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					Using Peer Reviews to Achieve
 Your Compliance Objectives

    Robert Emery, DrPH, CHP, CIH, CSP, RBP
      Executive Director, Environmental Health & Safety
          Associate Professor of Occupational Health
     Assistant Vice President for Research Administration
              Peer Reviews
• Peer: one that is of equal standing with another
• Peer review: an assessment performed by one
  that is of equal standing – a fresh set of eyes
• Can be used to verify that appropriate controls
  are in place for a particular program
• Particularly useful for high risk compliance
  areas to provide some level of assurance that
  appropriate systems and controls are in place
 Why Peer Reviews vs. Audits or
• Any “self review” is demonstrative of proactive,
  “good faith” efforts, but peer reviews:
   – afford reviews by knowledgeable persons
   – that are collegial rather than adversarial – allows for
     feedback, correction, clarification
   – provide an opportunity for self-correction
   – are mutually beneficial – great learning experience for
   – provide possible protections via voluntary self
UTS Environmental Advisory Committee:
• 1975 Informal gathering of Radiation Safety
• 1988 Informal gathering of Safety Directors
• 1989 Environmental Advisory Group
• 1990 Environmental Advisory Committee
   – subsequent incorporation of formal subcommittees
      • radiation safety
      • chemical & biological safety
      • fire and life safety
 UTS Environmental Advisory Committee:
• Share information and   • Develop responses for
  experiences               UTS for proposed
• Avoid duplication of      environmental legislation
  efforts                 • Peer reviews and other
• Establish some            assistance (mutual aid
  consistency               agreements?)
• Identify trends         • Basis for education and
• Develop system-wide       training
  contracts               • Enhance compliance
           UTS Compliance Initiative

• The UT System-wide compliance initiative served
  as a catalyst for the formalization of some of the
  EAC’s existing ad hoc processes, particularly risk
  assessments and peer reviews
• Important point: the compliance denominator for
  this area of risk is NOT mere compliance with
  existing regulations!
   – Strive more for standard of care, standard of excellence
   – Classic example: mold exposures
               Lessons Learned
• Establishment of system-wide goal: all components peer
  reviewed in 3 years
• Development of peer review process guidelines
• Development of initial component questionnaire –based on
  identified risk areas – completed by host site prior to site
• Selection of peer review team
• Invitations, costs, travel arrangements, notifications (note:
  food never hurts)
• Introductory meeting: intent, scope
• Allocation of space, equipment, supplies at host site
          Lessons Learned (con’t)
• Closing conference
• Written report – to host institution in 30 days, to include
   –   introduction,
   –   findings (good and not so good)
   –   recommendations,
   –   request for host response,
   –   conclusions
• Completed report, inclusive of host responses, comments
  in 45 days
• Important to define who the report goes to
• Utility of aggregate findings – systemic problems?
  Training needs?
     Importance of Intangibles
• During peer reviews, its easy to become
  focused on ridged compliance issues – but
  don’t overlook intangibles, such as
  – Work environment
  – Stakeholder impressions
  – Program responsiveness
• Can be indicative of underlying systemic
  issues, such as “organizational silence”
• The UTS EAC has been in the peer review process
  well before it was “cool”
• The process has served t strengthen programs
  across the system and has been mutually
• The process developed by the EAC can serve as a
  template for other risk group to follow
• Final comment – although there any many
  compliance risk groups, the EH&S function is the
  most inspected of all risk groups on our campuses

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