1. FY08 SHERM Metrics-Based Performance Summary Indicators of Performance in the Areas of Losses, Compliance, Finances, and Client Satisfaction

2. 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

3. 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

4. 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) Total (n = 538) Employees (n = 234) Residents (n = 181) Students (n = 123)

5. 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) 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.

6. FY08 Reported Injuries/Exposures by Population Class and Type 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

7. 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) 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

9. 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

10. Compliance Metrics With external agencies –Regulatory inspections, peer reviews –Other compliance related activities With internal assessments –Results of EH&S routine safety surveillance activities

11. External Agencies DateAgencyFindingsStatus Sep 20, 2007FM Global Insurance4 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

12. External Agencies DateAgencyFindingsStatus Nov 13, 2007Texas Department of State Health Services Radiation Control No items of non - compliance noted for Brownsville sub site No other action necessary Dec 6, 2007Texas Department of State Health Services Radiation Control No items of non - compliance noted for x-ray registration No other action necessary March 12, 2008Texas 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, 2008CDC Select Agent Division 9 items of non - compliance noted Corrected and agency notified

13. 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

14. 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

15. 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

16. Financial Metrics Expenditures –Program cost, cost drivers Revenues –Sources of revenue, amounts

17. 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

18. Total Hazardous Waste Cost Obligation and Actual Disposal Expenditures (inclusive of chemical, biological, and radioactive waste streams) Hazardous Waste Cost Obligation Actual Disposal Expenditures FY08 savings: $133,787

19. 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

20. 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

21. Client Satisfaction Metrics External clients served –Results of targeted client satisfaction survey Internal department staff –Summary of professional development activities

22. 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

24. 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

25. 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

26. 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

27. 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 360 o evaluations on supervisors to garner feedback from staff

28. 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

29. 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)