Policies,Administrative,UW Health Administrative,Material Management

Medical Waste Reduction Policy (5.33)

Medical Waste Reduction Policy (5.33) - Policies, Administrative, UW Health Administrative, Material Management


Page 1 of 3

Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Medical Waste Reduction Policy
Policy Number: 5.33
Effective Date: May 1, 2017
Chapter: Materials and Environmental Management
Version: Revision

The purpose of this policy is to work toward the reduction of medical waste in accordance with
Administrative Code NR526.


This policy establishes guidelines for the reduction of medical waste. It includes provisions for auditing
waste management practices, preparing and implementing medical waste reduction plans and assessing
plans for progress toward achievable goals.
Medical Waste-means infectious waste, as defined in s.159.07(7)(c)1.c.,Stats., and other waste that
contains or may be mixed with infectious waste. [s. 144.48(1)(b), Stats., as amended in 1991 Wisconsin
Act 39] (Containers, packages, and materials that contain infectious waste from a patient treatment area).
Medical Waste Generation Rate (clinics) – means the rate at which the clinic generated medical waste
during the 12 months covered by the audit. The waste generation rate shall be calculated by taking the
annual amount of waste in pounds, divided by 365 days, divided by the number of medical waste
generating rooms.
Medical Waste Generation Rate (hospital) – means the rate at which the hospital generated medical waste
during the 12 months covered by the audit. The waste generation rate shall be calculated by taking the
annual amount of waste in pounds divided by the total patient days same year.
A. Auditing Waste Management Practices
1. A waste audit must be conducted for each medical waste generating facility. The purpose
is to establish a baseline and to measure efficiency of the Medical Waste Reduction Plan.
UW Health shall complete this audit at least initially and every five years thereafter for
the whole medical facility or more frequently for any part of the facility if there has been
a significant change in solid waste characteristics or amounts of solid waste generated.
Audit results will be kept at the facility for a period of five years and be available to the
Department of Natural Resources (DNR) upon request.

Page 2 of 3

2. The waste audit shall contain the following information:
a. Source areas
i. The waste audit shall identify all areas within the medical facility where
solid waste, not just medical waste, is generated.
b. Waste types
i. The waste audit shall identify the types of waste that are generated within
each source area. These waste types may be: medical waste, hazardous
waste, recyclable materials and other solid waste
c. Quantity of medical waste
i. The waste audit shall identify how many pounds of medical waste the
medical facility, as a whole, generating during the previous 12 months.
d. Medical waste generation rate
i. The waste audit shall identify the rate at which the medical facility
generated medical waste during the 12 months covered by the audit.
e. Waste management practices
i. The waste audit shall identify how the medical waste is collected, stored,
transported and treated from point of generation to point of final
disposal, including any medical waste discharged to the a publicly owned
wastewater treatment system. The audit shall identify how non-infectious
waste was prevented from being mixed with infectious waste and any
waste types that are currently or may be mixed with infectious waste.
ii. After the review, the facility manager’s Medical Waste Reduction Plan
will be evaluated for improvement opportunities. Any changes will be
recorded and submitted with the progress reports to the DNR each year.
B. Medical Waste Reduction Plan
1. The Safety Director will ensure preparation of a waste reduction plan template that will
minimally include the following:
a. Goals and Objectives – the plan must list goals, objectives and a timetable for
reducing waste. Goals must include the following:
i. Meeting a target waste generation rate
ii. Preventing the mixing of infectious waste with non-infectious waste
iii. When practical, reducing the use of disposable items
iv. Maintain an effective plan through training, monitoring and assessment
2. The Facility Manager is responsible for completing the template, saving it for site
retention and sending an electronic copy to Safety by the end of January each year.
C. Baseline and Past Practices
1. The plan must briefly describe those practices used before the most recent waste audit
and any past efforts to reduce medical waste. It must also describe how alternatives to
disposable items were being evaluated, how medical waste management costs were being
estimated, if generation rate and manifest records were maintained and which positions
were responsible for implementing each of these activities.
D. Waste Management
1. The plan must include procedures for the collection, storage and transportation of
medical waste; including any medical waste discharged into publicly owned wastewater
treatment system. It must also state how it intends to prevent the mixing of noninfectious
waste with infectious waste.
E. Alternative to Disposable Items
1. The plan must include procedures for evaluating alternatives to disposables when
purchasing medical supplies.
F. Public Education

Page 3 of 3

1. Patients and visitors who have access to medical waste must be educated on the facility’s
waste disposal practices. Education may include labels on waste containers, educational
pamphlets or verbal instruction.
G. Staff Training
1. Initial and annual training will be done with all appropriate staff and providers with
regard to medical waste reduction plans, policies, goals and objectives.
H. Monitoring and Assessment
1. The plan must include procedures for doing all of the following:
a. Keeping waste manifests onsite for a period of at least 5 years
b. Inspecting waste containers periodically and enforcing the waste reduction plan
c. Reviewing the contents of the Medical Waste Reduction Policy every 5 years and
the waste reduction plan annually
d. Monitoring the medical facility annually for changes which would make it
necessary to repeat the waste audit
e. Reviewing the process of plan implementation annually
f. Assessing progress toward goals and objectives annually
g. Updating the policy and plan as necessary or at least every 5 years
h. Preparing and submitting progress reports as required by the DNR
I. Positions
1. The plan must identify employee positions that will be responsible for each of the
following activities:
a. Preparing the plan
b. Evaluating and implementing alternative waste management practices
c. Evaluating and implementing alternatives to disposables
d. Education, training and the activities associated with monitoring and assessment


Administrative Code NR526 (Medical Waste Management)
Wisconsin Act 335 – Waste Reduction and the Law

Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Safety

Approval Committee(s): UW Health Environment of Care Safety Committee; UW Health Administrative
Policy and Procedure Committee


Elizabeth Bolt
UW Health Chief Administrative Officer

Revision Detail

Previous revision: 122015
Next revision: 052020