FEATURE Laboratory self-inspection program participation as an indication of improved safety culture at Emory University In 2008, Emory University implemented a laboratory self-inspection program where researchers were asked to complete an annual inspection of their lab spaces and report findings to the Environmental Health and Safety Office (EHSO). This article will describe how the implementation of various research safety programs has had an impact on researcher participation in the annual laboratory self-inspection program over the past four years. Results will be discussed to show that increased participation in the program is an indication of improved safety culture and the development of an educational environment that fosters self-reporting in Emory laboratories. By Kalpana Rengarajan INTRODUCTION Organizations are increasingly con- cerned with achieving and demonstrat- ing safe research by controlling risks in a manner consistent with their own policies and objectives. This is based on increasing concerns expressed by several stakeholders across the globe and by the internal regulatory systems that are becoming more stringent. Sta- keholders include the researchers who perform hands on work, the principal investigators (PI), EHS staff and upper management. These stakeholders ask themselves the same question – am I doing the right thing, am I working safely and am I compliant? Other sta- keholders include funding agencies, lawmakers and professional organiza- tions. Several institutions review the risks associated with use of hazardous mate- rials (chemical, biological or radio- logical) in laboratory research. Such reviews are conducted in the form of laboratory inspections or audits to assess safety performance. Most of these inspections or audits are based on reg- ulatory requirements. What is lacking in most places when an inspection is com- pleted is an assurance provided to the organization that the questions asked during the safety inspection not only meet, but will continue to meet, legal and policy requirements. Thus to be effective, such inspections and follow up inspections need to be conducted within a structured management system that is integrated within the organiza- tion. A management system is a proven framework for managing and conti- nually improving an organization’s poli- cies, procedures and processes. 1 The goal of a management system approach is to increase an organiza- tion’s effectiveness and efficiency in identifying, understanding and mana- ging a system of interrelated process for a given objective. 2 An effective man- agement system approach is built on the concept of continual improvement through a cycle of planning, implement- ing, reviewing and improving the pro- cesses and actions an organization undertakes to meet goals. This is known as the Plan-Do-Check-Act Cycle prin- ciple (PDCA) 3 (see Figure 1). The author in this article explains how a management system approach was used during the implementation of a laboratory self-inspection program at their institution-Emory University. Emory University is located in Atlanta, Georgia. The main campus spans over 600 acres with a total of 26 research buildings with approximately 1,400 laboratory spaces. LAB SELF-INSPECTION BASICS – ‘‘PLAN’’ A comprehensive, integrated and com- pliance based laboratory self-inspec- tion form was developed to encompass various agencies’ regula- tory requirements (i.e., OSHA, EPA, CDC, NIH). The questions in the inspection form were designed such that when a researcher inspects their own lab, the answer to the line items would be yes, no, not applicable or corrected at time of inspection. HOW DID WE IMPLEMENT? – ‘‘DO’’ The laboratory self-inspection program was rolled out between 2008 and 2009 in a systematic way. The program was initiated one building at a time. EHSO scheduled two or three kick off meet- ings per building. The department administrators and researchers were informed of the roll out and an open Kalpana Rengarajan, Ph.D., MPH, RBP-Associate Director, Biosafety Officer is affiliated with Emory Univer- sity Environmental Health and Safety Office, 1762 Clifton Road, Suite 1200, Atlanta, GA 30322, United States (Tel.: 404 727 8863; fax: 404 727 9778; e-mail: [email protected]). 1871-5532/$36.00 ß Division of Chemical Health and Safety of the American Chemical Society 15 doi:10.1016/j.jchas.2012.02.003 Published by Elsevier Inc.
Transcript
FEATURE
Laboratory self-inspectionprogram participation as anindication of improved safetyculture at Emory University
KalpanaRBP-AssOfficer issity EnvOffice, 1Atlanta,(Tel.: 404e-mail: k
1871-5532
doi:10.101
In 2008, Emory University implemented a laboratory self-inspection program where researchers were askedto complete an annual inspection of their lab spaces and report findings to the Environmental Health andSafety Office (EHSO). This article will describe how the implementation of various research safety programshas had an impact on researcher participation in the annual laboratory self-inspection program over the pastfour years. Results will be discussed to show that increased participation in the program is an indication ofimproved safety culture and the development of an educational environment that fosters self-reporting inEmory laboratories.
By Kalpana Rengarajan
INTRODUCTION
Organizations are increasingly con-cerned with achieving and demonstrat-ing safe research by controlling risks ina manner consistent with their ownpolicies and objectives. This is basedon increasing concerns expressed byseveral stakeholders across the globeand by the internal regulatory systemsthat are becoming more stringent. Sta-keholders include the researchers whoperform hands on work, the principalinvestigators (PI), EHS staff and uppermanagement. These stakeholders askthemselves the same question – am Idoing the right thing, am I workingsafely and am I compliant? Other sta-keholders include funding agencies,lawmakers and professional organiza-tions.
Several institutions review the risksassociated with use of hazardous mate-rials (chemical, biological or radio-
Rengarajan, Ph.D., MPH,ociate Director, Biosafetyaffiliated with Emory Univer-
ironmental Health and Safety762 Clifton Road, Suite 1200,
GA 30322, United States727 8863; fax: 404 727 9778;
logical) in laboratory research. Suchreviews are conducted in the form oflaboratory inspections or audits toassess safety performance. Most of theseinspections or audits are based on reg-ulatory requirements. What is lacking inmost places when an inspection is com-pleted is an assurance provided to theorganization that the questions askedduring the safety inspection not onlymeet, but will continue to meet, legaland policy requirements. Thus to beeffective, such inspections and followup inspections need to be conductedwithin a structured management systemthat is integrated within the organiza-tion. A management system is a provenframework for managing and conti-nually improvinganorganization’spoli-cies, procedures and processes.1
The goal of a management systemapproach is to increase an organiza-tion’s effectiveness and efficiency inidentifying, understanding and mana-ging a system of interrelated processfor a given objective.2 An effective man-agement systemapproach is built on theconcept of continual improvementthrough a cycle of planning, implement-ing, reviewing and improving the pro-cesses and actions an organizationundertakes to meet goals. This is knownas the Plan-Do-Check-Act Cycle prin-ciple (PDCA)3 (see Figure 1).
The author in this article explainshow a management system approach
� Division of Chemical Health
was used during the implementationof a laboratory self-inspection programat their institution-Emory University.Emory University is located in Atlanta,Georgia. The main campus spans over600 acres with a total of 26 researchbuildings with approximately 1,400laboratory spaces.
LAB SELF-INSPECTION BASICS –‘‘PLAN’’
A comprehensive, integrated and com-pliance based laboratory self-inspec-tion form was developed toencompass various agencies’ regula-tory requirements (i.e., OSHA, EPA,CDC, NIH). The questions in theinspection form were designed suchthat when a researcher inspects theirown lab, the answer to the line itemswould be yes, no, not applicable orcorrected at time of inspection.
HOW DID WE IMPLEMENT? – ‘‘DO’’
The laboratory self-inspection programwas rolled out between 2008 and 2009in a systematic way. The program wasinitiated one building at a time. EHSOscheduled two or three kick off meet-ings per building. The departmentadministrators and researchers wereinformed of the roll out and an open
and Safety of the American Chemical Society 15Published by Elsevier Inc.
house formatwas used. Theprocessandimportance of the inspection programwas explained usingflyersand lab safetybinders. For any non-attendee, the EHSstaff personally visited them andexplained the process.
WHAT IS THE PROCESS?
Emory University’s inspection pro-gram consists of three components:[(Figure_2)TD$FIG]
Figure 2. Sample screen shot
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� P
of
I completed Lab Self-Inspection
� E HSO completed Lab Validation � E HSO completed Follow-Up Inspec-
tion
Researchers are required to completean annual self-inspection of theirlaboratory using the lab self-inspectionform. As a first step PI or designated labpersonnel physically walk through thelaboratory space and verify each lineitem on the inspection form. Inspection
Laboratory Self Inspection Form and Co
Journal of Chem
of labs and preparation rooms, coldstorage/environmental rooms, instru-ment/equipment rooms are alsorequired. Figure 2 shows the formatof the inspection form and correctiveaction plan form. The forms are avail-able at www.ehso.emory.edu. Oncompletion of self-inspection, theresearcher completes the correctiveaction plan (CAP) form and sends toEHSOviaAny itemthat wascheckedasno is listed on the CAP form with anaccompanying plan to correct the item.CAP form submission is proof that theresearcher completed their annual self-inspection. In the second step, EHSstaff uses the same inspection form toconduct an annual validation inspec-tion. The EHS staff sends their inspec-tion findings to the PI explaining itemsthat are out of compliance. In the thirdstep, EHS staff conducts a follow upinspection to verify that all items thatwere deficient during the validationinspection have been corrected. If itemshave not been corrected, EHS staff dis-cusses the need to correct the itemswiththe researcher and offer additional helpto correct the item if necessary.
Figure 3. Percentage of research buildings that participated in laboratory inspec-tion program.
[(Figure_4)TD$FIG]
Figure 4. Number of laboratories that performed laboratory self-inspections during2008–2011.
HOW WELL DID THE PROCESSWORK?
In the first round (2008) approxi-mately 60% of labs participated inthe self-inspection program. In 2007,Emory University signed the Environ-mental Protection Agency’s (EPA)Region 4 Audit Agreement thus joiningwith other participating colleges anduniversities throughout the Southeastin conducting voluntary self-audits ontheir campuses. Under the EPA agree-ment, participating colleges and uni-versities agreed to be audited by theirpeers. This allowed participatingschools in the region to essentiallyinspect each other using their owntrained auditors and expert consul-tants. After the peer audit, the collegeor university self-reported to the EPAany issues found and a plan to correctthe problems, with the understandingthat this may mitigate EPA imposedfines. In 2009, Emory University parti-cipated in the EPA Peer audit program.In preparation for the peer audit, EHSstaff inspected all the laboratories oncampus. This was the second year ofinspections after the initial implemen-tation of inspection program in 2008.Findings were documented and
Journal of Chemical Health & Safety, July/A
reported to each laboratory to correctitems that were non compliant. In2010, all of the research buildings par-ticipated in the self-inspection pro-gram. In 2011 approximately 90% ofthe research buildings participated inthe self-inspection program (Figure 3).Figure 4 shows the comparison ofnumber of labs that submitted CAPforms with findings to be corrected
ugust 2012
from 2008 to 2011. The trend lineshows that in the fourth round ofself-inspections, the number of labswith items to be corrected has droppedcompared to 2008.
WHAT WAS THE OUTCOME? –‘‘CHECK’’
EHS inspections prior to the EPA peeraudit helped us identify program gaps,as well as realized that our communi-cation strategies with the researchersneeded to be improved. Program gapsranged from a lack of a point contact inthe labs to contact directly and lack ofcommunication when researchersdepart from the university to havingtrouble getting issues resolved withcampus services and getting research-ers to keep shared areas compliant.
HOW DID WE CONTINUOUSLYIMPROVE THE PROCESS? – ‘‘ACT’’
Over the last four years several pro-grams have been implemented toimprove our research safety program.The following changes were incorpo-rated as part of the ‘‘continuousimprovement’’ process:
Building Liaisons: Each researchsafety team member (named as build-ing liaison) was assigned a set of build-ings to be responsible for. They became
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[(Figure_5)TD$FIG]
Figure 5. EHSO program improvements during 2008–2011.
the direct point of contact for research-ers for any EHSO issue.
Research Administrators: Thedepartment administrators were con-tacted personally to develop a betterworking relationship and emphasizeon their role to partner with EHS.
News Letter: Started publishing amonthly two page publication relatedonly to research safety and new initia-tives pertaining to laboratories. Thenewsletter is also used as an ongoingtraining tool. Researchers are requestedto read and sign the newsletter as doc-umentation which is placed in theirlaboratory safety binder.
Other Programs: Specific sub sec-tions on laser safety, green house, useof USDA regulated materials, etc.,were added to the inspection form.Also, an array of guideline documentswere published to the EHSO websiteto educate researchers on specifictopics that we saw as gaps during labinspections. Some of the guidelinesinclude: Safe Use of Sharps, Foodand Drink, Lab Decommissioning,Cold Room Use, Chemical Waste, Uni-versal Waste, and Electronic Waste.
Self-inspection linked to otherapprovals: Biosafety protocol approvalwas linked to completion of laboratory
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self-inspection. Also volunteers or min-ors registrations to perform researchactivities were also linked to comple-tion of lab self-inspection by research-ers.
Certificate of environmental compli-ance is signed by EHSO (part ofdepartment of defense grant applica-tion), only after completion of lab self-inspection.
Validation program: Research safetyliaisons conduct validation inspectionsusing the same form which theresearcher uses. The liaisons compareand track validation inspections withresearchers self-reported findings.Researchers are given a week’s timeto correct the findingsand liaisonscom-plete a follow up inspection to close thefindings. Figure 5 explains in a nut shellhowwehave attemptedandcontinue toimprove the inspection process.
HOW WAS SUCCESS MEASURED?
EHS validation inspection and postvalidation follow up is a very valuablemeasure to evaluate whether theresearchers had actually correctedthe deficient items. We analyzed2011 EHSO validation data and post
Journal of Chem
validation inspection data to determinewhat were the items in our inspectionprogram with the highest levels of non-compliance and how many of thoseitems were corrected. We selected allitems with over a 20% non-compliancerate. Table 1 shows the top 12 items thatwere out of compliance during 2011EHS validations. Figure 6 shows thedata of the top 12 that were non-com-pliant and what percent of the itemswere identified as corrected based onthe post validation follow up inspection.This trend is very encouraging sinceEHSO follow-up inspections showeda large increase in lab compliance.
AN IMPORTANT TOOL: THEMANAGEMENT SYSTEM APPROACH
The laboratory self-inspection programis truly a means for checks and balancesand helps to keep us audit ready. Thisprogram has facilitated more commu-nication between researchers andEHSO. This has also allowed EHSOled to foster a collaborative, rather thanapunitive relationshipwith the researchcommunity. The improved safety cul-ture has also led to beta test groupsfor any new program, researchers
ical Health & Safety, July/August 2012
[(Figure_6)TD$FIG]
Figure 6. Percentage of top 12 non-compliant Items (from 2011 validations).
Table 1. Top 12 Non-Compliant Items (from 2011 Validations).
1 Lab doors are posted with up-to-date laboratory signage2 All personnel have read and signed the Lab Rat monthly safety newsletter3 All chemicals are labeled with the full chemical name4 All mercury thermometers have been replaced with mercury-free thermometers5 Lab equipment/containers used to store biohazard materials have a biohazard label6 Someone in the lab has taken Shipping of Infectious & Biological Substances training in the past 2 years7 Biohazard waste containers are closed except when adding waste8 Sink is equipped with soap and paper towels for hand washing9 Airflow is negative to the corridor when appropriate
10 The chemical fume hood is free of material and equipment stored long term11 The lab eyewash station is tested and documented monthly by lab personnel12 A visual inspection of the fire extinguisher is conducted and documented monthly
submitting articles to Newsletter, andimprovement in severalotherprocesses.Self-inspection program facilitates theuniversity to be more ‘‘proactive’’approach rather than ‘‘reactive’’ interms of research and laboratory safety.
Our process has clearly shown thatthe laboratory self-inspection program
Journal of Chemical Health & Safety, July/A
has facilitated the illumination of pro-gram gaps, and ways to continuouslyimprove the University’s safety pro-gram. Figure 1 provides an outline ofhow this approach works.
� A
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truly effective system is formal,structured,plannedand documented.
ust 2012
� W
hen the players change, the systemdoes not. It keeps working to meetthe established long-term goals ofthe organization.
ACKNOWLEDGEMENTSThe author would like to acknowledgeMeagan Parrott, Rodrick Esaw,Dionna Thomas and Steve Arehartfor data contribution. The authorwould also like to thank Patty Olinger(director of EHSO) for her continuedsupport and encouragement to imple-ment new programs.
