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ttjoseph's 'tedical Center A n�nn4.er of 1:H1�' 1. Environmental tour findings relative to hazardous materials and wastes; 2. Inspections and findings, both internal and Regulatory Agency driven; 3. Spills, releases, and other emergencies; 4. Surveillance measures; 5. Occupational exposures; and 6. Substitution or reduction efforts. The manner in which the monitoring activities are conducted is in accordance with organization's quality improvement guidelines, in the Plan Do Check Act model. The Safety Committee, Integrated Quality Council, the Medical Executive Committee, and the Governing Board review results of the monitoring activities. PROGRAM EVALUATION On an annual basis, the Hazardous Materials & Waste Management Program is evaluated relative to its goals, objectives, scope, effectiveness and performance. This evaluation process is coordinated through the EC/Safety Committee, in conjunction with the Safety Officer, and other positions as appropriate. The continued appropriateness and relevance of identified program goals and objectives are assessed, as well as whether or not these objectives/goals were met. Processes and methodologies used to achieve and assess the objectives/goals are also reviewed for appropriateness and effectiveness. The scope of the plan is evaluated relative to Hazardous Materials & Waste management program operations, processes, activities and response. In addition, the program, equipment, technologies and systems are evaluated to ensure continuous regulatory compliance. The performance dimensions are reviewed to evaluate expectations of performance attainment, measurement techniques, process stability and improvement efforts and outcomes. To this end the EC/Safety Committee utilizes qualitative as well as quantitative tools (for example, rate, ratio, index, percentage, etc) that provide an indication of the organizations performance in facilitating improvement. The year is reviewed retrospectively to determine the extent to which the program was effective in meeting the needs of patients, visitors, staff and the organization, within the parameters of the given scope and goals/objectives. This analysis includes initiatives, accomplishments, problem solving, examples and other evidence of effectiveness. The result of the evaluation is used to form the basis for program improvement, goal setting, planning, validating progress and closure, and verifying continued applicability of program objectives. The evaluation report once approved by the EC/Safety Committee is presented to the Community Board and Hospital Leadership at their next scheduled meetings. simc R Revised 1/10