FY 17 SHERM MetricsBased Performance Summary Key Performance
FY 17 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 • UTHealth institutional missions: – 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 Personnel Property KPI #2 Compliance With external agencies With internal assessments KPI #3 Finances Expenditures Revenues KPI #4 Client Satisfaction External clients served 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
Total Number of Employee First Reports of Injury and Subset of Compensable Claims Submitted to UT System, FY 03 to FY 17 Oversight by SHERM Number of reports with no medical claims Number of reports with medical claims NOTE: UTHealth employee headcount increase 28% between FY 13 to FY 17 *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 17 (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. 14) UTSWMCD (0. 10) UTHSCH (. 08) UTMDACC (0. 04) Fiscal Year
FY 17 Property Losses § Retained Losses (inclusive of insurance deductibles) Retained Loss Cost Summary by Peril (Total FY 17 retained losses) Type Location Date Auto CDC 10/29/2016 $5, 000 Water SPH 12/04/2016 $2, 000 Water MSB 1/07/2017 $20, 000 Water MSB 1/17/2017 $89, 000 Mold SON 3/09/2017 $800 Water Housing 5/19/2017 $700 Vandalism UCT 5/29/2017 $2, 000 Auto Field 8/14/2017 $6, 000 Water Various $3, 700 TOTAL Cost Auto Vandalism $129, 200 NOTE: Above table does not include losses associated with Hurricane Harvey. Total losses expected to be approximately $10 mil with retained losses to UTHealth TBD. § Losses incurred and covered by third party – Auto -------10/2016 $5, 000 – Water------12/2016 $2, 000 – Hurricane--8/2017 approx. 10 M § Losses incurred and covered by UTS insurance § Auto—-------8/2017 $5, 000 *Hurricane loss not shown in graph
UTHealth Retained Property Loss Summary by Peril and Value, FY 06 to FY 17 Lightnin g/Fire* Hurrican e NOTE: FY 17 does not include Harvey losses Water *Lightning strike caused fire damage at student housing totaling $978, 000 loss
FY 18 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 emergency event education 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 – 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 1 September 9, 2016 Texas Commission on Environmental Quality No items of non-compliance (HCPC underground storage tank) Inspection file closed 2 September 14, 2016 Texas Department of State Health Services Radiation Control No items on non-compliance (UT Physicians – Memorial Bone & Joint clinic, X-ray R 26367, site 017) Inspection file closed 3 September 21, 2016 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – Memorial City Ironman clinic, X-ray R 26367, site 013) Inspection file closed 4 October 3, 2016 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – North West Ortho clinic, X-ray R 26367, site 016) Inspection file closed 5 October 6, 2016 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – Katy Ortho clinic, X-ray R 26367, site 000) Inspection file closed 6 November 11, 2016 Texas Department of State Health Services Radiation Control No items of non-compliance (UTHealth – Dental vans at OCB, X-ray R 1908, site 018) Inspection file closed
External Agencies Inspections Date Agency Findings Status 7 December 2, 2016 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – Cinco Ranch clinic, X-ray R 26367, site 015) Inspection file closed 8 December 16 -19, 2016 Texas Department of State Health Services Radiation Control No items of non-compliance (Two inspections: Broad license L 02774 of TMC campus site 000 and physical protection of category 1 and 2 materials) Inspection file closed 9 January 4, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UTHealth – MSU ambulance with CT and GPR dental clinic, X-ray R 10908, site 016) Inspection file closed 10 January 19, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – TMC Orthopedics clinic, Xray R 26367, site 030) Inspection file closed 11 April 5, 2017 Texas Department of State Health Services (on behalf of CMS) No items of non-compliance (Life safety inspection of HCPC) Inspection report pending
External Agencies Inspections Date Agency Findings Status 12 May 9, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – Pearland East Ortho, X-ray R 26367, site 031) Inspection file closed 13 May 16, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – MIST, Bellaire, X-ray R 26367, site 007) Inspection file closed 14 May 23, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians – Woodlands Ortho, X-ray R 26367, site 020) Inspection file closed 15 May 2017 State Fire Marshal’s Office Minor facilities related deficiencies identified (SPH RAHC Building – Brownville) Inspection letter pending 16 June 14, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UTHealth – veterinary use at BBSB and SCRB 3, X-ray R 10908, sites 022 and 023) Inspection file closed 17 June 15, 2017 Texas Department of State Health Services Radiation Control Alleged EPE not at prescribed frequency and expired permit (UTHealth Employee Health Services, X-ray R 10908, site 020) Awaiting response by DSHS from letter. Missing EPE documentation provided to clinic. X-ray permit renewal was in process at inspection and completed after inspection.
External Agencies Inspections Date Agency Findings Status 18 July 18, 2017 Texas Department of State Health Services Radiation Control Training records and dosimetry unavailable for unannounced inspection (UTHealth – Brownsville CRU, X-ray R 10908, site 024) Inspection file closed; training provided to bone densitometry operators and dosimetry reports provided. 19 July 18 -19, 2017 Centers for Disease Control and Prevention, Federal Select Agent Program Several minor observations and recommendations for improvement All observations addressed; inspection file closed 20 August 7, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UT Physicians 3 clinics: Urology, General Medicine, TMC Sports Medicine, X-ray R 26367, sites 033, 034 and 032) Inspection file closed 21 August 15, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UTHealth – Broad license L 02774, South Campus (BBSB, SCRB 3 and SOD), site 007) Inspection file closed 22 August 23, 2017 Texas Department of State Health Services Radiation Control No items of non-compliance (UTHealth – School of Dentistry Building, X-ray R 10908, site 009) Awaiting inspection report
Routine Internal Compliance Assessments • 6, 041 workplace inspections documented – Progression of routine surveillance program emphasis: labs, building fire systems, now mechanical and non-lab spaces – 2, 158 deficiencies identified (70% in non-lab spaces) – 789 of these deficiencies now corrected to date through improved communications with FPE – Remaining 1, 369 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, 739 individuals provided with required safety training – 70% of PIs have submitted chemical inventories for filing in database
Non-Routine Internal Compliance • Initial steps taken to meet DSHS Radiation Control mandate to decommission cyclotron by August 2021 • Modified approach to use of UTHealth Alert based on feedback from severe weather events • Safety oversight 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: – FY 17 Physical Security Access Controls
FY 18 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 UTHealth 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 – Program cost, cost drivers • Revenues – 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 Nonresearch area (sf) Source: FPE, Space Management
FY 17 Revenues • Service contracts – UT Physicians $396, 293 – UT Med Foundation WCI Administration $31, 993 • Continuing education courses/outreach – Training, honoraria, peer reviews, $18, 126 and fit testing for non-UTHealth personnel • Total $446, 412 NOTE: Equates to 17% of total SHERM budget for FY 17
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 2017 to annual rate of $403, 142 – Established dedicated “Hospital and Clinic Safety Program” 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
FY 18 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 • Revenues – Continue with service contracts and community outreach activities that provide financial support to supplement institutional funding – Unanticipated receipt of WCI RAP fund allocations in FY 2018 ($178, 399), but program will likely end soon
FY 18 Challenges - Financial • Current Financial Challenges – Funding forthcoming Cyclotron decommissioning • Approximately $1 million needed to decommission which includes build back of facility – FY 18 LERR request not funded – will reapply in FY 19 • 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 – 90 -day hiring delay impacting ability to fill vacant positions – Forthcoming transition of medical residents to UTHealth employees – 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 annual Area Safety Liaison training • Internal department staff – Summary of ongoing staff professional development activities
Client Feedback • Focused assessment of a designated program aspect performed annually: – FY 03 – Clients of Radiation Safety Program – FY 04 – Overall Client Expectations and Fulfillment of Expectations – FY 05 – Clients of Chemical Safety Program Services – FY 06 – Clients of SHERM Administrative Support Staff Services – FY 07 – Feedback from Employees and Supervisors Reporting Injuries – FY 08 – Clients of Environmental Protection Program Services – FY 09 – DMO/ASL Awareness Survey of Level of “Informed Risk” – FY 10 – Clients of Biological Safety Program Services – FY 11 – Feedback on new UTHealth Alert emergency notification system – FY 13 – Clients of HCPC Safety Program Services – FY 14 – Student Perception Survey question regarding safety program – FY 15 – Clients of Occupational Safety & Fire Prevention program services – FY 16 – Clients of HCPC Safety Program Services (re-evaluation of services since 2013 implementation) – FY 17 – Area Safety Liaison annual training
ASL Training Satisfaction Survey (FY 17)
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 PH 2173 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
FY 18 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 occupational health services provided to medical residents within the UT Medical Foundation Graduate Medical Education program • 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 360 o 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
SHERM Contribution to Teaching Institutional Mission • UT SPH academic instruction, student advising – Several SHERM employees awarded adjunct faculty positions at SPH • 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 - $11, 000 • Advising and hosting students for research projects and associated publications: Emery RJ, Gutierrez JM Contextual Information for the Potential Enhancement of Annual Radiation Protection Program Review Reports Health Phys. 113(2) 154 -64 2017. Emery RJ, Patlovich SJ, Jannace K. A pilot strategy for characterizing work activities conducted by environmental health and safety professionals in the academic research setting. Prof Saf. In publication Sept 2017. Tsenov BG, Emery RJ, Whitehead LW, Reingle Gonzalez J, Gemeinhardt GL. A pilot examination of the methods used to counteract insider threat security risks associated with the use of radioactive materials in the research and academic setting. Health Phys. In publication October 2017.
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)
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