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5t.acase1 h's Medical Center A.—I-.1 CA PROGRAM ORGANIZATION The Medical Center's leadership provides the program vision, direction, support, and appropriate resources to ensure hazardous materials and wastes are properly managed. The hospital's Safety Officer, in collaboration with the EC/Safety Committee, and department managers, are responsible for the overall management of the Hazardous Materials and Waste Management program including program design, implementation and monitoring. A multi -disciplinary EC/Safety Committee ensures that the Hazardous Materials and Waste Management program remains in alignment with the organization's core values, goals, mission and social purpose, by providing direction, determining priority, assessing performance against stated goals, and determining needed improvements. In this process, the EC/Safety Committee serves as the hub of the Information Collection and Evaluation System in conjunction with the Environment of Care - Risk Management Cycle and provides a forum and clearing house for discussion of pertinent issues and making of recommendations for resolving those issues. As a regular part of the EC/Safety Committee agenda, reports and issues pertaining to Hazardous Materials and Waste Management program are discussed and recommendations are made for program improvement through planning, teaching, implementing, responding, monitoring and improving. Functions of the EC/Safety Committee include: 1) proposing and reviewing policies and procedures, 2) reviewing and revising the County Office of Emergency Service's annual HMMP, 3) updating MSDS documents, 4) updating the "Spill Plan" and 5) evaluating the program. The hospital's leadership and its Community Board shall receive and consider a summary of significant issues, trends, and actions of the Hazardous Materials and Waste Management program, as well as an annual evaluation of the program's effectiveness. Department managers are responsible for ensuring the development and implementation of department specific procedures in coordination with the overall facility plan, for ensuring training of staff on their individual roles and responsibilities consistent with the plan, and ensuring active participation of their department in the implementation of the plan. All staff is responsible for participating in ongoing training, as well as demonstrating core competencies in the subject matter. They must ensure that their behaviors, work practices and operations are safe, responsible and in alignment with facility and departmental procedures, applicable training, and the provisions of this plan. RISK ASSESSMENT Risks associated with the management of hazardous materials and wastes are continually identified and reviewed. Methods utilized include Environmental Tours (EC/Safety) Rounds, product inventory management, the facility's Information Collection and Evaluation System, EC/Safety Committee review, and incident reports. The risk profile includes occupational exposures, site or individual monitoring, fires or chemical reactions, toxic releases to the environment, environmental mishaps, and legal exposures. simc 3 Revised 1110