Presidential Metrics

I wanted to take a moment to to let you know that at least some part of what we do is a priority of Dr. Rao’s and is being tracked as one of Meredith Weiss’ metrics of performance. In much the same way that all of us have cascading goals, Meredith meets quarterly with the President and the status of each of her performance metrics is discussed. The inclusion of BioRaft implementation as one of her performance metrics was her idea and for the first time in my career, something I’m responsible for – other than something blowing up or catching on fire – has Presidential visibility. Please see below for the exact language:


Key Presidential Priority? Priority and Goal THRESHOLD

Minimum Expectation


Meets Expectation


Exceeds Expectation



Accessible and Real-World Learning in an Urban Research University. Efforts to support and promote the transformation of the educational learning experience at VCU (through academics, technology, and/or human resource initiatives)



25% implementation of BioRaft Management Software for research laboratories that will allow inventory control; inspection finding management; and compliance controls accessible by researchers across the enterprise.



50% implementation of BioRaft Management Software for research laboratories that will allow inventory control; inspection finding management; and compliance controls accessible by researchers across the enterprise.



80% implementation of BioRaft Management Software for research laboratories that will allow inventory control; inspection finding management; and compliance controls accessible by researchers across the enterprise.


Why is this important? Because when researchers and others ask why they have to do this, we should start with the fact that it’s a valuable tool that will ultimately make their management of the laboratory easier. However, for the truly recalcitrant, perhaps letting them know that this is a Presidential priority may be helpful. The unintended consequence though is that we have to perform. We have to do everything in our power to make sure that what we said we’re going to do actually gets done.

You have the more difficult task of dealing with the researchers and others of the University community on a daily basis. I understand that I’m pretty far removed from that reality .. I haven’t done a laboratory or facility inspection in 15 years. You’re the experts on how to implement the President’s goal and I’m sorry you’re the ones tasked with implementing something that is such a drastic cultural change for our community. However, I hope you understand that this is ultimately a good process that will improve our support of VCU. We have to be champions of this process.


EHS Update January 2018


I want to take some time at the start of the new year to send out an update and the blog is a great way to share recent progress from the EHS team.  The format allows you to interact and comment directly, so please feel free to share your feedback.


Before I get started, I hope everyone had a good break and found some time to slow down and reflect.  I am struck by the dedication, kindness and good humor throughout Safety and Risk Management.  In my short time here I have been welcomed into your family and I really appreciate it.  I have included some highlights of the work we do to support research, education and clinical care.  SRM supports VCU in many different ways so here is a dive in the EHS pool.


Chemical Inventory

95% Response rate from researchers Over 380 rooms with inventory Over 10,000 chemicals in our library


The Laboratory Safety team (Larry, Kabrina, Bill, Greg and Danny) have been leading the collection of chemical inventory information and uploading it to the BioRAFT database.  This has been a team effort with staff across EHS, academic deans and chairs supporting the effort – including the Vice President of Research and Innovation chipping in.  Thank you Dr. Macrina and all the EHS staff who pitched in!  Congratulations are in order as we have reached over 95% response rate across campus.  We are completing final data entry and are working with the Richmond Fire Department to give them access to the data.  The database has information on chemicals in more than 380 rooms across campus and over 10,000 chemicals in the system at this time.


BioRAFT and Lab Safety Assessments 

337 VCU Principle Investigators

895 researchers and students to date

43 Buildings


BioRAFT is a EHS compliance software system with features that are customized to support research.  VCU purchased the system in 2017 and implementation is ongoing with important milestones upcoming.  We have 337 principle investigators/labs registered in the system and we are building the lab member database with 895 researchers total in the system (and counting!).  Larry Mendoza has been spearheading BioRAFT implementation and is working with customers from VCU and VCU Health.  Clinical Pathology will begin using BioRAFT for chemical inventory, equipment and safety assessments in the new year. 


The biosafety and lab safety teams are using the software for laboratory safety assessments now.  Data from the system will inform areas for improved training and focus.  We have performed over 80 lab assessments in BioRAFT since September and the Radiation Safety team will begin using the software in January for their first quarter assessments.  The average lab safety assessment results in 2.4 findings.  A summary of the most frequent lab safety findings is below:


High Frequency Assessment Findings:  BIoRAFT data through Dec. 2017

Finding Severity Type Occurrences # of Labs
Chemical storage compatibility issues – Intermediate hazard +2 Chemical 19 17
Chemical storage compatibility issues – Minor hazard +1 Chemical 12 12
Emergency contact information needed +1 General 12 10
Chemical waste satellite accumulation areas maintained improperly +2 Chemical 11 10
No Food/Drink postings required +1 General 11 10
Chemical fume hood – Low Flow warning (below 80 fpm at sash face velocity) or High Flow warning (above 120 fpm at sash face velocity) +3 Chemical 10 9
Chemical Hygiene Plan missing, inaccessible or expired +1 Chemical 10 10
Chemical labeling inadequate or missing +1 Chemical 10 8
Eye wash/safety shower concerns identified – minor +1 General 9 8
Freezers have not been defrosted regularly (more than 1 inch of ice build up) +1 General 8 8




The Biosafety team (Mike, Vickie and Virginia) continue their close interaction with the Office of Research and Innovation through the Institutional Biosafety Committee (IBC), the Institutional Animal Care and Use Committee (IACUC) and the Institutional Review Entity (for potential “dual use research of concern” or DURC technologies).  We are also beginning to work more closely with the Institutional Review Board (IRB) that serves as VCU’s independent ethics review entity for all research, particularly research involving human participants.  The IRB oversees all clinical trials (and much more).  That’s a lot of acronyms!  It’s also a lot of work for the biosafety team, supporting over $200 million dollars in funded research through review, approval and monitoring of research protocols.


Biosafety Program Snapshot:  June – August 2017

 IACUC protocol reviews  IBC MUA approvals/revisions  Bio. Material Transfer Reviews
192 43 51


In September, Mike Elliott and the biosafety team hosted the annual emergency response drill for the biosafety level 3 (BSL3) lab in conjunction with the research community, Fire Safety, Occupational Safety, VCU Police and Richmond Fire.  A big thanks should go to everyone in SRM who participated and to Dr. Jason Carlyon the principle investigator of the lab.  Below are a few action shots of the team:


 Radiation Safety


The radiation safety team (Mary Beth, Holly, Beth, Jason, Jon and Sara) has been busy supporting the health system and VCU research.  The group is responsible for all regulatory relations, dosimetry, area monitoring, radiological controls, training and sealed source/waste management.   The team will begin using BioRAFT in January for first quarter safety assessments and we will be updating the laser safety program with a third party program audit in the new year.   Here are a few highlights from the radiation safety team:

  • Worked with Radiation Oncology to ensure that installation of the high dose-rate remote afterloader (HDR) at the Hanover Medical Park meets the intent of all regulations and license conditions.
  • Met with new chair of Nuclear Medicine division and the chief technologist to discuss the current protocol for lymphoscintigraphy Tc-99m injections in the operating suite to detect sentinel nodes during surgical procedures for primary carcinomas (breast cancer, melanoma, etc.). The standard operating procedures will be updated by Nuclear Medicine to include training on making proper requests for the service, surgeon hands-on training, and waste disposal.
  • Held the quarterly Radiation Safety Committee meeting on 12/14/17.
  • Performed decommissioning survey of vacated labs in the Gateway Basement previously occupied by the Center for Molecular Imaging.
  • Performed required leak testing of all VCU and VCU Health alpha, beta, and gamma sealed sources.
  • Conducted laser safety analysis with Larry Mendoza in Dr. Golshahi’s lab in Biotech I. Recommendations were made regarding appropriate curtains for shielding and eye protection.  Also reviewed laser safety analysis for Dr. Kinsey in School of Engineering West Hall with Larry.  Currently reviewing the laser safety plan and updates will be included.


Industrial Hygiene Program


Valerie Pegues has been busy building the industrial hygiene program to support VCU Health and the academic campus.  The respiratory protection program is a priority and we have new guidelines and procedures in place.  The program includes risk assessments, training, equipment selection, medical clearance and fit testing.  Many of you may have been involved with this program when we host our fit testing blitz events for students in the School of Allied Health.  We are applying more science to the program with the use of quantitative fit testing equipment and a robust medical clearance program.


Exposure assessment focuses on the identification and measurement of workplace hazards.  It is an essential “front end” to any health and safety program.  Information and data on potential exposures can guide the efficient application of resources.  VCU has robust anesthetic gas monitoring programs for both VCU Health and in support grant funded animal research.      We have performed risk assessments in facilities, in research labs, animal research and at VCU Health.  Valerie’s work was able to identify and control a potential anesthetic gas exposure in a research lab in Kontos.  In addition, we have performed noise exposure analysis in facilities and the Division of Animal Research work locations and provided exposure control measures.



Quarterly Report for the First Quarter of Fiscal Year 2018

As we roll into a new semester and fiscal year, I wanted to update you on the work we’re all accomplishing and how that supports our mission to the University and Health System. You may recognize that this blog-style format is quite different from what we had prepared before. The reason for that is due to the feedback that I received from all of you during our focus group sessions over the summer. One of the commitments that I made to you was that I would improve my communication to you regarding the good work that our group is doing, my expectations of performance and to give you a forum to ask questions back.

Addressing the latter issue first, I’ve always noticed that an open door policy isn’t much of a policy if no one comes through the door. Therefore, you can ask me a question about any issue within the blog and I’ll answer to the best of my ability. If you want to send an anonymous message, then you can do so at the following: Anonymous Comment or Question. I’ll answer as a separate blog post so that the whole group can see the answer, unless requested otherwise.

Also, during a recent Division of Administration leadership session, Meredith’s team created a video for SRM. Please check out the link: SRM Video

Administrative News:

I would again like to thank and congratulate Mary Beth Taormina for her 40 years of service to VCU and VCU Health! Additionally, congratulations to Virginia Sykes with 20 years of service; Barbara Back with 10 years of service; Aaron Kaufmann with 10 years of service;  and Bill Riddell with 5 years of service. My apologies to Derek Carter, who missed the cut off date for five years of service by one day … see you next year!

The administrative team has been busy this past quarter, with Tracey and Carol processing 102 P-card transactions, 36 purchase orders and processing 56 invoices.

Additionally, Jonathan processed 200 IT requests, processed 13 IT contracts and completed 32 vendor reviews. Of note, 90 of the 200 IT issues were handled in house with an average resolution time of 1 business day, while all other transactions were completed in 3-5 business days.

From last year, our on-line learning for lab safety shows a slight increase in the number of courses taken, while the number of learners have remained largely the same. None-the-less, this is a huge improvement from 2015.

How does all this help our group?

  • Carol and Tracey’s use of their P-cards to register people for professional development = Improve Professional Staff Development objective = Improve OEHS
  • Jon’s review of Inspect Point software and coordination with the vendor and Tracy’s purchase of the software = Reduce Fire Safety Violations objective = Improve Risk Management
  • Tracking training enables lab inspectors to confirm lab worker training was done = Reduce Lab Finding objective = Improve OEHS

This is only a portion of what the administrative team does for us and I would like to thank them for their hard work! I would also like to take the opportunity to remind all of our staff to be mindful of the administrative work load when you ask them to help you.

Office of Environmental Health and Safety News:

Laboratory Safety

News from the Lab Safety staff includes the following:

  • We welcome Kabrina Tippett as our newest Lab Inspector. She has an interest in pursuing a career in our shared profession and I have no doubt that she’ll have my job in 10 – 15 years.
  • VCU’s Laboratory Safety Committee had its first meeting on 10/3/17.  There were questions regarding the scope of the committee, whether it needs to include art studios, etc., and the committee name.  A subcommittee for developing a new Chemical Hygiene Plan was established.
  • The team responded to a building evacuation incident at the Cary Street Gym involving pool chemicals.  It was a precautionary evacuation because the pool staff bought a new chlorination chemical that was incompatible with the old one that could have resulted in the release of chlorine gas and potentially cause an explosion. Below is a picture of Larry working the issue at the gym.
  • We said farewell to Eric Fidler as he moves onto a challenging position at the Virginia Institute of Marine Science (VIMS).

The laboratory safety inspections include Biosafety inspections as well and involve a variety of items that are consistent with our safety policy. The missing data in the 2nd QTR of 2017 is largely due to staff turnover. Once we’re fully staffed in that area, then the inspections will be continued on a more consistent basis.


Inspections only make up approximately 30% of the work done by the three members of the Biosafety team, the rest are protocol reviews. Of specific note, I want to highlight that three people (Mike, Virginia and Vicky) support approximately $150,000,000 per year in research through these protocol reviews.

Radiation Safety

Of note for the quarter:

  • We welcome Sara Adams as our new Radiation Safety Specialist. Sara comes to us with a great deal of knowledge and is a veteran of the US Navy!
  • Holly Dean and Mary Beth Taormina attended the 17th Annual Radiation Safety Roundtable at Penn State University. Valuable information was shared among radiation safety professionals during presentations and roundtable discussions and several new ideas for implementation into VCU’s Radiation Safety dosimetry program are being evaluated.
  • A significant leak in the ceiling has prompted a clean-out and reorganization of the radiation safety cold room.  Contractors were hired by FMD to seal all openings and clean fan coils for the refrigeration unit.  An evaluation of the integrity of the ceiling is ongoing and replacement may be necessary.  The work is on-going.

On average the Radiation Safety team completes 54 inspections per quarter, the results of which are shown below:

Industrial Hygiene

Valerie has been accomplishing great things and has been very busy, but one of the items that I wanted to highlight was her work in the Gross Anatomy Lab. Her identification of the ventilation issues in the gross anatomy lab and the subsequent corrective work done by facilities is a testament to her diligence, professionalism and persistence.

Risk Management and Insurance News:

Steve and Monee are currently carrying on the good fight in Dave’s absence. The following are the highlights of their work:

  • Completed the annual crash statistics report for the Virginia State police. Reported 18 chargeable accidents, 10 non chargeable accidents and 9 incidents for FY17. VCU owned vehicles were driven slightly more than 1,000,000 miles during this period.
  • Investigated three liability claims brought against the university. Two involved slip/fall injuries; one was for damage to personal property.
  • Settled three state property claims, including a mechanical fire at the Cary Street Gym – recovered $53,600. Also settled 6 auto claims, receiving payments totaling $7,642.
  • Scored motor vehicle records for 78 new drivers. Of these, 29 have completed all required training.

Fire Safety

I’m pleased to announce that the Fire Safety team have begun implementation of the Peer Review that was completed last fiscal year. They have started to take charge of the Fire Drills from the occupational safety group and are managing the fire extinguisher inspections via third parties. Additionally, with a recent new hire, the scheduling of activities between campuses will be coordinated through one system. It’s my intent in this to assure that consistency in our methodology leads to consistency in the outcomes between the two campuses.

For our metrics, Fire Safety track their data by calendar year, rather than fiscal year. In 2017 there have been 15 smoke related issues (or near misses) and 2 actual fires. All the near misses were related to food preparation in dorm rooms.

The total number of fire alarms have been consistent between calendar years.

Fire system issues are as follows involved the sprinkler system in the West Hospital, which was off-line on 15 AUG in order to replace the fire pump.

Occupational Safety

The occupational safety team has changed the way that they catalog inspections so that they are more consistent with the safety policy. They’ve been at this for three quarters now and it appears that inspection violations are decreasing this past quarter.

Additionally – and more importantly – there has been a 30% decline in the number of workplace injuries this past fiscal year (FY17) when compared to the previous fiscal year, with a corresponding decline in lost work days. This can be a changing metric as people report chronic injuries, but is good news overall.

Of note however, is the rise in more severe injuries among the Facilities staff. Christine, Aaron and Mike are working on additional training for the Facilities staff.

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