Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access (2020)

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87 Evaluation Considerations Transit agencies (TAs) will be able to make better decisions if they have information about the real-time impact of restroom access such as delays, safety-related events, and health costs. Knowing this will also help local union (LU) leaders and their members target their requests for improvements. Given that schedule-related costs are quantified by most TAs, while the benefits of better accommodating operators’ restroom needs are not directly measured, the tendency in transit scheduling practice may have tilted toward operational efficiency and reliability. Addi- tional impacts to consider include the financial and operational effects, for better or for worse, of changed schedules, the satisfaction of the riding public, and the burden carried by the work- force in terms of health and morale when restroom access is not adequate. The project findings suggest strongly that the major costs of making changes will center on scheduling and opera- tional efficiency. Untangling the other values from the responses of the many contributors can be difficult. The tools provided with this project are designed to sort out these and other values that should accrue from improved policies and practices. Restroom access in relation to operational costs is not a new consideration in transportation research. In 1999, TCRP Synthesis of Transit Practice 33: Practices in Assuring Employee Avail- ability suggested that restroom access may be a cause of operator absenteeism, noting schedule pressures, substandard facilities, and management communication and support (Volinski 1999, pp. 10–12). TCRP Report 77: Managing Transit’s Workforce in the New Millennium described C H A P T E R 6 Costs and Evaluation Organizational environment and practices Infrastruc- ture and capital planning Route planning SchedulingService delivery Cost assess- ment and evaluation

88 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access the Utah Transit Authority’s Bus Operator Restroom Task Team (McGlothlin Davis Inc. and Corporate Strategies Inc. 2002). TCRP Report 81: Toolbox for Transit Operator Fatigue mentions restrooms in the context of rest breaks that can counter the effects of fatigue (Gertler et al. 2002). These sources and many others in the intervening decades provide suggestions for reducing the financial impact of unscheduled breaks while at the same time acknowledging contradictions that may be involved in ensuring timely and efficient service that is also safe and responsive to health needs. Quantifiable benefits that may be associated with providing adequate restroom access include: • More reliable service delivery, • Reduced medical costs, • Reduced time lost because of existing health problems or informal rescheduling by transit operators, • Improved retention, • Less injury or property damage in vehicle accidents, and • Improved intangibles such as quality of life at work and at home. By its nature, unscheduled restroom access has an unpredictable effect on service reliability. Higher variability in time contributes to higher operating costs (Danaher et al. 2019). Increased unreliability, especially delays, can result in fewer restroom opportunities for vehicle operators. Some attempts to reduce this variability can lead to other practical problems. A news article from 2016 describes a TA’s collection of data to restrain restroom and other breaks taken by bus operators, which resulted in conflict between health needs and transit break policy: The agency is assembling monthly lists of bus and train operators who use the bathroom or otherwise take breaks too often, according to an internal SFMTA [San Francisco Municipal Transportation Agency] memo obtained by the Examiner. These breaks are called “702s,” which refers to the communication code an operator gives Muni central control when they need to take an immediate break. But operators who did not wish to speak on the record for fear of retaliation said pulling video of operators who may be on their way to the bathroom, or simply smoking a cigarette, is an invasion of their privacy. . . . The SFMTA, however, told the Examiner the agency needs to crack down on the worst offenders because excessive breaks could slow down the Muni system. (Rodriguez 2016) The purpose of this chapter is to demonstrate how TAs and LUs can collect and evaluate information to achieve consistent access to restrooms to support operator health, comfort, and safety and the TA’s bottom line. Good Practices Related to Evaluation and Costs While evaluation may seem like the last step in developing and carrying out a program or achieving organizational change, it is really a recurring phase. Earlier chapters have covered most of the evaluation steps that will need to be carried out by TAs, LUs, and vehicle opera- tors to develop, implement, and assess effective changes. That has most significantly included needs assessment involving all stakeholders (addressed in Chapter 2). Timely discussions across departments support and sometimes nudge the changes that are needed (see all chapters, espe- cially Chapter 2). Regular data collection on the status of facilities, service impacts, staffing, operator health, and retention documents how conditions continue to evolve (Chapter 3 and 5). In particular, inspections of existing restrooms by designated restroom access team members, along with input from affected operators, will help manage and address problems quickly (Chapters 3 and 5). Box 6-1 lists good practices for evaluations and costs. Table 6-1 lists the many different types of data mentioned by project participants that helped them understand how restroom access affects vehicle operations and the entire organization.

Costs and Evaluation 89 Box 6-1. Evaluation and Costs Policies and Practices Establish continuous evaluation and improvement, including stakeholder review of conditions. • Identify areas where policies do not match practices. • Measure satisfaction with policies and practices (operators, management). • Hold regular and ad hoc discussions with operators and supervisors. • Include restroom access on route feedback forms including maintenance issues. • Review inspections and complaints for patterns. • Measure impact on key indicators (service delivery, availability, safety) before and after implementing changes. Assess and contain costs. • Evaluate restroom-related delays. • Reduce dwell time by changing restroom access points. • Improve on-time service delivery by addressing access in scheduling. • Limit absenteeism by accommodating those with health concerns. • Leverage cost relative to benefits at key decision points. • Implement an energy-efficient and sustainable process. What Do TAs Already Record for Other Purposes? Data Comments On-time performance Reported as average; can assess time of day impacts. Actual versus scheduled layover times Recorded for each run; planned times eaten up by traffic, passenger changes; estimated average layover 10%; TAs admit to delays in updating times to match ideal, so not consistent across routes. Vehicle location (automatic vehicle location) Tracking problem areas. Dwell time Recorded for each stop, each bus; may be used to discipline. Missed trip/missed service Can be liquidated damage for contractors. Restroom locations Relative to routes, types, hours available. Maximum time between layovers with restroom access What is optimal? Scheduled versus actual. Walking time between stop and restroom Estimated or measured. Operator health conditions Health plan managing company can provide if requested. Safety incidents—employee and vehicle Links not usually established with restroom access. Use of breaks Keeping a record can become a pressure not to use the restroom when needed. Dispatch data Can estimate incidence; target problem areas. Table 6-1. Evaluating restroom access impacts.

90 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Most were recorded in the context of operations rather than restroom access specifically. For example, unscheduled use was captured via the TA’s call-in system—for example, radio call-in to request relief, automatic codes sent to central control that explain why the operator is diverging from the expected schedule, or records of oral or written late report comments. The data com- ments column in Table 6-1 defines some of the characteristics, including pros and cons, of each type of data discussed. Good Practices: Restroom Team Establishes Continuous Evaluation and Improvement, Including Stakeholder Review of Conditions A data-driven process is critical to creating successful employee engagement programs and initiatives. Creating successful employee engagement programs and initiatives is a data-driven process. All six fed- eral agencies profiled in Best Places to Work attributed their success in either improving or maintaining employee engagement to being able to draw on multiple data sources, in addition to the Federal Employee Viewpoint Survey, to “take the pulse” of the organization and identify areas for improvement. Besides employee survey data, agencies have used other indicators, including turnover rates, equal employment opportunity complaints, focus groups, and town hall meetings, to understand how their employees perceive the organization, gauge employee engagement, and identify areas for improvement. (City and County of San Francisco 2016, p. 21) The best plans can be undercut by unanticipated problems, by changing workplace conditions, and by lack of support on the ground. This means that even where strong policies have been established, the TA (and the LU, where it exists) needs to identify areas where practices do not match policies. Achieving stated goals and applying policies consistently are essential in maintaining support from TA leadership and staff—vehicle operators especially. Operators, union leaders, and even some TA restroom teams participating in this project fre- quently voiced concerns about gaps. Indications that policies are not being applied as planned may already be available in data collected by operations, human resources, or other departments. Potential sources include complaints or comments, meeting notes, and informal knowledge. Affected employees should review the TA’s policy documents to highlight issues or deficiencies. The questions in “Roles in Improv- ing Restroom Access” in Templates for Restroom Access Policies and Boilerplate Contract Language can be adapted to survey their experi- ence. The template “General Restroom Survey for Vehicle Operators” provides guidance on how to do this; this template can be adjusted for ongoing evaluation as well as initial needs assessment. Similarly, infor- mation can be collected by raising relevant questions from the “Needs Assessment” worksheet in Transit Operator Restroom Access Planning Tools on a regular basis. Because conditions and needs change, the restroom access team should continue to use these tools to measure satisfaction with policies and practices as expressed by both vehicle operators and management. In evaluating any of these areas, TAs will get better results by working with the operators and their representatives. Many LUs have been carrying out restroom access surveys on their own or in coordination with their international unions. The advantages go beyond improved labor relations: The union data can be useful in itself—it can establish baseline values with which the ongoing evaluation results can be compared—and the survey tools may provide useful templates for future data collection. Establish continuous evaluation and improvement, including stakeholder review of conditions. • Identify areas where policies do not match practices. • Measure satisfaction with policies and practices (operators, management). • Hold regular and ad hoc discussions with operators and supervisors. • Include restroom access on route feedback forms including maintenance issues. • Review inspections and complaints for patterns. • Measure impact on key indicators (service delivery, availability, safety) before and after implementing changes.

Costs and Evaluation 91 Many TAs hold scheduled and ad hoc discussions, often linked with schedule and route plan- ning cycles, with operators and supervisors. Despite these discussions, not all TAs record and report on restroom-specific trends. It makes sense to include restroom access on route feedback forms. The “Finder-Inspection Checklist” in Transit Operator Restroom Inventory Tools, like the online report formats described by several TAs, provides a formal way to collect and enter data. In some TAs, the restroom team may also want to integrate community and passenger con- cerns to improve restroom access practice. The “Development and Planning Steps” sheet in Transit Operator Restroom Access Planning Tools helps keep track of significant events carried out by various departments and takes advantage of mailed or online surveys and on-property data collection carried out by the TA. The extensive town hall meetings held by SFMTA during the planning for stand-alone permanent restrooms for employees can provide ideas for devel- oping effective engagement and data collection. As discussed above, data with which to measure the impact on key indicators such as service delivery, availability, and safety may already exist but probably need to be tweaked with an added element for the role of restroom access. This could involve adding a line to standard reporting forms. TAs frequently miss an important evaluation opportunity by neglecting to set baseline measures. When changes are planned, it is important to consider conditions and events that occur before and after implementing the changes. Typically, any identified improvements or decrements are not statistically significant. The outcomes measures have so many contributing factors that general trends over time may be more useful. The TA will likely need to establish its own metrics for relevant or adequate differences related to interventions. Such metrics are ideally set before the practices are initiated. Many of the costs related to improved restroom access have been discussed in previous chapters. Table 6-2 lists some of the target areas of improvements along with potential sources of information. Good Practices: Costs Are Assessed and Contained The restroom location will impact our long-term operational costs and on-time service. The distance from operator layovers dictates the minimum cost of time scheduled for access. Currently, the Restroom Policy has a limitation of 1,020 feet from the layover to the comfort station. Every effort should be made to design new facilities as close as possible to the layover to minimize future operational and cost-of- service rates. —Restroom Coordinator at large TA Target Measure Chapter Improved vehicle operator health Health plan reports, costs 1 Leveraged cost–benefit at key decision points Infrastructure and operations plans and reports 2 Reduced dwell time from closer restroom access points Tracking of pre- and post-times 3 4 Energy-efficient and sustainable infrastructure Operations and maintenance reports and costs 3 Service reliability related to restroom access TA analytics data, delay costs/minute 4 Decreased absenteeism through accommodations for health concerns Review of attendance to find trends 5 Table 6-2. Evaluation supports cost assessment and containment.

92 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Restroom concerns can affect TAs in many areas directly related to the bottom line. These include service delays, operator health claims, absenteeism, retention, and vehicle accidents. However, despite paying a lot of attention to restroom access, fewer than one in five TAs evalu- ated the overall costs it led them to incur, as shown in Figure 6-1. The costs of developing and maintaining restrooms were most likely to be analyzed, possibly because they were specified in department budgets. Extended dwell times and routing modifications, along with delays, were not assessed separately for restroom concerns by most TAs. Less than 10% evaluated restroom-related personnel and health costs. LUs were not asked about cost and impact measures, under the assumption that they would not have ready access to this information, which would make their responses less reliable. However, 19% of the TA participants did not know whether their restroom-related cost information was col- lected or analyzed. At some TAs where cost assessment was said not to take place, specific measures were nonetheless reported: Between 15% and 21% of the group reported tracking costs for building or renovating restrooms, keeping restrooms open, and establishing contracts for portable toilets or for use of restroom facilities. Costs are often cataloged informally or as part of other planning decisions rather than spe- cifically to calculate the portion attributable to improving restroom access as compared with the status quo. The size of the TAs affected their approach to costing. The larger ones had more staff involved and more automated data sharing. Size influenced how they collected data—for- mally, through shared databases and meetings, or informally, through ongoing discussions on a scheduled basis or as needed. The TAs with larger restroom access teams seemed to have a more granular sense of costs, as the wider knowledge base of the members was an asset. For example, planners may have up-to-date information on current budgets, and maintenance staff understand the costs required for TA-owned, as opposed to contracted, restrooms. In one large TA, one goal of the program was to make sure that the hardware used was consistent in all TA 0% 10% 20% 30% 40% 50% 60% 70% 80% Delays from unscheduled restroom use Extra run dwell times for scheduled breaks Routing modifications for restroom accommodation Runcut cost analysis Other service related costs Accommodations for specific health conditions Health care costs Personnel costs Other personnel costs Building or renovating restrooms Operating costs of keeping restrooms open Contracts with businesses for use of their facilities Portable toilet contracts Other facilities costs TAs that evaluate costs Others Figure 6-1. Survey results: How TAs look at restroom-related costs. Assess and contain costs. • Evaluate restroom-related delays. • Reduce dwell time by changing restroom access points. • Improve on-time service delivery by addressing access in scheduling. • Limit absenteeism by accommodating those with health concerns. • Leverage cost relative to benefits at key decision points. • Implement an energy-efficient and sustainable process.

Costs and Evaluation 93 restrooms, which reduced the costs related to purchasing parts and making sure they were easily available on repair or general maintenance runs. The major cost categories of concern highlighted by interviewed TAs and how they measure them are listed in Table 6-3 with comments and pros and cons in the second column. The overall position taken by TA project participants was that restroom considerations should be addressed in infrastructure development, in planning, and in scheduling. In practice, the impact and costs were often not assessed separately from contractual or mandated breaks, schedule recovery time, or capital planning. A review of cost variability in the transit industry suggested that TAs may fail to approach this analysis effectively because of a too-basic definition of their costs, which tend to be character- ized as budget line inputs and service outputs (Taylor et al. 2000). Adding cost factors such as time-of-day costs, vehicle operating costs, and variation of fares to consideration of restroom- related policies and changes could help them create better cost analysis structures, and integrate restroom access into the equation. Project participants were aware of delays related to unscheduled restroom use but have not typically measured the monetary impact. The costs related to adapting schedules—including increased or unnecessary dwell time—were acknowledged in the pushback against schedule adjustments made for restroom use, according to scheduling staff. Expected capital costs for building new facilities or renovating inadequate ones were frequently cited as a reason for relying on other approaches, including contracts with businesses. Only one source cited evidence for a potential health impact: An LU that managed the purchase of its own insurance was told that its rate of urinary tract infections was high enough to drive increased premiums. The insurance broker was unable to provide data that illustrated how large the impact might be. Many TAs have of course attempted to quantify the cost impact of service delays. One city system had been asked by a supervisor from the city board to estimate the overall cost of transit delays, as experienced by the city and passengers rather than the TA. The estimate considered time of day, average wage in the area affected, and total time lost by passengers. It was not granular about the impact line by line and did not result in changes to the system. According to the TA’s manager of performance and analytics, maintaining a running cost burden was a Table 6-3. Costs with restroom access components. What Do TAs Record? Data Comments Capital costs for building and renovation Explicit budgets developed for restrooms, general estimates for components. Maintenance and supplies Mostly wrapped into terminal location general budgets for cleaning and supplies; calculated or estimated for contracted locations. Operating costs related to delays, dwell time, and unscheduled use Usually not broken out by restroom access events. Health effects of limited access Rarely considered for restroom access event. Vehicle or operator safety Falls at freestanding restroom locations. Restroom safety improvements. No examples of restroom access vehicle events. Personnel for restroom access planning and support Restroom committee time. Location inspections. Additional staff detailed in cost tools.

94 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access challenge, because variable ridership on specified lines is hard to estimate, and the practice was discontinued. The manager did not feel it would be practical to sort out the cost of delays specifi- cally related to restroom access. When one large TA wanted to increase restroom access for bus operators during night ser- vice hours, it carefully assessed the related costs of moving the end of a route nearer to a transit station. The most significant cost was additional supervisor time for the location, in addition to the costs in staff time related to changing schedules. In this case, the costs were considered prohibitive. Part of the process of defining costs and benefits is establishing an estimate of the value of adequate restroom access to the organization or the operators. The health economics industry expert interviewed recommended that subjects be asked how much on the hourly rate or how much per year it would be worth to resolve any outstanding issues. The union response was unequivocal; it felt that trading safe and healthy working conditions for money on the table was inappropriate. One TA that was otherwise cooperative on restroom access had proposed negotiating the costs out of the operators’ financial package, according to the LU participant. Another LU participant pointed out that people working in fixed locations never have to con- sider this question. Obviously, every second of the day has a dollar figure accorded to it. I would argue that what is man- agement’s cost for using the restroom? They use the restroom all day long too and they’re not doing it to themselves, so that’s why should you do it to us? —LU President TAs in the project sample were willing to pay something for restroom access; however, the amount considered appropriate varied enormously. The burden ranged from informally resolving issues without a designated budget to a restroom-related capital line of $500,000 a year as part of terminal construction. Many of the agencies in the project interview sample clearly spent a significant amount in staff time in addressing restroom issues. There was a designated person responsible for rest- room issues in 11 of the 37 TAs that provided this information (30%). The time allotted for that person ranged from 1% to 100% full-time equivalent, with half reporting less than 7.5% full-time equivalent. Nine agencies (24%) had a separate restroom committee; there were joint committees, union leaders, and operations designees at eight other TAs that were identified as covering restroom issues. For many TAs, uncalculated time included that spent by committee members in meetings and doing inspections, operations staff time for negotiating contracts with restroom locations, and maintenance both for TA facilities and to clean the restrooms in outside locations where they had agreements to do so. Some TAs reported a per capita payment to businesses allowing operators to use their rest- rooms, or a monthly charge for maintenance or regular supplies. Most felt that these sums were reasonable when compared with the payoff and with the overall operating budget. These costs also ranged widely, as a function of the size of the TA and other considerations. One TA paid a stipend of $50 a month to commercial locations to cover supplies; another was preparing to rent an entire mall store to establish a reliable restroom and layover break space. For other TAs, community businesses were comfortable letting operators use restrooms for nothing. Cost Tools Operator health needs cannot be ignored on the basis of a return-on-investment analysis. Restroom access is a human right and a legal obligation of employers. At the same time, the best policies will support the TAs’ financial, organizational, and operational needs.

Costs and Evaluation 95 Most of these steps have been detailed earlier, so they are only summarized here. Finding out how much improved restroom access can save the TA begins when operations data are used to evaluate restroom-related delays. Route planning staff reduce dwell time by changing restroom access points. Schedule adjustments improve on-time service delivery by address- ing access in scheduling. Human resources and operations policies can limit absenteeism by accommodating those with health concerns. At each point, decision makers leverage costs relative to benefits at key decision points. Technologies that reduce energy use should follow whenever TAs implement an energy-efficient and sustainable process. The costs associated with improving restroom access are complex and appear on many sepa- rate ledgers. The Transit Operator Restroom Access Cost Estimation Tools, a set of Microsoft Excel spreadsheets, should help bring the information on these ledgers together and simplify how the data are collected and evaluated. These spreadsheets are designed to help TAs make decisions about restroom locations, types, times available, and other issues. Many of the sheets and fields were derived from tools shared by TAs that already have formalized their restroom planning and evaluation processes. The target cost areas were developed by staff at RLS and Associates on the basis of their professional knowledge of how TAs measure and track similar issues combined with survey and interview information on restroom-related costs from the current project. The template for the Transit Operator Restroom Access Cost Estimation Tools was derived from the Transit Worksite Health Protection & Promotion Program Planning, Evaluation, and ROI Template designed by the Transportation Learning Center for TCRP Report 169 (Gillespie et al. 2014). Transit Operator Restroom Access Cost Estimation Tools consists of six spreadsheets (Rest- room Costs Inventory, Direct Operating Costs, Other Direct Costs, Administrative Costs, Capital Costs, Total Costs), an optional chart for inputting pay rates that are used in multiple spreadsheets, and a costs and benefits spreadsheet presented in beta version because the back- ground metrics and values have not been tested or completely defined. The instructions for using these tools are given in the first spreadsheet and shown in Figure 6-2. Taking the Project Findings into the Field The interest in this issue has increased over the past 5–10 years, as shown by press reports, labor action, and the TA programs described by project participants. This project has made clear that, for many TAs, adequate restroom access is considered both an operational necessity and a matter of human dignity. The approaches discussed here also focus on creating a more humane work environment. In the course of the project interviews, TAs described thoughtfully targeted initiatives that coordinated available resources, recruited partners, and made innovative use of available tech- nologies. These stories were rightly shared with some pride. Participating TAs and LUs were also enthusiastic about the chance to find out what other organizations have been doing and to try new approaches. The practice guide and tools are based on the experiences and ideas of more than 100 TAs, with input from managers, super- visors, union leaders, vehicle operators, and industry experts. The initiatives even evolved during the course of this project—goals set at an initial interview had frequently been achieved and surpassed by a later one, and new targets or approaches identified. While this report provides a snapshot of what was happening in the transit industry between 2017 and 2019, it is the beginning of the story, not the end. Those in the industry—TA staff, local and international unions, and others—who are working on the many problems related

96 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access to restroom access and solving some of them are interested in getting their stories out to each other. They can provide evidence for the effectiveness of their approaches and warn about what might not work, formally and informally. This chapter closes the report with a few suggestions for disseminating ideas and answering questions. Discussion Groups Currently, regional online bulletin boards offer TA maintenance staff a forum for discussing issues that so often affect more than one location. Project participants voiced strong interest in discussing approaches to restroom access through an online group or in live phone calls. To be successful, this activity requires industry input, including at least minimal funding for the platform and for staff time to initiate and maintain a dialog. In the past, plans were made to maintain a similar group to follow up on the work of TCRP Report 169: Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention (Gillespie et al. 2014). While industry interest was strong, in the absence of formal commitment, the discussion was not maintained. Professional Meeting Focus Topic The safety roundabout session “Providing Adequate Break Time to Ensure Operator Safety & Wellness” held at the 2014 APTA Bus and Paratransit Conference brought together a small group of people with both concerns and experience in addressing restroom and other issues related to breaks. The publication of this report could signal a good time to revisit those issues. Figure 6-2. Instructions for Transit Operator Restroom Access Cost Estimation Tools. This workbook was developed to help transit agencies manage the inventory and expenses of restroom access and related costs. Each page includes an instruction box. To make viewing and printing the tables easier, the instruction box is placed below the data and linked by a button at the top of the page. All calculating cells are protected to prevent equations from being changed and harming outputs. You can change data and text in other cells. To unprotect worksheets and see or change the formulas, click Review > Unprotect Sheet. To re-protect worksheets, click Review > Protect Sheet. Most tables have some illustrative values entered. Delete these or type over with your own data. If practical, fill out each tab before the next. Otherwise you will have some empty calculated cells as you go along. For example, the “Total Costs” tab compiles total costs from each of the previous tabs to show the overall cost for all four categories. If you want to make up a pay rate sheet for all titles and link to that instead of adding pay rates to each relevant page each time they change, see “Pay Rates Sheet (Optional).” It might help you to list the source and date of this information as a note to the table, especially as you make changes. You can add additional lines in the tables as needed. First, unprotect the table. Insert the new rows you need above the patterned row. Then copy and paste the equation from the cells in the existing rows that are in calculating columns to fill the new cells. (The patterned row in each is set to ensure that the calculating row updates to include all needed cells.) Depending on the values you enter, you may need to move and adjust the charts that are generated to show your data to best advantage. You can copy and paste them anywhere in the workbook, including a new sheet, and the values will be maintained.

Costs and Evaluation 97 Many things have changed in 5 years, including technology, interest, and practices. Such a session could establish a network to support the discussion group described above. It could be structured as an open conversation, led by experienced industry experts, or include case examples of successful approaches. Project participants found this to be an attractive idea. Again, those active in the APTA meeting would need to plan and carry out the event. Documented Projects and Activities Case examples, beyond those in Part 1 of the Annex of Supporting Materials, could be col- lected online or in an industry publication. As one step, the project authors have set up a survey link, given at the end of this chapter, to find out how industry actors are using the tools and the report. This input on how the current report is being used—in particular, what was helpful and what good practices were successful—will provide evaluation information for industry stake- holders and for the TCRP research process. New insights and additional practices can be shared via the networks described above. Further Research Questions Neither the overall costs nor the specific impacts of limited restroom access have yet been established. The model for potential health effects is plausible, but it has not been established by epidemiological or clinical research. Health plan data could be a powerful tool in exploring any links. TAs can approach the question individually, analyzing their own health concerns related to restroom use. Estimating health costs at a generalizable level has proven to be very difficult, as health data are not well collated with employment nor commonly shared. The seminal work using health plan and worker compensation data undertaken at the National Institute for Occupational Safety and Health indicates some effective paths as well as barriers (Asfaw et al. 2013, Bushnell et al. 2011, Masterson et al. 2016, Wulsin et al. 2014). For example, exposures—that is, limited or ideal restroom access—will be very difficult to link to health outcomes that are common and caused by multiple factors that may be linked or may be independent, such as urinary tract infections. Any available clinical population of people with rarer diseases such as bladder cancer may not include enough bus drivers, and, conversely, the cohort of drivers for whom health data are available would need to be very large. So far, few transit employers have been willing to participate in the kind of joint labor–management–academic research projects that can access and analyze health plan data. The potential impact on operations may be easier to determine through the improved approaches to data collection and analysis described in this chapter. However, the impact likely varies enormously across TAs. Differences could be related to the size and location of the service area, the current level of restroom access, the flexibility of the TA’s operational structure, local and regional changes in transportation needs, and the status of labor relations. The same is true for estimating the costs of current restroom access programs and those of any mismatch between needs and resources. It is to be hoped that the tools produced for this project can help establish a consistent method for approaching impact measures and for providing baseline and outcome data that can be com- pared regionally or nationally through consortia and funded research projects. To assist in this process, please provide a brief report about your experiences in using this report and the associated tools at the following link: bit.ly/TCRPRestroomAccessUserSurvey.