Job Description
The **Program Manager Waste, Environmental Compliance and Environment of Care **reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and all other regulatory and accreditation standards.
Coordinates and leads work by identifying, analyzing, and managing hazardous materials compliance/safety issues for NMH. Responsible for providing planning, support, and overall coordination of environmental compliance and waste management programs for the hospital. Promotes hospital-wide awareness of potential health, safety, or environmental hazards; conducts hospital-hazardous materials training, manages the Environment of Care surveillance program, performs risk assessments, initiates action to assure timely resolution of identified hazards or unsafe work practice. Builds and maintains strong and positive working relationships with all contacts throughout the health system. This role interacts with regulatory and external agencies, completes associated reporting, and participates in regulatory inspections/surveys. The Support Services Program Manager has the authority to take immediate corrective action whenever conditions exist that may pose an acute threat to life or health or damage to equipment and buildings.
Responsibilities:
Hazardous Material Policy, Plan and Procedure Development:
- Develop and Maintain Hazardous Materials Policies for NMH as part of the Environment of Care (EOC) Committee
- Develop and maintain the Resource Conservation and Recovery Act (RCRA) Contingency Plan / Emergency Operations Plan
- Maintain the Spill Prevention, Control and Countermeasures (SPCC) Plan
Training:
- Develops and/or Provides training as required by Resource Conservation and Recovery Act (RCRA), Spill Prevention, Control and Countermeasures (SPCC) Plan, Department of Transportation (DOT) and International Air Transport Association (IATA) regulations
- Develops and Provides Pharmaceutical Waste Training (for NMH and NLFH) and Hazardous Drug (HD) Spill Response Training for EVS
- Oversees Chemical and Pharmaceutical (Rx) Waste Management Programs and assists with Regulated Medical Waste (RMW) Program
Participates in Chemical and Hazardous Drug Spill Response:
- Member of the Emergency Operations Team for Chemical Spill Response
- Chemo / Hazardous Drug Spill Response Team member
Ensures compliance with all regulatory reporting:
- Resource Conservation and Recovery Act (RCRA)
- Emergency Planning and Community Right-to-Know Act (EPCRA) / Superfund Amendments and Reauthorization Act (SARA)
- Clean Air Act Permit Program
- Department of Transportation Hazardous Materials
- Completes and maintains EVS online chemical inventories
- Participates in meetings of the Environment of Care Committee
- Ensures compliance with the Joint Commission (JC) standards for Hazardous Materials
- Completes Focused Standards Assessment annually when EOC Committee annual evaluation report is due
- Completes quarterly and annual Hazardous Materials and EOC Surveillance Reports, Dashboard
- Attends meetings of the Emergency Management Committee
- Interfaces with Regulatory Agencies and The Joint Commission
- Manages Environment of Care Surveillance process for NMH
- Monitors compliance and program goals
- Submits monthly and quarterly data to EOC survey team managers and main contacts on survey completion compliance
- Registers new departments, surveyors, managers, and directors in Sentact for EOC Rounds surveillance and deficiency closure purposes
- Participates in bimonthly survey and manager webinars with Sentact and assists with training development
- Schedules EOC rounds weekly surveillance
- Provides guidance to managers on closing EOC deficiencies
- Works with NMHC Accreditation, Clinical Compliance and Policy Manager Managers, and Sentact to update JC standards related to EOC survey questions
- Assists Northwestern Medical Group (NMG) locations with setting up Rx waste and RMW services and provides general environmental regulatory guidance to NMG sites as requested
- Acts as Subject Matter Expert for NMH and consulted by Other Regions for Hazmat Questions/Guidance
Additional Functions
- Maintaining confidentiality of employee and/or patient information.
- Keeps current on legislation, regulatory changes, code changes, maintains knowledge of current and emerging issues and trends in areas of specialty.
- Sensitive to time and budget constraints.
- Other duties as assigned.