HEALTH,SAFETYANDENVIRONMENT(HSE)

VISION,MISSION,CHARTER,SERVICESEXPECTEDANDPERFORMANCEOUTCOMES

VISION

ProtectthehealthandsafetyofJohnsHopkinsInstitutionsvisitors,faculty,employeesandstudentsby
insuringanenvironmentfreeofhazardsandprovidingappropriatemedicalcaretoinjuredemployees.

MISSION

TheJointCommitteeonHealth,SafetyandEnvironment(JCHSE)anditsoperatingunit,theDepartment
ofHealth,SafetyandEnvironment(HSE),isresponsibleformonitoringandinsuringcompliancewithall
federalandstatesafetyandenvironmentalregulationsforboththeJohnsHopkinsUniversity(JHU)and
Johns Hopkins Medicine (JHM) two separate, though, related corporations. The Executive Director of
Health,SafetyandEnvironmentservesasChairmanoftheJointCommittee.

Health,SafetyandEnvironmentisresponsibleformonitoringenvironmentalconditionsandcorrecting
hazardsastheyareidentified,aswellasforassessingandplacingindividualsinenvironmentstheyare
capable of working without harm to themselves or others. HSE is responsible for paying all workers
compensation claims for all entities of the Johns Hopkins Health System and the Johns Hopkins
University,MarylandCampuseswiththeexceptionofChildrensHospitalinFlorida.

GOVERNINGCOMMITTEE

UnderJointCommissionEnvironmentofCarerequirements,theJointCommitteeforHealth,Safetyand
Environment is the designated safety committee of the Johns Hopkins Hospital governing all
EnvironmentofCareactivities.TheCommitteeismadeofupmembersoftheUniversityandHospital
Administration,aswellasthefacultyandstaffofbothInstitutions.ThemembersoftheCommitteeare
asfollows:

EdwardJ.Bernacki,MD,MPH,Chair
ClydeBernett,CoChair
DaniBuchannan
JamesBukowski
PerryCooper
StephenDahl,Ph.D.
PatriciaDay
GeorgeEconomas
JohnGrinnalds
MarlaHallacy
GaryHayward,Ph.D.
JohnHighsmith
FrancesHumphrey,CRNP
DanielKuespert,Ph.D.
PaulaKent
JonathanLinks,Ph.D.
RobertMarshall
CaroleMartens
SebastianMinor
PollyTrexler
LoisScarborough
JohnSchaefer
BrianSchott
AnitaStone
PeterTollini
StanWadsworth
NatalieWallace

CHARTER

The Joint Committee and Health, Safety and Environment Department was created in 1992 by the
PresidentsoftheJohnsHopkinsHospitalandUniversity,consolidatingalloccupationalsafetyandhealth
related activities and compliance efforts of the Johns Hopkins University and Hospital into one
CommitteetoservicetheentireHopkinscommunity.Theinitialrationaleforthisconsolidationwasthat
Hospital and University employees work sidebyside and are exposed to common environmental
hazards. It was felt that it would be most efficient if a single entity oversaw the health and safety of
theseemployeesandthedevelopmentofcommonpoliciesandproceduresusedtoprotectthem.The
subsequentjustificationfortheconsolidationwastheabilitytoleveragethesafetyoperationtoprovide
services for a large population at lower cost. This brought in other Johns Hopkins Health System and
UniversityentitiestobeoverseenbytheJointCommittee.Thisconsolidationbroughttogetheragroup
of departments that were formally housed in four different organizations within the Hospital or
University. The stated objectives of the Committee and Department are compliance with federal and
state health, safety and environmental regulations and the management of occupational and
environmentalhealthrisksforJohnsHopkinsMedicineandtheJohnsHopkinsUniversity.

AUTHORITY

ThePresidentsoftheJohnsHopkinsUniversityandHospitalentrustasignificantamountofauthorityto
theJointCommitteetotakewhatevernecessaryactionstocorrectimmediatethreatstothehealthand
environmentofbothinstitutions.

RESPONSIBILITIESANDSERVICEEXPECTATIONS

SafetyManagement

Conducttwiceyearlysurveysofclinicalandlaboratoryfacilitiesinhealthcareoccupanciesandannualsurveysof
researchlaboratoryfacilities
PerformincidentinvestigationonallOSHArecordableinjuries.
ConductjobhazardanalyseswhenrequestedbyHumanResourcesorOccupationalHealthServices.
Reviewfacilitiesdesignsforcompliancewithfederal,stateandlocalfirepreventionandlifesafetycodes.
Monitorcompliancewithinsurancecarrierrequirementsandrecommendations.
Conductfirepreventionandsafetytraining.
Respondtofireandotheremergencysituations.
Conductemergencyresponsedrills.
Accompanylicensingandregulatoryagenciesduringfacilityinspections.
Designandimplementsafetycontrolprograms.
Reviewfacilitydesignandworkpractices.
Investigatecomplaintsfromemployees,facultyandstaffregardingsafetyissues.
Monitorfoodservicefacilitiestwiceyearly.
Conductsafetytraining(biohazard,HazCom,FireSafety,BloodbornePathogens,TB,etc.)
OverseeJointCommissionSafetyManagementPlan

EnvironmentalHealth(IndustrialHygiene&Ergonomics

Identifyandcontrolchemicalhazards.
Monitorandadministershazardouschemicalwastedisposalprogram.
Developandconducthazardcommunicationprogram.
Reviewfacilityandlaboratorypracticesforcompliancewithregulationsandgenerallyrecommendedstandards.
Consultondesignofcontainmentfacilities.
Conductenvironmentalsampling/monitoringasneededorrequired.
Respondandmitigatechemicalspillsandaccidents.
Investigatecomplaintsrelatedtoworkplaceexposuresandindoorairqualityissues.
Conducttrainingintheuse,controlanddisposalofhazardouschemicals.
Hazardouswastedisposal.
EPAcompliance(TitleV,EmissionsCertification,biannualchemicalwastereporting,greenhousegasreporting,
communityrighttoknowreporting)
OverseeJointCommissionhazardousmaterialsandwastemanagementplan

BiologicalSafety

RegisterrecombinantDNAinvestigatorsandactivities.
Inspectalllaboratoriesonanannualbasisforbiohazards.
Certifyandmaintainallbiologicalcontainmentcabinets
Registerbiologicalagentusageandpersonnelinvolved.
Consultondesignofcontainmentlaboratoriesandlaboratorypractices.
Respondtoemergencysituationinvolvingbiologicalagents.
Coordinatemaintenanceandcertificationofbiohazardcontrolequipment.
Conducttraininginlaboratorypracticesandcontrolanddisposalofbiohazardouswastes.

RadiationControl

Conductperiodicfacilitysurveyswithlicensingandregulatoryagencies.
Performmonthlyandquarterlymonitoringofpersonnelandradiationsources.
Conducttrainingconcerningradionuclides.
Reviewfacilitiesdesignsforcompliancewithfederal,stateandlocalguidelines.
Conductcalibrationofradiationmonitoringequipment.
Maintainlicensesforradioactivematerialsandregistrationsforxrayproducingequipment.
Order,receiveandinspectinventoriesanddeliverradioactivematerialstoNuclearMedicine,RadiationOncology
andSpecialChemistry.
Monitorpatientswhohavereceivedtherapeuticadministrationsofradioactivematerialsanddetermineradiation
safetyrestrictions,visitorlimitations,datewhenpatientmaybereleasedandwhenroommaybereassigned.
Quarterlyinspectionsofallareaswereradioactivematerialsarestoredorused.
Semiannuallytestcesiumbrachytherapysourcesforleakage.
Semiannuallyinspectgammairradiators.
Monitorexhauststacksforemissionofradioactivematerials.
Collect,process,storeanddisposeofradioactivewaste.
Supervisenecessaryactioninemergenciestominimizeproblemsandassurequickrecovery.
Investigateradiationaccidentsorradioisotopescontaminationandprovidestechnicalexpertisetoaccomplish
decontaminationwhenrequired.
Investigateandreportallpatientmisadministrationsinvolvingradiopharmaceuticalsorradiationtherapy.
InspectxraymachinesthatarenotintheJohnsHopkinsHospitalDepartmentofRadiology.
Assessmonetarypenaltiesfornoncompliancewithinternalradiationsafetystandards,radiationsafetytraining
andnonreturnofmonitoringbadges.
Conducttrainingforindividualsactivatingafluoroscopeonabiennialbasis.

Occupational Health Services (Homewood and East Baltimore Campuses)

Conductpreemploymenthealthscreening(HepatitisB.,Varicella,Rubella,Rubeola,HCT,STS,Urinalysis,Vision,
B/P,DrugScreen,HealthAssessment,TBTesting).
Performimmunizations(HepatitisB,Rubella,Rubeola,Tetanus,Rabies,MMR).
ConductFluVaccineProgram(immunizationofemployeesandfaculty/staff).
ConducttuberculosisprophylaxisevaluationsandtreatmentasnecessaryforPPDconverters.
Conducthealthscreenings.
Performreturntoworkclearance(anyemployeeabsentfromworkformorethansevendaysandanyemployee
whoreportsoffwithacommunicableorcontagiousdisease;anyemployeeinjuredinanonjobrelatedaccident).
Performhealthevaluations(employeesabouttoenterthedisciplinaryprocessarereferredbysupervisorstorule
outhealthproblems).
Performtuberculosissurveillance(screeningofemployeesatleastannuallyforexposure,asrequiredby
regulations).
Performhearingtests(scheduling,reviewing,andinterviewingallexposedemployees).
Conductrespiratoryprogram(medicalassessmentincludingpulmonaryfunctiontestingofallemployeesidentified
asneedingtoweararespiratorintheirjobassignment).
Conductlaserusesurveillance(schedulingandevaluationofallemployeeswithlaserexposure).
Conductethyleneoxidesurveillance(periodictestingofemployeesasnecessary).
Conductphysicianimmunizationprogram(reviewofrecords,immunizationsasnecessary).
ConductADAcompliance(jobassessments,employeeassessmentsforaccommodation;handicappedparkingas
necessary).
Evaluatecommunicablediseaseexposures(evaluationandtreatmentofallemployeesidentifiedasbeingexposed
topatientswithcommunicableorcontagiousdiseases,i.e.,varicella,meningitis,pertussis).
Maintainrecords(maintenanceandupdateofallemployeehealthrecordsforemploymentplusthirtyyears).
Performsdrugtesting(randomandforcausedrugtestingofemployeesreferredbysupervisorsorsubstance
abusecounselors).

EmployeeHealthandWellnessCenter

Evaluateandtreatnonoccupationalillnesses
Providereferralstoprimarycarephysiciansorspecialistsasneeded
Providegeneralmedicaladvicetopatients
Providesupportforemergencypreparednessintheeventofachemicalorbiologicalemergency
Coordinatehealtheducationandgeneralwellnessevents
PerformmonthlyROIcalculations
Performcasemanagementfornonoccupationalconditions
Performpreventivemedicalscreeningsandimmunizations

InformationTechnology

Developandmaintainoccupationalhealthandsafetysoftware.
ManagedatarequirementsforallHealth,SafetyandEnvironmentTrainingPrograms.
DevelopandmaintaintheHealth,SafetyandEnvironmentWebSite.
CoordinaterequestedreportsforMarylandStateWorkersCompensationCommissionandMedicare
PerformalldataacquisitionandanalysesofHealth,SafetyandEnvironmentactivities.
Createandmanageallonlinesafetytrainingprograms


OccupationalInjuryClinic

Performassessmentandtreatmentofworkrelatedinjuryandillness.
Conductpostexposuremanagementofbloodbornepathogens(HIV,HBV,HCV).
Conductearlydetection/interventionergonomicsprogram(incooperationwithSafetyandRehabilitation
Medicine).
Conductcasemanagementofworkers'compensationclaimsincooperationwithPPOphysicians,Human
Resources,SafetyManagementandIndustrialHygiene.
Manage5STIXProgramfortheJohnsHopkinsHospital,SchoolofMedicine,SchoolofPublicHealth,Community
PhysiciansandSchoolofNursing

WorkersCompensationOffice

Payandadjustworkers'compensationclaimsforallHopkinsentities.
Arrangeforlegaldefenseofworkers'compensationclaims.
PerformalladministrativeresponsesandfilingsforMarylandWorkers'CompensationCommissionandMedicare.
Providequarterlyreportstoexcessinsurancecarrier.
ProvideannualreporttoauditorsandadjustorsregardingactivitiesoftheJohnsHopkinsSelfInsuredWorkers
CompensationProgram.
ProvidecasemanagementservicesforallentitiesparticipatingintheJohnsHopkinsSelfInsuredWorkers
CompensationPlan.

DivisionofOccupationalandEnvironmentalMedicine

ThedivisionofOccupationalMedicineisnotacomponentofHealth,SafetyandEnvironment,butrathera
componentoftheDepartmentofMedicine.TheChairmanoftheJointCommitteeistheDirectoroftheDivision
andreportstotheChairmanoftheDepartmentofMedicineforthisfunction. TheDivisionisfundedviacontracts
withcorporations.

Performemployeroutreachandtraining
Providedisabilitymanagementtocontractedcompanies
Provisionofonsitemedical,nursing,andsafetyprogramstocontractedcompanies
ProvideFederalAviationAdministration(FAA)medicalexaminations
Providemedicalreviewofficerservices
ProvideIndependentMedicalExaminations(IME)
Impairmentevaluations
Worseningofcondition
Causalconnection
Secondopinion
Needforadditionaltreatment
Workcapacityassessment
Chartreviews
Provideoccupationalmedicalandsafetyconsulting
Provideworksitehazardevaluation/industrialhygienemonitoring
Provideergonomicsworkplace/processredesign
ProvideepidemiologicServices
Studydesign
Conductofscientificstudies
Clusteranalysis
Surveillance
Provideclaimmodelingservicesforinsurancecompanies
Providecasualtyinsuranceinventorymanagement

FUNDING

TheactivitiesofHealth,SafetyandEnvironmentarefundedbytheJohnsHopkinsHealthSystem,JohnsHopkins
HospitalandUniversitythroughtheJointAgreement.TheFunctionalUnitnumberforallJohnsHopkinsHospital
Safetybudgetsis#27,theHealthSystem#06andtheUniversitybudgetsarehouseunderseveralinternalorder
numbers(80008192,80008193,80008195,80006519,80024329).Thecontributionsforeachdivisioniscalculated
onapercenteffortbasis.Sinceitsfoundingin1992,Health,SafetyandEnvironmenthascomeinunderbudget,17
timesinthe21years.InFY12,thepercenteffortallocationswereasfollows:

Hospital39%
SOM40%
PublicHealth6%
KennedyInstitute1%
HomewoodCampus14%
Housing4%
Peabody8%
Facilities19%
Engineering27%
ArtsandSciences42%

TARGETPERFORMANCEOUTCOMES

Health,SafetyandEnvironmentstrivestoachievesafetyperformancethatisbestofclass.Exampleskeyoutcome
variablesinclude:

1. OSHARecordableIncidentRates,lessthantheBLSpublishedratesforhospitalsanduniversities
2. Needlestickinjuryrateslessthanpublishednationalratesfornursesandphysicians
3. Workerscompensationcosts(per$100ofpayroll),50%lessthancomparableMarylandHospitalsand
Universities
4. CorridorpatencyintheHospitalandUniversityofgreaterthan97%
5. Mandatedsafetytrainingcomplianceof95%orgreater
6. Zonemaintenanceresponsetimetofires,lessthanthreeminutes
7. CompliancewiththeMarylandDepartmentofEnvironmentRadiationStandards,100%
8. Personalradiationbadgereturnrate,greaterthan90%
9. Foodsafetysurveys,97%compliancewithBaltimoreCityHealthDepartmentregulations
10. Annualinspectionoflaboratoriesindicatingnosafetyviolations,98%compliance
11. Absenceofsafetyviolations
12. Absenceoffinesforsafetyviolations
13. JohnsHopkinsHospitalInfluenzaImmunizationRatesgreaterthan95%andStatemandated
immunizations(Rubeola,Rubella,etc.)at100%
14. TheDivisionofOccupationalMedicineachieveayearly10%growthrate