HEALTH AT THE DEPARTMENT
OF HOMELAND SECURITY
Protecting Those Who Protect Us
Committee on Department of Homeland Security Occupational Health
and Operational Medicine Infrastructure
Board on Health Sciences Policy
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract/Grant No. HSHQDC-11-D-00009/HSHQDC-12-J-00188/P00003 between the National Academy of Sciences and the Department of Homeland Security. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
International Standard Book Number-13: 978-0-309-29647-2
International Standard Book Number-10: 0-309-29647-1
Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2014 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2014. Advancing workforce health at the Department of Homeland Security: Protecting those who protect us. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON DEPARTMENT OF HOMELAND SECURITY OCCUPATIONAL HEALTH AND OPERATIONAL MEDICINE INFRASTRUCTURE
DAVID H. WEGMAN (Chair), Professor Emeritus, Department of Work Environment, University of Massachusetts Lowell
EDWARD BERNACKI, Professor of Medicine and Director, Division of Occupational Medicine; Executive Director of Health, Safety and Environment, Johns Hopkins University, Baltimore, Maryland
LESLIE BODEN, Professor, Department of Environmental Health, Boston University School of Public Health, Massachusetts
TOM CAIRNS, Principal, Cairns Blaner Group, LLC, Valencia, California
RICHARD H. CARMONA, 17th Surgeon General of the United States; Distinguished Professor, University of Arizona, Tucson
CHERRYL CHRISTENSEN, Corporate Medical Director, The Procter & Gamble Company, Cincinnati, Ohio
DON E. DETMER, Professor of Medical Education, University of Virginia, Charlottesville
ELLEN P. EMBREY, President/CEO, Stratitia, Springfield, Virginia
WILLIAM FABBRI, Medical Director, Office of Medical Services, Federal Bureau of Investigation, Washington, DC
JANIE GITTLEMAN, Chief, Occupational Safety, Health & Environmental Compliance (FAC-3A), Mission Services Office of Facilities and Services, Defense Intelligence Agency, Washington, DC
WILLIAM L. LANG, Senior Physician, Owl’s Nest, Inc., Arlington, Virginia
MICHAEL A. SILVERSTEIN, Clinical Professor of Environmental and Occupational Medicine, University of Washington School of Public Health, Olympia
DAVID N. SUNDWALL, Professor of Public Health (Clinical), Division of Public Health, Department of Family and Preventive Medicine, University of Utah–School of Medicine, Salt Lake City
W. CRAIG VANDERWAGEN, Senior Partner, Martin Blanck and Associates, Columbia, Maryland
AUTUMN S. DOWNEY, Study Director
FRANK VALLIERE, Research Associate
Y. CRYSTI PARK, Senior Program Assistant
BRUCE ALTEVOGT, Senior Program Officer
ANDREW M. POPE, Director, Board on Health Sciences Policy
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Jeannie Cimiotti, Rutgers University College of Nursing
Scott Deitchman, Centers for Disease Control and Prevention
Elaine Duke, Elaine Duke & Associates
Pamela A. Hymel, Walt Disney Parks and Resorts
Jeffery Lowell, Washington University School of Medicine
William S. Marras, The Ohio State University
Robert K. McLellan, Dartmouth-Hitchcock Medical Center
C. Crawford Mechem, Pennsylvania Hospital of the University of Pennsylvania
Richard J. Miller, Federal Occupational Health
Dean Smith, U.S. Department of State
Terri Tanielian, RAND Corporation
Mark Tedesco, NextCare Urgent Care
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Ellen Wright Clayton, Vanderbilt University, and Georges C. Benjamin, the American Public Health Association. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
The creation of any new institution or agency can be expected to entail a phase of growth and development. When a new agency is formed in a time of crisis, its evolution is further complicated by circumstance. Furthermore, if the agency is constructed from previously existing components along with newly created entities, both designers and new leadership face major challenges, and many roadblocks can be expected. This was the context for the Department of Homeland Security (DHS) when the nation responded to the harrowing events of September 11, 2001, by forming this new cabinet secretariat. Over the past decade, the agency has been learning and evolving slowly into its adolescence, and in the course of this evolution, it recognized a need to focus special attention on its most valuable asset—its employees.
Health and medical leadership in the department’s Office of Health Affairs (OHA) recognized that balancing the need for centralized authority and component agency autonomy in carrying out the full measure of its responsibilities posed particular challenges. It was critical to respect the prerogatives and character of the components while striving to instill a department-wide ethos through commonality of purpose. This balance was deemed critical to building and maintaining the quality and morale of the workforce.
With this need for balance in mind, OHA sought assistance from the Institute of Medicine (IOM) regarding how best to organize, across the department, the varied and complex programs and services designed to protect the occupational health of the DHS workforce and prepare it to fulfill its many operational missions. The committee empaneled to respond
to this request comprised 14 members selected to represent a broad range of expertise that included occupational and environmental health, health systems management, health economics, health information technology and data management, metrics/measurement/program evaluation, workers’ compensation/liability, human resources, and operational medicine. This broad range of backgrounds was necessary to bring proper attention to the task. During the course of this study, the members worked diligently to bring their expertise to bear, learning from and assisting one another to appreciate the complexity of the committee’s charge. As a result, the committee was able to develop recommendations that reflect and respect the needs of the agency and the complex, multidimensional missions with which it is tasked.
It should be noted that several committee members have had previous experience serving in leadership roles within DHS. This experience proved invaluable in grounding our work. We are particularly grateful to Dr. Jeff Runge, who served as liaison from the IOM Committee on Department of Homeland Security Workforce Resilience and shared his wealth of experience from his tenure as the DHS Chief Medical Officer.
Throughout our deliberations, we sought a common understanding of the full range of responsibilities faced by the department both within and across its many component units. We examined the work of other federal agencies as well as institutions in the private sector with reasonably analogous organizational challenges. In so doing, we came not only to better appreciate the difficulties faced by DHS but also to understand a variety of ways in which the same objectives might be met. Early on we received valuable input from Dr. J. D. Polk, Acting Chief Medical Officer at DHS, who provided his insights into the problems and challenges that represent the primary needs to be addressed by OHA. Our efforts were further enhanced by input from many researchers, agency personnel, and representatives of interested groups who graciously dedicated their time to responding to our inquiries and provided their insights and perspectives during our deliberations. Appreciation also is extended to those individuals who served as reviewers of this report.
Chairing this committee has been an education and a rewarding experience, the task made much easier by the friendly and supportive atmosphere of the committee meetings. Over the course of the study, we depended greatly on the high-quality intellectual and administrative skills of the IOM staff, under the able direction of study director Autumn Downey and her colleague Frank Valliere. Their energy and commitment were evident from the outset. Their tireless efforts in developing the necessary background information, undertaking a variety of research tasks, and regularly interacting with the committee members are reflected throughout the report. Their work was ably supported by project assistant Crysti Park. Additional
thanks are owed to Rona Briere for carefully editing and improving the structure of the report.
Finally, I wish to offer thanks and acknowledgment to my fellow committee members, all of whom gave generously of their time in addressing a stimulating and challenging task. I am confident that our conclusions and recommendations will help DHS achieve its overarching goal of a healthy, safe, ready, and resilient workforce, regardless of where they serve and what their missions may be.
David H. Wegman, Chair
Committee on Department of Homeland Security
Occupational Health and Operational Medicine Infrastructure
American College of Occupational and Environmental Medicine
Americans with Disabilities Act
Assistant Secretary for Health Affairs
California Commission on Peace Officer Standards and Training
Customs and Border Protection
Centers for Disease Control and Prevention
Code of Federal Regulations
Chief Human Capital Officer
Component Lead Medical Officer
Chief Medical Officer
continuation of pay
Designated Agency Safety and Health Official
U.S. Department of Homeland Security
U.S. Department of Defense
U.S. Department of the Interior
U.S. Department of Labor
U.S. Department of State
Designated Safety and Health Official
employee assistance program
electronic health information system
emergency medical services
emergency medical technician
electronic patient care record
Federal Air Marshal Service
Federal Bureau of Investigation
Federal Employees’ Compensation Act
Federal Employees Health Benefits
Federal Emergency Management Agency
Federal Law Enforcement Training Center
Federal Occupational Health
U.S. Government Accountability Office
U.S. Department of Health and Human Services
health information technology
health risk assessment
Human Resources Management
Immigration and Customs Enforcement
integrated health information system
Institute of Medicine
Johnson & Johnson
Lost Time Case Rate
Medical Liaison Officer
memorandum of understanding
medical quality management
National Aeronautic and Space Administration
nurse case manager
National Firearms and Tactical Training Unit
National Institute for Occupational Safety and Health
National Protection and Programs Directorate
U.S. National Park Service
National Research Council
Office of the Chief Human Capital Officer
Office of Health Affairs
Office of the Inspector General
Office of Personnel Management
occupational safety and health
Occupational Safety and Health Administration
Office of Workers’ Compensation Programs
Procter & Gamble
Protecting Our Workers and Ensuring Reemployment
return to work
Senior Medical Advisor
special weapons and tactics
Total Case Rate
Transportation Security Administration
Total Worker Health™
U.S. Coast Guard
U.S. Citizenship and Immigration Services
Department of Veterans Affairs
World Health Organization
|Absenteeism||Habitual absence from work.1|
|Chargeback||Mechanism by which costs incurred under the Federal Employees’ Compensation Act (FECA) for most injuries and deaths are billed to agencies.2|
|Disability management||A set of practices designed to minimize the disabling impact of injuries and health conditions that arise during the course of employment.3|
|Health promotion||A comprehensive social and political process that embraces actions directed at strengthening the skills and capabilities of individuals and changing social, environmental, and economic|
1IOM (Institute of Medicine). 2005. Integrating employee health: A model program for NASA. Washington, DC: The National Academies Press.
2 DOL (Department of Labor). 2014. Division of Federal Employees’ Compensation (DFEC) Procedure Manual. http://www.dol.gov/owcp/dfec/regs/compliance/DFECfolio/FECAPT5/#50700 (accessed January 27, 2014).
3Hunt, H. A. 2009. The evolution of disability management in North American workers’ compensation programs. Kalamazoo, MI: W.E. Upjohn Institute.
|conditions to relieve their impact on individual and public health.4|
|Integrated employee health system||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 improvement, surveillance, and other questions related to health.5|
|Lagging indicators||Retrospective measurements of system performance linked to outcomes.6|
|Leading indicators||Prospective measures linked to actions taken to prevent accidents.7|
|Medical readiness||The extent to which members of the operational workforce are free of health-related conditions that would impede their ability to participate fully in operations and achieve the goals of their mission.8|
|Medical threat assessment||A process for risk management in the context of operational medicine that involves the creation of a comprehensive mission preplan based on available intelligence and information on the nature of the response.9|
|Occupational health||An overarching term for activities aimed at maintaining and promoting workers’ health,|
4IOM. 2005. Integrating employee health: A model program for NASA. Washington, DC: The National Academies Press.
5Adapted from Cecchine, G., E. M. Sloss, C. Nelson, G. Fisher, P. R. Sama, A. Pathak, and D. M. Adamson. 2009. Foundation for integrating employee health activities for active duty personnel in the Department of Defense. Santa Monica, CA: RAND Corporation.
6Manuele, F. A. 2013. On the practice of safety. Hoboken, NJ: John Wiley & Sons.
7Manuele, F. A. 2013. On the practice of safety. Hoboken, NJ: John Wiley & Sons.
8DoD (Department of Defense). 2013. Joint publication 1: Doctrine for the Armed Forces of the United States. Washington, DC: DoD.
9CA POST (California Commission on Peace Officer Standards and Training). 2010. Tactical medicine: Operational programs and standardized training recommendations. Sacramento, CA: CA POST.
|ensuring the work environment is conducive to safety and health, and developing work organizations and cultures that support health and safety at work.10|
|Occupational medicine||A clinical specialty dedicated to the prevention and management of occupational injury, illness, and disability and the promotion of the health and productivity of workers, their families, and communities.11|
|Occupational safety and health||Activities aimed at ensuring safe and healthful working conditions, thus preventing work-related illness, injury, and death.12|
|Operational medicine||Preventive and responsive medical and health support services provided outside of conventional workplaces during routine, planned, and contingency operations to employees and others under an organization’s control.13|
|Organizational climate||Workforce perceptions of organizational practices.14|
|Presenteeism||On-the-job productivity loss that is related to, for example, conditions such as allergies, asthma, chronic back pain, migraines, arthritis, and depression; also, productivity loss resulting|
10GOHNET (Global Occupational Health Network). 2003. GOHNET newsletter. Geneva, Switzerland: WHO. http://www.who.int/occupational_health/publications/newsletter/en/gohnet5e.pdf (accessed December 22, 2013).
11ACOEM (American College of Occupational and Environmental Medicine). 2013. What is OEM?: Careers in occupational and environmental medicine. http://www.acoem.org/OEMcareers.aspx (accessed November 8, 2013).
12Occupational Safety and Health Act of 1970.
13Adapted from Fabbri, W. 2013. Operational medicine in other organizations: FBI. Presentation at IOM Committee on DHS Occupational Health and Operational Medicine Infrastructure: Meeting 2, June 10-11, Washington, DC.
14Rousseau, D. M. 2011. Organizational climate and culture. In Encyclopedia of Occupational Health and Safety, edited by J. M. Stellman. Geneva, Switzerland: International Labour Organization. http://www.ilo.org/oshenc/part-v/psychosocial-and-organizational-factors/macroorganizational-factors/item/29-organizational-climate-and-culture?tmpl=component&print=1 (accessed December 17, 2013).
|from caregiving, lack of job satisfaction, and organization culture.15|
|Public health||All organized measures designed to prevent disease, promote health, and prolong life among the population as a whole.16|
|Resilience||The ability to withstand, recover, and grow in the face of stressors and changing demands.17|
|Workforce health protection||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.|
15IOM. 2005. Integrating employee health: A model program for NASA. Washington, DC: The National Academies Press.
17Chairman of the Joint Chiefs of Staff. 2011. Chairman’s total force fitness framework. CJCSI 3405.01. http://www.dtic.mil/cjcs_directives/cdata/unlimit/3405_01.pdf (accessed January 27, 2014).