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

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

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

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

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

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

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

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

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—---3/2016 $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

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

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

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

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)

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

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

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

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

KPI #3: Finances Expenditures Revenues Program cost, cost drivers 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) Amount Not Funded Contracts & Training WCI RAP Rebate Institutional Allocation Non-research area (sf) Source: FPE, Space Management

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

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

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

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

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

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)

HCPC Client Satisfaction Survey (FY16)

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

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

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

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

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)

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

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)