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Biohazard waste management : A TQM perspective
Dr Shantanav P Chitnis

A Pilot Project was undertaken in an attempt to streamline the system of Biohazard Waste Management at Ruby Hall Clinic in accordance with the rules and regulations as laid down by the Ministry of Environment and Forests (MOEF), Government of India, vide notification issued at New Delhi on 20th July 1998. This project was instituted using a Total Quality Element approach. A report:

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The project has been described in terms of steps and Quality Control Tools used in the different stages of the PDCA Cycle-Plan, Do, Check and Act,

Plan

As is the norm, this project was initiated by submitting a project proposal to the medical director and obtaining his permission. Thereupon, data collection and analysis regarding the present system of biohazard waste management as part of the plan in the PDCA cycle was initiated. The quality control tools used were the flowchart and the cause-and-effect diagram. The current processes of biohazard waste management were delineated by flowcharting them, and this helped to identify effective points of intervention. From these points, old processes were either modified (segregation at the point of generation of wastes) or rejected and new processes devised (elimination of cardboard boxes to store syringes).

Cause-and-effect diagram

The cause-and-effect diagram, also known as the Fishbone or Ishikawa diagram, is a problem identification tool that organises potential causes of a desirable or undesirable effect. It assists in identifying root causes by asking five times, why a cause exists. Though used usually as a retrospective tool, the diagram was used as a prospective tool to plan for minimising chances of failure of the project. The four broad categories under which possible causes of failure were listed were - people, patrons, provisions and procedures. The various causes were thought up through brainstorming.

Do

As part of the DO of the PDCA Cycle, steps were taken to plan and implement the solution. The crucial point of intervention for preventing mixing up of infectious with non-infectious waste, thereby rendering the entire waste infectious was segregation of wastes at the point of generation. This required proper planning and requisition for various resources; human, financial, material, educational and time. Keeping in mind potential loopholes as envisioned in the cause-and-effect diagram, the entire project was planned out. Quality control tools now used were the Tree Diagram to list out the tasks required to be done and followed up, and Flowcharts to plan out new processes to be followed for waste segregation and waste collection.

The Tree Diagram

The tree diagram shows the complete range and sequence of subtasks required to achieve an objective. They are a variant of “decision trees” which have been used in operations research for many years in decision analysis. The first task that had to be done was that of building awareness regarding the loopholes in the present system of biohazard waste management. The rules laid down by the MOEF, Government of India, were downloaded from the Internet. Copies of the same were made available to the medical director, the nursing superintendent, the sanitation department in-charge, and the in-charge sister of I-ward.

After the project proposal was accepted, a potential team was formed. The in-charge sister, I-ward, headed this team. Team members included all the nursing staff of I-ward, the medical director, the nursing superintendent and the sanitation department in-charge acted as de facto consultant. New processes were developed through brainstorming by all the consultants, the team leader and the facilitator, and documented. These were later modified based on suggestions by some team members. The original document was amended five times before the final draft was produced. Salient points regarding segregation of wastes were collected into a checklist and distributed to all the 14 staff nurses of I-ward.

It was decided to use colour-coded bins as per Schedule II of the Rules Bins of three colours, blue, yellow, and black would be used, depending on biomedical waste category as laid down in the same schedule. It was decided that yellow bins lined with polythene bags would be used for all non-recyclable, infectious waste, blue bins would be used for all recyclable, infectious waste, and black bins would be used for all general, non infectious waste. The colour-coded bins would be stationed in the dirty utility room. Whenever it was required that a dressing be done, two trays would be prepared simultaneously; one holding the sterile items and another for carrying back old/ discarded swabs, gauze pieces, gloves, etc. When the dressing was over, both trays would be carried to the dirty utility to discard their contents into the yellow bin, while the gloves would be cut and deposited into the blue bin. When IV fluids were withdrawn, it would be the duty of the nursing staff doing so, to carry the patient’s IV tubing and IV bottle back to the dirty utility room, where it would be cut before disposal into the blue bin. Urobags, blood bags, romavac sets, post operative drainage bags, syringes, after cutting their nozzles, would all be treated similarly.

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(The author can be contacted at chitnis2000@hotmail.com)

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