UTMB EHS Annual Report FY25

LEADERSHIP

FROM THE AVP

Safety is everyone’s responsibilityyour actions make a difference.

It is my privilege to present the FY25 Environmental Health & Safety Annual Report. Over the past year, our department has advanced its mission with both resilience and innovation. A successful Joint Commission triennial survey affirmed our compliance and continuous improvement efforts, while the Third Coast Thunder radiological tabletop exercise showcased our leadership in emergency preparedness. We also developed and launched our first in-house HAZWOPER refresher course, expanding our training capabilities and strengthening emergency readiness.

This year has also marked a season of transition and growth. Several long-time colleagues retired after years of dedicated service, even as we welcomed new team members and celebrated numerous promotions and professional certifications. With these changes, we are proud to be operating once again at fully staffed levels and better equipped than ever to support UTMB’s mission.

The progress outlined in this report reflects not only regulatory compliance or operational metrics, but also the collective commitment of our team to a culture of safety. The milestones achieved this year underscore our adaptability, professionalism, and shared focus on protecting the health and safety of our community. As we look ahead, we remain committed to building on this foundation with the same determination that carried us through FY25. Will

MANAGEMENT TEAM

LUCY KOCH PROGRAM DIRECTOR ENVIRONMENTAL PROTECTION MANAGEMENT

• Hazardous Waste Management

• Radioactive Waste Management

• Pollution Prevention

• Air & Water Quality

T

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. William Pate AVP, EHS

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

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, PHD, UTMB PRESIDENT & CEO, UTMB HEALTH SYSTEM

BUSINESS OPERATIONS & INFRASTRUCTURE

JAMIE BAILEY, MBA, CPA, CFE, EVP & CHIEF FINANCIAL OFFICER

BUSINESS OPERATIONS & FACILITIES

COLIN HARTWELL, MBA, MS, CHFM, CEM, CEP, VICE PRESIDENT

ENVIRONMENTAL HEALTH AND SAFETY

WILLIAM PATE, DRPH, MBA, LMP, CHP, CIH, CSP, CPP, CHFM, CHMM, AVP

MANAGEMENT STAFF

TECHNICAL STAFF

ORGANIZATION CHART

Our commitment to safety safeguards is not just for our patients, employees, and students, but for our future.

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

• Life Safety Property Assessments

Together, we create a safer environment for all.

ENVIRONMENTAL PROTECTION

• Regulatory Compliance and Support

• Hazardous and Radioactive Waste Management

• Water Quality (Stormwater and Wastewater)

• Pollution and Spill Prevention

• Air Emission Permit Management

• Emergency Planning & Community Right to Know

• Medical Waste Compliance 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

HOW WE WORK

BUILDING RELATIONSHIPS

WORKING TOGETHER TO CREATE A CULTURE OF SAFETY

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.

The safest workplaces are built on collaboration and care.

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 FY25, EHS received 237 calls for emergency support ranging from fire alarm activations to hazardous material spills.

First responders participating in hands-on training and response exercises at the League City Campus.

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

• Stormwater programs

• Title V air permit management

• Hazardous materials spill cleanup

• Hazardous waste dsposal

YEAR IN REVIEW

HIGHLIGHTS

FIRE DEVICES

EMERGENCY RESPONSE

Fire alarm and fire sprinkler devices

UNIVERSITY SUPPORT

Requests for emergency response including 160 fire alarm responses

Pounds of chemical waste submitted for pickup via chemical pickup requests HAZARDOUS WASTE

EXTERNAL INPECTIONS

LAB INSPECTIONS

External regulatory and accreditation inspections supported

81,000 237 9 269,592 225 33,931 1,087 2,670 1,837

Lab inspections performed in more than 634 rooms

10,166,851

Total gross square footage EHS serviced for FY25

Chlorine residual and coliform samples collected to ensure safe potable water WATER SAMPLES

SAFETY EQUIPMENT

CHEMICAL INVENTORY

SAFE WORK PERMITS

Inspections of safety equipment performed

Chemicals maintained in institutional inventory and reviewed annually by EHS

Number of permits authorized (e.g., above ceiling, confined spaces)

PROGRAM AREAS

ENVIRONMENTAL PROTECTION MANAGEMENT

The Environmental Protection Management (EPM) program continues to advance its mission of strengthening compliance while building meaningful connections across UTMB and within the broader communities with its hazardous waste management programs. Recent initiatives highlight both regional collaboration and innovative outreach that are redefining how compliance is viewed and practiced.

RESEARCH OUTREACH INITIATIVES

Outreach to the research community has been a major focus this year, with several creative programs making compliance more approachable and engaging.

Research Waste Campaign: For this campaign, and FY25 goal, EPM developed and delivered posters to Satellite Accumulation Areas (SAAs) to relay quick, practical guidance on chemical waste management. The posters focus on proper waste handling procedures, container labeling requirements, and instructions for submitting chemical waste pickup requests. By giving easy-to-read info right where the waste is made, the campaign helps people avoid mistakes, keeps labs working the same way, and shows that UTMB cares about safety and doing things the compliant way.

Cookies and Compliance: In FY25, EPM started a branding initiative to increase awareness of hazardous waste management. This branding incorporates tie-dye for visibility, as well as a welcomeness to ask questions and feel comfortable with waste management.

By pairing compliance conversations while offering cookies, prizes, and games, the program has re-branded EPM from the image of “compliance cops” into approachable partners. Feedback from surveys shows that researchers are more willing to engage, ask questions, and share challenges in a supportive setting.

CUSTOMER SERVICE SURVEY RESULTS

The impact of these efforts is reflected in survey data and direct feedback from the research and healthcare community. Results show strong satisfaction with the EHS team’s responsiveness, communication, and ability to provide practical solutions. Researchers consistently report improved trust and appreciation for the program’s approachable, customer service-oriented manner. These findings support that the team’s focus on customer service is not only effective but also essential to long-term cultural change in compliance.

COMMUNITY OUTREACH INITIATIVES

By reaching out to the community, UTMB demonstrates its dedication to safe hazardous materials management and to preserving environmental quality for all.

“Trash Talk: Coloring Outside the Lines” CUHMMC: Meagan Thibodaux and Travis Chrisman recently shared the new outreach model through the presentation “Trash Talk: Coloring Outside the Lines” at Virginia Tech for the College and University Hazardous Materials Management Conference. This presentation highlighted unique approaches such as tie-dye branding, Cookies and Compliance outreach, and demonstrated how these strategies have built trust and improved participation. The presentation showed that UTMB is leading the way in how colleges and universities handle compliance.

PROGRAM AREAS

ENVIRONMENTAL PROTECTION MANAGEMENT

THE WWE RING - LEAGUE CITY WETLANDS PROJECT

UTMB EPM is represented in the Texas A&M AgriLife Galveston Bay Coalition of Watersheds. During this program year, EPM led initiatives to build and deploy the UTMB League City Campus Wetlands Project aligning with the Coalition’s project for Green Infrastructure. This initiative is focused on restoring wetlands to improve stormwater quality, reduce localized flooding, and provide valuable ecological benefits. Participation in this project supports UTMB’s MS4 permit commitments and demonstrates how regulatory requirements can be met through sustainable, real-world practices.

Beyond compliance, the wetlands project also creates opportunities for education and public engagement, allowing UTMB to be seen as both a scientific partner and a community leader in environmental protection. Multiple agencies, EPM employees, volunteers, and Scout Troops were able to come together to create the first floating wetland for UTMB, affectionately titled “The WWE Ring” for Waste, Water, and EPCRA regulations that tie into the project.

Meeting environmental compliance requirements for hazardous materials disposal, EPM delivers expert services for hazardous waste management. Servicing 1393 pickup requests, EPM handled 269,591 pounds of chemical waste across all campuses. In FY25, waste increased by 2%.

Regulated under the Texas Commission on Environmental Quality (TCEQ) and the U.S. Environmental Protection Agency (EPA), UTMB Galveston campus owns and operates its medical waste incinerator and autoclave system for medical waste disposal. FY25 disposal rates had a 6 % increase from the previous year.

PROGRAM AREAS

LIFE SAFETY AND ENVIRONMENT OF CARE COMPLIANCE PROGRAM

The Life Safety and Environment of Care Compliance Program (LS&EOCC) has a system-wide 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

‣ Successful completion of the triennial Joint Commission survey site visit for the accreditation on our hospitals.

‣ Facilitated a multidisciplinary compliance assessment of relocatable power tap use in Peri-operative Services.

‣ Completed the Life Safety and fire door upgrades to the Clear Lake Hospital Emergency Department.

‣ Delivered targeted safety, fire safety and emergency response training to over 1200 employees.

‣ Showcased a novel work practice on the Implementation of ATG Above Ceiling Work Permitting Process at the UT System 2024 Facilities Conference

‣ Facilitated community outreach with the League City Fire Department to host hands-on first responder fire response training exercises.

‣ Upgraded the fire alarm and notification systems in multiple buildings on the Galveston Campus.

‣ Completed the fire sprinklers in Moody Medical Library.

Future

• Finish installing fire sprinklers in School of Allied Health Sciences.

• Progress the Moody Medical Library Life Safety Egress Renovations.

• Continue to harden fire alarm network against catastrophe and improve cyber-security.

• Continue to upgrade the fire alarm and notification systems on all UTMB campuses.

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 continue to see an increase due to inflation and increased supply costs.

PROGRAM AREAS

RADIATION & OCCUPATIONAL SAFETY

The Radiation and Occupational Safety Program (ROccs) is dedicated to ensuring the health and safety of laboratory and healthcare workers across a broad range of environments. Our technical expertise spans multiple disciplines, including radiation safety, laboratory safety, food safety, water quality, and industrial and construction safety. We provide a wide array of services to support safe practices, including:

‣ Radiation and laboratory safety audits

‣ Calibration and use of survey equipment

‣ Receipt, survey of sealed source radioactive material packages

‣ Respirator fit testing and respiratory protection support

‣ Food safety inspections

‣ Industrial and construction site safety evaluations

‣ Comprehensive safety training across multiple disciplines

ROccs remains committed to advancing workplace safety through expert guidance, regulatory compliance support, and responsive service tailored to the needs of our campus and healthcare communities.

ACCOMPLISHMENTS:

Program Development & Training

‣ Successfully renewed our Radioactive Materials (RAM) license.

‣ Designed and implemented a new «Lab of the Quarter» recognition program to enhance laboratory inspection engagement.

‣ Developed and implemented the Construction Safety Orientation Program in both English and Spanish.

‣ Redesigned the Clinical Hazard Communication Program to improve chemical inventory access, including specific locations and quantities. EHS technicians are being trained to support this initiative.

Plans, Policies, and Regulatory Compliance

‣ Updated the EHS Weather Plan and Water Quality Plan.

‣ Implemented new EPA regulations and monitoring protocols for Dichloromethane (DCM).

‣ Integrated statutory and regulatory references into the Industrial Inspections Program to enhance documentation and compliance tracking.

Inspections, Monitoring & Safety Activities

‣ 5,996 respirator fit tests conducted, with 5393 passes—a 5% increase over last year. We also exceeded our customer satisfaction goal and increased our survey response rate by 20%. We look forward to ensuring another successful fit testing year ahead.

‣ 33 Confined Space Entries supported, including training the Utilities Team in proper procedures.

‣ 27 Crane Lifts approved.

‣ Construction Safety ended the year with zero recordable incidents under the ROCIP program.

‣ Maintained UTMB’s pool of 64 publicly available Automated External Defibrillators (AEDs).

Emergency Response & Safety Initiatives

‣ Developed and implemented Emergency Department Decontamination Training at Galveston and Clear Lake campuses. Training is scheduled for League City and Angleton next year.

‣ Adopted maintenance responsibilities for the “Stop the Bleed” Program under Occupational Safety.

EHS conducts annual inspections of industrial and mechanical spaces across all UTMB campuses to ensure safety compliance and performance. These inspections cover storage, housekeeping, chemical storage, PPE usage, ladder and fall protection, electrical safety, hearing conservation, and Lockout Tagout procedures. Inspections also assess the safety of Powered Industrial Trucks, Man-lifts, machine guarding, tools, and confined spaces, as well as fire safety and overall occupational safety hazards. All findings are documented and used to guide continual improvements in safety practices and regulatory 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. Regulatory inspections saw a peak in FY21 as regulators caught up from COVID, returned to normal levels in FY23-FY24 and took a decline in FY25 due to understaffing of State Inspectors.

EHS conducted 225 research lab inspections in FY25, identifying most issues in documentation, storage, and training. Moderate findings involved lab environment and emergency equipment, while waste, fume hoods, and pressurized systems showed minimal concerns. To address gaps, EHS will strengthen documentation and storage practices, expand training, and promote continuous improvement to ensure compliance and a safe research environment.

SERVICE HIGHLIGHTS

SUMMARY

TJC TRIENNIAL SURVEY

UTMB Environment of Care strategic preparations for the triennial Joint Commission hospital accreditation survey was a success demonstrating ongoing compliance and continuous improvement while creating a safe environment to deliver care to our patients.

Winter Storm Enzo shocked the Gulf Coast region with freezing temperatures, ice, and snow. Due to EHS’s preparedness, fast acting response and resilience, there was minimal damages to the building fire prevention systems.

MONITORING

In response to the EPA’s 2024 regulation reclassifying dichloromethane (DCM) as a probable human carcinogen, UTMB EHS collaborated with researchers to ensure compliance with strict exposure limits by facilitating DCM disposal, reviewing safety protocols, and implementing effective engineering controls. Ongoing monitoring of five research groups supports both regulatory adherence and a safer laboratory environment.

EMERGENCY PREPAREDNESS – EMERGENCY WEATHER DRILL AND HAZWOPER REFRESHER

In 2025, EHS overhauled its Emergency Weather Plan to streamline procedures and improve efficiency, culminating in a full-scale drill in May to validate the new approach. The exercise enhanced team coordination, readiness, and feedback integration within the emergency response framework. Additionally, in April, UTMB EHS delivered a customized HAZWOPER refresher course tailored to campus and clinic needs, emphasizing practical scenarios, hands-on activities, and SWOT analysis to strengthen preparedness and compliance with OSHA 29 CFR 1910.120. These efforts reinforced critical competencies in chemical, biological, and radiological incident response for improved safety and readiness.

THIRD COAST THUNDER RADIOLOGICAL TABLETOP EXERCISE

Third Coast Thunder showcased UTMB’s partnership with the U.S. Department of Energy and FBI to test readiness for radiological emergencies. The exercise strengthened interagency coordination, highlighted technical and organizational challenges, and reinforced UTMB’s role in providing medical expertise and hospital preparedness. Lessons learned will refine future training and response protocols, enhancing resilience for UTMB and the Gulf Coast community.

TITLE V AIR PROGRAM

Air permit deviations reported from UTMBs permitted combustion sources in Galveston continue to decline with significant process improvements over the years. Onsite inspections reported no reportable deviations.

COMMUNITY OUTREACH: RESEARCH DAY & LAB SAFETY WEEK

In 2025, UTMB EHS engaged in collaborative exchanges with Rice University and the University of Houston to share best practices in chemical safety and hosted undergraduate interns through new and existing programs, providing hands-on experience in industrial hygiene, environmental compliance, and occupational health and safety. These initiatives supported professional development and strengthened institutional partnerships in environmental health and safety.

UPGRADED FIRE ALARM SYSTEMS/FEATURES FOR HEALTHCARE BUILDINGS

Fire alarm systems and features were upgraded in several of UTMB healthcare buildings. These upgrades in technology provide reliable building integration systems, seamless servicing and security of the fire alarm system, mass notification, and revolutionary networking capabilities.

UTMB EHS oversees the Water Quality Program to ensure compliance with Centers for Medicare and Medicaid Services (CMS) and Texas Joint Commission (TJC) requirements, with Water Safety Specialist Amy Clark leading monitoring efforts across campuses to maintain safe chlorine levels and prevent waterborne pathogens. She collaborates with municipal suppliers, Business Operations and Facilities, and the Water Quality Management Team to address infrastructure changes and safeguard water quality across UTMB facilities.

SERVICE HIGHLIGHTS

THE JOINT COMMISION -TRIENNIAL ACCREDITATION SURVEY

In May 2025, UTMB underwent its 5-day unannounced triennial hospital accreditation survey by The Joint Commission (TJC), covering all campuses and clinical areas. Over the course of the survey, there were 43 total findings comprised of 91 observations, all of which were addressed and closed during the survey. Sustained oversight ensures ongoing compliance and continuous improvement, demonstrating the strength of UTMB’s culture of readiness, accountability, and cross-functional collaboration.

Strategic Preparation and Readiness

EHS led a coordinated, data-driven preparation effort to ensure full survey readiness:

‣ Third-Party Audits: Partnering with Property Services, EHS hosted third-party audits of key compliance programs, achieving 100% real-time resolution of findings and applying lessons learned to prevent repeat issues.

‣ Digital Compliance Library: A centralized, fully aligned repository ensured instant access to 100% of required documentation, enabling rapid responses and smooth surveyor navigation.

‣ Command Centers: Both physical and virtual command centers were established, leveraging Teams and SharePoint to track findings and corrective actions in real time, coordinate responses, and maintain situational awareness across all campuses.

‣ Survey Drills & Collaborative Readiness: Practice drills conducted confirmed that all participating staff were prepared to engage confidently with surveyors, validating response systems and readiness.

Survey Execution

Scribes and escorts supported the LS surveyors in the field, while virtual teams located at the Command Center simultaneously monitored notes, uploaded documentation, and coordinated corrective actions. EHS and Property Services worked together to swiftly reach 100% resolution of observations, demonstrating both the effectiveness of pre-survey preparation and the seamless collaboration across departments.

Impact and Closing

The 2025 survey validated UTMB’s progress in creating safe, reliable environments for patients, visitors, and staff. By combining data-driven preparation, collaborative execution, and transparent documentation, UTMB reinforced a culture of continuous quality improvement and regulatory compliance. Ongoing monitoring processes were expanded, and proactive rounding ensures that standards are maintained consistently across all campuses, supporting both safety and operational excellence. These efforts not only ensured survey success but also strengthened ongoing readiness and operational excellence across all facilities.

Multidisciplinary Constant Readiness rounding team, including EHS staff Dr. Mario Soares and Travis Chrisman, preparing to tour Perioperative Services

SERVICE HIGHLIGHTS

WINTER STORM ENZO AT UTMB

In mid-January 2025, Winter Storm Enzo swept across the Gulf Coast, bringing an unusual mix of freezing temperatures, ice, and snow to areas that rarely experience such conditions. On January 21, UTMB awoke to a rare winter wonderland, a scene both beautiful and challenging, as the storm impacted operations across all four campuses.

The extreme cold, coupled with intermittent power outages, posed significant risks to patient care, facility operations, and critical building systems. In response, UTMB promptly activated its emergency protocols, with the Environmental Health and Safety (EHS) team playing a pivotal role with the deployment of the ride-out crew.

EHS worked tirelessly to safeguard building life safety systems during the event. Sixteen dry sprinkler systems were drained of all condensate to prevent freeze damage, along with any additional wet sprinkler systems in buildings where power was lost. Fire alarm panels were actively monitored, and EHS personnel responded to alarm activations throughout the storm. These proactive measures prevented costly equipment loss, mitigated potential water damage, and ensured that patient care and research remained uninterrupted. The coordinated response during Winter Storm Enzo demonstrated EHS’s resilience, preparedness, and commitment to maintaining both safety and operational integrity in the face of severe weather.

SERVICE HIGHLIGHTS

DCM MONITORING PROGRAM

In compliance with the EPA’s 2024 regulation under the Toxic Substances Control Act, which classifies dichloromethane (DCM) as a probable human carcinogen with risks of liver, neurological, and reproductive effects, EHS collaborated with principal investigators to ensure laboratory safety. The EPA mandates that DCM exposure not exceed an 8-hour time-weighted average (TWA) of 2 parts per million (ppm) and a short-term exposure limit (STEL) of 16 ppm. To meet these stringent limits, EHS facilitated the disposal of unneeded DCM and guided researchers in submitting chemical safety protocols for review and approval by the Chemical Safety Committee. Currently, EHS is monitoring five research groups, organizing personnel into similarly exposed groups, and ensuring that engineering controls such as fume hoods and local exhaust ventilation are properly installed and functioning effectively to maintain safe exposure levels, ensuring both regulatory compliance and a safer laboratory environment.

Building relationships:

In March 2025, members of the Rice University EHS team as well as a representative from the University of Houston EHS team, visited UTMB to observe our approach to monitoring dichloromethane (DCM) exposures and implementing control measures. UTMB EHS subsequently visited Rice laboratories to provide guidance and share best practices, supporting the development of effective chemical safety strategies and fostering collaborative learning between the two institutions.

From May to August 2025, UTMB EHS hosted University of Houston undergraduate Elizabeth Ufodiama as an intern. During her time with the department, she gained hands-on experience in industrial hygiene and environmental health and safety practices, while contributing to ongoing EHS initiatives and fostering professional development.

SERVICE HIGHLIGHTS

EMERGENCY PREPAREDNESS – EMERGENCY WEATHER DRILL AND HAZWOPER REFRESHER

In April 2025, the Environmental Health and Safety (EHS) team developed and delivered an in-house HAZWOPER refresher course tailored specifically to the unique needs and challenges of UTMB campuses and clinics. This customized training allowed our team to focus on campus-relevant scenarios and reinforce key emergency response competencies, including:

• Incident Command and Emergency Communication

• Campus-Specific Hazard Identification

• Biological Incident Response

• Chemical Incident Response

• Radiological Incident Response

The course also featured hands-on training activities, such as:

• Proper use of two-way radios

• Fire extinguisher operation

• PPE selection and donning

• Detection and monitoring of radionuclides

Additionally, the course incorporated a SWOT analysis to evaluate and strengthen our preparedness strategies. This comprehensive approach was developed in alignment with OSHA 29 CFR 1910.120 to ensure compliance and enhance the safety and readiness of our personnel.

Weather Plan Drill

This year, EHS completely overhauled our Emergency Weather Plan to update and streamline the overall approach. Given the extent of the changes, we conducted a full-scale drill in May 2025 to ensure all EHS personnel were familiar with the new procedures and to validate that the plan effectively meets our operational needs. The drill covered activities, such as:

• Home preparation strategies

• Pre-training knowledge check

• Everbridge test

• Ride-Out requirements

• WFH requirements

• Bring Your Own Devce(BOYD) requirements

• Emergency Task List review

• Post-training knowledge check

Post-training knowledge check

The drill allowed each team to execute their specific components of the plan and provide feedback for potential improvements. The streamlined structure, along with tailored checklists for each group, significantly enhanced our ability to track progress and ensure a more efficient response process.

SERVICE HIGHLIGHTS

THIRD COAST THUNDER RADIOLOGICAL TABLETOP EXERCISE

Strengthening Preparedness Through Third Coast Thunder

In July 2025, UTMB partnered with the U.S. Department of Energy’s National Nuclear Security Administration (NNSA) and the Federal Bureau of Investigation (FBI) to host Third Coast Thunder, a weapons of mass destruction tabletop exercise in Galveston. The exercise tested local, state, and federal readiness for radiological emergencies while reinforcing collaboration among critical response agencies.

Third Coast Thunder brought together emergency responders, law enforcement, public health officials, and academic medical center representatives. Participants worked through a realistic radiological incident scenario that required coordination in crisis communication, threat assessment, health management, and continuity of operations. This effort highlighted the technical and organizational challenges of responding to a high-consequence radiological event.

response protocols, and enhance resilience for UTMB and the broader Gulf Coast community.

Third Coast Thunder demonstrated that protecting lives and maintaining public trust requires preparation long before a crisis occurs. By working with federal partners in radiological security, UTMB continues to advance its mission of safeguarding health and safety in a complex threat environment.

UTMB contributed medical expertise, hospital emergency planning perspectives, and specialized safety knowledge, ensuring exercise outcomes reflected the needs of healthcare systems. Participation also strengthened interagency relationships that are critical to unified response during an actual crisis.

Preparedness exercises such as Third Coast Thunder create the operational memory needed for effective action under pressure. They emphasize the value of proactive planning, clear communication, and shared accountability among partners. Lessons learned will guide future training, refine

SERVICE HIGHLIGHTS

TITLE V AIR PROGRAM

EPM oversees the air emission regulations governed by EPA and TCEQ. UTMB has a Title V Federal Operating Permit, as well as two TCEQ-required Standard Operating Permits (relating to air emissions sources). These permits establish the rules and guidelines that govern the operations of two combined heat and power (CHP) generating facilities, multiple steam-producing boilers, and numerous large-scale emergency generators used for backup power for the hospitals and UTMB campus. Locally, Galveston County Health District (GCHD) is charged with conducting periodic audits and inspections that review UTMB’s regulatory-required reporting responsibilities.

In July 2025, GCHD, along with TCEQ, conducted an extensive on-site inspection/audit at our Galveston campus that included a review of our files and records that pertained to the previous two years’ worth of self-reported deviations from our air permit requirements. The inspection included requests for many documents relating to all aspects of UTMB’s air permits that support our operations over that two-year timeframe. The inspection also included a walking field inspection of many of our facilities including the West Plant, East Plant, the Services Building (M-61) and several of our emergency generator locations. GCHD findings from the inspection were positive with no missing reportable deviations.

EPM is required to self-report, semi-annually, any violations or “deviations” pertaining to our air permits. The graph presents a summary of UTMB’s total reported deviations between May 2014 and May 2025. Data presented in the table reflects a significant drop in the number of reportable deviations over recent years.

Additionally, in 2025, a new natural gas-fired boiler was added to provide steam to the Galveston campus. The new boiler (M-61 Boiler4) in the Services Building (M-61) and was brought on-line in April 2025. The initial compliance certification testing was conducted on April 23, 2025, with emissions results that were well below the target regulatory levels.

SERVICE HIGHLIGHTS

COMMUNITY OUTREACH: RESEARCH DAY & LAB SAFETY WEEK

LABORATORY SAFETY WEEK

In conjunction with The Campus Safety, Health, and Environmental Management Association’s (CSHEMA) Laboratory Safety Awareness Week, EHS set-up display booths at various campus locations the week of 10 February to answer safety related questions. This was the first year EHS had an event in GNL. Additional locations included MRB as well as the knuckle which joins MRB, MMNP, & RB17. EHS advertised the event through various MS Teams pages (RSSC Page, UTMB Research Community Page) as well as EHS-Assistant distribution lists for PI’s, Lab Managers, and HCA’s. EHS also partnered with the Print Shop to create poster boards to advertise the event. EHS staff placed these in a variety of locations to drive interest. Lab Safety Awareness Week is an annual awareness event that recognizes the successes of laboratory health and safety programs and offers information and ideas on how to keep our faculty, staff, and students safe. Through a generous RAP grant provided by UT Systems, EHS distributed safety supplies, answered questions from students and staff, and set-up static displays. EHS also sponsored a Safety Bingo contest with various prize bags consisting of safety supplies for labs.

the information table in the Medical Research Building

RESEARCH DAY

Jeremy Davis (ROccs) discussing safety information with attendees

In May, EHS participated in UTMB’s Research Day Core Showcase. Representatives from each EHS discipline participated: ROccS, EPM, and LS/EOC attended to connect with researchers, students, and staff. EHS fielded questions and share helpful information about how EHS supports research activities across campus. From lab safety to hazardous waste management and radiation protection, our team is here to help ensure safe and compliant research environments. Research Day is an annual event presented by the Council of Vice Chairs for Research. Research Day 2025 highlighted the best of UTMB’s current research as well as the Core Showcase. The Core Showcase offers an opportunity for researchers to meet and learn more about the teams that support their activities.

LAB OF THE QUARTER

and

EHS established a Lab of the Quarter Program in FY2025 in order to recognize researchers who cultivate a culture of safety in their labs. Through a generous grant from the UT System Resource Allocation Program (RAP), EHS was able to present the lab a prize for receiving the award. Prize bag included a variety of UTMB-EHS branded merchandise containing several safety related items including spill kits, first aid kits, goggles, & glasses. Dr. Bryan Johnson’s lab was the inaugural winner of the Lab of the Quarter Award in FY25/Q1.

the Quarter Award in Q1 FY25

SERVICE HIGHLIGHTS

UPGRADED FIRE ALARM SYSTEMS/FEAURES FOR HEALTHCARE BUILDING

FIRE ALARM CONTROL PANEL ENHANCEMENTS FOR HEALTHCARE FACILITIES

Overview

For fiscal year 25, EHS Life Safety and EOCC program installed EST4 platforms from Edwards Fire Safety in 9 UTMB facilities. The EST4 fire alarm system is a revolutionary network architecture that simplifies implementation, servicing, and security for fire alarm, mass notification, and building integration systems. It serves as a versatile emergency communications solution suitable for both new constructions and retrofit projects, prioritizing property protection and safe evacuation while addressing UTMB’s cybersecurity challenges.

Upgraded UTMB Facilities

‣ 700 University Blvd, Eye, Ear, Nose, and Throat Clinics

‣ Primary Care Pavilion

‣ University Hospital Clinics

‣ Trauma Center

‣ Clinical Services Wing

‣ Clear Lake Campus Hospital

‣ John Sealy Annex

‣ John Sealy Annex (Old Children’s)

‣ Facilities Support Building (In-House Construction and Hazardous Waste Storage)

Key EST4 Panel Features

‣ Flexible IPv6 Network Design: Supports Class B, A, X, N, or full mesh topologies using fiber, Ethernet, or copper wiring, enabling scalable and reliable connectivity for large-scale installations.

‣ Proxy Firewall Security: Utilizes Advanced Encryption Standard (AES) with secure protocols, certified under FIPS Publication 197 by NIST, providing robust protection against cyber threats without relying on third-party devices.

‣ On-Board Web Server: Enables remote, device-independent access to system status reports for efficient monitoring and management.

‣ Built-In E-Mail and E-Mail-to-SMS Messaging: Delivers instant notifications for specific events to designated personnel, enhancing response times.

‣ Large Full-Color LCD Touch Screen with Tactile Buttons: Offers intuitive, fast access to service and responder functions for user-friendly operation.

‣ Five-Color LED Indicators: Provides at-a-glance system status; programmable colors reduce inventory needs and optimize existing infrastructure.

‣ Backward Compatibility with EST3: Reuses existing wiring, devices, and most local rail modules for cost-effective migrations; network-only systems can upgrade to support voice audio, adding value to retrofits.

‣ Overall, EST4 enhances reliability, scalability, and integration, making it a future-proof choice for life safety systems, especially as the predecessor EST3 reaches end-of-life.

SERVICE HIGHLIGHTS

WATER QUALITY PROGRAM AT UTMB

Environmental Health & Safety (EHS) manages the Water Quality Program at UTMB. Both Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) require healthcare facilities to manage risk of waterborne pathogens in building water systems by establishing policies, implementing procedures, and documenting management of a facility’s Water Management Plan. EHS employs a Water Safety Specialist (Amy Clark) who works with all UTMB campuses to perform regular monitoring and testing of water samples to ensure appropriate levels of chlorine are available within UTMB facilities and to document the absence of waterborne pathogens. This includes liaising with appropriate municipal water suppliers to ensure appropriately treated water is routinely delivered to UTMB. Amy also works with Business Operations and Facilities (BOF) when major maintenance or service changes occur in UTMB buildings that may affect water quality. These can include equipment changes, new construction, or demolition, use and pressure variations, and line breaks. Additionally, the Water Safety Specialist plays a critical role on UTMB’s Water Quality Management Team. This team consists of Executive Leadership from the Healthcare Enterprise, Infection Control, BOF, EHS, & Animal Research.

ACHIEVEMENTS, PROMOTIONS, AND ACCOLADES Achievements

ACADEMIC AND PROFESSIONAL CERTIFICATIONS

‣ Kendle Lopez – Master of Business Administration

‣ Travis Chrisman – Master of Science

‣ Dr. Jack Jacob – Certified Industrial Hygienist

‣ Walter Mays – Certified Life Safety Specialist (Healthcare Facility Manager)

‣ Kendle Lopez – Associate Safety Professional

‣ Adam Jennings – Certified Healthcare Facility Manager

‣ Amy Clark – Class D Water System Operator License

‣ Meagan Thibodaux – Registered Environmental Manager

‣ Travis Chrisman – Registered Environmental Manager

‣ Dr. Mario Soares – Certified Healthcare Facility Manager

‣ Dr. William Pate – Certified Risk Manager

PUBLICATIONS AND PRESENTATIONS

‣ Emma Villarreal published “Applying System Safety Analysis to Zoo Worker Disease Exposure Prevention” in Professional Safety.

‣ Meagan Thibodaux and Travis Chrisman presented “Trash Talk: Color Outside the Lines” at the College & University Hazardous Materials Management Conference (CUHMMC).

RECOGNITION AND AWARDS

‣ Meagan Thibodaux recognized among Galveston Daily News 40 Under 40.

‣ Adam Jennings nominated for the Nicholas and Katherine Leone Award for Administrative Excellence.

PROMOTIONS

‣ Kevin Hebert – Promoted to Sr. EHS Specialist

‣ Michael Puccetti – Promoted to Sr. EHS Specialist

‣ Corey Wilhite – Promoted to EHS Specialist

‣ Clinton Straitwell – Promoted to EHS Specialist

‣ Jake Ratka – Promoted to Sr. EHS Technician

Welcome to EHS

EHS Supervisor March 2025

Sr. EHS Specialist November 2024

EHS Technician July 2025

Const. Safety & Risk November 2024

April 2025

Green EHS Supervisor October 2024

January 2025

Mull EHS Technician Octobber 2024

EHS Technician September 2024

SharonWalters February2025 27yrs

KUDOs to our Employees of the Quarter

Q1 - JEREMY DAVIS, EHS SPECIALIST, ROCCS

Q3 - MEAGAN THIBODAUX, EHS SUPERVISOR, EPM

Q2 - TRAVIS CHRISMAN, SR. EHS SPECIALIST, EPM

Q4 - SCOTT COCHRAN, SR. EHS TECHNICIAN, EPM

Congratulations to Meagan Thibodaux, Environmental Health & Safety Supervisor, on being named the Fiscal Year 2025 Environmental Health & Safety Employee of the Year. This honor recognizes her outstanding leadership, dedication, and contributions to advancing EHS programs across UTMB. Meagan’s commitment to excellence sets a strong example for the department and the entire institution.

Holiday Celebrations

EHS Around Campus