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

Summary

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 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. 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 in 2002, DHS has been aggressively addressing the management challenges of integrating seven core operating component agencies¹ and 18 supporting offices and directorates. One of those challenges is creating and sustaining a coordinated health protection infrastructure. Seeking strategic advice on how to strengthen mission readiness while better meeting the health needs of its workforce, DHS’s Office of Health

__________________

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.

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.

A FRAMEWORK FOR WORKFORCE HEALTH PROTECTION

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 would impede its 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 DHS² during routine, planned, and contingency operations.

Meeting these two requirements necessitates implementing 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. To guide such a strategy, the committee developed a workforce health protection framework in which the essential and interconnected functions necessary to support an operational workforce are defined within two pillars:

1. Ensure medical readiness through injury and illness prevention, readiness assessment, disability management, and health promotion functions (occupational health).
2. Provide medical support for operations through medical threat assessment, preventive medicine, ambulatory medical care, and emergency medical services functions (operational medicine).

The function of measurement and evaluation spans both pillars and serves as a foundation for the framework, which is designed to achieve

__________________

²Throughout 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. The committee recognizes that the department is often required to provide emergency and urgent care to those in its custody and, in some cases, members of the public. The principles and recommendations for operational care outlined in this report are equally applicable to care provided to nonemployees.

• a prevention-focused approach to workplace injury and illness;
• ongoing readiness assessment to ensure an individual’s continued ability to carry out his/her responsibilities fully and safely;
• proactive medical case management to restore employees to a state of health and readiness as rapidly as possible;
• adequate and effective medical support services available when needed;
• promotion of physical fitness and healthy lifestyle choices to optimize human performance and readiness; and
• ongoing measurement and evaluation for decision making, accountability, situational awareness, and continuous quality improvement.

The underlying infrastructure that serves to integrate these functions includes the doctrine (plans, policies, and standards), organizational constructs (reporting structures, governance mechanisms), and resources (qualified personnel, budgets, information management systems) that enable mission capability.

WORKFORCE HEALTH PROTECTION AT DHS

With its strong focus on securing national borders and protecting critical infrastructure against acts of terrorism and other hazards, DHS often is referred to as a “guns, guards, and gates” organization—about half of its workforce is made up of law enforcement and security personnel. The other major operational arm of the DHS workforce comprises rescue and emergency response personnel. This large operational workforce with diverse worksites and mission requirements poses significant challenges for agency programs designed to keep workers, as well as others for whom the department assumes responsibility, healthy and safe. DHS has the highest rate of occupational injury and illness of all cabinet-level federal agencies, in part a result of the hazardous nature of the work being performed, but also indicating the need for stronger health protection systems and programs. In fiscal year 2011, the actuarial liability³ for workers’ compensation at DHS surpassed $2 billion—4.4 percent of the department’s overall appropriation. Furthermore, data from the 2012 Federal Employee Viewpoint Survey⁴ reveal that only 62 percent of DHS employees felt protected

__________________

³Actuarial liability is the projected amount that the Department of Labor would have to pay to cover all existing cases to resolution of the injury or death if an agency ceased to exist today. DHS is ultimately responsible for these costs.

⁴This survey, administered by the Office of Personnel Management, is a tool that measures employees’ perceptions of whether, and to what extent, conditions characterizing successful organizations are present in their agency (http://www.fedview.opm.gov).

from health and safety hazards on the job—a significantly lower proportion than the government-wide average of 77 percent.

Protection of the health and safety of the workforce, DHS’s most important asset, must be a key role and responsibility of agency leadership. At headquarters, responsibility for workforce health protection currently is divided between OHA and the Office of the Chief Human Capital Officer. The Secretary of DHS has delegated authority to the Assistant Secretary for Health Affairs, who is also the DHS Chief Medical Officer (CMO), for exercising oversight over all medical and public health activities. Yet several key health functions that intersect with personnel programs, including occupational safety and health, workers’ compensation (specifically, return-to-work/disability management), and health promotion, are being overseen by the Chief Human Capital Officer, with little or no strategic input from the CMO. Current OHA activities related to workforce health protection focus primarily on programs for medical quality management, operational medical support, medical countermeasures, and employee resilience.

It should be noted that occupational injury and illness rates are not uniformly high across DHS’s component agencies. This variability reflects both differing missions and operational conditions and differences among employee health, safety, and medical programs. The components have developed varying infrastructures and policies for carrying out the key workforce health protection functions; the administration of programs that support these functions is segregated in some and aligned in others.

The committee concludes that the current workforce health protection infrastructure at DHS is fragmented and uneven across the component agencies. Although some components, such as the Coast Guard, have a comprehensive occupational health and operational medicine infrastructure, others have not dedicated sufficient resources to providing their employees with even the most basic occupational health support services, let alone what is required to carry out the functions necessary to ensure mission readiness. Given the myriad potential impacts of this shortfall—mission failure, employee turnover and low morale, high health-related costs, liabilities—strengthening workforce health protection is critically important to achieving readiness and meeting mission requirements.

OPPORTUNITIES TO ADVANCE WORKFORCE HEALTH AT DHS

Through a review and assessment of the current occupational health and operational medicine infrastructure at DHS, the committee identified a number of opportunities for the department to significantly improve its mission readiness by promoting and sustaining the health, safety, and resilience of its workforce. Acknowledging the diversity among the DHS component agencies, the committee does not endorse a fully centralized approach to

the management and execution of workforce health protection programs. Many health, safety, and medical challenges are unique to individual agencies, and the components should have the flexibility to address these unique needs through programs tailored to their operational requirements. At the same time, however, there is a need and clear role for an empowered centralized health authority at DHS, with continuing support from the Secretary, to provide for and oversee the implementation of policies, standards, and programs designed to protect employee health and safety, promote efficiency and interoperability, and achieve cost savings. This authority also needs to serve as an advocate for workforce health protection, communicating clearly that these health- and safety-related functions are essential to mission readiness. Maintaining the health, safety, and resilience of every man and woman in the DHS workforce—whether they execute or support the mission—must be an organizational priority.

Strategic Alignment Through Committed Leadership

Assessments of employee health and safety programs in both the private and public sectors have demonstrated significant increases in employee morale, efficiency, and effectiveness with the implementation of robust programs fully supported by leadership. The committee believes that strong leadership providing clear direction is essential to both the design and delivery of the health, safety, and medical policies and programs of a large, diverse organization such as DHS. A formal strategy, guided by a vision statement directly linked to the organizational mission, can provide that direction while also demonstrating the commitment of senior leadership. Although a DHS Workforce Strategy was issued for fiscal years 2011-2016, this strategy does not address the promotion and protection of employee health, safety, and resilience as a critical means of sustaining an engaged workforce. The committee found no evidence that the Secretary of DHS has made such a clear and high-level statement of the value of protecting and enhancing the health and safety of the workforce. The committee concludes that DHS lacks a unified vision and strategy for ensuring the delivery of key health, safety, and medical support services across DHS in an efficient and coordinated manner.

Visible leadership commitment to this vision, demonstrated routinely across all levels of DHS, is essential to success. Heads of federal agencies have ultimate responsibility for their employees. Therefore, the strategy should communicate the Secretary’s commitment to the health, safety, and resilience of those charged with achieving the DHS mission, while holding leadership of the operating components accountable for implementing and adequately resourcing workforce health protection programs that are consistent with DHS policies and standards.

Organizational Alignment and Coordination

The fragmentation of workforce health protection functions and the absence of formal mechanisms for coordination and communication have resulted in siloed workforce health protection functions, contributing to inefficiency, a lack of accountability and transparency, and missed opportunities to achieve synergy through integration. The committee concluded that achieving the vision of a ready and resilient DHS workforce will require the organizational alignment of health, safety, and medical functions and resources throughout the department.

Alignment of Headquarters Oversight Functions

The committee was asked to consider the centralized oversight authority necessary to ensure an integrated workforce health protection infrastructure. Although many organizations with effective integrated health and safety programs employ a lead official who is not a physician, DHS is responsible for numerous operational medicine programs in addition to traditional workplace health, safety, and compensation programs. Thus, the committee believes there would be significant benefit to having a CMO, supported by a multidisciplinary team with collective backgrounds spanning occupational health, operational medicine, and health systems management, lead an aligned health protection infrastructure. Although the Secretary has delegated authority to the CMO for exercising oversight over all medical and public health activities for DHS, the CMO lacks visibility and strategic input on workforce health protection functions currently

administered through the Office of the Chief Human Capital Officer and within component agencies. The resulting ambiguity regarding the authority of the CMO to exercise the delegated oversight responsibility has compromised the CMO’s ability to align critical health protection functions across DHS for coordinated execution.

Implementation of this new aligned reporting structure will require reallocation of positions from the Office of the Chief Human Capital Officer to OHA. Additionally, alignment of occupational safety and health programs under the CMO will require that the CMO be designated as or report (directly or indirectly) to the Designated Agency Safety and Health Official.⁵ Responsibilities for the CMO in this aligned reporting structure should include but are not limited to

• promulgating department-wide policies and standards for integrating and coordinating all occupational health and operational medicine functions, including occupational safety and health, fitness for duty, disability management, and health promotion;
• developing a process for ensuring the implementation of DHS-wide health, safety, and medical standards;
• providing advice and guidance to the Secretary and component agency leadership on all matters related to health, safety, and medicine;
• overseeing component agencies’ medical quality assurance programs and ensuring that all DHS and outsourced providers of medical services are appropriately educated and trained and routinely

__________________

⁵The Designated Agency Safety and Health Official is designated by the head of a government agency as the individual responsible for its occupational safety and health program. As specified by Executive Order 12196 (1980), this person should have “sufficient authority to represent the interest and support of the agency head.”

• evaluated through credentialing, baseline training requirements, and a standardized competency assessment process;

• analyzing resource allocations and requesting budgetary adjustments as necessary; and
• submitting an annual measurement and evaluation report to the Secretary on the health, safety, and readiness of the DHS workforce.

To empower the CMO, the DHS Secretary should clearly establish, through both policy (revision of Delegation #5001) and action (holding component heads accountable for compliance with policies and standards promulgated through OHA), that the CMO has oversight responsibility for all DHS health and safety programs. Further, the CMO should be included as a member of DHS enterprise-wide governing bodies, such as Investment Review and/or Program Review Boards. The organizational context of the CMO position should support these interactions and should be evaluated in this regard.

Organizational Alignment Within DHS Component Agencies

Within the component agencies, the degree of organizational alignment varies widely. In components with aligned or partially aligned organizational structures in which health, safety, and/or medical programs and functions are collocated, the committee found evidence of increased information sharing and synergy. With the notable exception of the Coast Guard, however, component agencies lack a single point of accountability for all health, safety, and medical activities. Fragmentation of workforce health protection functions at the component level not only limits intracomponent coordination but also poses challenges for oversight at the headquarters level. The committee concludes that the current fragmented structure and distribution of health, safety, and medical authorities within DHS component agencies impedes the CMO’s ability to orchestrate a comprehensive and integrated workforce health protection strategy. Having a single point

of accountability for health, safety, and medical functions within each of the components would enhance the effectiveness of the CMO.

Establishment of a Coordinated Approach to Workforce Health Protection Across DHS

To promote integration, the CMO requires mechanisms for ensuring that critical programs are standardized and implemented consistently across DHS. Until recently, the CMO has had limited visibility on health and medical programs and challenges within component agencies. This lack of visibility has interfered with the CMO’s ability to monitor the readiness of the DHS workforce and to address department-wide health and medical issues through policy and program initiatives. The committee heard throughout

its information-gathering process that directives and proposed standards from OHA are disconnected from the needs and realities of the component agencies. The committee concludes that a mechanism is needed to enable the CMO to engage components in the development of medical and public health policy and to provide senior-level direction for an integrated DHS workforce health protection strategy.

The committee envisions the Medical and Readiness Committee as the key to the development of department-wide medical standards and policies responsive to the operational requirements of the components. The proposed committee would create formal channels for information sharing among components and the CMO, promoting both horizontal and vertical integration. However, although the proposed committee would play a key advisory role, the CMO should retain sole authority for setting DHS-wide medical policy.

A Governance Framework for Enterprise-Level Integration

Workforce health protection is a critical element of an agency’s mission support architecture and needs to function as part of a larger management system that also includes human resources, financial management, information systems and communications, acquisition planning and management, facilities management, and logistics. These elements together enable mission execution. Despite its clear role in mission support, however, workforce health protection has not been fully integrated into the DHS management infrastructure.

DHS headquarters and component agencies share responsibilities for complex programs supporting the health, safety, and mission readiness of the workforce, as well as providing for the medical needs of those who come under DHS control or protection during operations. Many workforce health protection functions span the intersection of health and human resources and therefore require coordination between the CMO and the Chief Human Capital Officer. Input from other members of the DHS management team⁶ may be required to ensure appropriate resourcing and management of occupational health and operational medicine programs. The committee found, however, that governance mechanisms put in place to facilitate the coordinated development of department-wide policy and practices related to employee health and safety are not currently functioning.

DHS’s Health, Safety, and Medical Council was established to facilitate a coordinated approach to achieving health, safety, and medical program objectives. Although it has not been active in recent years, the committee believes that its reconstitution with the participation of the CMO, key

__________________

⁶The management team (located within the Management Directorate) consists of the Chief Human Capital Officer, Chief Financial Officer, Chief Procurement Officer, Chief Information Officer, Chief Security Officer, and Chief Administrative Services Officer, and it is led by the Under Secretary for Management.

members of the DHS management team, and component leadership⁷ is critical to achieve department-wide consensus on strategies for addressing overarching and cross-cutting health, safety, and medical issues, as well as to engage component leadership in the development and implementation of policies that support the readiness of their workforce. Additionally, this senior-level Council would be responsible for managing the department-wide portfolio of health protection programs—assessing and prioritizing investments, eliminating redundancies among programs, and ensuring program alignment. In its vetting and decision-making process, the council should draw on recommendations and other information provided by program-level committees, including but not limited to the Medical and Readiness Committee proposed in Recommendation 5 and the Safety Managers Committee.

Functional Alignment

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, the committee identified the paucity of global health and medical policies and standards designed to set clear expectations and ensure that core quality and performance requirements are met by all components as a major barrier to the realization of an integrated health protection infrastructure.

A Common Approach to Ensuring Medical Readiness

Mission readiness depends on a workforce that is medically ready. The committee found that mechanisms for assessing, promoting, and sustaining medical readiness vary widely across DHS, and the CMO has promulgated few standards and policies designed to ensure consistency and interoperability. The committee concludes that a common approach to medical readiness is needed to enable the disparate component agencies to achieve appropriate mission readiness outcomes.

__________________

⁷Component representatives on the Health, Safety, and Medical Council should have decision-making authority. Components should therefore be represented by agency heads or component Designated Safety and Health Officials, who by definition have sufficient authority to represent the agency head.

Job performance requirements⁸ will drive the evaluation of readiness; it follows, then, that the frequency and content of job-related health and fitness evaluations should be consistent for similar job series across the department. Additionally, one of the main objectives of an employment life-cycle approach is the early identification of health-related conditions that impede individuals’ ability to carry out the responsibilities of their position fully and safely, so that they can be returned to a state of mission readiness. To meet this objective, components should establish early intervention and injury/illness case management programs that operate in close coordination with fitness-for-duty, injury/illness prevention, health promotion, and workers’ compensation programs.

A Comprehensive Capability for Providing Medical Support for Operations

Federal agencies are equally responsible for the health and safety of workers operating in the field and those stationed in more conventional workspaces. Operational medicine programs are a means by which occupational health and medical services are made available to those operating outside of conventional workspaces, and are essential to mission readiness. The lack of access to basic preventive and responsive medical services in field situations can result in preventable illness or injury, lost productivity, and logistical challenges that lead to mission failure. Additionally, the provision of timely and quality medical treatment to those in DHS care or custody is a legal responsibility of the department, and failure to meet this

__________________

⁸Derived from a job task analysis validated by an occupational health professional.

requirement may expose DHS to liability. The committee concluded that current operational medical support services are not adequately meeting the medical and operational needs of the DHS workforce and those in DHS care or custody. The CMO, working with relevant component agencies, should institute additional measures to ensure that all DHS components conducting operations outside of conventional workspaces meet standards of oversight and performance consistent with those of other public safety agencies.

Medical support for all routine, planned, and contingency operations, including those activities in which care of persons in custody is anticipated, should be explicitly addressed in component operational plans. The CMO should review such plans to ensure the engagement of medical personnel trained and equipped in a manner appropriate to the mission. Additionally, the CMO should assess compliance with policy and protocol and the quality of care rendered to all patients according to prospectively determined outcome measures. Although responsibility for execution of the operational medicine program should be delegated to Component Lead Medical Officers, the Secretary should hold component agency heads accountable for the effectiveness of such programs and their compliance with department-wide policies and standards.

Centralization of Common Services

Because of the wide variation among their missions, each of the component agencies has specific needs that are best served by support programs tailored to its operational functions. However, some common services should be centralized to promote efficiency and interoperability while ensuring the necessary level of service quality.

__________________

⁹The committee noted extensive contractor involvement in the direction of medical operations in some components. The role of contractors in the direction and oversight of medical operations should be delineated more clearly following analysis by the DHS General Counsel to ensure compliance with legal requirements set by the Federal Acquisition Regulations regarding inherently governmental functions.

The authority of the CMO to centralize common health-related services for purposes of quality, efficiency, and interoperability should be clearly articulated in the revised Delegation to the Assistant Secretary for Health Affairs and Chief Medical Officer. Common services the CMO should consider centralizing include but are not limited to

• medical quality management, including credentialing, maintenance of certification, and licensure;
• health information management capabilities as outlined in Recommendation 11;
• health professions education and training;
• medical logistics, including purchasing and distribution;
• public health services and consultations (e.g., immunization programs, travel medicine, risk communication, wellness programs); and
• requirements and technical oversight for contracts, interagency agreements, and memorandums of understanding with outside entities providing health and medical services to DHS and its component agencies.

Health and Safety Information Management

The CMO must be able to brief the Secretary regarding the health, safety, and readiness of the DHS workforce and to advocate for needed investments in prevention and health protection programs. Requisite to carrying out this charge is the capability to maintain situational awareness regarding the health and medical status of the DHS workforce and the major health and safety risks that impede readiness. This capability currently does not exist at OHA or anywhere else within the department. The September 2013 report of the IOM Committee on Department of Homeland Security Workforce Resilience identifies as a major gap the lack of a strategy, framework, and common set of metrics to support a comprehensive evaluation of workforce readiness and resilience. The findings of the present committee support that conclusion and also highlight the inadequacy of the current health and safety information management infrastructure, including the department’s informatics capability. Without such a system, integration of the DHS health protection infrastructure cannot be achieved.

An informatics and information technology capability is essential for implementation of the measurement and evaluation framework described in Recommendation 10 and for information sharing and knowledge management.

The strategic plan should provide the blueprint for a robust health and safety informatics and information technology infrastructure incorporating medical, public health, and consumer informatics capabilities. Elements of the plan should include

• a workforce strategy for relevant informatics and information technology personnel, including requisite responsibilities;
• a knowledge management structure within each unit and, where relevant, across the department; and
• a business case analysis demonstrating the return on investment.

CONCLUDING THOUGHTS

The DHS mission to protect the homeland is of critical importance, but the ability to achieve that mission is undermined by a workforce health protection infrastructure that is marginalized, fragmented, and uneven. The fragmented DHS health protection system is just one instance of an overarching management problem that the organization has worked diligently to overcome since its inception. DHS is not the first federal agency

to struggle with these considerable challenges; the Department of Defense (DoD) has worked for almost 70 years to overcome the culture and communication barriers to joint operations. Despite considerable progress, this is an ongoing process at DoD, and the same will be true for DHS for some time into the future. Through its recommendations (summarized in Box S-1), the committee has attempted to provide a foundation and a path forward for an integrated health protection infrastructure encompassing the programs, tools, and resources needed to enable the DHS workforce to fulfill the homeland security mission. In essence, the goal is to do on a smaller scale what the Homeland Security Act sought to accomplish more than 10 years ago—to weave the key functions and activities entailed in protecting the homeland into a unified, cohesive enterprise. To this end, the mission-ready DHS of the future will require an empowered and resourced CMO who, through partnership with the component agencies, institutes policies and global standards that permeate the entire organization to ensure the health, safety, and resilience of its workforce. Finally, if DHS is to meet the needs of its diverse workforce in the face of continuously evolving challenges, it will require a health protection infrastructure that remains agile; adoption of a learning health system approach will allow DHS to transform information into knowledge, which can be used to drive health system change in accordance with evidence-based best practices.

REFERENCE

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.

This page intentionally left blank.