How to Conduct a Medical Waste Compliance Audit in Your Facility

According to a study published by Sage Journals, American healthcare organizations produce an estimated 5 million tonnes/year of solid waste, including a substantial amount of sharps, pathological, and hazardous waste. If your facility is one of the hundreds of thousands of medical waste generators in our nation, it’s crucial that you perform a medical waste compliance audit to ensure that your waste contribution adheres to regulatory requirements for the proper storage, handling, transportation, and disposal of potentially infectious materials.

How Often Should You Conduct a Medical Waste Audit?

Regulatory agencies such as the Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA) can perform medical waste disposal audits without notice. Be prepared for these surprise audits by preempting their audit with your own. If your organization has not yet conducted an audit, now is the time. Once you’ve thoroughly audited your healthcare facility, schedule future audits at least annually.      

Who Needs to Perform Medical Waste Audits?

If you are a medical waste generator, that is, if your healthcare facility generates hazardous, biohazardous, radioactive, or sharps waste, you must perform regular medical waste audits. Regular healthcare compliance audits ensure that your facility is preventing environmental contamination and prioritizing public safety concerning the disposal of your waste.

The types of facilities that need to perform medical waste audits include:

• Hospitals
• Laboratories
• Nursing homes
• Veterinary clinics
• Blood banks
• Mortuaries
• Research facilities
• Dental practices
• Pharmacies
• Doctor’s offices

This is just a small sampling of the types of facilities that generate medical waste. If your organization uses red bags or containers, yellow bags or containers, or sharps containers, you must perform an audit.

Let’s review the 10 steps to performing a proper medical waste compliance audit.

Step 1: Assemble a Qualified Compliance Audit Team

When assembling your compliance audit team, ensure a multidisciplinary approach. Include nursing, management, administration, legal, IT, environmental, and maintenance representatives. Each discipline views medical waste compliance differently and can offer insight into its department’s role in maintaining compliance.

You may also choose to include an eternal auditor on your team. This representative can provide an unbiased view of how your organization handles its medical waste. Furthermore, your medical waste disposal service may provide additional insight and guidance on maintaining compliance as they are experts in their field and have seen the medical waste programs of many other organizations.

Step 2: Know the Regulatory Requirements for Medical Waste

If your facility is a medical waste generator, it’s imperative that you understand the regulatory requirements for medical waste. Set forth by the EPA, OSHA, U.S. Department of Transportation (DOT), various federal laws, and state and local ordinances, guidelines abound.

Before you begin a medical waste compliance audit, familiarize yourself with pertinent regulatory requirements. Gather regulatory guidelines on aspects such as:

• Medical waste classification
• Proper disposal of medical waste
• Separation of types of waste
• Proper medical waste storage techniques
• Frequency of pickup
• Transportation of medical waste
• Paper compliance
• Documentation and record-keeping

Failure to comply with medical waste regulations can lead to steep fines, imprisonment, and revocation of related licenses.

At MedWaste Management, we are committed to staying abreast of current and upcoming medical waste disposal guidelines on the federal, state, and local levels. California State Medical Waste Guidelines are updated and published directly on our medical waste page. Do you have more questions? Call us! We’re happy to walk you through everything you need to know!

Step 3: Develop an Audit Plan

Before you begin your medical waste compliance audit, you must develop a plan to keep all team members on track and on the same page. Your plan should outline:

• Team members
• Team member roles
• Audit objectives
• Data to be collected
• Method for collecting data
• Method for evaluating facility practices
• Staff involvement
• Audit timeline

The plan should also outline the compliance standards expected of the organization.

Step 4: Identify Your Facility’s Waste Streams

During your audit, consider your facility as a whole. What kinds of waste does your organization generate? Where does the waste come from? It’s during this step that you must identify your facility’s waste streams and determine if staff is routing them appropriately.

Start by considering each department and the types of waste it generates. Where does the waste end up? Is it being routed properly? Remember that waste streams will overlap, meaning you’ll likely identify waste, such as pharmaceuticals, in multiple departments. Additionally, take note of any behaviors that are wasteful and consider corrective actions that reduce waste generation in that area.

Step 5: Perform a Waste Segregation Analysis

Once you’ve identified your waste streams, perform a waste segregation analysis. This step will determine whether you’ve adequately trained your staff to sort waste into their respective designated bins.

Start by identifying your facility’s current waste sorting protocol. Then, observe your staff to confirm that they’re following the protocol. Additionally, conduct interviews with staff to ensure that they understand all relevant protocols and pinpoint any knowledge gaps. Allow staff to give feedback concerning the waste management policy and practices.

During this step, take note of any serious information gaps, breakdowns in policy communication, shortage of resources, or cross-contamination within the waste bins.

Step 6: Gather and Analyze Waste Data

When hiring your medical waste removal company, you’ll need to know what type and how much waste your facility generates. Collect this data during your medical waste compliance audit:

• Types of waste generated
• Weight and volume of waste generated (by type)
• Current sorting and storage methods

You can use this information in the future to identify increases or reductions in your waste generation. This is particularly helpful if you’ve developed an action plan to reduce waste.

Step 7: Confirm Medical Waste Disposal Compliance

Now that you’ve gathered all the pertinent information related to your organization’s medical waste, you need to confirm your compliance with all applicable laws and regulations. If you’re unsure which laws pertain to your facility, check out our guide to medical waste disposal regulations.

If you’re in California, MedWaste Management representatives will gladly walk you through your applicable laws.

Step 8: Recommend Actionable Corrective Actions

If, during the course of your data collection, you identify wasteful practices, non-compliance, or knowledge gaps within your staff, you need to recommend corrective actions that are both actionable and measurable. It’s not enough to state, “sort medical waste properly.” You must add information that details how and to what degree. Some sample actions include:

• Medical waste knowledge gaps will be closed, as evidenced by 100% of staff passing the medical waste handling training with a score of 70 or above by the stated date.

• Staff on all units will sort medical waste properly 100% of the time, as evidenced by four weekly inspections that identify no improperly sorted items. If, during the course of these weekly inspections, inspectors identify improperly sorted items, unit management will implement additional medical waste training, and assessments will continue until four consecutive inspections are passed. 

• Inspectors identified wasteful practices in several units. Unit staff stocked rooms with adult briefs of multiple sizes, personal care items, packages of bathing wipes, and medical supplies such as wound care items and saline syringes before patient admission. However, environmental services disposed of many of these items after patient discharge. 100% of unit staff will receive a refresher training on properly stocking rooms. Inspectors will re-visit prepared rooms after one week and find that staff has stocked them according to policy.

Create an environment built on teamwork and understanding by communicating findings, corrective actions, and rationales to all staff.

Step 9: Implement Training and Policy Changes

Implement your corrective training, training on new policies and procedures, and all policy and procedure changes to all staff. Even an administrator who does not work on the unit should know the facility’s waste management policies. This ensures that all staff participate in proper disposal techniques throughout the organization.

Step 10: Follow Up and Monitor

Finally, follow up on your facility’s medical waste management process regularly. Determine a schedule for performing full medical waste compliance audits and for performing periodic check-ins. Communicate frequently with your compliance team and increase inspections and training as required.

Conducting a medical waste compliance audit in your facility is a top priority. Without it, you may create a health and environmental safety hazard and land in hot water with several regulatory agencies.

If you’re in California, partner with MedWaste Management, the experts in hazardous and non-hazardous waste removal. They’ll help guide you through your compliance requirements and be your dependable, compliant waste removal service.

We are MedWaste Management – California’s medical waste disposal experts!

Established in 2008, MedWaste Management fills a need for compliant and safe medical waste disposal in the healthcare industry and the general public alike. We publish this blog to share valuable and practical information to help you stay safe, informed, and healthy!

Call us with any questions or to start service at (866) 254-5105. We are always happy to help!

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