36C24419R0060-004.pdf

Department of Veterans Affairs VHA DIRECTIVE 2005-011 Veterans Health Administration Washington, DC 20420 March 7, 2005

VHA GREEN ENVIRONMENTAL MANAGEMENT SYSTEM (GEMS) AND

GOVERNING ENVIRONMENTAL POLICY STATEMENT

1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy requiring VHA facilities to develop and implement Environmental Management Systems (EMS) that result in continual improvement to environmental programs and governing environmental policy.

2. BACKGROUND

a. VHA’s mission is to deliver quality health care to our Nation’s veterans. In accomplishing this mission, VHA must also demonstrate that it is committed to protecting and improving the environment. Implementation of EMS will ensure that VHA facilities take the necessary actions to integrate environmental accountability into day-to-day decision-making and long-term planning processes across VHA organizations, activities, functions, and services.

b. Executive Order (EO) 13148, “Greening the Government Through Leadership in Environmental Management,” requires that Federal agencies develop and implement EMS at all “appropriate facilities” by December 31, 2005.

c. VHA has defined all VA medical centers to be “appropriate facilities.” A multi-campus VHA Health Care System (HCS) under common management is a single appropriate facility for the purposes of developing and implementing EMS. Community-Based Outpatient Clinics (CBOCs) and other affiliated satellite VHA health care facilities are to be included in the parent VA medical center’s EMS.

d. Other VHA facilities not affiliated with VA medical centers may be appropriate facilities.

The determination of whether such a facility is an appropriate facility is to be made by the VHA Central Office organization or other VHA organization responsible for the management of the facility. The determination of whether a facility is an “appropriate facility” is to be based on facility size, complexity, and the environmental aspects of the facility’s operations. A facility would generally be considered an appropriate facility if it is either subject to registration or permitting by the U.S. Environmental Protection Agency (EPA) or state and/or local environmental regulators or otherwise could have a significant impact on the environment.

NOTE: As used in the remainder of this Directive, “VA medical center” refers to VA medical centers, VHA HCSs and other VHA facilities defined to be appropriate facilities.

THIS VHA DIRECTIVE EXPIRES March 31, 2010

VHA DIRECTIVE 20054-011

March 7, 2005

e. VA Directive 0057, VA Environmental Management System and Governing Environmental Policy, requires that VHA and other VA Administrations and Staff Offices develop governing environmental policy, as well as policy and appropriate guidance for the development and implementation of EMS at “appropriate facilities.”

f. For VHA, Green Environmental Management System (GEMS) is synonymous with “Environmental Management System” as used in EO 13148 and relevant International Organization for Standardization (ISO) standards, including ISO Standard 14001. GEMS was chosen to refer to EMS within VHA to prevent confusion with the Emergency Management System required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Environment of Care (EOC) Standard.

g. GEMS provides a systematic framework for VA medical centers to manage their environmental "footprint," i.e., the environmental impact associated with the operation of facilities and delivery of services. When implemented as part of the overall management system of a VA medical center, GEMS provide a set of processes and practices that enables a VA medical center to:

(1) Identify and address the impacts that the VA medical center’s work has on the environment;

(2) Evaluate how environmental programs are managed;

(3) Ensure compliance with applicable environmental requirements;

(4) Determine opportunities for further and continual improvement;

(5) Manage environmental responsibilities in a proactive manner and pay greater attention to environmental regulatory responsibilities;

(6) Integrate its environmental program with organizational structure, responsibilities, facility planning activities, work practices and processes, organizational goals, operations, and resource allocation;

(7) Prevent pollution and conserve resources;

(8) Enhance its image with regulators, patients, the public, and stakeholder groups.

h. VHA has published the Green Environmental Management System Guidebook (GEMS Guidebook) for use by VA medical centers in the development of their facility-specific GEMS.

This guidebook was developed by expert VA Central Office, Veterans Integrated Service Network (VISN) and VA medical center staff with strong collaborative support from EPA. The GEMS Guidebook provides a nine-step approach that, if followed, will construct a GEMS program that fully meets the requirements of EO 13148. The guidebook incorporates the principles of the ISO 14001 Standard entitled “Environmental Management Systems – Specification with Guidance for Use.”

i. The systematic approach of GEMS allows VA medical centers to better focus on implementation and integration of environmental management programs and take a more inclusive and proactive view of environmental protection. In demonstrating improved environmental performance through the implementation of GEMS, VA medical centers can improve relationships with Federal, state and local regulators, Veterans Service Organizations and other stakeholders.

j. The GEMS nine-step approach to managing the facility environmental program is similar to the JCAHO approach of continuous improvement used by health care facilities to manage issues related to the JCAHO EOC Standard. As a practical matter, many of the management and business processes developed by VA medical centers to address JCAHO requirements can be applied to the development and implementation of GEMS.

3. POLICY: It is VHA policy to incorporate VHA’s governing environmental policy into the operation and management of all organizations, activities, functions, and services and to develop and to implement GEMS by December 31, 2005, at all VA medical centers and other VHA facilities defined to be “appropriate” facilities.

4. ACTION

a. In accomplishing its mission to deliver quality health care to our Nation’s veterans, VHA staff responsible for the operation and management of VHA facilities, organizations, activities, functions and services is to incorporate VHA’s governing environmental policy into the operation and management of the facility, organization, activity, function and/or service for which they are responsible. It is VHA’s governing environmental policy to:

(1) Encourage VHA employees at all levels to be good stewards of the environment by complying with all applicable Federal, state and local environmental requirements; preventing pollution; reducing waste; conserving energy, water, and other natural and cultural resources;

and continually reviewing and improving environmental programs.

(2) Ensure top management commitment and accountability through the incorporation of position description elements and performance standards and/or measures related to environmental program management for appropriate senior-level VHA managers and other employees who have responsibilities related to the management of environmental programs.

(3) Place a high priority on obtaining funds and other necessary resources to ensure compliance by VA medical centers with Federal, state, and local environmental requirements, including implementation of GEMS. Top VHA managers must provide necessary support and resources to ensure the effectiveness of GEMS.

(4) Utilize sustainable practices to eliminate, minimize, or mitigate adverse environmental impacts.

(5) Evaluate and monitor the operations of VA medical centers to incorporate policies and procedures to reduce environmental vulnerabilities and ensure environmental compliance.

(6) Manage the operation of all VA medical centers throughout their life cycle, from planning and acquisition through disposal and/or decommissioning to protect human health and the environment and minimize adverse effects on the natural environment consistent with VHA’s mission.

(7) Comply with the requirements of VHA policy regarding Pollution Prevention (P2) Programs and integrate pollution prevention, waste reduction, natural resource conservation, affirmative procurement or “green” purchasing, life cycle costing, and environmental compliance into planning, purchasing, and operating decisions, wherever practicable. Implement source reduction as the pollution prevention method of choice, followed by reuse, recycling, treatment of wastes, and proper disposal.

(8) Use natural resources efficiently, and maintain and protect plant and wildlife habitat consistent with VHA’s mission.

(9) Recognize that the development and construction of VA medical centers must consider the unique conditions of the environment of which the facility is a part.

(10) Train all appropriate VHA staff as needed to satisfactorily carry out the environmental responsibilities of their positions.

(11) Solicit input regarding environmental matters affecting the operation of VA medical centers, as appropriate, from stakeholders including, but not limited to, staff, veterans, and the community.

b. Under Secretary for Health. The Under Secretary for Health (10) is responsible for ensuring that all VA medical centers and other VHA facilities defined to be “appropriate facilities” develop and implement GEMS and comply with Federal, state, and local environmental statutes and regulations and other environmental requirements, including the “Greening the Government” EOs.

c. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for:

(1) Issuing guidance and policies related to both the development and implementation of VA medical center GEMS and compliance with Federal, state and local environmental statutes and regulations and other environmental requirements.

(2) Managing VHA environmental programs at the national level.

d. Directors, VHA Organizations at VA Central Office. Directors, VHA Organizations at VA Central Office that are responsible for the operation of VHA facilities not affiliated with VA medical centers are responsible for:

(1) Defining which of their facilities are “appropriate facilities.”

(2) Developing and implementing GEMS at “appropriate facilities” by December 31, 2005.

e. Director, Safety and Technical Services. The Director, Safety and Technical Services (10NB) is responsible for overall program management of VHA efforts related to GEMS at the national level, to include:

(1) Developing policy and environmental program guidance for use by VISNs, VA medical centers in the development and implementation of GEMS and compliance with related Federal, state and local environmental statutes, regulations and other related environmental requirements.

(2) Developing a facility Self-Declaration Protocol to provide credible verification of the scope and effectiveness (i.e., status) of the facility GEMS.

(3) Acting as VHA liaison to EPA, Federal Environmental Executive, VA Agency Environmental Executive, and other Federal, state, and local government entities regarding EMS (GEMS) and related environmental issues.

(4) In conjunction with appropriate VA and VHA officials, developing performance standards and/or measures and position description statements related to GEMS for appropriate upper level VHA managers.

f. VISN Directors. VISN Directors are responsible for

(1) Ensuring GEMS are developed and implemented at VA medical centers for which they are responsible by December 31, 2005.

(2) Conducting an annual gap analysis using VHA’s E-SAFE protocol to determine the status and effectiveness of VA medical centers’ implementation of GEMS.

(3) Performing a gap analysis of VA medical center GEMS on an annual basis to determine the status and effectiveness of VA medical centers s’ implementation of GEMS. Gap analysis is performed by VISN health and safety staff or qualified consultants using VHA’s E-SAFE protocol. VISN health and safety staff performing gap analysis is to have completed 3-day or 5-day Registrar Accreditation Board (RAB) Environmental Management System Lead Auditor Training or other specialized EMS Auditor training approved by VHA. Consultants performing gap analysis are to have completed a 5-day RAB Environmental Management System Lead Auditor Training.

(4) Prior to December 31, 2005, any of the following may be performed in lieu of the gap analysis discussed in the previous paragraph:

(a) Environmental Management Reviews conducted by EPA;

(b) Gap analysis performed by VISN health and safety staff not trained in accordance with the requirements of preceding subparagraph 4f(3);

(c) Gap analysis by VA medical center’s GEMS Coordinator using VHA’s E-SAFE protocol that is reviewed and approved by VISN health and safety staff.

(5) Providing VA medical centers, for which they are responsible, resources needed to develop and implement VA medical centers GEMS and environmental compliance programs.

(6) Developing and implementing performance standards and/or measures and position description statements related to environmental program management for appropriate VISN managers and VA medical centers directors.

(7) Providing GEMS and other environmental training to VISN health and safety staff and other staff responsible for GEMS that is needed to:

(a) Oversee the implementation of GEMS at VA medical centers;

(b) Perform gap analysis to determine the status and effectiveness of VA medical centers’ implementation of GEMS; and

(c) Assess the effectiveness of VA medical centers environmental programs.

g. VA Medical Center Directors. VA medical center Directors are responsible for:

(1) Developing and implementing a facility GEMS by December 31, 2005, using either the nine-step process as defined in the GEMS Guidebook or an equivalent process. GEMS development is to be based on the principles of ISO 14001. NOTE: Guidance for developing the facility GEMS, including information on the nine-step process, can be obtained from the GEMS Guidebook. The GEMS Guidebook has been mailed to VA medical centers separately and is available on-line at the Center for Engineering and Occupational Safety and Health (CEOSH) website (http://vaww.ceosh.med.va.gov). Copies of VA medical center GEMS and other GEMS documentation is to be available both at VA medical centers, CBOCs and affiliated satellite healthcare facilities. The nine steps for developing a facility GEMS are:

(a) Appointing a GEMS Coordinator and GEMS Committee

1. The GEMS Coordinator ensures that the requirements of GEMS are established, implemented and periodically reviewed in accordance with the principles of ISO 14001. The http://vaww.ceosh.med.va.gov

GEMS Coordinator should have significant technical and program management knowledge and experience in environmental compliance and environmental programs.

2. The GEMS Committee is to be a multi-disciplinary committee established to coordinate and oversee the GEMS.

(b) Training the GEMS Committee. The GEMS Committee is to be trained to develop, monitor, and continuously improve the GEMS Program.

(c) Conducting Initial GEMS Gap Analysis. The purpose of the GEMS Gap Analysis is to compare the existing environmental program with the requirements for GEMS and determine how to build on existing programs and activities to “fill the gap” and move towards a more comprehensive GEMS. The Gap Analysis determines what activities are missing and need to be implemented to result in a comprehensive facility environmental management system.

(d) Identifying Significant Environmental Aspects. Environmental aspects are elements of the VAMC’s organization unit’s activities and services that 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) Establishing Operational Controls Over Significant Aspects. In this key step, standard operating procedures (SOPs), checklists and other control documents and activities are evaluated and updated where necessary to ensure that operational controls are effective. Many of these controls will already be in place and merely need to be documented. For other significant aspects, new controls will be established. This step also includes developing, publishing and distributing new policies and procedures for overall GEMS program activities.

(f) Setting and Achieving Environmental Objectives and Targets on an Annual Basis.

Establish goals and action plans for a few of the significant environmental aspects where continual improvement can be demonstrated.

(g) Training Staff on GEMS Policies and SOPs.

(h) Conducting a Comprehensive Environmental Compliance Audit Every 3 Years, as a Minimum. In order to implement GEMS by the deadline established in EO 13148, the first comprehensive environmental audit is to be conducted during calendar year 2005. This audit is to serve as a baseline for comparison with subsequent audits. Comprehensive environmental compliance audits are to be conducted by a qualified consultant (e.g., contractor) using the Army Corps of Engineers’ CP-Track audit protocol or other standardized audit tools specified by the Office of the Deputy Under Secretary for Health for Operations and Management. VA medical centers are to update the comprehensive environmental audits conducted by consultants on an annual basis using standardized audit protocol tools specified by the Office of the Deputy Under Secretary for Health for Operations and Management. Annual updating of comprehensive environmental audits may be conducted by qualified VA medical center staff.

(i) Preparing an Annual Report. The GEMS Committee will submit an annual report for approval or modification, and signature, to VA medical center Director via the GEMS Committee. The annual report needs to meet the JCAHO EOC requirement for an annual program effectiveness evaluation, and needs to include:

1. Accomplishments for the year, i.e., the results of targets and goals.

2. Resources expended.

3. Results of GEMS Gap Analysis and environmental compliance audit.

4. Status of action plan for correction of deficiencies identified in the GEMS Gap Analysis and environmental compliance audit.

5. Proposed targets and objectives for upcoming year.

(2) Operating facilities in a manner that complies with their facility’s GEMS and governing environmental policy, as well as Federal, state, and local statutory, regulatory, and other environmental requirements, including “Greening the Government” EOs.

(3) Developing facility-specific governing environmental policy by May 1, 2005. Facility-specific governing environmental policy is to incorporate the items contained in subparagraphs 4a(1) through 4a(11). Facility-specific governing environmental policy must include additional environmental requirements needed to meet facility-specific operating conditions and local and state environmental requirements.

(4) Taking necessary steps to meet goals established by action plans developed through the facility GEMS.

(5) Implementing actions to correct environmental deficiencies in a timely manner.

(6) Taking steps to obtain funding to effect correction of environmental deficiencies and problems and meet of goals established by GEMS.

(7) Communicating GEMS requirements and environmental compliance requirements to all staff.

(8) Including GEMS and other environmental requirements, as appropriate, in SOPs, work practices and other processes of all VA medical center operational units.

(9) Promoting the use of pollution prevention, waste reduction, affirmative procurement and use of environmentally preferable products through the Pollution Prevention (P2) Program.

(10) Taking appropriate action to make certain that work performed by contractors and consultants conforms to the requirements of the facility GEMS.

(11) Developing and implementing performance standards and/or measures and position description statements related to environmental program management for appropriate VA medical center managers and staff.

h. VA Office of the General Counsel and VA Regional Counsel. VA Office of the General Counsel and VA Regional Counsel are responsible for providing legal counsel and guidance, as necessary, to VHA organizations, including, but not limited to VA Central Office, VISNs and VA medical centers, regarding the development and implementation of GEMS, environmental compliance and other matters related to environmental program management.

i. Director, Center for Engineering and Occupational Safety and Health (CEOSH).

Director, CEOSH, is responsible for promoting best practices related to GEMS and environmental compliance by:

(1) Publishing and updating environmental guidebooks as part of the Safety Guidebook series; and

(2) Developing and managing information technology and web-based information services to support GEMS implementation.

j. Director, Little Rock Education Center. The Director, Little Rock Education Center, is responsible for developing and delivering training related to the development and implementation of GEMS.

5. REFERENCES

a. VHA Green Environmental Management System (GEMS) Guidebook 6A.

b. VHA Environmental Compliance Guidebook 6B.

c. Executive Order 13148, Greening the Government Through Leadership in Environmental Management, April 21, 2000.

d. Executive Order 13101, “Greening the Government through Waste Prevention, Recycling, and Federal Acquisition," September 14, 1998.

e. U. S. EPA Internet site (http://www.epa.gov).

f. Office of the Federal Environmental Executive Internet site (http://www.ofee.gov).

g. VA Directive 0057, VA Environmental Management System and Governing Environmental Policy, November 2004.

http://www.epa.gov http://www.ofee.gov

6. FOLLOW-UP RESPONSIBILITY: 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, Safety and Technical Services at (202) 273-5844.

7. RESCISSIONS: None. This VHA Directive March 31, 2010.

S/Jonathan B. Perlin, MD, PhD, MSHA, FACP Acting Under Secretary for Health

DISTRIBUTION: CO: E-mailed 3/10/2005 FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 3/10/2005