FY13 SHERM Metrics-Based Performance Summary

Indicators of Safety, Health, Environment & Risk Management (SHERM) Performance in the Areas of

Losses, Compliance, Finances, and Client Satisfaction

Overview

• The FY 2013 SHERM annual report provides a metrics-based review of program outcomes 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

Key Loss Metrics• Personnel

– First reports of injury by employees, residents, students– 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

FY13 Number of First Reports of Injury, by Population Type (estimated total population 11,078; employees: 5,665; students: 4,489; resident/fellows: 924)

0

100

200

300

400

500

600

700

FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13

Num

ber

of F

irst R

epor

ts

Fiscal Year

Total (n = 456)

Employees (n = 247)

Residents (n = 128)

Students (n = 81)

Oversight by SHERM

Total Number of Employee First Reports of Injury and Subset of Compensable Claims Submitted to UT System, FY03 to FY12

0

50

100

150

200

250

300

350

400

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Fiscal Year

Number of reports without medical claims

Number of reports with medical claims

Oversight by SHERM

OCB

HCPC

CDCREC

MSB

UTPB

SRBUCT SON

SPH

BBS

10129

11

20111

1

00

3

Number of Employee Reported Injuries by Location, FY13(of 247 total, 233 mapped, 14 occurred in miscellaneous public locations)

20SOD

6MSE

2 Housing

29 MHH

10 LBJ

1 CCC

1 JJL

1HMC

2UTPD

Annual UTHealth Incidence Rate of Reported Employee Injuries and Illnesses Compared to Hospital and University Rates and Three Major Companies With Generally Acknowledged

“Best in Class Safety” Programs, As Reported by the US Bureau of Labor Statistics

Workers’ Compensation Insurance Premium Experience Modifier for UT System Health Institutions Fiscal Years 03 to 13

(premium rating based on a three year rolling average as compared to a baseline of 1.00)

UTHSCT (0.09)

UTMB (0.12)UTHSCSA (0.09)

UTSWMCD (0.15)

UTMDACC (0.04)

Oversight by SHERM

Fiscal Year

FY13 Property Losses Retained Losses

Losses incurred and covered by third party–Water --12/2012 $1,700–Auto—--5/2013 $1,100–Water---11/2012 $22,000 (verbal agreement)

Losses incurred and covered by UTS insuranceAuto—9/2012 $2,300Auto—11/2012 $500Auto—5/2013 $4,100

Losses still in process of recovery from 3rd partyWater---7/2012 $175,000

Retained Loss Cost Summary by Peril (Total FY13 retained losses, $113,300)

Fire

Auto

Type Location Date Cost

Auto UCT 9/2012 $ 3,300

Water RAHC 9/2012 $21,000

Water UCT 11/2012 $22,000

Water MSB 12/2012 $ 1,700

Water SOD 1/2013 $ 2,000

Auto TMC 4/2013 $ 2,200

Water MSB 4/2013 $ 6,000

Auto OCB 4/2013 $ 2,100

Water UCT 5/2013 $10,000

Auto TMC 5/2013 $ 5,100

Water BBS 7/2013 $ 3,500

Fire NSH 8/2013 $30,000

Misc. ----- ----- $ 4,100

TOTAL $113,300

UTHealth Retained Property Loss Summary by Peril and Value, FY06 to FY13

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000

$450,000

$500,000

FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12 FY 13

Theft

Other

Water

Hurricane

Rapid Estimate of Water Damage Clean Up Cost Based on Area Affected and Type of Water 1

1 Estimate includes the cost of extracting water, removing affected materials if applicable, drilling holes in sheetrock, equipment rental, service charges, content manipulation, debris removal and moisture readings. Clean water is defined as potable water; dirty water typically involves sewage.

2Mitigating multiple rooms or multiple floors, inclusive of drying is more difficult if the affected area is separated by hard walls or floors, such as is the case of multiple offices or multiple floors.

3Estimated cost to clean up a single area affected that is not separate by hard walls.

If more than one room or one floor is affected 2

One area affected 3

Dirty Water

If more than one room or one floor is affected 2

One area affected 3

Clean Water

Square Feet Affected

FY14 Planned Actions - Losses• Personnel

– Closely monitor apparent increase in reported employee injury events, determine root cause and implement preventive measures.

– Develop means of estimating rate of employee injuries by building– Improve educational awareness activities 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– Incorporate into lease arrangements requirement for leaseholder

enrollment in new cost-effective UTS Tenant User Liability Insurance Program (TULIP)

Key Compliance Metrics

• 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 InspectionsDate Agency Findings StatusSeptember 14, 2012 Texas Department of State

Health Services, Radiation Control

No items of non-compliance identified from inspection (Hermann Hospital Building, UTHSC-H spaces, X-ray Registration R10908)

NA

September 19, 2012 Texas Department of State Health Services, Radiation Control

No items of non-compliance identified from inspection (Van housed at OCB with dental X-ray, X-ray Registration R10908)

NA

September 24, 2012 Texas Department of State Health Services, Radiation Control

No items of non-compliance identified from inspection (South Campus / BBSB & SCRB 3, Radioactive Material License L02774)

NA

External Agencies Inspections cont.Date Agency Findings StatusOctober 16, 2012 Texas Department of State

Health Services, Radiation Control

No items of non-compliance identified from inspection (Brownsville Site, Radioactive Material License L02774)

NA

June 11, 2013 Beecher Carlson – Property Insurance

No Recommendations NA

Internal Compliance Assessments• 4,508 workplace inspections documented

– Progression of routine surveillance program emphasis: labs, building fire systems, now mechanical and non-lab spaces

– 5,256 deficiencies identified (80% in non-lab spaces)

– 814 deficiencies corrected to date

– Remaining 4,442 deficiencies (predominantly minor issues) subject to follow up correction:

» Example: mechanical room deficiencies - unlabeled circuit breakers, missing outlet covers, etc.

– Working with Facilities to correct, tracking progress and reporting progress to appropriate safety committees

– 2,719 individuals provided with required safety training

– 73% of PIs submitted required chemical inventories (renewed initiative in FY13)

FY14 Planned Actions - Compliance

• External compliance– Update safety training to include updated hazard communication

regulations for the new globally harmonized system for the classification and labeling of chemicals (GHS)

• Internal compliance– Continue routine surveillance program. Incorporate lessons learned

from deficiency data into safety training to prevent recurrence– Continue to work with Facilities, Planning and Engineering to

systematically address deficiencies and support current projects to address fire safety violations.

• Provide regular updates to appropriate safety committees

– Continue emphasis on creation of chemical inventories for labs

Key Financial Metrics

• Expenditures– Program cost, cost drivers

• Revenues– Sources of revenue, amounts

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

FY09 FY10 FY11 FY12 FY13$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

FY09 FY10 FY11 FY12 FY13

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)

Non-research area (sf)

Institutional Allocation

Amount Not Funded

Contracts & Training

WCI RAP Rebate

*FY11 EHS assumed HCPC safety responsibilities.

Total Hazardous Waste Cost Obligation and Actual Disposal Expenditures (inclusive of chemical, biological, and radioactive waste streams)

FY13 savings: $140,005

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY 14

Total Hazardous Waste Cost Obligation

Actual Disposal Expenditures

FY13 Revenues• Service contracts

– UT Physicians $235,212– UT Med Foundation $27,645

• Continuing education courses/outreach– Miscellaneous training honoraria $15,497

• Total $278,354

FY13 Financial Challenges• Need to maintain awareness of cumulative erosive effect of

program budget not paralleling campus growth (measured by either square feet or institutional expenditures)

• Employee Health Clinical Services Agreement continues to be funded on Risk Management Resource Allocation Program, which is likely to disappear, so permanent line item funding is needed for this program.

FY14 Planned Actions - Financial

• Expenditures– Continue aggressive hazardous waste minimization

program to contain hazardous waste disposal costs– Renewal of UT System hazardous waste contracts

anticipated to have price increase, in particular, for biohazardous/medical waste.

– Continue to lobby for dedicated funding for Employee Health Clinical Services Agreement

• Revenues– Continue with service contracts and community

outreach activities that provide financial support to supplement institutional funding (FY13 revenues equated to about 12% of total budget)

Key Client Satisfaction Metrics

• External clients served– Results of HCPC Safety program client satisfaction survey

• 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

Survey of HCPC Employees Regarding Safety Program at HCPCWeb based survey distributed from July to August 2013 to all HCPC Employees. Survey response rate: 71 out of 436 (16%)

Survey Question Responses

Yes No No Opinion•Do you feel the EHS safety program at HCPC understands your needs 52 (73%) 8 (11%)

11 (16%)and requirements as an employee / healthcare provider at HCPC?

• Do you feel you have adequate access to the EHS safety program (safety 62 (87%) 2 (3%) 7 (10%)coordinator) via phone, email and/or in person?

•Do you feel the EHS safety program at HCPC has adequate knowledge to address 54 (76%) 6 (8%) 11 (16%)

your needs related to safety at HCPC?

•Do you feel the EHS safety program at HCPC responds to your requests in an 44 (62%) 5 (7%) 22 (31%)acceptable time frame?

•Do you feel the EHS safety program at HCPC is concerned about staff and patients 55 (80%) 5 (7%) 9 (13%)well-being? n=69

•Do you feel that the EHS safety program at HCPC establishes collaborative 45 (63%) 6 (9%) 20 (28%)relationships with other departments at HCPC?

•Do you feel the EHS safety program at HCPC communicates safety information 60 (85%) 3 (4%) 8 (11%) effectively?

•Do you feel the EHS safety program at HCPC has reduced interruptions due to 48 (68%) 5 (7%) 18 (25%) or the length of fire drills at HCPC while maintaining their effectiveness?

Better Same Worse No Previous Experience•If you have worked with other psychiatric hospitals, please rate 17 (25%) 23 (33%) 6 (9%) 23 (33%)how the current safety program at HCPC compares?

Key Findings• What did we learn?

– Majority of respondents feel the HCPC Safety program:• understands needs and requirements• have adequate access to the program• is genuinely concerned about the safety of staff and patients, and• communicates safety information effectively

– A significant proportion of respondents did not have an opinion regarding• respond time being acceptable• establishment of collaborative relationships and• reduction of interruptions

• Next steps

– Develop strategy to improve staff understanding of safety program roles and responsibilities– Explore other means of educational outreach– Possible re-survey in one to two years

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

FY14 Planned Actions – Client Satisfaction

• External Clients– Continue with “customer service” approach to operations– Participate in upcoming student satisfaction survey by contributing

assessment question on safety– Collect data for meaningful benchmarking to compare safety program

staffing, resourcing, and outcomes

• Internal Clients (departmental staff)– Continue with routine professional development seminars

• Special focus on emerging issues: safety culture, insider threats, GHS– Continue with involvement in training courses and outreach activities

– 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

• Impacts of budget reductions experienced at the end of FY11 persists, 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 by clients cannot be automated!

• Resource needs continue to be driven primarily by campus square footage (lab and non-lab)