Oversight Process

Laboratory Safety and Compliance Audits

This oversight procedure is designed to promote safety in the laboratory workplace and compliance with worker safety, environmental protection and fire prevention regulations as well as to implement UVM's Laboratory Health & Safety Policy

The steps in the Laboratory Compliance Oversight process:

  1. Laboratory self-inspections by faculty or designate;
  2. Audits of laboratories by Risk Management & Safety (RMS) personnel or delegates;
  3. Notification of audit results and response; and
  4. Audit of the program.

 

In accordance with UVM's policy for Laboratory Health and Safety:

  • The Faculty member or Principal Investigator (PI) of each lab is responsible for assuring that the lab is operated in a safe and compliant manner.
  • The Department Chair and Dean's Office share a responsibility for oversight of the PI and the research activities.
  • Risk Management & Safety, the Vice President for Finance and Administration and the Vice President for Research/Provost office share a responsibility for providing support, systems and tools to aid in these safety and compliance efforts.
  • UVM's Chief Compliance Officer is responsible for ensuring that a coordinated institutional perspective is present in compliance activities.

This oversight partnership can be used effectively to manage safety and regulatory issues without placing an unmanageable burden on any personnel.

 


 

Laboratory Safety Self-Inspections

Properly conducted, lab self-inspections assure that healthful working conditions are maintained and that regulatory compliance is achieved. Lab personnel are expected to look critically at all of their lab spaces each month and document findings on the Self-Inspection Checklist.

Specific labs may have issues that are not addressed by this checklist. Those lab personnel should work with Risk Management & Safety staff to modify this checklist to best fit their specific safety and compliance needs.

The general checklist is reviewed annually by Risk Management & Safety staff, to reflect problem areas identified during inspections and audits, as well as changes in regulatory focus.

 


 

Laboratory Compliance Audits

Risk Management & Safety personnel perform laboratory compliance audits of the laboratories in order to:

  • Provide feedback to lab personnel regarding their health, safety and compliance efforts;
  • Remedy lab environments that need improvement; and
  • Inform the UVM administration regarding potential risks.

Audits will be conducted following a risk-based schedule. Risk Management & Safety personnel will identify those labs that have either a higher consequence from an adverse occurrence or a higher probability of adverse occurrence. Labs will be audited according to the following priorities.

High Priority labs are audited once each calendar year.  High priority labs include those labs that:

  • Conduct high hazard activities or use high hazard materials (such as pyrophoric or highly toxic chemicals) in the professional judgment of Safety personnel;
  • Have been identified by an external entity (e.g. Department of Environmental Conservation, Fire Department) as areas that show a risk of non-compliance;
  • That have an accident or incident that shows a lack of preparedness, training or conformance; or
  • Labs with poor past performance.

 

Low Priority labs are audited at least once in every 3 years.  Low priority labs include those labs that:

  • Use relatively low hazard materials and operations; and
  • Have a history of positive conformance with environmental, health and safety requirements.

 

Risk Management & Safety personnel log each audit including the date of the audit, location,names of personnel responsible for lab operations, audit results and follow-up actions.  Risk Management & Safety personnel also assign a high or low priority designation to each lab.

Any lab that is conscientiously conducting self-inspections should have minimal corrective actions identified during an audit.


 

Notification and Response

Audit results will be communicated to UVM's Lab Supervisors, Department Chairs, College Deans, Vice President for Finance and Administration, Vice President for Research and Chief Compliance Officer as follows:

Labs Requiring Immediate Intervention are identified in an audit as having high likelihood of an adverse occurrence with serious consequences. RMS auditors will communicate these situations immediately to the PI, Chair, College Dean, Vice President for Finance and Administration, Vice President for Research and Chief Compliance Officer. The Chair and/or Dean are responsible for ensuring that the work environment is made safe before lab activities can continue. The Director of Risk Management & Safety, the Senior Assistant Director for Health and Safety, the Director and Radiation Safety Officer, or University Police have the authority to, at their sole discretion, close a laboratory should hazardous conditions present an imminent threat of injury to employees or students, or significant damage to University property or the environment. The cost of correcting safety and related compliance issues shall ordinarily be the responsibility of the academic unit, College or School; however, application may be made to the Provost and Senior Vice President and to the Vice President for Finance and Administration for funding assistance.

Labs requiring corrective action are identified as having areas of non-compliance without an obvious and immediate danger. Lab supervisors and Risk Management & Safety personnel are notified of necessary corrective actions that were identified during the audit.  Safety Personnel will work with the PI or his or her designee to develop a compliance schedule, generally not to exceed two weeks, and communicate this to the PI.  Corrective actions are recorded when complete.  If corrective actions are not completed on schedule, then the Department Chair will be notified.  If corrective actions remain uncompleted according to the schedule, the College Dean will also be notified, along with the Vice President for Finance and Administration, Vice President for Research and Chief Compliance Officer.

Labs that achieve excellence will be recognized in reports by EHS personnel to Department Chairs, College Deans, Vice President for Finance and Administration, Vice President for Research and Chief Compliance Officer.

All lab audit results will be reported in annual reports by Risk Management & Safety personnel to appropriate Department Chairs, College Deans, Vice President for Finance and Administration, Vice President for Research and Chief Compliance Officer. Risk Management & Safety will include in these reports a list of all labs audited within the department or college during the time period (or a notice that no labs were audited) along with results of audits and results of compliance schedules when applicable. If possible, the report will include a list of all labs that exist within that department or college regardless of audit status.

 


 

External Review of this Program

The efficacy of this program in achieving compliance with regulations and best management practices will be reviewed following inspections by external regulators and/or independent auditors contracted by UVM.  These reviews will occur as needed.