ADVANCING WORKFORCE
HEALTH AT THE DEPARTMENT
OF HOMELAND SECURITY

Protecting Those Who Protect Us

Committee on Department of Homeland Security Occupational Health
and Operational Medicine Infrastructure

Board on Health Sciences Policy

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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ADVANCING WORKFORCE HEALTH AT THE DEPARTMENT OF HOMELAND SECURITY Protecting Those Who Protect Us Committee on Department of Homeland Security Occupational Health and Operational Medicine Infrastructure Board on Health Sciences Policy

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for ap- propriate balance. This study was supported by Contract/Grant No. HSHQDC-11-D-00009/ HSHQDC-12-J-00188/P00003 between the National Academy of Sciences and the Department of Homeland Security. Any opinions, findings, conclusions, or recom- mendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13:  978-0-309-29647-2 International Standard Book Number-10:  0-309-29647-1 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2014. Advancing workforce health at the Department of Homeland Security: Protecting those who protect us. Wash- ington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general wel- fare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors en- gineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON DEPARTMENT OF HOMELAND SECURITY OCCUPATIONAL HEALTH AND OPERATIONAL MEDICINE INFRASTRUCTURE DAVID H. WEGMAN (Chair), Professor Emeritus, Department of Work Environment, University of Massachusetts Lowell EDWARD BERNACKI, Professor of Medicine and Director, Division of Occupational Medicine; Executive Director of Health, Safety and Environment, Johns Hopkins University, Baltimore, Maryland LESLIE BODEN, Professor, Department of Environmental Health, Boston University School of Public Health, Massachusetts TOM CAIRNS, Principal, Cairns Blaner Group, LLC, Valencia, California RICHARD H. CARMONA, 17th Surgeon General of the United States; Distinguished Professor, University of Arizona, Tucson CHERRYL CHRISTENSEN, Corporate Medical Director, The Procter & Gamble Company, Cincinnati, Ohio DON E. DETMER, Professor of Medical Education, University of Virginia, Charlottesville ELLEN P. EMBREY, President/CEO, Stratitia, Springfield, Virginia WILLIAM FABBRI, Medical Director, Office of Medical Services, Federal Bureau of Investigation, Washington, DC JANIE GITTLEMAN, Chief, Occupational Safety, Health & Environmental Compliance (FAC‑3A), Mission Services Office of Facilities and Services, Defense Intelligence Agency, Washington, DC WILLIAM L. LANG, Senior Physician, Owl’s Nest, Inc., Arlington, Virginia MICHAEL A. SILVERSTEIN, Clinical Professor of Environmental and Occupational Medicine, University of Washington School of Public Health, Olympia DAVID N. SUNDWALL, Professor of Public Health (Clinical), Division of Public Health, Department of Family and Preventive Medicine, University of Utah–School of Medicine, Salt Lake City W. CRAIG VANDERWAGEN, Senior Partner, Martin Blanck and Associates, Columbia, Maryland Study Staff AUTUMN S. DOWNEY, Study Director FRANK VALLIERE, Research Associate Y. CRYSTI PARK, Senior Program Assistant BRUCE ALTEVOGT, Senior Program Officer ANDREW M. POPE, Director, Board on Health Sciences Policy v

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Jeannie Cimiotti, Rutgers University College of Nursing   Scott Deitchman, Centers for Disease Control and Prevention Elaine Duke, Elaine Duke & Associates     Pamela A. Hymel, Walt Disney Parks and Resorts Jeffery Lowell, Washington University School of Medicine William S. Marras, The Ohio State University   Robert K. McLellan, Dartmouth-Hitchcock Medical Center C. Crawford Mechem, Pennsylvania Hospital of the University of Pennsylvania Richard J. Miller, Federal Occupational Health     Dean Smith, U.S. Department of State     Terri Tanielian, RAND Corporation     Mark Tedesco, NextCare Urgent Care     vii

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viii REVIEWERS Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the report’s conclu- sions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Ellen Wright Clayton, Vanderbilt University, and Georges C. Benjamin, the American Public Health Association. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface T he creation of any new institution or agency can be expected to entail a phase of growth and development. When a new agency is formed in a time of crisis, its evolution is further complicated by circum- stance. Furthermore, if the agency is constructed from previously existing components along with newly created entities, both designers and new lead- ership face major challenges, and many roadblocks can be expected. This was the context for the Department of Homeland Security (DHS) when the nation responded to the harrowing events of September 11, 2001, by forming this new cabinet secretariat. Over the past decade, the agency has been learning and evolving slowly into its adolescence, and in the course of this evolution, it recognized a need to focus special attention on its most valuable asset—its employees. Health and medical leadership in the department’s Office of Health Affairs (OHA) recognized that balancing the need for centralized authority and component agency autonomy in carrying out the full measure of its responsibilities posed particular challenges. It was critical to respect the prerogatives and character of the components while striving to instill a department-wide ethos through commonality of purpose. This balance was deemed critical to building and maintaining the quality and morale of the workforce. With this need for balance in mind, OHA sought assistance from the Institute of Medicine (IOM) regarding how best to organize, across the department, the varied and complex programs and services designed to protect the occupational health of the DHS workforce and prepare it to fulfill its many operational missions. The committee empaneled to respond ix

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x PREFACE to this request comprised 14 members selected to represent a broad range of expertise that included occupational and environmental health, health systems management, health economics, health information technology and data management, metrics/measurement/program evaluation, workers’ compensation/liability, human resources, and operational medicine. This broad range of backgrounds was necessary to bring proper attention to the task. During the course of this study, the members worked diligently to bring their expertise to bear, learning from and assisting one another to appreciate the complexity of the committee’s charge. As a result, the committee was able to develop recommendations that reflect and respect the needs of the agency and the complex, multidimensional missions with which it is tasked. It should be noted that several committee members have had previous experience serving in leadership roles within DHS. This experience proved invaluable in grounding our work. We are particularly grateful to Dr. Jeff Runge, who served as liaison from the IOM Committee on Department of Homeland Security Workforce Resilience and shared his wealth of experi- ence from his tenure as the DHS Chief Medical Officer. Throughout our deliberations, we sought a common understanding of the full range of responsibilities faced by the department both within and across its many component units. We examined the work of other federal agencies as well as institutions in the private sector with reason- ably analogous organizational challenges. In so doing, we came not only to better appreciate the difficulties faced by DHS but also to understand a variety of ways in which the same objectives might be met. Early on we received valuable input from Dr. J. D. Polk, Acting Chief Medical Officer at DHS, who provided his insights into the problems and challenges that represent the primary needs to be addressed by OHA. Our efforts were further enhanced by input from many researchers, agency personnel, and representatives of interested groups who graciously dedicated their time to responding to our inquiries and provided their insights and perspectives during our deliberations. Appreciation also is extended to those individuals who served as reviewers of this report. Chairing this committee has been an education and a rewarding experi- ence, the task made much easier by the friendly and supportive atmosphere of the committee meetings. Over the course of the study, we depended greatly on the high-quality intellectual and administrative skills of the IOM staff, under the able direction of study director Autumn Downey and her colleague Frank Valliere. Their energy and commitment were evident from the outset. Their tireless efforts in developing the necessary background information, undertaking a variety of research tasks, and regularly inter- acting with the committee members are reflected throughout the report. Their work was ably supported by project assistant Crysti Park. Additional

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PREFACE xi thanks are owed to Rona Briere for carefully editing and improving the structure of the report. Finally, I wish to offer thanks and acknowledgment to my fellow committee members, all of whom gave generously of their time in ad- dressing a stimulating and challenging task. I am confident that our con- clusions and recommendations will help DHS achieve its overarching goal of a healthy, safe, ready, and resilient workforce, regardless of where they serve and what their missions may be. David H. Wegman, Chair Committee on Department of Homeland Security Occupational Health and Operational Medicine Infrastructure

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xiv CONTENTS A Framework for Ensuring the Health of an Operational Workforce, 64 Ensuring Medical Readiness, 66 Providing Medical Support for Operations, 85 Measurement and Evaluation, 91 Integration of Essential Workforce Health Protection Functions, 94 References, 108 4 THE CURRENT STATE OF WORKFORCE HEALTH PROTECTION AT DHS 115 Ensuring Medical Readiness, 115 Providing Medical Support for Operations, 135 Integration of Workforce Health Protection Functions at DHS, 142 Opportunities to Advance Workforce Health at DHS: Gap Analysis, 146 References, 150 5 LEADERSHIP COMMITMENT TO WORKFORCE HEALTH 155 The Need for Committed Leadership, 155 The Current Strategic Approach to Workforce Health at DHS, 156 A Commitment to Workforce Health, 158 References, 164 6 ORGANIZATIONAL ALIGNMENT AND COORDINATION 165 Alignment of Headquarters Oversight Functions, 166 Alignment Within and Among Operational Components and Vertically with DHS Headquarters, 184 A Governance Framework for Enterprise-Level Integration, 194 References, 199 7 FUNCTIONAL ALIGNMENT 201 The Need for Functional Alignment, 201 Ensuring the Medical Readiness of the DHS Workforce, 202 Medical Support for Operations, 208 Centralizing Health Services, 212 References, 216

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CONTENTS xv 8 INFORMATION MANAGEMENT AND INTEGRATION 217 Information and Knowledge Management, 217 The Need for a DHS Measurement and Evaluation Framework, 219 A Systems Approach to Data Collection, 221 Enabling Health System Integration and Continuous Improvement Through Information Management Systems, 227 References, 236 9 CONSIDERATIONS FOR IMPLEMENTATION 239 Impact of an Integrated Health Protection Infrastructure, 239 Priorities for Implementing an Integrated Health Protection Infrastructure, 245 Concluding Thoughts, 247 References, 259 APPENDIXES A DEPARTMENT OF HOMELAND SECURITY COMPONENT AGENCY HEALTH PROTECTION PROGRAM DESCRIPTIONS 261 B REFERENCED POLICY DOCUMENTS 269 C PERFORMANCE MEASURE FRAMEWORK AND BALANCED SCORECARD EXAMPLE 299 D QUESTIONS FOR THE DEPARTMENT OF HOMELAND SECURITY COMPONENTS 305 E PUBLIC- AND PRIVATE-SECTOR APPROACHES TO WORKFORCE HEALTH PROTECTION 319 F COMMITTEE MEETING AGENDAS 329 G COMMITTEE BIOSKETCHES 345

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Acronyms and Abbreviations ACOEM American College of Occupational and Environmental Medicine ADA Americans with Disabilities Act ASHA Assistant Secretary for Health Affairs CA POST California Commission on Peace Officer Standards and Training CBP Customs and Border Protection CDC Centers for Disease Control and Prevention CFR Code of Federal Regulations CHCO Chief Human Capital Officer CLMO Component Lead Medical Officer CMO Chief Medical Officer COP continuation of pay DASHO Designated Agency Safety and Health Official DHS U.S. Department of Homeland Security DoD U.S. Department of Defense DOI U.S. Department of the Interior DOL U.S. Department of Labor DoS U.S. Department of State DSHO Designated Safety and Health Official EAP employee assistance program eHIS electronic health information system xvii

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xviii ACRONYMS AND ABBREVATIONS EMS emergency medical services EMT emergency medical technician ePCR electronic patient care record FAMS Federal Air Marshal Service FBI Federal Bureau of Investigation FECA Federal Employees’ Compensation Act FEHB Federal Employees Health Benefits FEMA Federal Emergency Management Agency FLETC Federal Law Enforcement Training Center FOH Federal Occupational Health GAO U.S. Government Accountability Office HHS U.S. Department of Health and Human Services HIT health information technology HRA health risk assessment HRM Human Resources Management ICE Immigration and Customs Enforcement IHiS integrated health information system IOM Institute of Medicine J&J Johnson & Johnson LTCR Lost Time Case Rate MLO Medical Liaison Officer MOU memorandum of understanding MQM medical quality management NASA National Aeronautic and Space Administration NCM nurse case manager NFTTU National Firearms and Tactical Training Unit NIOSH National Institute for Occupational Safety and Health NPPD National Protection and Programs Directorate NPS U.S. National Park Service NRC National Research Council OCHCO Office of the Chief Human Capital Officer OHA Office of Health Affairs OIG Office of the Inspector General OPM Office of Personnel Management

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ACRONYMS AND ABBREVATIONS xix OSH occupational safety and health OSHA Occupational Safety and Health Administration OWCP Office of Workers’ Compensation Programs P&G Procter & Gamble POWER Protecting Our Workers and Ensuring Reemployment RTW return to work SMA Senior Medical Advisor SWAT special weapons and tactics TCR Total Case Rate TSA Transportation Security Administration TWH Total Worker Health™ USCG U.S. Coast Guard USCIS U.S. Citizenship and Immigration Services VA Department of Veterans Affairs WC workers’ compensation WHO World Health Organization

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Glossary Absenteeism Habitual absence from work.1 Chargeback Mechanism by which costs incurred under the Federal Employees’ Compensation Act (FECA) for most injuries and deaths are billed to agencies.2 Disability management A set of practices designed to minimize the disabling impact of injuries and health conditions that arise during the course of employment.3 Health promotion A comprehensive social and political process that embraces actions directed at strengthening the skills and capabilities of individuals and changing social, environmental, and economic 1  IOM (Institute of Medicine). 2005. Integrating employee health: A model program for NASA. Washington, DC: The National Academies Press. 2 DOL (Department of Labor). 2014. Division of Federal Employees’ Compensation   (DFEC) Procedure Manual. http://www.dol.gov/owcp/dfec/regs/compliance/DFECfolio/FECA- PT5/#50700 (accessed January 27, 2014). 3  Hunt, H. A. 2009. The evolution of disability management in North American workers’ compensation programs. Kalamazoo, MI: W.E. Upjohn Institute. xxi

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xxii GLOSSARY conditions to relieve their impact on individual and public health.4 Integrated employee An infrastructure that would support all health system employee health activities; provide a way to link information about all aspects of the health of employees; and make this information available to leadership at all levels for the purposes of decision making, accountability, continuous improvement, surveillance, and other questions related to health.5 Lagging indicators Retrospective measurements of system performance linked to outcomes.6 Leading indicators Prospective measures linked to actions taken to prevent accidents.7 Medical readiness The extent to which members of the operational workforce are free of health-related conditions that would impede their ability to participate fully in operations and achieve the goals of their mission.8 Medical threat A process for risk management in the context of assessment operational medicine that involves the creation of a comprehensive mission preplan based on available intelligence and information on the nature of the response.9 Occupational health An overarching term for activities aimed at maintaining and promoting workers’ health, 4  IOM. 2005. Integrating employee health: A model program for NASA. Washington, DC: The National Academies Press. 5  Adapted from Cecchine, G., E. M. Sloss, C. Nelson, G. Fisher, P. R. Sama, A. Pathak, and D. M. Adamson. 2009. Foundation for integrating employee health activities for active duty personnel in the Department of Defense. Santa Monica, CA: RAND Corporation. 6  Manuele, F. A. 2013. On the practice of safety. Hoboken, NJ: John Wiley & Sons. 7 Manuele, F. A. 2013. On the practice of safety. Hoboken, NJ: John Wiley & Sons.   8  DoD (Department of Defense). 2013. Joint publication 1: Doctrine for the Armed Forces of the United States. Washington, DC: DoD. 9  CA POST (California Commission on Peace Officer Standards and Training). 2010. Tactical medicine: Operational programs and standardized training recommendations. Sacramento, CA: CA POST.

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GLOSSARY xxiii ensuring the work environment is conducive to safety and health, and developing work organizations and cultures that support health and safety at work.10 Occupational A clinical specialty dedicated to the prevention medicine and management of occupational injury, illness, and disability and the promotion of the health and productivity of workers, their families, and communities.11 Occupational safety Activities aimed at ensuring safe and healthful and health working conditions, thus preventing work- related illness, injury, and death.12 Operational medicine Preventive and responsive medical and health support services provided outside of conventional workplaces during routine, planned, and contingency operations to employees and others under an organization’s control.13 Organizational Workforce perceptions of organizational climate practices.14 Presenteeism On-the-job productivity loss that is related to, for example, conditions such as allergies, asthma, chronic back pain, migraines, arthritis, and depression; also, productivity loss resulting 10  GOHNET (Global Occupational Health Network). 2003. GOHNET newsletter. Ge- neva, Switzerland: WHO. http://www.who.int/occupational_health/publications/newsletter/ en/gohnet5e.pdf (accessed December 22, 2013). 11  ACOEM (American College of Occupational and Environmental Medicine). 2013. What is OEM?: Careers in occupational and environmental medicine. http://www.acoem.org/OEM careers.aspx (accessed November 8, 2013). 12  Occupational Safety and Health Act of 1970. 13  Adapted from Fabbri, W. 2013. Operational medicine in other organizations: FBI. Pre- sentation at IOM Committee on DHS Occupational Health and Operational Medicine Infra- structure: Meeting 2, June 10-11, Washington, DC. 14  Rousseau, D. M. 2011. Organizational climate and culture. In Encyclopedia of Occupational Health and Safety, edited by J. M. Stellman. Geneva, Switzerland: International Labour Or- ganization. http://www.ilo.org/oshenc/part-v/psychosocial-and-organizational-factors/macro- organizational-factors/item/29-organizational-climate-and-culture?tmpl=component&print=1 (accessed December 17, 2013).

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xxiv GLOSSARY from caregiving, lack of job satisfaction, and organization culture.15 Public health All organized measures designed to prevent disease, promote health, and prolong life among the population as a whole.16 Resilience The ability to withstand, recover, and grow in the face of stressors and changing demands.17 Workforce health The full scope of occupational health and protection operational medicine activities carried out to sustain and protect the health and effectiveness of deployable forces and members of the workforce exposed to nontraditional environments. 15  IOM. 2005. Integrating employee health: A model program for NASA. Washington, DC: The National Academies Press. 16  WHO (World Health Organization). 2013. Public health. http://www.who.int/trade/ glossary/story076/en (accessed December 23, 2013). 17  Chairman of the Joint Chiefs of Staff. 2011. Chairman’s total force fitness framework. CJCSI 3405.01. http://www.dtic.mil/cjcs_directives/cdata/unlimit/3405_01.pdf (accessed Janu- ary 27, 2014).