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Inspect and Audit EH&S Compliance in Laboratories
BY KEVIN M. COGHLAN

Environmental Health and Safety (EH&S) compliance programs for any company or institution with laboratories are increasingly complex and challenging to maintain.

Even the most basic plan involves maintaining a variety of permits, performing regular employee training, conducting inspections, complying with a myriad of chemical storage and handling requirements, and ensuring a number of contingency plans are current and complete.

Recordkeeping is a constant battle, whether it is for tracking hazardous chemical waste
manifests or for tracking regular employee monitoring (formaldehyde, radiation, etc.).

Environmental Health & Engineering (EH&S), a consultant, is often asked by organizations
to perform compliance reviews, or audits, to identify program deficiencies and to prioritize items for correction. Its auditors have documented a long list of commonly encountered deficiencies that has proven to be very useful in helping safety officers perform internal program reviews.

However, the real value is in understanding the factors that cause these deficiencies in order to build an efficient formula that will allow clients to optimize the allocation of a limited staff and
budget to maximize program effectiveness (and minimize the deficiencies).

By analyzing patterns in this long list of deficiencies, EH&E identified three systemic root causes of the vast majority of compliance issues.

Program Organization
A great many of the audit deficiencies found were directly related to missing or outdated documents, permits and licenses, inspections, and data collection requirements.
This is not entirely surprising due to the large number of requirements from wide range of federal, state, and local agencies. This problem is due primarily to the lack of a centralized and accessible program organizational structure.

We often find programs organized in folders on a network drive where they are largely unavailable to any but the EH&S personnel who know exactly where to look. Since only a few (or even one) can access the program material, this places pressure on a small number of personnel to keep all information current. EH&E evaluated a number of software to find a user-friendly, easily-maintained package that can make recording compliance easier. Not surprisingly, we did not find an EH&S management system that fully supported a laboratory operation; however, we identified an easy-to use, functional platform on which we could readily design our own system.

Microsoft Windows SharePoint is a web-based, project collaboration package that provides the functionality necessary to construct highly customized project sites that can combine data in a variety of formats. SharePoint allowed EH&E to design a site that provides a single centralized point of collection and access for all program documents, data, and activities. In addition,
SharePoint offers a highly developed (and intuitive) user interface, compatible with a variety of file types and basic project tools, including task lists, calendars and automaticemail notification of deadlines.

Laboratory Work Practices
The second root cause of deficiencies applied to laboratory safety and work practices. The deficiencies include improper storage and labeling of chemicals, out-of date chemicals, improperly maintained satellite accumulation areas, and improper use of personnel protective equipment. Fire and life safety issues include blocked aisles and exits, inaccessible first aid and spill kits, and inadequate signage.

The obvious response to reduce the number of deficiencies in this area is to increase the amount of classroom training for laboratory workers. However, in practice this was not found to be the most viable (or effective) solution. Attendance at classroom trainings is often very limited due to scheduling issues; it’s rare to be able to get each worker to attend more than the required single refresher class per year. Our staff found correcting laboratory work practices to be highly dependent on regular reminders and reinforcement.

We found the most effective method for minimizing laboratory safety deficiencies is a regular schedule of laboratory inspections. Laboratory inspections are a valuable teaching mechanism if used properly, because they can be performed in the context of the workers’ immediate environment.

The success of laboratory inspections is directly dependent upon the presence of a feedback mechanism to document corrective actions and to identify trends. To improve efficiency EH&E developed a laboratory inspection database using Microsoft Access that generates surveys, follow-up reports for laboratory managers, and summary reports for EH&S staff. Automating these key functions now allows the same EH&S staff to perform inspections of all laboratories quarterly. The result has been a 50 percent reduction in documented deficiencies in the first year, and a clear indication of which laboratories need more attention and which compliance issues require additional emphasis during classroom training.

The performance metrics provided by the laboratory inspection program have proven to be invaluable in other ways as well; they help to optimize classroom training, document improvement efforts on specific issues and laboratories, and aid in the justification of new program initiatives to upper management.

Safety Training
The third root cause of deficiencies reflects the struggle most organizations have meeting employee health and safety (H&S) training requirements. Employee H&S training is an essential part of meeting EPA and OSHA compliance requirements, and in a laboratory facility it is especially important in maintaining a safe workplace.

The inability of organizations to adequately train employees and to maintain accurate training records are common issues. Employee training is generally separated into two types: 1) orientation training at the time of hire, and 2) required annual refresher course. Training content can also be separated into two distinct types: 1) content applicable to all laboratories and organizations (standard content) and 2) content required for site-specific processes and activities.

There are many strategies for meeting training requirements, but most organizations use a classroom approach. This typically includes a presentation with handouts, videos or games to keep participant interest.

Classroom training requires a significant time commitment to prepare the curriculum and handouts and to track attendance. Meeting the training needs of an organization with more than 20 laboratory workers can become a significant part of the EH&S effort. Regular training courses
are necessary due to increases in personnel and employee turnover. New research projects
may also necessitate additional worker training on new procedures and equipment.

EH&E real-world experience has demonstrated that the addition of web-based training reduced the time needed for classroom training by 70 percent and decreased the amount of printed materials by 90 percent. Furthermore, it and has improved the compliance rate in several institutions from 70–75 percent to nearly 100 percent. The response from employee surveys has been universally positive, citing the flexibility in scheduling and the on-line quizzes as being most beneficial to them.

EH&S programs for organizations with laboratories are complex and difficult to manage, and the result is often a series of program deficiencies that pose a liability to the entire operation. Through analysis of the results of compliance audits performed in these organizations over many years, EH&E has identified three root causes; poor program organization and accessibility to documentation, non-compliant work practices, and insufficient health and safety training.

EH&E has developed strategies and tools for addressing each of these issues using commercially available software and has demonstrated significant improvements to existing EH&S programs in each area.

These strategies can be implemented at a very reasonable cost by existing EH&S staff in almost any organization. FSM Kevin M. Coghlan, MS, CIH, is the director of EH&S Compliance and Strategic Support for Environmental Health & Engineering, Inc./EH&E, Newton, MA and is responsible for oversight of the EH&S programs managed by EH&E at client facilities. www.eheinc.com.