Decommissioning and Disposal of Health Facilities and Health Technology

OVERVIEW

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for Decommissioning and Disposal of Healthcare Infrastructure and Health Care Technology.

• Part A outlines the national and provincial service and policy context which are the basic determinants of the decommissioning principles;
• Part B contains planning guidance and considerations;
• Part C develops these principles into a series of departmental requirements;
• Part D contains example worksheets and checklists and protocols
• Part E Example Worksheets, Checklists and Protocols

Parts C, D and E are intended to demonstrate how the principles prescribed in Part B can be applied in worked examples. Parts C or D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

POLICY AND SERVICE CONTEXT

Introduction

Healthcare systems are dynamic and constantly changing. Amongst other changes, there are changes in healthcare infrastructure and healthcare technology to meet socio-economic needs and emerging medical requirements.

Healthcare infrastructure is constantly being adapted to meet a population’s healthcare needs. Such adaptation requires alteration of physical infrastructure and construction of new infrastructure. During the alteration or construction of new infrastructure part of or entire old infrastructure becomes redundant and need to be removed from service by decommissioning to be either re-used for other purposes or disposed of.

Health Technology is constantly changing and evolving. This change results in a short life-cycle compared to fixed healthcare infrastructure. Such changes result in old technology being removed from service and posing a health and occupational risk if not properly decommissioned. Health Technology which is out of service might even be re-commissioned for use at less demanding facilities, upgraded or disposed of.

This document provides guidance on procedures to be followed in decommissioning and disposal of healthcare infrastructure and health technology.

Healthcare facilities can generate two distinct waste streams. This document deals only with the waste generated in the decommissioning process and not with the waste generated from the operational waste stream. The terms waste, healthcare waste and healthcare risk waste in this document therefore only refers to forms of decommissioning waste.

Mothballing exists as an alternative to decommissioning. This document does not detail or discuss the requirements and protocols for mothballing.

Regulations, Guidelines, Standards and Definitions

Standards

• This document should be read in the context of the SANS 10248-1 Management of healthcare waste Part 1: Management of healthcare risk waste from a healthcare facility
• The ISO 14001 is the international standard for environmental management of activities
• SANS 10234: 2008 Globally Harmonized System of classification and labelling of chemicals (GHS)

Guidelines

• The Western Cape Guideline for Environmental Management Plans (EMPs) 2005 gives guidance on the development of an EMP for the decommissioning phase of the facility life cycle.
• World Bank’s (1999) EMP Guidelines
• The Department of Water Affairs and Forestry’s EMP Guidelines (CSIR, 2002)
• DEAT Framework for Health Care Waste Management (May 2000)
• Department of Water Affairs & Forestry, 2005. Waste Management Series. Minimum Requirements for the Handling, Classification and Disposal of Hazardous Waste.

Acts and Regulations

• Public Finance Management Act No.1 1999
• Hazardous Substances Act 15 of 1973 and its amendments
• National Environmental Waste Management: Waste Act 59 of 2008, and its amendments
• National Waste Classification and Management Regulations R634 of 2013
• National Waste Information Regulations R625 of 2012
• Regulation R1332 of 3 August 1973 Regulations Concerning the Control of Electronic Products
• Nuclear Energy Act, 1999 (Act 46 of 1999).
• Standard for Infrastructure Procurement and Delivery Management (2016)

Definitions

Healthcare infrastructure, healthcare infrastructure in this document refers to hospital facilities, buildings, wet services, cold and hot water systems, electrical reticulations, Air-conditioning system (HVAC and all its components, split-units and other ventilation systems), plant equipment, catering equipment, IT equipment and any other systems and equipment which form part of the hospital facilities.

Health technology, health technology in this document refers to medical equipment and/or devices, their accessories and any component(s) and or system which may provide a link between equipment and/or devices which is used in healthcare for the purpose of preventing, diagnosing, or treating diseases as well as for monitoring and rehabilitation.

PLANNING FOR DECOMMISSIONING AND RETROFITTING

Background

While engineering systems and components may have a functional life of less than 25 years, healthcare buildings could have a life approaching 50 years. It is therefore likely that equipment and services would need to be decommissioned, retrofitted, revitalised and replaced at least once during the life of a building and these interventions should be planned for.

Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act, Generally Accepted Accounting Practice, Companies Act and Good Corporate Governance Practice.

When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

• Establishment of a disposal management committee.
• Development of and compliance with an Environmental Management Plan (EMP).
• Development and implementation of a risk assessment and hazard control plan.
• Assignment of a clinician and IPC manager with authority to approve or halt construction activities only under defined conditions.
• Power requirements of future expansions and installations.
• Emerging healthcare technologies.
• Space for removal and refitting of equipment.
• Potential and planning for recycling vs disposal of materials.
• Toxicity and environmental impact of gasses, paints and polymers.
• Specific healthcare services risks (IPC etc).
• Occupational Health and Safety Regulations and requirements.

Contamination Control and Risk Planning

A project risk assessment shall be conducted and consider the following aspects:

• Identification of occupancy groups which are susceptible to risks.
• Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
• Need for supplementary protection or support systems for building services.
• Impact on fire protection and response systems and action plans.
• Impact of noise and vibration on occupants and equipment

Opportunistic environmental or airborne microorganisms, allergens or hazardous materials which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk.

Where the environmental and risk assessments identify the need for intervention or mitigating controls, the precautionary matrix described below shall be considered in determining risk levels. The principles of contamination control for high risk sites includes the following:

1. Establishment of rigid non-permeable barriers, between patient or staff and construction activities, during construction with the inclusion of appropriate clean-down ante-rooms where traffic between occupied and construction areas is required.
2. Increased outdoor air equivalent ventilation rates with high ventilation efficiency to areas at risk.
3. Extraction and filtration systems serving the construction area. Where there is chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively recirculated it should be filtered with at least an EN1822-H13 final filter.
4. Establishing a protective pressure cascade or airflow from clean to contaminated zones

With acknowledgement to Nicholas Thorne (Life Healthcare), the following construction risk matrixes provide guidance on undertaking construction, maintenance, retrofitting and decommissioning work, whilst maintaining functionality and safety in a working healthcare facility.

PROCEDURE:

1. Locate risk profile by space-type using Table 1 below
2. Identify intended activity classification using Table 2
3. Determine class of precautionary measures using Table 3.
4. Implement minimum routine precautionary measure guidelines, given in Table 4, before, during and after construction activities commence on-site.
5. Complete “common sense” checks to ensure that adopted measures are sufficient and, where appropriate, provide either reduced or lesser measures.
6. Document and keep a record of descisions and actions

Table: Risk Profile by Space – Type

LOW RISK	MODERATE RISK	HIGH RISK	HIGHEST RISK
Office areas Service areas Plant rooms Kitchens	Rehabilitation Unit Endoscopy Units Nuclear Medicine Physical Therapy Diagnostic radiology/MRI Procedure Rooms	High Care Units/Wards Surgical Units/Wards Trauma / Resuscitation Room Eye Centre Laboratories (specimen) Theatre-non surgical areas Paediatric Units/Wards Pharmacy Surgical Stores	Operating Rooms CSSD Central Sterile Supply Department Cardiac Catheter Lab Intensive Care Units Medical Unit/Wards Any area caring for immuno-compromised patients

Table 2: Activity Classification

TYPE	ACTIVITIES
TYPE A	Inspection and Non-Invasive Activities Includes, but is not limited to: Removal of ceiling tiles for visual inspection limited to 1 tile per 10 square meters Painting (but not sanding) Wall-covering, electrical trim-work minor-plumbing and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.
TYPE B	Small scale, short-duration activities which create minimal dust Includes, but is not limited to: Installation of telephone and computer cabling Access to chase spaces Cutting of dry walls or ceiling where dust migration can be controlled
TYPE C	Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to: Sanding of walls for painting or wall covering Removal of floor coverings, ceiling tiles and casework New wall construction Minor ductwork or electrical work above ceilings Major cabling activities Any activity which cannot be completed within a single work shift
TYPE D	Major demolition and construction projects Includes, but is not limited to: Activities which require consecutive work shifts Requires heavy demolition or removal of a complete cabling system New construction

Table 3: Classification matrix

TYPE	LOW RISK	MODERATE RISK	HIGH RISK	HIGHEST RISK
TYPE A (Non-Invasive/Inspection)	I	II	II	III/IV
TYPE B (Minimal Dust)	I	II	III	IV
TYPE C (Moderate Dust)	I	II	III/IV	IV
TYPE D (Major Demolition)	II	III/IV	III/IV	IV

Table 4: Minimum routine precautionary measures guidelines

	Precautionary Measures Before and During Activity	Precautionary Measures Upon Completion of Activity
Class I	Execute work by methods to minimize liberating dust from construction operations Immediately replace a ceiling tile displaced for visual inspection
Class II	Provide active means to prevent airborne dust from dispersing into atmosphere Water mist work surfaces to control dust cutting Seal unused doors with tape Block off and seal air vents Place dust mat at entrance and exit of work area Remove or isolate HVAC system in areas where work is being performed	Wipe works surfaces with disinfectant Contain construction waste before transport in tightly covered containers Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area. Remove isolation of HVAC system in areas where work is being performed
Class III	Remove or isolate HVAC system in area where work is being done to prevent contamination of duct system Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins Maintain negative air pressure within work site utilizing HEPA filter equipped fan-filter units Contain construction waste before transport in tightly covered containers Cover transport receptacles or carts. Tape covering unless solid lid.	Do not remove barriers from work area until the completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environment Services Department Remove barrier materials carefully to minimize the spread of dirt and debris associated with construction Vacuum work area with HEPA filtered vacuums Wet mop area with disinfectant Remove isolation of HVAC system in areas where work is being performed
Class IV	Isolate HVAC system in the area where work is being done to prevent contamination of duct system Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from the non-work area or implement control cube method (cart with plastic covering and sealed connection site with HEPA vacuum for vacuuming prior to exit) before construction begins Maintain negative air pressure within work site utilizing HEPA filter equipped fan-filter units Seal holes, pipes, conduits and punctures appropriately Construct an anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site they can wear a cloth or paper coverall that is removed each time they leave the worksite All personnel entering the worksite are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area Do not remove barriers from work area until the completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environmental Services Department Perform periodic particle count tests in adjacent occupied spaced during construction as well as bacteriological tests using Agar plates.	Remove barrier material carefully to minimize spreading of dirt and debris associated with construction Contain construction waste before transporting tightly covered containers Cover transport receptacles or carts. Tape covering unless solid lid Vacuum work area with HEPA filtered vacuums Wet mop area with disinfectant Remove isolation of HVAC system in areas where work is being performed Perform deep cleaning and carry out Particle Count testing in completed areas where required.

Identification and responsible disposal of hazardous and toxic materials

Identification of Hazardous Materials

Definition of Hazardous Waste

1. According to the Hazardous Substances Act 15 of 1973 and National Environmental Management Waste Act 59 of 2008 and its amendments, hazardous waste is defined as:“any waste that contains organic or inorganic elements or compounds that may, owing to the inherent physical, chemical or toxicological characteristics of that waste, have a detrimental impact on health and the environment.”
2. The Department of Water Affairs & Forestry, 2005. Waste Management Series. Minimum Requirements for the Handling, Classification and Disposal of Hazardous Waste gives the following rule of thumb for waste classification: “If a waste emanates from a certain industry, for example the medical, metal, agricultural or textile industry, it is probably hazardous”
3. Hazardous waste (HW) can be generated during healthcare decommissioning where:

• Potentially hazardous materials are accidentally damaged, or spilled during decommissioning
• Residues accumulate from processes or pollution abatement activities such as, sludge, or filtration of contaminated dusts.
• Non-reusable or unserviceable parts contain hazardous materials such as in batteries or medical equipment, chemicals, etc.)
• Any materials, substances or products which have been banned by legislation or policy cannot be re-used.
• Any material is burned incinerated, accumulated, stored or treated, prior to disposal.
• Bio-hazardous materials are encountered in the decommissioning process.

Identification of Hazardous Decommissioning Waste

1. The Hazardous Substances Act 15 of 1973, the National waste management regulation R634 of 2013, SANS 10234: 2008 Globally Harmonized System of classification and labelling of chemicals (GHS) and the National Waste Information Regulations R625 of 2012 describe the identification, labelling and division of substances or products into groups in relation to the degree of danger, the prohibition and control of the disposal of substances which may cause injury, ill-health or death by reason of their toxic, corrosive, irritant, strongly sensitising or flammable nature.
2. Health facilities are required to establish complete descriptions of their generated hazardous waste, indicating quantities and composition. This information is to be included in the Hazardous Waste register.
3. This identification and classification is to be carried out according to the National Hazardous Waste Classification System.
4. Proper identification of hazardous waste is important for effective hazardous waste management. Health facilities planners should be aware that hazardous waste can be generated from different sources which can sometimes be overlooked or forgotten by the establishment. This may cause that part of the generated HW would not be registered.
5. For further information on healthcare waste and its identification and handling, the reader is referred to the Waste Disposal guidance article.

Material Safety Data Sheets (MSDS’s)

1. An MSDS must be available for all chemicals in the above categories in all areas where the substances are used, where the waste is generated and where it is segregated.
2. The MSDS must, as a minimum, comply with the format as required by the Occupational Health and Safety Act 85 of 1993 and in an ISO 9000/14000 format.
3. The MSDS must include a section on the classification of the waste according to the Minimum Requirements for the Classification, Handling and Disposal of Hazardous Waste.
4. The MSDS must include a section on the expected environmental fate, if dispersed into the environment, and
5. The preferred disposal options should also be given on the MSDS.

Hazardous Decommissioning Waste Segregation

1. Hazardous waste must be separated at source from non-hazardous waste. Additionally, mixing of different types of hazardous waste must be avoided in order to prevent any undesired or unpredicted harmful reactions between them. The reader is referred to the following for guidance:
   1. Department of Water Affairs & Forestry, 2005. Waste Management Series. Minimum Requirements for the Handling, Classification and Disposal of Hazardous Waste.
2. Proper identification of hazardous waste forms a basis for waste segregation. It is therefore essential that all personnel concerned are competent in relevant waste identification.
3. The segregation process should start at the waste generation points. Effective segregation will facilitate downstream waste management activities and requirements.
4. The reader is referred to the SANS 10248-1 Management of healthcare waste Part 1: Management of healthcare risk waste from a healthcare facility for normative guidance in the requirements for the collection, processing, storage and disposal of healthcare decommissioning waste.

PART E - EXAMPLE WORKSHEETS AND CHECKLISTS AND PROTOCOLS - 30 -

1. Checklist: Infrastructure Decommissioning and Disposal - 30 -

Stakeholder engagement checklist

No	Question	Commentary/Why is this important
1	Have you notified affected providers and offered to meet to explain the rationale and process?	Engaging with affected providers throughout the process is not only good practice may mitigate a legal challenge to the process and decisions at a later stage.
2	Have you analysed the outcome of any such meetings?	Following your meeting (or other form of communication) with the provider you should be able to answer and document the following what is their response? do they want to keep strictly to the terms of the contract? is there any indication of their willingness to agree to a variation in the contractual terms?
3	Have the providers in question attended any workshops that you have run on outcomes bases service/ infrastructure?	If not then they may not be able to understand the change in policy, direction and the context for service delivery. Analyse this and if necessary provide and communicate relevant information.
4	Having gone through these stages, what is your assessment of the provider’s attitude and the chances of reaching a negotiated solution?	It will be important to take stock at regular intervals through the process and to analyse and adjust plans according to the responses and attitudes of provider(s). The objective should always be to reach a negotiated position.
5	Is the provider inflexible?	If no negotiated solution can be found and the provider intends to stick strictly to the terms of the contract, and the contract does not provide any of the flexibility required to achieve services of the required nature, then a risk assessment and impact analysis should be undertaken.
6	Do you need to undertake a risk assessment and impact analysis?	This should include: a cost/benefit analysis Impact of decommissioning the service - effect on service users, provider organisation and on your ability to deliver services.
7	What is the advice of your legal department?	The facility owner’s legal department should be involved in the process.

Stakeholder Financial Review Checklist

No	Question	Commentary/Why is this important?
1	What will be the cost of decommissioning a service/ infrastructure?	This needs to be considered in terms of the potential cost (e.g. breaching or buying out a contract) if the consequences of continuing with the existing contract is limiting or risky in terms of performance or service quality.
2	What will the cost be of not decommissioning the service?	Against this needs to be set the adverse effect on performance judgement if the facility is not making progress with policy initiatives, or is not taking incisive action over services that can be considered of an adequate quality but may be of a poor or outdated service model.
3.	If a provider is completely inflexible have you considered working and discussing this with other facilities that do business with them?	This may help a provider to reconsider their stance and enter into discussion and negotiation to find common ground and agreed solutions.

Additional Stakeholder Review

No	Question	Commentary/Why is this important?
1	What is the quality of the service/ infrastructure?	Is service quality good or acceptable? Is there a risk that if the contract is changed then it might deteriorate? It is important to pay particular attention to process quality (i.e. the service user experience of receiving the service)
2	How effective is the service/ infrastructure, particularly in terms of outcomes? Or has the service/ infrastructure service got the potential and adaptability to be effective in terms of outcomes?	Although the service may not at this point be delivering the outcomes required you need to apply your analytical skills to evaluate whether the service, if changed, has the potential to be effective.
3	Is performance, against agreed measurables, meeting the requirements of, and standards set out in, the service specification?	If this is the case it will bode well for future delivery and effectiveness of services, taken together with other factors that will be looked at as part of any decommissioning / re-commissioning / re-tendering process.
4	Is the demand for the service/ infrastructure commensurate with the service/ infrastructure that the facility is committed to paying for (particularly if this is locked into a block contract)?	If there is no longer the demand for the service, or if the block purchasing of services need to be reduced within the contract period due to the development and implementation of the personalisation agenda, then consider whether there is scope for negotiating with the provider on this point.
5	Do you need to terminate a current contract? Have you sought advice from legal and contract service/ infrastructure?	Has the provider unilaterally changed any elements of the service, withdrawn service or failed to provide services that it is contractually bound to do to any significant or substantial degree? If any of these apply then they can be used as leverage to either ensure compliance or to get the provider to become more flexible and responsive to change contractual requirements.
6	Where you terminate a contract: Are you able to develop decommissioning / transfer / transition plans in conjunction with the provider?	This is vital to effect a smooth transfer and to minimise the impact on service users and staff.
7	Have you got a communication plan?	It is important to communicate well in advance with service users and the press / media, as well as other stakeholders.
8	Have you briefed elected members and other key stakeholders? Who else should you inform or consult with? - Link to stakeholder engagement section	It is important to brief anybody within the governance structure, other stakeholders who might be affected, or where there might be an impact on other services
9	Have you developed a decommissioning / transition / transfer plan?	This should be managed by a programme/project management approach:-Link to decommissioning / transition / transfer plan
10	Have you considered future contracts to ensure that they do not constrain you unduly?	Your contracts may need to be revised to be more flexible and include scope for periodically revising the service specification. Legal advice should be sought and examples sought from other facility.

Laboratory Equipment Decommissioning Checklist

Serial Number: -	Model: -	Manufacturer: -
Description: -	Installation Date: -	Decommissioning date: -
Acceptance Check	Comment	Pass (yes/no)
Is equipment documentation available (acceptance certificate, calibration certificates, service records and final tests)
Hazardous material exposure possible? (Biological, chemical, radioactive and others)
Decontamination procedure
Does the equipment planned maintenance schedule exist
Has the equipment been tested for electrical safety
Does the equipment pass all of the above conditions
Will the equipment be disposed or re-used for other/laboratory purposes
Make sure that all hazards material are disposed as per the disposal procedure for all equipment due for disposal and all equipment to be reused should comply with regulations and license requirements.

Laboratory Facility Decommissioning Checklist

Building Number -						Room Number -
License Number -
Acceptance Check					Comment					Pass (yes/no)
Inform the department of health of the intended decommissioning of the LAB
Decontaminate the room(s) and all exposed facilities of all the hazards?
Will the room(s) be disposed or re-used for other purposes?
Make sure that all hazards material are disposed as per the disposal procedure and all rooms to be reused should comply with regulations and license requirements.

Health Care Technology Decommissioning Checklist

Serial Number: -						Model: -
Manufacturer -						Description
Installation Date -						Decommissioning date -
Acceptance Check					Comment					Pass (yes/no)
Is equipment documentation presented (acceptance certificate, service record, final test )
Decontaminate the room(s) and all exposed facilities of all the hazards?
Reason for decommissioning?
Is the equipment functional?
Is the equipment CE marked?
Is the equipment class and type indicated?
Does equipment have the instruction manual?
Does the equipment pass all of the above conditions?
Will the equipment be disposed or re-used for medical purposes?										Make sure that all hazards material are disposed as per the disposal procedure for all equipment due for disposal and all equipment to be reused should comply with regulations and licence requirements.
Make sure that all hazards material are disposed as per the disposal procedure for all equipment due for disposal and all equipment to be reused should comply with regulations and licence requirements.