Hospital waste management: an informational assessment.INTRODUCTION
The proper and safe disposal of hospital waste constitutes an extremely important aspect of hospital operations from both a managerial and marketing standpoint. The term hospital waste refers to all waste generated from a hospital facility (Davis, 2001). The term medical waste refers to "that portion of hospital waste that includes wastes from patient diagnosis or treatment, or vaccination of humans or animals" (Davis, 2001). This study was designed to investigate current hospital waste management practices, and to provide a benchmark with which to gauge and improve these practices. Such practices are heavily impacted by factors such as responsibility for the protection of public health, privacy issues concerning confidential patient data, protection of the natural environment, stakeholder pressure, and compliance with extensive regulatory/legal requirements. In fact, more than a dozen regulatory agencies impose requirements on various aspects of hospital waste disposal (Kaiser, Egan & Shaner, 2001). These include the OSHA (Occupational Safety and Health Administration) and the EPA (Environmental Protection Agency).
On the other hand, green programs and practices resulting in proper handling and segregation of waste can offer significant cost savings (Joch, 2007) which may provide a competitive cost advantage.
It has been estimated that American hospitals generate about 6,600 tons of waste every day (h2e-online, 2008), and approximately 15% of hospital waste presents significant disposal problems as regulated medical waste (Joch, 2007; Rutala & Mayhall, 1992). It is also estimated that medical waste disposal costs seven to ten times as much to dispose of than conventional solid waste (Geiselman, 2002). This waste includes: biohazard wastes, pathological wastes, chemical wastes, radioactive wastes, and various other hazardous wastes (Davis, 2001).
Responsibility for environmental management can vary widely from institution to institution; from facilities management and housekeeping to designated environmental safety departments. Hospitals may continue to process some wastes on site, e.g. incineration, for economic or other reasons. Regulated outside service providers may be used for processing/disposal of specific types of waste. As the use of technology expands, on-line technology may be utilized for institutional tracking of waste.
Appropriate waste may also be recycled. It has been estimated that about 85% of hospital waste is similar to regular household waste (Rutala & Mayhall, 1992) and is therefore subject to more conventional disposal techniques. Recycling constitutes one important means to reduce total solid waste (Langrehr, Langrehr & Tatreau, 1992; Zikmund & Stanton, 1971).
In the area of privacy concerns, hospital waste also includes sensitive documents and computer files containing sensitive and confidential patient information. The HIPPA (Health Insurance Portability and Accountability Act) requires proper handling and disposal of sensitive and confidential patient information (Geiselman, 2002).
Hospitals may also participate in an Environment of Care (EOC) initiative. This initiative [supported by the Hospitals for a Healthy Environment Program (H2E) developed by the American Hospital Association in conjunction with the U.S. Environmental Protection Agency] ensures that a hospital is as safe, functional and supportive as possible for patients, visitors and staff.
Institutional size may also play a role in environmental performance. Bowen (2000) reviewed the academic research regarding firm performance on environmental issues. The research revealed that 90% of relevant studies reviewed indicated a positive correlation between the size of the organization and the level of environmental performance.
This research is based on a survey of hospitals which seeks to identify the key problems these institutions face regarding waste disposal, and the current practices that they employ. The impact of institutional size (based on hospital census) is also investigated in terms of its impact on environmental performance. The specific objectives of the study include:
* Collect basic accreditation information on the sample hospitals.
* Identify the title of the responsible executive at each organization who is responsible for overall waste management activities.
* Examine the use of on-site technologies for waste disposal.
* Rank the importance of criteria used to select an outside medical waste disposal provider.
* Investigate the degree of use of on-line technology to track waste.
* Explore the level of recycling activities.
* Investigate the disposal of sensitive documents.
* Determine the level of participation in the Environment of Care (EOC) Initiative.
* Examine the influence of size of institution on waste management activities.
The population for this study consists of hospitals wherein medical waste management, in compliance with OSHA and HIPAA requirements, is mandated. Included in this group are private and public hospitals. At each, there is a designated group, or individual, responsible for decision making (often the Director of Environmental Services or Facilities Director) as to medical waste management and disposal. It is this market segment to which the study was addressed. The names and addresses of 2,446 institutions were selected randomly from customer listings provided by a national medical waste service provider.
A pencil and paper survey was mailed to the 2,446 institutions selected, addressed to the executive at each responsible for waste management and disposal. These questionnaires included a cover letter describing the purpose of the study and requesting the appropriate waste disposal decision maker at each hospital to complete and return it. In addition, upon return of completed questionnaires, respondents were offered the opportunity to participate in a drawing for a $750 American Express Gift Check. Within the two-week response period allowed; 410 respondents / institutions (17%) completed and returned these questionnaires.
All data collected in this study were coded, tabulated and cross-tabulated. In a number of cases breakout totals (e.g. Job Title of Responsible Executive) do not add up to 410 because of missing data, as a few respondents (typically no more than 1%) did not answer all relevant questions.
An initial tabulation of the data indicated that some of the cells had little or no data captured and were therefore eliminated. They were the job functions of "Infection Control Practitioner" and "Committee." In addition for the same reason, the Daily Patient Census ranges "251 to 500" and "More than 500" were collapsed into "251 or more." As appropriate, t-tests of statistical significance were employed at the 95% confidence level to highlight statistical differences across sample cells. Each table presented is confined to the Total cell and the three Daily Patient Census cells, as no other cells deviated significantly from the Total cell (see Appendix 1).
Table 1 shows an overall summary of the findings in the study. Each category of findings will be discussed in turn.
Table 2 displays the sizes of the hospitals represented in the study as indicated by their daily patient census.
"The Joint Commission on Accreditation of Healthcare Organizations is an independent, not-for-profit organization that is dedicated to raising the level of quality in health care facilities" (Hazelwood, Cook & Hazelwood, 2005, p.72). Of responding institutions, three in four institutions are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (See Table 3). Smaller hospitals evidenced a lower level of JCAHO accreditation. A variety of other accreditations are mentioned. However, they all are in one of two categories. Either they are a Federal or State affiliated organization, or a professional society. An example of the former is the Washington State Department of Public Health. An example of the latter is the American Osteopathic Association.
"Directors of Environmental Services" are most likely those responsible for the management and disposal of medical waste (see Table 4). Other administrators' job titles of those who indicate responsibility are also shown.
It is to be noted that differences by sample cell are not significant, except that hospitals with a larger daily census are more likely to have an Environmental Services Administrator responsible than those with a daily census of less than 100. For hospitals 100-250, [t = 5.03] and for hospitals 251+, [t =2.76].
About seventy percent of the hospitals do not use on-site technology (see Table 5). No significant statistical differences in the use of on-site technology among hospitals of differing size were found at the 95% confidence level. Of those institutions that do use on-site technology, most often medical waste is being incinerated. The rationale for the use of on-site technology is primarily economic (see Table 6).
A series of eleven dimensions were rated by respondents (using a five-point Likert scale format, see Appendix 2) in terms of their importance in selecting an outsourced medical waste provider for their facilities (see Table 6). Ten of the eleven dimensions rated by participants (as a means of determining which aspects of the products and services provided are of importance in selecting a medical waste disposal provider) are considered "very to somewhat important" and would therefore deserve serious consideration in future customer and marketing activities. To further illustrate this, the mean of the eleven means considered was 4.58 on a 5 point scale.
At present, on line reporting tools are not particularly popular (see Table 8). Only about one in seven of the institutions contacted utilize them. It was found that the "none" response was significantly higher when hospitals in the 100 to 250 range were compared to larger 250 plus hospitals, indicating a lower usage of that tool among midrange institutions [t = 2.26]. By way of contrast, Table 9 indicates that about one-half of respondents would consider employing some on-line service in the future, with no statistical differences among responses found at the 95% level. So more on-line reporting is likely possible in the future.
About three-fourths of the hospitals in the survey recycle. The larger hospitals recycle at a significantly higher level than the smallest. Most often this involves cardboard and paper waste (see Table 10). This suggests that outside waste disposal service providers might consider offering this type of service, to this category of customers, in conjunction with their core business activities.
Respondents employ multiple resources in the disposal of sensitive documents in support of HIPPA. A significant difference was found between the smallest and largest institutions in terms of shredding done on site by an outsourced firm (see Table 11). Eight in ten institutions use an outside source while 42% perform such tasks on-site. This could suggest a possible hierarchy of disposal based on document sensitivity. Sensitive documents are often disposed of by more than one means depending on level of sensitivity.
Three-fourths of the institutions participating in this research are currently engaged in an "Environment of Care" (EOC) initiative (see Table 12). Most often, these initiatives are the responsibility of committees (see Table 12) including environmental and facilities management and infection control; CEOs and/or COOs are also involved in some hospitals.
Managers/Directors of Environmental Services are the most likely executives responsible for the management and disposal of medical waste. Institution size was found to be a mediating variable in the case of having a "Director/Manager of Environmental Services" as the executive with overall responsibility for hospital waste management. Institution size was also found to have some impact on the degree of hospital recycling, the outsourced disposal of sensitive documents on-site, and the use of online tools to aid the tracking and handling of waste. This does conform to Bowen's (2000) contention that institutional size may play a role in environmental performance.
However, institution size was not found to influence other variables studied which is in accord with the findings of Sharma and Henriques (2005), that the influence of institution size varies based on the specific type of environmental task or issue being addressed.
Over seventy percent of institutions do not use on-site disposal technology which indicates extensive use of outsourcing such activities. Of those institutions that use on-site methods, incineration was the most commonly used, for primarily economic reasons. Regarding the selection of an outside service to dispose of medical waste, the top five importance dimensions included reliability of service, environmental responsibility, accurate billing, price considerations, and attitude of employees.
At present it was found that about only 15% of institutions currently use online tools for documenting waste tracking. However, approximately 49% of remaining institutions would consider the use of such on-line tools. This would certainly indicate a need for on-line documentation and training services. Recycling was found to be quite common, with approximately three-fourths of institutions practicing recycling, and with cardboard and paper the most common materials. In terms of the disposal of sensitive documents, the survey indicated a combination of on and offsite shredding. It is possible that a disposal hierarchy exists based on the level of sensitivity. Finally, it was found that over three-quarters of respondent institutions are engaged in an EOC initiative.
This research sought to investigate the current practices employed by hospitals for waste disposal; in order to identify current hospital waste management practices, and to provide a benchmark with which to gauge and improve these practices in the future.
APPENDIX 1 Frequencies Total Sample (Base) n=410 (410) Daily Hospital Census Less than 100 242 100-250 117 251 or more 45 JCAHO Accredited Yes 309 No 101 Job Title of Responsible Executive Director of Environmental Services 245 Facilities Manager 50 Other 109 Use On-Site Technology for Disposal of Waste Yes 114 No 279 Hospital Recycles Yes 295 No 110 On-Line Reporting Tools Currently Use 62 Would Consider Using 201 Involved in EOC Initiative Yes 312 No 62 Dont' Know 36
Please rate the following dimensions in terms of their importance in selecting a Regulated Medical Waste service provider by checking the appropriate box after each.
Bowen, F.E. (2000). Environmental visibility: A trigger of green organizational response? Business Strategy and the Environment, 9, 92-107.
Davis, S.C. (2001). Demystifying "red bag" and other hospital wastes. Pollution Prevention Review, Summer, 1-14.
Geiselman, B. (2002). Hospitals waste money, consultant says. Waste News, 8(11), 4.
h2e-online. (2008). Waste reduction: Why focus on waste. Hospitals for a Healthy Environment. Retrieved July 7, 2008, from http://cms.h2e-online.org
Hazelwood, A., E. Cook & S. Hazelwood (2005). The Joint Commission on Accreditation of Healthcare Organizations' sentinel events policy. Academy of Health Care Management Journal, 1, 71-92.
Joch, A. (2007). A little green goes along way. Materials Management In Health Care, September, 19-22.
Kaiser, B., P.D. Egan & H. Shaner (2001). Solutions to health care waste: Life-cycle thinking and "green" purchasing. Environmental Health Perspectives, 109(3), 205-207.
Langrehr, V.B., F.W. Langrehr & J. Tatreau (1992). Businesses users' attitudes toward recycled materials. Industrial Marketing Management, 21, 361-367.
Rutala, W.A. & C.G. Mayhall (1992, Jan.). Medical waste: Society for Hospital Epidemiology of America position paper on medical waste infection control and hospital epidemiology, 13, 38-48. Reprinted in: An ounce of prevention: Waste reduction strategies for health care facilities. 1993. AHA ASHES. Appendix C, 198.
Sharma, S. & I. Henriques (2005). Stakeholder influences on sustainability practices in the Canadian forest products industry. Strategic Management Journal, 26, 159-180.
Zikmund, W.G. & W.J. Stanton (1971). Recycling solid wastes: A channels-of-distribution problem. Journal of Marketing, 35(July), 34-39.
Donald Bernstein, Roosevelt University
Ralph Haug, Roosevelt University
Marshall Ottenfeld, Roosevelt University
Carl Witte, Roosevelt University
Table 1: Summary Total Sample (Base) n=410 (410) Measures Daily Patient Census Less than 100 59% 100-250 29% 251or more 11% JCAHO Accredited 75% Job Title of Responsible Executive Director/Manager of Environmental Services 57% Facilities Manager 11% Director of Housekeeping 9% Committee 2% Use On-Site Technology for Disposal of Waste 28% Dimensions of Importance in Selecting Provider--Mean of Means (Table 7) 4.58 Hospital Recycles 72% Currently Use On-Line Reporting Tools 15% Would Consider Using On-Line Reporting Tools 49% Involved in EOC Initiative 76% Table 2: Daily Patient Census Total Sample (Base) n= (410) Census % Less than 100 59% 100 to 250 29% 251 to 500 9% More than 500 2% No Answer 1% Mean 128 patients Table 3: Accreditation By Daily Census Total Less Sample than 100 100 to 250 251 or More (Base) n= (410) (242) (117) (45) Agency JCAHO 75% 68% 86% 89% Government Agencies 19% 23% 16% 20% Professional Societies 6% 10% 4% 7% Don't Know 5% 7% -- -- Totals add to more than 100% due to multiple responses. Table 4: Title of Individual Responsible For Management and Disposal of Medical Waste By Daily Census Less Total than 100 to 251 or Sample 100 250 More (Base) n= (410) (242) (117) (45) % % % % Title Director/Manager of Environ. Services 57% 48% 74% *** 69% *** Director/Manager Facilities 11% 15% 6% 2% Director Housekeeping 9% 10% 3% 11% Director Plant Services/Operations 2% 4% -- 2% Committee 2% 1% 2% 2% Other 17% 21% 12% 14% Don't Know 2% 1% 3% -- *** p<.01 Table 5: On-Site Technology Employed By Daily Census Less Total than 100 to 251 or Sample 100 250 More (Base) n= (410) (242) (117) (45) % % % % Ever Use On-Site Technology (net) 28% 26% 26% 40% Incineration (burning of med. waste) 70% 80% 70% 33% Autoclave (steam trt. of med. waste) 34% 22% 50% 50% Own incinerator 11% 14% 10% 6% No On-Site Technology Used (net) 68% 71% 68% 56% Don't Know 4% 3% 6% 4% Table 6: Reasons for Using On-Site Technology Among Users By Daily Census Total Less 100 to 251 or Sample than 100 250 More (Base) n= (114) (64) (30) (18) % % % % Reasons Ever Use On-Site Technology More economical 61% 55% 77% 61% Better control (cradle to grave 30% 25% 33% 33% responsibility) More reliable service 15% 14% 10% 22% Don't Know 15% 16% 10% 22% Table 7: Selection of an Outside Regulated Medical Waste Service Level of Importance Ratings By Daily Census Weighted Means--Five Point Scales Total Less than 100 to 251 or Sample 100 250 More (Base) n= (410) (242) (117) (45) Importance Dimensions Reliability of service 4.97 4.95 4.99 5.00 Environmental responsibility 4.83 4.83 4.81 4.80 Accurate billing 4.80 4.79 4.83 4.80 Price for service received 4.72 4.70 4.77 4.78 Attitude of Driver 4.68 4.70 4.71 4.60 Attitude of Sales Rep 4.63 4.57 4.75 4.69 Reputation of service provider 4.53 4.48 4.66 4.47 Quality/size/selection of disposable waste containers 4.49 4.47 4.50 4.62 Provider who is financially sound 4.48 4.48 4.46 4.56 Availability for unscheduled pick-ups 4.41 4.35 4.48 4.58 Access to online documentation 3.83 3.82 3.78 4.07 Mean of Means 4.58 4.56 4.61 4.63 Scale: (5) Very Important, (4) Somewhat Important, (3) Neither Important nor Unimportant, (2) Somewhat Not Important, (1) Not Important at all. Table 8: On-Line Tools Currently Used By Daily Census Total Less 100 to 251 or Sample than 100 250 More (Base) n= (410) (242) (117) (45) Tools % % % % Container Report (detail of containers by size/weight) 13% 12% 8% 24% Dept Summary Report (detail of containers by size, weight and department) 12% 10% 9% 22% None 85% 85% 90% ** 74% Totals add to more than 100% due to multiple responses. ** p<.05 Table 9: On-Line Tools Not Currently Used But Would Consider Using By Daily Census Total Less 100 to 251 or Sample than 100 250 More (Base) n= (410) (242) (117) (45) Tools % % % % Container Report (detail of containers by size/ weight) 44% 46% 46% 33% Department Summary Report (detail of containers by size, weight and department) 45% 45% 47% 42% None 51% 50% 50% 58% Totals add to more than 100% due to multiple responses. Table 10: Hospital Recycling By Daily Census Total Less Sample than 100 100 to 250 251 or More (Base) n= (410) (242) (117) (45) % % % % Recycling (net) 72% 67% 78% ** 84% *** Cardboard 87% 86% 89% 90% Paper 73% 70% 75% 90% Plastic 31% 34% 26% 24% Medical Devices 26% 30% 18% 34% Metal Waste 6% 7% 4% 3% Not Recycling 28% 33% 22% 16% Totals add to more than 100% due to multiple responses. ** p<.05, *** p<.01 Table 11: Disposal of Sensitive Documents Management By Daily Census Less Total than 100 to 251 or Sample 100 250 More (Base) n= (410) (242) (117) (45) Management Program In Place % % % % Outsource to a company that shreds 47% 43% ** 47% 62% sensitive documents on site Shreds sensitive documents on site 42% 43% 42% 36% Outsource to a company that picks up 34% 36% 34% 29% sensitive documents and shreds off-site No program in place today 1% 1% 1% -- Totals add to more than 100% due to multiple responses. ** p<.05 Table 12: Environment of Care Initiative By Daily Census Total Less than 100 to 251 or Sample 100 250 More (Base) n= (410) (242) (117) (45) Involvement with EOC % % % % Initiative Yes (net) 76% 74% 82% 82% Functional Areas on EOC committee Environmental Services 89% 85% 92% 97% Facilities Management 89% 87% 92% 89% Infection Control 89% 89% 90% 84% CEO 25% 34% 15% 5% COO 21% 21% 23% 14% Safety/Security Committee 7% 6% 9% 5% No 15% 17% 10% 13% Don't Know 9% 9% 8% 5% Totals add to more than 100% due to multiple responses