Promising and Best Practices in Total Worker Health: Workshop Summary (2014)

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Total Worker Health in Large Businesses

Changing the workplace requires helping employees obtain skills, knowledge, and tools, and making them ready, aware, and engaged in improving their own health and well-being, said Ron Goetzel, Visiting Professor and Director of the Institute for Health and Productivity Studies at the Johns Hopkins Bloomberg School of Public Health and Vice President of Consulting and Applied Research for Truven Health Analytics. It also requires that employees be persuaded of a larger purpose than simply “my employer wants me to do this,” he said. He added that organizations sometimes do a lot that is really not very helpful to themselves, to their workers, or to the creation of a healthy company culture necessary to achieving health-promoting changes.

Establishing a healthy company culture depends on a supportive mission, Goetzel said. Companies that do not operate under a mission supporting employee health may not be ready for an integrated health and wellness program. Generic wellness programs are unlikely to properly fit the culture and mission of a particular employer or the characteristics and challenges of a particular set of employees. This field is dynamic, and

increasingly, leader organizations have gone far beyond a concern about employee weight management to recognizing the workplace culture must foster a sense of well-being for workers. These companies—most of them large—want employees to like and enjoy being at work, to like their co-workers, to feel the company is out to benefit them, and to understand they share the credit for their employer’s accomplishments and success, Goetzel said.

This session, moderated by Goetzel, asked several representatives of large businesses to reflect on the following questions:

• How are you approaching integration? What could it look like ideally?
• What innovative approaches are being used to achieve integration?
• What are the barriers to full integration, and what strategies are being used to overcome those barriers?
• Are there different approaches for different workers?

Speakers in this session included the following:

• Michael Carson, Global Director of Operations and Consulting for Health Services for The Dow Chemical Company. With 54,000 employees at about 300 sites in 49 countries, manufacturing more than 5,000 different products, and having 90 health clinics around the world, Dow has been involved in Total Worker Health initiatives for about 20 years.
• Maribeth Rouseff, Assistant Vice President of Employee Health Services and Wellness Advantage for Baptist Health South Florida, Inc. Baptist Health is the largest private employer in South Florida, with some 15,000 employees, $2.3 billion in total operating revenue, and annual health insurance costs of more than $100 million. Its corporation-wide wellness program, Wellness Advantage, was formed in 2000.
• Andrew Scibelli, Manager of Employee Health and Well-Being for NextEra Energy. With nearly 14,000 employees and revenues of approximately $15.1 billion (in 2013), NextEra provides electricity-related services in 27 states, is the largest North American supplier of energy from renewable wind and solar sources, and operates the nation’s third largest nuclear power generation “fleet.”

• Laura Welch, Medical Director for CPWR, which strives to reduce occupational injuries, illnesses, and fatalities in the construction industry through research, training, and service programs.

THE COMMUNITY CONTEXT FOR HEALTH

Dow Chemical has a very broad view of health, which takes into account the communities where employees live, the benefits the company offers workers and their families, and the products it makes, said Carson. Foundational to Dow’s approach is advocacy for the employees and connection with people on multiple levels—not just their fitness or cholesterol levels, but also the ways emotional or family factors affect their health. The understanding that Dow’s employees are the primary source of its competitive advantage means that, ultimately, good employee health links to corporate business strategies and priorities, including reduced direct and indirect costs. Specifically, Dow developed a health workplace index to better describe the issue of corporate culture. Carson said that the index embodies a company-wide understanding of the “drive to zero injuries and zero adverse events” and links it to safety, quality, and reliability.

NextEra Energy, likewise, believes its wellness initiatives are about more than improving awareness and changing behavior, said Scibelli. They are concerned with creating a culture and environment that supports health through the company’s facilities and policies.

Welch noted that for low-wage workers and those without employer relationships (independent contractors, those who work for franchises, and others), the worksite is only one possible locus for wellness intervention. Various community agencies, including local health departments and clinics, can play a major role in promoting worker health and well-being (Baron et al., 2014), a strategy Welch suggested NIOSH might support. What would be helpful, she said, would be a hotline, akin to a Poison Control Center, that community-based practitioners could call when a patient reports an occupational health problem. Such a resource would be an additional support to low-wage workers. Welch noted that the Migrant Clinicians Network set up a demonstration program like this that worked through a local community clinic.

Even large employers that do have employee relationships may have difficulty promoting behavior changes (e.g., improved nutrition) without addressing the availability of healthy food in the community. As another

example, under a comprehensive, community-grounded approach to smoking cessation, Welch suggested the worksite could disseminate information and cover the cost of antismoking drugs, the health clinic could reinforce the message in primary care visits, the health department could discuss the impact of smoking on families (e.g., asthma and low birth weight prevention), and other community organizations could perform additional roles, such as supporting increased excise taxes, mass media campaigns, and smoke-free laws.

In a discussion on a subsequent panel in the workshop, previous speaker Kathleen McPhaul, VHA, emphasized the importance of the wellness program’s connection to an employee’s primary care provider for follow-up. Ideally, the primary care provider should know what the person does on the job and what he or she is exposed to, she said. For example, Greg Howe, Wellness Manager at Lincoln Industries, gave local primary care providers tours of their facility, so they could see what employees are doing, day in and day out.

The Patient Protection and Affordable Care Act (ACA)¹ has heightened awareness of the importance of the community piece, as care providers that become accountable care organizations (ACOs) take on some of the responsibilities of a public health organization, said Robert McLellan, Dartmouth-Hitchcock. ACOs will have to identify causes of injury and illness and forge new partnerships, perhaps with employers, to remediate them before costly medical interventions, often of limited benefit, become necessary. So far, however, occupational health has essentially been missing from the national conversation around ACOs, McLellan said. In the future, or in some situations, occupational health services may not be necessarily employer based; they may be community based.

A FOCUS ON SAFETY

While a full-blown integrated worker safety, health protection, and health promotion initiative may take up to 20 years to develop, test, and refine—and indeed, it will likely never stop evolving—the fundamental task is ensuring worker safety. An employer that does not have a strong safety program may not be ready to launch wellness activities, Carson said.

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¹Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010).

Many large employers, like Dow, have a tremendous amount of experience with toxicologists, industrial hygienists, and other safety personnel, each with their own discipline, who have different insights on the factors associated with injuries in the workplace. Some of the insights he identified include

• Stress and fatigue (especially among shift workers),
• Substance abuse,
• Underlying health conditions, and
• Lifestyle factors (e.g., physical activity, tobacco use, weight).

A proactive injury management program at Dow revealed that the biggest single risk factor for injury was having a recent previous injury. The resultant multifactorial assessment of repeat injuries now assesses both individual health factors and systemic workplace factors that may have an influence and offer previously unrecognized opportunities for injury prevention.

At Baptist Health, a principal source of employee injuries has been patient transfers, with safe patient handling a prime example of the intersection of employee safety, health promotion, and quality of care, Rouseff said (see Box 4-1).

Nancy Lessin, United Steelworkers–Tony Mazzocchi Center, said employers should first look to change the job to improve safety and health, such as through the use of equipment to reduce or eliminate physical injuries, rather than focusing on worker behavior or habits. “Ergonomics is how you change the job to fit workers rather than how you change a worker to fit the job,” she said. Scibelli noted that in addition to stretching programs (described later in this chapter), NextEra Energy looks at the working environment and considers how to modify both the environment and the actual process of work to improve safety and health.

When Baptist Health employees return to work from physical rehabilitation, either with or without work restrictions, their rehabilitation therapists work with the exercise physiologists in the employee fitness center to develop an exercise plan. This reinforces the message that the organization is concerned about healing and recovery and makes it easier for the employee to maintain the requisite exercises, Rouseff said.

Ergonomic injuries are a particular challenge for the 1,000 Wind Fleet workers who service NextEnergy’s 10,000 wind turbines in 112 locations

scattered throughout the United States, Scibelli said.² These workers must climb internal ladders to the top of the 20-story turbines, carrying 80 to 90 pounds—and sometimes 110 pounds—of gear. Once they arrive in the confined work area, they must bend, lift, and twist, and remain in various awkward positions for extended periods. This particular work environment makes “ergonomic perfection” impossible, Scibelli said, but steps were needed in order to minimize the job’s inherent risks and workers’ frequent musculoskeletal strain and sprain injuries. In 2009, the

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²The blades on a wind turbine are longer than a football field, and each turbine generates enough electricity to power 250 homes, Scibelli said.

company initiated a stretching program, but it was ineffective and lacked employee support.

Wind Fleet personnel sought help from the company’s Health and Well-Being staff, and together, they developed a more dynamic stretching program, Scibelli said. Introduced in 2011, the new program includes a 10-minute video that demonstrates specific, more effective stretching techniques relevant to the demands of the job and teaches power lifting techniques. The program recommends that workers do warm-up stretches at the start of the work day, rest after the tower climb, take microbreaks³ between work tasks, and do another round of stretches after work. The importance of these steps has been reinforced through increased awareness of ergonomics and body mechanics, on-site coaching, management support, and peer engagement.

All sites and the majority of employees now are performing the stretching routines, and many are asking for more information and sharing constructive feedback. More than 80 percent of Wind Fleet technicians have completed the three-part training, and almost 90 percent say they believe it was successful. Meanwhile, NextEra is looking for ways to modify both the wind turbines’ work environment and the process of work. This experience reinforces the value of cross-disciplinary and cross-functional involvement, including workers on the ground, in program planning, and the importance of being willing to evolve programs that are not working.

INTEGRATING WELLNESS

When designing an employee wellness program, the traditional occupational health silos previously mentioned need to be crossed; “You have to have everyone working together,” Carson said. At the individual level, the Dow program works one-on-one with people across important dimensions of health. Looking to the future, the corporation would like to work with employees on new health promotion issues, like sleep and fatigue, building resiliency, and more effective use of technology, Carson said. Other new initiatives include efforts to create “active offices” that help employees avoid sitting all day (e.g., standing desks, standing offic-

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³Scibelli defined microbreaks as 3- to 5-second smooth, controlled movements in the opposite direction of the work, supported by breathing, that help workers focus on reducing task-related muscle tension and fatigue.

es, standing meetings); redesign clinics and wellness centers; and make stairways more inviting.

Baptist Health’s Wellness Advantage program has incorporated various existing employee health initiatives, such as the nine free employee clinics that care for minor illnesses and injuries, and stimulated environmental changes, including transition to healthier cafeteria menus, in partnership with the organization’s food service providers. Other components of the initiative are directed at individuals, such as employee fitness centers and several weight management, smoking cessation, and risk factor reduction programs, Rouseff said.

NextEra’s health and well-being program is about “influencing health, creating balance, fully engaging and helping our employees to be as high-performing as they can,” Scibelli said, and has the following five distinct, integrated components:

1. On-site primary care health centers that perform medical screenings and annual physicals, treat minor illnesses, and provide allergy injections, chest X-rays, and other services;
2. Nutrition counseling, including a high-touch weight management program and healthy foods in company cafés and vending machines;
3. Sixty-six fitness centers that do fitness testing, offer group classes, offer cardio- and strength-training equipment, and conduct fitness programs;
4. An employee assistance program that includes 24/7 help for stress management, depression and anxiety, alcohol and drug issues, sleep problems, and family issues; and
5. The largest component, health promotion, which includes heart health screenings, immunization clinics, educational programs, ergonomic support, stress management, tobacco cessation, and incentive programs.

NextEra Energy’s goals are to keep the program simple and high-touch, person-to-person, and peer-to-peer, said Scibelli.

A new program at Dow called “team agility,” allows workgroups to identify problems that may be contributing to stress. Sometimes these are work-related, and sometimes they are because of personal issues, but the company focus is on issues it can do something about, Carson said, recognizing that, while there is always stress, systems, supports, and culture can be built that help manage that stress.

However, workplace wellness approaches often focus on individual strategies to help workers manage stress and fatigue, but neglect to identify and eliminate or reduce occupational sources of stress and fatigue, Lessin said. Some major sources of worker stress are low pay, unreasonable workloads, and job insecurity—factors employers can (but often neglect to) remediate, she added.

LEADERSHIP AND IMPACT

Along with previous speakers, Rouseff credited leadership in her organization with creating the conditions and encouraging the breakdown of silos that have allowed Baptist Health’s wellness program to succeed.

Dow Chemical’s leadership development efforts include a module giving every corporate leader an understanding of employee health and the importance of life balance for themselves and for workers. There, too, leadership support is deemed essential to creating the alignment across corporate programs and priorities that will lead to more effective strategies to improve employee health and performance, Carson said.

The Dow health strategy has saved the company an estimated $150 million in the past decade, even as it has expanded preventive benefits. The rate of injuries and workplace-related illnesses has declined more than 80 percent, and overall employee health profiles have improved about 9 percent. Chronic health conditions are having less impact on workers, and fewer employees are at high risk of chronic illnesses, Carson said. At the same time, the acceptability of the program has improved, with more employees understanding their health risks and motivated to maintain a healthy lifestyle.

Scibelli said that the success of NextEra’s injury prevention program for Wind Fleet workers has prompted it to expand the program into other areas of the company, beginning with power generation.

Experience has shown the importance of giving leaders and managers talking points and messages so they know what they need to be saying and doing in order to promote workplace health and safety, Goetzel reiterated.

CONTINGENT WORKERS

The discussion of integrated wellness and safety initiatives in large companies can leave out the increasing number of workers who do not have a regularized employment relationship. Typically, Welch said, the 39 million low-wage workers in the United States (making, on average, $435 per week) tend to have contingent and temporary relationships with employers. These workers are disproportionately female, African American or Hispanic, foreign born, lacking a high school diploma, and under age 24. Commonly, they work as cashiers, food service workers, personal and home care aides, housekeepers, farm workers, and child care workers.

In construction, as well as other industries, a common practice is to hire independent contractors or have some third party between the lead company and the worker, Welch said. This may be a staffing or temporary firm, a labor contractor, or a franchisee. In some cases, even a large lead company may not have “employees” for whom it must provide benefits, contribute to unemployment insurance, or participate in workers’ compensation programs.

Outsourcing has several additional negative effects on workers, Welch said. Wages decline, in part because the intermediary company takes a portion of the wages to cover its costs. Researchers find that wage and overtime violations, including working without pay outside of the regularly scheduled work times, become more common (Bernhardt et al., 2009; Ruckelshaus et al., 2014). Even conscientious employers face difficulties in such an environment, as they must compete with lower-bidding firms. In the construction industry, for example, Welch said union contractors report keen competition from companies that treat every worker as an independent contractor, minimizing their benefit and insurance costs.