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UEOHC and School of Dentistry Collaborate to Improve Compliance

Health Care worker
Photo courtesy of the UNC-Chapel Hill Multimedia Library.
Compliance with medical surveillance and incident investigation are integral to providing a safe workplace not only for employees but patients. To facilitate those efforts, the School of Dentistry asked the UEOHC to partner with them to evaluate their internal protocols and procedures and enhance compliance efforts.

Under the University’s medical surveillance program, employees working in or entering a healthcare environment are required to have a complete immunization review in accordance with CDC/HICPAC Guideline for Infection Control in Health Care Personnel. The main purpose behind the University’s medical surveillance program is to reduce and/or eliminate employee susceptibility to occupational hazards in a healthcare environment. The School of Dentistry (SOD) and UEOHC identified some inconsistencies in internal communication guidance to employees. As a result, communication clarifications were implemented and disseminated to new faculty and staff and those currently out of compliance with University procedures.

The second compliance collaboration project involved exposures-reporting education for employees. Incident investigation of an exposure is critical to post-exposure prophylaxis (PEP) treatment plans and future mitigation of hazards. If an employee is involved in an exposure, it is crucial that the employee take immediate steps to care for the exposure site. The second priority is the timeliness of reporting the exposure incident to the UEOHC. For all parties involved in the exposure incident it is imperative to appropriately evaluate the exposure to determine the risk associated with the exposure. There are four key characteristics the UEOHC examines: type of exposure; infection status of source; substances posing risk; and susceptibility of employee exposed.

This collaborative review process was extremely fruitful and identified several educational gaps to which further materials were developed. Additionally, the SOD created a new position, Director of Clinical Compliance, to not only strengthen internal protocols but solidify an on-going partnership with UEOHC to enhance continuous compliance.

Performance measurement is a critical part of the EHS management system. Education, customer service and internal processes are the three most essential components of our work. The chart below indicates the performance in these areas over a five-year period with Level Four representing optimum performance. The adjacent tab shows the specific performance activities and the level of that performance for 2017.

Components, Years and Level Completed
Education Customer Service Internal Processes
2013 2014 2015 2016 2017 2013 2014 2015 2016 2017 2013 2014 2015 2016 2017
1 1 2 1 1 3 3 4 3 2 2 2 2 2 1


  • Provided education to 37 faculty and staff traveling abroad for University business.
  • Precepted senior nursing student from the Accelerated BSN program.

Customer Service

  • Fit-tested and provided consultative services for 555 individuals under the University’s Respiratory Protection program.
  • Provided occupational health medical services for 4,284 employees.
  • Provided on-site flu shots for Carolina Living and Learning, Chancellor’s office, Internal Medicine, and various other off-site medical locations.
  • Conducted medical surveillance and fit-testing for incoming School of Medicine new Clinical Fellows.

Internal Processes

  • Reviewed 1107 IACUC Animal Handler Symptom reviews.
  • Reviewed and updated clinical Bloodborne Pathogen, Tuberculosis, and Infection Control training materials.
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