1. FY11 SHERM Metrics-Based Performance Summary Indicators of Safety, Health, Environment & Risk Management (SHERM) Performance in the Areas of Losses, Compliance, Finances, and Client Satisfaction 1

2. Overview The objective of this report is to provide a metrics-based review of SHERM operations in FY11 in four key balanced scorecard areas: Losses Compliance Personnel With external agencies Property With internal assessments Finances Client Satisfaction Expenditures External clients served Revenues Internal department staff 2

3. Key Loss Metrics Personnel –First reports of injury 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 3

4. FY11 Number of UTHSC-H First Reports of Injury, by Population Type (estimated total population 11,198; employees: 5,556; students: 4,485; resident/fellows: 1,157) Total (n = 381) Employees (n = 192) Residents (n = 112) Students (n = 77) Oversight by SHERM 4

5. FY11 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) Employees (3.46) Residents (6.45) Students (4.29) * Rate calculated using Bureau of Labor Statistics formula = no. of injury reports x 200,000 / total person-hours of exposure. Oversight by SHERM 5

6. FY11 Compensable Injury Costs by Population Type (student costs not captured: paid directly by UTHSC-H Student Health or student’s insurance) Total ($78,785) Employees ($67,270) Residents ($11,515) 6

7. Employee Workers’ Compensation Insurance Premium Experience Modifier for UT System Health Institutions Fiscal Years 03 to 11 (discount premium rating as compared to a baseline of 1.00, three year rolling average adjusts rates for subsequent year) UTHSCT (0.07) UTMB (0.13) UTHSCSA (0.09) UTSW MCD (0.15) UTHSCH (0.07) UTMDACC (0.04) Oversight by SHERM Fiscal Year 7

8. FY11 Property Losses  Retained Losses  Losses incurred and covered by third party –Water damage OCB 2/2011 $47,334  Losses incurred and covered by UTS insurance  None Retained Loss Cost Summary by Peril (Total FY11 retained losses, $67,100) Fire Vandalism Theft TypeLocationDateCost WaterDBB2/2011$ 6,600 WaterCDC2/2011$ 600 WaterMSE3/2011$ 1,000 WaterOCB6/2011$ 4,000 WaterOCB6/2011$ 3,200 WaterUCT7/2011$11,700 MoldDBB7/2011$15,000 WaterUCT8/2011$ 3,400 WaterDBB8/2011$ 3,000 WaterUTPB3/2011$ 5,000 FireDBB3/2011$ 5,000 TheftsVarious$ 5,000 TOTAL$67,100 8

9. Retained Property Loss Summary by Peril and Value, FY06 to FY11 Water Hurricane 9

10. FY12 Planned Actions - Losses Personnel –Despite losses in staff (reductions in force, turnover) continue as best as possible with aggressive EH&S safety surveillance of workplaces and case management activities –Focus on staffing needs within SHERM for coming year as injury reports and WCI rates, although positive, are lagging indicators of program performance. Property –Continue to educate faculty and staff about common perils causing losses (water, power interruption, and theft), simple interventions, and prompt water loss response and mitigation –Conduct focused loss control assessments of key facilities based on objective financial assessments (property value, revenues, etc.) 10

11. Key Compliance Metrics With external agencies –Regulatory inspections, peer reviews –Other compliance related activities With internal assessments –Results of EH&S routine safety surveillance activities 11

12. External Agencies DateAgencyFindingsStatus September 17, 2010Texas Department of State Health Services Radiation Control No items of non- compliance identified (South Campus, Broad License L02774) NA March 3-4, 2011Centers for Disease Control and Prevention 13 alleged items of non- compliance (all minor) All alleged items satisfactorily addressed in response to CDC. July 1, 2011Willis HRH (Property Insurance) No recommendationsNA 12

13. Internal Compliance Assessments 4,003 workplace inspections documented –1,018 deficiencies identified –496 deficiencies corrected to date –Remaining 522 deficiencies subject to follow up correction – primarily: » mechanical room deficiencies, »inadequate clearance impairing sprinkler system efficacy, »and biological safety cabinets not certified. –Some issues associated with moves of labs to new facilities –1,638 individuals provided with required safety training 13

14. FY12 Planned Actions - Compliance External compliance –Work with FPE to address mechanical room safety issues identified during routine surveillance –Despite losses in staff (reductions in force, turnover) continue as best as possible with comprehensive safety surveillance program to prevent non-compliance. Incorporate lessons learned from non-compliance data into training programs to prevent recurrence Internal compliance –Continue routine surveillance program. Incorporate lessons learned from non-compliance data into training programs to prevent recurrence –Accommodate impacts of moving labs to new spaces and the remodeling of vacated spaces 14

15. Key Financial Metrics Expenditures –Program cost, cost drivers Revenues –Sources of revenue, amounts 15

16. 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 Serviced Modeled SHERM Resource Needs and Institutional Allocations Lab/clinic portion of total square footage Non-lab portion of total square footage Institutional allocation Amount not funded Contracts / Training WCI RAP Rebate *FY11 EH&S assumed HCPC safety responsibilities. 16

17. Total Hazardous Waste Cost Obligation and Actual Disposal Expenditures (inclusive of chemical, biological, and radioactive waste streams) Total Hazardous Waste Cost Obligation Actual Disposal Expenditures FY11 savings: $149,756 17

18. FY11 Revenues Service contracts –UT Physicians $ 200,000 –UT Med Foundation $ 26,057 Continuing education courses/outreach –Miscellaneous training honoraria $ 5,873 Total $ 231,930 18

19. FY11 Financial Challenges Cumulative erosive effect of program budget not paralleling campus growth (measured by either square feet or research dollars): –Loss of 3 part-time fire safety positions –Loss of local administrative support – subset of personnel resource to central administrative pool – loss of local safety committee support function –Absence of travel resources for staff professional development –Constant employee turnover due to uncompetitive salaries – loss of organizational knowledge Assumption of responsibility of HCPC safety with no budget Necessary codification of who bears the cost of employee health services associated with employees who provide clinical services external to UTHSC-H. Cost equates to a needed FTE 19

20. FY12 Planned Actions - Financial Expenditures –To avoid the prospect of program erosion, SHERM will focus specifically on: Ability to recruit for, and fill, all current safety position vacancies Direct supervision and budget control for HCPC safety program (discussions underway) Restoration of some degree of on-site administrative support (resolution in process) Restoration of some level of part time fire safety support (partially resolved) Phased addition of two Biological Safety Program Specialist positions to keep up with institutional growth and protocol complexity involving infectious agents and animal models (especially select agents), and assist with employee health aspects (fit testing) Revenues –Continue with service contract and community outreach activities that provide financial support to operate institutional program (FY11 revenues equated to about 10% of total budget) –Cultivate other fee-for-service programs such as the provision of safety services to new biotech start up companies in UCT 20

21. Key Client Satisfaction Metrics External clients served –Results of Biological Safety program client satisfaction survey Internal department staff –Summary of professional development activities 21

22. Client Feedback 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 – SHERM Administrative Support Staff Clients –FY07 – Employees and Supervisors Reporting Injuries –FY08 – Clients of Environmental Protection Program Services –FY09 – Survey of Level of “Informed Risk” –FY10 – Clients of Biological Safety Program 22

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24. Key Findings What did we learn? –94% report the Biosafety Program understands lab needs –98% report the program is responsive –93% report the program staff in knowledgeable –98% report the program provides helpful and courteous service –40% reported having no previous experience with other safety programs… –But of the 60% who had previous experience, 21 of 28 (75%) reported that the services provided by the UTHSC-H Biosafety Program were better than experienced elsewhere. 24

25. 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 Solicited non-monetary reward ideas from staff Participation in teaching in continuing education course offerings Involvement in novel student and disabled veteran internship training programs Membership, participation in professional organizations 25

26. FY12 Planned Actions – Client Satisfaction External Clients –Continue with “customer service” approach to operations –Collect feedback on new UTHealth Alert emergency notification system –Collect data for meaningful benchmarking to compare safety program staffing, resourcing, and outcomes Internal Clients (departmental staff) –Continue with professional development seminars –Continue with involvement in training courses and outreach activities –focus on cross training –Continue mentoring sessions on academic activities –Conduct staff survey focused on job satisfaction –Continue 360 o evaluations on supervisors to garner feedback from staff 26

27. 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 27

28. 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 is measurably high Budget reductions experienced at the end of FY11 impacted needed staffing, especially in light of continued campus growth (square footage and research expenditures). Important to protect against erosion of program. 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) 28