Health care becomes first target of OSHA ergo plan

Tough talk: OSHA warns bad actors’ to beware

Health care will be the first industry targeted as part of the U.S. Occupational Safety and Health Administration’s (OSHA) new "comprehensive plan" to reduce musculoskeletal disorder (MSDs) injuries, which relies on voluntary, industry-specific guidelines and selected enforcement action.

Days after releasing its new strategy for ergo-nomics, Labor Secretary Elaine L. Chao announced that safe patient handling in nursing homes would be the topic of the first draft guideline. Nursing homes also provide a model for enforcement, as OSHA cited the Beverly Enterprises case involving the nation’s largest nursing home chain as an example of successful enforcement of ergonomic hazards.

Both the guidelines and the Beverly model of "general duty clause" enforcement could easily be adapted to hospitals, employee health experts say. The Occupational Safety and Health Act states that employers have a "general duty" to maintain a workplace free of recognized, serious hazards.

"There’s now a de facto standard for patient handling and movement. It’s [the] Beverly [Enterprises case]," says Geoff Kelafant, MD, MSPH, FACOEM, chairman of the Medical Center Occupational Health Section of the American College of Occupational and Environmental Medicine (ACOEM) in Arlington Heights, IL, and medical director of the occupational health department at the Sarah Bush Lincoln Health Center in Mattoon, IL.

OSHA is hiring 17 additional solicitors, and the lawyers will be working as a team with inspectors to design an effective enforcement strategy, Chao told senators at an oversight committee hearing.

"The writing is on the wall now for hospitals to be on notice," says Bill Borwegen, MPH, occupational health and safety director of the Service Employees International Union (SEIU). "At this point, it’s just a matter of a worker calling OSHA and saying, We want you to come in and cite our employer for not having an adequate ergonomics program.’"

Still, Borwegen and other advocates for health care workers questioned just what OSHA would consider an adequate ergonomics program. OSHA has said employers won’t be cited for failing to follow the guidelines. OSHA has abandoned the idea of creating a regulatory standard and instead is emphasizing voluntary compliance.

OSHA chief John L. Henshaw geared his tough talk toward employers who ignore ergonomic hazards. The agency announced it has "a legal strategy designed for successful prosecution" that will "crack down on bad actors" who fail to protect workers from possible injury.

Advocates for health care workers renewed their push for a standard that would outline employers’ obligations. Within days of OSHA’s announcement, U.S. Sen. John Breaux (D-LA) introduced a bill co-sponsored by Sen. Arlen Spector (R-PA) that would force OSHA to issue a new ergonomics standard within two years.

"As far as we’re concerned, there was no meat in that plan," says Karen Worthington, MS, RN, COHN-S, occupational safety and health specialist for the American Nurses Association in Washington, DC. "Now more than ever, this Breaux bill is needed to force OSHA to work on a serious standard that will make a difference."

Occupational health organizations reiterated their support for a standard as well. Although ACOEM opposed OSHA’s earlier effort at ergo-nomics regulation as "fatally flawed," the organization expressed disappointment at the weak OSHA action. The Association of Occupational Health Professionals in Health Care (AOHP) in Pittsburgh still supports a standard, but reacted favorably to the preventive approach and enforcement strategy that OSHA announced.

"I’m glad they haven’t completely put it on the sidelines," says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, AOHP executive president and employee health nurse practitioner with Western Pennsylvania Hospital in Pittsburgh.

"They are going to try to address [ergonomics, although] certainly not in as broad an effort as in a standard. If they create some guidelines and continue research on ergonomics, that will ultimately help us," she says.

RNs, aides face high ergo risk

Beyond political pressure, OSHA faces some undeniable statistics: One in three injuries requiring time away from work involve MSDs. More than 577,000 work-related MSDs were reported in 2000. Some 44,000 of those were among nursing aides, orderlies, and attendants; 12,000 occurred among registered nurses, according to recent Bureau of Labor Statistics data.

Nurses once again were in the top 10 of occu-pations with the highest lost time due to MSD injuries, with 24.5 injuries per 1,000 full-time equivalent workers. Nursing aides ranked third, with 74.2 lost-time MSD injuries per 1,000 workers.

Those facts add up to greater OSHA scrutiny. Nursing homes will face OSHA inspections as part of a "National Emphasis Program," and hospitals are part of OSHA’s targeted inspection program. Kelafant predicts that OSHA will seek to set an example of a hospital or nursing home to show the agency’s intent to uphold the general duty clause enforcement. "They’re going to go after somebody," he says. "I think it’s not a matter of if, it’s a matter of when."

The new ergonomics plan takes a four-pronged approach of guidelines, enforcement, outreach, and continued research — a combination that Henshaw and Chao insisted would lead to the swiftest impact. "Our goal is to help workers by reducing ergonomic injuries in the shortest possible time frame," Chao said in a statement. "This plan is a major improvement over the rejected old rule because it will prevent ergonomics injuries before they occur and reach a much larger number of at-risk workers."

It has been about 12 years since then-Labor Secretary Elizabeth Dole promised action on ergonomics. OSHA began drafting a standard in 1995, but faced delays when Congress prohibited the agency from issuing a proposed or final guideline or standard. In November 2000, OSHA released its final standard, which drew sharp opposition, particularly to provisions that provided pay and benefit guarantees for employees with work restrictions. (See complete chronology, below.)

The ACOEM withdrew support for the final rule when it failed to require a medical diagnosis of work-related MSDs. Instead, the rule provided a checklist for employers to determine if an MSD was work-related.

Amid the controversy over the standard, Con-gress voted to rescind the rule in March 2001, an action supported by President George W. Bush.

In this latest OSHA action, Henshaw sought to win over skeptical labor union representatives. Shortly after issuing the "comprehensive plan," he met with them and assured them that OSHA would be serious about enforcement. In its released statements, the agency presented the approach as its best effort yet:

"For the first time, OSHA will have an enforcement plan designed from the start to target prosecutable ergonomic violations. Also for the first time, inspections will be coordinated with a legal strategy developed by Department of Labor (DOL) attorneys that is based on prior successful ergonomics cases and is designed to maximize successful prosecutions. And OSHA will have special ergonomics inspection teams that will, from the earliest stages, work closely with DOL attorneys and experts to successfully bring prosecutions under the general duty clause."

Guidelines tailored for patient handling

OSHA can make quick progress on patient-handling guidelines because such guidelines already exist. The Veterans Health Administration released a safe patient-handling guide earlier this year that has been lauded by many ergonomics experts.

"The fact that OSHA is going to embrace [the guidelines] means they’ll get wider dissemination. People are going to pay attention," Borwegen says.

Guidelines also allow OSHA to tailor its ergonomics interventions, rather than trying to create a one-size-fits-all rule, says ergonomics expert Guy Fragala, PhD, PE, CSP, director of environmental health and safety at the University of Massachusetts Medical Center in Worcester.

"If this [voluntary] approach is not effective in addressing some of the problems and making improvements, then we’ll have to look to other approaches," he says. "I’m not discouraged in any way by this [announcement]. I think it’s a step forward that a release has been made and that we are going to see activity in the area of ergonomics to improve working conditions."

Henshaw has asked the SEIU and nursing home industry to assist with the development of the guidelines. But despite that collaboration, political efforts continue for greater regulation.

"There will be an effort to look at states that want to deal with the epidemic of ergonomic injuries among their citizens," Borwegen says.

Meanwhile, OSHA immediately began its outreach program by announcing the 10 regional coordinators for ergonomics. (See list, below.) OSHA said it would provide courses and target training funds on ergonomics. The agency also said it will create a national advisory committee to "identify gaps in research related to the application of ergonomics and ergonomic principles to the workplace." OSHA would work with the National Institute for Occupational Safety and Health to increase research in those areas.

While many questions remained about how OSHA would implement its new ergonomics strategy, Fragala was at least encouraged by the activity. "As long as we keep moving forward, we are making progress," he says.