FY14 SHERM Metrics-Based Performance Summary Key Performance Indicators of Safety, Health, Environment & Risk Management (SHERM): Losses, Compliance, Finances, and Client Satisfaction

Overview This FY 2014 SHERM annual report provides a metrics-based review based on four key performance indicator (KPI) areas: KPI #1: Losses KPI #2 Compliance Personnel With external agencies Property With internal assessments KPI #3 Finances KPI #4 Client Satisfaction Expenditures External clients served Revenues Internal department staff

KPI #1: Losses Personnel – First reports of injury by employees, residents, students – Employee injury and Illness rate – Workers’ Compensation Insurance experience modifier Property – Losses incurred and covered by UTS Comprehensive Property Protection Program – Losses incurred but covered by outside party – Losses retained by UTHealth

FY14 Number of First Reports of Injury, by Population Type (estimated total population 11,398; employees: 5,868; students: 4,615; resident/fellows: 915) Total (n = 524) Employees (n = 243) Residents (n = 181) Students (n = 100) Oversight by SHERM

Total Number of Employee First Reports of Injury and Subset of Compensable Claims Submitted to UT System, FY03 to FY14 Number of reports without medical claims Number of reports with medical claims Oversight by SHERM

Annual UTHealth Incidence Rate of Reported Employee Injuries and Illnesses Compared to National Hospital and University Rates and Three Major Companies With Acknowledged “Best in Class Safety” Programs (national data source: US Bureau of Labor Statistics) Annual Reported Injury/Illness RatesAnnual Best In Class Rates

Workers’ Compensation Insurance Premium Experience Modifier for UT System Health Institutions Fiscal Years 03 to 15 (premium rating based on a three year rolling average as compared to a baseline of 1.00) UTHSCT (0.15) UTMB (0.13) UTHSCSA (0.11) UTSWMCD (0.13) UTMDACC (0.05) Oversight by SHERM Fiscal Year UTHSC-H (.07)

FY14 Property Losses  Retained Losses  Losses incurred and covered by third party – Auto --10/2013 $7,200 – Auto—11/2013 $22,500 – Auto---04/2014 $4,400  Losses incurred and covered by UTS insurance  Auto—10/2013 $2,300  Auto—02/2013 $2,500  Losses still in process of recovery from 3 rd party  Water---7/2012 $175,000 Retained Loss Cost Summary by Peril (Total FY14 retained losses, $129,000) Fire Auto TypeLocationDateCost Autofield10/07/2013$1,000 Autofield10/25/2013$7,000 AutoUCT11/20/2013$22,000 WaterUTP11/25/2013$93,000 WaterBBS12/26/2013$9,000 WaterNSH1/24/2014$12,000 WaterMSB2/28/2014$2,000 AutoSOD4/01/2014$5,000 Autofield5/11/2014$3,000 AutoMSB6/20/2014$1,000 FireNSH7/5/2014$3,000 LightningSFA8/01/2014$9,000 Misc $ 4,100 TOTAL$129,000 Lightning Strike

UTHealth Retained Property Loss Summary by Peril and Value, FY06 to FY14 Water Hurricane

FY15 Planned Actions - Losses Personnel – Closely monitor apparent increase in reported resident and student injury events, determine root cause and implement preventive measures. – Having objectively identified HCPC, CLAMC and FPE as having the highest rate of employee injuries, continue to implement targeted interventions accordingly – Improve educational awareness activities across campus through various mechanisms – webpage, postings, outreach presentations Property – Continue to educate faculty and staff about common perils causing losses (water, power interruption, and theft), simple interventions. – Develop additional predictive methods for prompt recovery after losses occur, specifically estimated length of time to recovery – Given their prevalence, drill down into data on water losses to identify root causes and preventive measures – Incorporate into lease arrangements requirement for leaseholder enrollment in new cost-effective UTS Tenant User Liability Insurance Program (TULIP)

KPI #2: Compliance With external agencies – Regulatory inspections; other compliance related inspections by outside entities With internal assessments – Results of EH&S routine safety surveillance activities

External Agencies Inspections (Radiation Safety Program) DateAgencyFindingsStatus September 11, 2013 Texas Department of State Health Services Radiation Control No items of non-compliance (HMC, and Smith Tower, X-ray Registration R10908, two sites) Inspection file closed January 23, 2014 Texas Department of State Health Services Radiation Control No items of non-compliance (GPR dental at UTPB, X-ray Registration R10908) Inspection file closed February 14, 2014 Texas Department of State Health Services Radiation Control No items of non-compliance (UCT, Employee Health Services X-ray R10908) Inspection file closed March 27, 2014 Texas Department of State Health Services Radiation Control No items of non-compliance (Brownsville CRU, X-ray R10908) Inspection file closed July 7-8, 2014 Texas Department of State Health Services Radiation Control No items of non-compliance (two inspections, broad license TMC campus and Increased Controls license L02774) Inspection file closed

External Agencies Inspections (Biological Safety Program) DateAgencyFindingsStatus April 29, 2014Department of Transportation (Pipeline and Hazardous Materials Safety Administration) No items of non-complianceInspection file closed July 8, 2014 Centers for Disease Control and Prevention (Department of Select Agents and Toxins) Minor observations only; corrected collaboratively by EHS and lab personnel (Koehler) All deficiencies corrected and CDC inspection report acknowledged as closed August 12-13, 2014 Centers for Disease Control and Prevention (Etiologic Agent Import Permit Program) Minor observations only; corrected collaboratively by EHS and lab personnel (Soto) All deficiencies corrected and CDC inspection report acknowledged as closed

Internal Compliance Assessments 4,469 workplace inspections documented – Progression of routine surveillance program emphasis: labs, building fire systems, now mechanical and non-lab spaces – 3,330 deficiencies identified (81% in non-lab spaces) – 2,054 of these deficiencies now corrected to date through improved communications with FPE – Remaining 1,276 deficiencies (predominantly minor issues) subject to follow up correction: » Example: mechanical room deficiencies - unlabeled circuit breakers, missing outlet covers, etc. – Working with FPE to track and report progress and reporting progress to appropriate safety committees – 3,071 individuals provided with required safety training – 76% of PIs submitted required chemical inventories (up from 73% in FY13)

FY15 Planned Actions - Compliance External compliance – Address new requirement for Institutional Biosafety Committee to consider dual use research of concern – Participate in 3-year renewal of institutional AAALAC accreditation providing information on safety-related aspects Internal compliance – Continue routine surveillance program. Incorporate lessons learned from deficiency data into safety training to prevent recurrence. – Continue to work with FPE to systematically address deficiencies and support current projects to address fire safety violations. Provide regular updates to appropriate safety committees – Continue emphasis on inventories for labs. Chemical inventories already a requirement Inventories for biological agents and toxins also likely to become a requirement due to recent events at federal facilities and subsequent NIH Biosafety Stewardship initiative

UT Physicians Service Agreement Professional Services Agreement includes: – Training, radiation safety permitting & surveys, general clinic surveys, fire & life safety surveillance, waste management, emergency preparedness & response, IAQ evaluations, asbestos/mold monitoring, accident/incident investigations, CAP/CLIA quality control monitoring, etc. Challenges – Unprecedented growth and rapid expansion of clinical locations and services – Dramatic increase in manpower requirements for CAP/CLIA oversight and compliance, waste collection, occupational health services, training, etc. Opportunities – Possible parallel expansion of EHS services to include clinical safety, infection prevention/control

Dramatic Growth of UT Physicians

KPI #3: Finances Expenditures – Program cost, cost drivers Revenues – Sources of revenue, amounts

Campus Square Footage, SHERM Resource Needs and Funding (modeling not inclusive of resources provided for, or necessary for Employee Health Clinical Services Agreement) Total Assignable Square Footage and Research Subset Modeled SHERM Resource Needs and Institutional Allocations Research area (sf) Non- research area (sf) Institutional Allocation Amount Not Funded Contracts & Training WCI RAP Rebate *FY11 EHS assumed HCPC safety responsibilities.

Annual Hazardous Wastes Volumes Generated (in pounds) (Inclusive of all Hazardous Biological, Chemical, and Radioactive Waste Streams) Total Hazardous Wastes (pounds) Cost per pound associated with each waste stream reflects average cost obligation for offsite disposal

Total Hazardous Waste Cost Obligation and Actual Disposal Expenditures (inclusive of chemical, biological, and radioactive waste streams) Total Hazardous Waste Cost Obligation FY14 savings: $129,823

FY14 Revenues Service contracts – UT Physicians $235,212 – UT Med Foundation $28,474 Continuing education courses/outreach – Miscellaneous training honoraria $6,580 Total $264,344

FY14 Financial Challenges Need to maintain administrative awareness of cumulative erosive effect of program budget not paralleling campus growth (measured by either square feet or institutional expenditures) Occupational Health Clinical Services Agreement continues to be funded on UTS Risk Management Resource Allocation Program, which will soon disappear, so permanent line item funding for this program is needed. Renewal of UT System hazardous waste contracts will result in price increases, in particular, for biohazardous and medical waste.

FY15 Planned Actions - Financial Expenditures – Continue aggressive hazardous waste minimization program to contain hazardous waste disposal costs – Continue to lobby for dedicated funding for Occupational Health Clinical Services Agreement Revenues – Continue with service contracts and community outreach activities that provide financial support to supplement institutional funding (FY14 revenues equated to about 10% of total budget) – NOTE: WCI RAP fund allocations to end in FY2016

KPI #4: Client Satisfaction External clients served – Results of safety question in Student Perception Survey for institutional reaccreditation purposes Internal department staff – Summary of ongoing professional development activities

Client Feedback Focused assessment of a designated program aspect performed annually: – FY03 – Clients of Radiation Safety Program – FY04 – Overall Client Expectations and Fulfillment of Expectations – FY05 – Clients of Chemical Safety Program Services – FY06 – Clients of SHERM Administrative Support Staff Services – FY07 – Feedback from Employees and Supervisors Reporting Injuries – FY08 – Clients of Environmental Protection Program Services – FY09 – DMO/ASL Awareness Survey of Level of “Informed Risk” – FY10 – Clients of Biological Safety Program Services – FY11 – Feedback on new UTHealth Alert emergency notification system – FY13 – Clients of HCPC Safety Program Services – FY14 – Student Perception Survey question regarding safety program

Student Perception Survey Total enrollment: 4,615. Number of respondents: 1,183 (26%) Exact Question on Survey: “UTHealth maintains adequate safety controls for possible hazards such as fires, infectious agents, chemicals, and radiation in my academic environment (classrooms or laboratories)”

Internal Department Staff Satisfaction Continued support of ongoing academic pursuits – leverage unique linkage with UT SPH for both staff development and research projects that benefit the institution Weekly continuing education sessions on a variety of topics Participation in teaching of continuing education course offerings Membership, participation in professional organizations Conducting a “Mentoring Day” where any interested staff member could meet with the VP SHERM to discuss professional development – will become an annual event

FY15 Planned Actions – Client Satisfaction External Clients – Continue with “customer service” approach to operations – Collect data for meaningful benchmarking to compare safety program staffing, resourcing, and outcomes – Conduct targeted client satisfaction survey for Occupational Safety & Fire Prevention program: Target FPE and Auxiliary Enterprises Internal Clients (departmental staff) – Continue with routine professional development seminars Special focus on emerging issues: safety culture, insider threats, GHS, Global Health Security – Continue with involvement in training courses and outreach activities – continued focus on cross training – Continue mentoring sessions on academic activities – Continue 360 o 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 continues to 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 continues to be measurably high The major area of current institutional growth is in the clinical setting, so SHERM will need to adjust to support these enterprises, including re-negotiation of the UT Physicians service agreement. The discontinuance of the UTS WCI Rebate program represents a challenge, especially for the Occupational Health program A successful safety program is largely “people powered” – the services most valued by clients cannot be automated! Resource needs continue to be driven primarily by campus square footage (total, lab and clinic square footage)