1. FY15 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. FY15 Number of First Reports of Injury, by Population Type (estimated total population 11,866; employees: 6,373*; students: 4,556; resident/fellows: 937)
Oversight by SHERM
Total (n = 447)
Employees (n = 290)*
Residents (n = 125)
Students (n = 32)
*UTHealth experienced an increase of 513 employees (8% increase) in FY15

6. Total Number of Employee First Reports of Injury and Subset of Compensable Claims Submitted to UT System, FY03 to FY15
Oversight by SHERM
Number of reports with no medical claims
Number of reports with medical claims

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 (0.11)
UTHSCH (.08)
UTMDACC (0.05)
Fiscal Year

9. FY15 Property Losses Auto Retained Loss Cost Summary by Peril
Retained Losses (inclusive of insurance deductibles)
Losses incurred and covered by third party
Auto --11/2014 $2,000
Misc.—12/2014 $1,000
Wind---02/2015 $17,000
Water--02/2015 $52,000
Mold—05/2015 $2,000
Losses incurred and covered by UTS insurance
Lightning—5/2015 ~$550,000+
Auto—11/2014 $1,500
Auto—05/2015 $1,000
Type
Location
Date
Cost
Water
SFA
9/17/2014
$1,000
Auto
field
11/03/2014
$2,000
MSB
11/11/2014
Wind
SON
2/16/2015
$17,000
UH3
2/21/2015
$52,000
NSH
3/03/2015
Mold
5/04/2015
Field
5/07/2015
Lightning
5/26/2015
~$250,000+
$5,000
6/22/2015
8/18/2015
Misc.
-----
$4,000
TOTAL
~$341,000
Retained Loss Cost Summary by Peril
(Total FY15 retained losses, ~$341,000)
Auto
Lightning

10. UTHealth Retained Property Loss Summary by Peril and Value, FY06 to FY15
Hurricane
Lightning
Water
Water

11. FY16 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
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
October 21, 2014
Texas Department of State Health Services Radiation Control
No items of non-compliance (X- ray R10908 – Dental Clinic at Greenspoint)
Inspection file closed
February 11, 2015
No items of non-compliance (X- ray R10908 – two inspections at MS Complex and MHH)
March 19, 2015
No items of non-compliance (Broad license L02774 – South Campus (BBSB, SOD, SCRB3))
April 22, 2015
No items of non-compliance (X- ray R10908 – Veterinary use at SRB)
April 27, 2015
State Fire Marshall’s Office
Minor facilities related issues (Phase III Housing)
Identified issues have been corrected
August 6, 2015
Federal Aviation Administration
No items of non-compliance (reviewed shipment of radioactive material records)

14. External Agencies Inspections
Date
Agency
Findings
Status
February 25, 2015
Texas Department of State Health Services Radiation Control
No items of non-compliance (SW Ortho Jones, X-ray R26367)
Inspection file closed
June 9, 2015
No items of non-compliance (Richmond Bone & Joint – Katy, X-ray R26367)
June 29, 2015
No items of non-compliance (South East Ortho - Astoria, X-ray R26367)
July 16 & 17, 2015
State Fire Marshall’s Office
Minor facilities related issues (various campus buildings)
Most corrective actions have been completed, EHS working with building contacts and Facilities to finalize
July 21, 2015 (two locations)
No items of non-compliance (Richmond Bone & Joint – Richmond and Sugarland locations, X-ray R26367)

15. Internal Compliance Assessments
5,454 workplace inspections documented
Progression of routine surveillance program emphasis: labs, building fire systems, now mechanical and non-lab spaces
2,570 deficiencies identified (73% in non-lab spaces)
664 of these deficiencies now corrected to date through improved communications with FPE
Remaining 1,906 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
3,388 individuals provided with required safety training
69% of PIs submitted required chemical inventories on file

16. FY16 Planned Actions - Compliance
External compliance
Address new requirement for institutions to evaluate protocols with possible dual use concerns
Host NIH Office of Biotechnology Activities site visit (first ever at UTHealth) for the review Institutional Biosafety Committee activities and compliance with NIH Guidelines for Research Involving Recombinant and Synthetic Nucleic Acid Molecules
Complete UT System Peer Review of EHS Program which must be completed every 3 years
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
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

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

18. 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
Non-research area (sf)
Institutional Allocation
Source: FPE, Space Management

21. FY15 Revenues Total $347,534 Service contracts UT Physicians $302,251*
UT Med Foundation WCI Administration $30,182
Continuing education courses/outreach
Miscellaneous training honoraria $15,101
and peer reviews
Total $347,534
*UTP contract renewed 4/1/2015 at new annual rate of $383,000. This figure represents fees collected under old and new agreement

22. 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 renewed in April 2015 at new annual rate of $383,000
New FTE position dedicated to clinical safety created in Sept 2015
Development of Risk Assessment program jointly between SHERM and UTPD to assess new clinic spaces
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

23. FY16 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
Address additional FTE needs identified for 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 (FY15 revenues equated to about 14% of total budget)
NOTE: WCI RAP fund allocations to end after FY2016!

24. KPI #4: Client Satisfaction
External clients served
Results of Client Satisfaction Survey for OSFP program distributed to key personnel who regularly utilize services from this program (e.g. Facilities, Auxiliary Enterprises, Building Space Coordinators, etc.)
Internal department staff
Summary of ongoing staff professional development activities

25. 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

26. OSFP Client Satisfaction Survey

27. 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 the delivery of continuing education course offerings
Participation in new SPH academic course on Biosafety & Infection Prevention
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

28. FY16 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
Repeat targeted client satisfaction surveys for SHERM components now that all programs have had survey conducted – focus on HCPC
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 360o evaluations on supervisors to garner feedback from staff

29. 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

30. 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, BCM)
Delivery of continuing education courses through UT SPH SWCOEH
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
2015: Seattle University, UConn, UT Southwestern, Temple University

31. SHERM Contribution to Teaching Institutional Mission
UT SPH academic instruction, student advising
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 SWCOEH
Outreach education through courses with professional organizations (HPS, ABSA, CSHEMA)

32. 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)
Advising and hosting students for research projects and associated publications:
Vellani, KH, Emery, RJ, Reingle-Gonzalez, JM. A data-driven model for estimating industry average numbers of hospital security staff. J Healthcare Protection Management, 31: ; 2015.
Lim H*, Agopian AJ, Whitehead LW, Beasley CW, Langlois PH, Emery RJ, Waller DK. Maternal occupational exposure to ionizing radiation and major structural birth defects. Birth Defects Research Part A: Clinical and Molecular Teratology, 103: ; DOI: /bdra
Patlovich SJ*; Emery RJ; Whitehead LW; Brown EL; Flores R. Assessing the biological safety profession’s evaluation and control of risks associated with the field collection of potentially infectious specimens. Appl Biosaf. 20: ; 2015.
Brown BJ*, Emery RJ, Delclos G, Pompeii L. An empirical model for estimating environmental health and safety program resourcing for colleges and universities. Prof Saf submitted April 2015.

33. 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)