FY08 SHERM Metrics-Based Performance Summary

Indicators of Performance in the Areas of

Losses, Compliance, Finances, and Client Satisfaction

Overview

• The objective of this report is to provide a metrics-based review of SHERM operations in FY08 in four key areas:

Losses Compliance Personnel With external agencies Property With internal assessments

Finances Client Satisfaction Expenditures External clients served Revenues Internal department staff

Loss Metrics

• Personnel– Reported injuries by employees, residents,

students

• Property– Losses incurred and covered by UTS

Comprehensive Property Protection Program– Losses incurred and covered by outside party– Losses retained by UTHSC-H

FY08 Number of UTHSC-H First Reports of Injury, by Population Type (total population 8,852; employee population 4,425; student population 3,587; resident population 840)

0

100

200

300

400

500

600

700

800

FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10

Fiscal Year

Nu

mb

er

of F

irst

Re

po

rts

Total (n = 538)

Employees (n = 234)

Residents (n = 181)Students (n = 123)

FY08 Rate of First Reports of Injury per 200,000 Person-hours of Exposure, by Population Type

(Based on assumption of annual exposure hours per employee = 2,000; resident = 4,000; student = 800)

0

10

20

30

40

50

60

70

80

FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10

Fiscal Year

Re

po

rte

d In

jury

Ra

te/2

00

,00

0 P

ers

on

-ho

urs

Employees (5.3)

Residents (10.7)Students (8.6)

*Rate calculated using Bureau of Labor Statistics formula = no. of injury reports x 200,000 / total person-hours of exposure.

FY08 Reported Injuries/Exposures by Population Class and Type

Medical Residents (n=181)

Cuts, Other than needles

Chemical Exposure

Slips, Trips, Falls

BBP Exposure

Needlestick

Employees (n=231)Allergic Reaction

Burn

Chemical Exposure

Slips, Trips, Falls

Animal or Insect Bite

Vehicle Accident

Assault

Foreign Body in Eye

BBP Exposure

Needlestick

Cuts, other than needles

Sprains and Strains

Contusion

Students (n=123)

NeedlestickBBP Exposure

Vehicle Accident

Allergic Reaction

Foreign body in eye

Contusion

Slips, Trips, Falls

Cuts, other than needles

In FY08, slight increases in student and medical resident sharps injuries were detected based on injury surveillance data tracking.

The increases stem largely from injury events that involve cutting tools and sutures. Specific interventions for these types of injuries will be a major focus of FY09 efforts

Workers’ Compensation Insurance Premium Adjustment for UTS Health Components Fiscal Years 03 to 09

(discount premium rating as compared to a baseline of 1, three year rolling average adjusts rates for subsequent year)

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

2003 2004 2005 2006 2007 2008 2009 2010 2011

UT Health Center Tyler (0.13)

UT Medical Branch Galveston (0.16)

UT HSC San Antonio (0.12)

UT Southwestern Dallas (0.16)

UT HSC Houston (0.09)UT MD Anderson Cancer Center (0.06)

Oversight by SHERM

FY08 Property Losses

Water Related

Fleet

Hurricane Dolly

Criminal Mischief**

Theft**

*Not inclusive of any recorded Capitol Assets inventory irregularities. For additional information contact UTHSC-H Capitol Assets Management

- Losses Incurred but covered by UTS Comprehensive Property Protection Program

Hurricane Dolly estimated loss to UTHSC-H Brow nsville, RAHC

$125,000

- Losses incurred by but covered by third party

Metro Bus damaged the Ross Sterling Breezew ay at MSB,

$25,000

- Retained Losses

Did not experience any reported losses due electrical pow er disruption

Retained Property Loss Summary By Peril(Total FY08 losses by cause and amount in dollars, Total

Loss~$231,970)*

FY09 Actions - Losses• Personnel

– Continue with aggressive EH&S safety surveillance of workplaces and case management activities for injured employees, with particular emphasis on the prevention of student and resident sharps injuries

– Improve synchronization with Employee Health Clinical Services Agreement to further contain Worker’s compensation Insurance premiums

• Property– Continue educating faculty and staff about perils causing losses

(water, power interruption and theft) and simple interventions– Conduct focused loss control assessments of selected facilities

based on objective financial assessments (property value, revenues, etc.)

– Ensure full recognition of extensive campus fire sprinkling efforts in property premium allocation modeling scoring

Compliance Metrics

• With external agencies– Regulatory inspections, peer reviews– Other compliance related activities

• With internal assessments– Results of EH&S routine safety surveillance activities

External Agencies

Date Agency Findings Status

Sep 20, 2007 FM Global Insurance 4 recommendations regarding facility equipment maintenance such as transformers, valve testing

Working with FPE regarding recommendations to fit into routine maintenance activities

Oct 30 – Nov 1, 2007

Texas State Fire Marshal’s Office

68 items of non-compliance noted from across the campus as part of a comprehensive building-by-building inspection

64 items corrected to date

4 require exploration of other means to address, but are being managed by various means

External AgenciesDate Agency Findings Status

Nov 13, 2007 Texas Department of State Health Services Radiation Control

No items of non -compliance noted for Brownsville sub site

No other action necessary

Dec 6, 2007 Texas Department of State Health Services Radiation Control

No items of non -compliance noted for x-ray registration

No other action necessary

March 12, 2008 Texas Department of State Health Services Radiation Control

1 item of non-compliance for inadvertently providing calibration services to Cyclotope not authorized by license

Service discontinued and agency notified

Aug 27, 2008 CDC Select Agent Division

9 items of non -compliance noted

Corrected and agency notified

Other Compliance-Related Activities

• Hosted voluntary National Nuclear Security Administration security review of radioactive sources subjected to increased controls requirements

• Successfully refuted assertions of non-compliance associated with radioactive materials increased controls requirements

• Completed and filed with Department of Homeland Security CFATS chemical inventory

• Completed and submitted to UTS/State Fire Marshall Office report regarding comprehensive campus fire safety program

• Participated in compliance training activities with UTS, NIH OBA and NNSA

• Made significant progress in updating institutional HOOP policy documents, particularly the TB surveillance policy which was the most outdated

Internal Compliance Assessments

• 3,627 workplace inspections documented– 887 deficiencies identified

– 305 deficiencies corrected to date– 582 best practice deficiencies subject to follow up correction –

primarily materials stacked too high in lab areas, possibly obstructing sprinkler discharge (underlying contributing cause is lack of lab space)

– 3,183 individuals provided with required safety training

– Some internal compliance was affected by moves from MSB into Impacts of moving laboratories into SRB & MSE, but worked with faculty to correct

– Focusing on the Employee Health Clinical Services program to improve medical surveillance issues

FY09 Actions - Compliance• External compliance

– Continue to work with FPE to systematically address building issues identified by SFMO & property insurance carriers

– EH&S continue aggressive routine surveillance program to provide services to community and correct possible issues to prevent non-compliance.

– Continue focus on security aspects related to research (select agent laboratories and irradiators)

• Internal compliance– Continue routine surveillance program– Focus attention on Employee Health medical surveillance to

improve compliance with aspect such as vaccines and health surveillance for health care and animal care workers

– Accommodate significant impacts of moving labs to new space and remodeling vacated space

Financial Metrics

• Expenditures– Program cost, cost drivers

• Revenues– Sources of revenue, amounts

0.00

1,000,000.00

2,000,000.00

3,000,000.00

4,000,000.00

5,000,000.00

6,000,000.00

FY05 FY06 FY07 FY08 FY09

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

FY05 FY06 FY07 FY08 FY09

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

$900,000

$1,000,000

FY05 FY06 FY07 FY08 FY09

Campus Square Footage, SHERM Resource Needs, and Funding(modeling not inclusive of resources provided for, or necessary for Employee Health Clinical Services Agreement)

Total Campus Square Footage and Lab/Clinic Subset

Modeled SHERM Resource Needs and Institutional Allocations(Not Inclusive of EHCSA)

SHERM Income (Worker’s compensation insurance rebates,

contracts services)

Lab area portion of total square footage

Non-lab portion of total square footage

Institutional allocation

Amount not funded

WCI RAP rebate *

UTP contract

IMM funding

Med Foundation

Training Services

* In addition to $214,710 from “Employee Health Account”, EHCSA received 90% of FY09 WCI RAP allocation

Total Hazardous Waste Cost Obligation and Actual Disposal Expenditures (inclusive of chemical, biological, and radioactive waste streams)

$0

$50,000

$100,000

$150,000

$200,000

$250,000

FY04 FY05 FY06 FY07 FY08 FY09

Hazardous Waste Cost Obligation

Actual Disposal Expenditures

FY08 savings: $133,787

FY08 Revenues

• Service contracts– UT Physicians $ 150,000– UT Med Foundation $ 24,094

• Continuing education courses/outreach– UT SPH SWCOEH $ 9,000– University of California System $ 1,000– University of Houston $ 17,400– Texas Medical Center $ 2,500– Miscellaneous training honoraria $ 13,950

• Total $ 217,944

FY09 Actions - Financial• Expenditures

– Continue with aggressive hazardous waste minimization program to contain costs

– Continue with development of cross functional staff, affording more cost effective services to institution

– Quantify the results of property loss prevention efforts to reduce amount of institutional losses

– Work with FPE to implement newly established “retained loss pool” to aid in the prompt recovery from uninsured losses

• Revenues– Continue with service contract and community outreach activities that

provide financial support to operate institutional program (FY08 revenues equated to about 10% of total budget)

– Explore other granting opportunities to provide support for emergency preparedness and business continuity efforts

Client Satisfaction Metrics

• External clients served– Results of targeted client satisfaction survey

• Internal department staff– Summary of professional development activities

Client Satisfaction

• Focused assessment of a designated aspect performed annually:

– FY03 – Clients of Radiation Safety Program

– FY04 – Overall client expectations and fulfillment of expectations

– FY05 – Clients of Chemical Safety Program

– FY06 – Clients who interact with Administrative Support Staff

– FY07 – Employees and Supervisors Reporting Injuries

– FY08 – Clients of Environmental Protection Program Services

Survey of Principal Investigators Utilizing Environmental Protection Program Services in 2007

Email based Zoomerang survey distributed from 11/5/07 to 11/30/07 to 88 Principal Investigators identified as requesting hazardous waste disposal services in 2007. Survey response: 30 out of 88, for a 34% response rate

Services at UTHSC-H were:

7. If you have been involved with the disposal of hazardous wastes at other institutions, please rate how the service provided at UTHSC-H compares? Worse Same Better No Previous Experience

0 (0%) 2 (7%) 13 (45%) 14 (48%)

Written Comments: (1) Thanks for all your efforts. (2) You guys are doing a great job. Keep it up. (3) I greatly appreciated the hazardous waste services provided by EHS. (4) Great job! (5) EHS is an outstanding group of people and the operation is extremely user friendly. (6) Good job (7) I do not have a heavy load of wastes, so don’t interact often with this process, but every interaction and enquiry has been handled very well, rapidly and professionally. Excellent program.

Responses

Survey Question Yes No No Opinion

1. In your opinion, have you been provided with the information necessary (either through a training class, in person, or on the EHS webpage) for you to safely manage and dispose of the hazardous waste materials generated in your work area? 30 (100%) 0 (0%) 0 (0%)

2. Does the provision of hazardous waste management supplies, such as containers, bags, and labels by EHS to your laboratory ease the process of complying with waste disposal procedures? 30 (100%) 0 (0%) 0 (0%)

3. Are the necessary labels to identify the contents of the chemical, biological, or radioactive wastes easy to complete? 26 (90%) 0 (0%) 3 (10%)

4. Are you able to easily request hazardous waste pickups utilizing the current voice mail system? 25 (83%) 1 (3%) 4 (13%)

5. Would an online hazardous waste pickup request be a more desirable means of submitting request for waste collection? 17 (57%) 7 (23%) 6 (20%)

6. After placing a hazardous waste pickup request, have your chemical, biological, or liquid radioactive wastes been collected within the stated three day time period? 23 (77%) 2 (7%) 5 (17%)

Key Findings

• 100% of respondents reported they were provided with the information needed to safely manage and dispose of hazardous materials generated in the workplace

• 100% of respondents reported the provision of supplies to the laboratory at no additional cost helped improve compliance with hazardous waste disposal procedures

• Current labels and phone system service request mechanism were reported to be easy to use by 83 – 90% of the respondents

• 57% of respondents indicated an online mechanism for requesting service would be beneficial

• 45% of respondents with previous experience ranked the UTHSC-H hazardous waste disposal programs better than other institutions

Internal Department Staff Satisfaction

• Continued support of ongoing academic pursuits

• Weekly continuing education sessions on a variety of topics

• Participation in teaching in continuing education course offerings

• Involvement in novel student and disabled veteran internship training programs

• Membership, participation in professional organizations

Staff Involvement in Emergency Preparedness, Response, and Recovery

• Significant time and effort was directed towards preparatory and recovery work for several notable storms in FY08– Hurricane Dolly, which inflected damage to the UT SPH

Regional Campus in Brownsville– Tropical Storm Edouard which eventually turned away from

Houston– Hurricane Ike, which inflicted significant regional damage

• Feedback from major program stakeholders regarding the information and services provided during these events was very positive

FY09 Actions – Client Satisfaction

• External clients– Continue with “customer service” approach to operations– Explore creation of on-line hazardous waste collection request

form as identified in client satisfaction survey– Conduct survey in FY09 to determine the level of “informed risk”

across the campus community

• Internal Clients (departmental staff)– Continue with professional development seminars– Continue with involvement in training courses and outreach

activities– Continue mentoring sessions on academic activities– Conduct 360o evaluations on supervisors to garner feedback

from staff

Metrics Caveats

• Important to remember what isn’t effectively captured by these metrics:

• Increasing complexity of research protocols

• Increased collaborations and associated challenges

• Increased complexity of regulatory environment

• Impacts of construction – both navigation and reviews

• The pain, suffering, apprehension associated with any injury – every dot on the graph is a person

• The things that didn’t happen

Summary• Various metrics indicate that SHERM is fulfilling its mission of maintaining a safe and healthy working

and learning environment in a cost effective manner that doesn’t interfere with operations:– Injury rates continue to be at the lowest rate in the history of the institution– Despite continued growth in the research enterprise, hazardous waste costs aggressively

contained– Client satisfaction is measurably high

• Nano scale and high level biosafety research activities will be area of significant growth in the near term future and will necessitate concurrent support. Regulatory oversight in these areas also likely to be high. Likewise, Fire & Life Safety and Emergency Response will also be an area of growth driven by new construction

• A successful safety program is largely people powered – the services most valued cannot be automated!

• Resource needs continue to be driven primarily by campus square footage (lab and non-lab)