ÍâÍøÌìÌÃ

Operating Policy and Procedure

HSC OP: 75.01, ÍâÍøÌìÌà Safety Programs

PURPOSE: The purpose of this Health Sciences Center Operating Policy and Procedure (HSC OP) is to provide guidance and assistance in the implementation of the various Texas Tech University Health Sciences Center (ÍâÍøÌìÌÃ) Safety Programs.

REVIEW: This HSC OP will be reviewed on January 15 of each odd-numbered year (ONY) by the Senior Director for Safety Services, with recommendations for revision forwarded to the Vice President for Facilities and Safety Services by February 1.

POLICY/PROCEDURE:

1. ÍâÍøÌìÌà Health and Safety Policy Statement

ÍâÍøÌìÌà is committed to providing a safe and healthy workplace for faculty, staff, students, volunteers, patients, and visitors through compliance with applicable federal, state, and local rules and regulations, and the safety policies and procedures established by the institution. ÍâÍøÌìÌà is responsible for providing information and implementing programs directed toward the health and safety of all institutional stakeholders, and for protecting the environment.

Supervisors are responsible for the health and safety of persons who report to them. Supervisors shall ensure that persons directed by them have been trained and made aware of specific hazards involved in their employment activities, and that they understand and comply with prescribed safety rules, regulations, policies, protocols, and work practices. Supervisors shall investigate all hazards of which they become aware and shall take appropriate corrective action. Employees have a duty and responsibility to work in compliance with statutory requirements and established safe work practices and to report unsafe or unhealthy conditions to their supervisors.

Contractors and subcontractors undertaking work for ÍâÍøÌìÌà will, as part of their contracts, comply with all relevant federal, state, and local workplace and environmental health and safety statutes and institutional policies and procedures.

Commitment to health and safety by individuals at all levels and functions is an integral part of ÍâÍøÌìÌÃ’s operations and the ÍâÍøÌìÌà Values-Based Culture.

The Safety Services Department is charged with the responsibility for providing the necessary support in the implementation of federal, state and local required safety programs and training. Individual divisions within Safety Services have the responsibility for managing specific safety programs. Within ÍâÍøÌìÌÃ, Unit Safety Officers (USOs) are appointed by the Department Heads. The USO is responsible for assisting the Department Head in implementing and managing the department Safety Program. The USO is an integral part of and is essential to the overall ÍâÍøÌìÌà Safety Program. USO duties include accident reporting, emergency procedures, and safety training. In addition, the USO acts as liaison between the department and the Department of Safety Services.

Each ÍâÍøÌìÌà Campus shall be responsible for implementing and maintaining the various safety programs. It shall be the responsibility of the Campus Business Operations Officer or designee for each campus to coordinate these safety programs with the Senior Director for Safety Services and the local Safety Services office on their campus.

The Department of Safety Services is responsible for carrying out the overall safety policies and procedures established by ÍâÍøÌìÌÃ. The department is structured to accomplish its responsibilities within six divisions, as indicated below:

Safety Services Department

Emergency Preparedness: Act as liaison with federal, state, & local emergency agencies; Develop and implement all campus emergency preparedness plans; Train personnel, test & exercise all campus emergency plans; Monitor Crematory Operation; Assess Indoor Air Quality (IAQ) & Odor Concerns as requested; Facilitate Major & Minor Hazardous Spill Response; Develop, Coordinate and Maintain Fire Response Plans; Prepare & Implement Interim Life Safety Measures (ILSM) as needed

Environmental Protection: Manage Indoor Air Quality Program; Manage Chemical & Biohazardous Waste Generation, Disposal, and Contracting; Monitor Environmental Sanitation; Assist & Coordinate activities with State Fire Marshal’s Office (SFMO); Monitor regulatory Updates on Environmental Protection

Fire & Life Safety: Conduct Fire Safety Training & Emergency Exercises; Inspect Fire Suppression & Alarm Systems; Manage Fire Extinguisher & Fire Suppression Systems Maintenance; Conduct Fire & Life Safety Inspections & Compliance Surveys; Review Construction & Renovation Plans for Fire & Life Safety Code Compliance; Develop, Coordinate and Maintain Fire Response Plans; Prepare & Implement Interim Life Safety Measures (ILSM) as needed

Laboratory Safety: Manage Laboratory Safety Program; Investigate Laboratory Incidents; Review Chemical Hygiene, Exposure Control, Hazard Communication, and Biological Safety Plans for the Laboratory Safety Manual; Conduct Laboratory Inspections, Training & Surveys; Manage Testing & Inspection of Fume Hoods, Safety Showers & Eye Washes; Edit & Maintain ÍâÍøÌìÌà Laboratory Safety Manual; Facilitate and periodically review Laboratory Safety Essentials Course Content; Review Research Protocols; Maintain Institutional Chemical Inventory; Monitor Biological & Chemical Safety Compliance

Radiation Protection: Manage Radiation Protection Program; Act as Liaison between TDSHS – Radiation Control Program & ÍâÍøÌìÌÃ; Review Applications and Amendments for Radioactive Material Sublicenses; Approve and Process Radioactive Material Orders; Inspect X-Rays & Lasers; Process Chemical and Biohazardous Material Orders; Edit & Maintain ÍâÍøÌìÌà Radiation & Laser Safety Manuals; Conduct Radiation & Laser Incident Investigation; Calibrate Radiation Survey Instruments; Conduct Radiation Lab Surveys; Manage Personnel Dosimetry Program

Safety Education & Training: Provide Safety Education & Training Programs; Maintain Central Database for Employee and Student Safety Training; Facilitate NESOP & Special Training Programs; Present Special Training Programs; Facilitate Laboratory Reagent Ethanol Distribution Program; Facilitate and periodically review Laboratory Safety Essentials Course Content; Produce HSC Safety Newsletter; Support Special Event Programs; Coordinate Unit Safety Officer Program; Edit & Maintain HSC Safety Manual & Safety Handbook; Assist with training for users of STAT!Alert Emergency Notification System

2. Safety Programs

The ÍâÍøÌìÌà Safety Programs Procedures and Policy are delineated in the following publications: ÍâÍøÌìÌà Safety Manual, Radiation Safety Manual, Laser Safety Manual, Laboratory Safety Manual and ÍâÍøÌìÌà Regulated Waste Disposal Manual. These manuals may be found online at the following Safety Services web page, Publications link:

ÍâÍøÌìÌà adopts all contents of the ÍâÍøÌìÌà Safety Manual, ÍâÍøÌìÌà Laboratory Safety Manual, ÍâÍøÌìÌà Regulated Waste Disposal Manual, ÍâÍøÌìÌà Radiation Safety Manual and the ÍâÍøÌìÌà Laser Safety Manual as policy. All departments, divisions and campuses shall implement applicable programs and procedures set forth in these ÍâÍøÌìÌà Manuals.

Basic safety practices and emergency procedures are equally applicable to employees, students, and volunteers. Employees, students, and volunteers should complete required safety training within two weeks of employment / matriculating to ÍâÍøÌìÌÃ.

Each of the respective Divisions of Safety Services is responsible for the development, coordination and implementation of environmental and safety programs / procedures to comply with applicable Local, State and Federal rules and regulations. Safety Services and its respective Divisions are responsible for coordination, collaboration and oversight of all ÍâÍøÌìÌà Safety Services Offices and environmental / safety compliance.

3. Emergency Preparedness

The Emergency Preparedness division is responsible for the development, implementation, and exercising of emergency preparedness plans for all campuses. The division serves as liaison with local, state, and federal emergency management/preparedness agencies.

4. Environmental Protection

The Environmental Protection Division is responsible for the design and implementation of methods necessary to ensure safe and environmentally responsible disposal of hazardous wastes in accordance with applicable local, state, and federal regulations and recommended guidelines. This division is responsible for monitoring indoor air quality (IAQ) and ensuring safe and environmentally-responsible air and water effluents. The Division manages the development, implementation and response training of ÍâÍøÌìÌà hazardous response activities.

5. Fire & Life Safety

The Fire & Life Safety Division is responsible for conducting on-going fire prevention activities, providing emergency response training, overseeing fire and life safety, and acting as a liaison with outside agencies on matters relating to fire and life safety and emergency planning. The Fire & Life Safety Division reviews all construction & remodeling projects for compliance with applicable Fire and Life Safety Codes.

6. Laboratory Safety

The Laboratory Safety Division is responsible for carrying out the policies established by ÍâÍøÌìÌà and recommendations set forth by the Institutional Biosafety Committee (IBC) and for ensuring that the operations and functions of ÍâÍøÌìÌà laboratories comply with local, state, and federal regulations and recommended guidelines. The Laboratory Safety Division regularly inspects laboratories and emergency safety equipment. Laboratory accident / incident / hazards are monitored, analyzed, and evaluated to provide indices of laboratory safety performance and trends.

This division recommends licensing and credentialing of investigators and laboratory personnel to the Institutional Biosafety Committee (IBC) for approval.

The Laboratory Safety Division facilitates Laboratory Safety Training and Hazardous Materials Shipping Training.

This division maintains and reconciles Institutional Chemical Inventories.

7. Radiation / Laser Safety

The Radiation Protection Division is responsible for the implementation of Texas Department of State Health Services – Radiation Control Program (TDSHS-RCP) rules and regulations and ÍâÍøÌìÌà policies and procedures regarding the use of radioactive material, x-ray-producing devices, and lasers or laser systems. The policies and procedures established by the ÍâÍøÌìÌà Radiation Safety Committee apply to users of radioactive material. The ÍâÍøÌìÌà Radiation Safety Manual sets forth policy and procedures applicable to all ÍâÍøÌìÌà users of radioactive material. A copy of, or a web-link to the ÍâÍøÌìÌà Radiation Safety Manual and the applicable TDSHS-RCP rules and regulations is required to be available in each laboratory using radioactive material. All x-ray utilization locations are required to have a copy of the Operating & Safety Procedures specific to the x-ray device(s) being used available in/at the site. The ÍâÍøÌìÌà Laser Safety Manual sets policy and procedures for all ÍâÍøÌìÌà users of lasers. A copy of the ÍâÍøÌìÌà Laser Safety Manual is required to be available in all clinics or laboratories using registered laser equipment. The Radiation Protection Division is responsible for the coordination of Radiation and Laser Safety training.

8. Safety Education & Training

The Safety Education and Training Division is responsible for the coordination of safety education and training programs prescribed in the ÍâÍøÌìÌà Safety Manual, and/or as deemed necessary for all ÍâÍøÌìÌà employees in order to reduce accident exposure and risk and meet regulatory requirements. This division is responsible for the development, implementation, assessment, and record keeping of general safety education, Radiation/Laser, Laboratory, and Fire/Emergency Response training of employees, volunteers, and students.

The general safety programs in place for employees, students, and volunteers are outlined below:

New Employees: New Employee Safety Orientation Program (NESOP)

Current Employees: Annual Refresher Safety Training

Students: Education Program for Students (STEPS)

Volunteers: Volunteer Safety Orientation Program (VSOP)