A collaborative evidence-based approach to improving workplace health and safety
Annalee Yassi, MSc, FRCPC, OHSAH and Institute of Health Promotion Research, University of British Columbia
Maziar Badii, MHSc, FRCPC, OHSAH and University of British Columbia
Elizabeth Smailes, PhD, OHSAH and Institute of Health Promotion Research, University of British Columbia
Karen Lockhart, MA, Research Manager, Institute of Health Promotion Research, University of British Columbia
The Occupational Health and Safety Agency for Healthcare (OHSAH) was established in British Columbia with joint union and employer governance to develop evidence-based programs to promote better workplace health and safety. A five-year Community Alliances for Health Research (CAHR) partnership resulted in several research-to-practice projects and over $108 million in savings between 2002 and 2005. The involvement of multiple stakeholders from the beginning of the research process, concrete senior management commitment, front line worker involvement and union advocacy for the implementation of research findings were critical factors in the success of these knowledge translation (KT) initiatives.
Community involvement in health research has become increasingly recognized as an effective way of addressing health disparities.1,2 In the workplace setting, key stakeholders must be involved if research on improving health is to be successfully translated into policy and practice. This case study illustrates how collaboration among unions, employers, government, insurers and an interdisciplinary team of researchers can lead to research that produces high-quality results in practice.
The Occupational Health and Safety Agency for Healthcare (OHSAH) was established in British Columbia with joint union and employer governance to develop evidence-based programs to promote better health and safety and effective early return-to-work practices.3 In 1999, CIHR established the Community Alliances for Health Research funding program, with objectives that dovetailed very well with OHSAH's mission. OHSAH thus became a vehicle for researchers in B.C. to join forces with health care unions and employers. A five-year research program, Making Healthcare a Healthier Place to Work: A Partnership of Partnerships, was established, governed by a research council composed of union leaders, employer representatives, researchers and representatives from both the Workers' Compensation Board of B.C. (WCB) and the insurance carrier for long-term disability.
The KT initiative
The OHSAH-CAHR partnership incorporated a joint labour-management problem solving approach that was crucial to success in addressing the sector's challenges.4,5 The research program consisted of numerous practice-to-research-to-practice initiatives developed with extensive input from stakeholders, especially health care employers (via the Health Employers Association of British Columbia, as well as specific health region representatives) and the four major health care unions in B.C. The initial research program included the creation of a cohort of health care workers for longitudinal study; a series of studies exploring work-organizational factors and their influences on injury rates in acute, extended and long-term care settings; an intervention study to address risks faced by home care workers; a study of decision making regarding substitution of toxic chemical substances; implementation of a regional occupational health and safety program; and two linked initiatives (discussed below) focused on decreasing injuries and disability from patient handling.
Results of the KT experience
1. The ceiling lift story
The combination of quantitative and qualitative results, allowed the audience to see both the bottom line results as well as the positive impact the lifts had on the workplace safety climate.
Systematic reviews have consistently found that health care workers are at high risk of musculoskeletal injuries (MSIs), with patient handling, lifting, and transfers posing particular problems.6,7 We conducted a rigorous evaluation of an overhead lift system at an extended care facility in B.C. to determine its effectiveness in reducing staff injuries and decreasing both staff and patient risk and discomfort. The payback period for direct costs associated with this ceiling lift program had been estimated at nearly four years, but our evaluation determined that, when the trend of rising compensation costs was considered, the payback period was almost half the time previously estimated.8 A follow-up evaluation using three years of additional data revealed a 40% reduction in total claims costs, an 82% reduction in lift and transfer claims costs, and an 83% reduction in lost hours due to lift and transfer injuries.9 Front line workers reported less pain and discomfort and there was general satisfaction from patients and their families.
The results were actively shared with decision makers, and a special meeting was held with senior managers, including health authority CEOs and senior WCB, Ministry of Health, and union personnel. Quantitative results, including a cost-benefit analysis, were presented, along with "testimonials" from front line workers and managers. The combination of quantitative and qualitative results, presented in formats ranging from PowerPoint presentations to fact sheets, allowed the audience to see both the bottom-line results as well as the positive impact the lifts had on the workplace safety climate. A CEO of one of the health regions, in hearing the results and recommendations, commented, "This is a no-brainer; let's do it!"
Due to the savings realized at VGH, the goodwill generated and the knowledge translated to decision makers at the health authorities, PEARS was subsequently expanded to all of B.C.’s health authorities.
The B.C. Ministry of Health and the WCB decided to allot over $20 million to the widespread implementation of lifts throughout the province, and also signed an agreement to implement appropriate no-unsafe-lift policies. Additional studies were conducted to address specific scenarios, training materials were developed on how to implement the program and install lifts and a system of ongoing evaluation was introduced.
2. Linking primary and secondary prevention
Injury rates for B.C. health care workers were very high by 1998, with the health care sector accounting for more time-loss claims than any other industries in B.C.10 The Prevention and Early Active Return-to-Work Safely (PEARS) program was developed with goals of decreasing the incidence of MSIs in health care workers, and decreasing the average duration of time lost to MSIs by returning injured employees to their regular duties more rapidly. It also aimed to identify and evaluate the critical success factors of a safe prevention and early return-to-work program and a culture of safety within the workplace. Joint union and employer steering committees provided guidance to the overall initiative.
The PEARS program combines three components—primary prevention, early intervention (prompt follow-up of injured workers, targeted workplace modifications and clinical treatment when required) and extensive evaluation. Initially, PEARS was implemented as a pilot program at Vancouver General Hospital (VGH), a large urban acute and tertiary care teaching hospital with over 6,000 employees. Injured employees were offered a range of on-site services such as physiotherapy; review of work tasks with advice and training; work environment assessment with modification and purchase of equipment as necessary; a graduated return-to-work program, consisting of modified duties and/or hours; and access to an on-site physician.
Evaluation of the first year of PEARS revealed that the time taken to return to work after an MSI was significantly less than the previous two years,11 and the average time-loss-per-person per year for registered nurses was reduced to 3.6 from 4.9 days. This resulted in associated total savings in compensation payments of $176,534, a 33% reduction from the previous year. Due to the savings realized at VGH, the goodwill generated and the knowledge translated to decision makers at the health authorities, PEARS was subsequently expanded to all of B.C.'s health authorities. PEARS programs are currently running in eleven sites across the province and serve over 37,000 health care workers.
These two examples offer a number of important lessons for KT, as well as the successful implementation of workplace interventions.
The involvement of multiple stakeholders created trust and a shared commitment to the objective of promoting a healthy workplace, as well as raising awareness and support for the initiative itself.
We attribute the success of the ceiling lift intervention to concrete senior management commitment to the health and safety of the workforce, illustrated by their willingness to make the required capital investment, and also to strong front line worker involvement in determining the details of the intervention. It is noteworthy that the study had initially been requested by the health facility that implemented the overhead lift program: the audience was therefore eager to receive the study results. There was also union advocacy for implementation of the findings, combined with solid bipartite support based on the evidence. The involvement of the range of stakeholders from the beginning, and the gathering of top decision makers together to interact with the researchers directly to discuss the findings were key to the success of this KT. Both the quantitative elements of the research, such as the cost-benefit analysis, and the use of qualitative research to collect local stories from various stakeholders, including front line workers and patients, played important roles.
The PEARS program marked a departure from previous injury and disability prevention programs in combining primary and secondary prevention. Preventive activities happen within the workplace where all stakeholders can observe improvement in the work setting, thus generating further confidence in the program. The program also had strong union support, attempted to get all stakeholders on side and had a mandatory ongoing evaluation component. The involvement of multiple stakeholders created trust and a shared commitment to the objective of promoting a healthy workplace, as well as raising awareness and support for the initiative itself.
Conclusions and implications
These initiatives led to dramatic decreases in injuries and time loss, producing over $108 million in savings in WCB premiums between 2002 and 2005.
These and other OHSAH-CAHR initiatives across the health care sector in B.C. have resulted in useful training materials, as well as numerous peer-reviewed articles,12-14 book chapters,15 and fact sheets. More importantly, these initiatives led to dramatic decreases in injuries and time loss, producing over $108 million in savings in WCB premiums between 2002 and 2005. The partnership has also resulted in a strong commitment between the partners to continue to work together in conducting high quality research into how best to address both the physical and psychological dimensions of disability in the health care workplace, adopting the same principles of collaboration and excellence in science—or what has been dubbed "good science and good will."
As we go to press, the key stakeholders—the unions, the employers, and the Ministry of Health—have all confirmed their ongoing support for the partnership. Core funding for the KT activity of OHSAH will be continued, and it is hoped that the CAHR program, or its equivalent through other CIHR programs, will continue to fund important research partnerships to support the scientifically rigorous knowledge acquisition that is needed for KT to be effective.
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10 Workers' Compensation Board of British Columbia. 2000. Healthcare industry: Focus report on occupational injury and disease. Richmond, BC: Workers' Compensation Board of British Columbia.
11 Davis, P. M., M. Badii, and A. Yassi. 2004. Preventing disability from occupational musculoskeletal injuries in an urban, acute and tertiary care hospital: Results from a prevention and early active return-to-work safely program. J Occup Environ Med 46 (12): 1253-62.
12 Miller, A., C. Engst, R. B. Tate, and A. Yassi. Forthcoming. Evaluation of the effectiveness of portable ceiling lifts in a new long-term care facility. Appl Ergon.
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14 Yassi, A., K. Tomlin, C. Sidebottom, K. Rideout, and H. De Boer. 2004. Politics and partnerships: Challenges and rewards of partnerships in workplace health research in the healthcare sector of British Columbia, Canada. Int J Occup Environ Health 10 (4): 457-65.
15 Engst, C., R. Chhokar, A. Miller, and A. Yassi. 2004. Preventing back injuries to healthcare workers in British Columbia, Canada and the ceiling lift experience. In Back injury among healthcare workers: Causes, solutions, and impacts, ed. W. Charney and A. Hudson., 253-64. Boca Raton, FL:, CRC Press LLC, Lewis Publishers.
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