ENVIRONMENTAL HEALTH & SAFETY ANNUAL REPORT FY 2023

ENVIRONMENTAL HEALTH & SAFETY ANNUAL REPORT FY2023

Addressing Environmental Health and Safety needs of the UTMB Community

1302 Mechanic Street Second Floor Galveston, TX 77555-1111 409.747.0515

utmb.edu/ehs

ENVIRONMENTAL HEALTH AND SAFETY

Aerial view of UTMB Campus, Cruise Terminal (foreground) and Pelican Island (midground) with a storm moving across the Galveston Bay in the distance. (July 2023)

Cover photo: UTMB Campus aerial view, east to west.

The Gulf of Mexico to the left, southwest. (July 2023)

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TABLE OF CONTENTS

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EHS LEADERSHIP

4

STATEMENTS

5

EHS ORGANIZATION

6

WHAT WE DO

8

HOW WE WORK

9

YEAR IN REVIEW

11

PROGRAM AREAS

12

SERVICE HIGHLIGHTS

18

BUILDERS RISK INSURANCE CARRIER VISIT

27

PEER REVIEW 2023

27

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ENVIRONMENTAL HEALTH AND SAFETY

EHS LEADERSHIP

CHARLES CARLISLE CO-AVP AD INTERIM, LIFE SAFETY & ENVIRONMENT OF CARE COMPLIANCE PROGRAM

• Fire Protection System Design, • • •

Inspections, and Maintenance Fire Safety Training Life Safety Inspections Joint Commission Compliance

• • • •

DE ’ANNE MEEH PROGRAM DIRECTOR ENVIRONMENTAL PROTECTION MANAGEMENT

Hazardous Waste Management Radioactive Waste Management Pollution Prevention Air & Water Quality

DR. WILLIAM PATE CO-AVP AD INTERIM, RADIATION & OCCUPATIONAL SAFETY PROGRAM

• Radiation, Laser, and MRI Safety • Industrial Hygiene/IAQ • Laboratory, Industrial, and Construction Safety

• Food Safety and Water Quality

We invite you to review the EHS Annual Report for FY2023. The report provides a snapshot of various programs, services, and collaborations from a uniquely talented team. Sharing this report presents tangible examples of our commitment to maintaining a safe and healthy working and learning environment for everyone involved in the institution’s education, research, and clinical service missions.

EHS programs are designed and set with a corresponding level of expectation for meeting the requirements of federal and state environmental and safety laws and university policies.

Procedures are developed to ensure processes minimize risks of adverse effects on people and the natural environment from operations and activities in UTMB facilities.

If you have any questions relating to the articles or information raised in this report, we welcome you to contact one of us.

Chuck, De’Anne, and Will

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EHS works diligently to keep our buildings, employees, students, and patients safe and healthy

STATEMENTS VISION, MISSION & VALUES VISION

VISION It is our vision to become a recognized national leader and innovator in campus environmental health and safety providing world class services.

MISSION

MISSION The mission of Environmental Health and Safety is to work with our customers to provide a workplace free of recognized hazards in support of the UTMB mission to improve health for the people of Texas and around the world.

VALUES

VALUES Integrity: Saying what we are going to do, and doing what we say.

Accountability: Holding ourselves and each other accountable for our responsibilities and achieving our goals.

Commitment: To protect the health and safety of our patients, employees, the public, and the environment.

Collaboration: Developing strategic partnerships that foster cooperation and collaboration.

Personifying Excellence: Providing the highest level of expertise, competence, and professionalism in our staff.

Quality: Going beyond regulatory “compliance” and aiming for best-in-class.

Environmental Stewardship: Taking the lead to protect the environment and preserve our natural resources.

Aerial view of UTMB Campus (east - west perspective of the Island) Annual Report

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ENVIRONMENTAL HEALTH AND SAFETY

EHS involvement is deeply integrated into all operations of UTMB -- from the beginning product of building our hospitals and research laboratories, to the end destination of waste management.

ORGANIZATION WHO WE ARE

Environmental Health and Safety is a part of Business Operations & Facilities (BOF).

Departments under this group provide institutional support through many business- and facilities-related processes. In addition to EHS, BOF includes the areas of Auxiliary Enterprises, Design & Construction, Portfolio Management, Property Services, and Utilities.

UTMB HEALTH

JOCHEN REISER, MD, PHD, PRESIDENT

BUSINESS OPERATIONS & INFRASTRUCTURE

C. AARON LEMAY, CPA, JD, MSED, INTERIM CHIEF BUSINESS AND FINANCE OFFICER

BUSINESS OPERATIONS & FACILITIES

STEVEN LEBLANC, PE, MBA, CHFM, VICE PRESIDENT

ENVIRONMENTAL HEALTH AND SAFETY

CHARLES CARLISLE, MS, CIH, CSP, CHMM, CO-AVP AD INTERIM WILLIAM PATE, DRPH, MBA, LMP, CHP, CIH, CSP, CPP, CHFM, CHMM, CO-AVP AD INTERIM DE’ANNE MEEH, MS, REM, CHMM, PROGRAM DIRECTOR MANAGEMENT

TECHNICAL STAFF

SUPPORT STAFF

Total 39 Employees 6

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ENVIRONMENTAL HEALTH AND SAFETY

Safety isn’t created by the safety department, but by the actions of supervisors and staff doing their jobs every day.

ORGANIZATION CHART

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ENVIRONMENTAL HEALTH AND SAFETY

WHAT WE DO

OUR TECHNICAL SPECIALTIES

RADIATION AND OCCUPATIONAL SAFETY • Chemical Safety • Fall Protection • Hearing Conservation • Aerial Lift and Crane Safety • Respiratory Protection • Construction Safety • Radioactive Materials Permitting and Licensing • X-ray and Laser Registration • Laboratory Evaluations LIFE SAFETY AND ENVIRONMENT OF CARE COMPLIANCE • Life Safety Systems Design, Installation, • • • • • • • • •

Testing, and Repair Facility Design/Compliance Reviews Fire Drills and Institutional Response Life Safety/Joint Commission Code Compliance Fire Extinguisher Inspections Environment of Care Compliance and Committee Support Life Safety Building Inspections Interim Life Safety Measures, Hot Work Permitting, and Above Ceiling Work Permitting Construction Compliance Management Mass Notification Integration

EPM staff working in the Galveston Chemical Accumulation Facility (CAF): Sr. EHS Technicians - Corey Wilhite and Scott Cochran, EHS Technician - Greg Calik, and EHS Specialist Kevin Hebert 8

ENVIRONMENTAL PROTECTION • Regulatory Compliance and Support • Hazardous Waste Management • Water Quality (Potable, Storm Water, and • • • • •

Wastewater) Pollution and Spill Prevention Air Emission Management Emergency Planning & Community Right to Know Medical Waste Management Compliance Training

COMMITTEES • Environment of Care Committee • Hazardous Material & Waste Management • • • • • •

Subcommittee Chemical Safety Committee General Safety Committee Radiation Safety Committee Safety & Security Management Subcommittee Mass Notifications & Communications Subcommittee Life Safety Committee

Principal EHS Specialist - Jim Stone, and Sr. EHS Specialist Morgan Gerami (ROccS), teaching at EHS Academy

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ENVIRONMENTAL HEALTH AND SAFETY

HOW WE WORK

BUILDING RELATIONSHIPS WORKING TOGETHER TO CREATE A CULTURE OF SAFETY

UNIVERSITY PARTNERS EHS works closely with other campus departments such as: Institutional Preparedness, Design & Construction, Property Services, Healthcare Quality & Safety, Infection Control & Healthcare Epidemiology, Portfolio Management, Utilities, Department of Biosafety, UT System Police, and the University’s schools.

COMMUNITY PARTNERS

CUSTOMERS EHS serves the entire UTMB community.

Our customers include patients, faculty, staff, students, campus visitors, and volunteers.

In FY23, EHS received 233 calls

EHS serves as a liaison with regulatory and compliance agencies such as: The Joint Commission, EPA, DEA, U.S. DOT, TCEQ, Texas DSHS, FAA, Texas State Fire Marshal’s Office, AAALAC, and local municipalities. EHS is charged with certain health and safety inspections and compliance for all applicable federal, state, and local regulations and other EHS requirements intended to protect safety, health, and the environment.

for emergency support ranging from fire alarm activations to hazardous material spills.

UTMBUTMB

Campus Collage of UTMB Facilities Annual Report

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HOW WE WORK UTMB SUPPORT

UTMB HEALTH EHS provides support to four hospital campuses, 85+ ambulatory clinics, and Correctional Managed Care (CMC) to ensure healthy and safe operations, protecting students, faculty, staff, visitors, and the environment.

TECHNICAL KNOWLEDGE

HEALTHCARE

TRAINING

• Construction plans review • Serve on regulatory committees • Subject matter experts on health and safety issues to ensure safe design, construction and operation of UTMB facilities

• Environment of Care • Committee Support • TJC documentation • TJC Compliance • Survey support • Risk Assessments • O.R. Fire Safety • Evacuation Drills

• Update and maintain online safety courses • Instructor-led training

LOCAL EMERGENCY MANAGEMENT • City of Galveston • City of Angleton • City of Webster • City of League City

SAFE WORK ENVIRONMENT • Odor & Indoor Air Quality response • Hazardous materials shipments • Risk assessments • Accident investigations • Emergency incident response • Exposure monitoring • Respirator fit testing • Occupational Health & Medical Surveillance Program • Safe Work Permitting • Environment of Care Tours 10

SAFE CAMPUS • 24/7 incident response • Food establishment inspections • Drinking water testing • Identification of slip/ trip/fall hazards • Spill cleanup • Facility Safety Audits • Fire System Repairs

RESEARCH • Technical review for renovations • Space evaluations • Fume hood certifications • Lab Audits • Controlled substance disposal • Protocol & permit reviews for committees • Consulting on safe lab practices • Equipment cleanup/ monitoring • Lab setup/closeouts

ENVIRONMENTAL • Storm Water Programs • Title V Permit Management • Hazardous Materials spill cleanup • Hazardous Waste Disposal • Potable Water System Permit

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YEAR IN REVIEW HIGHLIGHTS

FIRE DEVICES

70,000

10,285,114

Fire alarm and fire

Total gross square footage EHS serviced for FY23

sprinkler devices

UNIVERSITY SUPPORT

2,406

233 EMERGENCY RESPONSE

Requests for emergency response including 173 fire alarm responses

WATER SAMPLES

227

338,435 HAZARDOUS WASTE

Pounds of chemical waste submitted for pickup via chemical pickup requests

LAB SAFETY INSPECTIONS

EPM SERVICES OFFSITE

FIRE DOOR INSPECTIONS

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Research permits inspected for laboratory safety issues

32,143

1,642

Hours for 2 EPM staff, 2 days per week for chemical pickups, environmental compliance audits, eyewash/shower assessments, and RAD wipes at UTMB offsite campuses and clinics

Chlorine residual and coliform samples collected to ensure safe potable water

CHEMICAL INVENTORY

Chemicals maintained in institutional inventory and reviewed annually by EHS

2,612

1,573

Number of fire doors inventoried, evaluated, and inspected

Number of permits authorized

SAFE WORK PERMITS

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PROGRAM AREAS ENVIRONMENTAL PROTECTION MANAGEMENT The Environmental Protection Management (EPM) program provides dedicated technical services for protecting UTMB’s environmental liabilities with regulatory oversight for air and water protection, hazardous waste management, diesel and hazardous materials spill response, contingency planning, regulatory permitting and reporting, and provide customer services for hazardous chemical and radioactive material waste pickup and disposal. The environmental programs are integrated into the UTMB business objectives to achieve ownership, collaboration, and support that is necessary for compliance. EPM also provides compliance oversight and training for the UTMB pharmaceutical and medical waste management programs.

UTMB Galveston Campus owns and operates a medical waste incinerator and autoclave system that is regulated by the Texas Commission on Environmental Quality (TCEQ) and the U.S. Environmental Protection Agency (EPA). Accordingly, plant operators and supervisors must be trained and certified to operate the processing systems in accordance with regulations enforced by the Occupational Safety and Health Administration (OSHA).

The types of wastes authorized for storing, processing, and/or transfer under TCEQ Municipal Solid Waste (MSW) 2232A is defined in 30 TAC §326.3, and includes non-hazardous pharmaceutical waste, illicit drugs, contraband materials, and nonhazardous (trace amounts) chemotherapy wastes generated at local area clinical care related facilities.

UTMB medical waste is managed under consistent policies and procedures through the Galveston Medical Waste Processing Facility either onsite or through the U.T. System contracted vendor. Research generated medical waste is processed only at the Galveston Facility.

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Hospital and Research Controlled Substance Disposal Discarded pharmaceuticals are waste streams subject to environmental and public health regulations intended to protect patient and worker safety, avoid potential drug diversion as well as environmental pollution. They are subject to the waste regulations once they have been administered or have been partially administered to a patient and can no longer be used for its intended purpose. Controlled substance uses and regulation apply to clinics, research laboratories, and veterinary care practices. It is against federal government and UTMB policy and procedures to waste any medication or controlled substances to the sanitary system.

Pharmacy, inpatient, and clinical areas are responsible for maintaining security, recordkeeping, and disposing of controlled substances according the State and Federal regulations. UTMB policy and procedures include the use of the Deterra System and Solidifiers for rendering controlled substances non-retrievable.

Research laboratories and animal care facilities are asked to complete an EHS online chemical pickup request and a controlled substance disposal inventory form. EHS staff will schedule the time to meet with the licensed Principal Investigator/DEA license holder, provide a Deterra System Pouch, and assist with adding the controlled substance into the pouch with warm water to activate the carbon. The process is an acceptable treatment for dry solid medication and liquids rendering them inert and non-retrievable.

The used Deterra pouch is discarded with non-hazardous pharmaceutical waste for incineration. An electronic Chain of Custody is provided for destruction record.

Title V Programs BOF Property Services, Utilities, and EPM groups work together as key partners ensuring UTMB’s compliance with our EPAand TCEQ-required air permits necessitated by the Clean Air Act. This partnership includes cooperation from all groups to continuously monitor and track all emission sources 24/7.

This close alliance means that should an incident of any kind occur, we are all involved participants and we can act to make necessary adjustments or repairs to prevent and limit emissionrelated incidents. In recent years, this dedication to teamwork has proven to be instrumental in reducing our number and severity of reportable violations. Going forward, BOF is committed to maintaining these close relationships and the benefits they return. The photos depict several of the emission sources.

East Plant Stack

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West Plant Stack

Emergency Backup Generator

Incinerator Stack

Large Industrial Steam Boiler

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PROGRAM AREAS LIFE SAFETY AND ENVIRONMENT OF CARE COMPLIANCE PROGRAM The Life Safety and Environment of Care Compliance Program has a system-wide mission to provide employees, patients, and visitors with a safe physical environment. To do so, we are actively involved in the built environment from design of facilities, their construction, activation, maintenance, and even final decommissioning.

We identify potential problems, champion effective solutions, and track them to resolution.

During the useful life of our facilities, we conduct routine inspections and testing of Life Safety features to ensure code compliance and that they will function properly in times of an emergency. The program group also serves as the liaison to local fire officials, the Joint Commission Life Safety surveyor, and is responsible for fire emergency planning. We Billy Martin, Sr. EHS Specialist, and Todd Perry, Principal help develop departmental plans as well as EHS Specialist (LS&EOCC), training on proper use of building-wide and institutional responses to extinguishers at UTMB offsite clinics emergencies.

Accomplishments •

• • • • • • • • • • • •

Implemented enhanced Fire Door Inspections

Managed Texas State Marshal audits for 22 facilities Hosted an engaging Fire Skills Fair at GNL Delivered targeted safety and emergency response training to over 600 employees Partnered with other key UTMB departments to implement an Above Ceiling Work permit process Assisted Infection Control and Healthcare Epidemiology with transitioning to ICRA 2.0 for construction Provided support as Authority Having Jurisdiction on a high profile fast-track project to refresh the Galveston EHS In-Service Fire Safety Skills Fair Emergency Department Replaced older sprinkler heads in TDCJ Hospital Galveston with improved, tamper-proof models Provided training to healthcare leadership on use of mass notification systems in their areas Fire sprinklered the Moody Medical Library 4th floor book stacks area Upgraded Ashbel Smith “Old Red” building sprinkler system Fire sprinklered UTMB’s historic Open Gates Carriage House Upgraded the School of Nursing and Health Professions fire notification system 14

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Future • • • •

Finish installing fire sprinklers in Levin Hall, Moody Medical Library, and School of Allied Health Sciences Digital integration and automation of Fire Door Inspections with Property Services’ repair program (Maximo) Initiate Moody Medical Library Life Safety Renovations Harden fire alarm network against catastrophe and improve cyber-security

As a part of our ongoing efforts to be good stewards of UTMB resources, EHS constantly strives to reduce costs through competitive bidding of services, close attention to work service, efficiency, and effective maintenance strategies.

As part of the Life Safety & Environment of Care Compliance program mission, we provide employees, students, patients, and visitors with a safe physical environment to conduct business, study, deliver, and receive care. Our staff efficiently tests and inspects Life Safety features to ensure code compliance and that the Life Safety features function properly during an emergency.

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PROGRAM AREAS

RADIATION & OCCUPATIONAL SAFETY

The Radiation & Occupational Safety Program (ROccS) works to ensure the safety of laboratory and health care workers. Our technical expertise covers a wide range of areas including radiation safety, laboratory safety, food safety, potable water safety, and industrial & construction safety. Services offered include sealed source leak tests, receipt & surveying research radioactive material packages, laboratory safety audits, calibration of survey equipment, food safety inspections and permitting, respirator fit tests, and providing training on a wide range of safety topics.

Accomplishments •

•

•

•

• •

Successful planning and performance of a fullscale radiological incident drill within EHS. All EHS staff participated in several scenarios involving radioactive material under realistic conditions.

Texas Department of State Health Services (DSHS) x-ray and mammography inspections for the Galveston Campus, Angleton Danbury Campus, and Clear Lake Campus without violations.

Galveston Campus, Alvin Clinic, and Dave Bleakney Building DSHS inspections completed with no Respiratory Protection Program Classes OSHA Susan Harwood Training Grant violations within Radiation Safety scope of control.

Successful roll-out of new and improved chemical hygiene plan templates for research. These chemical hygiene plan templates will serve as a resource to researchers trying to create a chemical hygiene plan for their labs. Although labs are free to use their own format, EHS templates provide consistency in format as well as useful hazard communication information for labs to use.

Presented twenty classes on respiratory protection program development, implementation, and management to nearly 200 students as part of our OSHA Susan Harwood Training Grant.

Continued refinement in dosimetry distribution and return process has resulted in a significant reduction in late dosimeters at each campus, as well as a reduction in lost dosimeter fees as a percentage of overall FY spent (<4% in FY23 compared to 7.3% of dosimetry spent due to late fees in FY22).

Future • • • •

Renewal of UTMB’s Radioactive Material License in early 2024 will require significant work beginning in FY23.

League City Hospital expansion, as well as growth in ambulatory use of x-ray machines, will require significant radiation safety staff support to ensure successful and compliant project completion.

Anticipated x-ray and radioactive material inspection of Galveston Campus and Clear Lake Campus expected in FY24.

Growth in ROCIP construction projects (JSH Modernization, IDD, TDCJ Infirmary, and LCC expansion) anticipated.

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UTMB policy requires that anyone flying an unmanned aerial vehicle (drone) over UTMB property must receive a drone permit issued by EHS. This permitting is done to ensure the safe and compliant operation of drones over UTMB. With the increase of construction projects on the Galveston Campus, EHS has seen a significant increase in drone permit requests in FY23.

Despite reductions in research use of radioactive material, the use of ionizing and non-ionizing radiation continues to increase. The number of x-ray machines and dosimetry program participants has steadily increased over the years, primarily as a result of UTMB’s health care expansion. Regulatory inspections saw a peak in FY21 as regulators caught up from COVID and have returned to normal levels in FY23.

EHS performed over 200 laboratory safety consultations in FY23. During these visits by trained EHS staff, opportunities for improving researcher safety are identified with recommendations for corrective action. The majority of deficiencies identified in FY23 were related to inadequate or a lack of documentation, specifically related to chemical inventories being verified on an annual basis.

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SERVICE HIGHLIGHTS SUMMARY

FIRE DOOR INSPECTIONS In the past year EHS has re-engineered the UTMB Fire Door Inspection Program focusing on inventorying, evaluating, and inspecting over 2,600 doors across campus.

REACTIVE AND UNKNOWN CHEMICALS UTMB’s research activities involves the use of thousands of different chemicals on a daily basis. Although all chemicals will have some type of hazard, there are certain categories of chemicals that present a higher risk to those handling the waste. Reactive chemicals, including those that are potentially explosive due to exposure to heat, shock, or friction, create challenges for safe handling of the waste stream. EHS worked in FY23 to refine their processes for this waste.

FIRE & LIFE SAFETY PROJECTS The Fire and Life Safety (FLS) team planned, managed, and completed several projects to enhance the life safety of various buildings across campus.

EMERGENCY RESPONSE PREPAREDNESS During FY23, EHS focused on working to build their internal response capabilities through a series of emergency response exercises. As first-responders for emergencies on campus, EHS needs to remain ready to respond to a variety of incidents at all times. From donning and doffing of PPE during annual HAZWOPER refresher, to a series of radiological incident drills, to a hands-on Fire and Life Safety skills fair, EHS staff had plenty of opportunities to develop and practice the skills that need to safely respond to a variety of emergencies.

EARTH DAY 2023 For another year, UTMB hosted the annual Earth Day event on the plaza in from of the Moody Medical Library on Friday, April 14. Representatives from EHS were present to share information with students, faculty, and staff.

LIFE SAFETY & ENVIRONMENT OF CARE COMPLIANCE THIRD-PARTY AUDITS The Life Safety & Environment of Care Compliance team worked closely with a number of third-party auditors (e.g., fire marshals, insurance auditors, etc.) to ensure the safety of our buildings, staff, patients, and students.

ABOVE CEILING WORK PERMITTING Maintaining the integrity of our life safety systems (e.g., fire walls) is paramount in providing our patients, visitors, and employees with a high level of protection during fire and smoke events. To this end, EHS collaborated with Healthcare Epidemiology and Infection Control to implement an Above Ceiling permit system designed to ensure work above the ceiling is both code-compliant and safe.

LIFE SAFETY TRAINING Targeted safety training was one of the top goals for the Fire and Life Safety team in FY23.

EPM POLLUTION PREVENTION UTMB Galveston campus storm water discharges directly into Galveston Harbor to the north of Harborside Drive.

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SERVICE HIGHLIGHTS FIRE DOOR INSPECTIONS This past year, EHS partnered with Property Services to re-engineer the UTMB Fire Door Inspection Program in order to make it more efficient and effective. The goal was to provide an updated and accurate inventory while noting deficiencies both minute and sizable.

Once the doors are inventoried and categorized, the findings were given to Property Services for repair. To do this more effectively, EHS will implement a solution to integrate field inspections directly into the Property Services’ work order system, Maximo, during the inspecion. This collaborative effort will reduce pressure Sr. EHS Technician, Clinton Straitwell (LS&EOCC), inspects a fire door inside the ORs at Jennie Sealy Hospital

on the Call Center (2-4040) and ensure accurate inspections, details of corrective actions, and risk-based priority of repairs.

Properly maintained fire doors after 1/4/2017, John Sealy Hospital fire, kept the fire from spreading to John Sealy Annex Annual Report

EHS Technician, Jake Ratka (LS&EOCC), checks a fire rating tag on a laboratory door 19

ENVIRONMENTAL HEALTH AND SAFETY

SERVICE HIGHLIGHTS REACTIVE AND UNKNOWN CHEMICALS With the increase in compliance with disposal of chemicals from laboratories and laboratory clean outs, Environmental Protection Management began to collect chemicals considered “unknown,” meaning unlabeled chemicals or mixtures that lab personnel cannot speak to, as well as “reactives,” chemicals needing deactivation to be able to properly be transported to our disposal facility. These chemicals hold much higher hazards and require more tedious processing. Some may be temperature sensitive, shock sensitive, peroxide formers, or have other hazards attached to them. These chemicals are inventoried by Environmental Protection Management and are either deactivated if reactive or fingerprinted if unknown to determine hazards by the UT System contracted waste vendor prior to disposal.

Meagan Thibodaux, Principal EHS Specialist, packing temperature sensitive chemicals in ice for shipment

Veolia - Disposal Contractor 20

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SERVICE HIGHLIGHTS

LIFE SAFETY AND ENVIRONMENT OF CARE FIRE SAFETY IMPROVEMENTS AT UTMB

EHS, along with Design and Construction, is in the middle of a multi-year project to install fire sprinklers in the last of UTMB’s significant buildings. Facilities are prioritized according to size and occupancy. Current projects include: the Moody Medical Library, Levin Hall, and the School of Allied Health Sciences. After about 20 years in operation, sprinkler heads are to be changed to ensure reliability. EHS completed such a change-out in Old Red this past year. Future projects will include the Pharmacology building, the Materials Management Warehouse, and others.

Levin Hall – This project is to install a complete fire sprinkler system throughout Levin Hall, including the large auditorium, which proved to be quite a challenge. We are about halfway through this two-year project with the hardest parts behind us – the auditorium. This was a significant challenge and required that we scaffold the entire auditorium in less than a week, install the system and take the massive structure back out again. Since this is such a rare event, we collaborated with other groups such as Property Services and the Academic Enterprise to take the opportunity and perform some high-ceiling work, including the installation of a new state of the art projector along with a new sound booth in the back. Lastly, we had to conduct a deep clean so that it looked like we were never there.

The School of Allied Health Sciences – This project is also to install fire sprinklers throughout the building but also includes improvements in other fire safety elements of the building such as the fire exit stairs and mechanical shafts. The project has a 2-3 year time span and is approximately half completed.

Moody Medical Library – This project is multi-faceted and complex due to the design of this very unique building. The library requires a mix of solutions to protect its occupants, the irreplaceable collections, and the building itself. The fire sprinklering portion of the project should conclude in 2024 with other fire safety improvements extending sometime after that.

In the time since winter storm Uri, EHS has been implementing freeze-protection efforts such as converting our parking garage fire systems over to dry systems from the fully wet-type that suffered significant damage.

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SERVICE HIGHLIGHTS

EMERGENCY RESPONSE PREPAREDNESS

For UTMB, preparedness and resiliency are vital to ensure that we remain ready to continue serving our patients, students, and the public at all times. The size of a small city, UTMB can face a range of emergencies that require rapid response in order to limit the extent of damage and reduce time to recovery. EHS is one of a few departments within BOF and across the institution that serves an important role as emergency first responders.

In the middle of an emergency, such as a chemical spill or smoke in the building, the ability to provide a rapid and safe response is important. However, such a response can only be provided through effective training and periodic exercises to maintain these skills.

Every year, EHS staff complete at least eight hours of hazardous waste operations and emergency response (HAZWOPER) training. Although much of the training is didactic, involving lectures over important concepts, this year EHS chose to integrate a hands-on component to the training. During the training, EHS staff were given the opportunity to practice donning and doffing of chemical resistant suits and self-contained breathing apparatus (SCBA). During emergency situations, these pieces of personal protective equipment can be the only thing that is keeping EHS responders safe, so we want to make sure everyone knows how to use the equipment.

EHS has several plans developed documenting how we will respond to various situations. From chemical spills in a lab, to diesel fuel entering the storm drain, we have a plan in place. However, a plan that is not tested is one you cannot rely upon. With this in mind, in FY23 EHS conducted several emergency response exercises to ensure all EHS staff were prepared to respond to situations that might arise. As EHS has several employees new to the organization, the first exercise was a cross-campus scavenger hunt. This exercise identified several important locations across our various campuses, and required everyone to visit those locations and submit a selfie of them in front of the location. This exercise helped to introduce staff to places on campus that they might not have known about and helped ensure they could find the location if they needed to for a future response.

Next, EHS decided to test their radiological incident plans with a series of exercises conducted in the UTMB Health Education Center Simulation Lab. During these exercises, EHS staff responded to a variety of situations ranging from an I-131 patient who vomited on themselves in their patient room, to a spill of radioactive material in a research lab. EHS staff had the chance to get their hands on radiation detection equipment to try and find simulated contamination, and they were able to practice their personnel and surface decontamination and survey skills. Although a radiological incident has a low probability, the incorrect response to these kinds of events can have high consequences for the organization.

Kevin Hebert, EHS Specialist and Greg Calik, EHS Technician (EPM), and Samantha Thompson, EHS Technician (ROccS), cleaning radioactive vomit training simulation.

Chuck Carlisle, EHS Co-AVP ad interim, watching from the hallway.

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Kevin Hebert, EHS Specialist (EPM), checking area for radioactivity after cleaning up, as EHS Technicians Samantha Thompson (ROccs) and Greg Calik (EPM) observe.

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ENVIRONMENTAL HEALTH AND SAFETY

SERVICE HIGHLIGHTS EARTH DAY 2023 Each year Environmental Protection Management participates on the Earth Day Planning Committee and is heavily involved in event preparation and logistics. All of EHS participated in the event.

1.

1.

For this Earth Day event, Environmental Protection Management was able to obtain tree seedling donations from a new non-profit organization, Trees for Houston. A total of 500 seedlings comprised of varied species were picked up a few days before the event, which included: Shumard oak, American sycamore, American beauty berry, red bud, and sweet gum.

2.

4.

6.

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3.

5.

5.

Photos: 1. ROccS Booth - Dr. William Pate, Jeremy Davis, and Kendle Lopez 2. LS&EOCC Booth - Walter Mays and Dr. Tim Read 3. EHS Staff in front of EPM Booth - Dean Leathers, Dr. Mario Soares, Corey Wilhite, Mariia Arkhypova, Kevin Hebert, and Meagan Thibodaux 4. LS&EOCC Booth - Brandon Metting giving fire extinguisher usage training 5. EHS Staff preparing seedlings to be given away - Kevin Hebert, Eddie Stanaland, Jake Ratka, and Meagan Thibodaux 6. Dr. Mario Soares, Billy Martin, and Todd Perry loading vendor tables and supplies for set-up the day before the event 23

ENVIRONMENTAL HEALTH AND SAFETY

SERVICE HIGHLIGHTS

LIFE SAFETY & ENVIRONMENT OF CARE THIRD-PARTY AUDITS

The Life Safety and Environment of Care Compliance (LS&EOCC) team worked closely with a number of third-parties to ensure the safety of our buildings, staff, patients, and students.

The LS&EOCC team hosted the Texas State Fire Marshal for inspections at 22 of our healthcare facilities from hospitals to clinics. The team also welcomed the UT System Office of Risk Management, along with their consultants and insurers, for visits to 12 additional facilities. Finally, the LS&EOCC team participated in the Peer Review of our department from various UT institutions.

The team collaborated closely with stakeholders EHS Specialist, Brandon Metting, shows Texas State Fire Marshal, Marcus Rogers, fire suppression equipment in the John Sealy to implement corrections to findings and other Hospital during an October 2022 inspection recommendations from these third parties. While the Life Safety and Environment of Care Compliance team are highly trained subject matter experts and skilled technicians, we greeted these opportunities to improve our performance, increase our own knowledge and to better serve UTMB.

SERVICE HIGHLIGHTS

ABOVE CEILING WORK PERMITTING

In FY23, LS&EOCC created an Above Ceiling Work (ACW) permitting process and policy to ensure we are maintaining the integrity of our life safety building features. This process was a significant collaborative development in conjunction with numerous UTMB departments such as Healthcare Epidemiology and Infection control, Information Technology, Design and Construction and Property Services. The goal was to develop a process that better controls work above the ceiling while making compliance simpler and more streamlined. It succeeded and is currently being rolled out.

The implementation of this program will help ensure that we are in compliance with UTMB specifications, applicable codes, and that the integrity of the fire smoke barriers are maintained. Since LS&EOCC worked with UTMB partners across the institution to develop a process that combines multiple permits into one, this resulted in a process that expedites the approval, allowing easy policing by UTMB. Ultimately, it will help us ensure that the safety of our employees, patients and visitors is maintained.

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Annual Report

ENVIRONMENTAL HEALTH AND SAFETY

SERVICE HIGHLIGHTS LIFE SAFETY TRAINING Targeted safety training was one of the top goals for the Fire and Life Safety team in FY23. The team trained over 600 employees on life safety and emergency response topics. These courses included Police Safety Response Training (first responder training to fires and life safety events, radioactive events, and specific EHS awareness training), utilities specific industrial-based environmental and safety training, contractor-based food safety training, General Fire Safety training, OR Fire Safety training, and Emergency Evacuation and SKED training. Additionally, Fire and Life Safety participated in the Property Services BOF Safety Academy symposium where facilities management technicians and engineers were instructed in emergency response and fire safety principles.

Walter Mays, EHS Specialist, and Dr. Mario Soares, Principal EHS Specialist (LS&EOCC), teaching a UTMB Police Officer how to put out a small fire using the simulation fire training device

Dr. Tim Read, Principal EHS Specialist, explains emergency evacuation of patients using the SKED and Brandon Metting, EHS Specialist (LS&EOCC), defines mass communications

Reviewing building floor plans, noting exits Annual Report

Dr. Tim Read and Jennifer Riveira, Principal EHS Specialists (LS&EOCC), discuss the emergency evacuation techniques using the SKED

Emergency infant evacuation SKED training 25

ENVIRONMENTAL HEALTH AND SAFETY

SERVICE HIGHLIGHTS

EPM POLLUTION PREVENTION

UTMB Galveston campus storm water discharges directly into Galveston Harbor to the north of Harborside Drive. This section of the harbor services a helicopter pad, parking lots, fuel services and marina, shrimp boat docks, and a Yacht Club basin. EPM is responsible for ensuring UTMB campus activities do not impact the bay’s water quality from illicit discharges of diesel, litter, or sediment from land disturbance (construction).

Community education and outreach are essential to increasing awareness of the Galveston Bay Estuary System and inspiring others to become more involved in protecting the health of the bay.

UTMB’s storm sewer system is tidally influenced by the bay water with flow into and out of the storm water outfall. One of the storm water protection U.S. Coast Guard helicopter landing on UTMB helipad control measures is to make wet and dry weather observations of the UTMB outfall to ensure no threats are occurring.

During August 2023, EPM was notified of a diesel discharge in the harbor. Appropriate assessments of facilities and storage tank were conducted to ensure the diesel did not belong to UTMB. EPM took appropriate reporting procedures to the National Response Center and Texas General Land Office (GLO) initiating an investigation by the U.S. Coast Guard, GLO, and Texas Commission on Environmental Quality (TCEQ). The diesel was traced to a neighboring facility for mitigation responsibilities.

Conducting proper notification and working with outside agencies is part of EPM’s effort to partner with the States conservation programs and shows UTMB’s commitment to environmental preservation.

Texas General Land Office (GLO) 26

Incoming U.S. Coast Guard helicopter for landing Annual Report

ENVIRONMENTAL HEALTH AND SAFETY

BUILDERS RISK INSURANCE CARRIER Since the devastation of Hurricane Ike on the UTMB Galveston Campus in 2008, UTMB has made outstanding efforts to reduce risk to our facilities from future events. Although mitigation efforts can help to reduce risk, they will never be able to completely eliminate the risk of loss to our buildings. Therefore, we rely upon our insurance carriers to help protect the university in the event of a devastating loss.

In June, UT System and UTMB invited representatives from our various Builders Risk insurance carriers to visit the Galveston Campus and tour our facilities.

During this half-day visit, our insurance carriers were given an overview of UTMB operations and mitigation efforts in existing buildings from Property Services (PS), as well as plans for upcoming construction projects from Design & Construction (D&C). PS, D&C, and EHS provided the carrier representatives with a campus tour highlighting mitigation efforts in the East Plant, Jennie Sealy Hospital, the Clinical Services Wing, John Sealy Hospital, and Old Red.

Tour of Ashbel Smith building (a.k.a. Old Red)

It is not every day that UTMB is able to share the great work we do every day with our insurance carriers.

Events like this help us to strengthen our relationships with the insurance markets and help support lower insurance premiums.

PEER AUDIT 2023

UT System policy (UTS 174 Environmental Health and Safety) stipulates that each institution’s environmental health and safety programs will undergo peer review assessment every 3 yrs.

EHS invited a UT System team of peer subject matter experts to review our programs in May 2023. This year the review team members focused primarily on the following areas of the EHS program: laboratory safety, occupational safety, environmental protection, radiation safety, and fire and life safety. There was a two-day site visit which allowed for an opportunity to visit with program stakeholders and review a sampling of documents, reports, and metrics. By sponsoring this peer review, UTMB can point to a tangible example of its commitment to maintaining safe and healthy working and learning environments for all involved in the institution’s education, research, and clinical service missions.

General Overall Recommendations: The EHS staff members met were energetic, knowledgeable, and genuinely committed to ensuring the health and safety of the students, patients, and employees at all UTMB’s campuses. Campus stakeholders indicated a high level of confidence and trust in the EHS department and consistently noted that department staff often go above and beyond the normal call of duty to address the often-unique needs on campus. As noted in the previous peer review, expansion of facilities located away from the main UTMB campus can create challenges for the management of safety programs at the offsite locations.

Annual Report

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ENVIRONMENTAL HEALTH AND SAFETY

Welcome to EHS

P r o f es s i on a l Achievement Geraldine Giannotti Sr. EHS Specialist (LS&EOCC) • Master of Science in Management and Leadership (MS) Adam Jennings EHS Specialist (ROccS) • Certified Hazardous Materials Manager (CHMM)

Greg Calik EHS Technician EPM

Travis Chrisman Sr. EHS Specialist EPM

Scott Cochran Sr. EHS Technician EPM

Kevin Hebert EHS Specialist EPM

Jake Ratka EHS Technician LS&EOCC

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Morgan Gerami Sr. EHS Specialist (ROccS) • Master of Science in Management and Leadership (MS)

Sergio Garcia 28 yrs. Service August 2023

Annual Report

ENVIRONMENTAL HEALTH AND SAFETY

EHS Around Campus EHS staff donning PPE during HAZWOPER refresher training

Adam Jennings, EHS Specialist (ROccS), at PPE donning & doffing training

Eduardo Reyna, Construction Safety & Risk Manager (ROccS), teaching a Respiratory Protection class

Greg Calik, EHS Technician (EPM), moving drums for shipment at the Galveston CAF

Jim Stone, Principal EHS Specialist (ROccS)

Scott Cochran, Sr. EHS Technician (EPM), bulking chemicals at the Galveston CAF

Billy Martin, Sr. EHS Specialist (LS&EOCC), demonstrates fire extinguisher use

Swan Miller, EHS Specialist (ROccS), teaching a Respiratory Protection class

Earth Day: Brandon Metting and Walter Mays, EHS Specialists, Todd Perry, and Dr. Mario Soares, Principal EHS Specialists, tending the LS&EOCC booth

Jake Ratka, EHS Technician (LS&EOCC), doing preventive maintenance on a EHS truck

Earth Day: Corey Wilhite, Sr. EHS Technician and Kevin Hebert, EHS Specialist, in front of EPM booth

Darla Goodman, EHS Specialist (ROccS), during Emergency Response Preparedness training

Annual Report

EHS Monthly In-Service

EOC Tours: Billy Martin, Sr. EHS Specialist, and Todd Perry, Principal EHS Specialist, (LS&EOCC), training staff at offsite UTMB Clinics and Ambulatory Support

Greg Calik, EHS Technician, and Scott Cochran, Sr. EHS Technician (EPM), looking over the tank integrity for annual inspections with Utilities Supervisor, Beau Plite

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EHS Annual Report FY2022 Cover Photo: Aerial view of Seawolf Park and Port of Galveston. UTMB and Cruise terminals in background on left. left.