The audit focused mainl! on management and s!stem controls relating to waste management. The audit was carried out at the national district hospital, department of health, Free State province. Findings point out e-amples of the conse"uences of deficient management measures as well as non&adherence to the applicable laws, regulations and procedures. It is hoped that this report will give rise to corrective steps, which will contribute constructivel! to the establishment and implementation of proper management measures.
The audit focused mainl! on management and s!stem controls relating to waste management. The audit was carried out at the national district hospital, department of health, Free State province. Findings point out e-amples of the conse"uences of deficient management measures as well as non&adherence to the applicable laws, regulations and procedures. It is hoped that this report will give rise to corrective steps, which will contribute constructivel! to the establishment and implementation of proper management measures.
The audit focused mainl! on management and s!stem controls relating to waste management. The audit was carried out at the national district hospital, department of health, Free State province. Findings point out e-amples of the conse"uences of deficient management measures as well as non&adherence to the applicable laws, regulations and procedures. It is hoped that this report will give rise to corrective steps, which will contribute constructivel! to the establishment and implementation of proper management measures.
REPORT OF THE AUDITOR-GENERAL ON A SUSTAINABLE DEVELOPMENT AUDIT OF
MEDICAL WASTE AT THE NATIONAL DISTRICT HOSPITAL, DEPARTMENT OF
HEALTH, FREE STATE PROVINCE FOR THE 2002-2003 FINANCIAL YEAR 1. PURPOSE AND CONTENT OF THE REPORT 1.1 The purpose of this report is to bring the findings of the audit regarding the handling, storage and transportation of medical waste at the National District Hospital, Department of Health, Free State Province to the attention of the Free State egislature. The content of the report is based mainl! on the re"uirements of sections # and $ of the %uditor&'eneral %ct, 1(($ )%ct No. 1* of 1(($+ )%ct+. 1.* ,wing to time constraints an all&encompassing investigation was not conducted, nor would it be practicable. However, sufficient auditing was done to provide sufficient audit evidence for the findings contained in this report. The findings contained in this report point out e-amples of the conse"uences of deficient management measures as well as non&adherence to the applicable laws, regulations and procedures and should not be regarded as comprehensive. 1.# .t is hoped that this report will give rise to corrective steps, which will contribute constructivel! to the establishment and implementation of proper management measures as well as adherence to the applicable laws, regulations and procedures in the interests of the environment. 2. AUDITING CONCEPTS AND APPROACH *.1 The primar! ob/ective of a sustainable development audit is to focus on activities that ma! have an impact on the environment )air, water, soil, natural resources, fauna, flora+ and humans. *.* The audit focused mainl! on management and s!stem controls relating to waste management. Section # of the 0nvironmental 1onservation %ct, 1(2( )%ct No. 3# of 1(2(+ refers to re"uirements to establish whether environmental polic! is being complied with. *.# The 0nvironment 1onservation %ct, 1(2( )%ct No. 3# of 1(2(+ mandates the 4inister of 0nvironmental %ffairs and Tourism in terms of section *)1+ to determine the general polic! to be applied with a view to5 )a+ the protection of ecological processes, natural s!stems and the natural beaut! as well as the prevention of loss of biological diversit! in the natural environment6 )b+ the promotion of sustainable utilisation of species and ecos!stems and the effective application and re&use of natural resources6 )c+ the protection of the environment against disturbance, deterioration, defacement, poisoning, pollution or destruction as a result of man&made structures, installations, processes or products or human activities6 and )d+ the establishment and maintenance of acceptable living environmental needs of communities. *.7 The 1onstitution determines in section *7 that, amongst others, ever!one has the right& 8to an environment that is not harmful to their health or well&being6 and to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that& )a+ prevent pollution and ecological degradation6 )b+ promote conservation6 and )c+ secure ecologicall! sustainable development and use of natural resources while promoting /ustifiable economic and social development.9 *.$ The 'reen Paper on a New 0nvironmental Polic! for South %frica was released for comment during ,ctober 1((:. %ccording to the green paper, there was no overarching environmental polic! that reflected the view of the new democratic government. %s a result environmental concerns were not ade"uatel! ta;en into account in man! important areas of polic! and government administration. .t also states that government is accountable for the implementation of all aspects of environmental polic!. *.: The <hite Paper on 0nvironmental 4anagement Polic! for South %frica )white paper+ was published on *2 =ul! 1((3. .t contains, amongst others, the following provisions, which are particularl! relevant to the financial reporting aspects of environmental auditing5 *.:.1 8Full cost accounting5 Decisions must be based on an assessment of the full social and environmental costs and benefits of policies, plans, programs, pro/ects and activities that impact on the environment.9 *.:.* 8Polluter pa!s5 Those responsible for environmental damage must pa! the repair costs both to the environment and human health, and the costs of preventative measures to reduce or prevent further pollution and environmental damage.9 *.:.# 8To report periodicall! on the state of the South %frican environment5 )a+ To provide accurate, timel! and accessible information about the condition and prospects of the South %frican environment. )b+ To increase public understanding of these issues. )c+ To report on the effectiveness of policies and programs designed to respond to environmental change, including progress towards achieving environmental standards and targets.9 *.3 .t is not the %uditor&'eneral>s function to "uestion polic!. .t is, however, his responsibilit! to investigate the effect of polic! and the management measures that lead to polic! decisions. 3. SCOPE #.1 The audit carried out at the department focused on s!stems and processes to establish if reasonable measures were put in place )refer to section *2 of the National 0nvironmental 4anagement %ct, 1((2 )%ct No.1?3 of 1((2++ regarding medical waste @ handling, transportation and disposal. The following was specificall! covered5 )a+ Documentation review5 0valuating the management process in terms of the e-istence of policies, standard wor;ing procedures, and resources, monitoring and control6 )b+ Ph!sical inspection5 To establish the e-tent of compliance with the applicable legislation6 )c+ Disposal of e-pired medicine5 To focus on the procurement process and disposal thereof6 )d+ Process and control measures5 Should be put in place to mitigate an! impact on or harm to the environment andAor humans. #.* 0nvironmental law is a vast group of legal norms put together and forms an integral part of the management process. %n! legal principle, which relates to environmental management, whether directl! or indirectl!, or which has an actual or potential impact on the environment, should fall within the purview of environmental law. The most appropriate legislation relating to the aspects and impacts identified during planning and e-ecution of the audit was considered. egislation and other legal provisions considered, include5 & 1onstitution of South %frica, 1((: )%ct No. 1?3 of 1((:+ & National 0nvironmental 4anagement %ct, 1((2 )%ct No. 1?3 of 1((2+ & 0nvironmental 1onservation %ct, 1(2( )%ct No. 3# of 1(2(+ & ,ccupational Health and Safet! %ct, 1((# )%ct No. 2$ of 1((#+ & 4edicines and Belated Substances 1ontrol %mendment %ct, 1((3 )%ct No. (? of 1((3+ & HaCardous Substances %ct, 1(3# )%ct No. 1$ of 1(3#+ & Health %ct, 1(33 )%ct No. :# of 1(33+ & 1ompensation for ,ccupational .n/uries and Diseases %ct, 1((# )%ct No. 1#? of 1((#+ #.# The environmental audit was conducted in accordance with generall! accepted government auditing standards as well as the internal guidelines for the planning, e-ecution, reporting and follow&up of performance audits. .NT,S%.>s D'uidelines on 1onducting %udits of %ctivities with an 0nvironmental PerspectiveD too; account of environmental issues in regularit!, performance and compliance auditing. Paragraph *1? of the said guideline classifies performance audit with an environmental focus as one of the following five specific t!pes, namel!5 & %udits of government monitoring of compliance with environmental laws6 & %udits of the performance of government environmental programmes6 & %udits of the environmental impact of other government programmes6 & %udits of environmental management s!stems6 & 0valuations of proposed environmental policies and programmes #.7 The S%%S Statement, DThe 1onsideration of 0nvironmental 4atters in the %udit of Financial Statements9 )S%%S *$?1+, provides guidance to the audit team to enable them to establish whether the reporting entit! had appropriatel! recognised, valued and reported environmental costs, liabilities )including contingent liabilities+ and assets. ,nl! if, in the auditor>s /udgement, environmental matters ma! have a material effect on the financial statements of an entit!, should significant policies and procedures in respect to its monitoring of, and control over these environmental matters be ta;en into account in order to plan and develop an effective audit approach. .t is believed that the report that will be derived from an environmentalAperformance audit will assist the regularit! auditor in hisAher consideration of environmental matters in the auditing of financial statements. 4. OVERVIEW 7.1 %s mentioned above, the handling and disposal of medical waste is of importance to staff at hospitals and the public. Staff at hospitals do not wish to handle medical waste more than once or to dispose the waste in unsafe containers where used needles could pric; them. This ris; lin;s more closel! to occupational health and safet! issues. ,n the other hand, the public does not wish to find medicalAinfectious waste on general landfill sites, or used needles penetrating plastic refuse bags and in/uring the municipal waste removers. The above&mentioned issues could all result in severe harm to public servants and the public. 4edical waste generall! contains blood, human tissue, materials that are covered with blood or other bod! fluids and sharps. .f these infectious contents are disposed of at a landfill site it could have a potential or actual impact on the water andAor soil. This theme slot in with the definition of 8environment9 as indicated in the National 0nvironmental 4anagement %ct. The term 8environment9 is namel! defined ver! broadl! in terms of current statutes, and includes not onl! the natural environment and the impact on ecos!stems, fauna and flora, and natural resources, but also the environment and human health, safet! and welfare. )See section 1 of the National 0nvironmental 4anagement %ct, No. 1?3 of 1((2 and section 1 of the 0nvironment 1onservation %ct, No. 3# of 1(2(.+ 7.* Pollution is in turn defined broadl!. The National 0nvironmental 4anagement %ct for instance defines it as involving an! change to the environment caused b! substances, radioactive or other waves, noise, odours, heat or dust emitted from an! activit!, including storage or treatment of waste or substances, construction and the provision of services. This change must have had an adverse effect on human health or well being or on ecos!stems, or on materials useful to people, or have such an effect in future )section 1)1+)--iv++. Note that there is a separate statutor! definition for water pollution in the National <ater %ct, No. #: of 1((2. 5. EY FINDINGS AS WELL AS COMMENTS OF THE ACCOUNTING OFFICER AND CORRECTIVE STEPS ENVISAGED BY HIM 5.1 N! "#$!"%& '#() *!" (+,"-,$. &)!$'/ No records could be submitted for medicine stoc; and e-pired medicine at the National District Hospital in Eloemfontein. This indicates a lac; of ade"uate andAor sufficient internal controls in respect of medicine stoc; and e-pired medicine in the pharmac!, thus ma;ing it impossible to establish the nature and e-tent of e-pired pharmaceutical stoc; being ;ept in the pharmac! at the National District Hospital. M,0,1#-#0) $!--#0)/ %t the beginning of ,ctober *??*, the pharmacist at the hospital implemented the bin cards )rac; cards+ s!stem, in order to control and ;eep record of the amount of medicine received and issued from the medicine store. %lthough she did not ;now of an! record that should be ;ept for the e-pired stoc;, a file has been opened to ;eep record of e-pired medicine in future and the e-pired medicine will be ;ept separate from the other stoc; and reported upon on an annual basis. 5.2 I023". !0 %3). "#14&)#"/ The in/ur! on dut! register has been scrutinised to view the e-tent of needle pric; in/uries reported at the National District Hospital, but the nature of an in/ur! was not recordedAindicated in the register. .t was thus not possible to establish the nature of in/uries on dut! at the National District Hospital and the e-tent of certain t!pes of in/uries. M,0,1#-#0) $!--#0)/ %n additional column will immediatel! be added on the in/ur! on dut! )..,.D+ register, for the inclusion of details in respect of the t!pe and e-tent in/uries sustained. 5.3 T",40401/ No official action plan or programme e-ists for the formal training of staff with regard to environmental issues, health haCards and occupational health and safet! issues. No evidence could also be obtained to establish if training needs with regard to the said issues were assessed at the institution. .nsufficient training could lead to5 )a+ Personnel are not alwa!s being aware of legal and safet! re"uirements, which could lead to in/uries and possible claims. )b+ .n/uries and possible claims against the department. )c+ .nade"uate levels of technical and environmental e-pertise at the institution. M,0,1#-#0) $!--#0)/ %ccording to the training official training needs have been identified and nomination were made and sent through to Personnel Development but response has not been received. The nominees will then be responsible for training the other personnel in respect of health and safet! at the hospital )on the /ob training+. 5.4 E5,63,)4!0 !* $!-(64,0$# 74)+ #054"!0-#0),6 6#14&6,)4!0/ No provision has been made in the medical waste action plan for the National District Hospital to evaluate the institution>s compliance with the environmental legislation and regulations to prevent an! form of non&compliance with legislation in this regard. M,0,1#-#0) $!--#0)/ Nursing management has been re"uested to liaise with the environmental officer at the hospital )National+ to organiCe a wor;shop, with a view of implementing a s!stem that will monitor and evaluate the institution>s compliance to environmental legislation and regulations. 5.5 G#0#",)!" !* 7,&)#/ )a+ The National District Hospital does not alwa!s have direct access to a database regarding applicable legislation, regulations and procedures relating to the control, pac;aging and disposal of medical waste and other environmental legislation, thus ma;ing it impossible for all potential role pla!ers in respect of environmental issues to have access to applicable legislation. .t was further noted that the department was not in all instances aware that the! retain the ultimate responsibilit! for ensuring that waste is handled, stored, transported and disposed of in an environmentall! sound and responsible manner. )b+ .t was noted that a private firm is utilised to remove medical waste from the National District Hospital. No documentation of assessment could, however, be obtained to establish if the National District Hospital ensured that the private firm complies with environmental legislation before ma;ing use of their services. %lthough a private firm removes the medical waste the responsibilit! for compliance with environmental legislation remains with the originator of medical waste. )c+ No control register e-ists for the collection of medical waste b! the private firm. .t could therefore not be established whether follow&ups of outstanding waste manifests were done and whether the copies of waste manifests were alwa!s returned to the point of origin once the waste had been disposed of at a suitable permitted facilit!. This, inter alia, increased the ris; that manifests could be misplaced. M,0,1#-#0) $!--#0)/ 4anagement has tas;ed an official to obtain the 1Ds and hardcopies of the relevant legislation from the Department of <ater %ffairs, the official responsible for maintenance and casualt! department over the wee;ends has been assigned to contact other areas utiliCing the same waste management firm. % register will be implemented for the different t!pes of medical waste that is being removed from the institution and the monthl! infection control reports will include the report of inspections performed to monitor compliance, including compliance b! the private firm. No historical investigation of the private firm was performed, as the National Hospital does not have the capabilities to conduct such an investigation. However, the private firm responsible for the removal of medical waste at the National Hospital complies with legislation for waste removal. 5.8 S#(,",)4!0 !* -#%4$,6 ,0% -304$4(,6 7,&)#/ .t was noted during a visit to the National District Hospital that medical waste was mi-ed with other household )municipal+ waste and that the access to medical waste was not restricted. The following shortcomingsAdeficiencies identified, could give rise to various ris;s, namel!5 & 4edical waste )red bags and sharps containers+ is being stored in an unrestricted area. The area is accessible to passers&b! and could lead to serious health haCards and potential legal claims against the department. & %sh from the incinerator has been stored in metal containers in an unrestricted area since November *??*. This ash cannot be disposed of in the Free State Province and has to be transported to one of the two approved waste disposal sites in South %frica. The metal containers are accessible to passers&b!, while the ash in the metal containers can be regarded as haCardous. .t was noted that a crFche is situated within wal;ing distance of these metal containers and medical waste. The possibilit! of children coming into contact with the medical waste and incinerator ash cannot be ruled out since medical waste, sharps and incinerator ash are not being ;ept in a restricted area as re"uired. This state of affairs could lead to serious health in/uries and liabilit! claims against the department. - .nspection of household refuse bags revealed that medical waste is in certain instances placed in blac; refuse bags that are reserved for household waste onl!. The grading of the 4angaung ocal 4unicipalit! landfill site does not allow for disposal of medical waste. %ccording to a letter from the 4angaung ocal 4unicipalit! dated *( 4a! *??* the management of the National District Hospital were informed that medical waste was found in refuse bags for household waste during a visit to the hospital. The hospital was also informed that the removal of household waste would be suspended until the situation had been rectified. This had the implication that household waste would also have to be removed b! the firm responsible for the removal of the medical waste at a higher cost. This situation has not been rectified to date and the municipalit! has not !et resumed the tas; of removing household waste. M,0,1#-#0) $!--#0)/ The head of administration has been instructed to inform the maintenance section to clear rooms at a building not in use. The rooms will be used for storing red&bags and sharps container and loc;s will be provided. Guotations will be obtained as well to fence a certain area for blac; household bags. The "uotations from the two ash disposal sites in the countr! have been re"uested to dispose of ash ;ept at the hospital grounds, the process commenced in %pril *??# alread! but no response has been received to date. The ashes will be removed as soon as the "uotation process has been finaliCed and the head of administration will give monthl! feedbac; on the progress. Household wastes will as from the beginning of =une *??# be placed in transparent bags, and the entire medical waste the bags will be incinerated. 5.9 E054"!0-#0),6 (!64$./ Section *2 of the National 0nvironmental 4anagement %ct, 1((2 )%ct No. 1?3 of 1((2+ sets a re"uirement that an environmental management s!stem, based on the principles of .S, 17??1, should be implemented b! institutions. To date, no departmental environmental polic! which inter alia ma;es provision for an environmental management s!stem has been formulated and implemented at the National District Hospital. Thus there is no ade"uate polic! in place to address following environmental issues5 & prevention of pollution6 & promotion of sustainable development6 and & compliance with environmental legislation. <ith no proper environmental management s!stem in place and a general lac; of capacit! in the management of health care waste on the establishment of the National District Hospital, compounded b! limited financial and personnel resources, the enforcement of current legislation, regulations and procedures is, at best, reactive and not proactive. %n environmental information s!stem, based upon re"uirements b! regulators or the hospital>s own evaluation of environmental ris;s, was not maintained and the following could not be obtained5 & reports issued b! and correspondence with regulator! and enforcement agencies6 - reports issued b! environmental e-perts about the hospital, such as site assessments or environmental impact studies. M,0,1#-#0) $!--#0)/ There is no structure in the staff establishment at National to implement environmental management s!stem. Nursing management has been instructed to re"uest the environmental officer to conduct a wor;shop on s!stems that should be in place and how the! should be implemented. The recommended structure after the wor;shop will be forwarded to the H,D for implementation. 5.: L#1,6 $!5#",1# ,1,40&) $6,4-&/ No polic! documentation regarding emplo!ee claims in respect of occupational in/uries and disease could be obtained and it is not clear in which manner emplo!ee claims are being handled in this regard. M,0,1#-#0) $!--#0)/ There are no procedures available at the National Hospital, this matter has been forwarded to the provincial health and safet! unit to give necessar! proceduresAguidance and should there be no response b! the end of =une *??#, the legal unit in the H,D>s office will be contacted. 5.; O"1,04&,)4!0,6 &)"3$)3"#/ The organisational structure of the National District Hospital was obtained and it was noted that no provision had been made for the environmental positions, with the result that no individuals were identified for environmental control functions and duties. The waste management action plan indicates certain actions to be performed b! different ran; groups to achieve the set ob/ectives in the action plan. However, none of the dut! sheets obtained, indicates the actions to be performed in terms of the plan. .t is therefore doubtful if the waste management plan has !et been implemented, although it was signed on 1? September *??*. No dut! sheet could be obtained for a refuse department manager, and no such position was noted in the organisational structure. .t is therefore not clear which official will be responsible for the performance of the tas;s allocated to the refuse department manager in the waste management plan. M,0,1#-#0) $!--#0)/ Befer to comments made on point no. $.2 above. 5.10 I0$40#",)!" ,) )+# N,)4!0,6 D4&)"4$) H!&(4),6/ The incinerator at the National District Hospital had been in use until appro-imatel! November *??*. No certificate for the operation of the incinerator at the National District Hospital as re"uired b! section ( of the %tmospheric Pollution Prevention %ct, No. 7$ of 1(:$ could be obtained. % letter dated 1* 4arch *??1, issued b! the Department of 0nvironmental %ffairs and Tourism, was obtained from the 4angaung 4unicipalit! indicating that the incinerator at the National District Hospital did not compl! with all set standards of the %tmospheric Pollution Prevention %ct No. 7$ of 1(:$. Nevertheless the incinerator was utilised until appro-imatel! November *??*. The dut! sheet of the operator of the incinerator during *??* was obtained and scrutinised. The dut! sheet does not indicate that the official has been appointed to perform an! tas;s regarding the incineration of medical waste. The facts that the operator of the incinerator was not appointed in writing to perform such a tas;6 the incinerator did not compl! with all set standards6 and no certificate to operate the incinerator at the National District Hospital could be obtained could lead to liabilit! claims, should the official contract an! disease that could be related to the duties performed in the incineration process. .t was however not possible to establish if the official wore all the necessar! protective e"uipment and clothing during incineration since the incinerator had been damaged and had not been in use since November *??*. M,0,1#-#0) $!--#0)/ The use of the incinerator has been discontinued and should there be a need for the National Hospital to use the incinerator, the above mentioned recommendations will be implemented. 5.11I66#1,6 %3-(401/ .t was observed that waste was dumped appro-imatel! 1?? metres from the medical waste collection point. %ccording to section *? )1+ of the 0nvironment 1onservation %ct No. 3# of 1(2( no person shall establish, provide or operate an! disposal site without a permit issued b! the 4inister of <ater %ffairs. No such permit for this dumping areaAsite could be obtained and it is therefore regarded as an illegal dumping site. 0mpt! chemical bottlesAcontainers were also noted in this dumping area. 0mpt! chemical bottlesAcontainers were also noted at the bac; of the pharmac! and this is also regarded as illegal dumping since these bottlesAcontainers are regarded as haCardous waste and should be disposed of as such. The necessar! permit for this dumping areaAsite could also not be obtained and the area is therefore also regarded as an illegal dumping site. M,0,1#-#0) $!--#0)/ The garden service has been instructed to remove the waste dumped on the hospital grounds and ensure that the empt! chemical bottles are sent for re&c!cling. These bottles have been standing in the area for more than *? !ears, the "uotation process will be followed to remove these chemical bottles. 8. APPRECIATION . would li;e to e-press m! appreciation of the courtes! e-tended and assistance rendered b! the staff of the Department of Health during the audit. E.=.H. van Nie;er; for: %uditor&'eneral Eloemfontein ** =ul! *??#