Campus and Clinical Management Plan

Policy #: 2.00.000
Revision Date: 12/19/2015

1. Purpose and Scope

The purpose of this document is to describe the scope of the Campus & Clinical Division (CCD) of Environmental Health and Safety (EHS) and to its roles and responsibilities. The CCD provides services to Boston University (BU) and Boston Medical Center (BMC) and the Charles River and Medical Campuses to promote safety and maintain compliance with safety regulations. CCD works closely with other divisions of EHS and BU and BMC departments.

2. Definitions

  • ACES Plan: Formally used at Boston University this procedure describes the steps employees and staff will implement upon discovery of smoke or fire no matter how small. The ACES fire plan: alert, confine, evacuate and special assistance. The RACE plan replaces ACES however; some placards may still exist on campus.
  • Authorities Having Jurisdiction (AHJ): Those regulators, generally local authorities, that have jurisdiction in enforcing and interpreting regulations and standards.
  • Boston University (BU): the Charles River Campus (CRC) and Medical Campus (MED).
  • CCD: Campus & Clinical Division of Environmental Health and Safety (EHS): At BU, EHS reports to the Executive Director, Research Compliance (ORC). At BMC, EHS reports to the Senior Director, Facilities and Support Services.
  • Campus Incident Tracking System (CITS): This incident tracking system is a reporting system used by EHS to describe and track incidents and to identify corrective actions and root causes. CITS is accessible through the EHS website. Information about individual incidents is distributed via email through the system.
  • Continuity of Operations Plan (COOP): This plan provides details on the physical space that will be utilized in the event of an emergency in which current office space is rendered inaccessible or otherwise unusable.
  • Environment of Care (EC): A chapter within The Joint Commission (TJC) standards that addresses the work environment and safety and health practices and expectations. EHS is responsible for the administration of EC programs at BMC, as determined necessary or appropriate.
  • Environmental Protection Agency (EPA): The branch of the federal government tasked with protection of the environment. The EPA promulgates and enforces environmental regulations on a national level.
  • Hazard Communication: The communication of known hazards to employees who may be associated with them. Hazard Communication affords all employees the “right to know” about the hazards they may work with or around.
  • HAZWOPER: Hazardous waste operations and emergency response standards as defined by OSHA. Specifically, 29 CFR (Code of Federal Regulations) 1910.120.
  • Higher Education Opportunity Act: A federal law requiring the reporting of fire-related incidents, alarms, systems, and drills.
  • Industrial Hygiene (IH): Industrial hygiene is the art and science dedicated to the anticipation, recognition, evaluation, communication, and control of environmental stressors in, or arising from, the workplace that may result in injury, illness, impairment, or otherwise adversely affect the wellbeing of workers and members of the community.
  • The Joint Commission (TJC): An independent non-profit organization that accredits and certifies more than 17,000 health care organizations and programs in the United States. TJC accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
  • Massachusetts Department of Environmental Protection (DEP): The branch of the state government tasked with protection of the environment. The DEP promulgates and enforces environmental regulations on a state level. DEP regulations must be at least as strict as the national EPA regulations. In many circumstances—including in regards to hazardous waste, water emissions, air emissions, and underground storage tanks—DEP regulations overlap with and even exceed EPA regulations.
  • Massachusetts Division of Occupational Safety: The branch of the state government that promulgates and enforces worker safety regulations.
  • Occupational Safety and Health Administration (OSHA): The branch of the federal government tasked with the protection of US workers. The OSHA promulgates and enforces safety and health regulations on a national level.
  • RACE Plan: Used at the Boston University and Boston Medical Center, this procedure describes the steps employees and staff will implement upon discovery of smoke or fire no matter how small, the RACE fire plan incorporates the following: rescue, alert, confine, and extinguish.
  • Safety Information Management System (SIMS): is a web-based system used within EHS that is used to track inspection activities. It is mostly used to support inspection programs at BMC though can be used at BU as well. There are also modules for tracking training though those records are now maintained in RIMS.
  • USP 797 Environmental Assessments: A procedure used by EHS staff that describes the required environmental monitoring performed in support of the U.S. Pharmacopeia’s (USP) Revised General Chapter <797> Pharmaceutical Compounding—Sterile Preparations.

3. References

The CCD is responsible for ensuring BU and BMC compliance with a number of regulations, standards, and best practices, including but not limited:

3.1. Regulations

3.1.1. Federal Regulations
  • Occupational Safety and Health Administration (OSHA)
  • Environmental Protection Agency (EPA)
  • Higher Education Opportunity Act
3.1.2. State Regulations
  • Code of Massachusetts Regulations (CMR) State Building Code
  • Department of Public Health
  • Massachusetts Division of Occupational Safety
  • Department of Environmental Protection (DEP)
3.1.3. Local Regulations
  • Boston Fire Code
  • Brookline Fire Department
  • Boston Public Health Commission (BPHC)
3.1.4. Guidelines and Standards
  • The Joint Commission (TJC)
  • National Fire Protection Association (NFPA)
  • American National Standards Institute (ANSI)
  • U.S. Pharmacopeia’s (USP) Revised General Chapter <797>

3.2. Supplementary Documents

CCD maintains a comprehensive health and safety manual that includes policies, programs, SOPs, and guidance documents.

4. Roles and Responsibilities

Campus & Clinical Division (CCD) is responsible for developing, implementing, monitoring, and improving programs, including:

  • Health and Safety:
    • Accident investigation
    • Job hazard analysis
    • Blood borne pathogens
    • EHS On-Call program
    • Ergonomics
    • Exposure monitoring
    • Anesthetic gas monitoring
    • USP 797 Environmental Assessment
  • Fire Safety:
    • Fire prevention and response
    • RACE fire plans
    • Fire drill and critique plans
  • Worker Safety and Equipment Programs:
    • Confined space
    • Control of hazardous energy (Lock-Out Tag-Out)
    • Emergency eyewash and safety showers
    • Fall protection
    • Fork lift and industrial truck safety
    • Fume hood management
    • Hazard communication
    • Hearing conservation
    • Personnel protective equipment (PPE)
    • Respiratory protection program (e.g. fit testing)
    • Roadside worker safety
  • Construction Safety Programs:
    • Preconstruction Risk Assessment
    • Interim Life Safety Management Plan (BMC-specific)
    • Infection Control Risk Assessment (BMC-specific)
    • Asbestos management
    • Lead management
  • Hospital Safety and Environment of Care Programs: Many of the programs listed in this document apply to BMC. Programs specific to BMC include the Interim Life Safety Management Plan and the Infection Control Risk Assessment program. Other policies and procedures are vetted and approved through BMC’s Policies and Procedures Committee and are posted on the BMC Intranet in section 6 of the Policies and Procedures Manual.
  • Regulatory Relationships: CCD serves as a liaison between regulators and the university. Some of the regulators include:
    • OSHA
    • Massachusetts Division of Occupational Safety (on issues relating to asbestos, safety, etc.)
    • Massachusetts Department of Public Safety (DOS) (e.g., building permits, egress inspections, etc.)
    • Department of Environmental Protection (asbestos and lead programs)
    • City of Boston Inspectional Services Division (ISD)
  • Obtaining egress inspections as required through the Boston Fire Department (BFD), ISD, and DOS.
  • Inspecting facilities, generating corrective actions, and working with responsible departments to ensure that items are corrected.
  • Responding to incidents, including site management, communication, and remediation.
  • Providing training as appropriate and as required by the programs listed above.

Facilities Management & Planning (FMP) and Facilities Support Services (FSS):

  • Allotting time for staff to attend all required safety training programs.
  • Allowing access to fire safety systems maintenance and testing records and other fire safety-related maintenance items for EHS review.
  • Responding to incidents involving environmental health and safety issues.
  • Ensuring that workers and staff carry out their job functions in accordance with EHS policies.
  • Identifying project managers, as necessary, to assist in the smooth integration of safety measures required by the plans, policies, and agencies listed above.

Office of General Counsel:

  • Providing advice and legal counsel on incidents or complaints to regulatory authorities.
  • Negotiating, as necessary, with regulatory authorities if enforcement actions are taken against BU/BMC.

Academic and other University Departments:

  • Immediately reporting unsafe conditions to EHS.
  • Participating in fire drills and other exercises when requested or required.
  • Correcting deficiencies in a timely manner.

5. Special Requirements

The special requirements are as follows:

5.1. Equipment and Supplies

CCD maintains industrial hygiene (IH) equipment to monitor the environment that it serves, and also keeps up-to-date IH equipment lists. These lists identify each piece of equipment, its intended purpose, calibration and maintenance requirements, and estimated annual maintenance cost.

5.2. Safety

Safety requirements are plan-specific and are described in the programs list in Section 4: Roles and Responsibilities, above.

5.3. Training

All CCD staff members are trained to provide a comprehensive response to occupational safety and health concerns. Staff members are required to renew competencies as necessary and to attend local professional development meetings and seminars in order to remain current with changing regulations, standards, and best practices.

CCD staff members also participate in an annual Hazardous Waste Operations and Emergency Response (HAZWOPER) training session to be prepared to respond to incidents involving hazardous materials.

Training records are maintained within CCD and EHS offices.

5.4. Monitoring

Program performance within CCD is evaluated regularly and performance improvement is developed as needed.

IH monitoring is described in each of the IH-related programs. Results of monitoring are forwarded to the appropriate department managers and leadership within the Office of Research Compliance.

CCD also looks for systematic problems by monitoring fire alarm activity and other trending issues in order to identify root causes and take appropriate action.

5.5. Personnel Protective Equipment (PPE)

The CCD staff maintains basic PPE as required for routine tasks. Among the equipment maintained at all times are hard hats, flashlights, respiratory protection, and other emergency response equipment.

5.6. Medical Surveillance

EHS staff members are expected to participate in a rotating on-call schedule to respond to various emergencies on campus, including hazardous materials incidents. To this end, CCD staff also participate in a medical surveillance program through the Research Occupational Health Program (ROHP).

5.7. Other Prerequisites


6. Applicable Locations

All BU and BMC affiliated locations.

7. Procedures and Instructions

In general, the CCD provides guidance, oversight, and training to help a number of departments on both campuses and the hospital carry out their operations. See appendix 1 for more detail on programs CCD is responsible for.

Safety primarily remains the responsibility of each individual. The Campus and Clinical Division Safety Program can only be administered through cooperation between the individuals involved, CCD staff, and the relevant departments at BU and BMC, in order to develop and implement appropriate and effective health and safety programs. Building operation and maintenance, housing, and many other campus activities require input and direction from the CCD in order to ensure compliance with the various health and safety regulations that may apply.

CCD staff will carry out their responsibilities in a professional manner and will continue to promote safety awareness through safety program development and implementation, training of employees and staff, and monitoring of the environment to create and maintain a culture of safety.

8. Forms

Forms and signage exist for a variety of Campus and Clinical Division safety processes. Several attached functional charts further illustrate the disciplines within CCD, including the following:

  • BMC/BU-wide and EOC
  • Fire Safety
  • Worker Safety
  • Industrial Hygiene

CITS reports are generated for incidents and maintained through the EHS website and associated servers.

Forms are used by CCD programs and are defined in the programs listed within this plan. They are vital to the ongoing implementation of the programs.

9. Records Management

CCD maintains records in various forms. These records relate to policies, programs, SOPs, training programs, exposure and ergonomic assessments, and job hazard analysis. Additional reports are also maintained by the department.

CCD provides fit-testing of respirators. Records of fit-testing for BMC are forwarded to Occupational and Environmental Medicine. BU records are maintained in hard copy form in binders and on excel on the departmental drive, “Y Drive”.

Training records of sessions provided by CCD staff are also maintained in the online database. Hard copies of the training rosters are kept for three years.

The BMC Safety Committee minutes and associated records are maintained in both paper and electronic form for three years. Current records and working documents are posted on the committees SharePoint site for member use.

CCD staff members conduct many different types of inspections and assessments throughout BU and BMC. Records of these inspections are maintained in the online database.

SOP Revision History

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Version Section / Paragraph Changed Changes Made Effective Date
V.1 N/A None, Original Version 2.3.10
V.2 See Track Changes 5.27.10
V.3 Throughout Reformatted, made changes to program section 11.28.11
V.4 Throughout Edited 03.01.12
V.5 Throughout Updated based on review of CCD policy manual 10.01.13
V.6 Throughout and section 2 Minor edits. Also added SIMS to definitions. 03.01.14
V.7 Throughout Reformatted. Added detail to procedure section with campus and clinical tasks 12.19.15