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Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us (2014)

Chapter: 4 The Current State of Workforce Health Protection at DHS

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Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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4


The Current State of Workforce
Health Protection at DHS

“Every DHS component and headquarters office has a noble and worthy mission to protect the American public.”

—Thad Allen, Admiral, U.S. Coast Guard (Retired) (2012)

 

 

Whether securing the nation’s borders, managing disasters, or protecting commerce and transportation systems, the component agencies of the Department of Homeland Security (DHS) work in a wide variety of ways to accomplish one ultimate mission: protecting the homeland. As a result of differences in operational requirements, as well as the fact that many of the agencies existed long before the creation of DHS, approaches to ensuring workforce health also vary among the components. Chapter 3 identifies the key functions of workforce health protection and organizes them into a framework for ensuring the health of an operational workforce. This chapter examines the current implementation of those functions across DHS at both the headquarters and component levels, including the degree of functional integration. Where sufficient information was available to the committee, gaps and successful practices are identified. The chapter concludes with an overarching analysis of opportunities to strengthen the health infrastructure at DHS, which serve as the framework for the committee’s recommendations in Chapters 5-8.

ENSURING MEDICAL READINESS

As described in Chapter 3, four interrelated occupational health functions support medical readiness: injury and illness prevention, readiness assessment, disability management, and health promotion. In the sections below, each of these functions is examined in turn—first at the DHS

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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headquarters and then at the component level.1 Measurement and evaluation, as a foundational function in the committee’s workforce health protection framework, is examined in the context of each of the four medical readiness functions.

Injury and Illness Prevention

Injury and illness prevention at DHS is executed primarily through occupational safety and health programs, although health promotion and fitness-for-duty activities also can help reduce occupational injuries and illnesses. According to the Occupational Safety and Health Administration’s (OSHA’s) Safety and Health Program Management Guidelines,2 elements of an effective occupational safety and health program include management commitment and employee involvement; processes for hazard identification, prevention, and control; and safety and health training. In reviewing DHS’s injury and illness prevention programs, the committee considered the representation of these key elements.

Headquarters Level

As discussed in Chapter 2, DHS’s occupational safety and health program currently is administered from within the Office of the Chief Human Capital Officer (OCHCO), which is located within the Management Directorate. The Chief Human Capital Officer, as the Designated Agency Safety and Health Official,3 has responsibility for the program and is tasked with overseeing the development of policies, instructions, standards, requirements, and metrics related to safety and health programs, as well as with providing direction and advice on safety and health matters to DHS management (DHS, 2008b). The Designated Agency Safety and Health Official should, according to Executive Order 12196 (1980),

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1The committee did not have an opportunity to speak with occupational health program staff at the Secret Service, despite repeated requests (it did hear from a representative on the agency’s operational medicine program). Consequently, little information on medical readiness functions at the Secret Service was available for the committee to consider in its evaluation of medical readiness at DHS. Information provided here on Secret Service programs was gathered from publicly available documents and should not be viewed as a comprehensive description of those programs.

2Title 29, part 1926, of the Code of Federal Regulations (29 CFR 1926), subpart C, Safety and Health Program Management Guidelines.

3In accordance with DHS Management Directive 066-01 (see Appendix B), which established authority for the DHS occupational safety and health program, these responsibilities were originally delegated to the Chief Administrative Officer. However, the occupational safety and health program has been detailed to OCHCO, with permanent transfer awaiting the passage of a federal operating budget.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

have “sufficient authority to represent the interest and support of the agency head.”4 The committee believes the Chief Human Capital Officer has this authority. Nonetheless, given the significant safety and health challenges faced by DHS, the committee is concerned about the organizational distance between the Chief Human Capital Officer and the Chief Medical Officer (CMO), who shares responsibility for employee health, safety, and medical programs and has the appropriate background to provide the strategic direction needed to advance workforce health at DHS. The committee is concerned that, without an advocate for workforce health to advise the Designated Agency Safety and Health Official, health, safety, and medical programs will not receive the necessary focus and resources. The Chief Human Capital Officer declined a request to speak with the committee about DHS’s safety and health program,5 so the committee was unable to ask about her ability to provide the program with the focus and resources befitting its importance.

The department-level occupational safety and health program is staffed by two occupational safety and health managers (including the DHS Safety Manager) and an industrial hygienist (Anderson, 2013). OCHCO provides guidance for component programs through the DHS Safety and Health Manual in accordance with the requirements set forth in Title 29, part 1960, of the Code of Federal Regulations (29 CFR 1960), Basic Program Elements for Federal Occupational Safety and Health. Another responsibility of the office is to ensure that DHS and its component agencies comply with the standards set forth in the Occupational Safety and Health Act; to this end, the office audits component programs annually. The office also engages in injury and illness prevention activities, including risk mitigation, and participates in investigations of serious accidents with component offices.

The role of the Office of Health Affairs (OHA) in the DHS occupational safety and health program generally is restricted to consulting on policy development and participating in medical aspects of accident investigation, although OHA leads the department’s strategy for the use of medical countermeasures (antibiotics and vaccines) to mitigate occupational exposure to biological, chemical, and radiological threats (DHS, 2011). OHA and OCHCO work together and with other DHS offices (e.g., the Office of Operations Coordination and Planning) as needed on this and other cross-cutting issues, such as planning for pandemic influenza.

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4Executive Order 12196, Occupational Safety and Health Programs for Federal Employees.

5The DHS Safety Manager attended the committee’s first meeting as her designated representative and spoke with the committee about the division of responsibilities between OCHCO and the Office of Health Affairs (OHA). In response to a committee request, the Chief Human Capital Officer did submit a written statement describing her perspective on the committee’s task.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Component Level

As discussed in Chapter 1, injury and illness rates vary substantially across DHS components, with Total Case Rates6 ranging from 1.64 at the Federal Emergency Management Agency (FEMA) to 9.44 at Customs and Border Protection (CBP)7 (OSHA, 2013). This variability reflects differences in missions and work environments, but also in the robustness of safety and health programs, as described below.

Management commitment and employee involvement Management commitment to employee safety and health can be difficult to assess by any one factor, but often can be inferred from employee engagement in safety and health and overall program resourcing and performance (see Box 4-1). One means by which management can demonstrate a commitment to safety and health programs is through the establishment of clear policies. Some components, such as the Transportation Security Administration (TSA), have a stand-alone safety and health policy (TSA, 2009). Most have occupational safety and health manuals or handbooks containing both policies and procedures for, among other things, identification and control of safety hazards, program evaluations and inspections, mishap reporting and investigation, job safety analysis, training, medical surveillance, and infectious disease control (DHS, 2010a; FEMA, 2013; ICE, 2011; TSA, 2010; USCG, 2013).8 Another means of demonstrating management commitment is including safety and health outcomes in performance assessments for managers and supervisors, as required by 29 CFR 1960. However, the committee noted that this requirement is not universally met across components (McEachron, 2012).

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6As noted in Chapter 1, Total Case Rate is a standardized measure of the incidence of occupational injuries and illnesses and represents the total number of workers’ compensation claims submitted by an agency to the Department of Labor’s Office of Workers’ Compensation Programs per 100 employees (OSHA, 2013).

7The committee learned of and applauds recent CBP initiatives to reduce this notably high injury and illness rate, which is among the highest in the federal government and has shown no notable improvement in the past 5 years (Flinn, 2012). According to a headquarters safety and health evaluation (Flinn, 2012), the bulk of CBP injuries are incurred by Border Patrol agents, including a large number of relatively inexperienced agents, who operate on a daily basis under hazardous conditions, particularly along the southwest border. To address its high case rates, CBP conducted a study to determine leading root causes of injuries, is considering the implementation of physical ability standards, and recently launched a risk management program based on the Department of Defense’s operational risk management process (Flinn, 2012).

8The committee was provided or able to obtain copies of the cited occupational safety and health manuals. Manuals for CBP and the Secret Service were not provided to the committee despite requests, and the U.S. Citizenship and Immigration Services (USCIS) does not have its own manual.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

DHS employees participate in safety and health programs in several ways. Many of the components train collateral-duty safety officers to conduct workplace inspections, typically in low- or medium-risk environments. Additionally, several components, including CBP, FEMA, Immigration and Customs Enforcement (ICE), and TSA, reported to the committee that employees can participate in local/worksite safety and health committees or teams, which include a mix of management and nonmanagement employees and may include labor representatives as well. Such committees are effective at improving workplace safety because their members operate on the front lines and therefore are most familiar with the hazards involved.

Hazard identification, prevention, and control Processes for proactive hazard identification are fairly similar across DHS, although their implementation varies. This requirement is met primarily through regular safety and health inspections and job hazard analyses, which focus on hazards associated with the workplace and job processes, respectively. Most components have established procedures for job hazard analyses (also called job safety analyses), which are used to identify hazard prevention and control strategies (e.g., requirements for personal protective equipment). However, it was often unclear to the committee how the decision to conduct a job hazard analysis is made. Worksite inspections generally are conducted at least annually, and more frequently at some sites in accordance with risk estimates. Some components, such as the National Protection and Programs Directorate (NPPD), rely heavily on collateral-duty safety officers for inspections, while others, such as TSA and CBP, have numerous safety professionals embedded in field sites across the United States, in addition to collateral-duty safety officers who inspect their assigned areas on a more regular basis. As with the safety and health committees, embedded safety and health professionals are familiar with operating conditions and know local management, providing opportunities for improved hazard identification and mitigation and risk communication. In an example of good interagency collaboration, U.S. Citizenship and Immigration Services (USCIS), which lacks its own safety and health professionals, uses an interagency agreement to allow collocated (or nearby) CBP safety professionals to conduct annual inspections at USCIS offices. This type of arrangement may be beneficial for other DHS components that lack or have insufficient internal safety and health staff.

Incident reporting methods and risk communication strategies are important elements of hazard identification, prevention, and control processes. Rapid incident reporting can help ensure timely and appropriate medical evaluation and treatment for affected individuals, and also allows causes of an incident to be addressed more rapidly, thereby preventing additional incidents. Several components noted to the committee that hotlines are

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

BOX 4-1
Examples of Safety and Health Performance
Through Management Commitment at the
Department of Homeland Security

Transportation Security Administration (TSA)

TSA was established in 2001 but did not develop an occupational safety and health program until 2 years later. In 2003, the agency’s Total Case Rate (based on data from the Office of Workers’ Compensation Programs) was 23.3 per 100 workers—more than six times the government-wide average (Segraves, 2013). Since then, TSA has been working aggressively to reduce injury and illness rates through a robust occupational safety and health program that works closely with TSA’s workers’ compensation program. In 2012, TSA’s Total Case Rate was 4.5, representing an 81 percent decrease relative to 2005 levels (Segraves, 2013). These reductions were accomplished through

 

  • the development and implementation of policy and training programs designed to create a culture of safety;
  • assignment of Designated Occupational Safety and Health Officials at all major airports (155 total) to plan, implement, and manage airport-level health and safety programs;
  • designation and training of more than 300 collateral-duty safety officers to conduct informal inspections using TSA-developed checklists;
  • the development of intra-agency Optimization, Safety, and Hazard Mitigation Integrated Product Teams (with members representing safety and health, workers’ compensation, and security operations, along with personnel who develop standard operating procedures);
  • baseline hazard analysis of all TSA-occupied facilities;

available for incident reporting. In some cases, the lines are only for serious incidents (e.g., involving a fatality); by contrast, TSA requires reporting of all injuries and illnesses through its hotline by the end of the shift in which an incident occurred. TSA’s safety and health office reviews reported cases on a daily basis, making it possible to identify trends quickly and provide guidance to field sites when needed.

Once hazards have been identified, effective methods for risk communication can reduce their impact. Strategies for risk communication vary across DHS, encompassing printed notices, digital media (e.g., podcasts), and interpersonal communications. In a notable example of the latter, safety issues are shared at CBP during meetings of collateral-duty safety officers, facilitating risk communication (Flinn, 2012). This approach also enables sharing of best practices, which is particularly useful given the high

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×
  • targeting of mitigation efforts to airports making significant contributions to overall case numbers or exceeding benchmark levels for that fiscal year;
  • aggressive injury and illness reduction targets (currently an 8 percent annual reduction, twice the level set by the President’s Protecting Our Workers and Ensuring Reemployment [POWER] initiative);
  • reporting of all incidents through a dedicated hotline and a requirement to initiate investigation of an incident within 24 hours; and
  • implementation of a Safety Information System, which tracks data on recordable incidents and workers’ compensation claims, reports of unsafe conditions and corrective actions, hazard assessments (including job hazard analyses and inspection results), safety and health risk analyses, and limited-duty assignments.

U.S. Coast Guard

Between 2003 and 2011, the Coast Guard achieved a 47 percent decrease in its Total Case Rate. The Coast Guard attributes this steady decline to proactive safety programs supported by engaged leaders who actively communicate the critical importance of safety programs. Other contributing factors include an emphasis on training and operational risk management practices, along with personnel outreach efforts (USCG, 2011c). Operational risk management is being used to integrate occupational safety and health with operations. Using a systems approach, the Coast Guard is leveraging multiple hazard assessment programs, along with a safety climate assessment, to identify deficiencies that represent threats to employee safety or interfere with readiness and mission execution (USCG, 2011b). Hazard inventories are compiled and used during mission planning to identify hazards that may be encountered during a mission and potential mitigation strategies. The ultimate goal is to have a hazard inventory for every Coast Guard mission and/or task (USCG, 2011b).

turnover of collateral-duty safety officers (Rupard, 2013), and provides a way to augment more formal training. CBP safety and health specialists also provide quarterly briefings to field managers, directors of field operations, sector chiefs, and senior leaders at headquarters to ensure high-level awareness of injury and illness trends and progress (CBP, 2013b).

Other common elements of component occupational safety and health programs include medical surveillance, industrial hygiene, ergonomics, and immunization services. With the exception of the Coast Guard, components generally outsource these functions to a private vendor or to Federal Occupational Health.

Training and education Executive Order 12196 on federal occupational safety and health programs requires agencies to provide safety and health

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

training, at a minimum to supervisory employees, employees responsible for conducting occupational safety and health inspections, and all members of occupational safety and health committees. Some general training courses (e.g., those for collateral-duty safety officers) are offered at the headquarters level, but most components have developed their own courses tailored to their needs and challenges. Organizations external to DHS also can be good sources for component-tailored training and education. For example, CBP recently sent sector-level program managers to a National Safety Council training; managers returned with action plans for their specific sectors that were developed during the course (Flinn, 2012).

Measurement and Evaluation

Only a few occupational safety and health metrics are collected at the headquarters level; these are primarily those required by OSHA—Total Case Rate and Lost Time Case Rate (defined in Chapter 1). DHS’s occupational safety and health office also has developed a relative program rating based on the five-point scale used for assessments during annual occupational safety and health program reviews (Anderson, 2013). Currently, case rate data are submitted to headquarters annually; in the future, however, according to the DHS Safety Manager, the data will be collected quarterly and posted on a DHS dashboard for trend analysis and reporting to leadership (Anderson, 2013). Other occupational safety and health data available to headquarters include metrics collected through the President’s Protecting Our Workers and Ensuring Reemployment (POWER) initiative. POWER goal data are analyzed and posted quarterly online by the Department of Labor’s Office of Workers’ Compensation Programs (OWCP).

The absence of common core metrics (collected by all components) and a DHS-wide safety information reporting and record-keeping system precludes more granular data analysis at the headquarters level (Anderson, 2013). Besides case rate data, only serious accidents that require immediate reporting to OSHA (a fatality, a hospitalization, three or more people injured during the same event, or serious property damage) are reported to headquarters. All other incident data remain at the component level.

DHS component agencies also have noted that inadequate information systems impede not only trend analysis and program evaluation but also preventive activities such as tracking of hazard abatement. FEMA has requested a management information system on several occasions, but the request has not yet been approved (McEachron, 2012)—this despite the fact that management information systems are a federal agency requirement under Executive Order 12196. With its Safety Information System, TSA has been able to conduct detailed analyses of its safety data to identify airports making the most significant contribution to its overall incident rate (see

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Box 4-1). This system also has enabled targeting of mitigation strategies to those sites where the greatest impact can be achieved (Segraves, 2013). The Federal Air Marshal Service (FAMS) within TSA also conducts this kind of “market share” analysis using workers’ compensation and incident data to identify and target field offices contributing most to the overall agency burden (FAMS, 2013b).

Readiness Assessment

Readiness assessment provides operational commanders and DHS leadership (at both the headquarters and component levels) with information on the medical readiness of the workforce to carry out its missions. Readiness to perform a mission has two aspects—the fitness of individuals (physical and mental) to perform the essential functions of their position,9 and the absence of injuries and illnesses that would interfere with that capability. Both must be evaluated during readiness assessment. With the exception of the Coast Guard, clearly defined requirements for readiness generally are lacking at DHS, although, as discussed below, many components use fitness-for-duty evaluations to assess whether individuals can perform their essential job tasks.

Headquarters Level

The Delegation to the Assistant Secretary for Health Affairs and Chief Medical Officer assigns oversight responsibility for mission readiness functions, including preplacement evaluations, medical standards, fitness-for-duty examinations, health screening and monitoring, deployment physicals, and medical exam protocols, to the CMO. Notably absent from policies and standards promulgated by OHA, however, are guidance and standards related to medical readiness. OCHCO shares responsibility for fitness-for-duty processes and medical standards. OHA’s Occupational Health Branch Chief told the committee that OHA is serving in an advisory role to OCHCO, which makes the decisions on implementation of medical standards (Hope, 2013a).

OHA initiated an effort to develop a common medical standard for 1811 series law enforcement officers across DHS.10 A job task analysis was outsourced and a concurrence process initiated to elicit component approval for the vendor recommendations, but, for reasons not clear to the committee, the process was stalled during review in OCHCO (Hope,

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9Defined in Chapter 3 of this report.

10The 1811 series is the Office of Personnel Management job series for criminal investigators in the federal government.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

2013a). Since that time, senior medical advisors have come on board in multiple component agencies, and OHA is leveraging its relationship with these medical officers to elicit buy-in from the components in the development of more consistent fitness-for-duty practices.

Component Level

The committee observed significant variability in the process by which components determine whether applicants and employees can carry out their essential job functions, even for positions with similar functions (e.g., criminal investigators). In reviewing these processes, the committee examined whether components had instituted medical and/or physical capability standards and reviewed components’ procedures for conducting fitness-for-duty evaluations and adjudicating cases. Where appropriate, fitness-for-deployment processes also were reviewed.

Medical and physical standards Although the committee was not given the opportunity to review them, several components—including CBP, FAMS, the Secret Service, and the Coast Guard—reported that they have implemented medical and/or physical ability standards for law enforcement and other security- and safety-sensitive positions (e.g., mechanics, firefighters). At CBP, for example, fewer than 2 percent of weapon carriers are in positions lacking job-specific medical standards, and for those positions, an existing medical standard is being applied according to the physical requirements of the position and the essential job duties documented in the position description (CBP, 2013a). A “Use of Force” study is anticipated, which will establish a baseline medical standard for this small population of weapon carriers as an alternative to establishing standards for each position individually. The committee views the development of this standard as a possible function for OHA, so that any such standard could be applied across DHS. The development of a baseline standard, however, would require close collaboration with the components that would be applying it to members of their workforce.

Some positions at DHS must meet externally regulated standards. For example, CBP’s Air Interdiction Agents must meet medical examination requirements of the Federal Aviation Administration (CBP, 2013a). Likewise, all active-duty and reserve personnel11 in the Coast Guard must meet

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11Regarding Coast Guard civilian personnel, preemployment, periodic, and postemployment occupational medical exams and screenings may be necessary for positions that are “arduous, hazardous, or require a specific level of fitness to protect personal and public safety or to ensure security is not compromised,” including civilian law enforcement personnel (USCG, 2011d). A template medical examination record is provided in Commandant Instruction M12792.3A, Civilian Employee Health Care and Occupational Health Program; with the

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Department of Defense (DoD) Medical Standards for Appointment, Enlistment and Induction in the Armed Forces, although additional standards have been established for positions entailing unique risks, such as aviation personnel and divers (USCG, 2011a).

FAMS reported that, in addition to medical standards resulting from a job task analysis conducted in the 2005-2006 time frame, Supplemental Medical Officer Guidelines have been developed and are maintained to facilitate consistent interpretation and application of the standards. The guidelines serve as “the historical repository of process changes based upon advances in medical science, evolution in the medical clearance process and clarification of the [standards]” (FAMS, 2013d). No other components reported using this kind of “living document” approach, although it would appear to be a useful way to ensure that standards do not become obsolete and are applied consistently.

TSA, ICE, and FEMA all indicated that they are in the process of developing medical standards for safety- and security-sensitive positions. Medical standards for transportation security officers are required by the Aviation Transportation Security Act.12 Although not yet implemented, the standards have been developed based on the results of an outsourced job task analysis and are awaiting approval. ICE and FEMA also have begun the process of conducting job task analyses for law enforcement officer positions and incident management assistance team members, respectively (ICE, 2013; Macintyre, 2013). The committee noted that job task analyses are, as a rule, outsourced at DHS, but there appears to be no standardized process by which those analyses are performed (e.g., from what sources input is solicited [unions, human resources, OHA], what factors are considered, or how acceptable levels of risk are determined).

Several components have instituted physical ability or fitness13 requirements for applicants and, in some cases, recurring evaluations for employees.14 Physical requirements are not always linked to a component’s

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exception of firefighters, however, it is unclear whether documented medical standards are in place for some or all of these positions to serve as a benchmark.

12Aviation and Transportation Security Act (ATSA), Public Law 107-71, November 19, 2001.

13Physical fitness and physical ability (or performance) requirements are not always synonymous. Physical fitness requirements, such as timed runs and bench presses, may be general in nature, whereas physical ability requirements are specific to required job tasks (e.g., the ability to “hold a seven pound shotgun firmly to shoulder and have sufficient hand strength to be able to operate the slide action properly”) (FLETC, 2011).

14Assessments of physical fitness and physical ability also are conducted by the Federal Law Enforcement Training Center in the context of training programs in which DHS law enforcement officers may be required to participate on a recurring basis. Students are required to fill out self-assessments for course-specific physical performance requirements and, if applicable, to submit medical documentation on any conditions that impede their ability to participate

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

medical standards. At FAMS, for example, air marshals must participate in quarterly physical fitness tests, but the physical fitness program is housed in the training department, separate from the FAMS Medical Programs Division. Although participation is mandatory, there is no pass/fail cutoff.

Fitness-for-duty evaluation The committee noted significant variability in the implementation of fitness-for-duty evaluations for readiness assessment. Only the Coast Guard, FAMS, and the Secret Service conduct periodic evaluations; in other components, fitness-for-duty evaluations are requested only when indicated by concerns regarding an employee’s job performance or prior to return to duty (i.e., following an injury or illness). The Federal Protective Service recently suspended periodic medical evaluations of law enforcement officers, which had been opposed by union representatives because of concerns regarding mishandling of personal medical information and insufficient linkage to the ability to carry out essential job functions (Wright, 2013). The committee is unaware of any component other than the Coast Guard conducting exit health evaluations prior to separation.

At DHS, employing agencies determine who can conduct preplacement and employee fitness-for-duty evaluations (i.e., applicants and employees cannot choose their own medical examiner). These evaluations often are outsourced, either to Federal Occupational Health or to a private vendor. For example, CBP’s Minneapolis Hiring Center arranges for all CBP candidates to undergo a medical examination from a single contract vendor—Comprehensive Health Services—which provides clinics, medical review officers, and specialty physicians (e.g., ophthalmologists). Use of a single vendor for all examinations helps ensure consistency in the process. Some agencies, such as the Coast Guard and FAMS, have sufficient numbers of physicians and occupational health nurses on staff to conduct some evaluations internally. FAMS has found that bringing this function in house can be cost-effective (FAMS, 2013a).

In the absence of documented medical standards, medical information may still be requested prior to employment or in the context of fitness-for-duty evaluations for employees. For example, applicants for some ICE positions are required to submit to a medical examination prior to mandatory physical fitness testing that is part of the application process. The examining physician determines whether it is safe for the applicant to take the fitness test. For applicants with medical conditions that might affect their ability to complete the fitness test, documentation regarding the condition must be brought to the medical examiner.

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in training. However, it is unclear what response is generated at employing agencies when students do not meet fitness or physical performance requirements.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Adjudication and waivers Although most components outsource fitness-for-duty evaluations, some, such as FAMS, conduct their own reviews of the resulting medical information, whereas others rely on contracted medical review officers. At CBP, for example, in-house nurses evaluate all exam results and information submitted by personal physicians but refer complex cases to a contracted medical review officer for an additional medical opinion. CBP also utilizes a waiver review board consisting of field agents or officers and general counsel to evaluate the ability of a candidate to perform essential job tasks despite failing to meet medical standards. Such boards often are used to make determinations regarding employment for candidates and/or employees after considering recommendations provided by medical personnel. The Coast Guard and Secret Service also use medical evaluation or medical review boards to determine whether an individual can perform essential job functions, with or without reasonable accommodation (Secret Service, 2012; USCG, 2011a). As discussed in Chapter 3, a waivering process is required by 5 CFR 339. ICE reported to the committee that it is currently in the process of developing a waiver program.

Fitness-for-deployment evaluation Fitness-for-deployment evaluation is one area in which the committee observed notable gaps at DHS. Only the Coast Guard has a clear and robust process for pre- and postdeployment health evaluation, although these processes are specific to military personnel. The committee was told that the Coast Guard is working on deployment health requirements for deploying civilians, and that these requirements may be applicable to other DHS components (Dollymore, 2013). Given its extensive experience with such evaluations, the Coast Guard represents a valuable resource in this area that could be tapped by other components.

At ICE, fitness for deployment is handled on a case-by-case basis if an employee brings a medical concern to the supervisor’s attention. FEMA has been working on a pre- and postdeployment readiness evaluation (Crarey, 2013) for FEMA employees, as well as for DHS Surge Capacity Force volunteers.15 When a Surge Capacity Force was deployed to the Hurricane Sandy disaster site in 2012, no predeployment medical readiness evaluations were performed (Leffer, 2013).

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15Employees across DHS who want to help when the need is greatest can volunteer to staff a DHS Surge Capacity Force, which can be deployed during a disaster. More than 1,100 DHS employees were deployed during Hurricane Sandy.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Measurement and Evaluation

As described above, several components evaluate the fitness for duty of individual employees or candidates; however, the committee heard from only one component that tracks the readiness of its workforce. The Coast Guard requires all active-duty/reserve personnel to maintain readiness to deploy and aligns with DoD in its definition of individual medical readiness (DoD, 2013), which encompasses six required elements: (1) an annual periodic health assessment; (2) an annual dental screening with acceptable classification status; (3) current on readiness immunizations; (4) in possession of medical equipment (e.g., gas mask insert, eyeglasses if needed); (5) completed medical readiness lab tests (e.g., HIV, blood type, tuberculosis [TB] test, pregnancy test for women, DNA specimen); and (6) having no deployment-limiting conditions (pregnancy or less than 6 weeks postpartum, dental class 3 or 4, injury/illness requiring at least 6 months’ temporary limited-duty assignment). The periodic health assessment consists of

 

  • a health risk assessment;
  • clinical preventive services (e.g., vaccinations);
  • Occupational Medical Surveillance and Evaluation Program review and update;
  • individual medical readiness review and update; and
  • problem-based examination for determination of duty status.

At the individual level, status for each of the readiness requirements is recorded. This information is then aggregated to determine the proportion of the Coast Guard workforce meeting each readiness requirement and all requirements. Workforce readiness information currently is tracked in the Coast Guard Medical Readiness Reporting System. However, future readiness tracking will be conducted through the Coast Guard’s Integrated Health Information System.

To the committee’s knowledge, no other DHS components have defined the requirements for readiness. Without defined requirements, workforce readiness cannot be tracked.

Disability Management

The POWER initiative has drawn attention to the need to improve return-to-work rates at DHS and across the federal government. The number of lost production days (i.e., work days lost because of workplace injury or illness per 100 full-time employees) at DHS is more than double the government-wide average (89.4 versus 35.8) (OWCP, 2013). Since injured law enforcement officers often must receive medical clearance before

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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returning to duty, it is expected that lost production days may be higher for agencies with large law enforcement populations (Tritz, 2013). However, lost production days at DHS still far exceed those for the Department of Justice (64.6) and the Department of the Interior (46.8), both of which have substantial law enforcement populations (OWCP, 2013). These data indicate that more timely return to work through early intervention programs is an area for improvement at DHS. Not only do such efforts return employees to their livelihoods, but they also represent significant opportunities to achieve cost savings for DHS with respect to both continuation-of-pay16 and annual workers’ compensation chargeback costs.

Headquarters Level

Although return to work is specifically identified in Delegation #5001 (DHS, 2008a) as an area for which the DHS CMO has oversight responsibility, the committee learned that OHA’s role in this area currently is limited to medical consultation on an as-needed basis. Return to work/case management also was included in the 2009 memorandum of understanding (MOU) between OHA and the occupational safety and health program office as a lead program area for OHA (see Appendix B). However, the DHS Safety Manager informed the committee that the primary responsibility for medical case management at DHS headquarters lies with the workers’ compensation program manager and policy advisor, located in OCHCO, and that the program will be removed from future revisions of the MOU.17

According to the DHS workers’ compensation program manager and policy advisor, workers’ compensation and disability management currently are decentralized at DHS, with 14 workers’ compensation heads within components running individual programs (Myers, 2013). At the department level, the role of the workers’ compensation program manager and policy advisor is to work with the components, providing support on national-level issues that may have cross-cutting effects. In response to the POWER initiative, however, DHS is moving toward a more centralized approach to disability management by establishing a blanket purchase agreement for contracted medical case management services (Myers, 2013). DHS components will have the option of buying into the program and establishing component-specific task orders, which will be managed by component

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16As discussed in Chapter 3, the first 45 days after a claim is filed is termed the continuation-of-pay period. During this period, the employing agency continues to pay the injured/ill employee’s salary. After 45 days, OWCP takes over salary payments and then bills the agency annually (chargeback costs). Separate funds are used to cover these two sets of costs.

17E-mail communication, K. Anderson, DHS OCHCO, to A. Downey, Institute of Medicine, regarding proposed changes to OHA-Office of the Chief Administrative Officer Memorandum of Understanding, March 7, 2013.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

workers’ compensation managers. According to the performance work statement, the vendor will provide, implement, and maintain a full range of medical case management services, including certified/licensed registered nurses to act as medical case managers, a licensed medical review physician, a round-the-clock toll-free injury reporting hotline, injury care support services, support for new and historical workers’ compensation cases, and an enabling information technology solution. The program is expected to begin operating in 2014. The committee was not informed of the number of components that plan to utilize this service, although the CBP workers’ compensation program manager indicated that CBP’s Commissioner has authorized participation (Masterson, 2013).

Although this program facilitates a proactive approach to cost containment for return to work and workers’ compensation, the committee was concerned to note that this turnkey solution, as currently managed, is altogether disconnected from the internal medical infrastructure at DHS. OHA has not been involved in the development of the blanket purchase agreement,18 and it is unclear how component-level medical authorities will oversee task orders, despite the fact that several components now have medical personnel who can serve as medical reviewing physicians. Nor is there any apparent link to the DHS safety program functions. Although a hotline will be supplied for reporting purposes, it is unclear whether the first report-of-injury calls will be shared with component safety offices.

Component Level

The committee heard from only three components—–CBP, TSA, and FAMS—–regarding their disability management programs. Successful initiatives of these three agencies are highlighted below, but with such limited information, the committee was unable to draw conclusions about this capability across DHS as a whole.

As discussed in Chapter 3, OWCP assigns field nurses to manage workers’ compensation claims and to facilitate return to work. However, OWCP nurse case managers are not assigned until a claim has been accepted, which may be more than 45 days after the injury or illness is first reported. Since early intervention is known to improve return-to-work outcomes, two DHS agencies have implemented programs to initiate case management prior to assignment of OWCP field nurses. The two different models for component-level case management are described below; both have demonstrated success in improving return-to-work outcomes and achieving cost savings.

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18E-mail communication, I. Hope, DHS OHA, to A. Downey, Institute of Medicine, regarding DHS medical case management program, August 12, 2013.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Case 1: A contracted nurse case management program In 2005, TSA initiated a pilot nurse case management program focused on bringing best practices of private industry to the agency. The program included the creation of a round-the-clock hotline, a focus on early intervention, ongoing case management to facilitate care and return to work, and the provision of limited-duty (also called light-duty) opportunities (Mitchell, 2013). When an injury or illness occurs, a contracted nurse case manager is assigned to the employee and initiates contact within 24 hours of the incident to offer support and assistance. Through ongoing contact, the nurse monitors the employee’s medical condition to ensure quality medical care that facilitates medical progress and return to duty. Once implemented, the program decreased the average continuation-of-pay absence from 45 days to 12 days and reduced continuation-of-pay costs by more than 80 percent. In 2009, TSA was awarded the Theodore Roosevelt Workers’ Compensation and Disability Management Award for its work on reducing the cost of injuries incurred by employees while on the job (Mitchell, 2013). The program also was identified as a return-to-work best practice in a study conducted for OWCP by EconSys (Steinberg, 2012).

Case 2: An in-house nurse case management program FAMS, although a subcomponent of TSA, handles medical case management through its own in-house nurse case management program. FAMS nurse case managers are notified within 24 hours of a workplace injury and are available by phone around the clock to advise employees on medical follow-up (e.g., provide referrals) and suitability for airline travel (flight status). Nurse case managers then follow up with treating physicians to facilitate return to work. Currently, four nurse case managers provide 100 percent proactive management of claims, from initiation to resolution (Lewandowski and Weeks, 2013). A key aspect of the program is that the in-house case managers, who also review fitness-for-duty evaluations, are intimately familiar with FAMS job requirements and medical standards, and therefore can also facilitate parallel medical clearance processes. This dual role has prevented unsafe return to full duty for individuals cleared by OWCP (FAMS, 2013e). To avoid breaks in pay for those cleared by OWCP, FAMS nurse managers try to find them light-duty positions until medical clearance for return to full duty can be granted. FAMS medical staff also work with employees who become injured or ill outside of work to facilitate return to work for those who are removed from flight status (Lewandowski and Weeks, 2013).

Other return-to-work initiatives Although early intervention programs such as the nurse case management programs described above may be most effective at returning injured and ill employees to work in a timely manner, return-to-work programs also should focus on removing workers from

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

long-standing workers’ compensation case rolls. In response to separate Office of Inspector General reports on workers’ compensation case management (OIG, 2007, 2012), TSA and CBP initiated programs to return employees on periodic rolls to work. CBP, for example, implemented a program whereby hiring centers consider injured workers on the periodic roll first for vacancy announcements (Masterson, 2013), although it is too early to judge the ultimate success of this initiative. TSA actively targets employees who have been on periodic rolls for 9 months or more with its Concentrated Action for Recovery, Employment and/or Case Resolution (CARE) program. This collaborative effort, which features coordination among TSA’s medical director and periodic roll manager, local TSA workers’ compensation coordinators, the contracted nurse case managers, and OWCP, has resulted in the resolution of 36 cases to date, achieving estimated cost savings of more than $1 million and estimated avoided future costs of nearly $30 million (Mitchell, 2013).

Measurement and Evaluation

FAMS and TSA were the only components that provided the committee with information on how they are measuring the effectiveness of their disability management programs. TSA has demonstrated the effectiveness of its contracted nurse case manager program through metrics that include average continuation-of-pay period and continuation-of-pay costs, reductions in OWCP chargeback costs, and estimated cost savings from periodic resolution of roll cases. FAMS, too, measures program effectiveness through OWCP costs but also developed a “lost mission opportunities” metric as a productivity measure with a better link to the FAMS mission (see Box 4-2). Although 2 years is not long enough to permit conclusions about trends, data from 2009-2010 show that, despite a slight increase in total incidents, FAMS achieved a 5 percent decrease in workers’ compensation costs and a 20 percent decrease in lost mission opportunities, which it attributes to return-to-work efforts (FAMS, 2013b).

As DHS moves forward with its department-level medical case management program, it will need to ensure that appropriate metrics and measurement processes are established at both the component and headquarters levels to enable evaluation of program effectiveness.

Health Promotion

During the past 5 years, there has been increased emphasis on resilience and health promotion programs at DHS. One of the primary goals of the current DHS strategic plan is to enhance the DHS workforce. Listed among the four strategic objectives toward achieving this goal is to improve

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

BOX 4-2
Federal Air Marshal Service’s (FAMS’s) Lost Mission
Opportunities Metric: A Productivity Measure

To demonstrate to agency leadership that occupational injuries and illnesses have impacts beyond financial costs, staff of the FAMS Medical Program Section developed a Lost Mission Opportunities metric. This productivity measure estimates the number of potential FAMS flight missions that could not be executed because of injured employees out on workers’ compensation or restricted duty. Thus, the metric is responsive to both injury/illness incidence rates and the effectiveness of disability management practices and is linked to the agency mission, making it a powerful communication tool. Data considered in the calculation of this metric include total number of lost and restricted duty days and average number of daily missions (from the Mission Operations Center).

SOURCE: FAMS, 2013b.

employee health, wellness, and resilience (DHS, 2012a). Two of five key performance indicators under this objective directly address health promotion:

 

  • Sustain established programs such as the DHSTogether employee and organizational resilience initiative.
  • Implement workplace wellness programs, including employee resilience training.

As discussed in more detail in the 2013 report of the Institute of Medicine (IOM) Committee on Department of Homeland Security Workforce Resilience, however, responsibility for health promotion is diffused across DHS (IOM, 2013), and there appears to be no coordinated approach to improving the health of the DHS workforce.

Headquarters Level

Responsibility for health promotion programs (sometimes called wellness programs)19 at the headquarters level is divided between OHA and OCHCO, and the respective roles of each are not always clear, even to DHS staff (Hope, 2013b). OCHCO administers the department’s work-life program and provides components with resources and guidance on their health promotion and employee assistance programs. OCHCO also recently initi-

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19For consistency, and to emphasize the health-related nature of this function, the committee uses the term health promotion rather than wellness.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

ated a concurrence process for the first official DHS health and wellness policy, whose goal is to provide the department and its components with a “very general baseline” and affirm DHS’s commitment to employee health and wellness. In 2009, in response to a request from Deputy Secretary Lute, OHA created the DHSTogether program to focus on building resilience and wellness capacity throughout the department.20 The program provides components with guidance and a limited amount of seed money for the development of tools and programs that may have wider application within DHS (IOM, 2013). Until recently, this program was a collaborative effort of OHA and OCHCO,21 but it is now managed solely by OHA staff, and there is no clear coordination mechanism for the two offices with responsibility in this area.

Component Level

While OHA and OCHCO offer support and guidance for health promotion and resilience programs, it ultimately is left to the components to decide what level of services will be available to their workforce. The committee found that health promotion services often are combined with worklife services (financial management, legal assistance, family support), with employee assistance programs spanning these two categories and offering help with stress management, substance abuse, and mental health counseling. Common health promotion services include voluntary vaccination programs, health screening (diabetes, cholesterol, blood pressure), nutrition counseling, and online health risk assessments. In many cases, these services are outsourced to Federal Occupational Health or private contractors. Fitness is promoted in many components through fitness challenges, and in some cases by allowing employees to use work time for fitness activities;22 fitness facilities are available at some sites (IOM, 2013).

Even though many DHS employees have physically and mentally demanding jobs, in few cases is there a clear link between health promotion efforts and readiness outcomes. In the Coast Guard, health promotion efforts are built into the mandatory annual periodic health assessment, whose

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20The IOM Committee on Department of Homeland Security Workforce Resilience was convened to examine this program. That committee identified a number of gaps and presented recommendations and the foundations for a 5-year strategic plan for building a more ready and resilient workforce at DHS. The committee’s report is freely available for download via the National Academies Press website: http://www.nap.edu/catalog.php?record_id=18407 (accessed January 27, 2014).

21A staff person from OCHCO was detailed to spend 50 percent time on the program (IOM, 2013).

22FEMA allows employees to use 3 hours per week for fitness activities, and CBP currently is piloting a similar program (IOM, 2013).

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

completion is one of the Coast Guard’s readiness measures. The periodic health assessment includes a health risk assessment and clinical preventive services (e.g., vaccinations), and it addresses prevention of disease and injury by focusing on prevention strategies each member can incorporate into his/her lifestyle (USCG, 2011a). FAMS currently is developing an employee health and fitness program with the goal of effecting meaningful change in both the health of its workforce and its mission readiness (FAMS, 2013c). This program is a collaborative effort of an Integrated Product Team with representation from the FAMS Medical Programs Section, the Field Operations Division, and the Law Enforcement and Industry Training Division. The program will be managed at the local level by certified trainers and will include physical fitness education and training, nutrition education, health risk assessments, sanctioned fitness events, and easily accessible online tools and resources supporting health and wellness (FAMS, 2013c).

Measurement and Evaluation

Little has been done at the component or headquarters level (within OHA or OCHCO) to understand the major health risks affecting productivity, health costs, and workforce readiness at DHS. Several components offer health risk assessments, but to the committee’s knowledge, only the Coast Guard aggregates these data (for active-duty/reserve personnel only) into population health summaries that can be used to determine future programmatic needs (NMCPHC, 2012). Absent this kind of analysis, resources cannot be targeted to those risks with the largest impact, nor does DHS have the baseline information necessary to measure the effectiveness of interventions. The committee did not learn of any efforts to evaluate the effectiveness of health promotion programs or of metrics being collected for this purpose.23 Most data collection efforts are limited to tracking of utilization. In some cases, utilization data are used to determine future program offerings.

PROVIDING MEDICAL SUPPORT FOR OPERATIONS

As discussed in Chapter 3, key functions for providing operational medical support include medical threat assessment, preventive medicine, ambulatory medical care, and emergency medical services. Because of the

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23The Coast Guard reported that it is waiting until its new Integrated Health Information System is implemented to establish goals and metrics and evaluate the effectiveness of health and wellness interventions. FAMS indicated that it currently is working to identify measure-able quality indicators that can be used to evaluate short- and long-term outcomes of its new Employee Health and Fitness Program (FAMS, 2013c).

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

security-sensitive nature of such programs, however, the committee was unable to gather sufficient information to describe how each of these functions is carried out within the context of DHS operational medicine programs. In the following sections, therefore, several operational medicine programs are described more generally. This is followed by a discussion of challenges identified by the committee to the development of a coordinated DHS operational medicine capability.

Operational Medicine Programs at DHS

Headquarters Level

Among the CMO’s delegated responsibilities is support for “component leadership to ensure that operations have appropriate medical support” (DHS, 2008a). OHA initiatives to this end (DHS, 2010b) include

 

  • development of a strategy to ensure that DHS employees have robust occupational health support when they deploy in support of the DHS mission, and
  • participation in planning and exercise efforts to ensure that plans and procedures provide for medical and health support to DHS responders.

Within OHA’s Workforce Health and Medical Support Division is the Medical First Responder Coordination Branch, which facilitates operational medical support for mission-essential personnel. “The Branch works to identify first responder best practices; provides guidance and support for the implementation of those practices; and addresses gaps in first responder disaster planning, resources, and education” (DHS, 2013).

Within DHS are thousands of emergency medical services (EMS) providers whose primary focus is protecting the workforce during operations. Many component EMS systems were in place prior to the formation of DHS. As a result, EMS programs vary significantly across the department. OHA is working with the components represented in the Emergency Medical Services Training and Education Advisory Committee to align programs, ensure consistency with national standards, disseminate best practices and lessons learned, and improve efficiencies by sharing resources (DHS, 2012b). Through the collaborative efforts of the Emergency Medical Services Training and Education Advisory Committee, the CMO has promulgated standards and guidance materials for DHS EMS services, including the DHS Medical Services System Strategic Framework; the DHS Emergency Medical Services System Plan; and the DHS-Wide EMS Basic Life Support and Advanced Life Support Protocols, which provide floor and

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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ceiling standards of care for DHS EMS providers. Although this example of alignment and coordination represents a significant success for DHS, additional challenges remain for both EMS and the department’s broader operational medicine capability, as discussed later in this chapter.

Component Level

Within DHS are nine components with EMS or operational medicine functions in support of their workforce: CBP, ICE, FEMA, NPPD, the Federal Law Enforcement Training Center (FLETC), TSA, Science & Technology, the Secret Service, and the Coast Guard. In USCIS, duties that fall outside of conventional workspace are carried out overseas, where employees are covered through an International Cooperative Administrative Support Services agreement with the Department of State.24

Customs and Border Protection There are three primary operational offices within CBP—the Office of Border Patrol, the Office of Field Operations (Customs), and the Office of Air and Marine—all with the ability to provide medical support during operations. CBP’s Advanced Training Center has its own EMS program to support training activities. In total, CBP employs approximately 1,300 EMS providers—second in number only to the Coast Guard within DHS—who are embedded in operational units to provide medical support to employees, detainees, and the public when needed (Seifarth, 2013a). The vast majority of these personnel (about 1,000) are employed by the Border Patrol. Because they often operate as a collateral duty, it has been difficult to ensure even dispersal of the medical support capability across large areas, such as the southwest border (Wilson, 2013). As a result, EMS providers are not present at all Border Patrol and Customs stations at all times. The Office of Air and Marine currently has 50 EMS providers in support of its workforce and also offers medevac capabilities.

Coordination of medical activities across the operational offices and medical direction are provided by CBP’s Senior Medical Advisor, who reports directly to the Executive Director of the Joint Operations Directorate and the DHS CMO (Caneva, 2013). Medical direction is supplemented by nonfederal local medical directors because of the volume and size of the program.

Border Patrol agents work largely in high-risk and austere environments, often far from city centers and medical assistance. To address these

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24Some USCIS employees may be deployed temporarily to refugee areas. Refugee Corps employees who are deployed undergo Type A physicals and receive a 2-day Department of State overseas training course and a health lecture provided by Federal Occupational Health.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

challenging operational realities, the Border Patrol has trained a number of specialty medical providers who are embedded within operational teams. BORSTAR, the Border Patrol Search, Trauma, and Rescue Unit, is “a highly specialized unit capable of responding to emergency search and rescue situations anywhere in the United States” (CBP, 2009, p. 1). Becoming a member of the BORSTAR unit is a collateral duty, requiring 5 weeks of academy training. Following this basic training, BORSTAR agents complete an emergency medical technician (EMT) course to be certified as a Basic EMT; some agents go on to receive additional training, including paramedic training (CBP, 2009). The BORSTAR unit works closely with Border Patrol Tactical Units (SWAT-like tactical teams) and Special Response Teams, providing medical and other support during training and operations (CBP, 2009). Currently, there are approximately 200 BORSTAR agents with minimum certification as an EMT and 24 advanced-scope practitioners who have completed a specialized austere medicine training course (Bowcutt, 2013).

Although CBP has a relatively large force of EMS providers, notably absent are medical personnel with appropriate training to handle more routine and nonemergent medical issues that arise along the southwest border and other operational areas. The committee learned that a significant personnel drain along the southern border sectors is associated with the requirement for Board Patrol agents to escort detainees to medical facilities for medical clearance (prior to turnover to ICE or Health and Human Services in the case of children) and treatment of any injuries and illnesses (Polk, 2013; Zapata, 2013). The nearest emergency departments sometimes are hours away, and the use of emergency departments for medical clearance and treatment of minor injuries has led to significant and avoidable hospital costs (approximately $13 million for emergency department visits in fiscal year 2011) (Polk, 2013; Zapata, 2013).

Immigration and Customs Enforcement Within ICE’s Management and Administration Directorate, the National Firearms and Tactical Training Unit (NFTTU) provides armory services; training; guidance; and tactical and logistical support, including medical support for operations. NFTTU’s National Emergency Medical Services Program employs 50 EMTs and 3 paramedics (Davis, 2013), providing tactical medics who are embedded with ICE Special Response Teams—tactical teams “trained to conduct and/or manage high-risk enforcement operations using specialized weapons, tactics and equipment” (ICE, 2009, p. 3). Embedded medics provide medical threat assessments in advance of operations, preventive medicine and sick call care for force sustainment, and care under fire, and assist in transporting injured persons out of the hot zone. Medical providers also can be embedded in rapid response teams to support ICE staff deployed

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

to disaster sites, as occurred during Hurricane Katrina (Davis and Tang, 2006). Through a partnership with the Johns Hopkins Center for Law Enforcement Medicine, ICE utilizes a contracted physician advisor to provide continuing education and training, quality assurance, and access to clinical sites (Seifarth, 2013b; Tang, 2013).

U.S. Secret Service The Secret Service’s current medical support program was conceptualized in 1999 and developed with a systems approach using the National Highway Traffic Safety Administration’s criteria for EMS system development, which address training resources, medical oversight, logistics, and communications. The program provides medical support for national special security events and for protection details, both within and outside the United States. Medical direction and clinical training for practitioners are provided by the Johns Hopkins Center for Law Enforcement Medicine, which also provides referral services for occupational health issues (Stair, 2013).

To meet its operational medicine needs, particularly for national special security events, the Secret Service developed an advanced-scope Emergency Services Specialist position—paramedics trained in operational emergency medicine with a background in firefighting, hazmat, and rescue (Stair, 2013). This position enables the Secret Service to provide emergency services support in addition to emergency medicine (the capability to address hazardous materials and issues related to chemical, biological, explosive, radiological, and nuclear events, as well as rescue situations), a goal of which is to ensure greater self-sufficiency during national special security events. At national special security events, Emergency Services Specialists operate as part of three-person teams, which also include a physician and an agent, allowing them to deal with critical issues and patients where they are found. Given the small size of the Secret Service’s highly trained and specialized workforce, an operational medicine capability is critical to help prevent any mission-jeopardizing personnel losses. Within its workforce, the Secret Service currently has 330 agents who are trained as EMTs, 10 of whom are advanced providers. Also notable is that all gun carriers in the Secret Service are trained as first responders as part of the core training curriculum at the U.S. Secret Service James T. Rowley Training Center (Seifarth, 2013a).

Federal Air Marshal Service and Federal Emergency Management Agency FAMS and FEMA both employ EMS providers who can provide medical support for operations. The FAMS EMS providers have the ability to provide medical support to TSA employees at airports if, for example, a terminal must be closed off because of a security situation; during emergency situations on air flights, they may also provide emergency medical care to

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

members of the public. FEMA medical providers operate primarily in the context of urban search and rescue teams, providing support to team members and rescued individuals. However, these medical assets are controlled (e.g., subject to quality assurance) by the team’s sponsoring agency.

Measurement and Evaluation

Continuous quality improvement in the delivery of medical support services can be facilitated by run reviews.25 Deficiencies noted during such reviews can be used to direct future training and education efforts, thus closing the loop in the cycle of improvement. Although 100 percent run review has been easily attainable for components with low patient encounter volumes, such as ICE, others, such as CBP, have been unable to evaluate all patient encounters. With the adoption of the electronic patient care record, however, run review levels are expected to increase. The electronic patient care record also enables aggregation of other data (e.g., types of injuries, patient volume by geographic location) that can be analyzed at the headquarters or component level. This kind of data analysis could help direct training and/or resource deployment.

Challenges to a DHS Operational Medicine Capability

Among the challenges to the development of a DHS-wide operational medicine capability are the need to maintain skills and proficiency and the difficulty of advocating for appropriate resource investments.

Maintenance of Skills and Proficiency

One of the greatest challenges faced by EMS and operational medicine programs at DHS is maintaining the clinical competency of the medical providers (Seifarth, 2013a). For many providers, their role as EMTs or paramedics within their agency is a collateral duty. Additionally, since the primary medical function is force sustainment, call volumes may be very low. For example, providers in ICE’s operational medicine program may encounter only nine patients on average per year (Seifarth, 2013b). In addition, team mobility poses a challenge to integrating providers into local EMS systems for continued skills training (Wilson, 2013). Despite these challenges, standards of medical care must be maintained; they are

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25Also called record reviews, run reviews entail reviewing patient records for “appropriateness of documentation; disease management; age-appropriate treatment and preventive care; outcome review; continuum of care review; procedures performed; and protocol management” (Medical Quality Management Instruction 248-01-001).

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

not subject to the mission context and operational requirements. When providers cannot meet prospectively determined standards, they must be prohibited from practicing on behalf of the department until they can reachieve those standards (Tang, 2013). Nonetheless, a liability risk arises when providers fall out of certification but are needed to provide patient care in the event of a medical emergency. In such cases, providers may act out of obligation regardless of certification status.

Some DHS providers of medical care may maintain their skills through involvement in their local community EMS system (Matthews, 2013), but DHS still must have a means of determining their competency. One of the key questions for the committee is whether the programs of DHS components are being held to different standards. Varying approaches have been taken to medical direction at DHS. At CBP, a component medical officer is providing medical direction, supplemented by local physicians across the country. Other components have outsourced medical direction. ICE and the Secret Service both use contracted medical direction provided by the Johns Hopkins Center for Law Enforcement Medicine. In the absence of a centralized policy promulgated by the DHS CMO that specifies content and benchmarks for competency assessments, different medical directors may be holding providers to different quality care standards. Of note, DHS’s Medical Quality Management Directive (DHS, 2012c) and Instruction (DHS, 2012d) provide some requirements for component programs—for example, competency reviews are to be conducted at least twice per year—but do not specify assessment criteria.

Difficulty of Advocating for Appropriate Resource Investments

A second but closely related challenge reported to the committee is the difficulty of communicating the critical importance of an operational medicine capability to nonmedical component leaders who control resources. An investment is required to ensure that an adequate number of providers is available and to keep their certification up to date. Beyond the monetary investment, leadership commitment is needed to allow individuals to use work time to participate in training and clinical rotations (Tang, 2013). Border Patrol Assistant Chief David Wilson explained to the committee that with more than 1,000 EMTs and paramedics, potentially hundreds may be about to go out of certification at any given time (Wilson, 2013). In the absence of validated measures of program effectiveness and impact, convincing leadership of the need to invest resources in this capability can be a challenge. Additionally, those who understand the critical nature of such programs are not always in a position to advocate on their behalf.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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INTEGRATION OF WORKFORCE HEALTH PROTECTION FUNCTIONS AT DHS

In the preceding sections, DHS’s execution of the key workforce health protection functions that make up the framework laid out in Chapter 3 is described. As asserted in that chapter, however, these key functions should not operate in silos. A review of multiple private- and public-sector organizations revealed that efficiency and synergy can be achieved through organizational and functional integration. Infrastructure that supports integration includes the doctrine (plans, policies, standards), organizational constructs (reporting structures, governance mechanisms), and resources (personnel, information management systems) that enable mission capability. Mechanisms for integration of workforce health protection functions at DHS are described below. The committee was asked to perform case studies to explore the potential impacts of an integrated infrastructure, including the estimated cost savings. In the course of its information gathering, the committee learned of a program within DHS that provides an exemplary case study of the potential benefits—to mission, to costs, and to esprit de corps—that can be achieved through an integrated workforce health protection system. This case study—of the FAMS integrated medical program—is presented at the end of this section.

Integration Across DHS Headquarters Offices

Because responsibility for workforce health protection programs currently is divided between OHA and OCHCO, mechanisms are needed to facilitate horizontal integration at the headquarters level. In accordance with DHS Management Directive 066-01 (DHS, 2008b), the CMO and the Chief Human Capital Officer serve as co-chairs of the department’s Safety, Health, and Medical Council, whose purpose is to “support development of overarching safety, health and medical program policy, and the development of integrated tools and processes to support program functions” (OCAO and OHA, 2009). The Council also was intended to ensure successful coordination during an event of national significance (e.g., pandemic influenza). However, the Council currently is inactive, for reasons not clear to the committee. Prior to the departure of acting CMO J. D. Polk, there was some discussion of establishing a DHS Prevention Council in coordination with the Management Directorate that would be similar in scope to the National Prevention Council and serve a similar purpose (National Prevention Council, 2013). However, this initiative was stalled with the change in OHA leadership. On an ad hoc basis, working groups with representatives from multiple headquarters-level offices are formed to address issues with broad departmental impact. For example, OHA and

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

occupational safety and health staff participate in a working group with the DHS Office of Operations Coordination and Planning addressing pandemic influenza preparedness plans.

An MOU was created to delineate health program responsibilities of the Office of the Chief Administrative Officer26 and OHA (see Appendix B). This document, dated September 30, 2009,27 includes a list of health and medical program areas and designates the Office of the Chief Administrative Officer or OHA as having “shared, primary, or assist” responsibility for each. For example, Disaster Response is a shared responsibility, while Hazard Analysis is the primary responsibility of the Office of the Chief Administrative Officer with OHA assist. Medical Surveillance is listed as an OHA primary responsibility with Office of the Chief Administrative Officer assist. However, a footnote states that OHA responsibility is this area (and in others listed in the document) is “in an oversight role” and that the Chief Human Capital Officer “may provide services for these activities” (OCAO and OHA, 2009). It is unclear to the committee how oversight and service provision can be adequately coordinated in the absence of a functional coordination mechanism such as the Safety, Health, and Medical Council described above. In fact, the committee learned that OHA does not provide oversight for medical surveillance; monitoring of such programs for OSHA compliance is being carried out by the safety and health program staff in OCHCO.

Vertical Integration Between Headquarters and Components

Vertical integration between headquarters and components for safety and health functions is facilitated by DHS-wide policy, such as the DHS Occupational Safety and Health Manual (2010a), and by the DHS Safety Manager’s Forum, which includes all component safety and health managers and meets periodically to discuss department-wide programs and issues of concern. OHA also has developed chartered committees (e.g., the Health Care Quality Committee) and ad hoc working groups (e.g., the Electronic Health Information System Working Group) with component representatives to facilitate vertical coordination of policy and programmatic direction. OHA global policy and standards to this end include management directives and instructions (medical quality management and medical countermeasures) and standards of care for EMS providers. More recently, Senior Medical Advisors (see Box 4-3) have been helping to address issues

__________________

26The Chief Administrative Officer was the Designated Agency Safety and Health Official prior to the detailing of the safety and health program to OCHCO. The Chief Human Capital Officer has now assumed these responsibilities.

27Revisions to the MOU have been discussed but are currently on hold (Anderson, 2013).

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

BOX 4-3
The DHS Medical Liaison Officer Program

In 2011, DHS created the Medical Liaison Officer (MLO) program, whose goals are to ensure standardized and centralized medical oversight, enhance preparedness, increase medical protection, and increase health and workforce readiness. The MLO program supports Senior Medical Advisors (SMAs), physicians who report dually to the CMO and an assigned component, providing policy support and guidance on occupational health and workforce readiness issues, facilitating effective alignment of medical initiatives, and providing consistent clinical oversight throughout DHS (Patrick, 2013). SMAs create two-way information channels, conveying policies and guidance from OHA down to the component level while raising the Chief Medical Officer’s awareness of components’ health and medical challenges. Above all, they are advocates for workforce health protection.

There are currently five SMAs involved with the program, hired to address different areas of health or medical concern within components (e.g., fitness for duty, operational medicine). As a result, SMAs represent a broad array of background experience and training.

 

  • Customs and Border Protection (CBP): One SMA reports directly to the Joint Operations Directorate’s Executive Director, coordinating medical oversight and operational medicine activities across subcomponent agencies. A second SMA was recently hired to help integrate all occupational health functions across the Office of Human Resources Management.
  • Federal Emergency Management Agency (FEMA): The SMA is stationed in the Office of Response and Recovery, reporting directly to the Associate Administrator and with access to FEMA’s Deputy Administrator. The SMA’s primary focus has been on fitness for duty, and he is currently working to develop medical standards and clearance processes for Incident Management Assistance Teams.
  • Immigration and Customs Enforcement (ICE): The SMA is stationed in the Office of Human Capital, addressing issues related to fitness for duty, including a medical standards and waivers program.
  • Transportation Security Administration (TSA): Brought in to facilitate integration of medical and health functions across the agency, the SMA is stationed in the Medical Review Programs Branch and reports directly to the Chief Human Capital Officer.

of horizontal and vertical integration for medical programs and policies. Although this initiative is still evolving, the committee believes it has great potential to address the some of the integration challenges facing the DHS health system.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Integration Within Components

Components have used different methods to align and integrate workforce health protection functions. These methods include organizational alignment (into a single reporting structure), formation of multidisciplinary work groups (Integrated Product Teams), and information sharing through health and safety information technology systems. Examples are presented below.

In the Coast Guard, the Health Services, Safety and Environmental Health, and Work-Life offices are aligned organizationally into a single directorate, with one leader overseeing and accountable for all workforce health protection functions. Thus all health and medical policies affecting both military and civilian personnel are aligned (Dollymore, 2013). The Coast Guard currently is developing an Integrated Health Information System, which will provide for additional integration by ensuring timely electronic data capture for all workforce protection metrics currently captured by the numerous systems now in place.

In FEMA, the Safety, Health, and Medical Readiness Division creates an aligned reporting structure, facilitating integration of occupational health, environmental safety and health, and disaster operations activities (Brown, 2013; Crarey, 2013). The committee heard that this organizational configuration and regular meetings facilitate information sharing, coordination of activities, and joint planning among Branch Chiefs.

CBP has aligned all occupational health functions (although not operational medicine functions, which are managed at the subcomponent level) under the Office of Human Resources Management. However, there has been no health or medical professional with oversight responsibility to ensure functional integration. A Senior Medical Advisor recently was hired within Human Resources Management for this purpose (Caneva, 2013). CBP reported to the committee that these divisions communicate consistently to ensure coordination, although the separation of the workers’ compensation and safety and health functions was noted as a disadvantage (Rupard, 2013). Interdivisional working groups, such as one established to conduct an extensive study aimed at reducing injuries and workers’ compensation costs, facilitate coordination. Information technology systems also facilitate information sharing, primarily between workers’ compensation and safety programs. CBP has extensive fitness-for-duty activities. The committee noted surprising separation among those coordinating preplacement evaluations, those managing fitness-for-duty evaluations for employees, and disability management functions, all of which are organizationally separated.

TSA is not organizationally aligned; its workforce health protection functions are divided between the Office of Human Capital (medical

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

programs) and the Office of Finance and Administration (occupational safety, health, and environment). To facilitate integration, TSA has used Integrated Product Teams, such as the Optimization, Safety, and Hazard Mitigation Integrated Product Team (comprising personnel in safety and health, workers’ compensation, security operations, and development of standard operating procedures), formed to examine root causes of high injury rates and plan solutions (Segraves, 2013). Safety and health staff also partner directly with the Workers’ Compensation Office, reviewing on a daily basis every injury and illness reported through the Injury Care Hotline to identify trends and provide guidance and assistance to TSA field organizations when necessary. This integration is facilitated through TSA’s Safety Information System, which consolidates information on workers’ compensation claims, incident analysis, safety inspections, job hazard analyses, and process risk. When an injury claim form is filed through the Safety Information System, the occupational safety and health office is immediately notified, and pertinent data are provided to each administrative function. Within TSA, FAMS has its own integrated medical program, which includes occupational safety, health and environment, as well as EMS functions. This model program, and the benefits that have been realized through integration, are discussed in Box 4-4.

OPPORTUNITIES TO ADVANCE WORKFORCE HEALTH AT DHS: GAP ANALYSIS

Although a number of successful and promising practices are identified in the sections above, the overall picture of workforce health protection at DHS is one that is marginalized, fragmented, and markedly uneven. As a result, DHS is not realizing the many benefits of integration, including increased efficiency, interoperability, and synergy. As discussed in Chapter 3, the committee examined multiple public- and private-sector organizations, and from those evaluations, as well as current best practices available in the published literature, identified four elements essential to successful integration of workforce health programs: leadership commitment to workforce health, organizational alignment and coordination, functional alignment, and information management. During its review and assessment of the current occupational health and operational medicine infrastructure at DHS (discussed throughout this and earlier chapters), the committee considered the degree to which these essential characteristics are represented. Ultimately, deficiencies in each of these areas drove the committee’s recommendations in Chapters 5 through 8.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

Leadership Commitment to Workforce Health

Instilling the values of safety and health into the culture of the organization was key to the success of many of the programs the committee examined. This process begins with a vision of a safe, healthy, and resilient workforce, put forth by organizational leadership committed to its realization. The gaps described throughout this chapter and summarized below indicate a need for DHS leadership to promote and resource workforce health programs, to communicate their essential role in mission readiness, and to ensure accountability across the department.

Organizational Alignment and Coordination

Organizations with integrated health systems examined by the committee took steps to ensure coordination among those with responsibility for key health protection functions, although approaches to this end varied. Some combined all workforce health protection functions into a single reporting structure, while others with segregated health protection functions instituted measures designed to ensure alignment through systematic communication and coordination. DHS has not adequately executed either of these two approaches to organizational alignment, even though there is much shared responsibility among headquarters offices and components for workforce health protection functions to support mission readiness. Most notably, the respective responsibilities of OHA and OCHCO often are unclear, and coordination mechanisms are inadequate. Vertical integration is impeded by the absence of clear health leaders at both the headquarters and component levels. Achieving optimal readiness requires close coordination of activities frequently located in separate silos at DHS headquarters and within components. The degree of organizational alignment varies across the department, and as a result, a disconnect often exists between programs that should be working hand in hand.

Functional Alignment

Large, dispersed organizations in both government and the private sector rely on standards and global policies to ensure that operational units are achieving expectations for workforce health protection throughout the organization. The committee noted significant variability in the implementation and resourcing of workforce health protection programs across DHS. Although variability is not unexpected for such a large and diverse organization, failure to ensure consistency in certain critical functions represents a liability for the agency. The committee identified a paucity of global health and medical policies and standards with which to set clear expectations and

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

BOX 4-4
Case Study on the Federal Air Marshal Service: Promoting
and Maintaining a Culture of Health, Safety, and Readiness

The Federal Air Marshal Service (FAMS) is an operating unit of the Transportation Security Administration (TSA). Although FAMS has a history dating back to 1962, it has expanded significantly since the events of September 11, 2001. It is charged today with providing security aboard civilian commercial aircraft flying both domestically and internationally. Its agents are fully qualified and armed law enforcement officers. They provide round-the-clock coverage to fulfill this critical population safety mission and must be healthy both mentally and physically to discharge their responsibilities. Lost time due to injuries and other occupational health events can degrade the agency’s capability to carry out its mission.

Accordingly, beginning in 2007, an integrated program of activities related to nurse case management, fitness for duty, and workers’ compensation was initiated. This program, which is overseen by an internal medical director, was developed after extensive review of the literature and best practices in occupational safety and health in both the public and private sectors, which informed the policies and program design. The program is characterized by the use of defined standards and frequent review of program performance. The primary metrics focus on processes (e.g., timely and appropriate activities of the nurse case managers, such as ensuring contact with an injured agent within 48 hours of the injury) and outcomes (e.g., decreases in time lost due to injury, fitness of agents both individually and collectively against standards, workers’ compensation costs). Ultimately, the availability of agents for mission days is the most important metric to both the program and agency leadership. Between 2009 and 2010, through the efforts of its integrated nurse case management program, FAMS achieved a 20 percent reduction in lost mission opportunities, as well as a 5 percent reduction in workers’ compensation costs (approximately $500,000) (FAMS, 2013b).

The FAMS program has been highly integrated, involving daily collaboration of personnel in nurse case management; workers’ compensation; and occupational safety, health, and environment. This high level of integration—promoted by leadership commitment and a strong culture of health and safety, even though the Office of Workers’ Compensation Programs (OWCP) is organizationally separate from the other two groups—permits real-time injury investigations and shared communications.

An important feature of the program since its inception has been the integration of information and planning between the in-house nurse case managers and the OWCP coordinator. Clinical staff and the administrative coordinator for OWCP are collocated and meet both formally and informally on a routine basis to review individual cases and collective performance. This review includes an analysis of the types, frequency, severity, and impact of various causes of lost work time. This

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

information has been used to improve rehabilitation and prevention activities in a targeted manner (e.g., changing training practices), thereby reducing injuries and workers’ compensation claims, speeding recovery, and improving mission readiness. Use of this information also has resulted in a reduction in costs, although the recent relocation of the OWCP coordinator from the FAMS reporting structure back to TSA central offices has disrupted communications, and increases in workers’ compensation costs have since been noted.

The involvement of line supervisors was an important and early success of the program. Routine in-service education of supervisory agents is provided. Timely and concise discussion of individual cases takes place between the nurse case managers and supervisors to ensure a clear understanding of patient needs and limitations while respecting the patient’s privacy and concerns regarding adverse job actions. This communication strategy has engendered strong support for the program among supervisors and consideration of individual patient needs, and enhanced the trust relationship between patients and nurse case managers.

The nurse case manager’s role is critical and multifaceted. FAMS employs these occupational health nurses directly to maximize their involvement and familiarity with the agency’s mission and medical requirements, as well as the needs of its employees. The nurses have demonstrated clinical acumen and developed strong patient relationships that have made them a trusted part of the workforce. This close and lasting relationship has contributed to increased communication, improved reporting, enhanced patient education and recovery planning, and more effective recovery from work-related health issues.

Another exemplary feature of the program is the Employee Health and Fitness Program, recently initiated through a partnership among the FAMS Medical Programs Section, the Field Operations Division, and TSA’s Law Enforcement and Industry Training Division (FAMS, 2013c). This comprehensive employee wellness program has as its goal achieving improvements in employee health that will ensure mission readiness. The program will employ workplace illness data as well as individual health risk assessments to design and implement targeted health education (e.g., nutrition education, stress reduction, fitness knowledge) and fitness training and activities. Metrics have been developed with which to assess the program’s impact on both individuals and the overall success of the agency’s mission.

In summary, this integrated FAMS program has utilized medical and public health best practices to assess and improve the health of the agency’s employees. It has integrated fitness-for-duty evaluation, workplace and job task assessment and modification, return-to-work practices, and workers’ compensation management. It has used targeted metrics and assessments to measure and improve its performance. Finally, it has carried out an important function in ensuring that the agency can successfully fulfill its mission of providing security aboard civilian aircraft in difficult and demanding times.

Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
×

the absence of mechanisms to ensure that core quality and performance requirements are being met by all components as major barriers to DHS’s realization of an integrated health protection infrastructure.

Information Management

The sharing of information and knowledge throughout an organization is essential to breaking down silos and promoting integration. To this end, systematic data collection is required at the component level, along with mechanisms for consolidating information from across the enterprise. DHS has not implemented systems to meet either of these requirements. As a result, it has little in the way of a global-level view of employee health, safety, and readiness or knowledge regarding the major, cross-cutting impediments to achieving those outcomes. Unless this gap is addressed, a unified approach to advancing workforce health across the department cannot be achieved.

Organization of the Committee’s Recommendations

The gaps described above represent significant barriers to DHS’s ability to optimize its mission readiness by promoting and sustaining the health, safety, and resilience of its workforce. In the following chapters, the committee provides recommendations on steps DHS can take to address these gaps. The need for committed senior DHS leadership is first and foremost, as discussed in Chapter 5. The recommendations in Chapter 6 lay out a path for achieving organizational alignment through consolidated reporting structures and strong coordination mechanisms. In Chapter 7, the committee provides recommendations on how DHS can align critical functions that support mission readiness through global policies and programs that set clear expectations. Finally, in Chapter 8, recommendations focus on integration through the implementation of a systems approach to health and safety information management.

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Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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Suggested Citation:"4 The Current State of Workforce Health Protection at DHS." Institute of Medicine. 2014. Advancing Workforce Health at the Department of Homeland Security: Protecting Those Who Protect Us. Washington, DC: The National Academies Press. doi: 10.17226/18574.
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The more than 200,000 men and women that make up the Department of Homeland Security (DHS) workforce have been entrusted with the ultimate responsibility - ensuring that the homeland is safe, secure, and resilient against terrorism and other hazards. Every day, these dedicated individuals take on the critical and often dangerous challenges of the DHS mission: countering terrorism and enhancing national security, securing and managing the nation's borders, enforcing and administering U.S. immigration laws, protecting cyber networks and critical infrastructure, and ensuring resilience in the face of disasters. In return, DHS is responsible for protecting the health, safety, and resilience of those on whom it relies to achieve this mission, as well as ensuring effective management of the medical needs of persons who, in the course of mission execution, come into DHS care or custody.

Since its creation in 2002, DHS has been aggressively addressing the management challenges of integrating seven core operating component agencies and 18 supporting offices and directorates. One of those challenges is creating and sustaining a coordinated health protection infrastructure. Advancing Workforce Health at the Department of Homeland Security examines how to strengthen mission readiness while better meeting the health needs of the DHS workforce. This report reviews and assesses the agency's current occupational health and operational medicine infrastructure and, based on models and best practices from within and outside DHS, provides recommendations for achieving an integrated, DHS-wide health protection infrastructure with the necessary centralized oversight authority.

Protecting the homeland is physically and mentally demanding and entails many inherent risks, necessitating a DHS workforce that is mission ready. Among other things, mission readiness depends on (1) a workforce that is medically ready (free of health-related conditions that impede the ability to participate fully in operations and achieve mission goals), and (2) the capability, through an operational medicine program, to provide medical support for the workforce and others who come under the protection or control of DHS during routine, planned, and contingency operations. The recommendations of this report will assist DHS in meeting these two requirements through implementation an overarching workforce health protection strategy encompassing occupational health and operational medicine functions that serve to promote, protect, and restore the physical and mental well-being of the workforce.

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