FY14 SHERM Metrics-Based
Performance Summary
Key Performance Indicators of Safety, Health, Environment & Risk Management (SHERM):
Losses, Compliance, Finances, and Client Satisfaction
Overview
• This FY 2014 SHERM annual report provides a
metrics-based review based on four key
performance indicator (KPI) areas:
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
– First reports of injury 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
FY14 Number of First Reports of Injury, by Population Type
(estimated total population 11,398; employees: 5,868; students: 4,615; resident/fellows: 915)
Oversight by SHERM
700
Number of First Reports
600
Total (n = 524)
500
400
300
Employees (n = 243)
200
Residents (n = 181)
100
Students (n = 100)
0
FY03
FY04
FY05
FY06
FY07
FY08
FY09
Fiscal Year
FY10
FY11
FY12
FY13
FY14
Total Number of Employee First Reports of Injury and Subset of Compensable
Claims Submitted to UT System, FY03 to FY14
Oversight by SHERM
400
350
300
250
Number of
reports without
medical claims
200
150
100
Number of
reports with
medical claims
50
0
2003
2004
2005
2006
2007
2008
2009
Fiscal Year
2010
2011
2012
2013
2014
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
8
7
Hospitals
NAICS 622
6
5
4
3
2
1
Universities
NAICS 6113
UTHealth
Injury/Illness Rate per 100 Full Time Workers
Injury/Illness Rate per 100 Full Time Workers
8
7
6
5
4
3
2
1
0
0
2007 2008 2009 2010 2011 2012 2013 2014
Corning
DuPont
Dow
2007 2008 2009 2010 2011 2012 2013 2014
Workers’ Compensation Insurance Premium Experience Modifier for
UT System Health Institutions Fiscal Years 03 to 15
(premium rating based on a three year rolling average as compared to a baseline of 1.00)
Oversight by SHERM
0.60
0.50
0.40
0.30
0.20
UTHSCT (0.15)
UTMB (0.13)
UTSWMCD (0.13)
UTHSCSA (0.11)
UTHSC-H (.07)
UTMDACC (0.05)
0.10
0.00
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Fiscal Year

FY14 Property Losses
Retained Losses
Type
Location
Date
Auto
field
10/07/2013
$1,000
Retained Loss Cost Summary by Peril
Auto
field
10/25/2013
$7,000
(Total FY14 retained losses, $129,000)
Auto
UCT
11/20/2013
$22,000
Water
UTP
11/25/2013
$93,000
Water
BBS
12/26/2013
$9,000
Water
NSH
1/24/2014
$12,000
Water
MSB
2/28/2014
$2,000
Auto
SOD
4/01/2014
$5,000
Auto
field
5/11/2014
$3,000
Auto
MSB
6/20/2014
$1,000
Fire
NSH
7/5/2014
$3,000
Lightning
SFA
8/01/2014
$9,000
Misc.
-----
-----
$ 4,100
TOTAL

Losses incurred and covered by third party
–
Auto --10/2013 $7,200
–
Auto—11/2013 $22,500
–
Auto---04/2014 $4,400

Losses incurred and covered by UTS insurance

Auto—10/2013 $2,300

Auto—02/2013 $2,500

Losses still in process of recovery from 3rd party

Water---7/2012 $175,000
Cost
$129,000
Lightning Strike
Auto
Fire
UTHealth Retained Property Loss Summary by Peril and Value, FY06 to FY14
$500,000
$450,000
$400,000
$350,000
$300,000
$250,000
$200,000
$150,000
Other
Theft
$100,000
Water
$50,000
$0
FY 06
FY 07
FY 08
FY 09
Hurricane
FY 10
FY 11
FY 12
FY 13
FY 14
FY15 Planned Actions - Losses
• Personnel
– Closely monitor apparent increase in reported resident and student injury
events, determine root cause and implement preventive measures.
– Having objectively identified HCPC, CLAMC and FPE as having the highest
rate of employee injuries, continue to implement targeted interventions
accordingly
– 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
– Given their prevalence, drill down into data on water losses to identify
root causes and preventive measures
– Incorporate into lease arrangements requirement for leaseholder
enrollment in new cost-effective UTS Tenant User Liability Insurance
Program (TULIP)
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
(Radiation Safety Program)
Date
Agency
Findings
Status
September 11, 2013
Texas Department of State Health
Services Radiation Control
No items of non-compliance
(HMC, and Smith Tower, X-ray
Registration R10908, two sites)
Inspection file closed
January 23, 2014
Texas Department of State Health
Services Radiation Control
No items of non-compliance
(GPR dental at UTPB, X-ray
Registration R10908)
Inspection file closed
February 14, 2014
Texas Department of State Health
Services Radiation Control
No items of non-compliance
(UCT, Employee Health Services
X-ray R10908)
Inspection file closed
March 27, 2014
Texas Department of State Health
Services Radiation Control
No items of non-compliance
(Brownsville CRU, X-ray R10908)
Inspection file closed
July 7-8, 2014
Texas Department of State Health
Services Radiation Control
No items of non-compliance (two
inspections, broad license TMC
campus and Increased Controls
license L02774)
Inspection file closed
External Agencies Inspections
(Biological Safety Program)
Date
Agency
Findings
Status
April 29, 2014
Department of Transportation (Pipeline
and Hazardous Materials Safety
Administration)
No items of non-compliance
Inspection file closed
July 8, 2014
Centers for Disease Control and
Prevention (Department of Select
Agents and Toxins)
Minor observations only;
corrected collaboratively by EHS
and lab personnel (Koehler)
All deficiencies corrected and CDC
inspection report acknowledged as
closed
August 12-13, 2014
Centers for Disease Control and
Prevention (Etiologic Agent Import
Permit Program)
Minor observations only;
corrected collaboratively by EHS
and lab personnel (Soto)
All deficiencies corrected and CDC
inspection report acknowledged as
closed
Internal Compliance Assessments
•
4,469 workplace inspections documented
– Progression of routine surveillance program emphasis: labs, building fire
systems, now mechanical and non-lab spaces
– 3,330 deficiencies identified (81% in non-lab spaces)
– 2,054 of these deficiencies now corrected to date through improved
communications with FPE
– Remaining 1,276 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
– 3,071 individuals provided with required safety training
– 76% of PIs submitted required chemical inventories (up from 73% in FY13)
FY15 Planned Actions - Compliance
• External compliance
– Address new requirement for Institutional Biosafety Committee to
consider dual use research of concern
– Participate in 3-year renewal of institutional AAALAC accreditation
providing information on safety-related aspects
• Internal compliance
– Continue routine surveillance program. Incorporate lessons learned
from deficiency data into safety training to prevent recurrence.
– Continue to work with FPE to systematically address deficiencies and
support current projects to address fire safety violations.
• Provide regular updates to appropriate safety committees
– Continue emphasis on inventories for labs.
• 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
UT Physicians Service Agreement
• Professional Services Agreement includes:
– 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.
• Challenges
– Unprecedented 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
– Possible parallel expansion of EHS services to include clinical safety, infection
prevention/control
Dramatic Growth of UT Physicians
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
$3,000,000
Research
area (sf)
Amount
Not
Funded
$2,500,000
Contracts
& Training
WCI RAP
Rebate
$2,000,000
$1,500,000
Nonresearch
area (sf)
$1,000,000
Institutional
Allocation
$500,000
$0
FY09
*FY11 EHS assumed HCPC safety responsibilities.
FY10
FY11
FY12
FY13
FY14
Annual Hazardous Wastes Volumes Generated (in pounds)
(Inclusive of all Hazardous Biological, Chemical, and Radioactive Waste Streams)
300,000
250,000
Total Hazardous
Wastes (pounds)
200,000
Biological
Waste (~ $0.18/lb.)
150,000
100,000
Chemical
Waste (~ $2.06/lb.)
50,000
Radioactive
Waste (~ $8.00/lb.)
0
FY 07
FY 08
FY 09
FY 10
FY 11
FY 12
FY 13
FY 14
Cost per pound associated with each waste stream reflects average cost obligation for offsite disposal
Total Hazardous Waste Cost Obligation and Actual Disposal Expenditures
(inclusive of chemical, biological, and radioactive waste streams)
$300,000
$250,000
$200,000
Total
Hazardous
Waste Cost
Obligation
$150,000
$100,000
Actual
Disposal
Expenditures
$50,000
$0
FY 07
FY 08
FY 09
FY 10
FY 11
FY 12
FY 13
FY 14
FY14 savings: $129,823
FY14 Revenues
• Service contracts
– UT Physicians
– UT Med Foundation
• Continuing education courses/outreach
– Miscellaneous training honoraria
• Total
$235,212
$28,474
$6,580
$264,344
FY14 Financial Challenges
• Need to maintain administrative awareness of cumulative
erosive effect of program budget not paralleling campus
growth (measured by either square feet or institutional
expenditures)
• Occupational Health Clinical Services Agreement continues
to be funded on UTS Risk Management Resource Allocation
Program, which will soon disappear, so permanent line item
funding for this program is needed.
• Renewal of UT System hazardous waste contracts will result
in price increases, in particular, for biohazardous and
medical waste.
FY15 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
• Revenues
– Continue with service contracts and community
outreach activities that provide financial support to
supplement institutional funding (FY14 revenues
equated to about 10% of total budget)
– NOTE: WCI RAP fund allocations to end in FY2016
KPI #4: Client Satisfaction
• External clients served
– Results of safety question in Student Perception Survey
for institutional reaccreditation purposes
• Internal department staff
– Summary of ongoing 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
Student Perception Survey
• Total enrollment: 4,615. Number of respondents: 1,183 (26%)
• Exact Question on Survey: “UTHealth maintains adequate safety controls
for possible hazards such as fires, infectious agents, chemicals, and
radiation in my academic environment (classrooms or laboratories)”
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 teaching of continuing education course offerings
• Membership, participation in professional organizations
• Conducting a “Mentoring Day” where any interested staff member could
meet with the VP SHERM to discuss professional development – will
become an annual event
FY15 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
– Conduct targeted client satisfaction survey for Occupational Safety &
Fire Prevention program: Target FPE and Auxiliary Enterprises
• 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
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
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 continues to be measurably high
•
The major area of current institutional growth is in the clinical setting, so SHERM will need
to adjust to support these enterprises, including re-negotiation of the UT Physicians service
agreement.
•
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!
•
Resource needs continue to be driven primarily by campus square footage (total, lab and
clinic square footage)