The right program mix can offer value without breaking the bank

Experts say prioritize, prioritize, prioritize

No matter what stage you are in with your occupational health program, you will regularly face the challenge of setting priorities. If you’re beginning a new program, that need is obvious. However, if you are joining a new company, if your company has just been bought or sold, even if you’re looking ahead to a new budget year, tough decisions have to be made about which programs should be initiated or retained and which should be delayed or discontinued.

The task of being all things to all people is virtually impossible, but the good news is you don’t have to be. Occupational health experts say that the needs of your employees, the corporate culture, and management goals and objectives help set the initial parameters for your program. After that, it’s a matter of determining which programs can accomplish the greatest amount of good, which can save the most money, and which can create the most value.

Where do you begin?

With such a daunting task, the hardest decision can sometimes be determining your starting point. But industry observers say there are certain first steps that will work in nearly any environment.

"The best thing to do, whether you are going into a new company or into an existing company, would be to conduct a thorough needs assessment. Part of this would, of course, be assessing the financial conditions of the organization," advises Annette B. Haag, RN, MBA, COHN, president of Annette B. Haag & Associates in Simi Valley, CA. "There’s no sense shooting for the stars if you are in budgetary straits."

You’ve got to be aware of your overall task, adds Christine M. Kalina, MBA, MSA, RN, COHN-S/CM, FAAOHN, head of Chicago-based Christine M. Kalina & Associates. "Right now, I’m establishing a global occupational health program for a large international corporation," she explains. "This is further complicated by the fact that they are an extremely good corporate citizen, so we have to respect country-specific regulations. Our first step, then, is to look at international nurse practice, medical practice, and pharmacy acts — rules and regulations. The second part is a baseline assessment. This not a SWOT [strengths, weaknesses, opportunities, and threats] analysis, but rather just identifying what it is you have at present."

Margie Matsui, RN, COHN-S, CRRN, Mountain Western region director for the American Association of Occupational Health Nurses [AAOHN], starts with management. "No. 1, I interview my manager and assess the structure we’re reporting into," she says. "I want to know what their questions and priorities really are."

Management styles differ greatly, she notes. "People generally try to do the right thing, but often there are other issues going on. What I want to know is, what are the real goals of the request, and what am I trying to accomplish for my customers — upper managers and employees?"

Kalina emphasizes that you always have to keep your eye on the bottom line. "It’s critical not only to consider the clinical needs of the employee population, but the business needs of the company," she asserts. "We in occ-health walk a very fine line as we try to keep these things in balance."

Matsui strongly agrees. "It’s totally a balancing act," she says. "Occ-health may be integral to industry, but it’s seen as a cost rather than as promoting human capital. We are a blend of socialized medicine and capitalized medicine, so, for example, how do I weave these together in workers’ comp to produce a good product? In terms of the employees themselves, you look at needs, culture, and high-dollar injuries."

As these comments indicate, the needs assessment can be divided into several different areas. "What is the corporate culture? What is the worker population — rural, urban, high-tech?" Haag posits. "Then, what are the high-cost items for that particular company? What are the most frequent injuries?"

Haag recommends looking at the three top occupational and nonoccupational cost areas. "That’s where your resources should go first," she says. Then, move on to other areas, such as the company’s experience modification. "How are they doing premium-wise? Look at the loss runs — not only high costs, but frequency and severity," she recommends.

You’ve got to be flexible, Haag cautions. "As you do the needs assessment, you may find concerns not only in treatment but in compliance. You have to be prepared for that," she says. Also, consider what programs are already in existence, she continues. For example, do you have a safety program? A disaster response program? Travel medicine?

Finally, says Haag, be sure to benchmark so you do not have to reinvent the wheel. "Compare yourself to the best of the best when developing your program," she advises.

Strategy before structure

Another key part of the prioritization process is developing your strategy, says Haag. "I say you have to have a strategy before you can have the [program] structure," she asserts.

Kalina agrees. "Once you have assessed your needs and your resources, then you can develop a strategy," she says. "Perform a gap analysis — look at benchmark programs, see where you are and where you want to be, then determine how to get there." 

This is a difficult process, Kalina concedes. "Like Thoreau said, it’s one thing to paint a beautiful picture, but another to affect the quality of the day — that is the finest of the arts. That is what we in occ-health do. The knowledge that we have the ability to do this and to impact an entire community, that’s what keeps us going." Besides, she observes, "You simply have to have a strategy. If you have a great car and no map, you will just spin in circles. If you have great resources but no plan, you won’t get where you want to go."

Making tough choices

Conducting a thorough needs assessment and developing a strategy will not eliminate the need to make choices, say the experts; it will just help clarify the basis on which those choices will be made. Whatever the unique conditions of your business environment, there are some challenges, such as limited budgets and short staffs, that are fairly universal. How can occupational health professionals face those challenges? How exactly do you decide which programs to keep and which to cut, and are there ways to save some programs or services that at first glance simply have to be eliminated?

"Say your occupational health nursing staff has been cut by 50%, but you have to serve the same number of people," suggests Matsui. "You are no longer able to be out in the field, there’s not going to be as much in-person contact with employees, but you still want the programs. We’ve tried to do more electronically, like informing management of human resource information for cost centers, rather than for individual employees. In workers’ comp, we do more systems reporting on statistics; whereas in the past, the manager used to come into the unit to talk to you about specific cases."

"It’s really critical to identify what can be outsourced and what must be retained in-house," says Kalina. "This goes along with what you want to retain ownership of and why, and I don’t believe there’s a pat answer. You have to make these decisions based on your overall business strategy for your program."

Beyond that, the merits of each program must be weighed carefully. "For example, one program may require only 10% of your critical resources, while another needs 40%. So, you have to ask yourself, which will give me the biggest clinical and business bang for the buck?" she says.

On the clinical side, the health, safety, and well-being of the employees should be taken into account, adds Kalina. On the business side, it’s return on investment. "You also need to identify how you will demonstrate and quantify that return," she notes. "There can get a short-term return, but you also need to look at the long-term return and for any resources you need to look at payback time."

For Haag, "It always comes back to value." She describes a hypothetical company in which cardiovascular disease or diabetes may be high up on the "non-occ" costs list. "However, the company may be spending a lot on high-risk pregnancies," she suggests. "We can bring a program in for that company that may be extremely valuable to develop."

You must constantly ask yourself not only what your key priorities are, but which of those priorities make the greatest impact on your bottom line, she continues. "For example, one nurse I met with was concerned because she spent so much time doing audiometrics. Well, you don’t need a nurse for that," says Haag.

"You need to determine what to keep in-house and what to vendor out based on the needs of the company," Haag explains. "See where your staff time is being spent and how it brings value to the company."

A SWOT analysis also can help determine if you have the in-house strength, experience, or capability to provide a given service. "Your company may have a lot of stress, but no full-time EAP [employee assistance program] person. In that case, you may need to vendor out," says Haag. "Ask yourself what your [insurance] carrier can do for you."

Insurance companies can also help you save money, as they provide any number of programs, from immunization to fitness programs, says Haag. "The key is to use all your resources to the best of your ability."

Matsui’s employer handles health surveillance in-house, she notes, because "doing it internally is cheaper than sending employees to a clinic." On the other hand, she says, more and more contract employees are being used on the occ-health staff, because of lower benefit costs. It’s also important, she notes, to look at the life cycle of certain products, to determine which ones to hold and which to harvest out.

Flexibility a must

As you move from year to year with your program, flexibility can serve you well as you seek to prioritize, says Kalina. "When you develop a business plan, you must remember it is not carved in stone," she advises. "It is meant to be a framework and a living document. You may plan to have a given strategy in place for, say, three months, but at that time, you may want to do another needs assessment." How often should you revisit your plan? "That’s something experience and your gut will tell you," she says.

"We experiment back and forth with outsourcing and in-sourcing occupational health services," says Matsui. "Take integrating case management programs for short- and long-term disability, workers’ comp, and retiree services — we constantly seek to blend the best service and resources at the best cost."

Staffing flexibility also is important, Matsui adds. Instead of losing manpower to electronic streamlining, for example, she shifted resources into a range of programs such as special needs (high Asian population in assembly, new moms, automated external defibrillators); early outreach to prevent osteoporosis and its resulting disability; and healthy weight through stress reduction, cardiac fitness, diabetic prevention, and body image programs. She also has increased occ-health’s visibility through ergonomic changes in computer and assembly settings, as well as through making recommendations at the design stage for satellite units in the field.

In the end, says Matsui, "Program results depend on matching the culture and well-being goals of your customers with your resources, the individual talent and personalities put forth by your management and staff."

"You need to understand the occupational health principles and nursing practices that are required," adds Kalina. "Once you do that, design programs that will support those principles and practices but at same time can be prioritized, all things being equal, based on the needs assessment and also on the resources available."

The prioritization process can, in the end, pay considerable bonuses, notes Haag. "Determine your resources. Link your process to the resource," she affirms. "By doing a very good needs assessment and seeing what programs bring value and help the company achieve its goals, you can make a case for why you are needed."

For more information, contact:

  • Annette B. Haag, RN, MBA, COHN, Annette B. Haag & Associates, P.O. Box 2098, Simi Valley, CA 93062. Telephone: (805) 581-3234. E-mail:
  • Margie Matsui, RN, COHN-S, CRRN. Telephone: (310) 812-4181.
  • Christine M. Kalina, MBA, MSA, BS, RN, COHN-S/CM, FAAOHN, Christine M. Kalina & Associates, Chicago. Telephone: (312) 645-3770. E-mail: