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

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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

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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

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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

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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

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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)

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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

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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

VandalismTheft

Type Location Date Cost

Water DBB 2/2011 $ 6,600

Water CDC 2/2011 $ 600

Water MSE 3/2011 $ 1,000

Water OCB 6/2011 $ 4,000

Water OCB 6/2011 $ 3,200

Water UCT 7/2011 $11,700

Mold DBB 7/2011 $15,000

Water UCT 8/2011 $ 3,400

Water DBB 8/2011 $ 3,000

Water UTPB 3/2011 $ 5,000

Fire DBB 3/2011 $ 5,000

Thefts Various $ 5,000

TOTAL $67,100

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Retained Property Loss Summary by Peril and Value, FY06 to FY11

Water

Hurricane

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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.)

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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

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External AgenciesDate Agency Findings StatusSeptember 17, 2010 Texas Department of

State Health Services Radiation Control

No items of non-compliance identified (South Campus, Broad License L02774)

NA

March 3-4, 2011 Centers for Disease Control and Prevention

13 alleged items of non-compliance (all minor)

All alleged items satisfactorily addressed in response to CDC.

July 1, 2011 Willis HRH (Property Insurance)

No recommendations NA

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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

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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

Key Financial Metrics

• Expenditures– Program cost, cost drivers

• Revenues– Sources of revenue, amounts

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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.

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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: $149,75617

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

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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

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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

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Key Client Satisfaction Metrics

• External clients served– Results of Biological Safety program client

satisfaction survey

• Internal department staff– Summary of professional development activities

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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

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Survey of Principal Investigators Utilizing EH&S Biological Safety Program Services Email based survey distributed from 4/29/2010 to 6/2/2010 to 210 Principal Investigators identified as utilizing biological safety services in FY 2010.

Survey response rate: 47 out of 210 (22%)

Survey Question Responses Yes No No Opinion

1. Do you feel the Biological Safety Program understands your needs and 44 (94%) 3 (6%) 0 (0%) requirements as a faculty member or researcher?

2. Do you feel you have adequate access to the Biological Safety Program via 47 (100%) 0 (0%) 0 (0%) phone and/or email?

3. Do you feel the Biological Safety Program responds to your requests in an 46 (98%) 1 (2%) 0 (0%) acceptable time frame?

4. Do you feel the Biological Safety Program has adequate professional knowledge 43 (93%) 2 (4%) 1 (2%) to address your needs related to biological safety? (n= 46 responses)

5. Do you feel the Biological Safety Program provides helpful and courteous service? 46 (98%) 1 (2%) 0 (0%)

6. Are you able to obtain assistance if you are having issues submitting an Institutional 34 (72%) 1 (2%) 12 (26%) Biosafety Committee protocol, renewal, or update?

7. In your opinion, do you feel that accessing the Institutional Biosafety Committee 31 (66%) 4 (9%) 12 (26%) protocol submission forms online is convenient?

8. Does the online Institutional Biosafety Committee protocol submission process 22 (49%) 7 (16%) 16 (36%) provide adequate instructions for completion of the forms? (n=45 responses)

9. Do you feel the online protocol submission system allows for easier initial 26 (55%) 5 (11%) 16 (34%) submissions, updates, and renewals of Institutional Biosafety Committee protocols as compared to the previous paper-based process?

Better Same Worse No Previous Experience

10. If you have been involved with Biological Safety Programs 21 (45%) 6 (13%) 1 (2%) 19 (40%) at other institutions, please rate how the service provided at UTHealth compares?

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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.

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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

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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 360o evaluations on supervisors to garner feedback

from staff26

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

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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)

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