The University of Utah is committed to improving its culture of safety across all areas of campus, including in research laboratories. In October 2017, the U commissioned an external peer review, and in June 2018, it commissioned a University of Utah Presidential Task Force on Laboratory Safety to evaluate laboratory safety practices. Those recommendations are expected to be released at the end of May 2019. These reviews, alongside the State Legislative Lab Safety Performance audit that was released today, have identified important gaps in safety that the U is dedicating significant resources to address.
The university has already begun restructuring the U’s safety reporting system to most effectively take on the challenges identified. Effective May 1, 2019, the offices of Occupational and Environmental Health and Safety (OEHS) and Radiation Safety (RSO) were integrated into one departmental unit renamed the Office of Environmental Health and Safety (EHS). The merger will take advantage of the strengths of both units and will increase efficiency, enhance services and improve enforcement ability of lab safety inspectors.
Fred A. Monette has been appointed as interim executive director of EHS and will report directly to Vice President for Research Andy Weyrich. Monette currently serves as the director of RSO and is a board-certified health physicist who brings over 25 years of experience in radiation protection. The university has delegated Monette specific authority to take all reasonable actions to ensure laboratories comply with regulations, including shutting down operations.
Additionally, the U is in the process of implementing all of the state legislative audit’s recommendations and additional regulations to improve laboratory safety. Anyone who has questions, concerns or feedback about lab safety should submit those to firstname.lastname@example.org.
Below is a summary of the lab safety recommendations from the state legislative audit, along with the university’s responses to each.
Recommendation 1: The U president should direct administrators to prioritize and enforce the goal of eliminating repeat safety deficiencies from lab safety audits and inspections.
- The U implemented a new action process to address labs with repeat safety deficiencies. These include increased monitoring for labs with repeated deficiencies and implementing defined escalation actions for repeated offenders, including probation and shutting down labs.
- To achieve better oversight, the U changed the reporting structure for its safety units, effective May 1, 2019, to increase efficiency, improve enforcement ability and prioritize lab safety. Additionally, incentives for safety performance are being incorporated into the annual process for distributing infrastructure support for colleges, departments and research labs.
Recommendation 2: The OEHS should establish a systemic process to track safety deficiencies observed during its audits.
- The U is in the process of implementing a comprehensive laboratory management system (LMS). The On Site LMS is capable of better tracking laboratory inspection results, deficiencies and corrective actions. The LMS should be fully implemented by the end of 2019.
Recommendation 3: The OEHS should maintain an audit trail of lab personnel responses and corrective actions related to observed safety deficiencies during its audits.
- The enhanced LMS system described in the response to recommendation 2 will achieve this.
Recommendation 4: The OEHS should report on the percent of university personnel with exposure to bloodborne pathogens who were 1) offered hepatitis B vaccination and 2) the delivery rate for those requesting the service.
- The senior leadership will ensure that the hospital, human resources and OEHS will define roles and responsibilities regarding exposure to bloodborne pathogens. They will allocate necessary resources to identify employees who may be exposed to potentially infectious materials, including hepatitis B, have access to vaccines. We will also document offering and delivering the hepatitis B vaccine.
Recommendation 5: The OEHS should systematically track missing required chemical exposure assessments and retest those that identified exposures that exceeded acceptable limits.
- The university will employ an Industrial Hygiene tool that manages the timely delivery of exposure assessment data and retains records as required by regulation.
Recommendation 6: The OEHS should ensure that all deficiencies are reported regardless of their resolution status.
- The new On Site LMS will track laboratory deficiencies and corrective action status. Upon its implementation, the LMS will systematically track and routinely report all inspection results and the real-time status.
Recommendation 7: OEHS should review the services that it offers to ensure that they are consistent with its policies and responsibilities and do not impair independent audit services.
- The senior leadership is reviewing policies and responsibilities to ensure that OEHS is meeting the health and safety requirements and inspection independence is not compromised.
- The university’s senior leadership is developing a reinvigorated University Health and Safety Committee which will include a new Laboratory Safety Sub-Committee to ensure that university priorities are clearly communicated to OEHS, colleges, departments and research laboratories; and it will routinely evaluate inspection effectiveness.
Recommendation 8: Administrators should ensure that personnel and facilities under their leadership comply with local, state and national safety regulations and university safety policies.
- Restructuring the primary university health and safety units directly under the Office of the Vice President for Research, together with the reinvigorated Health and Safety Committee and new sub-committee structure, will enhance the university senior leadership’s ability to ensure compliance and improvements.
- A revised corrective action process includes escalation consequences for non-compliance.
Recommendation 9: University administration should assign responsibilities to ensure compliance with hepatitis B vaccination requirement, including identifying affected employees, tracking offers for vaccinations, documenting delivery of requested medical services and maintain required documentation.
- As described in the response to recommendation 4, the senior leadership will clarify and assign responsibilities to ensure compliance with OSHA’s hepatitis B vaccination requirement and will track document essential information.
Recommendation 10: Senior administrators should implement a system to assess the performance of safety and health programs that rely on key performance indicators identified in the audit report, the October 2017 peer review report and the university’s Lab Safety Culture Task Force’s report.
- The university will use the state legislator’s audit, the October 2017 peer review report, and the University’s Lab Safety Culture Task Force’s report to define meaningful key performance indicators. It will routinely report these key performance indicators to senior administrators and act upon them.
- The reinvigorated Health and Safety Committee and the new Laboratory Safety Sub-Committee will provide routine oversight and periodic assessment of program performance.
- As noted in the response to recommendation 2, the university is incorporating safety performance into the annual process for distributing infrastructure support to colleges, departments and research laboratories.
- The university will institute a rigorous self-audit system whereby an independent internal and/or external reviewer will periodically evaluate health and safety functional areas. We will implement their recommendations as appropriate.
Recommendation 11: The senior administration should submit a report on the implementation status of recommendations from the audit, the university’s October 2017 peer review and the Lab Safety Culture Task Force’s findings to the Legislature’s Higher Education Appropriations Subcommittee for its October 2019 interim meeting.
- The University of Utah will report the implementation status of recommendations from all entities listed above.
Recommendation 12: Lab research groups should utilize self-inspections prior to official OEHS audits.
- In addition to the self-inspections already occurring in some research laboratories, we will fully implement the self-inspection process across all colleges, departments and laboratories no later than the end of 2019.
- The new On Site LMS system will allow principle investigators to conduct self-inspections and upload the results for tracking and further action.
Recommendation 13: Safety committees should be made up of faculty for individual departments or colleges be used to provide peer-reviews and technical knowledge.
- The university will establish a system of safety committees within all colleges and departments as appropriate. Technical peers, experts and OEHS safety professionals will make up these committees.
- The new Laboratory Safety Sub-Committee of the Health and Safety Committee will include representatives from the college and department safety committees.