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Self-Auditing Hospital Environmental Compliance: Knowing What is Wrong is Better than Hoping for the Best

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The C-Suite must intend for the hospital to operate in compliance with environmental rules. A hospital will not naturally achieve or sustain compliance with environmental regulations. Management must set and pursue this goal.

Hospital operations are generally subject to regulation by at least ten federal environmental programs. Compliance with these rules can be achieved and practiced only if operations are regularly evaluated for adherence with the law. Compliance this year might look different three years from now. For example, in recent years, environmental regulations have changed with regard to exhaust emissions for diesel engine generators that provide backup power for hospitals, and regulation over the management and handling of pharmaceutical wastes has significantly changed.

Moreover, some environmentally compliant hospital practices, without review, gradually fall into noncompliance with environmental regulations. For example, laboratory or pharmaceutical inventories may eventually slide into disuse. As a result, the hospital may find itself in violation of EPA's rules for the storage, labeling and disposal of hazardous waste.

Environmental audits provide accountability for environmental managers, assuring that their processes are up to date and are being followed. A fresh review by a knowledgeable environmental consultant can identify best practices that should be implemented into the daily life of the hospital.

A hospital's processes for monitoring environmental compliance should be periodically reviewed by an outside environmental consultant.

Hospitals, by their nature, pose unique risks to the environment due to potential impacts to air, water and soil. For example:

  • Boilers and generators may emit or have the potential to emit certain thresholds of pollutants.
  • The storage of petroleum products and oil in above-ground containers may be in sufficient quantities that the hospital is required to have a comprehensive, updated plan for responding to spills.
  • Underground storage tanks for gasoline and fuel storage for backup power generators require spill and corrosion protection as well as inventory controls to assure the timely detection and correction of spills and leaks.
  • Hazardous waste, particularly pharmaceutical waste, must be categorized, labeled, stored and disposed of in accordance with EPA regulations.
  • The generation, treatment and discharge of wastewater must meet certain regulatory requirements.

The environmental auditor should look for not only environmental violations, but also hospital practices deviating from best practices. These are the areas of operation that are likely or at risk to become future violations. Environmental audits allow hospital management the opportunity to identify these practices that are, if no operational change is made, likely to mature into violations of environmental law.

The time to evaluate the hospital's environmental compliance is now.

Regulatory violations detected during the audit may, under the EPA's Audit Policy, qualify for exemption from certain penalties and even avoid criminal referral to prosecutors if the violations are timely reported to EPA, corrective action is completed on time and other criteria are met. The Audit Policy should motivate hospitals to perform periodic internal audits of environmental compliance. These audits are designed to determine whether:

  • the hospital has all necessary environmental permits in place;
  • the hospital is operating in compliance with these environmental permits;
  • any hospital practices are likely to trigger the assessment of a penalty if discovered by regulators;
  • any environmental regulations are being purposefully skirted by the hospital, thereby exposing the hospital and individual members of management to the risk of criminal liability;
  • the hospital's waste generation, storage and disposal practices are in compliance with solid waste, medical waste and hazardous waste laws; and
  • the hospital is maintaining records, such as inspection reports and training documentation, which federal or state environmental inspectors are likely to ask for during an inspection at the hospital.

Environmental audits which are properly conducted and reported can minimize the hospital's exposure to regulatory enforcement and private litigation.

Care must be given to how the audit is carried out and reported to management. If the audit is performed by an environmental consultant at the direction of legal counsel for the hospital, reports generated by the audit may be maintained as confidential. The environmental consultant works at the direction of outside legal counsel. Counsel uses the audit findings to provide legal advice to the hospital on issues of environmental regulatory compliance, as well as the pros and cons of self-reporting of violations to the USEPA under the agency's protocol. States have enacted various forms of environmental self-evaluation privileges, which also protect these environmental audit reports from discovery by third parties as long as the hospital undertakes and completes corrective action in a timely manner.

Routine periodic environmental audits produce multiple benefits.

When hospital management implements periodic environmental audits into the routines of the hospital's operations, hidden or unnoticed environmental violations come to light and corrections can be made. If the violations are reported to USEPA and are corrected in a timely manner, the hospital may reduce its liabilities for the violations. Moreover, environmental audits will identify opportunities for the implementation of best practices that are likely to reduce the risks of environmental violations in the future. Overall, the hospital will find itself a better corporate citizen.

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