Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line (2020)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

91 Using the roadmap from TCRP Report 169 as a guide, this chapter identifies elements from the case studies that demonstrate qualities of scalable and sustainable strategies. It discusses the best practices deployed by these wellness programs and provides examples from the case studies to showcase how each strategy has been applied in a transit agency environment. The chapter then identifies and evaluates potential measures and methods for benefit-cost and cost-effectiveness analysis of these programs as learned from the case study evaluations of this project. Finally, the chapter presents an implementation plan that suggests next steps for industry dissemination and application of the research results to transit agencies. 7.1 Scalable and Sustainable Strategies of Transit Wellness Programs TCRP Report 169 (Gillespie, Wang, and Brown 2014) described a research-based framework of six action areas for transit workplace health protection and promotion (WHPP). Reproducing a figure from that report, Figure 23 presents a transit workplace WHPP roadmap depicting the best-practice elements that make up each action area. The roadmap illustrates a model for best practices that has been developed to apply the current art and science of worksite health to the particular demands of work in the transit environment. The framework and best practices shown in Figure 23 were derived from the NIOSH Total Worker Health® approach and theory-based practice models, such as the SafeWell Integrated Management System for Worker Health and the World Health Organization Healthy Work- place Framework and Model. These frameworks and best practices were further based on information collected from stakeholders, including U.S. and Canadian transit agency staff, union leaders, and bus operators, and analysis by the authors and contributors to TCRP Report 169. The framework emphasizes the integration of health and safety in a holistic approach to addressing health issues, taking work organization, work environment, and organizational policies into consideration. In the remaining sections of this chapter, tables rate the five case studies examined for this project in relation to the best-practice elements of the WHPP frame- work. This examination provides insight into the strengths and weaknesses of the selection of programs currently implemented at the participating transit agencies and advises on the broader implementation of effective program elements at other agencies. 7.1.1 Preparation and Commitment In the areas of program preparation and organizational commitment, the five case locations selected for analysis are known in the industry for maintaining a healthy and safe culture. They C H A P T E R 7 Implementation Strategies

92 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line not only provide excellent workplace health and wellness programs but, working with their local unions, these sites have instituted related policies addressing work organization, work environment, and safety issues, such as bus route scheduling, restroom access, bus design and ergo nomics, and operator assaults. They excel in conducting organizational needs analysis before program initiation, understanding the nature and health risks of frontline transit occupations, the demographics and prevalence rates of health conditions of their employees in comparison to the general and local populations, health and workers’ compensation claims data, and premium trends. Several of the sites also gauged employee attitude, needs, and concerns through opinion surveys, and these programs have continued to conduct surveys through the years to adjust program design. Two programs had stable funding sources, using agency operating budget, insurance premium refunds, and/or labor management joint trust funds. For these two programs, program provisions were negotiated between management and labor and institutionalized in the collective bargaining agreements. These pro- grams tended to be larger in scale and could afford to offer a variety of activities, especially ones that focused particularly on frontline needs. The other three programs had smaller budgets and offer more limited program activities. Regardless of their scale, all five programs demonstrated many of the traits of effective programs. 7.1.2 Team Building All five case studies exhibited exemplary practices in the areas of team building for health promotion programs, as summarized in Tables 46–51. Several programs were equipped with a full-time wellness manager or coordinator, which demonstrated the organizational commit- ment and investment into the health and wellness of employees. Wellness committees, consisting Figure 23. Roadmap for transit health and safety. Source: Reproduced from Gillespie, Wang, and Brown (2014), Figure 8

Implementation Strategies 93 of members from all divisions and ranks of the organization, were assembled at the onset of the programs. Often the union president was personally involved in the committee activities, along with other frontline employees. This made it more likely that the needs and concerns of the workers who the program was to serve would be heard and built into the program design and ongoing adjustments. In nearly all cases, the union leadership supported the health promotion initiatives, actively participated, and promoted the program to represented employees. Some programs also used ambassadors and champions effectively to spread knowledge, encourage participation, and collect feedback. Table 46. Rating of case studies for WHPP best-practice elements: preparation and commitment. Best-Practice Elements Description IndyGo RTS TARC DART LA Metro Culture of health and safety The organization maintains a healthy and safe culture based on leadership and organizational commitment. üüü üü üü üüü üüü Organizational needs assessment The organization identifies workforce health status and needs and understands the sources of health problems. üüü üüü üüü üüü üüü Organizational resources Program planners identify resources including staffing, finances, programs, structures, and internal and external partners. üüü üü üü ü üüü Meeting needs with resources The organization develops a plan to provide effective health assessments, a healthy and safe environment, and targeted and population-based intervention programs for all employees. üüü üü üü ü üüü Blank = Not observed; ü = Present; üü = Strong; üüü = Exemplary Table 47. Rating of case studies for WHPP best-practice elements: building the team. Best-Practice Elements Description IndyGo RTS TARC DART LA Metro Taking the lead The organization designates dedicated staff to coordinate and implement the WHPP program. üüü üüü üü ü üüü Putting the team together Input is gathered from across the organization. üüü üüü üüü üüü üüü Management support Senior and midlevel management support WHPP initiatives as evidenced by documented communications, infrastructural initiatives, and health-focused policies. üüü üüü üü üü üüü Labor support Union leadership and other representatives support and influence the WHPP goals and content. üüü üü üü üü üüü WHPP committee The organization sets up and supports a group to take action on WHPP. üüü üüü üüü üüü üüü Champions and ambassadors Employee skills support and contribute to planning and implementation. üü üüü üü üü üüü Vendor integration The organization enlists insurance providers, healthcare providers, and other vendors to be partners in and contributors to the WHPP program assessment, planning, and implementation. * üüü üü üü ü üüü ü = Present; üü = Strong; üüü = Exemplary * Depending on the program, vendors might include financial services/retirement planning providers or area businesses like fitness centers, grocery stores, convenience stores, or farmers’ markets willing to provide discounts, services, or vouchers in support of the program.

94 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 7.1.3 Setting Targets With the targets and priorities set through comprehensive organizational needs analysis, these programs focused not only on addressing the identified health problems and conditions, but also on the contributing factors. The programs emphasized prevention as much as treatment, with HRAs and bioscreenings included as key components of almost all programs. The programs were designed to address transit- and occupation-specific risks, exposures, and conditions. 7.1.4 Implementation and Integration Vendor integration was a strong component in several programs. Health insurance providers provided periodic reports on claims and prevalence rates. These programs also built excellent relationships with third-party vendors that staffed onsite clinics, fitness centers, health fairs, and education sessions. Strong vendor integration was observed at two locations in particu- lar, where the health insurance providers were actively engaged in program design, provided detailed data analysis, and instituted strong incentives for employees to participate. In general, training was used to raise awareness and deliver program information. Few of the agencies had begun building the health and wellness program components into the training and apprenticeship programs for new-hire operators and mechanics. The two large programs built strong incentives into the employee contribution of health insurance premiums, which led to wider participation and a more meaningful program impact. Other programs offered smaller incentives, such as gift cards and coupons, to employees who participated in various events. All programs rewarded positive steps rather than punishing employees’ current health status. 7.1.5 Evaluation Like the cases that were examined in TCRP Report 169, the cases examined for the current research were rated weakest in establishing a comprehensive evaluation framework, using integrated data management, tracking progress, impact and outcome measures, and ROI calculations. Most of the case locations tracked some, but not all, participation data. The most commonly tracked impact and outcome measures were employee attitude, morale, and behavioral changes; health status (e.g., weight loss); health premiums; health claims; and workers’ compensation claims. Absenteeism was tracked, but this measure was rarely linked Table 48. Rating of case studies for WHPP best-practice elements: setting targets. Best-Practice Elements Description IndyGo RTS TARC DART LA Metro Setting priorities The organization establishes what matters and what can be done with available resources. üüü üüü üüü üüü üüü Comprehensive health risk focus The organization identifies and targets multiple contributing factors to operator health problems and conditions. üüü üüü üü üüü üüü Effective components WHPP program activities are based on feasible and effective practices that address the identified program targets. üüü üü üü üü üüü Transit-specific implementation Program planning and content address transit-specific risks, exposures, and conditions. üüü üü üü üüü üüü ü = Present; üü = Strong; üüü = Exemplary

Implementation Strategies 95 to participation in the health or wellness program or analyzed as a potential program outcome. None of the locations engaged in a comprehensive benefit-cost analysis on their own, but most were willing to provide the researchers with raw data for the analysis and showed strong interest in learning the results. 7.1.6 Growth Among the cases examined for this research, the two long-established, stable programs (LA Metro and IndyGo) have maintained their momentum through new and innovative program offerings, ongoing communication of program benefits with leadership and workers, and getting Table 49. Rating of case studies for WHPP best-practice elements: implementing and integration. Best-Practice Elements Description IndyGo RTS TARC DART LA Metro Inclusive range The WHPP program offers varied activities and resources. üüü üü üü üü üüü Transit-specific implementation The implementation structure is adapted to suit the mobile workforce, multiple base locations, and varied schedules including evening, night, early morning, and split shifts. üüü üü üü üüü üüü Effective communications The organization sets up a strategic, comprehensive, integrated communications plan with multiple communications pieces and delivery channels that are tailored to the transit population. üüü üüü üü üü üüü Training supports the program Training is designed to promote the program goals, not just deliver information, and is integrated into other agency training. üüü üü üü üüü üüü Equitable incentives The organization uses equitable, nondiscriminatory incentives that encourage active involvement and a healthy workplace culture. üüü ü üü üü üüü ü = Present; üü = Strong; üüü = Exemplary Table 50. Rating of case studies for WHPP best-practice elements: evaluating ROI and ongoing improvement. ü = Present; üü = Strong; üüü = Exemplary; -- = Not Observed Best-Practice Elements Description IndyGo RTS TARC DART LA Metro Evaluation framework The organization establishes a comprehensive WHPP program evaluation plan. ü ü ü ü üü Integrated data management Data collection, management, and analysis are coordinated throughout the organization. ü ü ü ü üü Process measures The organization tracks data on costs, participation, goals met, and barriers, and then uses the data to improve the program. ü ü ü ü üüü Impact and outcome measures The program documents change in impact measures and outcome measures. üü ü ü ü üü Cost-benefit and ROI Quantify cost savings when the program affects absenteeism, productivity (presenteeism), healthcare utilization, and other costs, and document other benefits. ü -- -- -- ü Data-driven ongoing improvement The organization communicates the impact of the program. ü ü ü -- üü

96 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line additional employees involved in the wellness committee and as ambassadors. The smaller programs also have continued to adapt based on changing employee needs and evaluation of earlier program activities, but it was observed that the overall direction of these programs can be vastly different. One program clearly was growing, as seen in the dramatic increase in the allocated budget after initial positive results, whereas another program was going into hiatus without a clear timeline for restarting, due to a key champion leaving their post. Numerous factors can affect the stability or growth of an agency’s program, and an analysis of why different programs took different directions was beyond the scope of this research project. 7.1.7 Summary As shown in these five case studies, when faced with the crisis of skyrocketing health premium costs, some transit organizations chose to involve stakeholders from all levels of the organi- zation and partners from outside to collectively tackle the critical issue. Rather than focusing on cutting benefits and reducing services, they paid attention to the underlying causes of the health premium increases: health conditions and health risks, and the environmental factors that contribute to them. Programs that have strong management and union support, provide strong incentives for employee participation, and receive the most funding support had the longest standing and demonstrated the most positive outcomes. The data analysis for this research did not demonstrate strong statistical findings on the benefit- cost of transit workplace health promotion programs. Despite this lack of conclusive findings, the organizations and employees recognized the tangible and intangible benefits of these programs. More systematic program evaluation, encompassing more systematic processes, outcome measures, and internal benefit-cost and ROI analyses using the measures laid out in the next section could enable these programs to continuously improve and communicate their value to leadership and participants. 7.2 Measures and Methods for Benefit-Cost and Cost-Effectiveness Analysis Transit agencies and unions can use several measures to track how successfully wellness programs reduce costs. Any gains from the implementation of a wellness program may require a long lead time (years) before its beneficial effects begin to affect measurable indi- cators like absentee hours. Except for cases when the negative health aspects of a particu- lar behavior are so extreme and widespread that an immediate change brought about by a new program would promptly reduce absentee hours, workers’ compensation, or healthcare spending, it is expected that benefits will only begin to be detected after a substantial lead time. For this reason, the process of tracking the success of the wellness programs at reducing costs should ideally be initiated before the program is implemented. If prior tracking is not possible, tracking should begin no later than as soon as the program is implemented. The Table 51. Rating of case studies for WHPP best-practice elements: carrying on (growth). ü = Present; üü = Strong; üüü = Exemplary; -- = Not Observed Best-Practice Elements Description IndyGo RTS TARC DART LA Metro Maintaining WHPP is essential to the organization, not an extra üüü üü üü -- üüü Growing The WHPP program adapts üü üüü üüü -- üüü

Implementation Strategies 97 challenge is setting up the systems to successfully and accurately document the full extent of what actually transpires. Before programs are initiated, it is useful to consider additional metrics the transit agency can record that would detect positive changes earlier than waiting for decreased absentee hours to manifest. Detecting improvements by periodically checking blood pressure and heart rate measurements, or by recording fitness performance, may impose only a minor inconvenience to employees in terms of time or privacy, but can provide early indications as to whether the program is showing positive results. The agency also should be committed to establishing a process to record program participation that allows for valid statistical significance testing. Regularly recording program participation and the extent of that participation is crucial to eventual success at measuring the effectiveness of these wellness programs. An attempt should further be made to quantify any changes in activity that occur outside of the wellness programs, whether those changes are good or bad. As a positive example, an employee may institute a personal program to add or improve his or her diet or exercise and fitness levels. As a negative example, a worker may experience new or changing stresses related to the medical problems of family members (e.g., a spouse, parents, or children). These complexities pose challenges in determining a method for measuring the impact of services, particularly when using a pre- and post-analysis model. It is nearly impossible to control for the additional programs or services that individuals participate in separate from the program being evaluated. If at all possible, however, this information should be obtained so that it can be incorporated into the subsequent statistical analysis. Ideally, the system the agency organizes to collect information that can be used for statistical comparisons will not be overly time-consuming and will ensure the privacy of the employees. Agencies could work with evaluation experts (possibly from a local college or university) to develop plans to regularly record program participation/extent, and health measures, including a well-designed short intake survey for which the answers will make subsequent statistical analysis more effective. Annual or quarterly surveys of employees could be useful in under- standing their participation, nonparticipation, and outside influences. If any kind of survey is attempted, it must be clear that the data will be kept confidential, that the data will not have any impact on an employee’s performance reviews, and that the data is vital to the agency’s efforts to provide a better quality of life for its employees. Having established a comprehensive set of data that will be collected and recorded at regular intervals, the analyses conducted to estimate improvements and cost reductions will be statistically valid and the success of the wellness programs can be systematically assessed. Any number of rigorous statistical estimation techniques and testing procedures can be used to extract and analyze information from the collected data. Benefit-cost and cost-effectiveness analyses are straightforward, productive exercises when suitable data are available. Figure 24 diagrams cost areas for employers and workers. Agencies can use these areas as targets when they design and modify wellness programs that have the reduction of bottom- line costs as one of their goals. 7.2.1 Employers 7.2.1.1 Absenteeism Measures The unit of analysis used for absenteeism is important for this measure, as is the method of analysis. Ideally, multiple categories of absenteeism should be classified in payroll so that the most detailed form of analysis can be conducted. For example, personal and sick days should be counted, as should be unpaid sick and personal leave, which may be a measure of extended

98 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line injury or illness and not workers maxing out on the sick day allocation. For this analysis, the project team used the total of sick, personal, unpaid sick, and unpaid personal (or the maximum subset of those categories available). To track trends in the number of sick days taken over time, the median or the average total days can be measured for different years. Different measures are likely to yield different results. For example, the average sick days will likely be higher than the median sick days for the population of workers or any subpopulation. Any given period could include cases of workers who have taken extended unpaid leave (e.g., more than 200 hours per year) due to a serious injury. Because the mean, or average, is sensitive to large numbers, it will appear somewhat inflated by the cases for which large numbers of sick days were taken. By contrast, the median is the number in the middle of the sample population—the point at which an equal number of employees fall above and below it. The median is less sensitive to distortion from a few large numbers, so the median may more accurately reflect the typical number of hours of sick leave taken. Another way of handling instances of unnaturally high numbers of sick hours is to remove the cases with uncharacteristically high numbers from the database, labeling them as outliers. In these cases, the project team chose to take into account the effect of these numbers on the database, both because it was hard to determine a cutoff for outliers and because the presence of such cases was relevant to our analysis. Subpopulations can be tracked for absenteeism by job type (maintenance/operator) or demographic (racial group, gender, age). Analysis at this level may be of interest if injuries and illnesses are correlated with features of the job or with risk factors for particular groups; the findings can be used to help design wellness programs that target interventions needed to improve the health of those groups. If an analysis is done, it is important to note that for Figure 24. Measures and methods for cost-benefit analysis of wellness programs.

Implementation Strategies 99 findings related to a subpopulation to be of significance, the subpopulation should have a sufficiently high number of members. For example, this research project did not make analytical conclusions about groups with 30 or fewer employees. 7.2.1.2 Turnover/Employee Exit Turnover is defined as the percentage of employees who leave in a calendar year divided by the total population of workers for that year. It can be calculated as long as the agency keeps track of the final day of employment. When this statistic is not available, it can be imputed from the last paycheck for that employee, though sometimes the timing of the paycheck varies with respect to the last day of work. Low turnover can be a sign of a healthy population. Health issues— whether mental, physical, or both—make up one factor that causes employees to exit a job. A more direct measure of employee exits related to health is the number of medical dis- qualifications of employees. Documenting the reasons for medical disqualifications could be important in understanding what health problems are so severe that they prevent transit workers from remaining employed so that agencies can design wellness programs to target these problems. Obtaining data about employee medical disqualifications was difficult, however, due to confidentiality concerns. Because the case numbers are low in most sites, it would be rela- tively easy to identify individuals. 7.2.1.3 Health Insurance Costs and Claims The costs of insurance claims can be used to measure the effectiveness of health programs. It also is possible to consider the total numbers of general health insurance and prescription claims, especially if cost data are not available. Ideally, to reveal possible impacts, baseline data from before the initiation of any health or safety initiative are compared to data tracked over time from the beginning of the program. Examination of insurance claims might also reveal the prevalence rates of common chronic conditions for the agency’s employees. As laid out in this report, transit workers are more likely to experience several chronic conditions—but rather than assume that the employees of any given agency have the same prevalence rates, an analysis of the types of claims could help provide a focus for program elements offered by the agency and what to measure going forward. This analysis can provide a benchmark for internal analysis and a way to compare incidence rates with the general population or sub- population of transit workers nationally, or with other members of the same insurance plan. These data should be collected over time as well. 7.2.1.4 Workers’ Compensation: Shared Cost With Society Several measures of workers’ compensation can be examined, such as the number of indem- nity claims and the total cost of claims. When considering either of these measures, the types of claims can be examined by type of injury, cause of injury, or by worker characteristics (e.g., age, race, sex/gender). By examining the number of claims and the costs of claims before and after a program is implemented the agency can assess whether there are program impacts. 7.2.2 Workers Various measures should be considered to understand the direct impacts of health and wellness programs on workers. The main areas identified for this research were lost wages, out-of-pocket medical expenses, and diminished quality of life. 7.2.2.1 Lost Wages To measure lost wages, leave without pay should be considered. If a worker is not covered by workers’ compensation, actual wages for that time can be calculated. Attempts should be

100 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line made to distinguish leave for health reasons from leave for personal use (e.g., vacation). Leave without pay also may be used to care for a loved one. If worker pay is replaced by workers’ compensation, the difference between regular pay and the amount received through workers’ compensation should be calculated. The amount of time at the reduced wage is used as a factor to calculate the lost wages. 7.2.2.2 Out-of-Pocket Medical Expenses Out-of-pocket expenses typically are tracked by the health insurance provider. This is an effective measure of the health expenditures for workers in a particular agency, but the amount spent will vary based on the type of insurance plan. Thus, this measure may not be useful for comparisons to other agencies. Within an agency, conducting a pre- and post-comparison of expenditures before and periodically after implementing a health and wellness program would be a useful measure of program effectiveness. 7.2.2.3 Quality of Life The Quality of Life Scale developed by Burckhardt and Anderson (2003) can be part of a regular survey effort to measure the impacts of a health and wellness program over time. This scale has been extensively tested and validated, though other measures can be considered. Improvements in health could conceivably impact the measures used in the Quality of Life Scale, an important dimension to consider. 7.3 Implementation Plan and Next Steps To promote wider industry adoption of the best practices at transit agencies, the information and cases presented in this report could be used to create a series of promotional materials. One- to two-page pamphlets could be developed highlighting the key characteristics of each site’s implementation model. Impacts on health, safety, and the bottom line could be featured. Fact sheets also could be created based on the case studies in this report. The fact sheets would describe the measures and methods used to track program outputs and outcomes, and would provide useful examples for other agencies regarding how to evaluate their own programs. Given the variations of agency programs, goals, and data reporting constraints, not all agency-created pamphlets would be uniform. Nonetheless, the creation of such pamphlets would create a broader universe of case studies and best-practice examples that could be compared and examined by agency peers. The project team suggests a two-step process for using this report to design wellness programs that benefit the health of transit workers: 1. Review the background research on the types of health issues workers are most likely to experience and the programs that are most effective in addressing them. The programs studied in this project may have been beneficial even though the analysis could not detect statistically significant effects. 2. Determine the key issues facing employees, the types of programs they would use, and a means of evaluating impacts before initiation are the critical steps to program imple- mentation and evaluation. Over time, agencies can assess the programs’ ROI and make adjustments as needed. Prior TCRP publications include resources to help design and track programs. In particular, the spreadsheet-based tool titled “Transit Operator Workplace Health Protection and Promotion Planning, Evaluation, and ROI Template” may be helpful. Based on the research in this report, using the “Outcome” tab could be a good starting place to track the key measures the programs are meant to impact. The tabs for “Financial Benefits,”

Implementation Strategies 101 “Cost,” and “ROI” provide a way to track results. The Excel-based document containing the template is available for download at no charge from the TCRP Report 169 webpage at www.trb.org. Presentations and discussions at industry conferences and webinars are key methods for dissemination of this report and its findings. Relevant industry events include the following: • APTA annual meetings, • The APTA Mobility Conference, • APTA Workforce Development Committee webinars, • Transportation Research Board annual meetings, and • Transportation Research Board/TCRP Webinars. The Transportation Learning Center’s Coach Operator Apprenticeship Committee and Bus Maintenance Apprenticeship Committee meetings can also be a platform for industry-wide dissemination. These two committees consist of management and labor representatives from over two dozen transit properties and focus on developing and expanding local registered apprenticeship programs for bus operators and maintainers. A critical component of these apprenticeships is education related to the health and safety of the frontline workers. Committee members can gain knowledge and awareness of the health risks and safety hazards associated with working as an operator or mechanic and strategies to mitigate the negative effect of these risks and hazards through a health promotion and protection program instituted by the agency and/or local union.