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

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Total Worker Health for
Small- and Medium-Sized Businesses

Smaller businesses have unique challenges and opportunities when establishing integrated safety and health programs, said Chia-Chia Chang, Public Health Analyst, NIOSH Total Worker Health program. On one hand, it may be easier to integrate programs because of fewer competing departments and worksites. On the other, she said, smaller employers have fewer resources to get things done and, therefore, may find it necessary to focus on specific occupational safety and health mandates; they may have higher turnover or more temporary or contingent workers, which may decrease the commitment to worker safety and health; or data may be harder to collect and analyze because of privacy concerns, a point reiterated by panelist Joe Nguyen, an employee of RACO and union president.

Although examples of truly integrated safety and wellness programs within smaller businesses were difficult to identify for the workshop, about half of all Americans work in settings with 500 or fewer employees. “We are a nation of small businesses,” said Lee Newman, Professor, Colorado School of Public Health, and Chief Medical Information Officer, Axion Health, Inc. “If we, NIOSH, do not grapple with this, then

we are failing the majority of workers in this country.” In fact, large employers may not need help, said Peter Wald, USAA. They have resources. If NIOSH was going to focus on a group of businesses, he said, it might focus on the smaller employers and encourage the larger employers to help. However, at the small, widely dispersed worksites of many large corporations, program implementation faces many of the same challenges a small business does. There may be few resources at these remote (or mobile) sites to plan, implement, and monitor a wellness program.

This session, moderated by Chang, asked several representatives of small- and medium-sized 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:

• Greg Howe, Wellness Manager for Lincoln Industries (Lincoln, Nebraska), which has some 620 workers at 5 sites of varying sizes, ranging from 8 people to about 500. The company is primarily a metal finisher, although it also engages in engineering, fabrication, polishing, plating, coating, assembly, and supply chain work.
• Lee Newman, Professor, Colorado School of Public Health, and Chief Medical Information Officer, Axion Health, Inc. A Colorado School of Public Health initiative, Health Links^TM1, is developing a healthy business certification and advising program in the state and which mostly serves businesses with fewer than 500 employees. In Colorado, 96 percent of small businesses have fewer than 50 employees, and no programs to improve worker health are specifically geared toward these employers.

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¹The Colorado School of Public Health asserts common law trademark rights for the term Health Links.

• Joe Nguyen, President of IUE-CWA Local 84913 and employee of RACO, a manufacturer of electrical boxes and fittings, and a small division of the much larger Hubbell Incorporated. Although RACO does not have a Total Worker Health program, over the years it has had components of such a program.

READINESS

Some businesses with fewer than 50 employees may consider themselves to be too small for a worksite wellness program or for integration of wellness and traditional safety programs, said Newman. His Colorado School of Public Health program works with small businesses on ways to translate research into practice around safety and health promotion, but the literature on small business applications “is sparse.” A systematic review of published articles on the worksite wellness component for small businesses—in terms of both adoption and effectiveness—found fewer than 20 studies that met the reviewers’ criteria for rigor (McCoy et al., 2014), and even less is known about the integration of health promotion and health protection/safety in small businesses, he said.

One of Lincoln Industries’ core beliefs is that “wellness and healthy lifestyles are important to our success,” and among the company’s success drivers is the statement that “a safe working environment is our commitment to each other,” said Howe. The commitment starts at the top and is shared by every single worker. According to Howe, such a foundational culture is necessary to support initiatives like Total Worker Health. With that culture in place, the company can support people to live healthy lifestyles and “to become the best version of themselves,” as Howe put it, which he believes will lead to optimal business performance.

A company may use formal means, such as surveys and environmental evaluations, to determine whether it is ready for an integrated program, but for small employers, Howe said, it may simply be a matter of asking peoples’ opinion about what they want when the company is looking at making an investment—a new product, new machines, or a new employee benefit. Such decisions require weighing where the company wants to grow and what its people most need in order to get there. According to Howe, typical drivers for small business decision making include the following:

• An interest in hiring and retaining quality people.
• A recognition that younger workers, especially, are more demanding about the kind of workplace they are being hired into, including evidence that the employer cares about workers and keeping them happy. (Several other workshop participants also noted the increasing preoccupation among employers regarding worker “happiness.”)
• The desire to be sure an initiative has buy-in from people already working there.

While top leadership support is vital, there has to be at least some support throughout the organization, Howe said.

INTEGRATION OPPORTUNITIES AND IMPACT

The following are examples of programs in which Lincoln Industries has integrated health and wellness:

• Fuel for Performance (covering sleep, fitness, and nutrition),
• HealthyU (an on-site free medical clinic),
• HealthyU Fit (an on-site fitness center), and
• Platinum Wellness.

The Fuel for Performance program works with individual teams and departments from across the company, providing individual professional coaches to help people establish their own goals, which they then work on for 12 to 16 weeks. (The types of exercises that people specifically requested, in order to make them feel better at work, were aimed at improving range of motion and flexibility.) The company started looking at the exercise and fitness domain using a sports medicine model. While the program produced some health and fitness benefits, Howe said, it also reduced absenteeism and was associated with both self-reported and supervisor-reported performance improvements. In addition, team camaraderie increased, as employees supported each other in their efforts to meet their individual goals.

HealthyU, the company’s free medical clinic available to both workers and families, provides primary care, health coaching, and acute care, and helps people access health care. Each clinic appointment is a minimum of 15 minutes, so even when a presenting problem is quickly ad-

dressed, Howe said, there is an opportunity for conversation about healthy lifestyle, if the person wants to discuss it.

In addition, massage therapists and physical therapists are available to help with any appropriate issues, regardless of whether an injury occurred at work. Because these therapists know the company so well, Howe said, they can provide greater ergonomic support and are brought in when the company is launching new processes, sitting in with the engineering and design team, in the hope of preventing ergonomic problems. Massage therapy fits the sports medicine model, and was offered to a group of workers whose rate of musculoskeletal injuries was trending up. At the same time, some robotics were brought in to lighten the load. Massage therapy is now offered weekly for members of that high-risk group, as a paid-time, on-the-clock benefit. Injuries among them have been almost eliminated, with no new injury for 4 years.

The Platinum Wellness Program is an employee incentive program that includes various health screening measures and addresses tobacco use. (In 2004, 42 percent of Lincoln Industries’ employees smoked; today only 13 percent do, and risk factors for diabetes and heart disease have likewise declined, Howe said.) Workers who achieve certain results receive points and are eligible for different rewards. One of these is a Platinum Mountain Climb, a company-paid trip to Colorado where the group summits a 14,000-foot mountain. In 2014, 270 employees qualified (though not all do the climb). How this differs from some other employer incentive programs, Howe said, is that it is an experience, one that employees are proud to have achieved.

Newman gave as an example his project’s experience with San Isabel Electric Association in Pueblo, Colorado, which is a “fairly hazardous” industry employing some 85 people. The integrated approach had leadership buy-in, and middle-managers and individual champions promoted a new wellness component to combine with the existing safety program. The result, Newman said, was both good public and community relations and “a healthier, happier, more productive workforce.”

Recognizing that one size does not fit all, the Colorado project does not start with any specific template for how—or whether—employer health and safety programs should be integrated. Instead, the project educates company leaders using an evidence-based framework for establishing a sustainable culture of safety and health. The framework allows them to determine which specific wellness and safety activities fit in their business framework and company culture. Employers currently offering no health and safety programs, Newman said, “may integrate

health and safety from the beginning,” while employers that already have both will want to carefully analyze whether there will be real benefits from integration before making changes.

A FOCUS ON SAFETY

Hazardous industries need to start their efforts with strong safety programs, Newman said, though small office-based companies may be able to start with wellness. Priorities may differ within the employee population, Nguyen said, with employees doing the “heavy lifting” preferring an emphasis on safety—including improved building maintenance to reduce hazards—with people in office jobs preferring wellness. Yet another group of workers might prefer that the monies spent on wellness be invested in higher wages or used to hire additional employees, in order to decrease the amount of mandatory overtime or ease productivity demands. In other words, employees may need building repairs, job repairs, and process repairs to make work healthier.

Nguyen emphasized the importance of having a joint labor and management safety committee, to assure input from people actually doing the work, day-to-day. While there is a tendency to go to “the experts” for safety solutions, he said, the workers actually may be the experts. As an example, his employer has a joint safety committee with four members from the company and an equal number from the union, and these members represent different managerial responsibilities and sectors of the workforce.

Nancy Lessin, United Steelworkers–Tony Mazzocchi Center, noted that the Occupational Safety and Health Administration’s permissible exposure limits are outdated and that NIOSH has, in many cases, come up with more protective recommended exposure limits. She challenged employers to consider:

• First, has the use of toxic substances been analyzed, in order to identify substances or processes that could be problematic, and their use eliminated or reduced by changing the process or using safer substitutes?
• If use is unavoidable, are they controlled to NIOSH’s recommended level?

Only the employer can do this, she said; the worker cannot.

Even with Lincoln Industries’ emphasis on wellness, attention to safety has not subsided. The total number of injuries among its workers declined from 46 in 2011 to 14 in 2013, and now stands at a rate below the industry average. Howe described an approach of looking at occupational risk by department—focusing on some concrete, current problem—and not trying to introduce a company-wide initiative in the beginning. Then the safety conversation can be expanded, under the notion that what is wanted is to look at the “whole human.”

Even though federal law requires adherence to specific safety standards, among the first 100 small businesses that Newman’s project has worked with in Colorado, 70 “have nothing going on in safety at all. There is no assessment of chemicals, nothing, zero.” This is another area in which good data can be useful, inasmuch as summary measures of safety may obscure heightened risks and opportunities for prevention in a particular work unit, department, or product line.

LEARNING WHAT WORKS

The Colorado certification project has launched some community-level interventions in order to learn more about what works in smaller employment settings, Newman said. In the pilot project, Health Links Colorado,² program managers provide education and advice for employers for starting an integrated wellness and safety program, information, and resources—especially local and free resources—and some funding. The project also connects employers with other small businesses attempting similar initiatives. For companies, the certification process begins with an online application that provides feedback, which is followed by an advising visit where project personnel discuss the safety and wellness profiles of the company, following the Total Worker Health model. The program includes an annual recertification, which focuses on continued improvements measured at the organizational level.

To keep management support, integrated health and wellness programs must be regarded as beneficial to both workers and employers, and be equitable and sustainable, Newman said. Although the evidence base is thin, programs should be evidence based to the extent possible and coordinated across health and safety. In any case, research will be a continuing challenge in working with the wide array and diversity of small

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²For more information, see www.HealthLinksColorado.org (accessed July 21, 2014).

employers. Small businesses and labor can establish consortia, collaboratives, coalitions, and information exchanges that may enable some of the innovations to move forward, including the necessary supporting research, Goetzel said.³

The Colorado project trains community health workers to talk to small businesses about a range of issues—safety, chronic disease, prevention, smoking cessation—depending on the employer’s interest. In the reactors panel at the end of the workshop, Nicolaas Pronk, Vice President for Health Management and Chief Science Officer, HealthPartners, Inc., said, this community piece is the key to future sustainability.

EMPLOYEE RELATIONS

As mentioned, concerns over privacy may be heightened in a small organization. Employees worry about the confidentiality of their health data, and managers worry about violating federal privacy requirements. Especially when a small employer uses an outside vendor to manage its wellness program, it needs to be sure that both data safeguards and quality measures are in place so it can trust the information provided about employees’ health status. Nguyen said there can be a conflict of interest, if reporting high rates of health problems would lead to a request for more vendor-supplied interventions. Also, in the reactors panel at the end of the workshop, Margaret Robbins, National Director, Occupational Safety and Health, Coalition of Kaiser Permanente Unions, said, management must ensure programs are truly voluntary, regardless of who is carrying them out, and voluntary in fact, not just by design, as coercive programs have engendered worker opposition.

In cases where safety programs are lacking, Newman said, the wellness programs management wants to introduce can be a Trojan horse. With an integrated approach, you can come in to work on wellness and introduce the idea of safety (e.g., hazardous substances control) as well, he said. But Lessin argued that only when the workplace is considered safe and free of hazardous chemicals, when hours, workload, and staffing are reasonable—all those issues that are solely under the employer’s control—

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³An example provided was the Council of Smaller Enterprises, with 14,000 members, which is the Cleveland region’s largest small business support program and includes advice and resources related to wellness programs. See http://www.cose.org/Manage%20Employees/Employee%20Benefits%20Consultation%20and%20Programs/Wellness%20Programs.aspx (accessed July 22, 2014).

can an employer credibly start talking to people about its concerns for their health.

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