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Suggested Citation:"1 Introduction." 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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1


Introduction

“The greatest asset of any organization is its workforce—without the people, the vision cannot be achieved or the mission accomplished.”

—General James B. Peake (IOM, 2013, p. xv)

 

 

The more than 200,000 men and women who make up the Department of Homeland Security (DHS) workforce have been entrusted with the ultimate responsibility—ensuring a homeland that 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 (DHS, 2010b). DHS, in turn, 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 more than a decade ago, DHS has been aggressively addressing the management challenges of integrating seven core operating component agencies1 and 18 supporting offices and directorates (DHS, 2010a; DHS OIG, 2012; GAO, 2012). One of those challenges is creating and sustaining a coordinated health protection infrastructure to support this heavily operational workforce. Seeking strategic advice on how to

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1DHS operating component agencies include U.S. Citizenship and Immigration Services, the U.S. Coast Guard, Customs and Border Protection, the Federal Emergency Management Agency, Immigration and Customs Enforcement, the U.S. Secret Service, and the Transportation Security Administration. Although the National Protection and Programs Directorate, which includes the Federal Protective Service, is officially a headquarters-level directorate, the committee considers it to be functionally an operating component.

Suggested Citation:"1 Introduction." 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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strengthen mission readiness while better meeting the needs of its workforce, DHS’s Office of Health Affairs (OHA) asked the Institute of Medicine (IOM) to provide recommendations for better integrating occupational health and operational medicine infrastructures throughout the department into a coordinated, DHS-wide system with the necessary centralized oversight authority. This report presents the findings, conclusions, and recommendations of the IOM committee empaneled to respond to this request.

BACKGROUND AND RATIONALE FOR THE STUDY

In DHS’s early years, the creation of an integrated and coordinated medical infrastructure was impeded by the absence of a centralized departmental entity with responsibility and authority for ensuring that the health of the entire DHS workforce was adequately promoted and protected (Lowell, 2005). OHA did not come into existence until 5 years after DHS was created, and as a result, many health- and medical-related activities fell, of necessity, to other headquarters offices—predominantly those with responsibility for managing the department’s human resources (Polk, 2013). Although human capital offices often play a critical role in the administration of workforce health protection programs, human resources personnel lack the medical and public health expertise necessary to guide the development of a coordinated health infrastructure.

Even after the creation of OHA and the Chief Medical Officer (CMO) position, a comprehensive understanding of the health needs of the DHS workforce remained elusive. Mechanisms were never put in place to ensure that employee health information would flow to the new centralized health authority for the department, nor was the CMO adequately empowered to ensure a coordinated approach to health risk reduction and effective health services department-wide. As a result, the CMO can see trailing indicators of the ineffectiveness of the current system but lacks the visibility and influence at the component agency level to know how best to direct resources for DHS-wide initiatives to address root causes.

Some component agencies, such as the Secret Service and the Coast Guard, have been in existence for more than a century and brought with them to DHS robust and effective workforce protection policies and processes. However, most component agencies are still working to put those kinds of systems in place. As a consequence, workforce health protection and medical services programs vary significantly across DHS, with little coordination and integration. The result has been preventable morbidity and mortality, avoidable liabilities, and inefficiency.

Suggested Citation:"1 Introduction." 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.
×

Evidence for this variability is seen in such traditional lagging indicators2 as the Total Case Rate and Lost Time Case Rate,3 which are standardized measures of the incidence of workplace injury and illness. Table 1-1 presents these data for 2012 for component agencies within DHS and other government agencies whose employees face similar workplace hazards. Although some differences in these metrics can be attributed to differences in missions and work environments, the rates vary significantly even among DHS agencies whose employees may face similar hazards (e.g., Immigration and Customs Enforcement and the Secret Service). DHS has the highest agency-wide Total Case Rate of all cabinet-level federal agencies (5.62 per 100 employees in 2012), and with a Total Case Rate of 9.44, Customs and Border Protection has the highest rate of any federal agency (OSHA, 2013). By comparison, these rates are significantly higher than those reported for hazardous private-sector occupations such as manufacturing (4.3), construction (3.7), and natural resources and mining (3.8), but comparable with those reported for public safety occupations at the state and local levels (6.5 and 10.4, respectively) (BLS, 2013).

High injury and illness rates have resulted in significant workers’ compensation costs for DHS, as shown in Table 1-2, which presents annual chargeback totals4 for DHS component agencies for 2010. For comparison purposes, data also are supplied for other cabinet-level departments. Because component workforces vary considerably in size, total costs can be

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2Lagging indicators are retrospective measurements of system performance linked to outcomes; these are the traditional measures of safety performance, such as occupational injury and illness rates and costs (Manuele, 2013). These indicators, however, have a key limitation: “While lagging indicators give information of direct concern to management, the workforce, and the public, they can only be used for improvement after the fact” (NRC, 2009, p. 8). Recent years have seen a shift in emphasis toward what have been termed leading indicators—in the safety context, prospective measures linked to actions taken to prevent accidents (Manuele, 2013).

3Total Case Rate 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. Lost Time Case Rate represents the number of claims resulting in lost workdays per 100 employees. These rates are calculated by dividing the number of total or lost-time workers’ compensation cases by the number of employees and multiplying by 100, for a rate per 100 employees (OSHA, 2013).

4Workers’ compensation chargeback costs are the dollar amounts that an employing agency must pay back to the Department of Labor’s Division of Federal Employees’ Compensation annually for all expenses related to workers’ compensation cases from that agency for the prior year. The Division of Federal Employees’ Compensation covers the costs associated with medical bills, lost wages (after 45 days), and schedule awards (for loss of, or loss of use of, body parts or functions) and then is reimbursed by the employing agency. It should be noted, however, that because annual chargeback costs reflect payments during that fiscal year for all open cases, regardless of when the injury occurred, this indicator is not very sensitive to recent improvements in prevention efforts.

Suggested Citation:"1 Introduction." 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.
×

TABLE 1-1 Federal Injury and Illness Statistics for Fiscal Year 2012 for DHS and Other Selected Federal Agencies

Department or Agency Employees Total Cases Total Case Rate Lost Time Cases Lost Time Case Rate Fatalities
Department of Homeland Security 198,542 11,156 5.62 4,779 2.41 6
Citizenship and Immigration Services   11,193     238 2.13     143 1.28 0
Customs and Border Protection   60,177 5,683 9.44 2,336 3.88 3
Immigration and Customs Enforcement   20,353     975 4.79     384 1.89 0
Federal Emergency Management Agency   17,083     281 1.64     122 0.71 2
Federal Law Enforcement Training Center     1,167         54 4.63       15 1.29 0
Transportation Security Administration   65,209   2,938 4.51   1,412 2.17 0
U.S. Coast Guard     8,935     279 3.12     200 2.24 1
U.S. Secret Service     6,821     143 2.1       47 0.69 0
DHS Other     7,604     565 7.43     120 1.58 0
Department of Justice 116,910   4,517 3.86 2,563 2.19 2
Bureau of Alcohol, Tobacco, Firearms, and Explosives     4,847     171 3.53       49 1.01 1
Bureau of Prisons   38,055   2,558 6.72   1,760 4.62 1
Drug Enforcement Administration     9,757     287 2.94       76 0.78 0
Federal Bureau of Investigation   35,776     932 2.61     447 1.25 0
U.S. Marshals Service     5,754     412 7.16     140 2.43 0
Suggested Citation:"1 Introduction." 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 the Interior*   80,764   4,215 5.22   1,482 1.83 9
Bureau of Indian Affairs     9,016     493 5.47     264 2.93 2
Bureau of Land Management   12,372     875 7.07     197 1.59 0
Bureau of Reclamation     5,477     230 4.2       58 1.06 0
Fish and Wildlife Service   10,407     473 4.55     103 0.99 1
National Park Service   27,982   1,798 6.43     761 2.72 6
Office of Surface Mining and Enforcement         512       15 2.93         7 1.37 0
U.S. Geological Survey     9,379     261 2.78       52 0.55 0

*Some Department of the Interior agencies (e.g., the Bureau of Land Management and National Park Service), like those within DHS, have notable populations of law enforcement personnel (e.g., national park rangers) and firefighters. Additionally, many Department of the Interior employees work in remote, austere areas and may face environmental hazards similar to those encountered by DHS employees. However, the proportions of employee populations in high-risk occupations may differ among these agencies, making direct comparisons of injury rates across departments problematic.

SOURCE: Data extracted from Department of Labor Occupational Safety and Health Administration Federal Agency Programs website in February 2013 (OSHA, 2013).

Suggested Citation:"1 Introduction." 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.
×

TABLE 1-2 Workers’ Compensation Costs by Federal Agency for 2010

Agency 2010 Annual Chargeback Total Actuarial Liability
Department of Homeland Security $160,502,455 $1,937,837,000
Customs and Border Protection $62,650,987 $773,590,146
Transportation Security Administration $42,871,729 $506,554,266
Immigration and Customs Enforcement $18,530,776 $211,097,509
U.S. Coast Guard $8,862,047 $108,590,146
Federal Emergency Management Agency $5,431,753 $59,464,544
Citizenship and Immigration Services $3,620,462 $43,173,691
Federal Law Enforcement Training Center $1,937,018 $20,843,114
Department of Veterans Affairs $182,212,000 $1,862,264,500
Department of Justice $104,573,000 $1,314,109,000
Department of Transportation $97,687,000 $976,754,100
Department of Agriculture $72,876,000 $881,454,200

NOTE: The committee could not be provided with data on Secret Service chargeback and actuarial liability costs.

SOURCE: Data on DHS workers’ compensation costs were supplied to the committee by the DHS Workers’ Compensation Program Manager and Policy Advisor (e-mail communication, Department of Homeland Security, response to IOM inquiry regarding department statistics: Chargeback totals and actuarial liability, February 20, 2013). The chargeback data for other federal agencies were extracted from Department of Labor (2013), and actuarial liability data were collected from http://www.dol.gov/ocfo/media/reports/20111005a.pdf (accessed December 19, 2013).

misleading; therefore, per capita chargeback costs for DHS component agencies are shown in Figure 1-1. In fiscal year 2011, the actuarial liability for DHS—the projected amount that DHS would have to reimburse the Department of Labor to cover all previously existing cases to resolution if the agency ceased to exist today—surpassed $2 billion.5 These costs represent a significant diversion of resources that might otherwise be devoted to achieving DHS’s mission.

Concerns about DHS’s current health protection systems and programs are further raised by the perceptions of the workforce regarding the health and safety aspects of working conditions, as captured in recent results of the Federal Employee Viewpoint Survey.6 In 2012, only 62 percent of DHS em-

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5E-mail communication, Department of Homeland Security, response to IOM inquiry regarding department statistics: Chargeback totals and actuarial liability, February 13, 2013.

6This survey, administered by the Office of Personnel Management, is a tool that measures employees’ perception of whether, and to what extent, conditions characterizing successful organizations are present in their agency. In 2012, the survey was offered to nearly 1.5 million federal employees, with a response rate of 46.1 percent. The data collected were weighted to produce survey estimates that accurately represent the survey population (OPM, 2012b).

Suggested Citation:"1 Introduction." 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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FIGURE 1-1 Fiscal year 2010 per capita chargeback costs.
NOTES: Data on Secret Service workers’ compensation costs could not be provided to the committee. Data for the Coast Guard are not depicted because of difficulties in obtaining an accurate estimate of the size of the Federal Employees’ Compensation Act–eligible workforce for that agency. CBP = Customs and Border Protection; FEMA = Federal Emergency Management Agency; ICE = Immigration and Customs Enforcement; TSA = Transportation Security Administration; USCIS = U.S. Citizenship and Immigration Services.

ployees indicated that they felt “protected from health and safety hazards on the job”—a significantly lower proportion than the government-wide average of 77 percent (OPM, 2012a). Although this figure represents an improvement relative to 2006, when just over half of DHS employees (53 percent) responded positively (OPM, 2011), there has been no sustained improvement in this area since 2008. For comparison purposes, other federal agencies with significant populations of public safety personnel, such as the Department of Justice and the Department of the Interior, had positive response rates closer to the government-wide average—74 and 79.2 percent, respectively, in 2012 (OPM, 2012b). The perception that employees are not adequately cared for and protected affects morale at DHS—a subject of past congressional hearings (U.S. House of Representatives, 2012)—and suggests inadequate attention in this area on the part of DHS leadership.

Box 1-1 provides a summary of the challenges related to workforce health protection at DHS discussed above and others that were highlighted by the sponsor during the presentation of the committee’s charge.

Suggested Citation:"1 Introduction." 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 1-1
Summary of Key Challenges Related to
Workforce Health Protection at DHS

 

  • The Office of Health Affairs was created 5 years after DHS was formed. After the Chief Medical Officer (CMO) position was created, mechanisms were never put in place to ensure that employee health information would flow to this new centralized health authority for the department (in part as the result of a lack of standardized reporting metrics and interoperable health information management systems).
  • Responsibility for oversight of workforce health protection functions is split between the Office of Health Affairs and the Office of the Chief Human Capital Officer. Mechanisms to ensure adequate coordination between these two offices are not functioning effectively. Moreover, the CMO has little visibility and strategic input on health functions overseen by the Chief Human Capital Officer, including those for which he or she has delegated oversight authority.
  • The health protection infrastructures of the component agencies, like the agencies themselves, are at different stages of maturity, resulting in a lack of uniformity in core competencies for employee health and safety programs across DHS.
  • Mechanisms to promote coordination and integration among component medical programs have only recently been introduced.
  • Injury and illness rates at DHS are higher than those at other federal agencies, associated annual workers’ compensation liability exceeds $150 million in chargeback costs, and many DHS employees do not feel protected from health and safety hazards on the job. These observations indicate that some component occupational health programs are not operating optimally.
  • Emergency room visits to address medical needs for detainees exceeded $12 million in fiscal year 2011, indicating that operational medicine programs are not adequately addressing the needs of those in DHS care or custody.

STUDY CHARGE AND SCOPE

Seeking strategic advice on how to strengthen mission readiness and protect the DHS workforce, OHA asked the IOM to review and assess the agency’s current occupational health and operational medicine infrastructure and, based on models and best practices from within and outside DHS, to provide recommendations for achieving an integrated, DHS-wide health protection infrastructure with the necessary centralized oversight authority (see Box 1-2 for the committee’s complete statement of task). While the study was sponsored by OHA, Senior Counselor to former Secretary Napolitano Judge Alice Hill spoke with the committee and expressed the support and appreciation of the Office of the Secretary.

Suggested Citation:"1 Introduction." 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 1-2
Committee on Department of Homeland Security Occupational
Health and Operational Medicine Infrastructure

Statement of Task

An ad hoc committee will review and assess the current agency-wide occupational health and operational medicine infrastructure at the Department of Homeland Security (DHS) and provide recommendations on how infrastructures within component agencies can be better integrated into a coordinated, DHS-wide system with the necessary centralized oversight authority. Specifically, the committee will

 

  • Review and assess DHS’s current occupational health and operational medicine infrastructure.
  • Explore the occupational health and operational medicine infrastructures established in other relevant federal agencies and organizations.
  • Identify the key functions of an integrated occupational health and operational medicine infrastructure.
  • Consider the necessary department oversight authority that will be required to ensure an integrated infrastructure.
  • Identify quality metrics that may be used for evidence-based quality improvements.
  • Perform case studies to explore the potential impacts of an integrated infrastructure, including the estimated cost savings.

In addressing the task, the committee will prioritize recommendations on short- and long-term measures DHS can adopt in order to optimize its mission readiness by assuring the health, safety, and resilience of its workforce; consideration will also be given to the impact of such measures on the agency’s liability and health care costs.

As described in the section on terminology below, the definition of operational medicine adopted by the committee encompasses health and medical support provided to persons in DHS care and custody during routine, planned, and contingency operations. However, assessment of health care provided to detainees within Immigration and Customs Enforcement detainment facilities, as well as the adequacy of the facilities themselves, was not considered to be within the scope of this study. Similarly, the provision of medical support to the American public during disasters and other applicable scenarios is the responsibility of the Department of Health and Human Services and as such was not addressed for this study

Suggested Citation:"1 Introduction." 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.
×

except as applicable under the committee’s adopted definition of operational medicine.

STUDY APPROACH

The committee had two objectives for the information-gathering phase of the study that were prerequisite to the development of its recommendations: (1) to collect information on the organizational structure, governance mechanisms, and policy background related to workforce health protection at DHS; and (2) to obtain the corresponding information for other government and private organizations that have successfully managed the same kinds of organizational and operational challenges faced by DHS and that might serve as models or sources of best practices.

To meet these objectives, the committee gathered information through a variety of means. First, it held three information-gathering meetings that were open to the public. The initial meeting, held in March 2013, focused on obtaining contextual background information from DHS, both at the headquarters level and from multiple component agencies on their medical infrastructures. Input was sought from the U.S. Office of Personnel Management on legal and regulatory issues relating to medical evaluation and clearance programs, and a representative from Federal Occupational Health7 presented on the outsourced occupational health services that agency provides to other federal agencies. In June 2013, the committee held a 2-day workshop at which it heard from experts representing DHS, other federal agencies, and private industry on occupational medicine, workers’ compensation programs, occupational safety and health, medical standards and clearance programs, operational medicine, and DHS’s Medical Liaison Officer Program. A third meeting, held in July 2013, was devoted to the issue of organizational effectiveness at DHS. Agendas for these meetings can be found in Appendix F.

The committee received public submissions of materials for its consideration at its meetings and by e-mail throughout the course of the study.8 A website was created to provide information to the public about the study and to facilitate communication with the committee.9 Throughout the study process, the committee reviewed publicly available literature, and also requested documents and information from DHS to better inform

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7Federal Occupational Health is a nonappropriated agency within the U.S. Department of Health and Human Services and is the largest provider of occupational health and wellness services to the federal government (FOH, 2013).

8A list of materials submitted to the committee’s public access file can be requested from the National Academies’ Public Access Records Office via http://www8.nationalacademies.org/cp/ManageRequest.aspx?key=49507.

9See http://www.iom.edu/DHSocchealthopmed.

Suggested Citation:"1 Introduction." 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.
×

its deliberations. To assess the extent of variability of and ensure a fair comparison across component agency programs, the committee drafted standardized lists of questions soliciting detailed information on the agencies’ medical, occupational safety and health, workers’ compensation, and wellness programs. The question lists (which can be found in Appendix D) were provided to component agency program managers, who were asked to submit written responses.10 The committee used the responses received in reviewing and assessing the current occupational health and operational medicine infrastructure at DHS, as described in Chapter 4 and throughout the report.

In 2012, OHA also asked the IOM to convene a committee to review its current workforce resilience efforts, identify gaps, and provide recommendations for a 5-year workforce resilience strategic plan (IOM, 2013). That committee began its work in December 2012 and publicly released its report, A Ready and Resilient Workforce for the Department of Homeland Security, in September 2013.11 Recognizing the interconnectedness of workforce health and resilience, the present committee carefully reviewed the report and recommendations of the IOM Committee on Department of Homeland Security Workforce Resilience, which it took into consideration in developing its own recommendations (see Box 1-3 for the statement of task and recommendations of the IOM Committee on Department of Homeland Security Workforce Resilience).

Case Studies

In developing the case studies of integrated infrastructure required by its charge (see Box 1-2), the committee was guided by references made by then Deputy CMO J. D. Polk to health systems in other federal agencies (e.g., the National Aeronautics and Space Administration and the Department of Defense). In addition to federal agencies, the committee examined other large public and private organizations with multiple centers or business units to identify mechanisms by which integration can be promoted. The committee also looked at agencies within DHS for examples of program integration that could be applied within other components. Brief descriptions of the organizations examined by the committee are presented in Appendix E; these descriptions reflect information obtained from a review of the available literature and from invited testimony by company or agency representatives. Based on an analysis of the information thus gathered, the

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10Written responses to the question lists were included in the study’s public access file.

11The report of the IOM Committee on Department of Homeland Security Workforce Resilience is freely available to download from the National Academies Press website: http://www.nap.edu/catalog.php?record_id=18407 (accessed January 22, 2014).

Suggested Citation:"1 Introduction." 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 1-3
Committee on Department of Homeland
Security Workforce Resilience

Statement of Task

An ad hoc committee will conduct a study and prepare a report on how to improve the resilience (physical and mental well-being) of the Department of Homeland Security (DHS) workforce and identify the elements of a 5-year strategic plan for the DHSTogether program. The report will build on existing analysis of current capabilities, best-known practices, and gaps in current resilience programs.

Specifically, the committee will

 

  • Explore existing tools for improved workforce resilience, including a review of employer resilience programs which includes, but not exclusively, military and law enforcement.

o   Assess current policies, programs, activities, and resources that address employee resilience across DHS.

  • Identify resilience gaps in the DHS workforce and recommend activities to close those gaps.
  • Develop the elements of a 5-year strategic plan with year-by-year recommended activities to close those gaps.

o   Priority activities will be identified based on potential impact, to enable DHS to make choices based on the value of the activity.

  • Identify measures and metrics to track continuous improvements and to mark successful implementation of DHSTogether and the improving resilience of the DHS workforce.

Summary of Recommendations

  1. Develop and promote a unified strategy and common vision of workforce readiness and resilience in DHS.
  2. Clarify and expand the roles and responsibilities for workforce readiness and resilience in DHS.
  3. Review and align responsibility and accountability for workforce readiness and resilience in DHS.
  4. Establish a sustainable leadership development program in DHS.
  5. Improve organizational communication to enhance esprit de corps; cultivate a culture of readiness and resilience; and align public perception of DHS with its accomplishments.
  6. Develop and implement a measurement and evaluation strategy for continuous improvement of workforce readiness and resilience in DHS.
  7. Implement a 5-year strategic plan for workforce readiness and resilience in DHS.
Suggested Citation:"1 Introduction." 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.
×

committee identified three cases of exemplary integrated workforce health systems—Johnson & Johnson, the U.S. Department of the Interior, and the Federal Air Marshal Service—that warranted more detailed examination and helped inform the committee’s recommendations. Within this report, these organizations are highlighted as case studies, each of which provides a detailed description of the organization’s approach and the benefits realized through integration, including the potential for cost savings when such information was available.

Study Challenges and Limitations

Despite its best efforts to conduct a thorough assessment of the current DHS occupational health and operational medicine infrastructure, the committee experienced difficulties during its information-gathering process, including

 

  • variability in responses to the committee’s question lists, resulting in uneven levels of information on component health protection programs; and
  • lack of access to some relevant information (e.g., policies, medical standards, business cases), either because documents were deemed for official use only as a result of security concerns or because policies and plans, such as plans to implement a DHS-wide electronic health system, were still under development.

The committee was not asked to conduct a comparison of DHS’s component agencies and instead focused its efforts and this report on higher-level challenges related to integration of the DHS health protection infrastructure. More detailed and uniform information on component programs, however, would have enabled the committee to address some aspects of its task (e.g., identification of quality metrics, estimation of cost savings) with greater specificity.

Guiding Principle

Early in the study process, the committee converged around the principle that the primary questions related to integrating the occupational health and operational medicine infrastructure in this extremely large organization are best understood as public health challenges. The committee conducted its review through this lens, applying a concept of public health akin to that defined by the World Health Organization (WHO) (2013), which describes public health as follows:

Suggested Citation:"1 Introduction." 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.
×

Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a particular disease.

WHO (2013) describes three main functions critical to the public health enterprise:

 

  • assessment and monitoring of the health of populations at risk to identify health problems and priorities;
  • formulation of policies designed to solve local and wider health problems and priorities; and
  • assurance that the population has access to appropriate and cost-effective care, including health promotion and disease prevention services.

As described (and in practice), the public health infrastructure of an organization is by its very nature a multidisciplinary activity. It is not limited to medical professionals but requires such other skills as safety engineering, industrial hygiene, health education, labor relations, human resources, and fiscal management. Because of this multidisciplinary nature, the development of an integrated infrastructure is a difficult task requiring that a wide range of stakeholders join together to achieve a common purpose or mission; also required are clarity of mission, clear role definitions, and coherent and accountable leadership. Guided by these assumptions, the committee investigated the coherence and comprehensiveness of the health protection system within DHS, paying close attention to the existence of related initiatives and their effect on the health of the department’s employees.

TERMINOLOGY USED IN THIS REPORT

For purposes of this report, the committee considers that DHS consists of seven operating component agencies (Federal Emergency Management Agency, Citizenship and Immigration Services, Customs and Border Protection, Immigration and Customs Enforcement, Transportation Security Administration, U.S. Secret Service, and U.S. Coast Guard), directorates (National Protection and Programs Directorate, Science and Technology Directorate, Management Directorate), centers (Federal Law Enforcement Training Center, Center for Domestic Preparedness), and offices (e.g., Health Affairs, Policy). Component or component agency refers to one of the seven operating component agencies along with the National Protection

Suggested Citation:"1 Introduction." 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.
×

and Programs Directorate, which, since the transfer of the Federal Protective Service from Immigration and Customs Enforcement in 2009, is increasingly serving an operational role. Subcomponent refers to agencies and offices located within component agencies. For example, the Federal Air Marshal Service is a subcomponent agency within the Transportation Security Administration.

Myriad terms can be used to classify the activities that encompass employee health promotion and protection efforts. The same term often may have different meanings for different people and organizations, and likewise, different terms frequently are used interchangeably. Even when terms are sufficiently different that they cannot be used interchangeably, there may be significant overlap in activities that are categorized under one term or another, making clear distinctions impractical. This committee was tasked with assessing the occupational health and operational medicine infrastructure at DHS. While recognizing the existence of various acceptable definitions for these and other related terms, the following definitions are used in this report.

Occupational Health

The committee views occupational health as an overarching term that encompasses a variety of important areas of concern for ensuring a safe, healthy, and resilient workforce. The consensus definition of the International Labour Organization/WHO Joint Committee on Occupational Health (1950) reads:

Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and, to summarize: the adaptation of work to man and of each man to his job.

In 1995, the 12th session of the Joint Committee added to this definition a consensus statement, reading:

The main focus in occupational health is on three different objectives: (i) the maintenance and promotion of workers’ health and working capacity; (ii) the improvement of working environment and work to become conducive to safety and health; and (iii) development of work organizations and working cultures in a direction which supports health and safety at work and in doing so also promotes a positive social climate and smooth operation and may enhance productivity of the undertakings. The concept

Suggested Citation:"1 Introduction." 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.
×

of working culture is intended in this context to mean a reflection of the essential value systems adopted by the undertaking concerned. Such a culture is reflected in practice in the managerial systems, personnel policy, principles for participation, training policies and quality management of the undertaking. (Coppee, 1998)

Integral to this definition is the concept that occupational health practices should not be reactive but proactive in terms of ensuring employee health. The definition highlights the importance of prevention of injury and illness due to working conditions and other adverse health factors, health promotion, and the development of an organizational culture that values such practices. For the purposes of this report, the term occupational health encompasses occupational safety and health (including safety, industrial hygiene, and ergonomics), health promotion, and disability management (early intervention and return-to-work) activities. Thus, the scope of occupational health spans the three levels of prevention—primary, secondary, and tertiary—that form the hierarchy of prevention:

Primary prevention is based on measures designed to promote general optimum health or specific protection against disease agents or the establishment of barriers against agents in the environment. Secondary prevention is prompt and adequate treatment of the pathogenic process as soon as it is detectable. Tertiary prevention is corrective therapy, when the disease has advanced beyond its early stages, in order to prevent sequelae and limit disability, or, if too advanced, to address rehabilitation needs. (Leavell and Clark, 1958)

Occupational Safety and Health

Practitioners in the field of occupational safety and health work to prevent work-related illness, injury, and death. According to the Occupational Safety and Health Act,12 an injury or illness is considered “to be work-related if an event or exposure in the work environment either caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness.” Occupational safety and health specialties include occupational safety (or safety engineering), industrial hygiene, and ergonomics.

Occupational Medicine

The American College of Occupational and Environmental Medicine (ACOEM) defines occupational medicine as a clinical specialty dedicated

__________________

12Public Law 91-596.

Suggested Citation:"1 Introduction." 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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to the “prevention and management of occupational and environmental injury, illness, and disability, and the promotion of health and productivity of workers, their families, and communities” (ACOEM, 2013a). “The major role of the occupational and environmental physician is to evaluate the interaction between work and health” (ACOEM, 2013b). Occupational and environmental medicine physicians must understand their role not only as the director of a medical program but also as an integral part of a business organization, and therefore must understand problems from both management and employee perspectives. ACOEM (2013b) outlines five qualifications of the occupational and environmental medicine physician essential to ensuring employee health; he or she must:

 

  1. have a general knowledge of worksite operations and be familiar with toxic properties of materials used by employees, and the potential hazards and stressors of work processes;
  2. be qualified to determine an employee’s physical and emotional fitness for work;
  3. be capable of diagnosing and treating occupational and environmental diseases and competently handling injuries;
  4. possess knowledge of rehabilitation methods, health education techniques, sanitation, workers’ compensation laws, regulatory requirements (local, state, and federal), and systems for maintaining medical records; and
  5. be able to organize and manage the delivery of health services.

Occupational health nurses also play an important role in promoting, sustaining, and restoring worker health. They may span the occupational medicine and occupational safety and health fields, helping to ensure integration of these functions. According to the American Association of Occupational Health Nurses, modern roles for these nurses include case management, counseling and crisis intervention, health promotion and health risk reduction, support for legal and regulatory compliance, and identification of worker and workplace hazards (AAOHN, 2012).

Operational Medicine

For purposes of this report, operational medicine is defined as preventive and responsive medical and health support services provided outside of conventional workplaces during routine, planned, and contingency operations to employees and others under an organization’s control.13

__________________

13This definition of operational medicine was adapted from that used by the Federal Bureau of Investigation (FBI) and is consistent with DHS’s use of the term.

Suggested Citation:"1 Introduction." 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.
×

Throughout this report, the concept of operational medicine is addressed primarily in terms of how DHS is prepared to care for its employees in field and other operational settings. However, the committee recognizes that DHS often is required to provide emergency and urgent care to those in its custody and, in some cases, to members of the public. While recommendations related strictly to those in DHS custody are beyond the scope of this study, the committee believes that the principles and recommendations for operational care in this report are equally applicable to care provided to nonemployees.

Operational medicine draws on several medical disciplines: occupational medicine, preventive medicine, primary care, and emergency medicine. Although people commonly interpret operational medicine as emergency medical services, it entails far more than such care—preventive and ambulatory medical care, as well as medical threat and resource assessments, are also important elements of operational medicine.

Figure 1-2 depicts the relationship among occupational health, occupational medicine, occupational safety and health, and operational medicine as defined by the committee. Occupational medicine and occupational safety and health can be seen as subsets of the activities that fall within the broader category of occupational health, with significant overlap between them. As discussed above, while the primary focus of operational medicine programs generally is protection of the operational workforce, medical support services also are provided as needed to allied law enforcement officers, subjects in custody, and other third parties who find themselves

images

FIGURE 1-2 Relationship among occupational health, occupational medicine, and operational medicine.

Suggested Citation:"1 Introduction." 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.
×

within a control area of an operation; thus, operational medicine does not fall entirely within the domain of occupational health.

Workforce Health Protection and Medical Readiness

An operational workforce has unique health requirements related to its ability to carry out its mission. In acknowledgment of these needs, the committee defines workforce health protection broadly as the full scope of occupational health and operational medicine activities carried out to sustain and protect the health and effectiveness of deployable forces and members of the workforce exposed to nontraditional environments. This definition does not exclude nonoperational members of the workforce; the effectiveness of the operational workforce is dependent on those who perform critical support functions. This concept is expanded in Chapter 3.

Adapted from the concept used by the Military Health System, medical readiness is the extent to which members of the workforce are free of health-related conditions that would impede their ability to participate fully in operations and achieve the goals of their mission. The concept of medical readiness applies not only to personnel whose job description incorporates response duties but also to temporary employees, volunteers, and other departmental personnel who volunteer for response missions beyond their usual job description.

Integrated Employee Health System

The committee found the definition of an integrated employee health system provided by Cecchine and colleagues (2009) in a recent study on integrating employee health activities at the Department of Defense to be useful and adapted it for application to DHS. For the purposes of this report, the committee defines an integrated employee health system as an infrastructure that would support all employee health activities; provide a way to link information about all aspects of the health of employees; and make this information available to leadership at all levels for the purposes of decision making, accountability, continuous quality improvement, and surveillance.

ORGANIZATION OF THE REPORT

This report is organized into nine chapters that collectively characterize an integrated approach to workforce health protection and delineate steps DHS can take to integrate its occupational health and operational medicine infrastructure to better support its workforce and others whose medical needs become the responsibility of DHS during the course of operations.

Suggested Citation:"1 Introduction." 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.
×

Chapter 2 describes DHS’s overall mission and organizational structure, health and safety challenges, and health protection mission and the organizational structure of its health system. Chapter 3 presents a framework for a health system that supports an operational workforce, identifying key functions, models for integrating those functions, and characteristics of successful integrated programs. Chapter 4 describes the current occupational health and operational medicine infrastructure within DHS, including both gaps and best practices. Chapters 5 through 8 present the committee’s recommendations, organized according to four elements the committee identified as essential to successful integration of workforce health programs. Chapter 5 addresses the importance of leadership commitment to workforce health. Chapter 6 provides recommendations on organizational alignment to support integration of the key functions of health protection. Chapter 7 deals with strategies for alignment of the critical functions that support mission readiness. Chapter 8 focuses on the role of information management in the implementation of integrated health protection. Finally, Chapter 9 provides some considerations for implementation of the committee’s recommendations, including priorities and projected benefits.

REFERENCES

AAOHN (American Association of Occupational Health Nurses). 2012. AAOHN information sheet. Pensacola, FL: AAOHN.

ACOEM (American College of Occupational and Environmental Medicine). 2013a. What is OEM?: Careers in occupational and environmental medicine. http://www.acoem.org/OEMcareers.aspx (accessed November 8, 2013).

ACOEM. 2013b. What is OEM?: Physicians new to occupational medicine. http://www.acoem.org/occmed.aspx (accessed November 8, 2013).

BLS (Bureau of Labor Statistics). 2013. Employer-reported workplace injuries and illnesses—2012. USDL-13-2119. Washington, DC: BLS.

Cecchine, G., E. M. Sloss, C. Nelson, G. Fisher, P. R. Sama, A. Pathak, and D. M. Adamson. 2009. Foundation for integrating employee health activities for active duty personnel in the Department of Defense. Santa Monica, CA: RAND Corporation.

Coppee, G. H. 1998. Occupational health services and practice. In Encyclopaedia of occupational health and safety, 4th ed., edited by J. M. Stellman. Geneva, Switzerland: International Labour Organization. Pp. 16.18-16.22.

DHS (Department of Homeland Security). 2010a. Bottom-up review report, July 2010. Washington, DC: DHS.

DHS. 2010b. Quadrennial homeland security review report: A strategic framework for a secure homeland. Washington, DC: DHS.

DHS OIG (Office of the Inspector General). 2012. Major management challenges facing the Department of Homeland Security. OIG-13-09 (Revised). Washington, DC: DHS OIG.

DOL (Department of Labor). 2013. OWCP annual report to Congress FY 2011. Washington, DC: DOL.

FOH (Federal Occupational Health). 2013. About us. http://www.foh.dhhs.gov/AboutUs (accessed December 22, 2013).

Suggested Citation:"1 Introduction." 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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GAO (U.S. Government Accountability Office). 2012. Department of Homeland Security: Additional actions needed to strengthen strategic planning and management functions. GAO-12-382T. Washington, DC: GAO.

International Labour Organization/World Health Organization Joint Committee on Occupational Health. 1950. Report of the first meeting, 28 August–2 September 1950. Geneva, Switzerland: International Labour Organization.

IOM (Institute of Medicine). 2013. A ready and resilient workforce for the Department of Homeland Security: Protecting America’s front line. Washington, DC: The National Academies Press.

Leavell, H., and E. Clark. 1958. Preventive medicine for the doctor in his community: An epidemiologic approach. New York: McGraw-Hill.

Lowell, J. A. 2005. Medical readiness responsibilities and capabilities: A strategy for realigning and strengthening the federal medical response. Washington, DC: DHS. http://webharvest.gov/congress110th/20081217150105/http://oversight.house.gov/documents/20051209101159-27028.pdf (accessed January 16, 2014).

Manuele, F. A. 2013. On the practice of safety. Hoboken, NJ: John Wiley & Sons.

NRC (National Research Council). 2009. Evaluation of safety and environmental metrics for potential application at chemical agent disposal facilities. Washington, DC: The National Academies Press.

OPM (Office of Personnel Management). 2011. Federal Employee Viewpoint Survey: Department of Homeland Security agency management report. Washington, DC: OPM.

OPM. 2012a. 2012 Federal Employee Viewpoint Survey results: Department of Homeland Security agency management report. Washington, DC: OPM.

OPM. 2012b. Federal Employee Viewpoint Survey results: Governmentwide management report. Washington, DC: OPM.

OSHA (Occupational Safety and Health Administration). 2013. Federal injury and illness statistics for fiscal year 2012: End of year totals. https://www.osha.gov/dep/fap/statistics/fedprgms_stats12_final.html (accessed November 11, 2013).

Polk, J. D. 2013. The charge to the committee. Presentation at IOM Committee on DHS Occupational Health and Operational Medicine Infrastructure: Meeting 1, March 5, Washington, DC.

U.S. House of Representatives. 2012. Building one DHS: Why is employee morale low? Committee on Homeland Security, Subcommittee on Oversight, Investigations, and Management. 112th Congress, 2nd Session, March 22, Washington, DC.

WHO (World Health Organization). 2013. Public health. http://www.who.int/trade/glossary/story076/en (accessed December 23, 2013).

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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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