Galveston beach toward west end of Island with wildflowers and greenery.
Cover photo: Students and employees walking around the UTMB Galveston Main Campus.
LEADERSHIP
FROM THE AVP
Safety is everyone’s responsibilityyour actions make a difference.
It is my privilege to introduce the FY24 Environmental Health & Safety Annual Report. This year has been marked by significant progress and development in our efforts to ensure the safety and well-being of everyone within our institution. Our dedicated team has worked tirelessly to implement new initiatives, enhance existing programs, and foster a culture of safety that permeates every aspect of our operations.
Throughout the past year, we have navigated a period of substantial evolution within our department, refining our approach and adapting to new challenges. These advancements reflect our unwavering commitment to maintaining a safe and compliant environment. From strengthening our emergency preparedness protocols to advancing our compliance with accreditation and regulatory agency requirements, each milestone is a testament to the hard work and collaboration of our entire community. We are proud of the progress we have made and remain focused on continuous improvement in the years to come.
As you explore the report, I encourage you to consider the impact of our shared commitment to environmental health and safety. The work we do is vital to the success of UTMB’s mission, and I am confident that together we will continue to build on this year’s achievements.
Will
Dr. William Pate AVP, EHS
MANAGEMENT TEAM
D E ’ANNE MEEH PROGRAM DIRECTOR ENVIRONMENTAL PROTECTION MANAGEMENT
• Hazardous Waste Management
• Radioactive Waste Management
• Pollution Prevention
• Air & Water Quality
JE T ’AIME NEWTON PROGRAM DIRECTOR RADIATION & OCCUPATIONAL SAFETY PROGRAM
• Radiation, Laser, and MRI Safety
• Industrial Hygiene/IAQ
• Laboratory, Industrial, and Construction Safety
• Food Safety and Water Quality
DR.
MARIO SOARES PROGRAM DIRECTOR
LIFE SAFETY & ENVIRONMENT OF CARE COMPLIANCE PROGRAM
• Fire Protection System Design, Inspections, and Maintenance
• Fire Safety Training
• Life Safety Inspections
• Joint Commission Compliance
STATEMENTS
VISION, MISSION & VALUES
Commitment to safety isn’t just a policy; it’s a way of life.
To become recognized as an instrumental department within the institution and a national leader and innovator in campus environmental health and safety providing world class services.
Collaborate with our customers to enable a workplace free of recognized safety and environmental hazards in support of the UTMB mission.
Quality: Going beyond regulatory “compliance” and aiming for best in class
Commitment: To protect the health and safety of our patients, employees, the public, and the environment
Integrity: Saying what we are going to do and doing what we say
Excellence: Highest level of expertise, competence, and professionalism of our staff
Collaboration: Developing strategic partnerships that foster cooperation
Accountability: Holding ourselves and each other accountable for our responsibilities and achieving our goals
Environmental Stewardship: Taking the lead to protect the environment and preserve our natural resources
Aerial view of Galveston Island rooftops from UTMB toward the calm waters of the Gulf of Mexico (southwesterly)
ORGANIZATION
WHO WE ARE
A culture of safety begins with each of us - let’s lead by example.
Environmental Health and Safety (EHS) is a key component of Business Operations & Facilities (BOF), which encompasses a broad range of essential services that support our institution’s mission. Alongside EHS, BOF includes Auxiliary Enterprises, Design & Construction, Portfolio Management, Property Services, and Utilities. Together, these departments ensure that our facilities and business operations run smoothly, providing a safe and efficient environment for all.
UTMB HEALTH SYSTEM
JOCHEN REISER, MD, P H D, UTMB PRESIDENT & CEO, UTMB HEALTH SYSTEM
BUSINESS OPERATIONS & INFRASTRUCTURE
JAMIE BAILEY, MBA, CPA, CFE, EVP & CHIEF FINANCIAL OFFICER
BUSINESS OPERATIONS & FACILITIES
STEVEN L E BLANC, PE, MBA, CHFM, VICE PRESIDENT
ENVIRONMENTAL HEALTH
AND SAFETY
WILLIAM PATE, D R PH, MBA, LMP, CHP, CIH, CSP, CPP, CHFM, CHMM, AVP
MANAGEMENT
ORGANIZATION CHART
Dr. Mario Soares
Life Safety & Environment of Care Compliance Program Dir.
Todd Perry Kassandra Larson Vacant
EHS Supervisors
Morgan Gerami Vacant Sr. EHS Specialists
Walter Mays
Michael Puccetti
Emma Villarreal
Fernando Diaz EHS Specialists
Clinton Straitwell Sr. EHS Technician
Jake Ratka EHS Technician
Our commitment to safety safeguards is not just for our patients, employees, and students, but for our future.
Dr. William Pate AVP
Humberto Espino Sr. Administrative Manager
Victoria Castillo Sr. Business Coordinator
Alexandra Daniel Business Coordinator
De’Anne Meeh
Environmental Protection Management Program Je T’Aime Newton
Radiation & Occupational Safety Program Director
Eddie Stanaland Meagan Thibodaux EHS Supervisors
Travis Chrisman Dean Leathers Sr. EHS Specialists
Kevin Hebert EHS Specialist
Sharon Walters Management Analyst II
Corey Wilhite
Scott Cochran Sr. EHS Technicians
Matthew Irwin EHS Technician
David Stephenson Jim Stone Vacant
EHS Supervisors
Vacant
Construction Safety & Risk Prevention Manager
Adam Jennings Sr. EHS Specialist
Darla Goodman
Kendle Lopez
Amy Clark
Jeremy Davis EHS Specialists
Samantha Thompson
Jennifer Corona EHS Technicians
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 Planning 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
Together, we create a safer environment for all.
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
• Radiation Safety Committee
• Safety & Security Management Subcommittee
• Mass Notifications & Communications Subcommittee
• Life Safety Committee
First responders participating in hands-on training and response exercises at the League City Campus
Mike Puccetti, LS&EOCC EHS Specialist, testing a fire hydrant with Galveston Public Works staff
HOW WE WORK BUILDING RELATIONSHIPS
UNIVERSITY PARTNERS
EHS collaborates closely with a wide range of campus departments, including Institutional Preparedness, Design & Construction, Property Services, Quality Management & Patient Safety, Infection Control & Healthcare Epidemiology, Portfolio Management, Utilities, the Department of Biosafety, UT System Police, and the University’s schools. These partnerships are essential to maintaining a safe and compliant environment across all aspects of our institution.
COMMUNITY PARTNERS
EHS acts as a liaison with key regulatory and compliance agencies, including The Joint Commission, EPA, DEA, U.S. DOT, TCEQ, Texas DSHS, FAA, Texas State Fire Marshal’s Office, AAALAC, and local municipalities. Our department is responsible for conducting health and safety inspections and ensuring compliance with all relevant federal, state, and local regulations, as well as other EHS mandates designed to protect the safety, health, and environment of our community. EHS also partners with local first responders to support hands-on training and response exercises.
WORKING TOGETHER TO CREATE A CULTURE OF SAFETY
CUSTOMERS
EHS is dedicated to serving the entire UTMB community, ensuring a safe and healthy environment for everyone who steps onto our campus. Our reach extends to patients, faculty, staff, students, visitors, and volunteers, all of whom rely on our commitment to safety and compliance. By fostering a culture of safety, we aim to protect and support the well-being of every individual who is part of our community, enabling them to focus on their vital roles in education, research, and healthcare.
In FY24, EHS received 224 calls for emergency support ranging from fire alarm activations to hazardous material spills.
HOW WE WORK
UTMB SUPPORT
UTMB HEALTH
Every voice counts in our mission for a safer tomorrow.
EHS provides support to four hospital campuses, over 85 ambulatory clinics, and Correctional Managed Care (CMC) facilities, ensuring healthy and safe operations across all sites. Our efforts are focused on protecting the well-being of students, faculty, staff, visitors, and the environment, reinforcing our commitment to a safe and compliant institution.
TECHNICAL KNOWLEDGE
• 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
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
HEALTHCARE
• Environment of Care Committee (EOCC) support
• TJC documentation
• TJC compliance
• Survey support
• Risk assessments
• O.R. fire safety
• Fire & evacuation drills
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
TRAINING
• Update and maintain online safety courses
• Instructor-led training
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 dsposal
YEAR IN REVIEW HIGHLIGHTS
FIRE DEVICES
EMERGENCY RESPONSE
75,000
Fire alarm and fire sprinkler devices
UNIVERSITY SUPPORT
224
Requests for emergency response including 173 fire alarm responses
HAZARDOUS WASTE
ONLINE TRAINING
FIRE DOOR INSPECTIONS
215,003
Pounds of chemical waste submitted for pickup via chemical pickup requests
WATER SAMPLES
10,143,066
Total gross square footage EHS serviced for FY24
7,421
Number of UTMB employees receiving EHS online training for FY24 (excludes Annual Online Training)
2,609
Number of fire doors inventoried, evaluated, and inspected
CHEMICAL INVENTORY
LAB SAFETY INSPECTIONS SAFE WORK PERMITS
Chlorine residual and coliform samples collected to ensure safe potable water
230 2,396
Research permits inspected for laboratory safety
32,116
Chemicals maintained in institutional inventory and reviewed annually by EHS
1,836
Number of permits authorized (e.g., above ceiling, confined spaces)
PROGRAM AREAS
ENVIRONMENTAL PROTECTION MANAGEMENT
The Environmental Protection Management (EPM) program is dedicated to advancing sustainable practices and ensuring robust environmental compliance across UTMB’s four campuses. EPM delivers expert services in managing and mitigating environmental impacts, with a focus on regulatory compliance, air and water protection, and extensive hazardous waste management. Our comprehensive approach includes air quality management, Spill Prevention, Control, and Countermeasure (SPCC) planning, stormwater management, Emergency Planning and Community Right to Know programs, water quality programs, and rapid response to spills. EPM oversees and integrates environmental initiatives with UTMB’s business objectives, supporting one Large Quantity Generator, three Small Quantity Generators, and numerous Very Small Quantity Generators. EPM is committed to fostering a culture of ownership and collaboration while providing oversight and training for pharmaceutical and medical waste management for compliance with The Joint Commission. Environmental Protection Management’s goal is to uphold environmental health and ensure strict compliance with all regulatory standards.
In FY2024, there were no large inventory cleanouts in the warehouse therefore, the total waste decreased by 123,432
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). UTMB medical waste is managed under consistent policies and procedures through the Galveston Incinerator Service Center either onsite or through the U.T. System contracted vendor. Research generated medical waste is processed only at the Galveston Facility.
lbs. from FY23.
New Biohazard Carts
EHS purchased new biohazard carts for EVS to transport medical waste from all campuses. They are much lighter, can rotate 360 degrees, take up less corridor space when moving around the hospitals, and they are significantly less expensive than the large flatbed carts currently in service. A couple of the flatbeds will remain with Sodexo as backups, and the rest will go to Rolando Del Cid, Utility Operations Supervisor, for use at the Incinerator Service Center in Galveston.
UTMB Medical Waste Monitoring
As one of the Hazardous Materials that UTMB produces, our medical waste is monitored by the Environmental Protection Management (EPM) group within Environmental Health and Safety (EHS). As you may be aware, UTMB processes our own medical waste on site, and it is important for our waste to be properly packaged, transported, and processed at UTMB’s Incinerator Service Center. EPM is promoting proper handling of medical waste for disposal through educational posters mounted in Medicine Preparation and Soiled Utility rooms and presenting at Skills Fairs.
Medical waste is disposed of via red or yellow bags packed into a cardboard medical waste box that should not exceed 30 lbs. and labeled with the department and date. Improper packing can lead to leaks and loss of integrity of the box.
• Red bag waste includes blood and blood products, microbiological wastes, body fluids, sharps, and other soiled disposable medical paraphernalia that is treated by steam sterilization and shredded prior to landfill disposal.
• Yellow bag waste is incinerated on site and includes trace amounts of chemotherapy medications, pharmaceutical wastes, and pathological wastes consisting of animal and human body parts, tissues, organs, and human anatomical remains.
Any fluids being disposed of as medical waste (e.g., body fluids, liquid medications) must be solidified or in a leakproof container. Solidifiers can be purchased through materials management along with various sharps containers. Blue and yellow sharps containers are for incineration and should be placed in a yellow bag set out for EVS unboxed and unbagged if they are too large. Red sharps containers, found in clinic spaces only meant to collect sharps resulting from biological collections, are collected in red bags. When your medical waste boxes are full and ready for pickup, call 2-4040, and EVS will transport the boxes to the Medical Waste Holding Room.
The other waste stream we have is any highly hazardous medicine designated by the EPA to require specific treatment methods and disposal, and we refer to these as RCRA (Resource Conservation Recovery Act) medicines. These are collected in designated black boxes, and once they are full, a Chemical Waste Pick-up form is submitted (found on the EHS website www.utmb.edu/ehs) for EPM to collect. Only employees with hazardous materials handling training can remove these from your department.
Alton Caldwell with Sodexo (center) receives new biohazard carts from Scott Cochran - EPM, and Jake Ratka - LS&EOCC
PROGRAM AREAS
LIFE SAFETY AND ENVIRONMENT OF CARE COMPLIANCE PROGRAM
The Life Safety and Environment of Care Compliance Program (LS&EOCC) has a systemwide 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 help develop departmental plans as well as building-wide and institutional responses to emergencies.
Accomplishments
• Improved and streamlined Fire Door Inspections program through the digital integration and automation of Fire Door Inspections with Property Services’ repair program (Maximo).
• Facilitated a multidisciplinary compliance assessment of relocatable power tap use in Peri-operative Services.
• Upgraded multiple parking garage fire sprinkler systems to mitigate future freeze damage.
• Delivered targeted safety and fire safety and emergency response training to over 500 employees.
• Partnered with other key UTMB departments to implement an Above Ceiling Work permit process.
• Implemented the installation fire sprinklers in Levin Hall, Moody Medical Library, and School of Allied Health Sciences.
• Facilitated community outreach with the League City Fire Department to host hands-on first responder fire response training exercises. Updated fire monitoring and alarms systems at multiple regional clinics.
Future
• Finish installing fire sprinklers in Moody Medical Library, and School of Allied Health Sciences.
• Initiate Moody Medical Library Life Safety Egress Renovations.
• Continue to harden fire alarm network against catastrophe and improve cyber-security.
Todd Perry (LS&EOCC) performing Sked® rescue training to clinical staff
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. Testing costs have seen a nominal increase due to inflation.
PROGRAM AREAS
RADIATION & OCCUPATIONAL SAFETY
The Radiation & Occupational Safety Program (ROccS) works to ensure the safety of laboratory and health care workers. Our technical experience covers a wide range of areas including radiation safety, laboratory safety, food safety. Water quality, and industrial & construction safety. Services offered include sealed source leak tests, receipt & surveying research radioactive material packages, laboratory & industrial 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 full-scale chemical spill response drill within EHS. All EHS staff participated in a chemical spill involving diesel under realistic conditions.
• Successful roll-out of new EHS inspection checklist which included a 34% reduction in questions to reduce administrative burden. Additionally, statutory and/or regulatory reference are now cited with findings.
• UTMB’s Construction Safety & Risk Manager was an invited speaker for Texas A&M’s Architectural Program, presenting information on managing construction safety programs in selfinsured environment (ROCIP).
• Conducted 5,700 fit tests during the fiscal year, exceeding projections projections by 34%. The Team is continuing to improve the process to make things more efficient.
• Achieved substantial completion on installation of the radioactive material security upgrades across the Galveston Campus.
• Completed the annual hazardous chemical inventory updates for the healthcare functions in preparation for TJC inspections and is working to make Hazardous Communication Act information easier to access in the new Fiscal Year. In collaboration with EPM, participated in the development of the USP 800 compliance plan for Hazardous drugs in healthcare which was finally implemented in May 2024.
• EHS assisted in the return to campus following Hurricane Beryl by inspecting all campus buildings for safety issues and damage. ROccS continued to follow up for several weeks after the return to normal operations to assess water damage and employee concerns.
• Successful migration of UTMB to new radiation dosimetry vendor.
• Texas Department of State Health Service (DSHS) inspections:
o Radioactive Materials inspections for Galveston Campus, Angleton/ Danbury Campus and Clear Lake Campus with no violations.
o X-Ray inspections for Victory Lakes Town Center and Clear Lake Campus Hospital with no violations.
o Mammography inspections for Galveston, League City Campus, and Clear Lake Campus with no violations.
Future
• Renewal of UTMB’s Radioactive Material License in early 2025 which required significant work beginning in FY24.
• Anticipated Texas Department of State Health Service (DSHS) inspections:
o Radioactive Materials inspections for League City Campus.
o X-Ray inspections for Angleton/Danbury Campus, Galveston Campus, League City Campus and Several Offsite Clinics.
EHS chemical spill response drill
Eduardo Reyna (ROccS) presenting on Owner and Contractor Controlled Insurance Programs for Texas A&M’s Architectural Program
EHS conducts annual inspections of industrial and mechanical spaces across all hospital campuses to ensure safety compliance. These inspections cover general housekeeping, chemical storage, PPE usage, ladder and fall protection, electrical safety, hearing conservation, and Lockout/ Tagout procedures. They also assess the safety of Powered Industrial Trucks, ManLifts, machine guarding, tools, and confined spaces, as well as fire safety and overall occupational safety practices. The findings are documented and used for educational purposes to improve safety and compliance.
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. In FY24 the number of regulatory inspections is on the increase due to renewals of radioactive material permits.
In FY24, EHS conducted 230 laboratory safety consultations, focusing on enhancing researcher safety and compliance. Key findings highlighted inadequate chemical inventory documentation, with many labs not verifying inventories annually. To address this, we recommended implementing regular verification systems, updating documentation, and offering additional staff training. Our goal is to improve safety and compliance through proactive support and tailored recommendations.
SERVICE HIGHLIGHTS
SUMMARY
FIRE DOOR INSPECTIONS
Fire doors are critical in preventing the spread of smoke and flames during a fire, as proven by their role in limiting damage.
REACTIVE AND UNKNOWN CHEMICALS
In 2021, EHS oversaw the collection and removal of 10 expired peroxide forming chemicals from research labs.
LIFE SAFETY & ENVIRONMENT OF CARE COMPLIANCE WITH RPT S
Relocatable power taps (RPTs) are a common cause for citations due to inappropriate use creating fire and electrical safety issues in hospitals.
EMERGENCY WEATHER PREPAREDNESS
In Fiscal Year 2024, the Houston/Galveston region faced a series of significant weather events, including a winter freeze, a Derecho, Hurricane Beryl, and an exceptionally active rainy season.
LEARNING EXPEDITIONS”
Veolia hosts the first annual Global Learning Expeditions bringing operations managers together from 27 countries, to the University of Texas Medical Branch.
RESEARCH COMMUNITY OUTREACH
EHS organized a Laboratory Safety Awareness event at UTMB in February, 2024.
FIRE ALARM MONITORING & NETWORK ENHANCEMENTS
In FY24 Life Safety and Environment of Care Compliance focused efforts in enhancing UTMB’s fire alarm monitoring system (FireWorks™).
ANGLETON-DANBURY CAMPUS TRANSITIONS TO SQG STATUS
Angleton-Danbury Campus transitioned to a Small Quantity Generator (SQG) due to the weight of waste accumulated onsite each month.
TITLE V AIR PERMIT
Air permit deviations reported from various permitted combustion sources at Galveston campus over the past ten (10) years and significant improvements seen since 2018.
EHS TRAINING (SAFETY TRAINING & SKILLS FAIRS)
Targeted fire safety and response training and Skills Fairs continues to be top goals for the Fire and Life Safety and the Environmental Protection Management teams.
SERVICE HIGHLIGHTS
FIRE DOOR INSPECTIONS
Fire doors are critical in preventing the spread of smoke and flames during a fire, as proven by their role in limiting damage during the January 2017 fire at UTMB’s John Sealy Hospital. However, fire doors are only effective if properly maintained and repaired. In FY24, Environmental Health and Safety partnered with Property Services to evaluate, streamline, and improve the fire door inspection process, ensuring both regulatory compliance and more importantly, the safety of our patients, students, faculty, staff, and visitors. This effort included creating a comprehensive inventory to ensure that no fire doors were overlooked. Inspection criteria were reviewed and updated to meet current codes, and inspectors received fire door inspection and assessment training. Additionally, the project was supported by Resource Allocation Program funding, allowing for the adoption of a tablet-based inspection system. This new technology not only streamlines the inspection process but also enhances the overall efficiency and effectiveness of the fire door maintenance and repair efforts.
Jake Ratka, LS&EOCC, providing fire door inspections
Jake Ratka, LS&EOCC, providing fire door inspections
SERVICE HIGHLIGHTS
REACTIVE AND UNKNOWN CHEMICALS
In FY21, EHS oversaw the collection and removal of 10 expired peroxide forming chemicals from research labs. Peroxide-forming chemicals (PFCs) are chemicals that can form explosive peroxide crystals or liquids over time. In 2023, EHS revised the UTMB Policy for PFCs to include periodic testing and time limits for maintaining PFCs. This resulted in an 85% reduction of expired peroxide former findings during lab inspections.
As part of its Annual Laboratory Safety Inspection service, a review of the lab’s chemical inventory is performed. Special attention is assigned to chemicals that are time-sensitive and have potential physical hazards. In January 2024, EHS was able to identify a container of dry 2,4, 6-trinitrolphenol (picric acid) in a lab. When hydrated, picric acid is typically safe to handle, but it becomes a powerful explosive when dry. Dry picric acid is extremely sensitive to heat, shock, and friction. The moistened solid is classified as a flammable solid. In this case EHS contracted with a chemical waste vendor to deactivate and dispose of the chemical with no injuries.
In August 2024, EHS was able to identify a container of dry 2,4-Dinitrophenylhydrazine (DNPH) in a lab. Dry DNPH is friction and shock sensitive. For this reason, it’s supplied damp or ‘wetted’ when a school purchases it from a chemical supplier. If DNPH is stored improperly and left to dry out, it can become explosive. In this case EHS contracted a chemical waste vendor to deactivate and dispose of the chemical with no injuries.
Ethyl Ether Anhydrous
Dry 2,4,6-trinitroplphenol (picric acid)
2,4-Dinitrophenylhydrazine (DNPH)
SERVICE HIGHLIGHTS
LIFE SAFETY & ENVIRONMENT OF CARE COMPLIANCE WITH RPT S
Relocatable power taps (RPTs) are a common cause for citations due to inappropriate use creating fire and electrical safety issues in hospitals. Hospitals can use RPTs in patient care areas under certain circumstances in accordance with federal codes and guidelines.
LS&EOCC led a multidisciplinary group including leadership from Perioperative Services, Property Services, Clinical Equipment Services and Housekeeping services to execute a plan to provide guidance on the safe and appropriate use of RPTs in the operating rooms and identify novel strategies to mitigate fire and electrical safety risks. These strategies included:
• Staff education
• Retooling staff workflows
• Implementing engineered solutions
• Developing novel systems to safely support the surgical practices
Through the above initiatives, the multidisciplinary team was able to improve compliance with current codes and, more importantly, the safety of our patients and staff. The RPTs shown in the photos above and below are used in operating rooms to protect and support critical equipment.
SERVICE HIGHLIGHTS
EMERGENCY WEATHER PREPAREDNESS
Weather-Related Impacts and Emergency Response
In Fiscal Year 24, the Houston/Galveston region faced a series of significant weather events, including a winter freeze, a Derecho, Hurricane Beryl, and an exceptionally active rainy season. These events led to numerous flooding incidents affecting our campuses and clinics throughout the year. The diverse nature and frequency of these weather challenges underscore the importance of a robust and adaptable response strategy to ensure the safety and operational continuity across our facilities.
Given the broad geographic spread of UTMB’s operations— encompassing four campuses, 60+ off-site clinics, and multiple counties—it is crucial that our institution remains vigilant and prepared. Throughout the year, UTMB proactively communicates with staff, disseminating critical notices and updates tailored to seasonal weather conditions to ensure preparedness. Campus readiness is fundamental to protecting our infrastructure and maintaining overall operational effectiveness.
The EHS department maintains a comprehensive Emergency Weather Plan, which is rigorously reviewed and updated annually. This plan delineates specific roles and responsibilities and is designed to be adaptable to evolving weather conditions. Coordination with the Institutional Safety Officer ensures that our response strategies are integrated and effective. Key components of the plan include redundancy measures and resource management to ensure that backup systems and personnel are in place.
To validate and enhance our preparedness, EHS conducts annual drills simulating various scenarios. In FY24, EHS executed a Hurricane Response exercise. This drill was focused on evaluating and refining our hurricane response protocols, emphasizing preparation and response up to the point of landfall. While the exercise excluded post-storm and FEMA-related tasks, it was instrumental in identifying areas for improvement and fortifying our response strategies.
Laboratory and Facility Preparation
Due to power outages after Hurricane Beryl, EHS staff were moved to the Health Education Center, one of the few buildings left with power, to begin posthurricane assessments and subsequent repairs.
In advance of the winter freeze, EHS issued a detailed preparation notice specifically for our laboratories. This communication included recommended precautions to safeguard personnel, research materials, and equipment. It addressed potential impacts such as prolonged power outages, power fluctuations, utility disruptions, water infiltration, and travel difficulties. Additionally, the notice provided guidance on office and laboratory safety, as well as personal preparedness, to reinforce staff awareness and enhance overall safety during severe weather events.
The weather events of FY24 highlighted the critical need for ongoing vigilance and effective emergency preparedness. UTMB’s proactive measures, including timely communication, comprehensive planning, and regular drills, have proven essential in mitigating the impact of these events. As we move forward, continuous evaluation and enhancement of our weather response strategies will remain a priority to ensure the safety and resilience of our campuses and clinics.
Turbulent weather over UTMB Galveston Campus from Hurricane Beryl
SERVICE HIGHLIGHTS
RISK MANAGEMENT, VEOLIA GLOBAL EXPEDITION, AND COLLEGE & UNIVERSITY HAZARDOUS MATERIALS MANAGEMENT CONFERENCE
Meagan golfing with attendees at Moody Gardens
The University of Texas System Higher Education Risk Management Conference, held at Moody Gardens in Galveston, Texas, offers a thorough exploration of critical risk management areas including human resources (HR), environmental health and safety (EHS), security, compliance, and legal issues. It serves as a crucial platform for professionals nationwide to collaborate and discuss emerging trends and challenges at the highest attended conference on record. The record turnout underscores the conference’s growing importance. With diverse sessions covering risk trends, best practices, and innovative strategies, the event provided valuable insights and fostered meaningful discussions among risk management professionals. Meagan Thibodaux, EHS Supervisor, (photo left) sat as the UTMB representative on the conference board. She served as a liaison and introduction speaker for Colonel Mike Fossum, COO of Texas A&M University at Galveston (photo right) on his keynote speech about his time as an astronaut and risk management in relation to space flight.
The University of Texas Medical Branch (UTMB) had the honor of hosting part one of Veolia’s Inaugural Global Learning Expedition (LEX). This landmark event brought together plant and operations managers from Veolia sites across thirteen countries for a week dedicated to learning and sharing best practices in hazardous waste management.
One of the key aspects of the event was the opportunity to host Veolia’s leadership and expedition participants and collaborate with Environmental Protection Management at UTMB. This collaboration allowed both Meagan Thibodaux and Travis Chrisman to present a range of processes related to waste generation and emergency response scenarios that we manage for the UT System. The participants, along with Veolia Leadership, (photo left) conducted a site visit of UTMB. These included tours of the university, including Old Red and the Virtual Reality Health Education Center to showcase UTMB’s impact to healthcare and education. It was an excellent platform to discuss Best Management Practices (BMPs) relating to hazardous waste management and explore how these practices can be applied and adapted internationally.
Additionally, the annual College and University Hazardous Materials Management Conference (CUHMMC), held recently at Purdue University in West Lafayette, Indiana, serves as a pivotal platform for professionals in the field of hazardous materials management. This premier conference brings together waste managers, technicians, and consultants from colleges and universities nationwide to exchange valuable knowledge and best practices in waste management in University Settings.
A standout session at this year’s conference was delivered by Meagan Thibodaux, EHS Supervisor, and Travis Chrisman, Senior EHS Specialist (photo right). Their presentation, titled “Trash Talk: Cultivating Vendor Relations,” offered an in-depth exploration of managing hazardous materials through effective vendor partnerships. They addressed critical aspects such as vendor compliance, service quality, cost management, and the vetting process, and providing attendees with practical insights to improve their waste management strategies. Also, a special offering of this conference is an annual RCRA Refresher Training for those who attend the conference for training compliance. This year, Meagan Thibodaux was a subject matter expert presenter for the RCRA along training with Bret Turner (photo left) from CU Anschutz.
SERVICE HIGHLIGHTS
RESEARCH COMMUNITY OUTREACH
In February 2024, EHS organized a Laboratory Safety Awareness event at UTMB. This was conducted in conjunction with the Campus Safety, Health, and Environmental Management Association’s (CSHEMA’s) Laboratory Safety Awareness Week initiative. CSHEMA is a national organization whose mission is to support and to educate campus-based EHS professionals to empower and to improve the EHS profession in campus environments. EHS set-up static displays in MRB to promote safety initiatives in the lab, provide free PPE, and allow laboratory teams to utilize safety equipment (i.e., fire extinguishers). Additionally, EHS sponsored a Safety Bingo event which awarded door prizes to winners.
Winners’ photos: (top left to right) 1. Adam Jennings presenting tote bag to Bandana Bera, Dr. Prideaux’s Lab; 2. Paige Diaz & Dr. Coady, Dr. Coady’s Lab; 3. Susana Oaxaca-Torres, Dr. Torres’ Lab; 4. JeT Newton presenting tote bag to Jully Singh, Dr. Leezza’s Lab; 5. Adam Jennings presenting tote bags to Prem Shankar, Dr. Prideaux’s Lab and 6. Jason Herring, Dr. Sowers’ Lab. Winners without photos: Kristyn Gonzales, Dr. Abbott’s Lab; Leandra Koff, Dr. Laezza’s Lab; and Sadhana Chauhan, Dr. Endsley’s Lab.
SERVICE HIGHLIGHTS
FIRE ALARM MONITORING AND NETWORK ENHANCEMENTS
In FY24, Life Safety and Environment of Care Compliance focused efforts in enhancing UTMB’s fire alarm monitoring system (FireWorks™), completing fiber network phase I installation, and fire alarm panel upgrades to EST 4. The current and future enhancements will provide a greater level of cyber security.
UTMB’s fire alarm monitoring system known as FireWorks™ was upgraded to UL7, 2 server redundant configuration. The new application and servers have increased cyber security protection and eliminate single point of failure for UTMB’s four regional campus locations, approximately 70 buildings. FireWorks™ is a critical application not only for monitoring fire systems, but also integrates mass notification and emergency communications (Galveston Campus only) announcements such as Dr. Pink, active shooter, and future immediate weather emergencies (i.e. tornado warning).
The Phase I installation of the stand-alone fire alarm fiber network in the Galveston campus Healthcare core and 2 data center facilities was completed in mid-February. The fiber network enhancement will allow the Galveston Healthcare facilities fire systems to continue monitoring in the event of a cyber-attack on the UTMB IS network. The configuration and activation of the fire alarm fiber network will be completed by the end of FY25.
With the EST3’s product line phasing out and discontinued devices, migration to the EST4 provides a variety of benefits; these include direct fiber network connectivity, UL7 (servers) cyber security compatibility, upgraded product line, customizable LED color options, faster download times and a full color touchscreen.
Fernando Diaz, LS&EOCC EHS Specialist, checking a new fire alarm panel
Convergint technicions completing fiber network Phase I on UTMB’s FireWorks™ fire alarm monitoring system
SERVICE HIGHLIGHTS
ANGLETON-DANBURY CAMPUS TRANSITIONS TO SQG STATUS
This year, the Angleton-Danbury Campus (ADC) transitioned from a Very Small Quantity Generator (VSQG) to a Small Quantity Generator (SQG) due to the weight of waste accumulated onsite each month. The reclassification increases regulatory requirements, and the changes will add a reduction in the allowable time hazardous waste can remain onsite from unlimited (or until 1,000 kg was accumulated) to 180 days, provided the total accumulation stays below 6,000 kg. Some of the new requirements include enforced manifest requirements, need for an employee to be available to respond to emergencies at all times, maintenance of records (waste determinations), and weekly inspections. The shift occurred after exceeding the hazardous waste accumulation limit one month following several months when ADC was within 50 pounds of the threshold. The addition of ACL top machines used for sample analysis in the lab made it challenging to comfortably remain a VSQG. This is not a permanent decision, and we may revert to VSQG status if conditions allow. However, given the ongoing growth of ADC operations, it is likely the campus will remain a SQG for the near future.
SERVICE HIGHLIGHTS
TITLE V AIR PERMIT
The graph shows the total number of reported air permit deviations over the last 10 years and significant improvements seen since 2018
One of the responsibilities of the Environmental Protection Management (EPM) department at UTMB is to track and report air-emissions generated from various permitted combustion sources that operate on the Galveston campus (e.g., generators, combustion turbines, boilers, and a medical waste incinerator). Part of the reporting aspect of these responsibilities includes selfreporting any deviations to our regulatory mandated permits. The deviations can be operational-related deficiencies, or deviations relating to exceeding our various permit-authorized emissions limits. The graph indicates that reportable incidents have shown a dramatic decrease over the past five to six years and can be attributed to the close relationship between our EPM staff and the Utilities and Property Services operators, and the amount of time that both staffs have dedicated to learning the regulatory and permit-driven operational and emissions requirements and limitations. The support and encouragement from our upper management has also played a significant role in these considerable improvements.
SERVICE HIGHLIGHTS
EHS TRAINING (LIFE SAFETY TRAINING AND SKILLS FAIRS)
Targeted fire safety and response training continues to be one of the top goals for the Fire and Life Safety team. The team trained over 500 employees on life safety and emergency response topics. These courses included General Fire Safety training, OR Fire Safety training, Emergency Vertical Evacuation (Sked®) training. Additionally, Fire and Life Safety and Environmental Protection Management (EPM) participated in the Research and Healthcare Skills Fairs delivering fire safety and fire extinguisher hands-on training to hundreds of staff including nurses and patient care technicians. EPM trains and demonstrates the correct medical waste segregation to include RCRA and non-RCRA pharmaceuticals, and provides hazardous materials and waste management procedures for proper disposal of healthcare waste.
Fire extinguisher training provided by LS&EOCC to OR staff at Clear Lake Campus
EHS provides Skills Fair for TDCJ
Emma Villarreal, LS&EOCC, De’Anne Meeh, EPM, and Dean Leathers, EPM
EOC Readiness Rounds
Dean Leathers, EPM, Billy Martin and Jake Ratka, LS&EOCC, provide OR Skills Fair and Fire Extinguisher Training
Research & Healthcare Skills Fair and Fire & Life Safety training
Eddie Stanaland, and Dean Leathers, EPM, provide training
Welcome to EHS
EHS Specialist January 2024
May 2024
2024
Achievements, Promotions, and Accolades
• Dr. Mario Soares earned a Certified Safety Professional (CSP) Certification
• Clinton Straitwell earned an Associates of Science, Social & Behavioral Sciences
• JeT Newton earned an Associate Safety Professional (ASP) Certification
• Jeremy Davis earned an Associate Safety Professional (ASP) Certification
• Emma Villarreal was accepted for two publications:
I. Primary author: “The Power of System Safety Techniques: Application of System Safety Analysis to Zoo Worker Exposure Prevention”, American Society of Safety Professionals (ASSP) Professional Safety journal. Scheduled for print in March 2025.
II. Coauthor: “Sex and Gender Differences in Alzheimer’s Disease: Genetic, Hormonal, and Inflammation Impacts”, International Journal of Molecular Sciences (IJMS).
• Jeremy Davis was promoted from EHS Technician to EHS Specialist
• Dr. Mario Soares was promoted from EHS Supervisor to Program Director, Life Safety & EOC Compliance
• JeT Newton was promoted from EHS Supervisor to Program Director, Radiation & Occupational Safety
• Meagan Thibodaux and Travis Chrisman presented at The College & University Hazardous Materials Management Conference entitled “Trash Talk: Cultivating Vendor Relationships in Waste Management” at Purdue University
Emma Villarreal
Kassandra Larson EHS Supervisor June
Amy Clark EHS Specialist
Alexandra Daniel Business Coord. August, 2024
Matthew Irwin EHS Technician August, 2024
Fernando Diaz EHS Specialist July, 2024
January2024
ChuckCarlisle March2024
Holiday Celebrations
EHS Around Campus
Todd Perry (LS&EOCC) and Kevin Hebert (EPM) participate in Constant Readiness Rounds at League City Campus
Employee Service & GEM Awards with UTMB President, Dr. J. Reiser
Scott Cochran, EPM receives the Professionalism Award
Corey Wilhite (EPM) bulking chemicals (left photo) and Travis Chrisman (EPM) (right photo) performing an inspection in the EPM Chemical Accumulation Facility
Adam Jennings (ROccS) and Dr. Mario Soares (LS&EOCC) during Lab Safety Awareness Week
De’Anne Meeh (EPM) enjoying her 30 yr. Retirement Celebration
EHS Retreat - June 2024
EHS Booth for Research Day with Jake Ratka (LS&EOCC), Meagan Thibodaux (EPM), Jeremy Davis (ROccS), and Fernando Diaz (LS&EOCC)
EHS Emergency Response Drills March 2024
Kevin Hebert & Corey Wilhite (EPM) picking up chemical waste
Scott Cochran (EPM) participated in EHS CPR Training
Aerial photo of storms moving in over eastern Galveston Island. UTMB is seen in background (center).