ESTABLISHING
THE RIGHT MEDICAL PROGRAM FOR YOUR WORKSITE:
THE
OCCUPATIONAL HEALTH DELIVERY SYSTEM
INTRODUCTION
Are
you remembering the "health" in your occupational
safety and health program? The Occupational
Safety and Health Act of 1970 aims "to
assure so far as possible every working
man and woman in the Nation safe and healthful
working conditions . . ." Toward this
end, OSHA's Safety and Health Program
Management Guidelines strongly urge the
identification and control of health hazards
and the implementation of a medical program.
A
medical program is another name for the
systems that employers put in place to
ensure occupational health expertise within
the overall safety and health program.
Having a medical program does not necessarily
mean that you must go out and hire a doctor
to work at your company. There are many
ways for you to find and use occupational
health expertise. This chapter will help
you decide what will work best for your
business.
We
call the medical program the occupational
health delivery system, or OHDS. This
term will help you remember that a comprehensive
program is more than an after-the-fact
response to work-related injuries and
illnesses. It also includes the activities
that uncover the safety and health hazards
in your business and that help you formulate
a plan for prevention or control. It is
a management system in the same way that
the actions you take to promote safety
are a management system.
You
may find it more difficult to establish
the goals and objectives for your OHDS
than for the other parts of your safety
and health program. The harm it prevents
may not appear obvious at first. For example,
an employee who is experiencing hand pain
and who gradually is developing a cumulative
trauma disorder (CTD) may seem to have
a less serious problem than the employee
who has a severe cut or broken bone from
an accident. But our experience is that
work-related health problems are no less
serious in terms of loss and human suffering
than the more obvious injuries.
An
effective OHDS will help reduce all types
of safety and health hazards and the resulting
injuries and illnesses. The positive results
from such a program will be measurable
by a decrease in lost workdays and workers'
compensation costs. You also can expect
this program to help increase worker productivity
and morale.
WHO
SHOULD MANAGE THE OHDS?
You
will find that the OHDS works best when
managed by occupational health professionals
(OHPs). A physician or a registered nurse
with specialized training, experience
and knowledge in occupational health which
will work with you but not necessarily
as your employee. This arrangement works
best because safety professionals, industrial
hygienists, occupational medicine physicians
and occupational health nurses all have
their own areas of specialized knowledge.
You cannot expect to get all the information
and service your safety and health program
needs from only one type of specialist.
If you tried, you might overlook or mis-identify
a dangerous hazard in your business.
Appendix
10-3 contains a description of the different
ways that physicians and registered nurses
receive specialty training in occupational
medicine and health and the different
services that they can provide you. Chapter
12 contains information about some of
the services you can get from safety professionals
and industrial hygienists.
WHAT
SERVICES DO YOU NEED FROM YOUR OHDS?
There
is no such thing as a standard OHDS. There
is no substitute for examining the special
characteristics of your business and developing
an OHDS that is right for you. These special
characteristics include:
-
The actual processes in which your employees
are engaged;
-
The type of materials handled by your
employees;
-
The type of facilities where your employees
are working;
-
The number of employees at each site
under consideration;
-
The characteristics of your work force,
such as age, gender, ethnic group and
educational level; and
-
The location of each operation and its
distance from health care facilities.
As
you look at the characteristics of your
employees and workplace, you should be asking
yourself questions such as:
-
Are there hazards in the process, materials
or facilities that make it likely that
employees will get sick, hurt or will
suffer abnormal health effects from
their work?
-
Are there so few employees that onsite
occupational health resources are less
practical than off-site contract services?
Are there so many employees that time
and money will be saved by installing
onsite resources?
-
Are there special characteristics of
the workers that make them more vulnerable
to illness or injury or less likely
to understand the safety and health
hazards of the worksite?
You
should be aware that under the Americans
with Disabilities Act (ADA) employers may
require employees to submit to medical examination
only when justified by business necessity.
It is our judgment that a health and safety
concern qualifies as a business necessity.
The results of any medical examination are
subject to certain disclosure and record
retention requirements (see Part 1910.120
of Title 29 of the Code of Federal Regulations),
but also are subject to confidentiality
requirements of the ADA. The ADA's employment-related
provisions are enforced primarily by the
U.S. Equal Employment Opportunity Commission.
-
Is there anything about the workplace
that makes it important to have occupational
health assistance closer or more rapidly
obtainable?
Answering
these questions will put you in a better
position to decide which OHDS services you
need. The services are listed below. Appendix
10-1 includes some examples of how different
companies of varied sizes tailor their OHDS
activities.
THE
RANGE OF OHDS FUNCTIONS
There
are three basic types of OHDS activities:
1.
Prevention of hazards that cause illnesses
and injuries,
2.
Early recognition and treatment of work-related
illness and injury, and
3.
Limiting the severity of work-related
illnesses and injury.
Preventing
Hazards
-
Make sure that your safety and health
policy shows that you are as concerned
about your employees' health as their
safety. (See Chapter 2.)
-
Make sure that qualified OHPs help you
identify the hazards and potential hazards
of your workplace. (See Chapter 7.)
Use OHPs in the development and presentation
of health training and other preventive
activities, including the various measures
required by OSHA's Bloodborne Pathogens
standard. (See Chapter 11 and OSHA Publication
2254, "Training Requirements in OSHA Standards
and Training Guidelines").
Remember
that it is your responsibility to determine
if you have employees who fall within
the scope of the Bloodborne Pathogens
standard and to make arrangements for
compliance for these employees. Staff
nurses, physicians and emergency response
personnel are covered by the standard,
even where no other employees appear at
risk of occupational exposure to infectious
diseases. (For more information on this
standard, see OSHA Publication 3127, "Occupational
Exposure to Bloodborne Pathogens.")
-
Provide professional occupational health
expertise as a resource to your safety
and health committee. (See Chapter 4.)
-
Be sure to include your OHDS in your
annual self-evaluation. (See Chapter
12.)
Early
Recognition and Treatment
-
Use OHPs to help you decide, on the
basis of existing or potential hazards
at your workplace, when you may need
to conduct baseline and periodic testing
of your employees and new hires for
evidence of exposure. This is called
"health surveillance" and is required
by some OSHA standards for specific
types of exposures.
-
Use OHPs to do the testing needed for
health surveillance.
-
Make sure records are kept of employee
visits to first aid stations, nurse's
office, contract clinic or hospital.
Have an OHP review the symptoms reported
and the diagnoses to see if there appear
to be patterns that indicate an occupational
health problem.
-
Provide first aid and CPR assistance
through properly trained employees on
every shift. Make sure that these employees
keep up their certifications and that
they receive adequate training in the
hazards specific to the worksite. The
Occupational Exposure to Bloodborne
Pathogens standard (Part 1910.1030)
outlines specific training requirements
for employees expected to render first
aid at work. It is essential that employees
understand the hazards from bloodborne
communicable diseases and how to protect
themselves.
-
Make sure that the OHPs whom you use
have current credentials, have had recent
occupational health continuing education,
and understand the hazards of your worksite.
These standards will help ensure their
ability to recognize early symptoms
of occupational health problems and
begin prompt and appropriate treatment
to prevent disability.
-
Make sure that standardized procedures
-- called "protocols" in the medical
community -- are used throughout your
occupational health delivery system,
particularly if you are using more than
one contractor for health services.
(For more information, see Appendix
10-5).
-
Have one of the OHPs keep your employee
injury and illness records, whenever
feasible. Make sure your recordkeeping
system effectively ensures the confidentiality
of individual employee medical records.
Limiting
Severity
-
Coordinate the emergency response of
all responsible individuals or departments
at your worksite and of all emergency
organizations off the worksite, such
as the fire department, any contractual
organization or a nearby community hospital.
Everyone needs to know exactly what
to do and what to expect from others.
(See Chapter 8 and OSHA Publication
3088 (revised 1991), "How to Prepare
for Workplace Emergencies.")
-
Maintain contact through your OHP (whether
you are an employee or provided by contract)
with any employee who is off work due
to an occupational illness or injury.
-
Keep in touch with the practitioner
providing treatment and care to ensure
that the treatment is appropriate and
that the employee is responding as expected.
-
Use your registered nurse or physician
to help advise an employee who is off
work for an extended period about workers'
compensation rights and benefits and
ongoing care.
-
Use these OHPs to provide evaluation
aimed at determining whether an employee
can resume full duty after injury or
illness or whether work duties need
to be modified.
-
Consult your physician or registered
nurse for help with the development
of a modified duty position to ensure
that the employee can perform the work
and benefit from feeling productive
again.
-
Develop and deliver health care in accordance
with Federal and state regulations,
for example, OSHA standards, workers'
compensation laws and public health
regulations.
SUMMARY
Your
business' medical program, what we call
its occupational health delivery system,
is an important part of your safety and
health program. It can deliver service
aimed at preventing hazards that can cause
illness and injury, rapidly recognizing
and treating illness and injury, and limiting
their severity.
To
determine which of these services are
appropriate, you need to consider your
business' special characteristics. These
include the type of processes and materials
your employees work with and the resulting
or potential hazards. Other things to
consider are the type of facilities in
which employees work, the number of workers
at each site and the characteristics of
this work force such as age, gender, cultural
background and educational level. The
location of each operation and its nearness
to a health care facility also are important.
Whether
you hire or contract with an occupational
health professional, make sure this person
has specialized training, experience and
up-to-date credentials. Then use that
professional to help you develop and deliver
the services you have chosen.
APPENDIX
10-1
EXAMPLES
OF OCCUPATIONAL HEALTH DELIVERY SYSTEMS
Here
are three examples of OHDSs at large,
medium and small workplaces. The first
is a manufacturing firm with about 1,800
employees divided between two locations.
The second is a meatpacking company employing
about 500. The last example is a small,
independent janitorial service with 35
employees. These examples show that each
company's service needs are individual
and that their methods for providing the
services are best provided by people whom
you hire as your own employees; in other
situations, it may be better to contract
for these services. In our examples, notice
that sometimes employers use community
agencies to supply services. Using community
agencies may save you money.
BACKGROUND
INFORMATION ON THE SAMPLE COMPANIES
Company
One. One thousand of the workers employed
by the larger manufacturing company are
at one site, where the components of their
major product are manufactured. A second
site, five miles away, has 500 employees
and includes a line where the components
are assembled. Also in that building are
the facility's maintenance department
and a garage where the company trucks
other vehicles are parked and serviced.
At that same site, but in a different
building, are the executive offices that
house all the administrative divisions,
such as accounting, human resources, marketing
and a small showroom.
The
manufacturing site is 17 miles from the
nearest medical facility. The light assembly
and administrative site is 12 miles from
the nearest medical facility. The company
runs two shifts, each eight hours. These
are a day shift and an evening shift.
There are two security personnel working
alone from midnight to 7 a.m.
Company
One employs a safety professional to head
its safety department and an occupational
health nurse practitioner to head its
OHDS. Both departments have other professional
and non-professional staff to support
the department heads. The safety department
and OHDS both have offices at the manufacturing
site.
Company
Two. Company Two, the meatpacking
company that employs 500 workers, has
460 people working in the slaughter department
and the department where carcasses are
dismantled. These divisions operate on
a day shift of 10 hours. In addition,
there are 20 people who perform plant
sanitation and maintenance functions on
an overlapping evening shift. There also
are 20 employees in supervisory positions
and in administrative positions such as
personnel, payroll, and safety and health.
The
plant is seven miles from the nearest
health care facility. The company employs
a full-time occupational health nurse
(registered nurse) and a full-time safety
director.
Company
Three. Company Three, the small, independent
janitorial agency, provides cleaning and
light maintenance services for commercial
buildings. There are 35 employees: the
owner-manager, three clerical support
personnel, an evening supervisor, and
30 service personnel - 20 men and 10 women.
The service personnel report to a central
office from which they are dispatched
in teams of two or three in company vans.
The service personnel all work on evening
shift from 5 p.m. to 1:30 a.m. Two of
the clerical employees work a day shift,
9 a.m. to 5:30 p.m. One clerical employee
works a shift that spans the day and evening
shifts. The supervisor works the same
evening shift as the service personnel.
No
safety, industrial hygiene or occupational
health professionals are employed by this
company.
In
the sections below you will find major
portions of an OHDS and descriptions of
our three sample workplaces' handling
of these tasks.
HAZARD
ANALYSIS
Company
One. The basic work of providing a
comprehensive assessment of hazards (see
Chapter 7) was done by a committee composed
of the safety director of manufacturing,
the supervisor of maintenance and two
line employees, one from day shift and
one from evening shift. In addition, a
consultation was requested from the liability
insurance company's loss control division.
The consultation was conducted by an industrial
hygienist who confirmed the need to monitor
for noise in the manufacturing area. She
also helped the occupational health nurse
practitioner and the human resources director
write job descriptions for the major employee
classifications. The descriptions emphasized
important safety and health considerations
such as the amount of weight lifted and
the chemicals handled.
A
second consultation was obtained from
the department of occupational medicine
at the nearby university. The occupational
medicine physician suggested a design
for an optional health surveillance program
for cumulative trauma disorders (CTDs)
in the shoulders, arms and hands of the
employees in light assembly. The program
is designed to use personnel and other
resources already available at the company.
Company
Two. The meatpacking company's safety
and health committee consisted of the
safety director, the occupational health
nurse, a supervisor and four hourly employees,
one each from the slaughter, fabrication,
sanitation and maintenance departments.
This group's hazard assessment included
basic safety and industrial hygiene evaluations
as well as a complete ergonomic review
following the "OSHA Ergonomic Program
Management Guidelines For Meatpacking
Plants." Their assessment included a check
for potential exposures to communicable
diseases from the slaughtered animals.
The committee developed a list of questions
about safety and health conditions and
potential hazards in the plant. To answer
these questions the committee performed
a series of walk-throughs and employee
interviews.
In
addition, the safety director and the
occupational health nurse analyzed the
actual jobs being performed by line employees
for potential ergonomic problems. OSHA's
ergonomic guidelines helped them identify
those positions that involve the specific
activities associated with the development
of CTDs. Furthermore, they reviewed all
of the material safety data sheets (MSDSs)
for all the chemicals used for cooling
and sanitation at the plant.
Company
Three. At company three the owner-manager
of the janitorial service was aware, from
reading the newspaper, that OSHA was enforcing
protective measures for workers exposed
to ergonomic hazards. She contacted the
OSHA-funded, state-run consultation service
and received information about the criteria
that were being used for enforcement.
This information guided her in organizing
a management system that would meet the
enforcement requirements. At the owner's
request, consultation personnel examined
this system and other aspects of the company's
safety and health program, including the
hazards to which employees were exposed.
They helped develop protection against
the hazards found and recommended a CTD
training program with an emphasis on back
injuries. They also recommended a driver
safety program.
EMPLOYEE
TRAINING
Company
One. The safety director and the occupational
health nurse practitioner designed training
programs to be delivered during employee
orientation. The programs inform the employees
about the company's safety and health
policies and program and alert them to
the specific hazards in their jobs and
what they need to do to protect themselves.
The training is conducted by safety department
and OHDS staff members who have been prepared
by taking special train-the-trainer courses.
Employees are invited to contact the safety
director, the occupational health nurse
practitioner or their supervisors if they
have further questions. The training includes
a short test at the end to demonstrate
that the employees understand their specific
risks and how to protect themselves. There
is a regular schedule for follow-up training.
Because
the plants of Company One are more than
10 minutes away from the nearest medical
facility, the decision was made to establish
emergency response teams in both locations
and on both shifts. The teams are set
up on a volunteer basis and consist of
five employees per shift per location
plus all the security personnel. The company
contracts with the American Red Cross
to provide training and refresher classes
in first aid and cardiopulmonary resuscitation
(CPR) at the workplace.
Because
the emergency response team members in
the course of their duties could be exposed
to infectious diseases such as hepatitis
B and AIDS, they are covered by OSHA's
Bloodborne Pathogens standards. Consequently,
in addition to the training required by
the standards, they also have been offered
the hepatitis B vaccine, personal protective
equipment to protect them against exposure
has been selected and distributed to them
by the occupational health nurse practitioner.
Company
Two. Management decided to conduct
the employee training program using their
own company personnel. The safety director
designed the training program to address
hazards such as fire, walking surfaces,
cuts, elevations and ammonia leaks. The
occupational health nurse designed training
that promotes hygienic practices to reduce
the possibility of exposure to biologic
hazards such as brucellosis, anthrax and
Q fever associated with animal handling.
In many respects the activities performed
by the workers to protect the meat from
contamination, as required by the U.S.
Department of Agriculture, also protect
them. Where this is not the case, the
program is designed to emphasize what
employees need to know and do to protect
themselves. The nurse also developed material
that informs the employees about the early
signs and symptoms of CTDs and ways to
help prevent them.
The
occupational health nurse and the safety
director at the meat packing company together
instruct the employees about the chemical
and temperature hazards associated with
the industry. Additional classes are held
for the clerical, sanitation and maintenance
workers. Supervisors also are trained
to recognize the early symptoms of ergonomic
problems so they can encourage workers
to report these problems as readily as
other injuries or illnesses.
Five
volunteers from each plant area or unit
and all the supervisors from each shift
make up the company's emergency response
team. A commitment of one year is expected
of members of the team. These employees
are covered by OSHA's Bloodborne Pathogens
standards. They all were given first aid
training that include instruction and
practice in how to protect themselves
from exposure to bloodborne pathogens
such as the hepatitis B and AIDS viruses.
Retraining occurs for all team members
at the anniversary date, when new members
are added.
Company
Three. At company three the state
OSHA consultation office suggested contracting
with a nearby occupational health clinic,
already providing work-related employee
health services, to conduct training in
the prevention of CTDs with an emphasis
on back safety. In addition, the employees
are informed about the contents of the
cleaning solutions they are using along
with proper mixing techniques and the
use of gloves and protective eye glasses.
The MSDSs, which list toxic ingredients,
are explained, and employees are told
where these documents are kept.
The
initial class was provided at the janitorial
service company's central office. Since
then new employees are instructed at the
clinic as part of their pre-placement
physical examination and orientation.
Finally, the owner received booklets promoting
safe defensive driving and the use of
seat belts from the Automotive Occupant
Restraint Council. These booklets were
distributed to all current employees and
are included in the orientation materials
for all new employees. The employer plans
to develop and distribute to all employees
a brief self-test based on the booklet.
The
employer encourages the service personnel
to take a beginning first aid course offered
through a local municipal adult education
program by granting paid time for the
class. The evening supervisor was required
to take the beginning and advanced first
aid course. Each van is supplied with
a first aid kit, as is the office. The
service employees are instructed to report
all injuries and illnesses to the supervisor
at the end of their shift or sooner by
phone if they think that the problem requires
the employee to go to a nearby emergency
room or contract occupational health clinic.
HEALTH
SURVEILLANCE
Company
One. Machines in two departments were
extremely noisy. The safety director designed,
and the maintenance department constructed,
double layered sheet rock walls with sound
reducing baffles between them around the
two machines. Then the company contracted
with an industrial hygienist to perform
an environmental sound survey. This survey
showed that, even after construction of
the sound baffles, the noise level in
one of the departments was still too high.
The company also contracted with a nearby
audiologist to perform baseline pure tone
hearing tests on all current employees.
New employees for the department designated
as too noisy are tested as part of their
orientation. The required annual audiometric
testing is done by this same audiologist.
The occupational health nurse practitioner
conducts the education program about hearing
conservation. She also did the research
necessary in order to purchase the best
hearing protectors for the employees.
Company
Two. They consulted with the occupational
medicine physician to develop a CTD surveillance
program. As one result, the physician
made the portion of the pre-placement
physical examination that dealt with the
upper extremities and the back more detailed
for the workers in the slaughter department
and the division where carcasses are dismantled.
At the six-month and one-year anniversary
dates randomly selected employees are
invited back to be reexamined. Examination
results that indicate early development
of CTD are reported to the employees,
and management is informed about which
positions need further evaluation. However,
no personal information that identifies
particular employees is released to management.
Company
Three. Company Three had no need of
health surveillance.
ANALYSIS
OF EMPLOYEE USE OF THE OHDS.
Company
One. A clerk in the OHDS office is
assigned to enter information about each
employee visit onto a spread sheet that
includes the date, the time of day, the
employee's department, the employee's
complaint and the treatment rendered.
Totals from the graph are examined by
the occupational health nurse practitioner
every month. Any unusual clusters of complaints
are investigated by the safety committee.
Company
Two. At company two the occupational
health nurse maintains a spread sheet
of all employee visits to the health office.
She combines this information with that
received from the contract occupational
medicine physician to form a report that
is presented to the safety and health
committee each month. This report and
the accident reports become the basis
for special safety and health emphasis
programs within the company.
Company
Three. For company three the contract
occupational health clinic sends a monthly
statement to the employer that summarizes
all bills that have been submitted to
the company's workers' compensation insurance
carrier. This summary includes both diagnostic
and treatment information. The employer
analyzes this information for trends in
injuries and illnesses as one way of determining
if employees are being exposed to identified
hazards, if hazards exist that have not
been identified or if employees need more
training about hazards.
ESTABLISHING
STANDARD PROCEDURES
Company
One. The occupational health nurse
wrote procedures for the "first aiders"
to use when administering first aid, CPR
and emergency transfer of ill or injured
workers. She also wrote procedures that
describe the standardized assessment and
onsite treatment that she uses for employee
illnesses or injuries and for all health
surveillance programs.
Company
Two. At company two the occupational
health nurse and the contract occupational
medicine physician worked together to
write procedures for all the treatment
given in the OHDS office, including the
dispensing of over-the-counter medications.
They also wrote procedures for hygienic
practices for the employees exposed to
biologic hazards. These procedures were
intended to ensure that employees do not
consume food, beverages and tobacco products
with contaminated hands, and that they
do not accidentally contaminate their
street clothes or shoes before leaving
the plant. The safety director and the
occupational health nurse developed procedures
for ensuring that the employees of contractors
performing pest eradication operations
do not accidentally expose employees to
pesticides. Finally, this same team developed
procedures that included proper work techniques
and frequent knife sharpening to prevent
ergonomic problems.
Company
Three. For company three the state
OSHA consultation staff worked with the
owner to develop standardized procedures
for first aid and emergency situations.
They also wrote specific procedures for
mixing and using all the cleaning solutions
using the buddy system for lifting heavy
objects and rotating tasks involving lengthy
repetitive motions such as vacuuming.
Discussion of the procedures is included
in the new employee orientation.
EARLY
RECOGNITION AND TREATMENT
Company
One. The occupational health nurse
practitioner who heads this department
has graduate level training in assessment
and management of occupational illnesses
and injuries. She is licensed to treat
many of the employees' occupational injuries
and illnesses using previously approved
standard procedures. A referral relationship
has been established by contract with
a local hospital that has an emergency
room and an occupational medicine clinic.
Employees with illnesses or injuries that
are assessed by the nurse practitioner
which are too severe to be treated onsite
are transferred to the emergency room.
Those employees who are receiving treatment
by the nurse practitioner and do not respond
as expected are referred to the occupational
medicine clinic. In this way, a majority
of the company's work-related injuries
and illnesses are treated within the OHDS.
Company
Two. Company two has a policy that
encourages employees to promptly report
symptoms of illness and injuries to the
occupational health nurse. The nurse treats
minor illnesses and injuries in the plant
health office using dressings, ice and
over-the-counter medications. She refers
more sever problems to the contract physician.
This nurse has taken a continuing education
course in the recognition and conservative
treatment of CTDs and is able to implement
early treatment and referral. She also
is able to review preventive measures
with the employees at each visit.
Company
Three. At company three the contract
clinic's medical director has completed
a mini-residency in occupational medicine
and has ample knowledge of the risks to
which this company's workers could be
exposed.
MEDICAL
CASE MANAGEMENT
Company
One. The occupational health nurse
practitioner works with the personnel
manager to develop a case management system
for all employees who are off work with
illnesses or injuries lasting more than
five days. The system consists of a method
for prompt treatment authorization, a
referral list for second opinions, assistance
in filling out insurance forms, communication
with the insurance carrier to ensure timely
benefit payments, and ongoing contact
with the employee and the family.
Company
Two. At company two the occupational
health nurse and the contract occupational
medicine physician maintain close communication
about all employees with work-related
injuries and illnesses that are not responding
to treatment as expected. The occupational
health nurse ensures that specialist referrals
occur promptly. The nurse practitioner
also works closely with the supervisors,
proposes modified duty positions and clears
these work proposals with the treating
physician. This facilitates employees'
returning to work as soon as possible.
Company
Three. At company three the owner functions
as the human resources director as well
as the manager. As such, she is in close
contact with any employee who experiences
lost worktime related to industrial injury
or illness. She does not, however, have
access to her employees' individual medical
records, which are maintained confidentially
at the contract occupational health clinic.
She considers this adequate case management.
Her workers' compensation insurance carrier
assists her by providing information about
helping injured and ill workers return
to work quickly. The suggestions have
prompted her to increase the frequency
with which she makes telephone contact
with these employees.
COORDINATION
FOR EMERGENCY SERVICES
Company
One. The safety director, the occupational
health nurse practitioner and the head
of the security department worked together
to develop a system whereby all employees
in each department know their exact responsibilities
in the event of an emergency. They also
discussed their plan with the local fire
department that will be responding to
emergency calls.
Company
Two. At company two the occupational
health nurse practitioner and the safety
director head the team and respond to
each emergency. The plant receptionist
is responsible for contacting outside
emergency organizations and is included
in the emergency response team meetings.
Company
Three. At company three because employees
move from one workplace to another instead
of having a fixed worksite, no special
arrangements were made with emergency
organizations. The company, however, did
make its own emergency preparations (discussed
under "Employee Training.")
RECORDKEEPING
Company
One. The OSHA 200 Log, the MSDSs and
the results from the noise surveillance
are maintained in the OHDS office, where
the occupational health nurse practitioner
can answer employee questions. All employee
visits to the OHDS office are documented
in the individual employee medical record.
Company
Two. At company two the OSHA 200 Log,
the MSDSs and the results from the CTD
surveillance are kept in the OHDS office,
where the occupational health nurse can
answer employee questions. All employee
visits to the OHDS office are documented
in the individual employee medical record.
Company
Three. At company three the OSHA 200
Log and the MSDSs are maintained by the
owner and are available for the employees
to see upon request. Individual employee
medical records are kept at the contract
occupational health clinic and remain
confidential.
For
more detailed information about recordkeeping,
see Appendix 10-2.
SUMMARY
The
examples demonstrate how three different
employers provide OHDS services using
a combination of in-house resources, sub-contractors
and government agencies. Some of the sub-contractors
bring their services to the premises,
while in other situations the employees
travel to the contractor. In each case
the employer has selected services based
on the special characteristics of the
business process, the potential exposures
within that process, the business location
and the employee population.
Each
OHDS includes activities aimed at the
prevention of exposures, the early recognition
and treatment of work-related illnesses
and injuries, and a reduction in the severity
of and potential for disability from work-related
illness and injury.
APPENDIX
10-2
RECORDKEEPING
OSHA
requires that certain records be kept.
Employee visits to the health office or
to an off-site clinic or health care professional's
office will generate additional records.
Maintaining your records using the resources
of your OHDS is a good idea. The occupational
health professionals connected with your
OHDS have the training to answer your
employees' questions about these records
and to decide whether their complaints
are work-related.
What
follows is a description of the health-related
records that you should have in your business.
It is meant to give you enough information
to decide if you want to manage these
records within your OHDS. You need to
consult the standards or the other references
for more details. The Code of Federal
Regulations (CFR) numbers or publication
titles have been included for your convenience.
For further assistance, contact the OSHA-funded,
state-operated consultation service.
OSHA-200
LOG
OSHA
requires that you keep track of all the
work-related injuries and illnesses that
occur at your worksites. OSHA Form 200,
often called the OSHA-200 Log, is used
for this purpose. Another form, the "Supplementary
Record of Occupational Injuries and Illnesses"
(OSHA Form 101), or its equivalent, also
must be kept. Employers often use the
"First Report of Injury," required by
the workers' compensation system, as this
supplementary record.
THE
OSHA RECORDKEEPING STANDARD, 29 CFR 1904
This
standard also tells how long you must
keep the records and how you are to inform
your employees about the injuries and
illnesses occurring in your company. For
more information, see this standard and
the Bureau of Labor Statistics' 1986 guidelines
entitled "A Brief Guide to Recordkeeping
Requirements for Occupational Injuries
and Illness," or the more comprehensive
"Recordkeeping Guidelines For Occupational
Injuries and Illnesses" (both published
as OMB 1220-0029).
ENVIRONMENTAL
AND EMPLOYEE HEALTH MONITORING RECORDS
When
you do any type of environmental monitoring,
such as air sampling, OSHA requires that
you keep the results. If you test employees
for exposure to hazards you must keep
this information also. The publication
"Access To Employee Exposure and Medical
Records," 29 CFR 1910.20, tells you that
employees and their representatives must
be allowed to see and copy the records,
and indicates how long the records must
be kept.
RECORDS
REQUIRED FOR SPECIFIC HAZARDS
OSHA
has issued a number of standards specifying
things that you must do when your business
involves certain hazards. Often this includes
testing employees and the workplace for
signs of the hazard. When this is the
case, the standard also tells how long
you must keep the results of the tests.
Three examples of this type of standard
are the bloodborne pathogens standard,
29 CFR 1910.1030, the asbestos standard,
29 CFR 1910.1001(m), and the occupational
noise exposure standard, 29 CFR 1910.95.
HAZARD
COMMUNICATION
The
Hazard Communication Standard addresses
more than recordkeeping. It tells you
how you must communicate to your employees
and your community about the chemicals
you use or make in your business. Because
the standard requires that you keep certain
documents and communicate certain information,
we will discuss it here.
The
standard says, among other things, that
you must keep a list of all hazardous
chemicals present at your worksites. You
must have labels and signs to warn people
about these chemicals. You must have material
safety data sheets (MSDSs) for all hazardous
chemicals. MSDSs provide information from
the manufacturer about the ingredients
and health effects of a chemical. In addition,
employees must be trained about the chemicals
to which they are exposed. The training
must include information about what you
are doing to protect employees and what
they need to do to protect themselves.
(See 29 CFR 1910.1200.)
INDIVIDUAL
EMPLOYEE HEALTH RECORDS
Employee
visits to the health office will generate
records that should be kept in order to
document what treatment is being provided
and how the employee is responding. This
data also can be analyzed by an occupational
health professional seeking to uncover
unrecognized hazards.
An
important reminder: The confidentiality
of individual employee health information
is a fundamental concept of good occupational
health practice. Moreover, your employees'
legal rights to privacy extend to information
that may be contained in their workplace
health records. Therefore, access to these
records should be controlled by health
professionals who understand the requirements
of confidentiality and the circumstances
under which disclosure may be made. It
is not proper for an employer to review
individual employee health records. Should
an employer wish to examine health information,
for example, in order to spot injury or
illness trends, this review must be limited
to anonymous aggregate data. Such data
can be compiled by the health professional
who controls the individual employee records
or by another person who is properly authorized
to examine the records.
APPENDIX
10-3
QUALIFICATIONS
OF OHDS PERSONNEL
Once
you have decided which safety and health
services you want to provide through your
OHDS you need to decide who will provide
the services. There are several factors
to consider:
-
Your OHDS must be organized so that
the personnel providing the services
are not working alone when state law
requires that they be supervised by
a registered nurse or physician.
-
The occupational health professionals
you use must have specialized, up-to-date
training or experience in the methods
of occupational health care.
-
You must choose whether to hire OHDS
personnel as your own employees or whether
to contract outside your company for
their services.
OCCUPATIONAL
HEALTH PROFESSIONALS
Occupational
health professionals are medical doctors
(MD), doctors of osteopathy (DO), and
registered nurses (RN). They hold a license
to practice their professions, and they
are entitled to practice independently
under this license, using the standard
procedures described in Appendix 10-5.
Occupational
Medicine Specialists. Occupational
medicine specialists are medical doctors
(MD) or doctors of osteopathy (DO) who
have additional training or experience
in the treatment of work-related illnesses
and injuries. This training or experience
can be acquired in different ways:
-
A number of universities offer residency
programs that enable MDs and DOs to
become board certified in occupational
medicine through the American Board
of Preventative Medicine.
-
Professionals graduating from schools
of medicine or osteopathy before January
1, 1984, may qualify for board certification
by the "alternative pathway." This involves
a combination of education and practical
experience in the field of occupational
medicine.
-
Shorter programs, called mini-residencies,
offer academic training in occupational
medicine.
-
MDs and DOs can obtain advanced education
in occupational medicine by taking continuing
education courses.
-
There are MDs and DOs working in occupational
medicine who have gained advanced knowledge
through experience working in the field
for extended periods.
A
qualified occupational medicine specialist
should be capable of performing or managing
all the OHDS activities described in Appendix
10-1.
Occupational
Health Nurses. Occupational health
nurses are registered nurses (RN) who
have received specialized training in
occupational health. Like physicians with
specialties in occupational medicine,
occupational health nurses may gain this
training through formal college programs,
continuing education or experience working
in the field. A registered nursing license
allows nurses to perform many health evaluation
and care functions independently. An occupational
health nurse should be capable of performing
or managing most of the OHDS activities
described in Appendix 10-1.
Nurse
Practitioners. Nurse Practitioners
are registered nurses who have completed
formal advanced training in physical assessment
and the management of minor, stable illnesses
and injuries. In most states, they are
licensed or certified for advanced practice
by state licensing boards. Nurse Practitioners
perform many health evaluation and care
activities independently. They perform
physical exams; diagnose health problems
using laboratory tests, x-rays or other
tests; and treat employees who are ill
or injured. In most states, Nurse Practitioners
perform any other activities using written
protocols developed collaboratively with
a physician. Nurse practitioners can take
additional training and specialize in
the treatment of occupational illnesses
and injuries. When working with standard
procedures, nurse practitioners should
be capable of performing all the OHDS
program activities described in Appendix
10-1.
SUPPORT
PERSONNEL
Support
personnel can provide more limited services.
They have received specific training and
usually are certified or licensed by the
educational institution where they received
the training. Sometimes licensing or certification
is granted by the state. The scope of
practice for support personnel requires
that they work under the supervision of
licensed health professionals except when
delivering first aid. Licensed vocational
nurses (LVNs), licensed practical nurses
(LPNs), emergency response personnel (sometimes
called emergency medical technicians or
EMTs), and first aid personnel are in
this category.
Licensed
Vocational and Licensed Practical Nurses.
LVNs and LPNs are licensed by state
agencies to perform certain health care
activities. These include taking blood
pressures and applying dressings. These
persons must practice under the supervision
of a physician or a registered nurse.
First
Aid and Emergency Response Personnel.
"First aiders" perform the function
of first response. They provide temporary
treatment until care of the ill or injured
person can be transferred to someone with
more advanced training. This includes
performing treatments such as splinting
and applying ice or pressure dressings,
and also transporting the ill or injured.
A person does not need a background of
formal health care education to be trained
in first aid and cardiopulmonary resuscitation
(CPR). A certification in first aid usually
is granted by training providers such
as the American Red Cross after the student
completes a standard curriculum and demonstrates
competence. When employers assign first
aid responsibilities to their employees,
proper training, certification and regular
updating of the instruction are important:
even first aid techniques can be harmful
when done incorrectly.
CPR
sometimes is included in first aid courses,
but a separate class may have to be taken.
CPR is the act of providing temporary,
life-sustaining artificial circulation
and respiration when these functions have
stopped. It is performed before and during
the stricken person's transfer to a medical
facility. As with first aid, persons completing
CPR training are certified by the organization
offering the training. CPR performed incorrectly
can injure the person receiving it. When
employers use employees as "first aiders"
and expect them to perform CPR, the employees
must be thoroughly trained, and this training
must be updated at least annually.
WARNING:
It is possible for persons rendering first
aid or CPR to be exposed to the viruses
that cause hepatitis B and AIDS. This
is because the "first aider" can come
in contact with body fluids, such as blood,
that might contain these viruses. Because
of this potential for exposure, all employees
with first aid or CPR duties are covered
by the full scope of OSHA's Bloodborne
Pathogens standard, 29 CFR 1910.1030.
The standard requires that an employer
train these employees in how to protect
themselves from potentially infectious
body fluids. It also requires that the
employer provide personal protective equipment,
offer the hepatitis B vaccine, provide
medical follow-up or any occupational
exposure, and meet other requirements.
Emergency
response personnel, sometimes called emergency
medical technicians (EMTs), have received
advanced training in first aid, CPR and
other life support techniques. With certain
restrictions, they can perform sophisticated
emergency procedures and transport ill
and/or injured people.
The
OHDS should retain records of the original
training, licenses, update courses and
certification of all employees participating
in the delivery of occupational health
services, including first aid, CPR and/or
emergency response activities. The Bloodborne
Pathogens standard requires that all training
records be kept for 3 years and that the
records contain training dates, the content
or a summary of the training, names and
qualifications of trainers, and names
and job titles of trainees.
Like
other employees with first aid responsibilities,
EMTs are covered by the full scope of
OSHA's Bloodborne Pathogens standard.
APPENDIX
10-4
EVALUATING
THE QUALIFICATIONS OF HEALTH CARE PROFESSIONALS
Whether
you choose to employ professional health
care personnel or to contract with outside
vendors it is important to evaluate their
qualifications. Remember that occupational
health professionals are people selling
a service. You should use the same smart
consumer skills with physicians and registered
nurses that you apply to anyone who is
trying to sell you something.
Here
are some questions to ask prospective
professional health care providers:
- What
type of training has the health care
provider had?
-
Physicians:
