S02_Attachment_7_VHA_Directive_7707_VHA_GEMS.pdf

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Department of Veterans Affairs VHA DIRECTIVE 7707 Veterans Health Administration Transmittal Sheet Washington, DC 20420 December 29, 2015

VHA GREEN ENVIRONMENTAL MANAGEMENT SYSTEM (GEMS) AND

GOVERNING ENVIROMENTAL POLICY STATEMENT

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Green Environmental Management System (GEMS) Directive establishes policy to conform to Department of Veterans Affairs (VA) Directive 0057, VA Environmental Management Program.

2. SUMMARY OF MAJOR CHANGES: This VHA Directive updates policies and responsibilities for the VHA GEMS Program.

3. RELATED ISSUES: VHA GEMS Guidebook.

4. RESPONSIBLE OFFICE: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the contents of this Directive. Questions may be directed to the Director, Occupational Safety, Health and GEMS Programs (10NA8) at 202-632-7889.

5. RESCISSIONS: VHA Directive 2005-011, dated March 7, 2005, is rescinded.

6. RECERTIFICATION: This VHA Directive is scheduled for recertification on or before the last working day of December 2020.

David J. Shulkin, M.D.

Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publications Distribution List on 12/30/2015.

December 29, 2015 VHA DIRECTIVE 7707

VHA GREEN ENVIRONMENTAL MANAGEMENT SYSTEM (GEMS) AND

GOVERNING ENVIROMENTAL POLICY STATEMENT

1. PURPOSE

This Veterans Health Administration (VHA) Directive establishes VHA environmental policy. It also establishes VHA Green Environmental Management System (GEMS) as the primary approach for addressing environmental performance in a manner that meets the requirements of Federal, State and local environmental statutes and regulations; applicable Executive Orders and VA and VHA Directives. AUTHORITY:

42 U.S.C. 4321 and 4332.

2. BACKGROUND

VHA’s primary mission is to deliver quality health care to our Nation’s Veterans. In accomplishing this mission, VHA is committed to operating in compliance with applicable environmental regulations and executive orders to protect and improve the environment. Implementation of GEMS will ensure VHA facilities take the necessary actions to integrate sound environmental compliance and sustainability practices across VHA organizations, activities, and services.

3. POLICY

It is VHA policy that parent facilities and designated appropriate facilities shall maintain a GEMS program encompassing the sites under their control. VHA organizations not affiliated with a VA medical facility or a VA Central Office parent organization shall develop and implement GEMS at all designated facilities. It is VHA policy that GEMS programs will be operated in a manner that ensures compliance with relevant environmental standards; increases the efficiency of energy, water and other resource usage; helps reduce regulated air emissions; utilizes pollution prevention principles; incorporates environmentally preferable practices for the design, construction and operation of buildings; and ensures that VHA facilities are good neighbors in the local communities. All VHA facilities will comply with all Federal, State, and local environmental statutes and regulations and other environmental requirements described in applicable VA Directives, VHA Directives, and Executive Orders (EO).

4. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for:

(1) Ensuring that all VHA-designated appropriate facilities develop and implement GEMS Programs to comply with all applicable Federal, State, and local environmental statutes and regulations and other environmental requirements, such as appropriate VA Directives, VHA Directives and Executive Orders.

(2) Ensuring that adequate funding is available to staff and train environmental personnel, VISN GEMS Managers, and GEMS Program Managers at appropriate facilities, and to fund appropriate environmental projects.

VHA DIRECTIVE 7707 December 29, 2015

(3) Establishing GEMS Program performance standards for the Deputy Under Secretary for Health for Operations and Management.

b. VA Office of General Counsel and VA Regional Counsel. VA Office of General Counsel and VA Regional Counsel are responsible for providing legal guidance to VHA organizations regarding environmental compliance issues and other matters related to environmental program management.

c. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management is responsible for:

(1) Disseminating guidance and policies related to both the development and implementation of GEMS Programs at appropriate facilities.

(2) Providing guidance on Federal, State and local environmental statutes and regulations and other environmental compliance requirements, such as Executive Orders or VHA Directives.

(3) Ensuring the development and implementation of VHA environmental programs and policies.

(4) Establishing GEMS Program performance standards for the Assistant Deputy Under Secretary for Health for Administrative Operations.

d. VHA Central Office Organization Directors. VHA Central Office (VHACO) organization directors (for VA facilities other than VA medical facilities, such as the Consolidated Mail Outpatient Pharmacy) are responsible for:

(1) Designating which facilities under their control are appropriate facilities for implementation of GEMS programs and this Directive.

(2) Developing, implementing, and managing GEMS at VHA-designated appropriate facilities.

(3) Ensuring that facilities under their control comply with applicable Federal, State, local environmental regulations, Executive Orders, VA and VHA policies.

(4) Providing information and reports related to GEMS and environmental programs to the Deputy Under Secretary for Health for Operations and Management or the Office of Occupational Safety, Health and GEMS Programs upon request.

NOTE: VHA-designated appropriate facilities should refer to the References section and VHA GEMS Guidebook for more information on requirements and available program guidance.

e. Assistant Deputy Under Secretary for Health for Administrative Operations.

The Assistant Deputy Under Secretary for Health for Administrative Operations is responsible for:

(1) Maintaining and overseeing the Office of Occupational Safety, Health, and GEMS Programs.

(2) Ensuring the development and implementation of VHA environmental programs and policies.

(3) Ensuring that staffing and funding are adequate to maintain the GEMS Program.

f. Director, Office of the Assistant Deputy Under Secretary for Health for Policy and Planning. The Director, Office of the Assistant Deputy Under Secretary for Health for Policy and Planning is responsible for ensuring that the Healthcare Analysis & Information Group (HAIG), a field unit under the Office of Strategic Planning and Analysis, provides support to the GEMS program for program reviews and management studies, including but not limited to the annual VHA Environmental Survey.

g. Director, Office of Occupational Safety, Health, and Green Environmental Management System Programs. The Director, Office of Occupational Safety, Health, and Green Environmental Management System Programs or designee is responsible for:

(1) Managing VHA GEMS and environmental programs at a national level and act as the technical advisor.

(2) Providing funding to support GEMS staff and environmental projects at the VISN and facility level.

(3) Advising VA and VHA senior officials on matters involving GEMS and environmental program management as it pertains to VHA.

(4) Developing policy and environmental program guidance for use by VISNs, VA medical facilities, and other VHA organizations and facilities in the development and implementation of GEMS and compliance with related Federal, State and local environmental statutes, regulations and other related environmental requirements Executive Orders, and VA and VHA policies.

(5) Develop and implement national goals and strategic plans for the GEMS program.

(6) Obtain GEMS and environmental program management data and information as needed from VISNs and VA medical facilities.

(7) Act as VHA liaison to EPA, Federal Environmental Executive, Council of Environmental Quality, VA Senior Sustainability Officer, and other Federal Agencies, and as appropriate, State and local government entities regarding related environmental issues.

(8) Act as a VHA point of contact for other VA and VHA organizations on matters related to environmental program management.

(9) Develop performance standards and/or measures and position description statements for GEMS positions.

(10) Appoint a VISN GEMS Manager or VA medical facility GEMS Program Manager to represent the VHA on the VA Environmental Management Task Force, and other VA/VHA environmental committees to support GEMS.

(11) Develop GEMS and environmental management training for national application in conjunction with VISNs, VA medical facilities, Employee Education System and others.

(12) Ensure that staff performing activities with legally mandated training requirements, credentialing or certifications receive such training, as well as periodic updating of training.

(13) Maintain effective communication to share best environmental practices to meet regulatory requirements and implement strategic goals.

h. Director, Center for Engineering and Occupational Safety and Health. The Director, Center for Engineering and Occupational Safety and Health (CEOSH) is responsible for:

(1) Publish and update the VHA GEMS Guidebook.

(2) Develop and manage technical solutions to include web-based tools and information services to support GEMS implementation.

(3) Provide and manage a web-based environmental management and compliance audit tool (e.g. CP Track) for VHA–wide use and provide user support.

(4) Appoint a CEOSH representative to serve on the VA Environmental Task Force and other committees, as requested by 10NA8.

i. VHA Chief Learning Officer. The VHA Chief Learning Officer collaborates with the 10NA8 Director to develop and deliver training related to the development and continuing education of GEMS personnel.

j. VISN Directors. VISN Directors must:

(1) Ensure that a GEMS Policy is developed and implemented for the VISN.

(2) Ensure that GEMS programs are developed and implemented for all appropriate facilities for which they are responsible.

(3) Provide VHA-designated appropriate facilities the resources needed to develop/implement GEMS Programs in conformance with International Organization for Standardization (ISO) 14001.

(4) Ensure VHA-designated appropriate facilities comply with Federal, State and local environmental statutes, regulations and other related environmental requirements, Executive Orders, VA and VHA policies.

(5) Provide a full-time VISN GEMS Program Manager and ensure the provision of, at minimum, a full-time GEMS Program Manager at each VA medical facility as required by VA Directive 0057.

(6) Ensure VISN GEMS Program Managers conduct annual VISN External GEMS Audits (VEGA) in accordance with the ISO14001 framework and any supplemental guidance that may be issued by 10NA8.

(7) Develop and implement performance standards and/or measures and position description statements related to environmental program management for appropriate VISN managers and VA medical facility Directors.

(8) Conduct third-party compliance audits on a tri-annual basis for appropriate facilities within their VISN to audit all applicable environmental regulations, to ensure that no appropriate facility goes more than three years between audits.

(9) Ensure environmental management and compliance audit deficiencies are entered into CP Track (or other nationally designated tool) and tracked to abatement/completion.

(10) Ensuring that environmental training is provided to VISN GEMS Program Managers, to provide the following capabilities:

(a) Assess compliance with applicable environmental regulations at appropriate facilities within the VISN.

(b) Oversee the implementation, operation and effectiveness of GEMS programs at appropriate facilities within the VISN.

(c) Receive Lead ISO 14001 Auditor training or an equivalent training program in order to properly perform VEGAs to assess conformance to the ISO 14001 Environmental Management System standard.

(11) Upon request, provide information and reports related to GEMS and environmental programs to the Deputy Under Secretary for Health for Operations and Management or 10NA8 upon request.

(12) Report all Federal, State, and local regulatory agency inspections at VISN Facilities to Central Office utilizing the Issue Brief format.

k. VA Medical Facility Directors. VA medical facility Directors must:

(1) Develop, implement, and maintain a facility GEMS program that conforms to Executive Orders, VA and VHA environmental policies, ISO 14001 principals, and applicable environmental standards.

(2) Include GEMS and other environmental requirements, as appropriate, in Standard Operating Procedures, work practices, equipment, construction, procurement, and other processes.

(3) Select and appoint a Facility Sustainability Officer from their Senior Leadership, per VA Directive 0055, VA Energy and Water Management Program, as the champion for environmental sustainability programs within their organization.

(4) Ensure all applicable or relevant and appropriate position descriptions require compliance with GEMS Program requirements.

(5) Provide adequate resources to fund the GEMS and environmental management programs, environmental compliance findings, and GEMS non-conformance findings.

(6) Provide at least one GEMS Program Manager (Full Time Equivalent Employee) for the facility. GEMS Program Managers shall have the technical and program management knowledge and experience needed to understand and provide knowledgeable guidance on the environmental responsibilities for the facility, as specified by VA Directive 0057.

(7) Train employees on the environmental aspects and impacts of their job activities and ensure they satisfactorily perform operational controls.

(8) Ensure staff members performing activities with legally mandated training requirements and/or certifications or licenses are in compliance and/or receive required training when assigned to these duties. Retraining frequency shall be established by the appropriate facility in order to maintain competency, and as required by law.

(9) Ensure regulatory deficiencies are resolved on a risk priority basis.

(10) Establish a multi-disciplinary GEMS Committee to assist the GEMS Program.

Each parent facility shall set annual goals in order to pursue continual improvement of environmental performance.

(11) Provide information and reports related to GEMS and environmental programs to the Deputy Under Secretary for Health for Operations and Management or 10NA8 upon request.

(12) Report all Federal, State, and local regulatory agency inspections at VISN Facilities to Central Office utilizing the Issue Brief format.

l. VISN GEMS Managers. VISN GEMS managers must:

(1) Monitor GEMS development and implementation for the VISN’s facilities.

(2) Ensure the VISN GEMS Manager or a qualified consultant conducts an annual VEGA is at least annually for each VISN VHA-designated appropriate facility.

(3) Ensure appropriate facilities receive a third-party compliance audit on a tri-annual basis.

(4) Oversee the collection of environmental management and compliance audit results in CP-Track (or other national designated tool) and track to abatement/completion; ensure accurate data submission for VA/VHA environmental data calls and surveys.

(5) Provide guidance, oversight and consultation to facility GEMS Program Managers ensuring environmental compliance and ISO 14001 conformance within the

VISN.

(6) Coordinate with Network Contracting Office (NCO) to arrange for tri-annual third-party environmental compliance audits and complete other VISN environmental contracts.

(7) Assist in the development of regional and national VHA policies that govern the GEMS Program.

(8) Act as VISN liaison to the regional EPA office, Federal Environmental Executive, Council of Environmental Quality, VA Senior Sustainability Officer, and other Federal, State, and local government entities regarding environmental management systems and related environmental issues for their particular region.

m. GEMS Program Manager. The GEMS Program manager must:

(1) Implement and periodically review GEMS requirements in accordance with the principles of ISO 14001, Federal, State and local environmental statutory law, Executive Orders, VA and VHA policies, and this directive.

(2) Identify training, policies, operational requirements and engineering controls needed to comply with environmental regulatory requirements.

(3) Work with management to address environmental findings and ensure that the medical center’s programs satisfactorily address environmental compliance, operational controls and procedures related to environmental aspects.

(4) Monitor environmental compliance through ongoing review of operations and program management as they pertain to Federal, State and local environmental statutes, regulations and other related environmental requirements, Executive Orders, VA and VHA policies.

(5) Assess performance as it relates to regulatory compliance and GEMS program conformance, and informing facility management of findings. Act as the primary point-of-contact with Federal, State, and local regulatory agencies for environmental issues.

(6) Identify environmental aspects, including ‘significant environmental aspects’, in order to focus on the activities that pose the greatest potential (positive and negative) with regard to environmental regulatory compliance.

(7) Establish operational controls for significant aspects. Evaluate and update standard operating procedures (SOPs), checklists and other control documents and activities where necessary to ensure that operational controls are effective and documented.

(8) Set environmental objectives and targets, based upon the significant environmental aspects, on an annual basis in order to pursue continual improvement of environmental performance. Develop an Environmental Management Plan for each target and significant environmental aspect.

(9) Cooperate and assist with the VEGA. Develop an action plan with management to address VEGA findings and corrective/preventive actions to address environmental deficiencies in a timely manner. Collect environmental management and compliance audit results in CP Track (or other nationally designated tool) and track to abatement/completion.

(10) Immediately notify the VISN GEMS Manager for inspections conducted by US Environmental Protection Agency, State environmental regulatory agencies, local environmental inspection agencies, and when required to notify an environmental regulatory agency due to a spill/release or other incident.

(11) Prepare and submit an annual management review report of the GEMS program following ISO 14001 protocol to the VA medical facility Director and VISN GEMS Program Manager.

(12) Develop and submit all required documentation to external regulatory agencies including but not limited to EPA.

(13) Serve as the technical expert of the VA medical facility GEMS Committee. Direct the committee’s activities in coordination with the VA medical facility Director or Associate Director.

(14) Develop a communication plan to ensure employees are aware of the GEMS program and the environmental aspects and impacts pertaining to their job duties.

(15) Develop an environmental training plan for affected staff so they are competent to perform operational controls related to the environmental aspects and impacts of their job.

(16) Act as the technical advisor for environmental contracts.

(17) Act as the VA medical facility liaison to the local or regional EPA office, and other Federal, State, and local government entities regarding EMS (GEMS) and related environmental issues for their facility.

NOTE: Contact VISN GEMS Manager to determine who has primary liaison responsibility.

5. REPORTS

All VHA organizations shall provide information and reports related to GEMS and environmental programs to the Deputy Under Secretary for Health for Operations and Management or 10NA8 upon request and within the requested time frame.

6. REFERENCES

a. 40 CFR, Protection of the Environment.

b. 48 CFR, Federal Acquisition Regulations System.

c. Executive Order 13693.

d. VA Directive 0057, Environmental Management Program.

e. VA Directive 0062, Environmental Compliance Management.

f. VA Handbook 0062, Environmental Compliance Management

g. VA Directive 0064, Environmental Management Systems.

h. VA Handbook 0064, Environmental Management Systems

i. Environmental Agency (EPA) Website: http://www.epa.gov/

j. ISO 14001, Environmental Management Standard.

k. VHA Center for Engineering and Occupational Safety and Health (CEOSH), Green Environmental Management Systems (GEMS) Resources:

http://vaww.ceosh.med.va.gov

l. CEOSH VHA GEMS Guidebook: http://vaww.ceosh.med.va.gov

7. DEFINITIONS

a. Appropriate Facilities. An appropriate facility is any health care facility defined in VHA Handbook 1006.02, VHA Site Classifications and Definitions, plus all administrative and ancillary buildings owned by VHA that can have a significant impact on the environment (directly or indirectly, individually or cumulatively) due to the operations of those facilities or organization’s mission, processes or functions.

b. Environmental Management System. An environmental management system (EMS) is a set of processes and practices that enable an organization to increase its operating efficiency, continually improve its overall environmental performance, and better manage and reduce its environmental impacts. EMS implementation shall reflect http://www.epa.gov/ http://vaww.ceosh.med.va.gov/ http://vaww.ceosh.med.va.gov/ the International Organization for Standardization (ISO) 14001 Environmental Management System Standard.

c. Environmental Management System Policy Statement. An environmental management system policy statement is a statement of an organization’s commitment to continual improvement; pollution prevention; and compliance with applicable environmental regulatory and internal VA and VHA requirements. The policy statement should be concise, communicated to all employees, made available to the public, and signed by senior management at the facility.

d. Environmental Aspects. Environmental aspects are elements of administration or staff office facility activities, products, or services that interact, or may interact, with the environment. Significant environmental aspects are identified in order for an organization to focus on the activities that pose the greatest potential, both positive and negative, with regard to environmental protection.

e. Environmental Impact. Environmental impact is any change (complete or partial) to the environment, whether adverse or beneficial, resulting from an administration’s or staff office’s functional mission or activities.

f. GEMS. For VHA, Green Environmental Management System (GEMS) is synonymous with “Environmental Management System” as used in Executive Order 13693, Planning for Federal Sustainability in the Next Decade, and the ISO Environmental Management System Standard 14001. When implemented as part of the overall management system, GEMS provide a set of processes and practices that:

(1) Identify and address the impacts that an appropriate facility has on the environment.

(2) Ensure compliance with applicable environmental requirements and manage environmental regulatory responsibilities in a proactive manner.

(3) Determine opportunities for continual improvement with a focus on pollution prevention principles and enhancing the image of VHA with internal and external parties.

(4) Integrate GEMS with organizational structure, responsibilities, facility planning activities, work practices and processes, organizational goals, operations, and resource allocation.

g. Parent Facility. A facility that has management authority for multiple facilities, such as a VA Health Care System (HCS), or VA medical facility.

h. VEGA. VISN External GEMS Audit (VEGA) is an audit performed, or overseen, by the VISN GEMS Manager to assess conformance to the principals of the current ISO 14001 Environmental Management System standard.