Congratulations! Employee health gets its very own Joint Commission standard

JCAHO focus is key as some see a weaker OSHA

The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has placed a sharper focus on employee health by reorganizing existing requirements into a separate standard for 2001. The new standard, which states simply, "The hospital plans for worker safety," isn’t the full-blown set of standards many employee health professionals would like to see. Nonetheless, the change gives employee health greater visibility in the Joint Commission hospital accreditation manual. The change is especially welcome at a time when some worry that the Occupational Safety and Health Administration’s (OSHA) enforcement mandate has been weakened under the Bush administration.

"[OSHA]’s just in limbo," says Kae Livsey, RN, MPH, public policy and advocacy manager for the American Association of Occupational Health Nurses in Atlanta, who notes that as of mid-April, OSHA still had no permanent administrator. "[The agency’s] just hanging out there in the breeze with no direction and an inability to do anything. It’s a pretty frustrating time."

Each OSHA regulation becomes a battleground. Fresh from victory in killing the ergonomics standard, lawyers for the National Association of Manufacturers filed suit against the agency’s record-keeping standard. They assert the standard would unfairly inflate injury reports by including nonwork-related injuries that may be aggravated by work activities.

Meanwhile, worker advocates vowed to renew their push for an ergonomics standard. The Bureau of Labor Statistics reported a total of more than 582,000 work-related musculoskeletal disorders (MSDs) for 1999, which represented one in three of all workplace injuries requiring time away from work. (See "Injuries put RNs in top 10 of riskiest jobs," in this issue.)

"One thing we’re good at is being tenacious," says Bill Borwegen, MPH, occupational health and safety director of the Service Employees International Union (SEIU) in Washington, DC. "We’ve only been working on this [ergonomics standard] for 10 years. I feel we’re just getting started."

Hospitals may no longer need to worry about OSHA’s ergonomics standard, but they could face questions, nonetheless, from Joint Commission surveyors. As part of a long-standing partnership with OSHA, Joint Commission surveyors receive training on that agency’s requirements, notes John Fishbeck, associate director of the department of standards for the Joint Commission. Even without an ergonomics standard, a surveyor might ask to look at injury data, notice a large number of patient handling injuries, and ask what measures the hospital has taken, he says.

In the 2001 accreditation manual, a new Environment of Care standard (EC.1.1.1) states that "the hospital plans for worker safety." The standard is very brief; other employee-health-related issues are still imbedded in other sections, such an infection control. The introduction to the Environment of Care section in the Joint Commission manual mentions visitor and staff safety as well as patient safety, says Fishbeck. (See table.)

Table: Joint Commission Environment of Care Excerpt

The goal of this function is to provide a safe, functional, supportive, and effective environment for patients, staff members, and other individuals in the hospital. This is crucial to providing quality patient care and achieving good outcomes. . . .

Standard EC.1.1.1
The hospital plans for worker safety.
Intent of EC.1.1.1
The hospital identifies activities to reduce the risk of worker injuries. Worker safety planning includes identifying processes for reporting and investigating all incidents of occupational illness, and personnel injury.
In addition, worker safety planning establishes an orientation and education program that addresses:
• general safety processes;
• area-specific safety;
• specific job-related hazards;
• provision of safety-related information through new employee orientation and continuing education.
Examples of Evidence of Performance for EC.1.1.1
• Staff interviews
• Incident reports of work-related injuries/illnesses
• Orientation and staff education plans

"The requirements we highlighted for 2001 really were existing requirements, buried within existing standards," he says. "We identified the ones relating to workers’ safety and put them in a separate standard to give them more visibility."

The new language is an important addition, says Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at the Sarah Bush Lincoln Health System in Mattoon, IL. Kelafant was a consultant to the Joint Commission Committee on Healthcare Safety and supported the creation of separate employee health standards. "There is now explicit verbiage that says you must do this," he says. "It doesn’t say just TB or bloodborne pathogens; it says worker safety."

Kelafant, who is chairman of the Medical Center Occupational Health Section of the American College of Occupational and Environmental Medicine in Arlington Heights, IL, and coordinates an e-mail list on medical center occupational health, notes that occupational health physicians and nurses are reporting more requests for information from Joint Commission surveyors.

This year, as environment of care provisions are added to the new patient safety standards, again there will be an eye toward overall safety, says Fishbeck. "It’s important that this [focus on patient safety] be integrated in how you maintain safety for visitors and staff as well," he says.

Meanwhile, several OSHA initiatives were caught in the transition between the Clinton and Bush administrations. OSHA’s bloodborne pathogen standard became effective April 18, as expected. But the record-keeping rule remained under review, along with other regulations that had been issued in the last days of the Clinton presidency. As a part of that review, OSHA pulled back the paperwork reduction information sent to the Office of Management and Budget as a part of routine rulemaking.

OSHA’s record-keeping standard, which would take effect in 2002, involves new streamlined forms and incorporates the reporting of needlesticks. It includes a privacy provision and clarifies what injuries are work-related and the definition of first aid. The standard redefines how employers should count lost workdays.

The record-keeping rule also was designed to facilitate the ergonomics standard with new reporting requirements for MSDs, notes Baruch Fellner, a Washington, DC, lawyer who represents the National Association of Manufacturers and the National Coalition on Ergonomics. "One of the things we have found is a continuous decline of MSDs over the last 10 years," he says. "The effect of this new record-keeping standard would be to reverse that so proponents of the ergonomics standard could say, See what an epidemic we have.’"

OSHA’s proposed tuberculosis standard seems indefinitely stalled, and some observers wonder if OSHA will shy away from further rulemaking. "For those of us concerned about the health and safety of workers, it’s really frustrating to just see [rules] sitting on hold," says Livsey.

The president’s proposed budget cuts funds for developing safety and health standards by $1.2 million to $13.9 million for FY 2002. Training grants also would decline by $3 million, while the enforcement budget would rise by $3 million. In a release explaining the proposed budget, OSHA said it will "continue to base all standards on clear and sensible priorities and review existing rules to revise or eliminate obsolete and confusing standards or provisions of standards." Overall, the agency’s budget of $425.8 million represents a slight increase of $400,000, and a reduction of 94 full-time equivalent employees.

OSHA officials insist the agency’s commitment to worker safety is as strong as ever. "The safety and health of America’s workers is vital to our nation’s overall well-being and is my first priority," Labor Secretary Elaine Chao said in a statement. Ergonomics, a major battleground for both unions and industry, promises to be a test of that commitment. After Congress rescinded the ergonomics standard, both Bush and Chao expressed support for a new effort to reduce MSDs. "This is a serious problem," said Chao. "We are addressing it head-on, and we intend to find a solution that works."

Sen. John Breaux (R-LA) introduced a bill calling for OSHA to develop a new ergonomics standard within two years, but directing the agency to exclude injuries that are pre-existing but aggravated by work or that occur outside work. It would also prohibit the agency from requiring an expansion of existing state workers’ compensation protection — a particularly contentious part of the rescinded standard. Meanwhile, Sen. Arlen Spector (R-PA) scheduled hearings in April on the need for ergonomics standards.

The SEIU began shifting to a new strategy that will target state and local legislation, a tactic it has used effectively with other issues. A state-by-state effort gained the passage of 17 state laws on safer needle devices and ultimately led to federal legislation.

"The bottom line is we were outgunned 10 to 1 by corporate money on the last go-round [with ergonomics]," says Borwegen. "We didn’t mobilize like industry mobilized. We’re going to keep trying. The government cannot continue to ignore a hazard that leads to one-third of all workplace injuries."