hospital facility engineer.
Waste Management Officer (WMO)
The WMO is responsible for the day-to-day operation and monitoring of the waste management system. It is therefore essential that he or she has direct access to all members of the hospital staff (see slide 20). The WMO is directly responsible to the Head of Hospital. He or she should liaise with the Infection Control Officer, the Chief Pharmacist, and the Radiation Officer in order to become familiar with the correct procedures for handling and disposing of pathological, pharmaceutical, chemical, and radioactive wastes.
In the area of waste collection, the WMO should:
-control internal collection of waste containers and their transport to the central waste storage;
facility of the hospital on a daily basis;
liaise with the Supplies Department to ensure that an appropriate range of bags and containers for health care waste, protective clothing, and collection trolleys are available at all times;
ensure that hospital attendants and ancillary staff immediately replace used bags and containers with the correct new bags or containers;
directly supervise hospital attendants, ancillary workers and waste handlers assigned to collect and transport health care waste.
Concerning waste storage, the WMO should:
ensure the correct use of the central storage facility for health care waste, which should be kept locked but should always be accessible to authorized hospital staff;
prevent all unsupervised dumping of waste on the hospital grounds.
To supervise collection and disposal of the waste, the WMO should:
coordinate and monitor all waste disposal operations;
monitor methods of transportation of wastes both on- and off-site and ensure that wastes;
collected from the hospital are transported by an appropriate vehicle to the designated treatment and disposal site;
ensure that waste is not stored for longer than specified in the guidelines and that the transport organization (which may be the local authority or a private contractor) collects the waste with the required frequency.
For staff training and information, the WMO should:
liaise with the Matron (or Senior Nursing Officer) and the Hospital Manager to ensure that the nursing staff and medical assistants are aware of their own responsibilities for segregation and storage of waste and the correct closing and sealing of bags and containers and that the responsibilities of hospital attendants and ancillary staff are limited to the handling and transport of sealed waste bags and containers;
liaise with Department Heads to ensure that all doctors and other qualified clinical staff are aware of their own responsibilities regarding segregation and storage of waste the correct closing and sealing of bags and containers and that the responsibilities of hospital attendants and ancillary staff are limited to the handling and transport of sealed bags and containers;
ensure that hospital attendants and ancillary staff are not involved in waste segregation and that they handle only waste bags and containers that have been sealed in the correct manner;
ensure that waste handlers are properly trained, that refresher training in waste collection, treatment and safe and sufficient disposal methods, including how to operate and maintain machines and technology, is provided on a routine basis;
ensure compliance with occupational health measures including current practices for Post Exposure Prophylaxis (PEP) as well as the provision and use of well working personal protection equipment (PPE) for health workers and waste handlers.
For incident management and control the WMO should:
ensure that written emergency and contingency procedures are available, that they are in place at all times, and that personnel are aware of the action to be taken in the event of an emergency;
investigate and review any reported incidents concerning the handling of health care waste (in liason with the Infectious Control Department).
In addition, the WMO should continuously monitor certain parameters (listed in Box 5.1 of the Blue Book).

24. Roles and Responsibilities
Department Heads:
Responsible for segregation, storage, and disposal of waste generated in their departments
Matron and Hospital Manager:
Responsible for training nurses, medical assistants, and other ancillary staff in the correct procedures for HCWM
Department Heads
Department Heads are responsible for the segregation, storage, and disposal of waste generated in their departments. They should:
ensure that all doctors, nurses, and clinical and non-clinical professional staff in their departments are aware of the segregation, sealing and storage procedures and that all personnel comply with the highest standards;
encourage medical and nursing staff to be vigilant so as to ensure that hospital attendants and ancillary staff follow correct procedures at all times.
ensure that key staff members in their departments are given training in waste segregation and disposal procedures;
continuously liaise with the WMO to monitor working practices for failures or mistakes;
Matron and Hospital Manager
The Matron (or Senior Nursing Officer) and the Hospital Manager are responsible for training nursing staff, medical assistants, hospital attendants, and ancillary staff in the correct procedures for segregation, sealing, storage, transport, and disposal of waste. They should therefore:
liaise with Department Heads to ensure coordination of training activities, other waste management issues specific to particular departments, etc.
participate in staff introduction to, and continuous training in, the handling and treatment and disposal of health care waste;
liaise with the WMO and the advisers (Infection Control Officer, Chief Pharmacist, and Radiation Officer) to maintain the highest standards;

25. Roles and Responsibilities
Chief Pharmacist/Radiation Officer:
responsible for safe management of pharmaceutical stores, cytotoxic agents and waste minimization
radiation officer duties are specific to radioactive wastes
Supply Officer:
liaises with the WMO to ensure continuous supply of required items
Hospital Engineer:
installs and maintains waste storage facilities and handling equipment that comply with specifications of national guidelines
Chief Pharmacist
The Chief Pharmacist is responsible for the sound management of pharmaceutical stores and for pharmaceutical waste minimization. His or her duties are to:
liaise with Department Heads, the WMO, the Matron, and the Hospital Manager, giving advice,
in accordance with the national policy and guidelines, on the appropriate procedures for pharmaceutical waste treatment and disposal;
coordinate continuous monitoring of procedures for the treatment and disposal of pharmaceutical waste;
ensure that personnel involved in pharmaceutical waste handling and treatment and disposal receive adequate training;
stay current on the proper treatment and safe disposal of expired, damaged and unusable pharmaceuticals, pharmaceutical packaging and equipment.
The Chief Pharmacist also has the special responsibility of ensuring the safe utilization of genotoxic products and the safe management of genotoxic waste.
Radiation Officer
The duties and responsibilities of the Radiation Officer are the same as those of the Pharmaceutical Officer but relate to radioactive waste. There may also be additional regulation regarding the storage of radioactive wastes on site. These regulations need to be adhered to for the safety of those handling the wastes.
Supply Officer
The Supply Officer should liaise with the WMO to ensure a continuous supply of the items required for waste management (plastic bags and containers of the right quality, spare parts for on-site health care waste treatment equipment, etc.). These items should be ordered in good time to ensure that they are always available, but accumulation of excessive stores should be avoided. The Supply Officer should also investigate the possibility of purchasing environmentally friendly products (e.g. PVC-free plastic items).
Hospital Engineer
The Hospital Engineer is responsible for installing and maintaining waste storage facilities and handling equipment that comply with the specifications of the national guidelines. She or he is also accountable for the adequate operation and maintenance of any on-site waste treatment equipment and is responsible for the staff involved in waste treatment, ensuring that:
staff receive training in the principles of waste disposal and are aware of their responsibilities under the hospital waste management plan;
staff operating on-site waste treatment facilities are trained in their operation and maintenance.

26. Roles and Responsibilities
Infection Control Officer:
- liaise with the waste management officer on a continuous basis and advise on the control of infection and standards as they relate to waste treatment and disposal
Infection Control Officer
The Infection Control Officer should liaise with the WMO on a continuous basis and provide advice concerning the control of infection and the standards of the waste treatment and disposal system. His or her duties are to:
identify training requirements according to staff grade and occupation;
organize and supervise staff training courses on safe waste management;
liaise with the Department Heads, the Matron, and the Hospital Manager to coordinate the
training.
The Infection Control Officer also has overall responsibility for chemical disinfection, sound management of chemical stores, and chemical waste minimization.

27. Steps for Developing a HCWM Plan
Draft the HCWM Plan – contents (cont’d):
Describe the new practices, including
Flowchart for waste segregation
Procedures for handling, storage, transport, etc.
Monitoring procedures for segregation of waste categories and their destinations
Emergency procedures
Procedures and practices
1. Simple diagram (flow chart) showing procedure for waste segregation.
2. The procedures for segregation, storage, and handling of wastes requiring special
arrangements, such as autoclaving.
3. Outline of monitoring procedures for waste categories and their destination.
4. Contingency plans, containing instructions on storage or evacuation of health care waste in
case of breakdown of the treatment unit or during closure down for planned maintenance.
5. Emergency procedures.

28. Steps for Developing a HCWM Plan
Draft the HCWM Plan – contents (cont’d):
Describe the new technologies, including
Drawings showing locations of containers, storage areas, and collection routes/timetable
Design specifications (types of bags, bins, trolleys, sharps containers, etc.)
Information on the treatment technology and preventive maintenance schedules
Material and human resources required by the technologies (numbers needed, number of personnel needed)
Create a program with defined objectives, a timeline, achievable outcomes and measurable indicators for a HCWM program
Details for inclusion in the waste management plan
Location and organization of collection and storage facilities
1. Drawings of the establishment showing designated bag or disposal container for every
ward and department in the hospital; disposal container shall be appropriately designated for health care waste or other waste.
2. Drawings showing the central storage site for health care waste and the separate site for
other waste. Details of the type of containers, security equipment, and arrangements for
washing and disinfecting waste-collection trolleys (or other transport devices) should be
specified. The document should also address eventual needs for refrigerated storage
facilities.
3. Drawings showing the paths of waste-collection trolleys through the hospital, with clearly
marked individual collection routes.
4. A collection timetable for each trolley route, the type of waste to be collected, the number of
wards and departments to be visited on one round. The central storage point in the
facility for that particular waste should be identified.
Design specifications
1. Drawings showing the type of bag holder to be used in the wards and departments.
2. Drawings showing the type of trolley or wheeled container to be used for bag collection.
3. Drawings of sharps containers, with their specification.
Required material and human resources
1. An estimate of the number and cost of bag holders and collection trolleys.
2. An estimate of the number of sharps containers and health care waste drum containers
required annually, categorized into different sizes if appropriate.
3. An estimate of the number and cost of colour-coded bags or bins to be used annually.
4. An estimate of the number of personnel required for waste collection.

29. Steps for Developing a HCWM Plan
Draft the HCWM Plan – contents (cont’d):
Describe plan for waste minimization
Waste prevention
Source reduction
Reuse
Recycling
Composting
Biodigestion
Energy recovery

30. Steps for Developing a HCWM Plan
Draft the HCWM Plan – contents (cont’d):
Training plan
Mandatory requirements, course topics, refresher training, documentation/certification, evaluation
Worker health & safety plan
Contingency plan for spills, equipment breakdown, technology maintenance downtime, and emergencies
Capital, operating and maintenance costs of HCWM equipment and treatment technology
Training: Training courses and programmes.

31. Steps for Developing a HCWM Plan
Draft the HCWM Plan – contents (cont’d):
Detailed roadmap for achieving the goals and objectives
Subdivide the work into manageable components
Define the scope and achievable outcomes of each component
List activities for each component, as well as sequencing and estimated duration of activities (timeline), required human resources, budget, measurable indicators, and persons responsible for implementation and/or supervision of each component
Clearly define the measurable indicators of achievement

32. Steps for Developing a HCWM Plan
Draft the HCWM Plan – contents (cont’d):
System of regular monitoring and evaluation
Provisions for documentation, record-keeping, and reporting
Periodic review and updating of the HCWM Plan

33. Steps for Developing a HCWM Plan
Other considerations when developing the HCWM plan
Take into account future growth and expansion of the facility
Evaluate the effectiveness of existing measures, costs or cost savings of added measures, environmental & energy impacts
Conduct an assessment of reusables vs. disposables to reduce waste without compromising the patient safety
Consider environmentally friendly, state-of-the-art, non- incineration treatment technologies
Consider an incentives program, such as awards for the most improved department, recognition of environmental champions, pay bonuses, educational credits, career development, etc.
Instructor please note: Not all plans and teams look the same. We are only presenting the ideal situation here. Most facilities and countries work with limited resources. Therefore, this is a chance to appreciate the system they have in place and help them think through how they can enhance their program, or at least build a basic program.
Use the GEF model hospital policy document. It is easier for hospitals to start with this and make amends where necessary.

34. Tools for HCWM Planning
Use activity timelines (e.g., Gantt chart)

35. Tools for HCWM Planning
Track expenditures and control costs
Planning
Work authorization and release
Cost data collection and reporting
Cost accounting
Management reporting
The top figure shows different phases of a typical management cost and control system. The table gives an example of a cost account variance analysis used by cost account manager.

36. Tools for HCWM Planning
Strategies to address organizational problems that hinder implementation
Process strategies
Team building, sensitivity training, conflict resolution, leadership modeling, mentoring, effective facilitation and communication strategies
Structural strategies
Job enrichment, benchmarking and performance management, reward systems, organizational restructuring

37. Parameters to be Monitored by the Waste Management Officer
Waste generated each month by waste category in each department
Maintenance of the treatment technology
Waste handled safely and in accordance with the safety operation procedures:
Occupational safety (e.g. use of PPE)
Proper segregation at source
Availability and use of bags, containers, bins and other equipment
Marking, labeling and signage
Internal transport and storage
Treatment and disposal
Parameters should be continuously monitored by WMO

38. Parameters to be Monitored by the Waste Management Officer
Financial aspects of healthcare waste management:
direct costs of supplies and materials used for collection, transport, storage, treatment, disposal, decontamination, and cleaning;
training costs (labor and material);
costs of operation and maintenance of on-site treatment facilities; costs for contractor services
Occupational safety and public health aspects:
Incidents resulting in injury, “near misses”, or failures in the handling, separation, storage, transport, or disposal system – these should be reported to the Infection Control Officer and the Waste Management Officer, and will be the basis for measures to prevent recurrences.

39. Reporting Once the HCWM system is put in place:
The Waste Management Team reviews the HCWM Plan annually and initiates changes necessary to upgrade the system
The Waste Management Officer prepares an annual report approved by the head of the hospital and submits the report to the government agency responsible for healthcare wastes
Annual report should include data on waste generation and disposal, personnel and equipment requirements, and so on

40. Potential Obstacles
Lack of knowledge at the individual and establishment level
Lack of top management commitment
Lack of national policy
Healthcare staff unaware of health and safety risks
Unaware of environmental and public health risks
No one assigned responsibility for healthcare waste
Lack of budget for implementation
Begin small and expand
Instructor: Discuss solutions to these potential obstacles. This will help participants in their exercise as well.
Awareness of legislation and laws
Training of staff and public
Management buy-in: costing calculators
Identify responsible team and members

41. Is your HCWM plan working?
Revised objectives?
introduce segregation practices in all departments in the next year
Level of consistency and coordination throughout hospital/all departments
Cost-effectiveness
Key leaders, administration, clinician support
Managed effectively- monitoring data
Changes in staffing, disposal policies, to meet new goals?
Meet all regulatory requirements?
Sufficient, periodic and ongoing education and training of all staff?
Visual reminders and reinforcements of practices
posters, in-service education sessions
New technology?
Adequate budget?
OHS committee?
Contingency plans?
Future plan projections?
Some indicators that you may use to monitor success of you plan.

42. Preliminary Draft for Discussion
What do you consider as the most important aspects when creating an effective healthcare waste management plan?
What details are included in your facility’s own waste management plan? How do they compare to the elements included in the ideal WMP?
How does your HCWM program align with the national and local regulations and guidelines?
What is the typical waste management structure in your own facility?
Do you have a waste management team with delegated responsibilities? Who makes up this team?
Who should be responsible for implementing a waste management plan, and what are some of the essential steps that need to be taken?
What are some of the obstacles to successful implementation of a WMP that you see in your facility?
Given some of the monitoring indicators for an effective HCWM plan, do you think the current plan in your hospital or facility is working?
Preliminary Draft for Discussion