Healthcare waste hazards assessment using EWGM-FMEA: Case study in Oman

Abstract

In the last years, particularly after Covid-19, Health care waste (HCW) has increased significantly due to the increasing population and number of healthcare organizations. HCW produces a significant risk of infectious contamination and injury. Accordingly, healthcare waste management plays a vital role in creating waste management strategies, and policies and implementing waste management plans. To build robust healthcare management systems, the risk assessment process is a key step. This paper assesses the top hazards of healthcare waste at Sultan Qaboos University Hospital (SQUH) in Oman using the Exponential Weighted Geometric Mean-Failure Mode and Effect Analysis (EWGM-FMEA). Fifteen healthcare waste hazards were selected to apply the tool. These hazards are ranked to prioritize the top hazards wastes. This assessment helps in identifying the most crucial hazards,whiche the policymakers should pay attention thus, the main countermeasures could be conducted. These hazards were proposed based on the conducted survey questionnaire and interviews accordingly, and analyses of the data have been carried out. The applied tool examined the importance of quantifying healthcare waste to apply the appropriate corrective actions which can be applied to mitigate the harm and the negative effects of healthcare waste. The results of the assessment tool will help policymakers in developing clear plans for management, disposal of wastes, and segregation. Furthermore, prioritizing healthcare waste explored the importance of integrating tthe raining plans of workers with the healthcare waste management policy. Although the prospective managerial and policy implications of this research, some limitations could be studied by future researchers. Firstly, the sample covered one hospital that may be representative of only one hospital in Oman which constrains the generalization of results. Secondly, the number of identified waste hazards is fifteen so, increased the number of hazards may help policymakers in building a more effective healthcare waste management plan which will reflect in improving the healthcare management system in the organization, mitigating the harmful effects on human health and the negative effects on the environment.

Keywords:

• exponential weighted geometric mean (EWGM)
• Failure Mode and Effect Analysis (FMEA)
• healthcare waste management
• risk priority number (PRN)
• risk assessment
• robust healthcare management system

1. Introduction

Health is one of the sustainability pillars of societies (Ananth et al., 2010; Li et al., 2019). Over recent decades, health care waste has increased due to increasing the number and size of health organizations and increasing the population level (Carnero, 2020). Similarly, in the last decades, the number of healthcare facilities in the Arabian Gulf region has increased, which increases healthcare waste (Mohamed et al., 2009). These healthcare facilities include hospitals, clinics, dental practices, blood banks, pharmacies, medical research services, and laboratories. Globally, overall healthcare waste management costs associated are significant, the USA had the highest percentage of gross domestic product spent on healthcare were accounted for 17.4% (David et al., 2019; Doyle et al., 2017; Henriques & Richardson, 2004; Hughner & Kleine, 2008; Şahin & İlgün, 2019; Vaccari et al., 2018). On average, Oman’s health expenditure was 6.4% of general government health expenditure in 2017 (WHO, 2020). The health system in Oman is provided in facilities mostly owned by the Government. The Government covers about 81% of the total health expenditure, providing 83.1% of hospitals, 92.5% of hospital beds, 62.2% of outpatient services, and 94.5% of inpatient services (Ministry of Health Sultanate of Oman, 2015).

In the last years, particularly after Covid-19, healthcare waste has increased significantly due to the increasing population and number of healthcare organizations (Pilbeam et al., 2022). A lot of countries, particularly developing countries, do not have clear standards or processes to manage these wastes (Baaki et al., 2022; Frost et al., 2021). These countries need to emphasize service health efficiency (Şahin & İlgün, 2019). Low-income countries have challenges and suffer from a shortage of healthcare staff and poor healthcare management processes (Kovacs & Lagarde, 2022). On average, developed countries produce up to 0.5 kg of hazardous health care waste per hospital bed per day. The management of healthcare waste is an essential part of a national healthcare system. However, it was found in 22 developing countries that (20–60%) of healthcare facilities don’t have appropriate healthcare waste management systems (WHO, 2016). Inappropriate or mismanagement of health care waste management systems may cause harm and negative serious consequences like infections, burns, sharps-inflicted injuries, poisoning, and pollution (Gomes et al., 2021). HCW needs to be prioritized due to the harmful effects on health and the environment (Shbool et al., 2021; Wafula et al., 2019). Therefore, hazards of healthcare waste should be identified, quantified, and managed properly to mitigate(Shi et al., 2020).

2. Literature review

This section investigates the conducted research related to the healthcare sector. These researches explored that waste management is a challenge due to the absence of a healthcare waste management plan or process. Hence, managing healthcare waste and improving the quality of healthcare is one of the main challenges facing health policy makers (Doyle et al., 2017; Frost et al., 2021). Accordingly, healthcare waste hazards are not assessed correctly.

The risks related to healthcare waste have increased attention due to the potential harm from healthcare waste (Cagliano et al., 2011; Carolan et al., 2016; Villa et al., 2016). Wastes generated from health care activities have a greater chance of causing infection (Akpieyi et al., 2015; Carnero, 2020). Thus, healthcare waste assessment is the first step to improving the waste management process (Musungwa & Kowe, 2022). Hospitals are crucial service industries of health care for patients (Chanamool & Naenna, 2016). The Healthcare waste management process is considered a source to avoid infection (Ananth et al., 2010). The main concern of a hospital is delivering high-quality care and minimizing waste (Voudrias, 2018). Improper segregation of HCW may lead to mixing this waste with non-hazard waste hence, the number of hazardous waste increases. Accordingly, the risk of injury and toxic effects, management, and disposal cost will increase (Carnero, 2020). The risk of infection and risks produced from HCW can be reduced by 2–5%. One of the main methods to achieve that is by conducting a simple training program in healthcare waste management. For example, a holistic training program in hazard segregation may save 26.3% (Carnero, 2020). Similarly, healthcare management can be improved by good communication skills and educational training programs (Fatteh et al., 2022). Classification of Health Care wastes according to the World Health Organization (WHO) can be categorized into two groups. General waste which forms about (75–80%) and (20–25%) is considered hazardous healthcare waste. The latter may cause health and environmental risks (Maamari et al., 2015; WHO, 2016).

Healthcare waste management is a high and key priority environmental concern, where unsuitable management of this waste may cause damage and harm to humans (Cagliano et al., 2011; Maamari et al., 2015). 45% of the patient-safety incidents were caused by management and organizational failures and around 50% caused by human errors (Akpieyi et al., 2015) .

All healthcare waste categories should be effectively handled to prevent human health problems and environmental pollution (Kontogianni & Moussiopoulos, 2017). Further, healthcare waste ranking may help managers to create an effective and robust contingency plan to deal with these wastes based on their ranking hence, resource allocation and cost ascertainment involve effectively.

Estimation of potential hazards may help in developing suitable correction actions which can prevent and mitigate the negative influence. Very few studies have been conducted on healthcare wastes, mainly in the middle region (Bdour et al., 2007). There are no authorized data about healthcare waste (Vaccari et al., 2018). Hence, more research is required to build a database for healthcare waste sources and assessment of these wastes. Furthermore, healthcare decision-makers should generate a more robust and agile healthcare management process (Pilbeam et al., 2022). To achieve this aim, accurate measurements and assessments are required. This database enables top management to have good budgeting for healthcare waste management.

There is a great need to rank the produced healthcare wastes quantitatively to boost the healthcare waste management practices in different healthcare facilities. Proper management of healthcare wastes is needed to determine the impact on health and the environment thus, it can be minimized (Chaerul et al., 2008; Moraes et al., 2022). Large quantities of waste and hazards can be generated from healthcare facilities. Improper healthcare waste management may lead to harmful impacts on the health and the environment sides. Thus, to build a robust healthcare waste management approach, an effective risk assessment process is needed. However, a suitable hospital healthcare waste handling process has to contain segregation, treatment of healthcare risk waste, internal collection, and waste disposal.

In recent years, there is increasing pressure to develop a sustainable approach to healthcare waste management (Ananth et al., 2010; Arni et al., 2021). However, building a healthcare waste management approach is a very complicated process (Chaerul et al., 2008). Chanamool and Naenna (2016) proposed the application of Fuzzy FMEA to prioritize and assess failures that occur in an emergency department further, helping the emergency department to select suitable corrective actions. A fuzzy FMEA model is developed to assess failures in an emergency department, where errors or failures occurring will significantly affect the safety of patients and the goodwill of the hospital. Hence, emergency departments should be monitored. This model could reduce the limitations of conventional FMEA and increase the level of confidence on hospitals. Healthcare waste management has been assessed in 91 facilities. The results shows that,most of healthcare facilities don’t comply with healthcare management legislation (Da Silva et al., 2005). Bdour et al. (2007) asses the medical wastes management practice in Jordan through a conducted survey. The results showed that there are no definite regulations or practices for the classification and segregation of wastes. Coker et al. (2009) investigate the obstacles and prospects of medical waste management in Nigeria. These challenges and obstacles are found due to a lack of quantitative data on healthcare waste hazards. These data are crucial for managing and planning of waste management process. Liao and Ho (2014) applied FMEA to assess and investigate the risks related to biomedical waste in hospitals. Further, FMEA is used to improve the quality of the healthcare management system by reducing the biomedical waste outsourcing risk. Kumar and Gupta (2017) explore healthcare waste management in India through a survey questionnaire the results show that private hospitals are producing more healthcare waste compared to public hospitals. Zamparas et al. (2019) assess the available techniques and methods of managing and handling infection waste in a general hospital in Greece. Adu et al. (2020) execute a sectional study in Ghana to evaluate the behavioral patterns of waste sorting through questionnaires and focused group discussions.

Risk management in the health care sector has become a hot topic, particularly after the Covid-19 pandemic. The strategy for risk management depends on the dynamics of main influences (Akpieyi et al., 2015). Developing a suitable healthcare waste management approach to assess and evaluate wastes should be applied. Many researchers have explored the legislations and practices of healthcare waste management but, no research assessed the healthcare waste hazards quantitatively. Thus, this paper applied the FMEA-EWGM methodology to assess various healthcare wastes at Sultan Qaboos University Hospital (SQUH) in Oman. The tool is validated using collected data from Oman). This research helps in developing the healthcare waste management procedure in hospitals. However, FMEA is a proper tool to manage the health care waste hazard where it s considered as a proactive risk assessment tool (Akpieyi et al., 2015).

The objectives of this study can be summarized as:

• 1. Collect and identify different types of healthcare waste hazards at Sultan Qaboos University Hospital (SQUH) in Oman;

• 2. Assess these wastes according to their severity, likelihood, and controllability (delectability);

• 3. Calculate the new RPN of each healthcare waste hazard;

• 4. Ranking these wastes based on their assessment. Then, a robust management procedure and strategy could be implemented based on appropriate countermeasures.

This paper utilizes the improved FMEA (EWGM-FMEA) methodology to assess and investigate healthcare wastes and rank different types of healthcare hazards at Sultan Qaboos University Hospital (SQUH) in Oman. Applied this methodology provids a systematic approach for continuous improvement in the healthcare management process.

This methodology helps in supporting the decision-making process effectively by reducing waste hazards and healthcare risks. Accordingly, healthcare management towards risk management in an organization can be improved. The developed methodology is applied at (SQUH) in Oman. An extensive validation can be conducted in a different healthcare organization to get all benefits.

3. Study area

Oman is a country in Western Asia. It is situated on the southeastern coast of the Arabian Peninsula with an area of 309,5 km² and a population of 4, 534 million people in 2022. There are over 59 hospitals in Oman and 897 medical centers and clinics. The hospitals in Oman provide a high-quality level of health care. The largest hospitals and health centers are located in Muscat (Capital of Oman), like the Royal Hospital of Oman and the Sultan Qaboos University Hospital(Ministry of Health, Oman, 2022).

4. Healthcare waste management in Oman

Healthcare waste management becomes a vital issue in all world countries(Kyhlstedt et al., 2021; Shi et al., 2020), particularly after the Covide-19 pandemic. Oman, like these countries, pays attention to healthcare waste hazards. Healthcare facilities in Oman generate around 4,500 tonnes of healthcare waste per year. Hazards on healthcare waste include (15–20%) of the total healthcare waste produced which may cause a serious risk of infection contamination and injuries. Experts estimate a significant rise in the produced healthcare waste after 2020 due to the Covid-19 pandemic (Oman Environmental Service Holding Company, 2022). Oman witnessed a more than 300% increase in healthcare waste production between (2012 and 2018; Al-jaradi, 2021). However, there is no previous published research quantifying and assessing the healthcare waste particularly, the hazards portion. This study investigates analyses and assesses the hazards of healthcare waste at Sultan Qaboos University Hospital (SQUH) in Oman. This paper applied the improved Failure Mode and Effect Analysis (FMEA) and provide a framework for identifying, assessing, and ranking different wastes and recommends areas for future improvements.

In this context, it’s very crucial to develop systemic approaches able to detect wastes hence, organizational and technological countermeasures for continuous improvement can be developed.

5. Methodology

Various failures may occur in a work process. Healthcare waste may have a negative effect on health and the environment. Thus, these failures can be addressed and prevented by implementing the FMEA tool (Chanamool & Naenna, 2016). The main steps examined in this research are summarized in Figure 1.

Figure 1. Schematic Diagram of the Executed Steps.

In this methodology, the assessment of wastes can be evaluated by considering three factors: severity (S), occurrence (O), and Delectability (D). Due to the limitation of the conventional FMEA, much research has been conducted to improve this tool. The proposed approach in this paper combines the analytic hierarchy process (AHP) technique with the exponential and weighted geometric mean method (AL Mashaqbeh, Munive-Hernandez and Khurshid Khan, 2019). Integrating AHP with EWGM allows for avoiding the repetition of RPNs. This methodology helps in proposing countermeasures to prevent or mitigate the negative effect of hazards and risks. The study has been conducted in a sample of Sultan Qaboos University Hospital (SQUH) in Oman. Thus, this paper aims to assess and rank various types of healthcare

(1) $\mathit{E}\mathit{WGM}-\mathit{RPNI}=3\text{^}\mathit{xis}\text{^}\mathit{ws}\times 3\text{^}\mathit{xio}\text{^}\mathit{wo}\times 3\text{^}\mathit{xid}\text{^}\mathit{wd}$(1)

waste hazards. Equation (1(1) $\mathit{E}\mathit{WGM}-\mathit{RPNI}=3\text{^}\mathit{xis}\text{^}\mathit{ws}\times 3\text{^}\mathit{xio}\text{^}\mathit{wo}\times 3\text{^}\mathit{xid}\text{^}\mathit{wd}$(1) ; AL Mashaqbeh, Munive-Hernandez and Khurshid Khan, 2019) is applied to calculate the new RPN using the EWGM.

Where EWGM is the exponential weighted geometric mean.

(xi: first risk indicator, the rating values for Severity (S), occurrence (O) and detection (D) are between 1 and 5. WS, WO,WD are the weights of S, O and D (will be calculated by analytic hierarchy method).

5.1. Data collection

The data was collected through a questionnaire and interviews by visiting SQUH. The questionnaire consists of closed-ended questions that provide the required data (hazards of healthcare waste generated at the hospital), further, it includes a Likert scale table to prioritize each hazard accordingly, the RPNs by the conventional tool and by the improved FMEA are calculated. The interviews were conducted with the responsible managers and the involved employees in the handling and disposal of healthcare waste. Through these interviews and surveys, the healthcare waste hazard is identified, prioritized, assessed, and ranked based on the new RPN using the improved FMEA tool.

By applying Equation 1(1) $\mathit{E}\mathit{WGM}-\mathit{RPNI}=3\text{^}\mathit{xis}\text{^}\mathit{ws}\times 3\text{^}\mathit{xio}\text{^}\mathit{wo}\times 3\text{^}\mathit{xid}\text{^}\mathit{wd}$(1) , the weights of the three risk factors (WS, WO, and WD) are estimated through the questionnaire and the conducted interviews using the AHP. These estimated values are (WS = 0.57, WO = 0.33, and WD = 0.097). The values (O, S, and D) are assessed using the Likert scale (1–10). Where (1) value denotes to risk is minimal, unlikely of occurrence, and very high probability to be detected. While (10) indicates that risk will result in severe/catastrophic failure to satisfy performance expectations/targets of operations/ supply/services, the risk is almost inevitable, and very low probability to detect the risk. After the data is collected and the hazards are assessed, the results of this assessment are explored in Table 1. The table includes the top 15 healthcare hazards at (SQUH) in Oman

Table 1. Top risks/hazards in waste management at Sultan Qaboos University Hospital

ID	Criteria Weights	0.57	0.333	0.097	EWGM
	Top Risks/hazards in waste Management at (SQUH)	S	O	D	EWGM	EWGM RANK
1	Wrong waste segregation	5	10	2	538.944	7
2	Uncontained contaminated waste	6	4	5	436.158	8
3	No use of PPE while handling infectious waste	7	7	9	889.451	4
4	Unorganized/lack of safety cabinets	5	5	4	359.190	11
5	Wrong disposal of chemical waste	8	3	5	640.569	6
6	Improper storage of chemical	4	6	5	299.013	14
7	Delayed management of chemical spillage	6	3	7	388.142	9
8	Recapping of syringe	9	3	6	841.224	5
9	Accidental bag leaks and spills	5	5	3	346.980	10
10	Rusted water pipes	4	4	1	193.036	15
11	Contaminated water for immune-compromised patient	10	3	3	980.219	3
12	Occupational hazard to healthcare worker exposure to blood and body fluid	9	7	6	1409.757	1
13	Autoclave machine leakage	8	6	6	988.805	2
14	Failure to reach required temperature of incinerator	5	4	10	352.907	12
15	Overfill of sharps box practice	5	4	6	330.235	13

6. Results and discussion

The data collected from interviews and questionnaires were analyzed. The main results are summarized in the following sections. Table 1 summarizes the list of the top 15 hazards of healthcare waste and their content. This study has assessed the top risks/hazards in waste Management at Sultan Qaboos University Hospital (SQUH) in Oman using EWGM-FMEA. A total of fifteen items in the waste management process at SQUH were identified and evaluated through the questionnaire survey and the conducted interviews using the scale (1–10). Out of these fifteen, the occupational hazard to healthcare workers’ exposure to blood and body fluid is the top one by new RPN = 1409.757 and the lowest hazard is Rusted water pipes by new RPN = 193.036. A comparison between the traditional RPN values and the improved RPN is examined in Figure 2.

Figure 2. Comparison between EWGM rank and traditional rank.

Figure 2 displays the comparison between healthcare waste hazards ranked in the top 15 graded by traditional rank and by EWGM scoring method. The highest-ranking hazard in EWGM was 1409.757, “Occupational hazard to healthcare worker exposure to blood and body fluid”. The next three highest-ranking waste hazards in EWGM were 988.805, 980.219, and 889.451 for Autoclave machine leakage, contaminated water for the immune-compromised patient, and No use of PPE while handling infectious waste respectively. On the other hand, the highest-ranking hazard in the traditional RPN was “No use of PPE while handling infectious waste” which was graded number 4 in the EWGM ranking. The next three highest-ranking hazards in the traditional RPN were Occupational hazards to healthcare workers’ exposure to blood and body fluid, Autoclave machine leakage, and Failure to reach the required temperature of the incinerator correspondingly.

The identified waste hazards examined how exposure to blood and body fluid has a severe effect where these hazards ranked the top one. Further, contaminated water for the immune-compromised patient has a negative influence. In addition, this research explored the role of wearing suitable Personnel Protective Equipment (PPE) in minimizing the harm and severe effect of healthcare waste hazards. Where un-using of PPE hazard ranked the third one. Furthermore, this research shows the importance of building a proper procedure for the disposal of chemicals and segregation. These two waste hazards ranked also among the top five wastes. On the other hand, this paper emphasizes the role of training workers in the waste management procedure where training is a key factor in increasing the safety culture in organizations.

7. Conclusions

Healthcare waste management becomes a crucial issue in all world countries, particularly after the Covid-19 pandemic. Oman, like these countries, pays attention to and increases awareness of healthcare waste hazards.

From the identified wastes it can be examined different wastes which have negatively impacted human health and the environment. Hence, creating a robust healthcare management system and implementing appropriate countermeasures to mitigate these different wastes is a vital step. The identified waste hazards examined how exposure to blood and body fluid has a severe effect where these hazards ranked the top one. Further, contaminated water for the immune-compromised patient has a negative influence. In addition, this research explored the role of wearing suitable Personnel Protective Equipment (PPE) in minimizing the harm and severe effect of healthcare waste hazards. Where un-using of PPE hazard ranked the third one. Furthermore, this research shows the importance of building a proper procedure for the disposal of chemicals and segregation. These two waste hazards ranked also among the top five wastes. On the other hand, this paper emphasizes the role of training workers in the waste management procedure where training is a key factor in increasing the safety culture in organizations.

This paper aims to apply an assessment risk tool to assess different healthcare wastes at (SQUH). Accordingly, these wastes are quantified and ranked according to the calculated EWGM-RPNs. The applied tool was effective where fifteen waste hazards were identified and assessed according to their severity, occurrence, and delectability. The applied tool shows how the newly improved FMEA is efficient in identifying and quantifying wastes. Finally, it can be concluded that this effective tool helps in designing healthcare waste management strategies and policies accordingly, and improvement plans can be established.

To keep continues improving in the healthcare sector, provide a high service level and mitigate as can as possible the harmful effects of healthcare wastes, healthcare organizations should develop proper and effective clear plans for management and disposal of wastes. Also, organizations should integrate training plans of workers with the healthcare waste management policy. These actions can be implemented by quantifying and assessing healthcare waste hazards.

8. Implications and limitations

8.1. Managerial implications

It was observed that healthcare waste increased due to increasing healthcare demands, particularly after the Covid-19 pandemic. This increase will increase the impact on health waste production which should be effectively managed. Accordingly, managerial interventions are needed. To understand these interventions, accurate identification, assessment, and ranking of healthcare waste should be implemented. EWGM-FMEA is a proactive and vital tool that is applied to assess the different types of healthcare wastes at (SQUH) in Oman. This assessment and ranking help manager to pay attention more to the severe healthcare waste hazards consequently, human health and the surrounding environment can be maintained for a time.

The applied framework provides a systemic approach based on expert knowledge. This tool helps of sustaining continuous improvement. To explain how this methodology is applied, the methodology is populated in a large hospital in Oman. However, more case studies are required to assess various waste and hazards in the healthcare sector.

8.2. Policy implications

Healthcare waste management systems should be analyzed consequently, action plans should be developed based on the final rank of wastes. This framework will help decision-makers in the healthcare sector to develop efficient strategies for implementing waste management processes in Oman.

8.3. Limitations

Although the prospective managerial and policy implications of this research, some limitations could be studied by future researchers. Firstly, the sample covered one hospital that may representative of only one hospital in Oman which constrains the generalization of results. Secondly, questionnaire surveys and interviews are used to collect data that may have some response bias. Thirdly, the number of identified waste hazards is fifteen so, increased the number of hazards may help policymakers in building a more effective healthcare waste management plan which will reflect in improving the healthcare management system in an organization, mitigating the harmful effects on human health and the negative effects on the environment. However, researchers do their best to collect the required data efficiently and objectively through valid sources.

9. Recommendations

The study has assessed healthcare waste management in Oman. The below recommendations are hereby made:

• 1. There is a need for cooperation among all involved parties in the healthcare waste management process (hospitals, waste managers, and government) in implementing an effective reliable and safe healthcare waste management strategy.

• 2. It is recommended to use the results of the improved FMEA tool to build legislation and policy.

• 3. Train all staff and provide them with the needed knowledge about the process of healthcare waste management and associated health hazards and risks.

• 4. There is a need for further research regarding healthcare waste, not covered by this research. This helps in developing comprehensive management tools for healthcare waste management.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors received no direct funding for this research.