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P. Proposition 65: A policy exists to comply with the Safe Drinking Water and Toxic Enforcement Act (Prop. 65) regulations. This purpose of this policy is to ensure minimize/prevent exposure to the identified chemicals and products. To protect the staff, public and environment by identifying chemicals and products utilized in the affiliate and provide the proper notifications. MONITORING THE PROGRAM A. The ongoing monitoring of the Hazardous Materials and Waste Management Program regarding actual or potential risks is based on the Information Collection and Evaluation System (ICES). ICES includes data that is collected from a variety of program components such as the results of inspections, emergency drill critiques, spill incident reports, ongoing monitoring of performance indicators and problem -prone or legal requirements of the program. The hazardous waste coordinator then provides a report to the Environment of Care/Safety Committee that includes a summary of identified issues, trends, needs and opportunities, and proposed resolutions. The Environment of Care/Safety Committee will continue to monitor the Hazardous Materials and Waste Management Program for effectiveness and provide support. B. Based on information that is collected and evaluated, the Hazardous Waste Coordinator will develop performance indicators to measure the process or outcome in high risk, high volume or problem -prone area(s). The performance indicators will be approved by the Environment of Care/Safety Committee and subsequently presented to the integrated quality services committee (quality management committee) via an EOC Report. Utilizing the information collection and evaluation system (ices), the Environment of Care/Safety Committee identifies and communicates one or more performance improvement activities at least annually to the hospital's leaders for consideration and inclusion in the hospital's priority setting for improvements. The vehicle for reporting performance indicators is the quarterly safety EOC Report. C. Departments will be surveyed periodically per regulation. All support service areas will be inspected at least once a year. These surveys will include identification of hazardous materials and waste issues. D. An annual audit of department specific hazardous materials/wastes and procedures are performed. Results are reviewed and deficiencies are corrected. E. Hazardous material drills are conducted on an annual basis to assess and improve staff response to a hazardous materials or waste spill or exposure. F. Annually, the Hazardous Materials and Waste Management Program is evaluated based on its objectives, scope, performance and effectiveness. The Safety Coordinator initiates an annual evaluation of the Hazardous Materials and Waste Management Program by reviewing various indicators, records and reports regarding the overall performance of the Program. This evaluation is submitted to the Environment of Care/Safety Committee for approval and then forwarded to Administration, Quality Management, and the governing board for review and comment. EDUCATION A. Education is one of the important elements of a successful Hazardous Materials and Waste Management Program. Education is determined by problems identified in the performance improvement activities of each department and the Environment of Care/Safety Committee, changes in the Environment of Care and by regulatory and accreditation requirements. B. Employees involved in the handling, storing or disposing of hazardous waste shall: 1. Be trained appropriately based on affiliate's specific requirements. Records of training provided to employees will be documented. Hazardous Materials and Waste Management Plan. Rehieved 3/I6/2022.Official copy at http://sh-s[ch.policystat.com/policy/ page 7 of 8 10532958/. Copyright 8 2022 Sutter Tmcy Community Hospital