Ensure safety of water for drinking, cooking, personal hygiene, medical activities, cleaning and laundry for the purpose intended (62). Concrete examples may include the following.
· A WSP is implemented, possibly as part of a wider WASH safety plan (see Error! Reference source not found.in Selected tools).
· Drinking-water meets WHO GDWQ or national standards (63) (see section 3.2.1 Drinking-water for further information).
· Non-potable water is used only for cleaning, laundry and sanitation and is appropriately labelled.
Water/sanitation; health
Health care
Universal health coverage
Regulation; other management and control
UBN.TB.ZZ&UEP
Planning in relation to water quality
Health services, systems and policies
Ensure availability of sufficient water at all times for drinking, food preparation, personal hygiene, medical activities, cleaning and laundry (62).
Note: Sufficient water relates to minimum water quantities required in the health care setting. Set figures are available for planning and designing water supply systems. Actual figures of water quantities required depend on a number of factors, such as size of facility, services offered and number of patients accessing services, climate, level of care and local water use practices.
Water/sanitation; health
Health care
Universal health coverage
Infrastructure, technology and built environment
UET.TK.ZZ&UEP
Public facilities or infrastructure development in relation to water collection, treatment and supply services, systems and policies
Health services, systems and policies
Provide sufficient water-collection points and water-use facilities in the health care setting to allow convenient access to, and use of, water for medical activities, drinking, personal hygiene, food preparation, laundry and cleaning (62).
Concrete examples may include the following.
• A drinking-water station with safe drinking-water available and accessible for staff, patients and carers at all times and in main waiting areas and/or entrances to each ward and in all rooms where patients stay overnight or receive specialized care.
• Functioning hand hygiene stations (water and soap or alcohol-based hand rub) are available at all points of care and service areas.
• Hand-washing facilities (water and soap) within 5 metres of all toilets or latrines and at least one shower or bathing area per 40 in-patients or per ward (whichever is lower) and are functioning and accessible.
Sector principally involved in planning/ implementation:
Water/sanitation; health
Level of implementation:
Health care
Universal health coverage
Instruments:
Infrastructure, technology and built environment
UEP.TK.ZZ&UET
Public facilities or infrastructure development in relation to health services, systems and policies
Water collection, treatment and supply services, systems and policies
Provide adequate, accessible and appropriate toilets for patients, staff and caregivers (62). Concrete examples may include the following.
• A sufficient number of functional toilets are available, separated by sex and by staff/patient status.
• Toilets are easily accessible, safe to use and are appropriate for local technical, financial, cultural and social conditions.
• Toilets have a functioning handwashing facility with soap and water within 5 metres.
• Toilets are cleaned at least once daily and are adequately maintained and repaired if any problems arise.
• At least one functional toilet provides the means to manage menstrual hygiene needs and can be accessed by those with limited mobility.
• Excreta and wastewater is safely managed and treated according to WHO guidelines (64).
Sector principally involved in planning/ implementation:
Water/sanitation; health
Level of implementation:
Health care
Universal health coverage
Instruments:
Infrastructure, technology and built environment
UEP.TK.ZZ&UEU
Public facilities or infrastructure development in relation to health services, systems and policies
Sewerage services, systems and policies
Promote correct use of water, sanitation and waste facilities (62). Concrete examples may include the following.
• Staff, are trained and educated about IPC practices, environmental cleaning and waste management necessary for limiting disease transmission, and compliance and monitoring activities are undertaken regularly (65).
• Dedicated, trained cleaning staff are available and appropriate and wellmaintained materials for cleaning (i.e. detergent, mops, buckets, etc.) are available.
• Hand hygiene promotion materials are displayed in all wards/treatment areas and clearly visible.
• Facilities and resources enable staff, patients and caregivers to practise behaviours that control disease transmission in an easy and timely way.
Health
Health care
Universal health coverage
Information, education and communication
UEP.VE.ZZ
Infection control measures in relation to health services, systems and policies
+
VED.PH.ZZ&UEP
Training in hygiene behaviours
Health services, systems and policies
+
VED.VB.ZZ&UEP
Awareness raising about hygiene behaviours
Health services, systems and policies
Ensure rapid and safe wastewater disposal (62, 66).
Concrete examples may include the following.
• Wastewater is conveyed safely away from the facility to treatment with minimal leaks/overflows.
• Wastewater drainage is built and managed to avoid contamination of the health care setting or the broader environment.
• A stormwater (i.e. rainwater) and greywater drainage system is in place that diverts water away from the facility into a safe drainage or leach field and does not carry contamination from the health care setting to the outside surrounding environment.
• Hazardous chemical waste and pharmaceuticals are not discharged into wastewater.
Water/sanitation
Health care
Infrastructure, technology and built environment
UEP.TK.ZZ&UEU
Public facilities or infrastructure development in relation to health services, systems and policies
Sewerage services, systems and policies
Implement an IPC programme (37). The basic set of IPC guidelines should include as a minimum:
· standard precautions;
· hand hygiene;
· use of PPE;
· sterilization and medical devices decontamination;
· safe handling of linen and laundry;
· health care waste management;
· patient placement;
· respiratory hygiene and cough etiquette;
· environmental cleaning;
· principles of asepsis;
· prevention of injuries from sharp instruments and post-exposure prophylaxis;
· transmission-based precautions;
· aseptic technique and device management for clinical procedures, according to the scope of care.
Since the scope of practices may be very different in health care facilities according to the type of care offered, the guidelines should prioritize the most frequent and/or risky practices and settings.
Health
Health care
Universal health coverage
Other management and control
UEP.VE.ZZ
Infection control measures in relation to health services, systems and policies
Educate/train health care facility staff on crucial moments to perform hand hygiene and appropriate techniques for hand washing and hand rubbing (39).
Five moments when to perform hand washing in health care include:
· before touching a patient
· before clean/aseptic procedure
· after body fluid exposure risk (and after glove removal)
· after touching a patient
· after touching a patient’s surroundings.
More detailed guidance is available in the WHO guidelines on hand hygiene in health care (67).
Health
Health care
Universal health coverage
Information, education and communication
VED.PH.ZZ&UEP
Training in hygiene behaviours
Health services, systems and policies
+
VED.PM.ZZ&UEP
Education about hygiene behaviours
Health services, systems and policies
Consider as much as possible options for waste minimization, environmentally preferable purchasing and green procurement, and safe reuse, recycling and recovery (68). Concrete examples may include the following.
• Ensure all staff practise appropriate waste segregation at all points of care using a three-bin system.
• Raise awareness about and train medical staff in clinical and general practices to use or waste fewer materials, with techniques such as the “first in, first out” principle (what has been purchased first, should also be used first).
• Choose approaches to ordering supplies that generate less waste, such as more frequent ordering of relatively small quantities, particularly for unstable products, and selecting products that produce less or less hazardous waste.
• Use physical rather than chemical cleaning methods (e.g. steam disinfection).
• Purchase hazardous chemicals centrally and monitor their use.
• Procure equipment made from plastics that can be more easily recycled (e.g. polyethylene, polypropylene and polyethylene terephthalate instead of polyvinyl chloride or mixed materials such as paper covered in plastics).
• Implement an environmental management system.
Waste
Health care
Other management, and control, regulation
UEP.WJ.ZZ&UEV
Policy change in relation to health services, systems and policies
Waste collection and disposal services, systems and policies
Ensure safe segregation, collection, transportation, storage, treatment and disposal of health care waste (62, 66). Concrete examples may include the following.
• Trained waste handlers are available and have sufficient PPE to carry out their duties safely.
• Waste segregation should be nationally standardized, should rely on a uniform colour coding or labelling system and should at the least segregate general waste from sharps waste and (other) infectious waste.
• General waste and infectious or hazardous waste should be collected, transported and stored separately.
• Collection and internal transportation should happen at fixed times and fixed waste routes from the most to the least hygienically sensitive area.
• Internal waste storage locations must be totally enclosed and well separated from other areas; the storage location for infectious and sharps waste must be clearly identifiable with floors and walls sealed or tiled. External waste storage should be fenced as a minimum. Only authorized staff should have access to the waste storage areas. Maximum storage times for infectious waste, which are temperature dependent, need to be considered.
• In general, health-care waste should be treated using a technique which minimizes the formation and release of chemicals or hazardous emissions. Infectious and sharps waste should generally be treated by steam or other non-burn technologies where these options are locally available and sustainable.
• Final disposal should happen in designated places outside the premises of the health care facility. A functional burial pit/fenced waste dump or municipal pick- up should be available for disposal of non-infectious (non-hazardous/general) waste and waste disposal areas should be built to withstand climate-events and emergencies.
• Pharmaceutical waste should be treated and disposed of safely by one of the following options: at a centrally managed safe treatment & disposal facility (i.e. offsite)/ sent back to the manufacturer/coincinerated by industries using hightemperature kilns.
Waste
Health care
Other management and control
UEP.WJ.ZZ&UGS
Policy change in relation to health services, systems and policies
Wastes or scraps
Prioritize electrification of all health care facilities to ensure basic health care services (69). See also energy subsection (point 14) under Climate change/environmental degradation below.
Energy
Health care
Universal health coverage
Infrastructure, technology and built environment
UEP.TK.ZZ&UGF
Public facilities or infrastructure development in relation to health services, systems and policies
Electricity generation and supply
Building: build and renovate in an environmentally responsible and sustainable way (70, 71). Concrete examples may include the following.
• Siting: orientation relative to the sun path, accessibility by public transport, foot and bike, with access to water, and not in a flood-prone area.
• Lighting, shading: use of natural sources (daylight and vegetation) and renewable energies such as solar energy.
• Ventilation: use of natural ventilation, optimized window siting that enables cross ventilation.
• Walls and roofs: insulation, double walls and roofs, reflective materials and colour, built to withstand extreme weather events.
Construction
Health care
Infrastructure, technology and built environment
UEC.TM.ZZ&UEP
Environmental modification in relation to architecture and construction services, systems and policies
Health services, systems and policies
Food: implement a sustainable food system (70). Concrete examples may include the following.
• Implement a sustainable food plan, which includes local/regional food procurement.
• Reduce the use of disposable products.
• Implement measures to reduce food waste.
Food
Health Care
Other management and control
UAB.TM.ZZ&UGR&UGS&UEP
Environmental modification in relation to food
Agriculture
Wastes or scraps
Health services, systems and policies
Energy: develop or update clean energy policies to promote increased healthsector reliance on clean energy, promote energy efficiency and ensure that appropriate resources and responsibilities are allocated to the management (and maintenance) of health facility energy resources (70, 71).
Concrete examples may include the following.
• Implement energy conservation plans.
• Use clean energy sources for heating water and electricity.
• Replace inefficient light bulbs such as incandescent bulbs with more efficient alternatives such as LED, if suitable for the application.
Energy
Health care
Regulation, taxes and subsidies, infrastructure, technology and built environment
UGJ.WJ.ZZ&UEP
Policy change in relation to renewable energy sources
Health services, systems and policies
Water: reduce the use of potable water (70). Concrete examples may include the following.
· Develop/update a water conservation plan.
· Employ water conservation strategies such as a rainwater capture system for uses other than drinking.
· Repair leaking faucets and pipes.
· Use technologies to maximize water savings such as high-efficiency plumbing fixtures, low-flow or motion-activated faucets (where regular water quality monitoring exists) and dual-flush toilets.
· Raise awareness among staff, patients and visitors about the need to conserve water.
· Reduce water use for landscaping such as through drought-relevant species, drip irrigation or mulching.
Water/sanitation
Health care
Regulation, infrastructure, technology and built environment, Information, education and communication
UET.TM.ZZ&UEP
Environmental modification in relation to water collection services, systems and policies
Health services, systems and policies
Establish safe procedures for procuring, storing, dispensing and proper disposal of pharmaceuticals (70).
Health
Health care
Regulation, other management and control
UEP.WJ.ZZ&UGL
Policy change in relation to health services, systems and policies
Chemicals and chemical products
Phase out/replace items that contain mercury, complying with the Minamata Convention on Mercury (66, 72).
Health
Health care
Regulation
UGL.WI.QE&UEP#ICD- 11 XM1FG4
Enforcement of restrictions through laws or standards in relation to chemicals and chemical product
Health services, systems and policies
Mercury
Phase out or replace substances with high ozone depleting or global warming potential (70). Concrete examples may include the following.
· Buy equipment that uses minimally polluting refrigerants and has a reduced refrigerant charge.
· Ensure regular maintenance of equipment containing refrigerant to avoid leakage or release into the atmosphere.
· Phase out ozone-depleting substances in fire suppression systems.
Environment, health
Health care
Regulation
UGL.WI.QE&UEP&UBS
Enforcement of restrictions through laws or standards in relation to chemicals and chemical products
Health services, systems and policies
Climate change
Implement procedures and guidelines to ensure that justification of radiologic imaging becomes an effective, transparent and accountable part of normal radiological practice (73, 74).
Health
Health care
Universal health coverage
Regulation
UEP.WI.ZZ&UEP&UBR
Restrictions through laws or standards in relation to health services, systems and policies
Health services, systems and policies
Radiation
Enhance the implementation of the principle of optimization of radiation protection and safety (73, 74). Concrete examples may include the following.
· Develop and regularly update evidence-based imaging referral guidelines and make them available at the point of care as decision- support tools for enhance justification of radiological procedures (75, 76).
· Establish and use up-to-date diagnostic reference levels for adult and paediatric patients, and quality assurance programmes for radiological procedures.
· Implement harmonized criteria and develop detailed guidance for the release of patients after radionuclide therapy.
· Apply technological solutions, such as electronic health records, for harmonized monitoring of radiation exposure.
Health
Health care
Universal health coverage
Regulation
UEP.WI.ZZ&VC1
Restrictions through laws or standards in relation to health services, systems and policies
Safety-related behaviours, unspecified
Ensure that heath care staff are appropriately trained in radiation protection. Pay particular attention to the training of health professionals in situations of implementing new technology (74).
Health
Health care
Universal health coverage
Information, education and communication
UEP.PH.ZZ&UBR
Training in health services, systems and policies
Radiation
Prevent medical radiation incidents and accidents (73, 74).
Points to consider may include the following.
· Integrate radiation protection contents into the curricula of medical and dental schools, and in the education and periodic training of health professionals involved in the use of radiation in health care.
· Create reporting and learning systems for medical radiation incidents/accidents and near misses, perform root cause analysis and prospective risk assessment analysis to inform preventive actions and enhance safety culture (75).
· Implement independent safety surveillance and verification and perform periodic quality and safety assessments in health facilities using radiation for diagnostic or therapeutic purposes.
Health
Health care
Universal health coverage
Assessment and surveillance, other management and control
UEP.VC.ZZ&UBR
Public health surveillance in health services, systems and policie
Radiation
+
UEP.PM.ZZ&UBR
Education in health services, systems and policies
Radiation
Increase awareness about radiation benefits and risks among health care staff and patients. Train health care staff in radiation risk communication. Enable an active and informed decision-making process for patients (73, 74, 76).
Health
Health care
Universal health coverage
Information, education and communication
UEP.VB.ZZ&UBR
Awareness raising in health services, systems and policies
Radiation
+
UEP.PH.ZZ&UBR
Training in health services, systems and policies
Radiation
+
UEP.PN.ZZ&UBR
Advising in health services, systems and policies
Radiation
See Chapter 3. WASH, including the fact sheets under Selected tools in section 3.3 Sanitation.
• WHO/UNICEF 2019: Monitoring WASH and related infection prevention and control in delivery rooms – draft module (77)
• WHO/UNICEF 2018: Water and Sanitation for Health Facility Improvement Tool (WASH FIT) (78) WASH FIT is a risk-based management approach developed by WHO and UNICEF to assist health care facilities improve quality of care through improved WASH. It includes an assessment tool to enable a comprehensive assessment of WASH and IPC within a facility.
• WHO/UNICEF 2018: Core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals (79)
• WHO 2010: Hand Hygiene Self-Assessment Framework (65)
• WHO 2008: Essential environmental health standards in health care (62)
This report contains an assessment checklist which provides a set of questions for the listed recommendations on water quality and quantity, water facilities and access to water, excreta disposal, wastewater disposal and health care waste disposal.
• WHO 2020: WHO IPC core components – implementation tools and resources (80), which includes a facility-level assessment tool.
• WHO/UNICEF 2020: Knowledge portal on WASH and waste in health care facilities (81) This includes over 400 tools, standards and training reports, mostly for the country level.
• WHO/UNICEF 2020: Global progress report on WASH in health care facilities: fundamentals first (61)
Publication provides the latest data on access and implementing World Health Assembly resolution WHA72.7 on WASH in health care facilities, country case studies and efforts to integrate WASH with health.
Health care waste management
• WHO 2014 and 2017: Safe management of wastes from health-care activities, second edition and a summary of guidance (66, 68)
Handbooks for public health managers and policy-makers, hospital managers, environmental health professionals, and all administrators with an interest in and responsibility for waste management.
• WHO 2019: Overview of technologies for the treatment of infectious and sharp waste from health care facilities (82)
Climate change/environmental degradation
• WHO 2020: WHO guidance for climate-resilient and environmentally sustainable health care facilities (83)
This guidance provides a set of suggested interventions in four key areas for providing safe and quality care in the context of climate change: i) the health workforce; ii) water, sanitation, hygiene and health care waste management; iii) sustainable energy services; and iv) infrastructure, technologies and products.
• PAHO 2017: Smart Hospitals Toolkit (70)
The Smart Hospitals Toolkit is a practical guide for hospital administrators, health disaster coordinators, health facility designers, engineers and maintenance staff to achieve Smart Health Facilities by conserving resources, cutting costs, increasing efficiency in operations and reducing carbon emissions.
• UNDP 2020: Solar for Health (84)
The Solar for Health initiative supports governments to increase access to high-quality health services through the installation of solar energy photovoltaic systems (PV), ensuring constant and cost-effective access to electricity, while also mitigating the impact of climate change and advancing multiple SDGs.
• Health Care Without Harm/UNDP (2020): Sustainable Health in Procurement Project (85)
UNDP’s Sustainable Health in Procurement Project is a programme in collaboration with Health Care Without Harm that aims to reduce the harm to people and the environment caused by the manufacture, use and disposal of medical products and by the implementation of health programmes.