STANDARD OPERATING PROCEDURE BIO MEDICAL …

1 FORTIS HEALTHCARE LIMITED P a g e1 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only STANDARD OPERATING PROCEDURE BIO MEDICAL WASTE MANAGEMENT SOP Number: Version Number: Effective Date: 1st July 2016 Supersedes Version: Next Review Date: 31st March 2017 Prepared By: Dr Ravneet Kaur, Dr Anita Arora, Dr Anita Sharma Reviewed By: Dr Akash Sud Approved By: Dr Bishnu Panigrahi FORTIS HEALTHCARE LIMITED P a g e2 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only Table of Contents S. No. Section Page I Change Control Information 4 II Functional Organizational Structure 5 III Scope & Objectives 6 IV Common Abbreviations 7 V Definitions 8 VI Involved Personnel (Roles & Responsibilities) 9 VII Flowchart 10 VIII Process 10 01.

2 Duties of the Occupier 11 02. Bio- MEDICAL Waste Management 15 03. Segregation Of Waste 24 04. Waste Removal & Transportation 26 05. Treatment and Disposal 28 06. Waste Storage & Transportation to Waste Treatment Facility 32 07. Licensing & Other requirements for Bio- MEDICAL Waste management 34 08. Minimum terms of Service Level Agreement with the Vendor 40 09. Biomedical Waste Audit 42 Annex 1 Labels for Biomedical waste containers/bags 44 Annex 2 Labels for transport of Biomedical waste containers/bags 45 Annex 3 standards for treatment and disposal of Biomedical waste 46 FORTIS HEALTHCARE LIMITED P a g e3 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only S. No. Section Page Annex 4 Bio MEDICAL Waste Record 56 Annex 5 Application for Authorization 57 Annex 6 Authorisation 61 Annex 7 Annual Report 63 Annex 8 Accident Reporting 68 Annex 9 Biomedical Waste Audit Sheet 69 FORTIS HEALTHCARE LIMITED P a g e4 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only I.

3 Change Control Information Version Number: Effective Date: 1st July 2016 Supersedes Version: Next Review Date: Changes Made: Reason for change: Adding Interpretations received from CPCB Dt 08/06/2016 FORTIS HEALTHCARE LIMITED P a g e5 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only II. Functional Organizational Structure (Organogram) (TO BE DEVELOP ED BY FACILITY) FORTIS HEALTHCARE LIMITED P a g e6 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only III. Scope and Objectives of process The goal of the department To ensure that biomedical waste is handled and disposed in a safe manner The scope and complexity of services provided by this department Biomedical waste is generated in all patient care areas and needs to be managed as per the applicable statutory regulations The methods used in order to customize services Biomedical waste segregation Biomedical waste storage till transportation to final treatment/disposal site The extent to which the level of care/ services provided meets customer needs are: Color coded waste disposal bags are conveniently available at waste generation sites.

4 Waste is stored and transported in closed bags/bins to central area where it is kept till collected for final disposal. Regulatory agencies relevant to this State Pollution Control Board Staffing plan Supervisor 1 GDA/Housekeeping - as required FORTIS HEALTHCARE LIMITED P a g e7 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only IV. Common Abbreviations Sl. No. Abbreviation Full Form 1 Listed in each process FORTIS HEALTHCARE LIMITED P a g e8 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only V. Definitions Sl. No. Term Definition 1 Authorised Person "authorised person" means an occupier or operator authorised by the prescribed authority to generate, collect, receive, store, transport, treat, process, dispose or handle bio- MEDICAL waste in accordance with these rules and the guidelines issued by the Central Government or the Central Pollution Control Board, as the case may be.

5 2 Bio- MEDICAL Waste "bio- MEDICAL waste" means any waste, which is generated during the diagnosis, treatment or immunisation of human beings or animals or research activities pertaining thereto or in the production or testing of biological or in health camps, including the categories mentioned in Schedule I appended to these rules. 3 Handling handling in relation to bio- MEDICAL waste includes the generation, sorting, segregation, collection, use, storage, packaging, loading, transportation, unloading, processing, treatment, destruction, conversion, or offering for sale, transfer, disposal of such waste. 4 Major Accident Major Accident means accident occurring while handling of bio- MEDICAL waste having potential to affect large masses of public and includes toppling of the truck carrying bio- MEDICAL waste, accidental release of bio- MEDICAL waste in any water body but exclude accidents like needle prick injuries, mercury spills.

6 5 Management management includes all steps required to ensure that bio- MEDICAL waste is managed in such a manner as to protect health and environment against any adverse effects due to handling of such waste. 6 Occupier Occupier means a person having administrative control over the institution and the premises generating bio- MEDICAL waste, which includes a hospital, nursing home, clinic, dispensary, veterinary institution, animal house, pathological laboratory, blood bank, health care facility and clinical establishment, irrespective of their system of medicine and by whatever name they are called. FORTIS HEALTHCARE LIMITED P a g e9 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only VI. Involved Personnel (Roles & Responsibilities) Sl. No.

7 Process Functional Responsibility Charge 1 Segregation of Waste at source Doctors, Nurses, Technicians, GDAs (including all employees involved in generation & segregation of BMW) MS, CoN 2 Transport to temporary Storage Area Housekeeping Head Admin 3 Transport to Central Garbage Area Housekeeping Head Admin 4 Storage and Handover to Collecting Agency Housekeeping, Security Head Admin 5 Timely Submission of Reports to Authorities Housekeeping/Administration Head Admin 6 Licensing Administration Head Admin 7 Display on Website Housekeeping, Marketing Head Admin, Head - Marketing 8 Oversight Infection Control Committee Chairman, Infection Control Officer, MS, CoN, Head Admin FORTIS HEALTHCARE LIMITED P a g e10 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only VII.

8 Flowchart NA VIII. Process 1. Duties of the Occupier 2. Bio- MEDICAL Waste Management 3. Segregation of Waste 4. Waste Removal & Transportation 5. Treatment and Disposal 6. Waste storage & Transportation to Waste Treatment Facility 7. Licensing and other requirement for Bio- MEDICAL Waste Management 8. Minimum terms of Service Level Agreement with the Vendor 9. Biomedical Waste Audit FORTIS HEALTHCARE LIMITED P a g e11 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only DOCUMENT IS BASED ON BIOMEDICAL WASTE MANAGEMENT RULES (2016) # All Interpretations based on clarifications received in meeting with CPCB dt 08/06/2016 Biomedical Waste Management BMW / SOP No. 01 _____ Title: Duties of the Occupier It shall be the duty of every occupier to- (a) take all necessary steps to ensure that bio- MEDICAL waste is handled without any adverse effect to human health and the environment and in accordance with these rules (b)

9 Make a provision within the premises for a safe, ventilated and secured location for storage of segregated biomedical waste in coloured bags or containers in the manner as specified in Table I, to ensure that there shall be no secondary handling, pilferage of recyclables or inadvertent scattering or spillage by animals and the bio- MEDICAL waste from such place or premises shall be directly transported in the manner as prescribed in these rules to the common bio- MEDICAL waste treatment facility or for the appropriate treatment and disposal, as the case may be, in the manner as prescribed in Table 1; (c) pre-treat the laboratory waste, microbiological waste, blood samples and blood bags through disinfection or sterilisation on-site in the manner as prescribed by the World Health Organisation (WHO) or National AIDs Control Organisation (NACO) guidelines and then sent to the common bio- MEDICAL waste treatment facility for final disposal; #Interpretation - The Pre-treatment can be done by Autoclaving (d) phase out use of chlorinated plastic bags, gloves and blood bags within two years from the date of notification of Bio- MEDICAL Waste Management Rules, 2016; (i.)

10 E. latest by 27th March 2018). (e) not to give treated bio- MEDICAL waste with municipal solid waste; FORTIS HEALTHCARE LIMITED P a g e12 o f 80 STANDARD OPERATING PROCEDURE for Bio MEDICAL Waste Management This document contains proprietary information of FORTIS HEALTHCARE LTD For internal circulation only (f) provide training to all its health care workers and others, involved in handling of bio MEDICAL waste at the time of induction and thereafter at least once every year and the details of training programmes conducted, number of personnel trained and number of personnel not undergone any training shall be provided in the Annual Report; (g) immunise all its health care workers and others, involved in handling of bio- MEDICAL waste for protection against diseases including Hepatitis B and Tetanus that are likely to be transmitted by handling of bio- MEDICAL waste.