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Carolina's Management System

"Absolutely nothing is good enough if it can be made better."
- Ozzie Smith, Hall of Fame Shortstop

General
     Carolina's Management System (CMS) describes the system used by the Department of Environment, Health and Safety (EHS) to manage environment, health and safety at the University of North Carolina at Chapel Hill (UNC).

Historical Context
     Quality management systems have their origins in the quality management standards of the 1970’s and 1980’s. These systems are used to describe an organization's quality management system; evaluate its performance; define policy, practices, objectives and targets; and provide a catalyst for continuous improvement. Quality standards first existed for products and services (i.e., ISO 9000). In the 1990’s the International Organization for Standardization (ISO) expanded the scope of quality systems by publishing a standard for an Environmental Management System (EMS), which relies on methods and a framework similar to ISO 9000.
     In December 2004, the American Council on Education and the U.S. Environmental Protection Agency sent a letter to University Presidents, asking them to, "consider the merits of developing an EMS or similar integrated approach." The letter did not suggest that universities should adopt an Environmental Management System that follows ISO’s prescribed standard, but instead noted that an effective EMS, "does not require formal accreditation and certification" and that "a management system is most effective when an institution tailors its program to reflect its own distinct culture."

     Although formal, ISO-certified quality and environmental management systems have not been widely adopted in higher education, many of their quality improvement concepts and methods are being actively practiced by colleges and universities. This is true at UNC. Consistent with the December 2004 letter, we have made several alterations to the Environmental Management System described by ISO to tailor Carolina’s Management System to reflect UNC’s distinct culture. First, its scope has been expanded to include health and safety. Also, Carolina’s Management System builds upon elements already in place at UNC, such as the strategic planning used by the Division of Finance and Administration (where EHS resides) and the Workplace Safety Program required by all State Agencies. The CMS also incorporates strategic planning and EHS’ assessment plan for UNC’s accreditation by the Southern Association of Colleges and Schools (SACS). By building our CMS on a foundation of successful existing programs, we feel that a CMS with the scope described here has the best potential to be sustainable and successful in the long-term.
     Carolina's Management System for environment, health and safety meets all of the objectives recommended in the December 2004 letter. Our CMS:

     Carolina’s Management System includes all of the elements of an environmental management system (EMS) described by ISO. Also noteworthy is that most elements of Carolina’s Management System have been in place for many years—far before the December 2004 letter. The rest of this document is a detailed description of the CMS, following the format of that standard, issued in November 2004 (ISO 14001: 2004). We do not always describe our CMS activities as being part of Carolina's Management System, so the following table explains comparable terms and methods of the SACS Assessment and EMS with Carolina’s Management System.

 
Carolina's Management System
SACS Assessment Management
Environmental Management System
Plan Strategic Planning

Goals

Performance Measures

 Objectives

Outcomes (intended or expected)

Measures

 Objectives

Targets
Do Employee Work Plans

Training, information, consultation and outreach

Lab Safety and Hazard Management Plans

Emergency response

 Assessment Methods Implementation and Operation
Check CLIP/HMP Inspections

Monthly and annual reports

Performance reviews

 Assessment Results Checking
Act Enforcement policies

Policymaking

Annual Strategic Plan Renewal

 Reassessment

Improvements

Actions

 Corrective and Preventive Action

Scope
     ISO allows an organization complete freedom to define the scope of its EMS. An EMS may encompass the entire organization, or a small unit or activity. The scope of responsibility for Carolina's Management System is limited to the Department of Environment, Health and Safety, and the aspects of University operations and activities that EHS can control, influence or has responsibility for. EHS is responsible for the management of most University environment, health and safety compliance programs. Other EHS responsibilities are described in University EHS policies and procedures, and in EHS' mission statement.
     The scope of Carolina's Management System can include any University activity or service that may have a significant impact on any aspect of the health, safety or environment of our students, faculty, staff, visitors or community.

Policy
     Carolina's Management System for environment, health and safety is founded on our Environment, Health and Safety Policy. The Policy and its purpose are documented in Chapter One of UNC’s Environment, Health and Safety Manual. This Policy has been approved by the University Safety and Security Committee, and the Chancellor. It represents UNC’s commitment to compliance, accident and pollution prevention, and continual improvement. This Policy applies to all students, faculty and staff, and to all persons working for or on behalf of UNC. Posting on our web site makes it freely available to all students, faculty, staff and visitors, as well as the general public.
     The Department of Environment, Health and Safety’s commitment to compliance, accident and pollution prevention, and continual improvement is described in its statements of Mission, Vision and Core Values.

Planning
     Carolina's Management System for environment, health and safety has a strategic plan, which is renewed annually. The strategic plan identifies aspects, objects and targets for the coming year. EHS’ strategic planning also includes a review of our processes for continuous improvement and risk identification. We review the effectiveness of training, communication, safety plans, emergency response, inspections, reports and documentation, enforcement policies, corrective actions and other important elements of our management system.

Aspects
     EHS’ annual strategic plan renewal identifies aspects that have a significant impact on the environment, health and safety of the University, so that they are considered when setting our goals and measures. The Department of Environment, Health and Safety is organized into Sections that are responsible for the following broad aspects of teaching, research and service conducted by the University:
  • Environmental Management
  • Environmental Permitting
  • Waste Management
  • Fire Safety
  • Emergency Response
  • Industrial Hygiene
  • Biological Safety
  • Laboratory and Chemical Safety
  • Radiation Safety
  • Laboratory Inspections
  • Workplace Safety
  • Workers' Compensation
  • Employee Health
Legal and Other Requirements
     Many of the above EHS responsibilities are driven by legal requirements — Federal rules and regulations or those of the State of North Carolina. In addition, all State Agencies in North Carolina are required to implement the State Employees Workplace Requirements Program for safety and health. The Workplace Safety Program requires the creation of "safety and health committees to perform workplace inspections, review injury and illness records, make advisory recommendations to the agency's managers, and perform other functions determined by the State Personnel Commission to be necessary for the effective" (NC Statutes 143-584).
     UNC must also comply with requirements of various accrediting bodies. For example, the UNC Student Health Service and physicians who work at UNC Hospitals are subject to the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JACHO).
     UNC has several avenues that it uses to identify legal and other environmental requirements. First, EHS staff stay informed of legal requirements through periodicals, listserve subscriptions, continuing education and participation in professional organization, such as Campus Safety, Health and Environmental Management Association, the Health Physics Society, the American Conference of Industrial Hygienists, the American Biological Safety Association, the Institute of Hazardous Materials Management, and the American Chemical Society. Second, EHS has excellent support from the Office of University Counsel. Attorneys there have been assigned responsibility for certain EHS aspects, and are available at any time. UNC’s general counsel is a member of the University Safety and Security Committee. Lastly, EHS is a member of—or actively participates with—several organizations that monitor and inform of legal and compliance developments. These organizations include the American Council on Education, the Council on Government Relations, Howard Hughes Medical Institute, National Association of College and University Business Officers and the Campus Consortium for Environmental Excellence. While there is no set legal review strategy, campus staff call on these advisors when there is a perceived need.

Objectives and Targets
     EHS establishes and maintains its objectives (goals) and targets (performance measures) during its annual strategic plan renewal. When identifying health, safety and environmental aspects, we follow the Balanced Scorecard model (see reference below) to categorize goals and measures:

  • Customer/Stakeholder Service
  • Improvements to a Critical Process
  • Learning, Growth and Innovation
  • Financial Accountability and Performance
     For each of these categories, each EHS Section is responsible for annually proposing goals and measures in that pertain to their areas of responsibilities, consistent with UNC’s Environment, Health and Safety Policy.
     Current EHS objectives and targets (strategic plans, goals and measures) were presented at the March 9, 2005 EHS Strategic Planning Retreat. They are detailed in the following presentations:
FY 2005-6 Goals and Measures for Radiation Safety
FY 2005-6 Goals and Measures for Environmental Affairs
FY 2005-6 Goals and Measures for Fire Safety and Emergency Response
FY 2005-6 Goals and Measures for the University Employee Occupational Health Clinic
FY 2005-6 Goals and Measures for the Collaborative Laboratory Inspection Program
2005 EHS Director's Goals

Management Program
     Responsibility for achieving objectives (goals) and targets (performance measures) is designated by their inclusion in each EHS Section Manager’s annual Work Plan. When assigned by EHS Section Managers, Work Plans also hold EHS staff responsible for objectives and targets.
     To broadly reach UNC students, faculty and staff, objectives and targets may be incorporated into EHS training, information (e.g., EHS web content), consultation and outreach. Objectives and targets may also be included in Laboratory Safety Plans (required of every UNC laboratory) and Hazard Management Plans (required of every UNC workplace where hazardous materials are used.)
     The annual strategic planning timetable is:
May 1 – Each EHS Section’s goals/objectives, measures, actions and targets due for next FY
May 31 – Annual WPPRs (Work Plans and Performance Reviews) due for staff
July 1 – EHS target date to input current FY SACS Assessment Plan—intended outcomes, proposed measures, actions and targets
August 1 – EHS Sections to report accomplishments for previous FY
August 1 – EHS target date to input SACS Assessment Results for previous FY—description of results and how the results will be or have been used to improve the service
September 1 – For each EHS Section, EHS Annual Report is published (i.e., retrospective goals, measures and accomplishments, and prospective goals and measures)
October 1 – Provost’s 2006 target date for to input SACS Assessment Results for previous FY and input current FY SACS Assessment Plan
February 1 – Provost’s 2006 target date for updating SACS Assessment Report for previous FY and current FY Assessment Plan
     The EHS Annual Report is also presented at a Departmental Meeting sometime during the year

Implementation and Operation
     The operation of Carolina's Management System for environment, health and safety is a continuous process. Its everyday activities are much broader than the objects and targets identified in the annual strategic planning process. Further, the CMS is dynamic and can respond quickly to incidents, emergencies, new findings and laws, and changes in UNC priorities and needs.

Resources, Roles, Responsibility and Authority
     By State Statute and other laws, UNC Administration is obligated to support health and safety, environmental stewardship, compliance, and to ensure that resources and authority is provided to effectively manage these systems at the University.
     The Director of Environment, Health and Safety manages the CMS. The EHS Director will initiate planning, actively manage implementation and operations, review inspections and progress reports, and direct necessary corrective and prevention actions. In the EHS annual report, s/he will report on the performance of the CMS and recommend improvements.
     The roles and responsibilities of Section Managers and other EHS staff are detailed in their work plans. With respect to environment, health and safety, the roles and responsibilities of students, faculty and staff are detailed in UNC's safety manuals.
     Authority for CMS implementation, as well as ensuring compliance with EHS Policies, is granted by UNC Administration, enforcement policies and Workplace Safety Committees.

Competence, Training and Awareness
     All UNC students, faculty and staff (including EHS staff) are required to receive training appropriate to their duties and work environments. EHS offers many types of training programs, both on-line and instructor led. Among many other topics, the training includes:

  • The importance of compliance with EHS policies and procedures.
  • How their work activities can significantly impact environment, health and safety.
  • Their roles and responsibilities, including emergency preparedness.
  • Consequences of noncompliance.
     Competence is demonstrated and documented by post-tests and by EHS inspections of workplaces. When a variance from policies and procedures is discovered, EHS inspectors will provide information and consultation.

Communication
     Many methods are successfully used to communicate CMS aspects, goals, policies, procedures and other important environment, health and safety information. Depending on the content, these communications may be targeted towards students, faculty, staff, visitors, contractors or the community. For clear, simple and effective communications, we do not always describe our CMS activities as being part of Carolina's Management System. Communication methods include:

  • EHS web site (This site has extensive content.)
  • Safety training
  • UNC's safety manuals
  • Workplace Safety Committees
  • Internal listserves (e.g., Principal Investigators, Emergency Coordinators, Hazmat Shippers, etc.)
     As necessary, EHS has published articles in the campus newspaper, The Gazette, and have published campus-wide emails or letters to Deans, Directors and Department Heads.

Documentation
     This document includes, links or references the Carolina's Management System’s scope, policy, objective and targets, annual report, and other records regarding significant impacts. Also described are each of the main elements of the CMS, and an explanation of how they interact.
     Monthly progress reports are prepared and are available from the EHS Director. EHS’ SACS Assessment plan is documented and managed by WEAVE online system for online assessment management, assessable via the EHS Director. Addition detail, descriptions and information about the elements and of the Carolina Management System can be found in these documents:
2005 EHS Strategic Plan Renewal
EHS Planning and Implementation Process
SACS Effectiveness Assessment

Control of Documents
     By posting this document on the EHS web site, it is freely available to all students, faculty and staff.
     This document will be reviewed and updated annually by EHS managers prior to May 1 of each year. The calendar provided in Management Program section above describes when and how other CMS documents will be updated.
     These documents are subject to the EHS Records Retention and Disposition Schedule on file with the UNC Records Management Program (in accordance with North Carolina General Statutes 132-1. "Public Records").

Operational Control
     All UNC operations and activities are subject to the Environment, Health and Safety Policy, as well as the procedures described in UNC's safety manuals. Those operations and activities associated with this year’s objectives (goals) and targets (performance measures) are identified in the March 9, 2005 EHS Strategic Planning Retreat presentations, above.

Emergency Preparedness and Response
     The Emergency Response Manual for EHS Staff and UNC's Emergency Plan identifies potential emergency situations. These documents describe our preparedness and response procedures to mitigate environmental, health or safety impacts that may be associated with emergencies.
     Supplemental emergency preparedness and response plans exist to address specific UNC emergencies. These plans include spill prevention control and countermeasure plans (SPCC), hazardous waste contingency plans, select agent incident plan, UNC emergency warning and communication plan, and the OSHA emergency action plan, as well as individual emergency action and business continuation plans of UNC departments and administrative units.
     After an emergency, EHS reviews our response, implements appropriate preventive measures, and revises the plans accordingly. The Emergency Response Manual and Emergency Plan are tested with periodic reviews, drills and exercises.

Checking and Corrective Action
     Carolina's Management System for environment, health and safety includes procedures to identify problems and fix them. As with any system, documentation and periodic review is important to maintain effectiveness.

Monitoring and Measurement
     Key characteristics of UNC’s operations and activities that have a significant impact on health, safety or the environment are monitored and measured by various means by EHS staff. Information to track performance, relevant operational controls, and conformance with UNC’s objectives (goals) and targets (performance measures) is recorded during EHS surveys (inspections) of laboratories and other workplaces, documented in our information system (HASMIS), and sometimes recorded with monitoring equipment. Accidents, injuries and incidents (including hazardous materials incidents) are tracked in HASMIS. UNC fire and security alarms are tracked by the Department of Public Safety. Requests for corrective action to UNC environment, health and safety systems are tracked by the Facilities Services work order system.
     EHS staff survey and inspect laboratories as part of our Collaborative Laboratory Inspection Program (CLIP). EHS staff survey and inspect shops and other non-laboratory workplaces as part of our Hazards Management Program (HMP). Findings of variance from EHS requirements and standards is documented in our Health and Safety Information System (HASMIS) and in post-inspection CLIP and HMP letters to laboratory Principal Investigators and workplace supervisors.
     Schedules vary for calibration and maintenance of equipment used by EHS for health, safety and environmental monitoring. EHS Section Managers are responsible for this, as well as maintaining calibration and maintenance records.
     Every month, EHS prepares a report to track activities, progress towards goals, conformance with plans, and performance targets/ measures. This monthly report is submitted to the Associate Vice Chancellor for Campus Services.

Evaluation of Compliance
     Compliance with relevant environmental, health and safety legislation and regulations is evaluated by CLIP and HMP inspections done by EHS staff. CLIP inspections are done quarterly for users of radioactive materials, and annually for other laboratories. HMP surveys are done annually.
     UNC environment, health and safety activities are also periodically inspected by regulatory agencies, the Office of State Personnel and other outside entities. For example, the North Carolina Department of Environment and Natural Resources (DENR) inspects UNC hazardous waste operations every 1-2 years. In 2004, the North Carolina Department of Labor (DOL) conducted four OSHA investigations at UNC. In each case, regulatory agency inspectors carefully evaluated UNC operations and activities for compliance with state and federal law, and documented their findings in a letter to UNC. If warranted, UNC made corrective action and documented those in a response to the regulatory agency.
     Records of our CLIP and HMP surveys, regulatory agency inspections, and other compliance evaluations are subject to the EHS Records Retention and Disposition Schedule on file with the UNC Records Management Program (in accordance with North Carolina General Statutes 132-1. "Public Records").

Nonconformity, Corrective Action and Preventive Action
     EHS has the authority to handle and investigate nonconformance, to take action to mitigate potential impacts, and to initiate and complete corrective action. UNC health, safety and environmental policies describe responsibilities and enforcement of procedures, practices and standards. In accordance with UNC policy, departments, administrative units and individual students, faculty and staff may be held responsible for handling nonconformance and for initiating and completing corrective action.
     UNC safety orientation training includes risk prevention by teaching students, faculty and staff to recognize and avoid nonconformity, hazardous conditions and noncompliance. Upon notification, EHS will investigate such health, safety and environmental risks. EHS investigations are also initiated from staff observations, accident and injury data, experiences learned from peer institutions, and circumstances that anticipate hazards at UNC. EHS documents these investigations and corrective actions in emails and formal reports.
     For CLIP and HMP surveys, laboratory Principal Investigators and workplace supervisors are sent letters to notify them of nonconformance and corrective actions. Corrective actions are documented in their response or subsequent CLIP and HMP surveys.
     Any corrective or preventive action taken to eliminate the causes of action and potential nonconformances will be appropriate to the magnitude of problems and commensurate with the health, safety and environmental impact encountered. When corrective actions are necessary, written policy and procedure will be review and, if appropriate, revised to avoid a recurrence. EHS' strategic planning includes a review of the effectiveness of training and communication, inspections, risk identification, enforcement policies and corrective actions.

Control of Records
     Training records, records of CLIP and HMP surveys, and other health, safety and environmental records are maintained in EHS’ Health and Safety Information System (HASMIS). HASMIS program routines perform record disposition, archiving and retrieval. For example, training records are archived in a permanent data file upon notice by Human Resources’ information system that a person is no longer employed by UNC. HASMIS includes multiple ways of record tracing and searching. HASMIS complies with UNC information technology security policies and standards, which ensures reliable backup, retrieval, and protection against damage, deterioration or loss.
     Each EHS Manager is responsible for the identification, maintenance and disposition of other health, safety and environmental records for their Section’s areas of responsibility.
     Monthly reports track key EHS performance measures. Annual EHS reports evaluate the progress and accomplishments of the past year, and set new goals and measures for the coming year. Records of CMS implementation are referenced in the Documentation section, above. Records of CMS results achieved are provided in the annual report, as well as documentation of recent EHS planning, goalsetting, performance measurements and accomplishments. See:
2005-2006 EHS Accomplishments
2004-2005 EHS Accomplishments
2003-2004 EHS Accomplishments
January 2004 EHS Strategic Plan Update
2002-2003 EHS Accomplishments
February 26, 2002: EHS Strategic Planning Retreat
2002 EHS Goals
2001 EHS Goals
     All health, safety and environmental records are subject to the EHS Records Retention and Disposition Schedule on file with the UNC Records Management Program (in accordance with North Carolina General Statutes 132-1. "Public Records").

Internal Audit
     An audit of Carolina’s Management System will be undertaken by EHS Managers as part of the annual strategic planning renewal. This audit will determine if the CMS conforms to its plan, described operation and record retention plans. The audit will consider past audits, and will determine if the CMS is properly implemented and maintained. This audit will be reported in the annual report.
     In addition, a similar system audit by external auditors will be undertaken periodically. Prior to establishing our management system as Carolina’s Management System, UNC hired an outside consulting firm to perform a preliminary system audit. This audit—which probed a traditional scope EMS for UNC—helped to instead settle on a different scope for our CMS. As described above, CMS’ scope has been expanded from the scope of a formal EMS to include health and safety, and—at the same time—limited to those aspects for which the Department of Environment, Health and Safety has direct responsibility.

Management Review
     Monthly reports to UNC administration document progress on meeting goals (objectives) and performance measures (targets). EHS' annual report, strategic plans and accomplishments will be submitted to UNC administration for their review the CMS and EHS operations. The annual report will include recommendations of EMS manager, a review of the internal audit results, and relevant communications from outside parties. When circumstances change, and to promote continuous improvement, UNC administration is very active in directing revision of policies, goals and performance measures of Carolina's Management System for environment, health and safety.

References
Letter to University Presidents from Sheldon Elliott Steinbach, American Council on
     Education, and Robert S. Benson, U.S. Environmental Protection Agency, December
     2004. See http://counsel.cua.edu/Environment/EPA_ACE_Letter.pdf

Environmental management systems—Specifications with guidance for use, ANSI/ISO
     14001-2004, American Society for Quality, American Society for Testing & Materials,
     NSF International, November 2004

Southern Association of Colleges and Schools Council on Accreditation and School
     Improvement (SACS CASI), http://www.sacscasi.org/

"The Balanced Scorecard—Measures that Drive Performance," Harvard Business Review,
     January-February 1992

Environmental Management Systems: Do They Improve Performance?, Project Final
     Report, National Database on Environmental Management Systems, University of
     North Carolina at Chapel Hill, 30 January 2003. See http://ndems.cas.unc.edu/

June 2005          
Environment, Health & Safety
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Chapel Hill, NC 27599
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