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checkAudit all hazardous waste-related activities for compliance and beyond

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Identify all current activities that relate to hazardous-material purchases, material and waste-handling, collection, and disposal to ensure that the facility is in compliance with any regulatory or statutory laws pertaining to hazardous chemical waste, which also includes the responsibility to minimize the use of hazardous chemicals. Adopting activities to comply with these laws will avoid potential monetary fines and ensure that hazardous waste is managed and disposed of in an environmentally appropriate manner.

  • Project Talking Points

    • Healthcare waste is undoubtedly complex due to the sheer volume of waste and because up to 15-20% of the waste stream is highly regulated by multiple regulatory agencies including EPA, OSHA, DOT, JCAHO, DEA and others. Items like regulated medical waste, pharmaceutical and hazardous chemical waste, radiological waste, sharps and others are expensive to manage -- up to 10 -100 times more than solid waste or recycling.
    • Overlapping regulations make compliance even more complex. From cradle-to-grave, the oversight of the same material can cross several different regulatory agencies – most are not in conflict, but it can be confusing nonetheless. When regulations conflict, the most stringent rule always trumps all others. Take for example, a hazardous pharmaceutical drug:
      • Manufacture of a pharmaceutical drug - FDA
      • Transportation – DOT
      • Safe Use – OSHA (HazCom - labeling, storage, training), Respiratory Protection (if aerosolized), Bloodborne Pathogen- BBP (if a sharp) and DEA if it’s a controlled substance
      • Waste management – RCRA (hazardous waste)
      • Transportation – DOT (handling, packaging, Labeling)
      • Treatment/Disposal – RCRA, CWA, CAA, TSCA
    • Auditing all hazardous waste activities will:
      • Identify vulnerabilities within areas such as disposal, storage, packaging, transportation, etc.
      • Ensure staff are following hospital PPE standards. Identified gaps in PPE practice standards allow for re-training opportunities and improvements in worker health and safety.
      • Keep your hospital updated on current and future pertinent regulations.
      • Identify opportunities to replace hazardous chemicals with less hazardous alternatives.
  • Triple Bottom Line Benefits

    • Cost Benefits:  Enhancing regulatory compliance and mitigating the potential of receiving associated fines
    • Environmental Benefits: Protecting the natural environment through reducing/eliminating hazardous waste release into the environment
    • Social benefits: Creating safer, healthier environments through the proper management and disposal of hazardous waste
    • Quality and outcomes - Metrics are in development. If you have suggestions, please  contact us or participate in the discussion below.

  • Purchasing Considerations

    If you have suggestions for purchasing considerations, or suggested sample contract language for any product or contracted service, please participate in the discussion below.

  • How-To

    1. Determine who's on the team. Identify a lead to handle the auditing and management process. Typically the designated Safety Officer, as part of the Safety Committee, Joint Commission Environment of Care Committee, and/or Hazardous Materials Sub-Committee oversees hazardous waste management. Team members should include:
      • Safety/Hazardous Material Committee Member(s)
      • Environmental Services
      • Facilities
      • Lab
      • Pharmacy
      • Radiology
    2. Familiarize yourself with all applicable regulatory agencies to understand which agency regulates which waste. Also see the Roadmap’s Waste Compliance page.
    3. Partner with your hazardous waste vendor as a trusted resource for auditing and management of hazardous waste. While you should rely on your vendor and the business community as a resource, ultimately you are legally responsible for cradle-to-grave oversight. Use EPA’s Healthcare Environmental Resource Center as a resource.
    4. Know your hospital's generator status:
      • Generator categories:
        • Conditionally Exempt Small Quantity Generator (CESQG)-Generates less than 100 kg/month (This is 220 pounds or about half of a 55 gallon drum and never accumulates 1000 kg or more.
        • Small Quantity Generator-Generates from 100 to less than 1000 kg/month and never accumulates 1000 kg or more.
        • Large Quantity Generator-Generates 1000 kg/month or more OR generates 1 kg (2.2 lbs) or more of an acutely hazardous or severely toxic waste.
      • Small and Large Quantity Generators must comply with the following hazardous waste requirements:
        • Obtain Federal EPA generator ID number
        • Manifest waste
        • Evaluate generator status annually
        • Maintain waste records for 3 years
        • In addition, Large Generators (but not SQG or CESQG) must complete EPA Biennial Reports. Biennial Reports of hazardous waste activity are due to EPA by March 1st of each even-numbered year.
    5. Create an inventory of all hazardous chemicals and ensure MSDS’s are available for every chemical found onsite.
    6. Verify hazardous waste storage area requirementsare being met:
      • Waste cannot be stored more than 90 days without a TSD permit (180 days for Small Quantity Generators). CESQGs are exempt and therefore there is no time limit for hazardous waste stored on site.
      • Storage area floor should be impervious (e.g. paint concrete floor and up several inches on wall) - with dike (to hold 10% of volume or volume of largest container) and no drain to sewer.
      • Areas are clearly designated as either a main hazardous waste accumulation point, as a satellite accumulation point, or as a universal waste storage area.
      • Entry doors are posted with proper labeling requirements.
    7. Ensure all hazardous waste containers:
      • Are sealed (except when adding or removing wastes), in good condition and compatible with the material in the containers.
      • Are properly labeled with the words “Hazardous Waste” and an accumulation start date. Satellite accumulation points such as a waste xylene jug in the laboratory may be labeled with identifying words (e.g. “Waste Xylene”) and does not need an accumulation start date until the jug is full.
    8. Conduct weekly inspections of the hazardous waste accumulation points and keep a findings record of these inspections. Corrective actions should be recorded, assigned to an accountable person and discussed at the Safety/Hazardous Materials Committee.
    9. Ensure all hazardous waste is properly managed and minimized or eliminated whenever possible. Common hazardous waste found in hospitals includes:
      • Xylene
      • Mercury
      • Listed Chemotherapy Drugs (undiluted leftover or outdated that must be discarded)
      • Lead/Cadmium alloy (i.e.Cerrobend in Radiation Oncology Mold room unless recycled as scrap metal)
      • Formaldehyde (if not poured down drain)
      • Lead-acid batteries exempt if properly recycled (are not even universal waste)
      • X-ray film: Many brands of films typically pass the TCLP test and are not hazardous. Hospitals need the TCLP test results to prove exemption from hazardous waste requirements until enough data on types of x-ray films can be gathered to claim material or process knowledge. If x-ray file is sent for silver recovery it must be counted as hazardous waste. It is recommended that you obtain TCLP test documentation from the manufacturer.
        • Oils/solvents/oil-based paints(Note: Recycled oil is not regulated as hazardous waste unless mixed with other constituent and exhibiting characteristic hazard
        • PCB transformers, ballasts and lamps: Some hospitals may still utilize PCB containing transformers, ballasts and lamps. Check with state regulations before disposing of these materials. For example, under the Small Capacitor Exemption, TSCA has allowed the disposal of non-leaking, intact “Small Capacitors” (i.e. less than 3 pounds of PCB dielectric fluid) in a municipal solid waste landfill, although some states do not allow this exemption. Specific state PCB regulations and disposal restrictions may vary.
      • For a more detailed hazardous waste assessment, review purchasing records and MSDS inventories for the entire organization. Check that list against the hazardous waste manifest inventory. Create an action plan for improved management if you find any discrepancies.
    10. Ensure key policies are in place, reviewed regularly by the EOC committee and that staff are trained on the policy. The main policies include OSHA’s Hazard Communication policy and a Hazardous Materials Management plan that includes your hazardous waste generator status and the hazardous waste determination processes you used; receipt, storage of chemicals, labeling, training and education, inspections of all locations that store hazardous chemicals and waste, recording keeping, etc.
    11. Confirm all necessary training and education is in place. OSHA’s Hazard Communication policy requires training to all employees on the first day of the job, which includes basic information like what is a hazardous chemical? How can you tell? How do you read an MSDS, NFPA label and why is it important. All staff should know that chemicals are never drain disposed or thrown away in the regular trash without express permission, and reason why it is allowed. Staff should also understand your facility's preference to reduce or eliminate hazardous chemicals by purchasing less toxic, or non-toxic, alternatives and to use those that are onsite safely. All staff should also be trained on spill policies and procedures, and the use of personal protective equipment. Employees who handle hazardous material that are offered for transport from offsite locations should receive appropriately training as well.
    12. Ensure a 3 year back-log of all required paperwork, manifests and invoices are organized, completed correctly and on-site (generation site) at all times. If an inspection occurs this may be one of the first items the inspector reviews. Healthcare Environmental Resource Center has information regarding these requirements.
    13. Continuously research and identify less hazardous or non-hazardous chemicals and products whenever possible (e.g. formaldehyde and xylene substitutes, water-based products).
    14. Stay updated on all hazardous waste regulatory changes by using “RSS Feeds”. First go to your State EPA (called many different things by state) and sign up for their RSS feed, check for relevance to hazardous waste regulations.
    15. Consider specifying preference for less-toxic or non-toxic materials in all RFPs. Specify particular materials of concern that you want to target (e.g., mercury, DEHP, etc.). All material acquisitions should go through a simple screening process to assess any chemical considerations that can be addressed.
  • Tools

    If you have an ROI tool, calculator, or similar resources to share, please contact us or participate in the discussion below.

  • Regulations, Codes and Standards, Policies

  • Cross References: GGHC

    • GGHC v2.2 Chemical Management
      • Prereq 1 - Polychlorinated Biphenyl (PCB) Removal and Asbestos-Containing Materials (ACM) Management
      • Prereq 2 – Chemical Management Policy and Audit
      • Credit 1.5 – Indoor Chemical Contaminant Reduction – Laboratory
      • Credit 1.6 – Indoor Chemical Contaminant Reduction – Radiology
  • Education Resources

    If you have any information or resources to contribute, please contact us or participate in the discussion below.

  • More Resources

  • PIM Descriptors


    Level: Beginner

    Category List:

    • Hazardous Waste
    • WASTE

    PIM Attributes:

    • Chemicals
    • Environmental Health and Safety

    Improvement Type:

    • Operations
    • Toxics Reduction


    • Interdepartmental
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