UTMB Health Environmental Health and Safety Annual Report 2019

ENVIRONMENTAL HEALTH & SAFETY ANNUAL REPORT

FY2019

1302 Mechanic Street Second Floor Galveston, TX 77555-1111 409.772.1781

utmb.edu/ehs

Addressing Environmental Health and Safety Needs of the UTMB Community

Safety for employees starts on Day 1 with a presentation from Environmental Health & Safety in New Employee Orientation. ing a new employee the finer points of using a fire extinguisher.

Cover photo: The front of the Ashbel Smith Building, also known as Old Red. Built in 1891, this was the first building of the University of Texas Medical Branch.

TABLE OF CONTENTS

Chuck Carlisle is teach-

OVERVIEW

4

LEADERSHIP

5

STATEMENTS

6

ORGANIZATION

7

MANAGEMENT

8

WHAT WE DO

9

HOW WE WORK

10

YEAR IN REVIEW

12

EXPANDING OUR FOOTPRINT

13

PROGRAM AREAS

14

SUPPORT SERVICES

25

ENVIRONMENTAL HEALTH AND SAFETY

OVERVIEW ABOUT US

Environmental Health and Safety works to protect the health and safety of patients, faculty, staff, students, and visitors at UTMB and ensure compliance with local, state, and federal regulations.

Environmental Health and Safety, EHS, is a department with a mission to work with our customers to provide a workplace free of recognized hazards in support of the UTMB mission to improve the health for people of Texas and around the world. EHS works closely with other departments such as UT Police Department, Property Services, Design & Construction, Facilities Risk Management, and Human Resources to achieve our mission.

EHS is organized into several primary program areas based upon technical specialty or focus. Our program areas include Biological Safety, Environmental Protection Management, Fire & Life Safety, Occupational Safety, Radiation Safety, and Joint Commission Compliance. Several support services offered by EHS include Select Agent Compliance, Food & Drinking Water Safety, On-Call Response, Construction Project Support, and Training and Outreach.

Although many of the things we focus on come from accreditation organizations such as The Joint Commission or federal, state, and local regulations, our goal is to exceed those minimum standards, apply best practices, and aim for being best-in-class. Our desire is not to be regarded as the “safety police,� but to work with our customers to help them achieve their goals by the safest means possible.

Todd Perry, EHS Consultant in the Fire & Life Safety Program, provides fire safety training to OR staff.

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Annual Report

ENVIRONMENTAL HEALTH AND SAFETY

LEADERSHIP FROM THE AVP Welcome to the FY2019 Annual Report for Environmental Health and Safety (EHS).

This is a condensed snapshot of the various programs within EHS, our services and a sample of our accomplishments throughout the year. We have not attempted to describe everything we do because it would be a long read. Instead, we have provided facts and information that will provoke some thought about campus safety and hopefully, reflect the contributions of the entire staff.

EHS has many programs to help provide a safe and environmentally responsible campus, but we cannot do it alone, we encourage all at UTMB to embrace the safety culture. We hope you find this information to be both interesting and useful.

Jack

JACK TARPLEY AVP, EHS

SAFETY IS THE RESPONSIBILITY OF EVERY MEMBER OF THE UTMB COMMUNITY: STUDENTS, FACULTY, STAFF, AND VISITORS.

Annual Report

Together we must maintain a healthy and safe campus and foster a culture of safety throughout the university.

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ENVIRONMENTAL HEALTH AND SAFETY

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.

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ENVIRONMENTAL HEALTH AND SAFETY

ORGANIZATION WHO WE ARE Environmental Health and Safety is a part of Business Operations & Facilities (BOF). Units 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, Facilities Risk Management, Property Services, and Utilities

UTMB HEALTH

BEN G. RAIMER, MD, MA, FAAP PRESIDENT AD INTERIM

BUSINESS OPERATIONS & FACILITIES

MICHAEL SHRINER, AIA, MBA, VICE PRESIDENT

ENVIRONMENTAL HEALTH AND SAFETY JACK TARPLEY , ASSOCIATE VICE PRESIDENT

SOPHIE BROCARD, PROGRAM DIRECTOR CHUCK CARLISLE, PROGRAM DIRECTOR DE'ANNE MEEH, PROGRAM DIRECTOR WILLIAM PATE, PROGRAM DIRECTOR

MANAGEMENT

TECHNICAL STAFF

SUPPORT STAFF

Total 49 employees Annual Report

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ENVIRONMENTAL HEALTH AND SAFETY

MANAGEMENT THE TEAM

SOPHIE BROCARD PROGRAM DIRECTOR, IBSO, ARO BIOLOGICAL SAFETY PROGRAM

• Biological Safety • Laboratory Inspections • Select Agent Compliance

DE’ANNE MEEH PROGRAM DIRECTOR ENVIRONMENTAL PROTECTION MANAGEMENT • Hazardous Waste Management • Radioactive Waste Management • Water Quality & Pollution Prevention

8

CHUCK CARLISLE PROGRAM DIRECTOR FIRE & LIFE SAFETY PROGRAM

• Fire Protection System Design, Inspections, & Maintenance • Fire Safety Training • Life Safety Inspections

WILLIAM PATE PROGRAM DIRECTOR, RSO, LSO RADIATION SAFETY PROGRAM OCCUPATIONAL SAFETY PROGRAM • Radiation, Laser, & MRI Safety • Industrial Hygiene/IAQ • General & Construction Safety • Food Safety, Water Quality

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ENVIRONMENTAL HEALTH AND SAFETY

WHAT WE DO OUR PROGRAMS AND SERVICES PROGRAM AREAS BIOLOGICAL SAFETY • • • • •

IBC Administration & Support Laboratory Audits Biological & Biohazard Material Shipping Biosafety Training Biocontainment Unit Support

OCCUPATIONAL SAFETY • • • • • •

Chemical Safety Fall Protection Hearing Conservation Aerial Lift and Crane Safety Respiratory Protection Construction Safety

ENVIRONMENTAL PROTECTION • • • •

Regulatory Compliance and Support Hazardous Waste Management Water Quality (Stormwater and Wastewater) Pollution and Spill Prevention

FIRE & LIFE SAFETY • • • •

Fire/Life Safety Systems Compliance Facility Design Reviews Facility Fire/Life Safety Commissioning Fire Extinguisher Inspections

RADIATION SAFETY • Radioactive Materials Permitting and

SERVICES SELECT AGENT COMPLIANCE • Select Agent Compliance Management & Support

FOOD AND DRINKING WATER SAFETY • Food Safety Inspections • Drinking Water Testing

ON-CALL RESPONSE • On-Call Program • 24/7 Emergency Response

CONSTRUCTION PROJECT SUPPORT • New and Existing Construction Review • Design and Construction Standards • Construction Safety

TRAINING AND OUTREACH • Training Management • Campus Outreach

JOINT COMMISSION COMPLIANCE • EOC Tours • Risk Assessments • Committee Support

Licensing • X-ray and Laser Registration • Laboratory Evaluations

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ENVIRONMENTAL HEALTH AND SAFETY

HOW WE WORK BUILDING RELATIONSHIPS

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

WORKING TOGETHER TO CREATE A CULTURE OF SAFETY

In FY19 EHS Received 260 calls for emergency support ranging from fire alarm activations to hazardous material spills.

COMMUNITY PARTNERS EHS serves as a liaison with regulatory and compliance agencies such as The Joint Commission, EPA, DEA, U.S. DOT, TCEQ, Texas DSHS, FAA, CDC Federal Select Agent Program, Texas State Fire Marshal’s Office, NIH Office of Science Policy, ALAAC, 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.

CUSTOMERS EHS serves the entire UTMB community. Our customers include patients, faculty, staff, students, campus visitors, and volunteers.

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ENVIRONMENTAL HEALTH AND SAFETY

HOW WE WORK UTMB SUPPORT

UTMB HEALTH EHS provides support in ensuring healthy and safe operations on campus, protecting students, faculty, staff, and visitors, and ensuring protection of the environment.

TRAINING

TECHNICAL KNOWLEDGE * Construction plan review

* Update and maintain online safety courses * Instructor-led training as requested

* Environment of Care

* Serving on regulatory committees * Subject matter experts on health and safety issues to ensure safe design, construction and operation of UTMB facilities

HEALTHCARE

RESEARCH

* Committee Support

* Technical review for renovations

* TJC documentation

* Space evaluations

* Survey support

* Fume Hood & Biosafety cabinet

* Risk Assessments

certifications * Lab Audits

ENVIRONMENTAL

* Controlled substance disposal

* Storm Water Programs

COMMUNITY SUPPORT

* Committee reviews

* Support of Regional Ebola Treatment Center Biocontainment Critical Care Unit

* Consulting on safe lab practices * New PI orientation * Equipment cleanup/monitoring * Lab setup/closeouts

SAFE WORK ENVIRONMENT

* Title V Permit Management * Chemical and Biological spill cleanup * Hazardous Waste Disposal

SAFE CAMPUS

* Odor & Indoor Air Quality response

* 24/7 incident response

* Hazardous materials shipments

* Food establishment inspections

* Risk assessments

* Drinking water testing

* Accident investigations

* Identification of slip/trip/fall hazards

* Emergency incident response * Exposure monitoring * Respirator fit testing

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* Spill cleanup * Facility Safety Audits * Fire System Repairs

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ENVIRONMENTAL HEALTH AND SAFETY

YEAR IN REVIEW HIGHLIGHTS

3 ENVIRONMENTAL PROGRAMS

Environmental permits submitted or renewed

7 TRAINING AND OUTREACH

363

260 EMERGENCY RESPONSE

HAZARDOUS WASTE

Requests for emergency response including 165 fire alarm responses

BIOLOGICAL SAFETY

12

Laboratory audits completed in FY19 encompassing 963 total laboratory & vivarium rooms

4,335

115,000

Individual chemical waste items submitted for pickup via 867 chemical pickup requests

Addressable (individual) fire alarm devices inspected and tested annually

FIRE ALARMS

1,134,739

65 FOOD, WATER, SANITATION

Training modules developed or updated including participation in New Employee Orientation

Food safety inspections of inpatient kitchens and retail food locations performed

UNIVERSITY SUPPORT

Increase in gross square footage from FY18 that EHS supports

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ENVIRONMENTAL HEALTH AND SAFETY

EXPANDING OUR FOOTPRINT OPENING OF CLEAR LAKE CAMPUS In early 2018, the 191-bed hospital known as Bay Area Regional Medical Center closed suddenly and declared bankruptcy. Seizing upon the opportunity to acquire finished hospital space in a high-growth market, UTMB Health decided to enter into a 15-year lease agreement to operate what is today known as the UTMB Clear Lake Campus Hospital.

Although a fully functioning hospital at the time of its closure, a lot of work was necessary to reactivate the building and bring it up to high standards UTMB requires for its patients. With the lease agreement signed on October 25, 2018, leadership put in place an ambitious goal to have the facility up and ready to serve patients on March 30, 2019.

Over the next five months, EHS worked tirelessly, in collaboration with Property Services and Design & Construction to get the building ready for occupancy. EHS evaluated the entire building for Joint Commission and Life Safety compliance, tested and commissioned fire alarm and fire suppression systems, setup processes for hazardous waste disposal, and evaluated existing radiation shielding in imaging areas.

With the opening of a new hospital also comes the hiring of new employees. Each new employee requires training to familiarize them with not only the building, but also give them the tools to perform their work safely. EHS provided training to all new building occupants as part of the “Day in the Life� on-boarding process to familiarize them with topics such as building fire safety features, emergency procedures, and hazard communication.

UTMB Clear Lake Campus as seen from aerial drone footage.

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ENVIRONMENTAL HEALTH AND SAFETY

PROGRAM AREAS BIOLOGICAL SAFETY PROGRAM The Biological Safety Program is responsible for programs concerning the safe use of recombinant and/or synthetic nucleic acids, infectious agents, and potentially infectious materials such as human sourced materials in the research, teaching, and clinical laboratories at the University of Texas Medical Branch. This includes training, auditing, and consulting with researchers, laboratory personnel, faculty, and healthcare staff concerning compliance with the federal and state laws and regulations in these areas. .

Belinda Rivera providing some hands-on biosafety training.

Our mission is to ensure the safe use of recombinant and/or synthetic nucleic acids, infectious agents (including select agents), and potentially infectious materials in research, teaching, and healthcare activities to eliminate or reduce the potential exposure to personnel or the environment. In order to accomplish this goal, we maintain an interactive partnership between the Biological Safety Program, the principal investigators, the laboratory support staff, UTMB police department, property services, and healthcare staff. In addition, our program, in cooperation with the Institutional Biosafety Committee, is charged with oversight of regulatory compliance at the university regarding the storage and use of hazardous biological materials.

Accomplishments • David Blakeman received a Bachelor of Science in Occupational Safety and a Graduate Safety Practitioner designation • Nicolette Ward received both an Associate Safety and Certified Safety Professional certifications • Je T’aime Newton received the UTMB Police Golden Whistle award • Belinda Rivera presented at the 2019 Southern Biosafety Association Conference on, “Transitioning away from grant funding to Institutional Funding Lessons Learned” • Elhhadidy M, El-Tholoth M, Brocard, Anne-Sophie. “Implementation of Active Learning Approach to Teach Biorisk Management and Dual-Use Research of Concern in Egypt”. Applied Biosafety. 2019; 24(2):100-110 • Conversion of all the facility and security manuals to electronic web-forms, thus reducing the administration burden and increasing compliance Future • Continue to reduce the administrative burden on the research faculty and staff

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ENVIRONMENTAL HEALTH AND SAFETY

Biosafety Training

Biological Shipping Program

We offer twelve theoretical and practical training core courses from BSL2 to BSL4, including animal biosafety, and non-human primate training. FY19 totaled 1,057 training contact hours, which includes trainees across all of UTMB as well as external clients, which brought in $60,650.00 and UTMB sponsored programs, outreach.

Institutional Biosafety Committee - IBC Biosafety works with the IBC members to execute the committee’s mission, which is to ensure research is conducted in a manner compliant with government regulations (e.g., NIH Guidelines, Federal Select Agent Program, USDA, etc.) and UTMB policies and procedures.

Biosafety ensures that they work together with the committee members to provide assistance to investigators with the submission, planning, and conducting of research protocols in accordance with the regulations and UTMB policy and procedures.

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ENVIRONMENTAL HEALTH AND SAFETY

PROGRAM AREAS OCCUPATIONAL SAFETY PROGRAM The Occupational Safety Program provides a variety of services to support the safety of patients, employees, students, and visitors across UTMB. Services provided include chemical safety support, accident and near-miss investigations, ladder, forklift, and compressed gas safety, food safety, potable water quality, and construction safety. The Occupational Safety Program also provides industrial hygiene monitoring and indoor air quality evaluations to ensure employees are not over-exposed to hazardous chemical or physical agents at UTMB. Michael Shulke, Occupational Safety & Fire Prevention Technician, fit testing a health care worker.

Accomplishments • Medical Plaza One project was awarded a Silver Safety Through Exemplary Performance (STEP) Award by UT System. This award recognizes those projects that demonstrate exceptional leadership that delivers safety excellence and positive change within the construction industry • Developed and implemented Mobile Crane program and procedures for EHS notification • Issued food operation permits for the new Clear Lake Campus Hospital inpatient kitchen and retail food services • Supported the installation of redundant potable water line installation at Galveston Campus and League City Campus • Evaluated and provided recommendations to ensure water safety for the Clear Lake Campus Hospital • Supported the development of LOTO procedures for the East, West, and Central Plants • Conducted Confined Space inventory and classification across Galveston Campus • Full implementation of UTMB Construction Safety Program including access to insurance claims data to allow local monitoring of safety performance • Conversion of the Drone permitting process into an electronic web-form • Implemented hearing conservation audiogram program among Property Services & Utilities • Held successful safety shoe event for Property Services, Utilities, Design & Construction, and Auxiliary Future • Finalize confined space program to include training & permitting process • Full roll-out and implementation of electronic chemical inventories and SDS management system • Develop and implement an auditing program for High Risk Hazardous Chemical Safety plans • Implementation of new food grading system as part of food safety inspections

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ENVIRONMENTAL HEALTH AND SAFETY

Since data began being tracked in FY17, UTMB and CMC have maintained a combined Days Away, Restricted, & Transferred (DART) rate that is below the industry benchmarks published by the Bureau of Labor Statistics. Total incident rate remains above industry benchmarks, primarily due to our reporting of all injuries including those not traditionally defined as “OSHA recordable”. Although UTMB’s DART rate remains stable, the total incident rate continue to trend downward at rates exceeding those seen across industry.

Total (UTMB & CMC) Incident Rate & DART Rates: FY17-FY19 12

10

8

6

4

2

0

SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG

FY17

UTMB TRI

FY18

FY19

UTMB DART

Number of Fit Tests Performed Employees who may be exposed to respiratory hazards might be required to wear a respirator if alternative methods of preventing exposure are not feasible. In FY19, over 2,200 fit tests were performed, continuing a trend where more people are requiring this service. Over 14 % of fit tested individuals were students in the UTMB School of Medicine.

2300 2250 2200 2150 2100 2050 2000 1950 1900 1850 1800 1750

FY16

FY17

FY18

FY19

Rolling Owner-Controled Insurance Program 12Month Recordable Incident Rate FY19 3.5 3

OSHA National Average: 3.1

2.5 2

UT System Average: 2.0

1.5 1 0.5 0

Sept

Oct

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Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

The UTMB Construction Safety Program, supported with a full-time Construction Safety & Loss Prevention Manager working in close collaboration with Facilities Design & Construction, has seen UTMB achieve consistent safety performance exceeding UT System & industry benchmarks. As measured with the 12 month recordable incident rate (RIR). UTMB continues to outperform industry’s national average RIR of 3.1 as well as the UT System average RIR of 2.0.

Aug

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ENVIRONMENTAL HEALTH AND SAFETY

PROGRAM AREAS ENVIRONMENTAL PROTECTION MANAGEMENT

Jordan Sweet, Jeff Casey, Traci Lloyd, and Dean Leathers (L to R) receiving & bulking hazardous waste in the Galveston Chemical Accumulation Facility.

Sustainable management of the earth’s resources and environmental preservation are a primary objective for everyone in the EHS family at UTMB. Environmental Protection Management (EPM) programs are responsible for maintaining air, water and waste pollution control through permits and regulations for multiple campuses in southeast Texas. These programs are designed to protect the University’s campuses and surrounding communities from the threat of an accidental release associated with air, water and soil contamination, as well as from hazardous materials or hazardous wastes.

Accomplishments • Meagan Thibodaux presented at the 2019 College and Universities Hazardous Materials Management Conference on the “Hazardous Waste Challenges of Opening an Abandoned Hospital” • UTMB’s pollution prevention (P2) programs include solvent distillation, lead acid battery recycling, hazardous waste pre-packaging and continuous improvement through waste stream monitoring and education. In FY19, the P2 goals in FY19 achieved cost savings of $44,030 and a reduction of hazardous waste by 3 tons • MS4 permits for League City Campus and Galveston Campus were both renewed with the TCEQ. • TCEQ inspection of the HEC job site; no violations were cited • Completed a Comprehensive Compliance Investigation of the UTMB Title V permit by Galveston County Health District and TCEQ Region 12 • Registered Clear Lake Campus as a Small Quantity Generator of Hazardous Waste with TCEQ Future • Implementation of Environmental Management System • Implementation of new environmental programs at CLC due to Small Quantity Generator status • Working with Healthcare and Research enterprises to refine the UTMB Medical Waste disposal process • Implementation of a tablet-based satellite accumulation area inspection program 18

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ENVIRONMENTAL HEALTH AND SAFETY

During FY19, UTMB generated over 260 tons of medical waste. 49 percent of the medical waste generated was disposed of on-site through incineration, with the remaining disposed of through our contractor, Stericycle. Sources of medical waste at UTMB include our clinical activities as well as research.

Over 82 percent of UTMB’s hazardous waste was generated by the Galveston Campus. As a Large Quantity Generator, EPM is responsible for ensuring UTMB complies with stringent TCEQ requirements for hazardous waste management and disposal. League City Campus and Clear Lake Campus are both Small Quantity Generators and account for 11 percent of total generated hazardous waste. The Angleton Danbury Campus and offsite clinics are all Very Small Quantity Generators and account for 7 percent of total hazardous waste.

UTMB facilities on the mainland generate significant amounts of hazardous waste that EPM works to ensure is managed appropriately. In FY19, the Clear Lake Campus moved from Very Small Quantity to Small Quantity Generator status, increasing the level of regulatory requirements UTMB must comply with.

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ENVIRONMENTAL HEALTH AND SAFETY

PROGRAM AREAS FIRE & LIFE SAFETY PROGRAM The Fire and Life Safety Program has a systemwide mission to provide employees, patients, and visitors with a safe physical environment.

To do so, we survey the environment, identify potential problems, champion solutions and track them to their resolution. In addition, we achieve this goal through routine inspection and testing of Life Safety features of our facilities to ensure code compliance and that they will function properly in times of an emergency.

The Fire and Life Safety group also assists in the safe and compliant design, construction and commissioning of UTMB facilities, acting as the Fire and Life Safety performing a QA/QC inspection with Design and Construction at the new Health Edlocal Authority Having Jurisdiction (AHJ) for Life ucation Center. From left to right: Michael Puccetti, Tracy Ross (Design & Construction), Mario Soares, Safety for UTMB-owned properties.

Timothy Read, Brandon Metting and Rick Weems

(Design and Construction).

Accomplishments • Fire and Life Safety successfully commissioned (inspected and tested all of the Life Safety features) over 687,000 square feet of new building space, including the following: 1. League City, Medical Plaza 1 2. Biocontainment Critical Care Unit (BCCU) 3. Health Education Center (HEC) building 4. Clear Lake Campus hospital and clinics • Enhanced and simplified work flows for hot work permits, Interim Life Safety Measures permits, utility shut-down management through use of a series of new web-based applications to increase efficiency • Continued our outreach and cooperative training with the Galveston Fire Department through a series of training exercises, including: 1. Confined space rescue exercises 2. Communication testing and exercises 3. Forced-entry exercises 4. Fire response exercises • Entered into a successful partnership with our sister institution, M. D. Anderson Cancer Center. In this partnership, UTMB maintains the facilities at our League City Campus and Fire and Life Safety inspects, test and repairs all the fire and Life Safety systems of the facility • Continued to work with the Women, Infants and Children group to enhance the security of some of our most vulnerable patients.

• Replaced the fire alarm system in the Shope Laboratory building

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ENVIRONMENTAL HEALTH AND SAFETY

Future • Continue to optimize various safety permitting processes such as Hot Work, Interim Life Safety Measures and Pre-Construction Risk Assessments through implementation of new web tools and more closely aligned work flows • Continue improving voice-capable mass notification and evaluate integration with other platforms such as Everbridge • Assist with the safe construction and commissioning of John Sealy Hospital Modernization, League City Hospital Expansion, and various renovation projects • Improve/Revise Life Safety Building Inspections to include web-based tracking and management • Continue with the improvement of comprehensive, Building-Specific Fire Response Plans and train with Galveston Fire Department to implement effectively • Improve online fire safety courses

Fire and Life Safety Training Kitchen Fire Safety Training 2% Annual Required Fire Safety Training (live classroom sessions) 16%

EHS Academy Training 22%

Fire Drills 16%

Building Orientation Training 34%

SKED Training 10%

In order to reduce the risk of a fire event, our staff directs numerous defined training programs across our multiple campus locations. These training programs are intended for the purpose of instructing UTMB employees, researchers, and students concerning site-specific policies and procedures designed to ensure a safe physical environment.

43,200 Fire extinguisher inspections performed across 3,100 active fire extinguishers As part of the Fire and Life Safety mission, we provide employees, students, patients, and visitors with a safe physical environment to conduct business, study, delivery, and receive care. Our staff 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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ENVIRONMENTAL HEALTH AND SAFETY

PROGRAM AREAS RADIATION SAFETY The Radiation Safety Program works to ensure UTMB is in compliance with regulations and recommendations for the safe use of radioactive materials, x-rays, lasers, and strong magnetic fields. Services offered include performing leak tests and inventory of sealed sources, receiving & surveying all research radioactive material packages, calibration of radiation survey instruments, bioassays, facility shielding design & verification, as well as administrative oversight of regulatory licenses and registrations.

Sr. Radiation Safety Technician Debra Harper assists with an x-ray room shielding verification.

Accomplishments • Supported the opening of the Clear Lake Campus by performing field verification of installed lead & identifying pre-existing shielding deficiencies that required correction Post-opening Radioactive Material inspection of Clear Lake Campus received no violations • Successful development and implementation of annual fluoroscopy training for all users • Development of new institutional MR Safety Committee that includes representation from across the UTMB institution • Submitted timely renewal of League City Campus mammography registration M01143.

• Successful renewal of League City Campus stereotactic mammography registration M01144 & UTMB Laser Registration Z00488 • MQSA Inspections of Galveston Campus and Angleton Danbury Campuses had no violations • X-Ray Inspections of Southshore Harbor & Galveston County Medical Examiner’s Office had no violations Future • Updating of MRI Safety Training for health care & development of requirements for research • Transition to electronic documentation for contamination surveys • Complete technical renewal for mammography registrations M01143 (LCC) and M01373 (ADC) • Implement formalized MR Safety Audit program across the institution • Galveston Campus & League City Campus Broad Scope Radioactive Material license inspections in FY20 • Anticipated updates to Texas regulations on medical use of radioactive materials & x-rays 22

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ENVIRONMENTAL HEALTH AND SAFETY

Number of Authorized Permits (RAM, X-Ray, Laser) by Fiscal Year

The number of Authorized Permits (which includes radioactive material use, x-ray use, and laser use) has steadily dropped through the years. This drop is related primarily to reduced use of radioactive material in research, a trend that is seen nationwide.

85 80 75 70 65 60

FY16

FY17

FY18

FY19

Radiation Safety Effort Indicators by Fiscal Year 1000 800 600 400 200 0

FY16

FY17

Number of X-Ray Machines

FY18

FY19

Number of Dosimetry Participants

9 8 7 6 5 4 3 2 1 0

Despite reductions in research use of radioactive material, the use of ionizing and non-ionizing radiation in health care continues to increase. The number of x-ray machines and dosimetry program participants has steadily increased over the years, primarily the result of UTMB health care expansion. Regulatory inspections remain steady, indicating continued need for EHS resources to support institutional compliance.

Regulatory Inspections

With more than 800 people spread across four regional campuses and 8 off-site x-ray facilities participating in the UTMB radiation dosimetry program, ensuring timely return and actual use of the radiation badges is a struggle. CY19 YTD has seen improvement in late return percentages (16% late) compared to CY18 (24%). Unused dosimeters remain static at 12% returned unused.

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ENVIRONMENTAL HEALTH AND SAFETY

Top: Employees in EHS supporting a regional Ebola exercise at the Galveston Campus. As one of 10 hospitals in the United States identified to serve as a Regional Ebola and Other Special Pathogens Treatment Center, UTMB EHS’s Biosafety Program works closely with our healthcare partners to ensure the ability for our employees to safely treat these highly infectious patients. Environmental Protection Management trains to ensure that any waste generated from these activities is managed appropriately to minimize risk to UTMB employees, patients, and the community.

Bottom: Researchers working in the Galveston National Lab.

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ENVIRONMENTAL HEALTH AND SAFETY

SUPPORT SERVICES SUMMARY SELECT AGENT COMPLIANCE EHS staff work with UTMB Galveston National Lab (GNL)/Keiller Complex leadership, High Containment Laboratory Directors, Academic Enterprise, UTMB Police, Animal Resources Center, Property Services, Biocontainment Engineering, and UTMB executive leadership to ensure the safety and security of the select agents as well as maintaining our FSAP registration. The Biosafety Program is responsible for managing UTMB Select Agent compliance to ensure all regulatory requirements are met.

FOOD AND DRINKING WATER SAFETY EHS staff are responsible for permitting of retail food locations and inpatient kitchens, as well as conducting food safety inspections of the same. EHS also works to ensure the safety of drinking water by performing water quality testing and assisting with resolving water quality issues.

ON-CALL RESPONSE EHS provides an emergency on-call program to ensure incident response 24 hours a day/7 days a week at all UTMB facilities. Incidents that EHS responds to include hazardous material spills, fires, odors, animals, and lab incidents.

PROJECT PLANNING AND DESIGN REVIEW The Project Planning and Design Review process is vital to ensure that facilities are designed and constructed to meet established safety and environmental regulations and best practices. EHS works closely with Facilities Design & Construction to coordinate projects needing EHS input. EHS continues to support construction throughout the project, including supporting construction safety and fire system commissioning and building integration testing.

TRAINING AND OUTREACH EHS offers a variety of health and safety training opportunities to the campus community including classes in laboratory safety, laser and radiation safety, occupational safety and environmental concerns. The UTMB International Biosafety Training Center provides world-renowned biosafety & biocontainment training to both internal and external customers. EHS participates in campus events such as the Annual Earth Day and Joint Commission Fairs to share safety information..

JOINT COMMISSION COMPLIANCE EHS is deeply involved in ensuring compliance with The Joint Commission standards that apply to our Health Care enterprise. From coordinating the Environment of Care Tour process, to participating in all of the Environment of Care-related Committees, EHS works hard to ensure the safety of our patients, employees, students, and visitors.

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ENVIRONMENTAL HEALTH AND SAFETY

SUPPORT SERVICES SELECT AGENT COMPLIANCE • • •

UTMB is categorized as a super entity by the Federal Select Agent Program (FSAP) due to the size and complexity of our Select Agent Program UTMB has over 50,000 square feet of registered space that includes BSL2, BSL3, BSL3E, BSL4, ABSL3, ABSL4, ACL3, and ACL4 facilities 149 individuals are designated as Tier 1 on our registration and are required to undergo additional training, security, medical, and mental health clearances

This year UTMB had:

Accomplishments • Unannounced CDC/DSAT/DHS Inspection of our BSL3E/BSL4 Effluent Decontamination System resulted in no findings • Annual BSL4 CDC/DSAT and USDA/ AgSAS Inspection resulted in no findings. This is the first time this has ever occurred in the history of UTMB’s Select Agent Program

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Future • Continue to refine our registration through eFSAP in order to decrease the potential for inadvertent non-compliance • Continue to investigate different ways EHS can use webforms or other electronic means in order to decrease the administrative burden on our customers while maintaining compliance with federal regulations • Currently awaiting major changes to the Biosafety in Microbiological and Biomedical Laboratories (BMBL) and the release of the 6th edition • Currently awaiting the release of the biennial proposed changes to the Federal Select Agent Regulations. Once published, UTMB will have a 30-day window to become compliant with any new requirements

Annual Report

ENVIRONMENTAL HEALTH AND SAFETY

SUPPORT SERVICES FOOD AND DRINKING WATER SAFETY Ensuring the safety of the food and water our patients, visitors and employees enjoy is the priority of UTMB’s Food Safety and Water Safety Programs. With an on-staff Registered Sanitarian, EHS inspects all inpatient kitchens and retail food establishments. EHS also conducts frequent routine sampling of our potable water systems to meet regulatory requirements and minimize risk of waterborne microorganisms such as Legionella.

Number of Chlorine Residual & Coliform Samples Collected in FY19 # of Chlorine Residuals

14

200

12

150

10

100

6

8 4

50 0

2 Sept Oct Nov Dec

Jan

Feb Mar Apr May Jun

Chlorine Residuals

Dan Marsh, Sr. Water Quality Specialist, performing water quality assessments in one of UTMB’s research areas.

Jul

Aug

# of Coliform Samples

16

250

0

Coliform Samples

Periodic monitoring of water quality through collection of chlorine residual samples, temperature measurement, and coliform sampling helps to ensure a high quality of water is maintained at UTMB while minimizing the potential for growth of waterborne bacteria.

Accomplishments • Elimination of potable water pre-treatment and reduction in Public Water System sampling resulted in sampling cost savings of over $17,000 per year • Evaluated Clear Lake Campus inpatient and retail food facilities and supported attainment of City of Webster food permit • Supported the design and commissioning of new food service location in the Healthcare Education Center • Performed risk assessment of the new Clear Lake Campus potable water system ans supported development and implementation of flushing plan and interior water feature maintenance program • Successfully revised and updated UTMB’s Water Quality Management Plan to include cooling towers and the new Clear Lake Campus • Supported campus construction and growth by reviewing 23 contractor chlorination and flushing plans Future • Implementation of a food grading system for food safety inspections • Roll-out of new clinical unit after-hours food preparation system may require support from EHS • Increasing attention being paid by The Joint Commission and CMS on issues related to potable water quality will continue to require effort to ensure compliance and safety Annual Report

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ENVIRONMENTAL HEALTH AND SAFETY

SUPPORT SERVICES ON-CALL RESPONSE EHS responds to a variety of emergency situations and incidents during regular work hours and oncall, after hours.

EHS may be called out to respond to anything from “near-miss” situations, where a major accident was avoided, to major fires and explosions. More commonly, EHS on-call staff respond to chemical spills, hazmat exposures, unusual odors, and lab equipment incidents.

EHS staff cleaning up a spill of acetic acid in a health care building.

Members of the EHS On-Call Team getting a tour of the East Plant from Utility Operations Manager Tim Lewis.

Accomplishments • Supported the university by responding to over 260 incidents during working hours, after hours, and on weekends and holidays • Implemented the use of Microsoft Teams for the On-Call team, providing them with mobile access to emergency response procedures, equipment manuals, and rapid communication with all team members Future • Continue to improve the on-call program through procedure review, communication, and training 28

EHS staff responding to a caustic spill outside of the Services Building.

Annual Report

ENVIRONMENTAL HEALTH AND SAFETY

SUPPORT SERVICES CONSTRUCTION PROJECT SUPPORT

Plan Review for the USP800 Pharmacy Renovation Project.

Accomplishments • Supported new and ongoing construction projects, including but not limited to: • -Construction of the new Healthcare Education Center • -Expansion of the League City Campus with the Medical Office Building, Parking Garage, and

Hospital Expansion • -John Sealy Hospital Modernization project • -USP800 Pharmacy renovation projects • Hiring of a Construction Safety & Loss Prevention Manager to support ongoing ROCIP & In-House construction projects Future • Optimization of construction-related permit processes • Continue anticipated need for EHS involvement in construction support as part of:

-Completion of the John Sealy Hospital Modernization project

-Completion of League City Campus Hospital expansion

-Renovation of Angleton Danbury Campus Emergency Department

-Continuing expansion and relocation of off-site clinic facilities including Victory Lake Town Center

expansion • Implementation of formal project safety training for non-ROCIP construction projects Annual Report

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ENVIRONMENTAL HEALTH AND SAFETY

SUPPORT SERVICES TRAINING AND OUTREACH

26,644

EHS online trainings were completed in FY19 across 16 courses.

Accomplishments • Developed, updated and published multiple training courses (Healthcare & Non-Healthcare annual online EHS training, medical waste disposal, Spill Prevention and Preparedness, Fluoroscopy Dose Optimization, Forklift Safety) • Began presenting at the UTMB New Employee Orientation • Participated in and supported the UTMB Earth Day 2019 event • Presented EHS training at Joint Commission Fairs and Day-in-the-Life training sessions

Sheri Brodie, Biosafety Specialist, demonstrates her creativity by participating in the Earth Day 2019 Recycle in Style Fashion Show.

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EHS Consultant, Vickie Jones, teaching a BSL2/3 course in the Dominican Republic.

Dean Leathers, Sr. Environmental Protection Specialist, providing hazardous waste disposal training to nurses at Clear Lake Campus.

Annual Report

ENVIRONMENTAL HEALTH AND SAFETY

SUPPORT SERVICES JOINT COMMISSION COMPLIANCE

Billy Martin, EOC Compliance Manager, and Dean Leathers, Sr. Environmental Protection Management Specialist, participating in Environment of Care Tours.

Accomplishments • Successful triennial inspection by The Joint Commission • Implemented new Joint Commission standards related to fluoroscopy • All patient care areas toured every 6 months to proactively identify & reduce risks in the Environment of Care Future • Refining the process of back-of-house audits to ensure full facility TJC-readiness.

• Continue to improve the pre-construction risk assessment, interim life safety measures, and infection control risk assessment processes

Annual Report

EOC Tours Completed 90 80 70 60 50 40 30 20 10 0

2015

2016

2017

2018

2019

Number

As the amount of buildings and clinics increase, the number of Environment of Care Tours performed also increases.

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Clockwise from top left: Entrances to Jennie Sealy Hospital on the Galveston Campus, Clear Lake Campus Hospital, Angleton Danbury Campus Hospital, and the League City Campus Hospital.