FY08 SHERM Metrics-Based Performance Summary Indicators of Performance in the Areas of Losses,...
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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)