The workplace is where 156 million working adults in the United States spend many waking hours, and it has a profound influence on health and well-being. Work-related injuries and illnesses can impact quality of life. Although some occupations and work-related activities are more hazardous than others and face higher rates of injuries, illness, disease, and fatalities, workers in all occupations face some form of work-related safety and health concerns. Not only are such hazards a threat to worker well-being and hence to the nation’s health, but one study estimated the annual cost of occupational injuries, illnesses, and deaths in the United States at $250 billion (in 2007 dollars), which is more than the $219 billion for cancer and more than half of the $431.8 billion for cardiovascular disease. Reducing that health burden is the goal of occupational safety and health (OSH) surveillance.
OSH surveillance provides the data and analyses needed to understand the relationships between work and injuries and illnesses in order to improve worker safety and health and prevent work-related injuries and illnesses. Information about the circumstances in which workers are injured or made ill on the job and how these patterns change over time is essential to develop effective prevention programs and target future research. The nation needs a robust OSH surveillance system to provide this critical information for informing policy development, guiding educational and regulatory activities, developing safer technologies, and enabling research and prevention strategies that serves and protects all workers.
The 1987 National Research Council report Counting Injuries and Illnesses in the Workplace: Proposals for a Better System provided initial guidance to organize and enhance OSH surveillance in the United States. Responses to that report resulted in a number of improvements, primarily ones that addressed injury surveillance. While the 1987 report was instrumental to many noted improvements in OSH surveillance, major changes have occurred in the past 30 years that necessitate this new study—a comprehensive reassessment of the state of OSH surveillance. The three key federal agencies involved with occupational safety and health—the National Institute for Occupational Safety and Health (NIOSH), the Bureau of Labor and Statistics (BLS), and the Occupational Safety and Health Administration (OSHA)—called on the National Academies of Sciences, Engineering, and Medicine to undertake a study to develop a vision and steps toward a national surveillance system for occupational safety and health for the 21st century (see Statement of Task in Box 1-1).
Over the past 30 years, there have been remarkable changes in the landscape of work. These include major changes in the geographic and proportional distribution of industries, the nature of work, the demographics of the workforce, and employee-employment arrangements. Employment in manufacturing has declined, while there has been significant growth in employment in the service sector, including health care. Individuals are likely to be working more than one job over their working life, and may hold multiple jobs at the same time. The workforce is much more diverse, with many more women, racial and ethnic minorities, and immigrants employed. Growth has occurred in nonstandard work arrangements (such as the use of independent contractors and the outsourcing of functions to other entities) and in “on-demand” or “gig” work (where employment is characterized by short-term contracts or freelance work). With these shifts in work and the workforce, employment is more precarious and many workers lack the protections and rights afforded by laws and regulations that make them more vulnerable and subject to abuse. Approaches to OSH surveillance have generally not evolved to address the changing nature of work.
OSH surveillance is a collaborative effort of federal, state, and local agencies and stakeholders across employers, employee organizations, professional associations, and other organizations. The federal agencies that play the major roles are BLS, OSHA, and the Mine Safety and Health Administration (all in the Department of Labor), and NIOSH (in the Centers for Disease Control and Prevention (CDC) of the Department of Health and Human Services (HHS)). Since the 1890s, BLS has collected statistical data on work-related injuries, illnesses, and fatalities. The OSH Act of
1970 created both OSHA and NIOSH, charging OSHA with responsibility for setting and enforcing safe and healthful workplace standards and tasking NIOSH with conducting research, experiments, and demonstrations relating to occupational safety and health and with developing criteria for recommended standards. There are a number of other federal agencies with responsibilities and programs pertaining to OSH surveillance and prevention. State agencies also play a critical and complementary role in partnership with federal agencies. State agencies collect, analyze, and disseminate data from local sources to guide preventive action at the state, regional, and local levels; provide aggregated data to federal agencies for national surveillance; and fill in gaps in national surveillance data. The strong role of workers and employers is crucial for ensuring accurate and complete data and for using this information to implement workplace improvements. In addition, health care facilities and organizations, workers’ compensation systems, and insurance companies have data that are relevant to OSH.
Surveillance is defined as ongoing, systematic collection, analysis, and interpretation of health data, essential to the planning, implementation, and evaluation of public health practice, closely integrated with the dissemination of these data to those who need to know. There is no single, comprehensive OSH surveillance system in the United States, but rather an evolving set of systems using a variety of data sources that meet different surveillance objectives, each with strengths and weaknesses. The major focus to date has been on collecting data on health outcomes, with less emphasis on collection of data on hazards and exposures.
OSH surveillance activity is also spread across multiple federal and state agencies, as agencies collect, store, analyze, and interpret data to meet their specific agency needs. Resources are limited for OSH surveillance, partly because responsibility for occupational issues is bifurcated between labor and public health and partly because of limited core funding allocations specifically for OSH surveillance. There are also barriers to sharing information among federal and state agencies due to long-established conventions, and also barriers to sharing information between employers and employees, largely due to lack of trust.
A major change has been in the evolution, effectiveness, and relative ubiquity of information and communications technology (both methods and tools) since the 1987 report. Advances in data collection and storage, analytic methods, sensors, and mobile devices allow information to be collected and connected with central collection resources. Social media have also become sources of insight regarding societal trends and offer one of many methods for information dissemination. OSH surveillance efforts will need to leverage newer technologies and tools for identifying, organizing, analyzing, and interpreting data in more innovative, powerful, and cost-effective ways. Doing so could reveal problems, trends, and emerging issues
within and across sectors, groups, and geographic regions of workers. Also, these technologies offer opportunities to improve the dissemination of information to those that can use surveillance data to take preventive action, thereby improving worker safety and health and reducing associated human and economic costs of work-related injuries and illnesses.
The Committee on Developing a “Smarter” National Surveillance System for Occupational Safety and Health in the 21st Century undertook its
task by first considering the goals of an ideal national surveillance system and establishing a set of guiding principles (see Box S-1). Then it examined the current roles and activities of different agencies and stakeholders, and studied OSH surveillance in other countries for possible lessons learned. Next, the committee explored promising new developments, such as the household survey, electronic health records, autocoding of occupational information, electronic reporting, use of workers’ compensation data, and improvements in occupational hazard and exposure surveillance. Then the committee considered ways to enable an effective national OSH surveillance system, including a clear rationale and prioritization for surveillance, coordination of surveillance strategies, effective use of information technology, and utilizing practitioners with appropriate skills. Finally, to address the demands and concerns of the current and future workforce, and ultimately to protect workers, the committee envisioned how to achieve a more cohesive and “smarter” system in the United States by providing both near- and long-term recommendations for moving the current system into the 21st century.
VISION FOR A “SMARTER” SYSTEM
The committee’s vision for the future of OSH surveillance is a collaborative system of systems. Recognizing the varying mandates and roles of many relevant stakeholders, the committee believes that it is possible to strengthen the ongoing coordination and data sharing across federal agencies, between federal and state agencies, across state agencies (e.g., labor and health), and with employers and workers to result in the maximum possible engagement of all. A system of systems approach to OSH surveillance would minimize the undercounting of occupational injuries and illnesses by gathering sufficient data that include nontraditional occupations and worker groups in a representative manner and enhancing prevention-relevant information in surveillance data to include race and ethnicity as well as occupation and industry. It would expand outcomes to include chronic diseases and their causes and include leading indicators, primarily through adequately detailed exposure information. Further, this system would maximize appropriate use of technologies to facilitate all surveillance processes and create structures for disseminating information to levels where it can be acted upon.
Critical enabling components can be leveraged by agencies responsible for implementing the smarter system. Such efforts begin by extending the capacities of the agencies through targeted enhancements of both existing systems and technical personnel, and through effective communication across agencies. This will be complemented by information and other inputs available through employers, employee representatives, relevant
intermediaries, and individuals along with engaged health care systems, all taking full advantage of state-of-the-art technology.
Engagement of employers and health care providers could result in substantive improvements by augmenting existing resources (e.g., effective implementation of electronic reporting) along with development of new resources, such as voluntary within-industry partnerships to engage collectively in exposure surveillance. Individual workers will play an essential role in the smarter system, independent of employer relationship, by participating in population health surveys that incorporate occupational information (e.g., the Household Survey of Occupational Injuries and Illness, the National Health Interview Survey, the Behavioral Risk Factor Surveillance System, and the Medical Expenditure Panel Survey). Information from these surveys complements information from other data sources as there is no single definitive data source that covers all aspects of work injuries and illnesses.
Evolving health care systems, along with technology embedded in the delivery system, can greatly facilitate enriched inputs of data on work that can be linked to health outcome data. Inclusion of occupational information in the electronic health record and advances in health care reporting structures can improve reports of work-related health conditions.
Fundamental to a successful smarter system is the sufficient and creative use of information technology capacity and resources. These include effective autocoding of occupational information in all appropriate records, electronic reporting wherever possible from all traditional and emerging reporting sources, and development of hardware and software for simplified, efficient, and real-time collection of information (e.g., exposure and compliance data). To enable the system fully, methods and tools need to be developed for timely and effective collection and analysis of surveillance data. In addition, software needs to be designed and disseminated so that all relevant stakeholders can undertake their own examination of surveillance information and act on findings as quickly as possible to improve worker safety and health.
GETTING TO A SMARTER SYSTEM
Based on a systematic review of current surveillance efforts and barriers, the committee examined several approaches to advancing this vision. First and foremost, OSH surveillance needs to become a priority if it is to serve the core function of providing the information essential to guide public health actions to improve worker safety and health. Surveillance often exists in the background of public health programs, rising to a level of importance only at times that call for emergency action. However, the system needs to seamlessly collect, collate, and assess information without inter-
ruption to support evidence-based actions, emergency or otherwise. With surveillance as a priority, the development of a centralized coordination of a system of systems can provide the essential evidence to guide prevention efforts that advance program objectives in the most cost-effective manner.
Recommendation Q (meta-recommendation): The Secretary of HHS, with the support of the Secretary of Labor, should direct NIOSH to form and lead a coordinating entity in partnership with OSHA, BLS, and other relevant agencies. The coordinating entity should:
- develop and regularly update a national occupational safety and health surveillance strategic plan that is based on well-articulated objectives;
- coordinate the design and evaluation of an evolving national system of systems for OSH surveillance and for the dissemination of surveillance information provided by these systems;
- publish a report on progress toward the strategic plan’s implementation at least every 5 years, documenting advances toward achieving a 21st Century Smarter Occupational Safety and Health (OSH) Surveillance System; and
- engage partners, including other federal health statistics agencies, state agencies with OSH responsibilities, and stakeholders.
This recommendation is the cornerstone for the advice offered by the committee. The envisioned coordinating entity is essential if the system of systems is to be a cross-agency vision and plan for moving forward, if the other recommendations are to be properly prioritized and carried out, and if the resulting system of systems is to be guided effectively by the principles and objectives of an ideal national occupational safety and health surveillance system.
As a system of systems, this smarter system will need to provide specific and clear-cut objectives for each of the surveillance systems within the overall system, and include concrete objectives for each key federal agency. It would also include detailed plans for engagement of the state-based OSH programs that identify priority conditions for expanded surveillance, provide guidance on how to use the data generated by the states, and, whenever possible, identify lead agencies (both federal and state) for these conditions. Resource needs would need to be organized, projected, and articulated. Benchmarks need to be identified and realistic timelines need to be specified for measurable progress. Furthermore, evaluation will be essential for expanding or replicating successful systems at different levels of the organization as appropriate, and for terminating systems that no longer meet objectives.
Long-term objectives will require greatly expanded data resources paired with improved methods for assessing burden. All actors face
constraints due to limited resources and complicated historical precedents. Therefore, whenever possible, recommendations are presented with both near- and long-term constituents. The near-term parts are meant to be possible within existing resources and constraints. The longer-term parts are expected to require new resources (financial and personnel) along with the evolution of elements that are beyond the direct control of the leadership for OSH surveillance. Nonetheless, if the recommended stakeholders fail to take initial steps that can lead to longer-term developments, continuing progress toward the best possible surveillance system will either be delayed or impossible.
The committee reviewed evidence for assessing the magnitude of the OSH problem nationally and, where possible, at the state level. It also considered the social and economic costs of the burden of injury and illness that are borne by individuals and society. The limited evidence available still proved useful in establishing the context for the committee’s work. However, neither the OSH community nor the public health community as a whole currently has adequate information and analysis to assess this burden properly and to track it effectively. Therefore, we have offered a way forward to a more complete, ongoing effort to measure and report on the burden and importance of occupational disease and injury to our nation and its people.
The Overall System
In setting forth OHS surveillance as a national priority, the responsible agencies, most centrally NIOSH, will need to delineate a clear line of responsibility and authority over each agency’s surveillance activities and personnel. Unless leadership structurally and distinctly recognizes and articulates these actions, the system is incapable of achieving the identified goals. Agencies need to ensure that links across agencies are as seamless as possible and that barriers are eliminated for timely, efficient sharing of data and information. The overall system will need to be founded on a close working relationship between federal and state partners because coordinated federal and state systems offer immense advantages over either operating independently. The report accordingly stresses the value of an effective federal-state partnership and strengthened state efforts, both to facilitate and serve a national effort to identify and monitor priority conditions and emerging problems, and to foster prevention programs at the level that can best address these concerns (see Recommendation C).
Recommendation C: NIOSH should lead a collaborative effort with BLS, OSHA, the states, and other relevant federal agencies to establish and strengthen state-based OSH surveillance programs.
The most effective intervention activities will need to act on the causes and not the consequences of OSH problems. Exposure and hazard surveillance points the way to primary prevention, particularly important for long-latency occupational diseases. Consequently, a sequence of efforts is designed to construct a robust exposure component of the envisioned surveillance system. The report calls for an immediate collaborative effort of federal agencies to initiate the development of a comprehensive approach for exposure surveillance that builds and updates a database of risks and exposures to predict and locate work-related acute and chronic health conditions for prevention (see Recommendation H).
Recommendation H: NIOSH, in consultation with OSHA, should place priority on developing a comprehensive approach for exposure surveillance.
The effectiveness of the overall system of systems will depend on the resources and methods of biomedical informatics. Developments occur so rapidly in this area that a lack of experienced, engaged personnel leads to lost opportunities and compromised system effectiveness. Most critical is the need for NIOSH to attract adequate informatics personnel and resources (see Recommendation J), though recruiting and maintaining informatics experts in the public sector can be challenging. Informatics capacity will need to be leveraged to enable OSH agencies, particularly NIOSH, to use advanced computational and analytical tools and to monitor advances in information technology (see Recommendations L and M). It will be important to engage the scientific community by working with the National Library of Medicine to facilitate easy discovery of the importance of the connections between work and disease or injury in published research (see Recommendation K). A collaborative federal effort is needed to promote and support education and training of the surveillance workforce by identifying core competencies required for OSH surveillance (e.g., epidemiology, biomedical informatics, and biostatistics) and to engage educational institutions to establish or modify training programs accordingly (see Recommendation P).
Recommendation J: NIOSH should build and maintain a robust internal capacity in biomedical informatics applied to OSH surveillance.
Recommendation K: NIOSH should work with the National Library of Medicine to incorporate core OSH surveillance terminologies, including those for industry and occupation, into the Unified Medical Language System.
Recommendation L: NIOSH should lead efforts to establish data standards and software tools for coding and using occupational data in electronic health records.
Recommendation M: NIOSH and BLS, working with other relevant agencies, academic centers, and other stakeholders, should coordinate and consolidate, where possible, efforts to develop and evaluate state-of-the-art computational and analytical tools for processing free text data found in OSH surveillance records of all types.
Recommendation P: NIOSH, OSHA, and BLS should work together to encourage education and training of the surveillance workforce in disciplines necessary for developing and using surveillance systems, including epidemiology, biomedical informatics, and biostatistics.
Data Collection and Processing
Surveillance starts with collecting and processing relevant data, followed by data analysis and interpretation that can guide policy and interventions. The sources and quality of inputs to the smarter system are thus crucial. The issue of undercounting of occupational injuries and illnesses is highlighted from two perspectives: cases that are out of scope or cases that are simply unreported. Failure to count occupational injuries that are out of scope is a recognized consequence of surveys or other assessments that do not capture data on some segments of the working population. For example, the Survey of Occupational Injuries and Illnesses (SOII) does not cover or capture injuries to workers who are self-employed (e.g., independent contractors) or who work on small farms. When the 1987 NRC report called specific attention to both perspectives, the Bureau of Labor Statistics responded by addressing that which was within its control and now has ongoing efforts to understand the reasons for underreporting. The underreporting problem, however, is complex and multifactorial. Additionally, there are limitations in the identification and reporting of chronic diseases associated with work. Further, many of the systems that collect information on injuries and illnesses do not collect occupationally-related data.
One of the major inputs to OSH surveillance is through the SOII and the report discusses needed enhancements to the SOII, including that would better inform public health actions for underserved populations. Injury and illness recording can be improved by better characterizing work-related injuries and illnesses in a manner that enhances usefulness at the worksite as well as at national and state levels (see Recommendation A). Developing ways to incorporate information on race, ethnicity, and employment arrangements will allow for identification of vulnerable worker popula-
tions and risks that may be associated with different types of employment arrangements.
Recommendation A: BLS and OSHA should collaborate to enhance injury and illness recording and the Survey of Occupational Injuries and Illnesses (SOII) to achieve more complete, accurate, and robust information on the extent, distribution, and characteristics of work-related injuries and illnesses, and affected workers, for use at the worksite and at national and state levels.
The committee supports the BLS plan to implement a Household Survey of Occupational Injuries and Illnesses (HSOII), as it will fill in data gaps for populations of workers who are missing from employer-based injury reporting and will provide worker input (see Recommendation D). Another largely untapped resource for injury surveillance data is the workers’ compensation system, and the report promotes the expanded use of workers’ compensation data for occupational injury and illness surveillance (see Recommendation F).
Recommendation D: BLS should place priority on implementing their plan for a Household Survey of Occupational Injuries and Illnesses (HSOII).
Recommendation F: NIOSH, with assistance from OSHA, should explore and promote the expanded use of workers’ compensation data for occupational injury and illness surveillance and the development of surveillance for consequences of injury and illness outcomes, including return to work and disability.
Work-related disease information (as opposed to injury) has been almost absent from occupational health surveillance, which was noted in 1987 and remains true today. Several recommendations address this priority component of data collection, including the enhanced assessment of self-reported health through the National Center for Health Statistics or an expanded HSOII (one component of Recommendation D) and the development of a comprehensive approach for exposure surveillance (see Recommendations D and H). Also key are occupational disease monitoring (see Recommendation B) and the specification of industry and occupation as core variables in all federal health surveys (see Recommendation G). The latter recommendation addresses the unparalleled opportunity to gain information on the distribution of exposure-related factors in a manner modeled on the highly successful experience in the European Union, which has over 25 years of experience in such efforts.
Recommendation B: NIOSH, working with the state occupational safety and health surveillance programs and across divisions within the agency, should develop a methodology and coordinated system for surveillance of both fatal and nonfatal occupational disease using multiple data sources.
Recommendation G: HHS should designate industry and occupation as core demographic variables collected in federal health surveys, as well as in other relevant public health surveillance systems, and foster collaboration between NIOSH and other CDC centers in maximizing the surveillance benefits of including industry and occupation in these surveys and surveillance systems.
For OSH surveillance, a forward-looking aspect of data collection and processing concerns how best to remove the barrier to recording and interpreting occupational information in medical records and in population surveys of all types. The report accordingly recommends that NIOSH, with an evolving biomedical informatics capacity, lead efforts to establish data standards and software tools for coding and extracting occupational data in electronic health records. These records are increasingly becoming standard practice, and there is an opportunity to make substantial long-lasting progress to eliminate barriers to linking occupation and disease (see Recommendation L). The creation of a cross-agency effort is needed to develop and evaluate state-of-the-art computational and analytical tools for processing free text data found in OSH records of all types (see Recommendation M).
Data Analysis and Information Dissemination
Successful collection and processing of surveillance data alone does not make a successful surveillance system. The system also requires thoughtful analysis, careful interpretation, and then dissemination of results to engage in policy development or public health action for prevention. Attention to analysis and interpretation is essential when calling on partners to provide new or more data, even if that requirement is facilitated through electronic reporting. Accordingly, a program that provides for better reporting, such as the OSHA electronic reporting initiative, needs to be accompanied by a robust plan for analyzing, interpreting, and disseminating the information. OSHA, its sister agencies, and stakeholders will need to develop and publicize plans to maximize the utility of their new electronic reporting initiative by providing means and methods for ongoing analysis and dissemination of these data with special attention to serving individual employer needs while simultaneously minimizing duplication of reporting by employers (see Recommendation E).
Recommendation E: OSHA, in conjunction with BLS, NIOSH, state agencies, and other stakeholders, should develop plans to maximize the effectiveness and utility of OSHA’s new electronic reporting initiative for surveillance.
Of equal importance is the need for the dissemination of surveillance findings and analyses in useful formats for informing and evaluating prevention. There is a need to make regular reports to the nation that publicize the overall burden of occupational injury and disease in terms of the burdens on health, the economy, and society (see Recommendation I). NIOSH, OSHA, and BLS are already engaged with dissemination and, while ideas are provided throughout the report on how these efforts could be enhanced, most important is the need for an effective alert mechanism. A smoothly operating alert mechanism should be created that receives, enhances, and rapidly publicizes to those who need to act on the signals of emerging OSH problems either as new associations of work and illness or injury or of old associations found in new settings (see Recommendation N). Appropriate and timely attention to surveillance findings, routine or new, is essential for prevention and thus requires that a smooth and centralized mechanism be established for timely ongoing dissemination of cross-agency information to all relevant actors (see Recommendation O).
Recommendation I: NIOSH should coordinate with OSHA, BLS, and other relevant agencies to measure and report, on a regular basis, the economic and health burdens of occupational injury and disease at the national level.
Recommendation N: To identify emerging and serious OSH injuries, illnesses, and exposures in a timely fashion, NIOSH (in coordination with OSHA, BLS, and the states) should develop and implement a plan for routine, coordinated, rapid analysis of case-level OSH data collected by different surveillance systems, followed by the timely sharing of the findings.
Recommendation O: To promote and facilitate the use of surveillance information for prevention, and to present more comprehensive information on the extent, distribution, and characteristics of OSH injuries, illnesses, and exposures, NIOSH (in coordination with and input from OSHA, BLS, and the states) should establish a coordinated strategy and mechanism for timely dissemination of surveillance information.
Worker safety and health is of paramount importance to thriving workers and workplaces, and accordingly to society as a whole. Ensuring and improving worker safety and health is a commitment taken seriously, and diligently acted upon, by numerous federal, state, and local agencies; workers and worker organizations; employers and employer organizations; and many others. More can be done to inform and improve these efforts through strengthening OSH surveillance in the United States. With the rapid changes in the nature of work in the United States, and with new risks added to those that have always existed, the nation clearly needs a smarter OSH surveillance system of systems for the 21st century. This report provides the evidence and recommendations for a greatly enhanced OSH surveillance system that is envisioned to be smarter, more dynamic, and more highly coordinated.