1. FY16 SHERM Metrics-Based Performance Summary
Key Performance Indicators for Safety, Health, Environment & Risk Management (SHERM):
Losses, Compliance, Finances, and Client Satisfaction

2. UTHealth Institutional Missions and SHERM’s Role, Contributions
Teaching
Research
Service
Service to the Institution: SHERM’s Primary Role
4 Key Performance Indicators (KPI) of safety services provided
Service to the Community
SHERM also contributes to the other key institutional missions as well

3. SHERM’s Four Key Performance Indicators (KPI) for Safety Services to the Institution
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

4. KPI #1: Losses Personnel
Numbers of first reports of injury submitted 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

5. FY16 Number of First Reports of Injury, by Population Type (estimated total population 13,064*; employees: 7,272; students: 4,811; resident/fellows: 981)
Oversight by SHERM
Total (n = 456)
Employees (n = 277)
Residents (n = 146)
Students (n = 33)
*UTHealth experienced an increase of 1,198 in total population (10%) in FY16
** FY15 represents the first complete year of tracking visitor/patient injuries, n=46;
FY16 = 48 total injuries; SHERM continues to advertise the use of reporting form for these incidents

6. Total Number of Employee First Reports of Injury and Subset of Compensable Claims Submitted to UT System, FY03 to FY16
Oversight by SHERM
Number of reports with no medical claims
Number of reports with medical claims
*Increase in UTP clinics has resulted in greater risk of injury due to higher clinical injury exposures

7. 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 Rates
Annual Best In Class Rates
UTHealth

8. Workers’ Compensation Insurance Premium Experience Modifier for UT System Health Institutions Fiscal Years 03 to 16 (premium rating based on a three year rolling average as compared to a baseline of 1.00)
Oversight by SHERM
UTHSCT (0.19)
UTMB (0.16)
UTHSCSA (0.12)
UTSWMCD (0.10)
UTHSCH (.08)
UTMDACC (0.05)
Fiscal Year

9. FY16 Property Losses Auto Retained Loss Cost Summary by Peril
Retained Losses (inclusive of insurance deductibles)
Losses incurred and covered by third party
Water --10/2015 $2,000
Auto—---3/ $1,000
Losses incurred and covered by UTS insurance
N/A
Retained Loss Cost Summary by Peril
(Total FY16 retained losses, ~$41,000)
Type
Location
Date
Cost
Water
MSE
10/26/2015
$2,000
BBS
11/30/2015
$700
Auto
Field
12/07/2015
$1,700
12/08/2015
$28,000
12/14/2015
$3,500
JJL
$500
MSB
2/06/2016
$3,000
SOD
3/02/2016
$1,000
7/05/2016
UCT
TOTAL
~$41,000
Auto

10. UTHealth Retained Property Loss Summary by Peril and Value, FY06 to FY16
Lightning/Fire*
Hurricane
Water
Water
*Lightning strike caused fire damage at student housing totaling $978,000 loss

11. FY17 Planned Actions - Losses
Personnel
Closely monitor increase in reported employee injury events (largely from the clinic setting) determine root cause and implement preventive measures.
HCPC focus on addressing workplace violence related issues (e.g. patient on staff violence leading to injuries)
Improve educational awareness activities across campus through various mechanisms – webpage, postings, outreach presentations
Equip personnel working in high risk settings with improved exposure protocols for possible after hours exposures (e.g. NHP, B. anthracis, prions, MPTP)
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

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

13. External Agencies Inspections
Date
Agency
Findings
Status
December 3-4, 2015
UT System Office of Risk Management (peer review conducted every 3 years)
Several recommendations to improve EHS programs and associated processes
Inspection file closed
December 9, 2015
National Institutes of Health, Office of Biotechnology Activities
Request for more details in all future IBC meeting minutes; incident response plans must be approved by IBC; amend HGT plan for serious adverse events
All items addressed; IBC meeting minutes and approved incident response plans submitted to NIH OBA; inspection file closed
December 28, 2015
Texas Department of State Health Services Radiation Control
No items of non-compliance (Non-Invasive Cardiology on Fannin, Radioactive Material L05465)
February 1, 2016
State of Texas Fire Marshal (re- inspection of academic buildings and Phase III housing)
Corrective actions by UTHealth found to be sufficient from previous inspections in FY15
March 25, 2016
No items of non-compliance (Bay Area Pediatrics, X-ray R26367, Site 026)
March – July 2016
Environmental Protection Agency
No items of non-compliance (MSB and old DBB buildings)

14. External Agencies Inspections
Date
Agency
Findings
Status
April 21, 2016
Texas Department of State Health Services Radiation Control
Fluoroscopic Equipment Performance Evaluations were not performed within 14 months. Newly acquired UT Physicians clinic had difficulty w/ EPE provider (Davis Clinic, X-ray R26367, site 025)
UT Medical Physics Group has been selected as preferred vendor; EHS now provides reminders one month prior to due date; Radiation Control agreed with this action; inspection file closed.
April 26, 2016
No items of non-compliance (HOSP Park Plaza / Binz, X-ray R26367, Site 027)
Inspection file closed
May 18, 2016
No items of non-compliance (Sugarland Ortho, X-ray R26367, Site 011)
Identified issues have been corrected
May 19, 2016
No items of non-compliance (Bayshore Multispecialty, Radioactive Material, L05465)
May 23, 2016, inspection was originally scheduled April 18, 2016 (flooding)
No items of non-compliance (HOSP Bellaire, X-ray R26367, site 028)
July 7, 2016
Centers for Disease Control and Prevention – Etiologic Agent Import Permit Program (SPH Regional Campus – Brownsville/Edinburg)
Minor recommendations for improvement related to Edinburg laboratory facilities
Inspection file closed; Import permit granted

15. Routine Internal Compliance
5,150 workplace inspections documented
Progression of routine surveillance program emphasis: labs, building fire systems, now mechanical and non-lab spaces
2,663 deficiencies identified (70% in non-lab spaces)
776 of these deficiencies now corrected to date through improved communications with FPE
Remaining 1,887 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
4,885 individuals provided with required safety training
71% of PIs have submitted chemical inventories for filing in database

16. Non-Routine Internal Compliance
Participation on panel to prepare for new Campus Carry Law
Deliberation with DSHS Radiation Control regarding cyclotron decommissioning requirement
Modified approach to use of UTHealth Alert based on feedback from severe weather events
Safety oversight for forthcoming TRB major construction projects at UCT, MSB, and SPH
SHERM has also been actively involved with internal audits performed by UTHealth Auditing and Advisory Services:
FY16 Insider Threats
FY17 Physical Security Access Controls

17. FY17 Planned Actions - Compliance
External compliance
Educate UTHealth & UTPhysicians clinics about new State of Texas Radiation Control program to conduct unannounced x-ray inspections
Address new requirements for institutions to evaluate human gene transfer protocols under the recently revised NIH Guidelines
Begin initial steps in the process of decommissioning the cyclotron facility as required by the State of Texas Department of State Health Services
Explore adoption of Subpart K for hazardous waste management program in light of increased regulatory scrutiny of academic institutions by EPA
Internal compliance
Continue aggressive routine surveillance program. Incorporate lessons learned from deficiency data into safety training to prevent recurrence.
Continue to work with FPE to systematically address identified deficiencies and support current projects to address fire safety violations.
Provide regular updates to appropriate safety committees
Transition available online safety training from EHS website to LMS system
Continue emphasis on lab inventories
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

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

19. 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)
Amount Not Funded
Contracts & Training
WCI RAP Rebate
Institutional Allocation
Non-research area (sf)
Source: FPE, Space Management

22. FY16 Revenues Total $423,224 Service contracts UT Physicians $385,700
UT Med Foundation WCI Administration $31,993
Continuing education courses/outreach
Training, honoraria, peer reviews $5,551
Total $423,224

23. UT Physicians Service Agreement
Professional Services Agreement:
Agreement includes services such as 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.
Contract increased by 3% in April 2016 to annual rate of $394,490
New “Hospital and Clinic Safety Program” created within SHERM to support clinical activities within UTPhysicians as well as HCPC
Challenges
Continued 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
Continued focus on possible parallel expansion of EHS services to include patient safety, infection prevention/control

24. FY17 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 because of impending discontinuance of UTS WCI RAP
Additional FTE added to OSFP program due to forthcoming significant construction renovation projects at MSB, UCT, and SPH
Revenues
Continue with service contracts and community outreach activities that provide financial support to supplement institutional funding (FY16 revenues equated to about 17% of total budget)
Unanticipated receipt of WCI RAP fund allocations in FY2017 ($189,000), but program will now end

25. FY17 Challenges - Financial
Current Financial Challenges
Funding for forthcoming Cyclotron decommissioning
Approximately $1 million needed to decommission – and this does not include build back of facility
Disruption of EHS services based on our of CYF (office space for staff, hazardous waste management, safety training room, PPE
Loading dock will be monopolized for several days once decommissioning commences – will need to coordinate with MSB administration and Facilities to ensure activities do not conflict with TRB construction projects
Current shortfall in funding for Occupational Health Program
$450,000 needed to effectively run program
WCI RAP funds being used to support program, but these funds not likely to be issued again in the future
Sources need to be identified to fill gaps

26. KPI #4: Client Satisfaction
External clients served
Results of Client Satisfaction Survey for HCPC safety program distributed to key personnel who regularly utilize services from this program (e.g. HCPC leadership, employees, contractors) – comparison made to 2013 survey results show improvements in all areas
Internal department staff
Summary of ongoing staff professional development activities

27. 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
FY15 – Clients of Occupational Safety & Fire Prevention program services
FY16 – Clients of HCPC Safety Program Services (re-evaluation of services since 2013 implementation)

28. HCPC Client Satisfaction Survey (FY16)

29. 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 wide variety of topics
Introduction of novel “Safety Geek of the Week” staff recognition award for superior service delivery
Participation in the delivery of continuing education course offerings
Participation in SPH academic course PHM 2890 Biosafety & Infection Prevention
Adjunct academic appointments in SPH EOHS department for doctorally-prepared staff (n=6)
Membership, participation in professional organizations
Annual conduct of “SHERM Mentoring Day” where any interested staff member can meet with the VP SHERM to discuss professional development plans and seek advice, suggestions

30. FY17 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
Client satisfaction survey for employees within UTPhysicians clinics targeted for FY17
Internal Clients (departmental staff)
Continue with routine professional development seminars
Special focus on emerging issues: safety culture, insider threats, change management, Global Health Security
Continue with involvement in training courses and outreach activities – continued focus on cross training
Continue mentoring sessions on academic activities
Continue 360o evaluations on supervisors to garner feedback from staff

31. Institutional Safety Service KPI 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

32. SHERM Contribution to Community Service Institutional Mission
Safety support to UT Physicians clinical operations
Staff membership on area university Institutional Biosafety Committees (e.g. Rice University, Baylor College of Medicine)
Delivery of continuing education courses through UT SPH
Participation in the management of the Southern Biosafety Association (local affiliate of ABSA International) by SHERM staff members
Outreach education through invited lectures provided to local and national professional organizations
Provision of subject matter expert interviews on safety-related topics to local and national media
Invited university safety program peer reviews
2016: NUS (Singapore), KAUST (Saudi Arabia), Cleveland State University

33. SHERM Contribution to Teaching Institutional Mission
UT SPH academic instruction, student advising
Several SHERM employees obtained adjunct positions at SPH this year
Guest lectures at other UTHealth schools (UT MS and GSBS) and other area institutions (TAMU, TWU, TSU, UHCL, UHD)
Host student internships, practica. Advising for UT MS Scholarly Concentration students
Continuing education courses through UT SPH
Outreach education through courses with professional organizations (HPS, ABSA, CSHEMA, Eagleson Institute)

34. SHERM Contribution to Research Institutional Mission
NIEHS training grant and Ebola supplement (Year 5 $282,209 + $110,000 supplement)
Participation in other funded grants (NIOSH ERC SWCOEH, TSU Health Physics Program)
Evaluation of Safety for Mobile Stroke CT Unit - publication
SOD handheld x-ray device safety evaluation & subsequent presentation in Seoul, Korea
Advising and hosting students for research projects and associated publications:
King, Kristin

35. Summary
Various measures and metrics indicate that SHERM continues to meet its objective of maintaining a safe and healthy working and learning environment in a cost effective manner that doesn’t interfere with operations, while also making active contributions to the institutional missions:
Injury rates continue to be among the lowest within the UT System
Despite continued growth in the research enterprise, hazardous waste costs aggressively contained
Client satisfaction continues to be measurably high
And while providing these services, SHERM also actively contributes to the teaching, research, and community service missions of the institution
The major area of current institutional growth is in the clinical setting, so SHERM will need to adjust accordingly to support this enterprises
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!
SHERM resource needs will continue to be driven primarily by the square footage to which services are provided (total, lab and clinic square footage)