A frank discussion of EHS: Services, status, and what lies ahead
October 1, 1998 10 minutes read
A frank discussion of EHS: Services, status, and what lies ahead
Your efforts are critical, but is your department a 'bottom feeder'?
Editor's note: Hospital Employee Health presents another in our series of Roundtable discussions on timely issues of concern to employee health practitioners (EHPs). The format allows you to share your opinions directly and to learn what your colleagues think about important matters affecting your career and practice.
In this time of rapid change in the health care industry and in individual health care institutions across the country, many EHPs are concerned about the status of their employee health service (EHS), whether they will be merged with another department, or even if they might be eliminated entirely. Services provided vary from hospital to hospital, as do ratios of employees to EHPs and to whom the manager reports within the hospital hierarchy. This month's Roundtable will enable you to see how your department and opinions compare.
If you would like to be a future Roundtable participant, please fax your name, facility address, and phone number to the Editor at (770) 664-7103, and indicate the topics that interest you.
HEH: The services employee health departments provide vary among hospitals. What services does your department offer?
Ellen Knott: We do triage for work-related injuries, annual assessments, basic assessment at time of hire, immunizations, blood draws, follow-up on all invasive incidents, and tuberculosis testing. We provide service to a large research contingent at the [Penn State University] College of Medicine so we do rabies, botulinum, and vaccinia inoculations.
Bonie Koch: I do pre-employment and annual assessments, all the surveillance, immunizations, TB testing, bloodborne pathogen exposure follow-ups and counseling, and workers' compensation case management. I see about 7,000 people a year.
Gabor Lantos: EHSs should provide everything from A to Z, from preplacements to medical surveillance, hazard identification and control, case and claims management, right through to rehabilitation and return to work. I believe in providing primary care, not to replace the family doctor but at least to address the presenting complaint, whether it's occupationally related or not. For example, if a person wants a blood pressure check, we should check it and if it's up, we should make the appropriate referral. Of course, it depends on the resources of the department.
Catherine Pearsall: We provide what's absolutely necessary as far as regulations and standards are concerned: immunizations, initial histories and physicals, workers' comp follow-up, some episodic care, TB skin tests, and respirator fit-testing. We also just started a wellness program for our employees. Our first phase is a weight management program, and the second phase will be an exercise program. We're also going to start a smoking cessation program for our employees. This can help with employee morale and decreased medical costs and absenteeism.
Marian Seib: I do medical surveillance, admitting physicals, coordinate everything that is required to meet regulations, coordinate respirator fit-testing with the respiratory therapy department, immunizations, exposure follow-up, workers' compensation, and I chair the wellness committee.
HEH: What do you think is an appropriate ratio of EHPs to employees?
Knott: It depends on the kinds of services you provide. Practitioners who also do workers' compensation assessments and follow-ups need a higher ratio. We don't do that here. We are able to manage with two EHPs, although we could use another part-timer.
Koch: I'm the sole practitioner. I have a relief nurse now when I'm on vacation and have just started using her a few times to help when I'm here. I'd like to have someone 20 hours a week so I could get up on the floors to do a little preventive work and a little more teaching.
Lantos: The number of practitioners is dependent on the hospital's structure, culture, and specific hazards; on its management's commitment, support, and expertise; on expectations regarding risk management, absenteeism, claims management, disability, and rehabilitation; and on work outsourced or done by other departments.
As an absolute minimum, we recommend one occupational health nurse and one safety person for the first 500 employees, and one nurse for every additional 500 employees.
Pearsall: I have an RN who works with me. Ratios depend on the scope of services provided by the department and the type of practitioners in the department. Some places have nurse practitioners; some have RNs and LPNs. Some have medical directors doing physicals while RNs run the rest. Some have volunteers helping file and answer phones. Computerization is also very important. It's hard to state an ideal ratio unless you put in all those other pieces.
Seib: I basically run [the EHS] myself, but I've trained three other nurses to help with health assessments. They help me do physicals when I'm not here. The ideal ratio used to be 1 to 750, but that was before all the increased regulations.
HEH: Under what hospital department or division is your EHS placed? Do you think it's the most appropriate place in the hospital hierarchy?
Knott: We've just been rerouted to the department of medicine. Previously we were under the department of nursing, but that department has been eliminated and all of the nurses put in their specialty area. We have a very strong supervisor who is very interested in employee health and has been very supportive. We also have a medical director who is extremely supportive, and so far we haven't stumbled. The best place for an EHS would be under something called quality services, which would include all the ancillary services such as infection control, safety, risk management, and utilization and review.
Koch: I report to nursing, but I don't think it matters to whom I report because you have to be neutral in this kind of job. You can't be administration, and you can't be staff. I need the cooperation of nursing because they help me read some of my TB tests. I think because I'm one of them, I get a lot of cooperation from them and I need their help.
Lantos: The EHS should be in a prominent location within the organization's structure so as to readily convey the importance of, and management's commitment to, health and safety. There should be a visible, direct link to senior management. The EHS manager should be able to make or directly influence corporate policies. The unit must be seen to be independent; it should not be subordinate to another department. The manager should report to a senior vice president or even directly to the president.
Pearsall: We're under the outpatient department. Our location is removed from the general flow of the hospital, and it offers employees a safe place to come to discuss certain sensitive issues. We're accessible yet private. I answer to the vice president of professional services as far as the organizational chart. I like reporting directly to a high-level administrator. Because I'm a nurse practitioner, I work in collaboration with a medical doctor, so our medical director is the other person I report to.
Seib: I'm under human resources. [EHS placement] needs to be structured according to how the hospital is set up. That's how they justified it a long time ago, and that's how it's been kept. It works very well here.
HEH: How do you think administration views your EHS in terms of status or importance at your facility? Do you experience certain problems and limitations?
Knott: We've just gone through a merger, and we're praying it doesn't affect us. Whenever institutions merge, in order to make it work, [administrators] need more and more control, and they want everybody to walk lock-step. We're one of three widely separated campuses involved in the merger. We all have our own history of how to do things, but it's working for each of us as individuals. We know how to be of the most service to each of our clientele, and we would hate to be made uniform without having any input into the changes that may happen to us. Employee health is a bottom-feeder organization, so often changes get handed down to us and we have no input.
The fact that we're non-revenue-producing in any organization means you have to watch all your pennies and be very sure you do not overspend.
Koch: I feel my bosses don't have a clue what I do or how important it is. They don't realize how much work is involved in managing compensation claims. They don't appreciate the amount of work involved, even for a needlestick. Employees show me a lot of respect and ask my opinion, and that pleases me because I have spent a lot of time getting certified and studying.
Lantos: The biggest problem for EHSs today is lack of understanding by management of the benefit it can provide. Management basically views it as a fringe benefit for employees rather than as a benefit to the employer in terms of helping manage human resources. An EHS can provide very valuable feedback to management from within the organization. It can provide information on where a problem is arising, be it absenteeism, injuries, needlesticks, or infections. That's valuable feedback to management that something is wrong.
Management typically subjugates employee health to some other department and considers it to be a first-aid clinic for the most part. Employee health managers have to take a business approach and demonstrate to administrators, using business terminology, that they can meet the needs and interests of management and not just employees. Generally speaking, that is a failure across the board in EHSs. Either they don't know it needs to be done, or they don't know how.
Pearsall: We're in a wonderful position. We have a lot of employees who look up to us, yet we have our foot in the door with administration so they can help us bridge the gap between work-related issues and being an advocate for employees.
Seib: We are in a pretty good financial climate here, and our hospital is doing extremely well. There's no question of somebody encroaching on my job, as long as I do a good job. I have high visibility here. I've never felt like I needed to apologize for employee health. [I've been told that] I brought it from the horse-and-buggy days to the jet days. My biggest limitation is time - time to get everything done.
HEH: How important do you think it is for hospitals today to provide and maintain an in-house EHS, in the face of widespread cost-cutting and other changes in the health care industry? What is the future for the EHS?
Knott: Unless you receive administrative support and unless you can come up with some creative methods for proving your worth, you have limited capability for providing a full range of services; therefore, I think there's the distinct possibility of becoming an OSHA-checker. Your function will become keeping your institution clean with OSHA.
So far our institution has kept us autonomous, and we've been allowed to stand on our own, which is a very enviable position. We've picked up all sorts of duties, such as managing mask fit-testing for the entire hospital, to keep ourselves freestanding. You have to be politically aware to keep yourself autonomous, but most of us are not powerful enough to control our own destinies.
Koch: Right now it's critical [to have an EHS], especially when you have a staffing crunch. Employees have to work a lot of overtime, and there are increases in back injuries and needlesticks because employees are tired. We are employee advocates in identifying health conditions such as high blood pressure or diabetes during annual assessments and can go to managers to intervene for employees who are having problems on the job.
I don't worry about job security, but in this day and age I don't know. It doesn't help to whine about how much you have to do, but I constantly try to let physicians and administrators know what I do because they say we're not a money-making department. We may not make money, but do they realize what it would cost if they had to contract out these services? And a JCAHO or OSHA fine could cost thousands of dollars.
Lantos: Employee health has to be an independent department. I don't have a problem with employee health and safety being together, as long as it's not subsumed by some big loss control department. It can work with infection control but not under infection control.
An in-house EHS has intimate knowledge of specific work environments and organizational climates, so it can address strategic, economic, and psychological dynamics and exigencies of the workplace. It can reduce the frequency and severity of illnesses and injuries and their associated direct and indirect costs. A hands-on, continuous, on-site EHS works together with labor and management to address the mutuality of their respective interests to provide cost-effective programs with a win-win strategy.
Pearsall: It's absolutely vital to have [an EHS] for employees' morale, health promotion, and satisfaction. It's also cost-effective to provide health care services within a facility.
Seib: EHSs are extremely important. I always tell new people at employee orientations that we are blessed that the hospital funds us and that they have this place to come to be protected. There's no other place for employees to go; we really function as an employee advocate, so it's vital.
I have to justify what I do and keep current. The biggest thing right now is for us to know we have to change on a daily basis. We need to be flexible as things change in our hospital and as we are expected to change the ways we do things. If [administration] asks you to do something and that's not the way you do it, you'd better see if you can do it that way because if you won't, they'll find somebody who will be flexible. Employee health professionals need a pretty strong business sense to be able to justify their existence, and if people belong to professional organizations, they will get that kind of help.
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