Memphis VAMC Tracks Progress

The Veterans’ Health Administration (VHA) is the largest integrated healthcare system in the United States, providing comprehensive care to over 8.3 million veterans every year. The VHA is comprised of 150 medical centers, over 1,500 community based outpatient clinics, community living centers, Veteran Centers and Domiciliaries. The VHA, as part of the Department of Veterans’ Affairs (VA), has to meet federal mandates such as the 50% diversion requirement in Executive Order 13693 in addition to the general regulations associated with regulated medical waste and hazardous waste. Since 2005, the VA has used the Green Environmental Management System (GEMS) to most effectively protect the environment and the health and safety of its patients, employees, and visitors. The program helps facilities comply with local, state, and federal requirements and generally act as stewards of the environment. To explore some of the particular challenges and opportunities associated with waste diversion at VA Medical Centers (VAMCs), GEMS Coordinator Sandra Dickey described some of her experiences at the VAMC Nashville and VAMC Memphis in Tennessee.

Before moving to VAMC Memphis, Dickey served as the GEMS Program manager for four years at VAMC Nashville. There, according to a 2015 GreenGov Nomination, Dickey “developed and implemented a multi-faceted sustainability management approach...increasing diversion from landfilling of waste via new reuse and recycling programs, and reducing hazardous waste quantities via recycling initiatives.” These programs included recycling over 2,700 pounds of lead shielding and x-ray film; 1,500 pounds of plastic slide cartridges; and 1,250 pounds of used stock solution gallon containers; and composting 35,000 pounds of used research animal bedding.

Dickey transferred to VAMC Memphis in November 2015, filling the GEMS Coordinator position that had been vacant for several years. “I am starting from the beginning here,” Dickey admitted, “building on some of the programs that have fallen by the wayside.” One of her first actions at Memphis was to organize a GEMS Committee to discuss environmental issues throughout the organization. The committee consists largely of service leaders, a service being similar to a department such as nursing, the clinical lab, or the business office. However, because some services are more involved than others, Dickey also looks for individuals who are personally motivated to care for the environment, “I want service leadership buy-in and the everyday staff member who really cares about these [GEMS] initiatives as well.” This mix of leadership and active personnel ensures that the GEMS program has a facility-wide reach.

The VAMC Memphis is accredited by the Joint Commission and therefore has weekly environmental care rounds. These rounds require service leaders to walk through all service areas, patient care areas, and even the housekeeping closets. The intensive and thorough checks aid Dickey’s waste diversion efforts, “We can really see where programs are working and where they are not working through those environmental care rounds. We look at the facility and ensure that waste streams are being diverted properly.” VAMC Memphis also uses the Greenhealth Tracker, which is described on the Practice Greenhealth website as an “environmental data tracking tool [that] helps your facility understand how hundreds of thousands of waste disposal dollars are being spent and organizes information by each type of waste.”

One type of waste present at any medical facility is regulated medical waste (RMW). RMW is any waste that is a bio-hazard saturated in blood or bodily fluids. There has been an evolution in understanding RMW. Previously, something such as a Band-Aid with a drop of blood on it would be considered infectious “red bag” waste whereas today, as Dickey explained, “we realized that the materials really did have to saturate for materials to truly pose an infectious control problem.” Not only has this evolution decreased the amount of RMW, but the standard treatment of the waste has changed. Formerly, all RMW was incinerated and now that only happens in select instances. Dickey described the RMW procedures in place at Memphis, “Our waste actually goes to a facility in Cleveland, Tennessee and it goes through what is best described as a large, industrial autoclave. It is treated with high temperatures, high steam, and high pressure in a chamber that denatures anything infectious that could be associated with that regulated medical waste. Once the waste is treated, there is hardly anything left. If there are sharps that ended up in the RMW, they are recycled.” Dickey is confident in her management of RMW despite potential year-to-year fluctuations, “There are a number of different factors that could go into us seeing a slight increase in RMW, but the numbers from 2005, 305 tons, compared to last year’s 68 tons show true program management to reduce that tonnage.”

Another significant waste stream at VAMC Memphis is pharmaceutical waste. According to Practice Greenhealth, pharmaceutical waste is “not one single waste stream, but many distinct waste streams that reflect the complexity and diversity of the chemicals that comprise pharmaceuticals.” This waste is therefore monitored by various local, state, and federal regulators including the Environmental Protection Agency (EPA) and the Drug Enforcement Administration (DEA). Dickey confirmed that “the most difficult waste stream is definitely pharmaceutical waste.” One of the difficulties in handling pharmaceutical waste is the knowledge discrepancy among those responsible for disposal. Pharmacists and nurses often have limited training in hazardous waste management while safety and environmental services personnel often have limited knowledge of active ingredients and formulations of pharmaceuticals. To properly handle all of the expired, half-used, or turned-in pharmaceuticals, Dickey “[goes] above and beyond” and is “capturing all pharmaceutical waste and treating it as hazardous waste.”

The other challenge Dickey emphasized was related to tracking the various waste streams. With no one in the GEMS role for several years, Dickey was not only responsible for gathering waste data on an ongoing basis, but she also had to retroactively ensure the accuracy of past data. Gathering the data on solid waste was actually more challenging than the hazardous waste as the solid waste contracts had been executed by the environmental services department and handled by housekeeping services. On her arrival, Dickey began playing catch-up, trying to track down missing solid waste invoices that had not been entered in to the Practice Greenhealth tracker.

Despite challenges gathering data, Dickey has made significant progress at VAMC Memphis and attributes much of that success to the VA’s Practice Greenhealth affiliation. Remarking on the tool, Dickey noted, “Practice Greenhealth is an amazing tool that the VA has provided for us. The waste tracker is only part of the tool. It is also education outreach and how you can manage your program to be completely sustainable, looking at all aspects of sustainability in healthcare.” One of these aspects will always be financial sustainability. Healthcare facilities struggle with controlling costs without compromising the quality of care, but Dickey’s work at VAMC Memphis demonstrates the potential to do just that through careful waste management.