Workforce health protection is a critical element of an agency’s mission support architecture and must function as part of a larger management system that includes human resources, financial management, information systems and communications, acquisition planning and management, facilities management, and logistics; these elements together enable mission execution (Allen, 2012). Since its beginning, the Department of Homeland Security (DHS) has faced many challenges related to the horizontal and vertical integration of these various management functions (GAO, 2012a,b). In response to a 2009 charge by the Secretary to create “one DHS,” the Under Secretary for Management developed an Integrated Strategy for High Risk Management that provides a plan and performance measures for horizontal and vertical integration of the department’s management functions (DHS, 2013b). Despite its clear role in mission support, however, workforce health protection has not been included in larger management system integration efforts at DHS.
DHS operates using a matrix management approach whereby functional leaders (e.g., human resources) in the components receive direction both from component line leadership and from the functional leader at the DHS headquarters level (e.g., the DHS Chief Human Capital Officer). Despite the advantages of this approach, such as improved information sharing across organizational units (Ford and Randolph, 1992), challenges can arise, including confusion regarding authorities, turf battles, and loss of accountability (Bartlett and Ghoshal, 1990). At DHS, ensuring employee health under a matrix management structure is further complicated by the absence of a single leader for health functions at both the headquarters and,
in most cases, the component level. This chapter presents the committee’s recommendations for how DHS can achieve organizational alignment and coordination to support the integration of its workforce health protection functions.
The committee was asked to consider the centralized department oversight authority required to ensure an integrated health protection infrastructure. Based on its assessment (described in detail in Chapter 4), the committee concludes that (1) the fragmentation of workforce health protection functions and the lack of sufficient delegation of authority to the Chief Medical Officer (CMO) have resulted in ambiguity and uncertainty regarding roles and responsibilities; and (2) the absence of formal mechanisms for coordination and communication has resulted in stovepiped workforce health protection functions, contributing to inefficiency, a lack of accountability and transparency, and missed opportunities to achieve synergy through integration. To realize the vision of a ready and resilient workforce (IOM, 2013), DHS needs to align its resources with its strategic objectives, develop performance metrics, and hold its health and line leadership accountable for the health of its employees. Meeting these needs is extraordinarily difficult in a fragmented organization. It is not enough to ensure that the key operational functions exist; the organizational construct needs to support their integration. In the following sections, the committee presents different authority structure models derived from an analysis of successful systems in other organizations and its findings on the integration challenges associated with the current model at DHS. Based on an analysis of alternative oversight mechanisms to better promote integration, including both segregated and aligned approaches,1 the committee concludes that achieving an integrated health protection system will require organizational alignment such that there is oversight from a centralized health authority who can serve as an advocate for workforce health protection.
Models for Oversight Mechanisms to Promote Health System Integration
Integrated management systems for workforce health are multidisciplinary in nature, requiring input from those with expertise in health,
1As the committee uses these terms, segregated refers to an approach whereby employee health-related responsibilities are split between two headquarters-level offices (Office of Health Affairs [OHA] and Office of the Chief Human Capital Officer [OCHCO]), whereas aligned refers to a reporting structure whereby managers for all health-related functions report directly to a single leader within one office.
safety, human resources, legal requirements, and operations. Consequently, it can be challenging to determine the optimal arrangement of responsibilities for health protection functions across multiple stakeholder entities. In the course of this study, the committee examined the organizational and authority structures for employee health programs in multiple public- and private-sector organizations to identify general mechanisms for ensuring integration (described in more detail in Appendix E). From this assessment, two general mechanisms emerged: (1) shared oversight of segregated functions, and (2) aligned reporting structures. Both have advantages and disadvantages. Determining how best to divide responsibility for different functions is a major challenge associated with the segregated model, whereas determining optimal organizational context (leadership and organizational placement) can be difficult with an aligned model. These two models are discussed in more detail below. Although the committee tried to include a diverse set of organizations in its analysis, it acknowledges that other models might have been identified with a larger sample.
Model 1: Shared Oversight of Segregated Functions
In several of the organizations reviewed by the committee (e.g., Johnson & Johnson [J&J], Procter & Gamble [P&G], the National Aeronautics and Space Administration [NASA], and the Department of Defense [DoD]), employee health and wellness programs are organizationally segregated from safety programs, and integration is achieved through coordinated, global policies and standards that apply across all component agencies (or business units) and are developed by an oversight council that brings the heads of both groups together. The committee noted that under this model, safety functions, which are inherently operational in nature, often are overseen by operational units (e.g., supply chain operations, mission assurance).
At J&J, employee health and wellness programs (including health promotion, mental health, travel health, medical surveillance, and health clinic services) are aligned and integrated under the global medical director, but safety (injury prevention) and industrial hygiene programs are managed separately. The global medical director reports through human resources, while the head of safety reports through supply chain operations. To ensure integration of global policies and standards, both sit on an Environmental Health and Safety Leadership Council (Isaac, 2013).2 Similarly, at NASA, safety falls under the Safety and Mission Assurance Directorate, but all other employee health protection and promotion functions (e.g., occupational health, environmental health, health physics, physical fitness and health promotion, workers’ compensation, and employee assistance)
2The health system at P&G is organized similarly to that of J&J.
fall under the Office of the Chief Health and Medical Officer. Both report directly to the NASA Administrator (NASA, 2013).3 The Chief Health and Medical Officer—who is also the NASA Designated Agency Safety and Health Official (DASHO)—and the Chief Safety and Mission Assurance Officer are both members of the Mission Support Council, which facilitates senior management involvement in and oversight of NASA’s occupational safety and health program (NASA, 2012). At DoD, responsibilities for workforce health protection fall under two separate Under Secretaries of Defense (USDs): the USD for Acquisition, Technology and Logistics and the USD for Personnel and Readiness. The Office of the USD for Acquisition, Technology and Logistics has primary responsibility for safety and occupational health policy, while the Office of the USD for Personnel and Readiness is responsible for DoD’s medical programs and for programs and budget related to occupational health aspects of the Defense Health Program. The Defense Safety Oversight Council, which is chaired by the USD for Personnel and Readiness, helps ensure coordination among these offices (Cecchine et al., 2009).
Model 2: Aligned Reporting Structures
In the second model, workforce health protection functions, including safety, are aligned into a single reporting structure. Organizations with aligned health protection functions that were reviewed by the committee included the Department of the Interior (DOI), the Smithsonian Institution, and the Johns Hopkins Medical Institution and University. It should be noted that workers’ compensation is included in this aligned structure only for the Johns Hopkins system; in the other two cases, this function is managed within human resources, although DOI occupational medicine personnel offer support for such programs by conducting case reviews (DOI, 2013). Neither DOI nor the Smithsonian has a designated CMO or medical director, although both organizations employ physicians to direct occupational health programs that are part of the aligned health protection reporting structures.
At DOI, occupational safety and health and occupational medicine functions are aligned within the Office of Occupational Safety and Health, the director of which is also the Executive Director of the DOI DASHO Council—a high-level decision-making body comprising the department DASHO and the bureau-level DASHOs. The Smithsonian aligns occupational health, safety, environmental management, and fire protection under the Director for the Office of Safety, Health and Environmental Management. At Johns Hopkins, a large multicenter academic and medical institution, the
3The NASA Administrator is the agency head.
safety, occupational medicine, environmental health, workers’ compensation, and employee assistance programs are all aligned under the Executive Director for Health, Safety and Environment, who is also the Chair of the Joint Committee for Health, Safety and Environment and the Occupational Medicine Division Director (Bernacki, 1999).
The Current DHS Oversight Model for Workforce Health Protection Functions
As described in earlier chapters and delineated in Table 2-2 in Chapter 2, current workforce health protection and promotion activities at the DHS headquarters level are divided between two mission support offices: the Office of Health Affairs (OHA) and the Office of the Chief Human Capital Officer (OCHCO), the latter being located within the Management Directorate. Briefly, health protection responsibilities under the CMO encompass primarily medical quality management, medical support for operations, medical countermeasures, employee resilience programs, and medical readiness functions, whereas programs located within OCHCO include occupational safety and health, workers’ compensation, disability management, and health promotion. This organizational and authority structure most closely resembles the segregated model described above, although the division of health and medical functions between offices is a notable difference (for example, medical surveillance and medical case management are overseen from within OCHCO, but other medical functions are the responsibility of the CMO). Even in other organizations examined by the committee where safety (and in some cases, industrial hygiene) is overseen by an operational unit, medical functions are generally collocated. Additionally, in contrast with the organizations described above employing a segregated model, safety functions at DHS currently are not overseen by an operational entity.
Like other organizations with segregated employee health protection programs, DHS established an oversight council to promote functional integration. A 2008 DHS Directive (066-01; see Appendix B) directed the formation of a DHS Safety, Health, and Medical Council to facilitate the coordinated formulation of department-wide health, safety, and medical program policy and the development of integrated tools and standardized processes to support program functions (OCAO and OHA, 2009). The Council was to be co-chaired by the CMO and the DASHO—currently the
Chief Human Capital Officer4—and attended by the component Designated Safety and Health Officials (DSHOs).5 However, the committee learned that the Council has been inactive for more than a year (Anderson, 2013), although no explanation was provided as to the reason for this.
Integration Challenges Associated with the Current DHS Health System Model
As discussed in earlier chapters, the Secretary has delegated authority to the Assistant Secretary for Health Affairs, who is also the DHS CMO, to exercise oversight over all of the department’s medical and public health activities (see Appendix B for a full description of the authorities vested in the CMO under Delegation #5001). This delegation was initiated in 2008 and has not been reviewed or revised to reflect more than 5 years of experience and changing circumstances. A memorandum of understanding was put in place in September 2009 (see Appendix B) to delineate more clearly the responsibilities of OHA and the Office of the Chief Administrative Officer (whose responsibilities have now been assumed by the Chief Human Capital Officer). However, the matrix designating lead and shared responsibilities for each program was found to be inaccurate with regard to actual current responsibilities. For example, health promotion is listed as an OHA responsibility, but policy and guidance for health promotion currently are led by the Human Capital Policy and Programs Division within OCHCO.6 A revision process was initiated but was interrupted by management turnover within OHA.7
The memorandum of understanding lists several functions for which the CMO has primary responsibility in an oversight role, but the provision of services themselves may be carried out through OCHCO (OCAO and
4Under Directive 066-01, the DHS Safety, Health, and Medical Council was to be co-chaired by the CMO and the Chief Administrative Officer, who initially served as the DASHO for the department. When the DHS occupational safety and health program was detailed from the Office of the Chief Administrative Officer to OCHCO, the Chief Human Capital Officer assumed the title of DASHO and the attendant responsibilities.
5The committee found that the organizational placement of the DSHOs varied across DHS, but as defined by Executive Order 12196, these officials are responsible for agency occupational safety and health programs and must have “sufficient authority to represent the interest and support of the agency head.”
6At former Secretary Napolitano’s request, OHA established a workforce resilience program, which the Institute of Medicine (IOM) Committee on Department of Homeland Security Workforce Resilience found to be isolated from other workforce health promotion initiatives run by OCHCO.
7E-mail communication, K. Anderson, DHS OCHCO, to A. Downey, Institute of Medicine, regarding proposed changes to OHA-Office of the Chief Administrative Officer memorandum of understanding, March 7, 2013.
OHA, 2009). In the absence of formal mechanisms for interaction between the two offices, it is unclear how the intersection of these responsibilities can be managed effectively. A current initiative to improve medical case management at DHS provides an example of how the CMO lacks visibility and strategic input with respect to the health-related functions currently administered through OCHCO, including medical functions for which the CMO has delegated oversight authority. The committee learned that a department-wide program to facilitate early medical case management for employees who have filed workers’ compensation claims is being established and will be managed at the headquarters level by the Workers’ Compensation Program Manager and Policy Advisor within OCHCO (Myers, 2013). Despite the fact that oversight authority for return to work was delegated to the CMO, OHA is not involved in the administration of this program.8 As there are no medical personnel within OCHCO, a contracted medical officer will be responsible for medical oversight of case managers (DHS, 2013a). Reliance on contracted medical support for functions that could be overseen by in-house medical authorities contributes to a lack of role clarity for the CMO, diminishes the authority of the position, and poses a barrier to ensuring integration of outsourced functions into an overarching DHS health protection strategy and system.
Although personnel from OHA and the occupational safety and health (OSH) office continue to collaborate on policy development, accident investigation, and preparedness planning in the absence of formal and regular coordination mechanisms (Anderson, 2013), such interaction occurs on an ad hoc basis, resulting in redundancy and missed opportunities for synergy. During testimony at the committee’s first meeting, the DHS Safety Manager commented that OHA and the OSH office sometimes “lean forward simultaneously and start in parallel directions on something that comes up…. Our chief people ask us the same question that their people do. We both end up working on the answer independently and needlessly” (Anderson, 2013). Such inefficiencies could be reduced by high-level coordination through established governance mechanisms (e.g., the Health, Safety, and Medical Council) and through the development of a unified strategic approach to workforce health protection. A unified approach would need to be guided by a clear picture of employee health status and needs throughout the department and would require executive-level decision making regarding strategic prioritization and resourcing. It is not clear how this could be achieved in the absence of communication between the DASHO and the CMO.
8E-mail communication, I. Hope, DHS OHA, to A. Downey, Institute of Medicine, regarding medical case management program, August 12, 2013.
Based on the challenges described above (and in more detail in Chapter 4), the committee concludes that the current segregated system for workforce health protection is not functioning optimally. Revision of key policy documents (the 2008 delegation and memorandum of understanding) and reconstitution of the Health, Safety, and Medical Council would help improve coordination between offices, but the committee is concerned that, in the absence of additional accountability mechanisms, DHS will not achieve lasting change. Increased accountability through organizational transformation is necessary to promote health system integration and ensure mission readiness at DHS.
Alternative Oversight Mechanisms to Promote Health System Integration at DHS
The committee considered two alternative oversight mechanisms that could facilitate improved integration: (1) leaving health protection responsibilities segregated but reorganizing reporting structures such that someone with sufficient authority would have responsibility for ensuring coordination between the CMO and the Chief Human Capital Officer; or (2) aligning all workforce health protection functions into a single reporting structure.
There is currently significant organizational distance between the two offices with oversight responsibility for workforce health protection functions (OHA and OCHCO), with reporting structures remaining separate until the Deputy Secretary level. As a result, the CMO and Chief Human Capital Officer are not held accountable for coordinating efforts, including ensuring the functioning of formal governance mechanisms such as the DHS Health, Safety, and Medical Council. According to the DHS Chief Human Capital Officer, “Inefficiencies that do arise are usually due to a difference in executive prioritization and program resourcing that result from the alignment of OHA under the CMO and OSH/OCHCO within the Management Directorate.”9 This observation is consistent with the committee’s findings, and it is this imbalance of prioritization and resourcing that is key to understanding many current challenges with health system integration at DHS. Consequently, the committee considered whether a segregated health protection infrastructure would be more effective with placement of
9E-mail communication, K. Emerson, DHS OCHCO, to A. Downey, Institute of Medicine, regarding integration of occupational health and operational medicine infrastructures at DHS, December 24, 2013.
the CMO in the Management Directorate10 at the same level as the Chief Human Capital Officer, with the Under Secretary for Management overseeing both offices and holding the CMO and Chief Human Capital Officer accountable for coordination. This arrangement would be consistent with the DHS Chief Human Capital Officer’s suggestion that “improved ‘integration’ could be achieved through an organizational structure in which the occupational health and operational medicine personnel currently placed in OHA could be moved ‘closer’ to the OSH office, with a shared upper-level executive somewhere below the current level.”11
The main advantage of this approach is that it would reduce the organizational distance between the CMO and the Chief Human Capital Officer in a way that would be less disruptive than organizational alignment of workforce health protection functions, because responsibilities within OCHCO and OHA would remain the same and reporting relationships would change only for the CMO. Synergy resulting from the close association of occupational safety and health, health promotion, and disability management with human resource functions such as benefits and labor relations would be preserved. However, the committee also sees several disadvantages to this segregated model. First, it would place the Under Secretary for Management in the position of having to be a constant arbiter between entities (OHA and OCHCO) that have diverse missions, goals/objectives, and priorities. The segregated approach could be successful only if formal and regular coordination mechanisms were established at the senior leadership (i.e., CMO and Chief Human Capital Officer) and program (e.g., occupational health) levels. Establishment of these mechanisms would in turn depend on the institution of clear accountability measures, enforcement of which would fall to the Under Secretary for Management. Success would also depend on the development of a coordinated strategic approach informed by baseline data on core health-related metrics. In contrast to other organizations utilizing the segregated approach, DHS has not established such measures, and the information management systems required for data collection and analysis are not yet in place.
In addition to the above challenges, the segregated approach would perpetuate an artificial divide between key occupational health functions that should be operating seamlessly in conjunction with one another. For
10It should be noted that OHA is responsible for many activities beyond workforce health protection (e.g., biodefense-related activities), which may make placement of the CMO within the Management Directorate undesirable. However, the committee was not asked to examine responsibilities of the CMO outside of those related to occupational health and operational medicine, and therefore cannot speak to that issue.
11E-mail communication, K. Emerson, DHS OCHCO, to A. Downey, Institute of Medicine, regarding integration of occupational health and operational medicine infrastructures at DHS, December 24, 2013.
example, safety should be an integral component of operational medicine programs to ensure that prevention and monitoring of injuries and illnesses are applied equally in field- and facilities-based settings. Also, dividing responsibilities between offices collocated within the Management Directorate would not solve some of the current integration challenges related to lack of clarity regarding roles and responsibilities described above. In light of the inherent interconnectedness of these functions, the committee believes that an attempt to redistribute responsibilities is unlikely to result in optimal integration. Given the serious sequelae when health protection systems fail to function optimally (e.g., preventable morbidity and mortality, mission failure), deficiencies resulting from segregation of these functions would outweigh synergies achieved through integration with human resources functions.
While recognizing the disruption and other short-term challenges that would accompany organizational realignment, including potential staff resistance, the need to redefine reporting relationships, and requirements for budgetary reallocation, the committee believes that organizational alignment provides the best opportunity for successful health system integration at DHS, given the current ineffectiveness of governance mechanisms and the immaturity of supporting infrastructure, such as information management systems. This conclusion is consistent with the findings of a 2005 report on medical readiness at DHS that recommends the establishment of an entity with responsibility for both occupational safety and health and medical support for operations (Lowell, 2005). Creating a single reporting structure and consolidating responsibility for all workforce health protection functions under a single leader would better ensure functional integration and would affirm and empower an enterprise-wide approach. The comprehensive view of employee health status and needs across the department enabled by such alignment could facilitate more efficient management of resources; enhanced communication with leadership, components, and all DHS employees; more consistent performance measurement; improved accountability and transparency; and ultimately, increased organizational effectiveness and synergy.
Alignment of Headquarters Health Protection Oversight Functions
Many large organizations with effective integrated health and safety programs employ a lead official who is not a physician. In both federal organizations found by the committee to have aligned health infrastructures (DOI and the Smithsonian), physicians with responsibility for occupational health and medicine activities report to a nonmedical office director. Unlike DHS, however, neither has a CMO or equivalent position. Although the CMO, as the head of DHS’s health office, is an obvious candidate to
lead an aligned health infrastructure, the committee also considered the comparative advantages and disadvantages of alignment under the Chief Human Capital Officer.
The main advantage of alignment under the Chief Human Capital Officer would be the opportunity to integrate human resources functions (e.g., employment and benefits) with health and safety functions. The role of human resources in integrated employee health management systems has increasingly been acknowledged (McLellan et al., 2012), and the ability to adjust benefits based on health-related outcome data has been shown to reduce health care utilization and costs (Bunn, 2010). Compared with private organizations that are leading the integration of health and human resources functions, however, government agencies have less flexibility to tailor benefits (which are to some degree controlled by the Office of Personnel Management), and DHS lacks the systems for data integration that would enable evidence-based adjustments to the design of benefits, so the degree of synergy that could be achieved with alignment under the Chief Human Capital Officer is limited.
In addition to the human resources aspects of health protection functions, medical and operational aspects must be considered in determining the organizational context for an aligned reporting structure. The Chief Human Capital Officer is a resource manager without line operational authority and lacks the necessary training and experience to provide medical oversight and strategic direction for an integrated health system. DHS is responsible for numerous operational medicine programs in addition to traditional occupational health, safety, and compensation programs. Given the operational and security-sensitive nature of these programs, oversight at the headquarters level cannot be outsourced. Thus, the committee believes there would be significant benefit to having a medical professional lead an integrated occupational health and operational medicine infrastructure. The committee also believes the CMO would have the professional credibility needed to unify these functions across the department’s component agencies through coordination with component medical officers who are responsible for the implementation of policies and standards promulgated by the CMO (see Recommendation 4 below). Finally, the designation of the CMO as the lead agency official for workforce health protection would emphasize the central role of health and medical support in fulfilling the DHS mission, thereby raising the visibility of this vital function across the department and underscoring the Secretary’s commitment to protecting the DHS workforce.
Acknowledging that the Chief Human Capital Officer has significant interests in an effective workforce health protection program, the committee believes the CMO, whose responsibilities span policy, resource management, and operations, would be better suited to providing the public health leadership required to develop and coordinate the full spectrum
of health promotion, occupational safety and health, occupational and operational medicine, and disability management functions. For this organizational arrangement to be successful, however, the CMO would need to coordinate closely with the Chief Human Capital Officer on human resources-related aspects of the workforce health protection portfolio (see Recommendation 6 on a governance framework). The CMO also would need to be supported by a multidisciplinary team of policy advisors and program management staff with collective backgrounds encompassing the range of disciplines presented in Box 6-1.
Recommendation 2: Align and integrate all occupational health and operational medicine functions under the Chief Medical Officer.
The Secretary of the Department of Homeland Security (DHS) should design and implement a single reporting structure that effectively aligns and integrates all DHS employee health- and safety-related functions. The Secretary should designate and empower the Chief Medical Officer as the lead agency official responsible for establishing DHS-wide health, safety, and medical policies, standards, and programs and ensuring that component agency programs are implemented in a manner consistent with these policies and standards.
It must be strongly emphasized that, although the committee is recommending alignment under the CMO, its vision for this infrastructure is that of a multidisciplinary rather than a strictly medical health protection enterprise. As articulated in its guiding principle (see Chapter 1), the committee believes a broader population health approach is necessary to ensure the promotion and protection of employee health at DHS in a holistic manner. Implementing such an approach will require a coherent strategy and a dedicated, multidisciplinary team of individuals supporting the CMO.
Responsibilities of the DHS Chief Medical Officer in an Aligned Reporting Structure
To ensure that the CMO is adequately empowered to coordinate the development, implementation, and oversight of DHS-wide policies, standards, and programs addressing the promotion and protection of the health of the DHS workforce, the Secretary should review and revise the Delegation to the Assistant Secretary for Health Affairs and Chief Medical Officer (DHS
Delegation #5001).12 Responsibilities for the CMO should include but not be limited to
- promulgating department-wide policies and standards for integrating and coordinating all occupational health and operational medicine functions, including occupational safety and health, fitness for duty, workers’ compensation and disability management,13 and health promotion;
- developing a process for ensuring the implementation of DHS-wide health, safety, and medical standards;
- providing advice and guidance to the Secretary and component agency leadership on all matters related to health, safety, and medicine;
- overseeing component agencies’ medical quality assurance programs, and ensuring that all DHS and outsourced providers of medical services are appropriately educated and trained and routinely evaluated through centralized credentialing, baseline training requirements, and a standardized competency assessment process;
- analyzing resource allocations and requesting budgetary adjustments as necessary; and
- submitting an annual measurement and evaluation report to the Secretary on the health, safety, and readiness of the DHS workforce.
The responsibilities outlined above largely are already explicitly stated or implicit in Delegation #5001. However, the committee asserts that, in addition to the position’s current authority, the CMO’s responsibilities should include oversight for health promotion, disability management, and occupational safety and health programs in accordance with Title 29 of the Code of Federal Regulations, part 1960 (29 CFR 1960), Basic Program
12Related documents that should also be reviewed and revised include DHS Directive #066-01, Safety and Health Programs (July 25, 2008), and the Memorandum of Understanding between the Office of the Chief Administrative Officer and OHA (September 30, 2009).
13It is important to note here that execution of disability management functions must be closely coordinated with the administrative functions associated with workers’ compensation benefits. The importance of this is highlighted by the disruptions to functional coordination between workers’ compensation personnel and nurse case managers that followed the removal of the former from the Federal Air Marshal Service (FAMS) medical program reporting structure (see Box 4-4 in Chapter 4). Separating these two interconnected functions would be at cross purposes with the committee’s task to advise on the creation of an integrated health protection infrastructure; thus, inherent in the committee’s recommendation to integrate disability management with other health and safety functions is the alignment of all elements of workers’ compensation programs, including the administration of workers’ compensation benefits, under the CMO.
Suggested Competencies for the
Office of the Chief Medical Officer
The committee does not believe the DHS Chief Medical Officer (CMO) must be a board-certified occupational medicine physician to lead the implementation of a unified DHS workforce health protection strategy. However, the committee found the core competencies for Occupational and Environmental Medicine physicians of the American College of Occupational and Environmental Medicine (ACOEM, 2008) to be a useful base for developing the following competencies that should be represented in the collective expertise of the CMO and those in his or her immediate team to support the CMO’s role as primary advisor to the DHS Secretary on health and medical issues. Although the ACOEM competencies were developed for practitioners of occupational medicine, the committee found that many of these competencies are equally applicable to the practice of operational medicine, with the caveat that special consideration must be given to experience with the unique requirements associated with operating outside of conventional workspaces.
- Clinical Occupational and Environmental Medicine: Knowledge and skills to provide evidence-based clinical evaluation and treatment for injuries and illnesses that are occupationally or environmentally related.
- Tactical Emergency Medicine: Training and experience in working with law enforcement or military operational personnel in delivering operational medical support, including sick call, urgent, and emergency health care in field or austere conditions.
- Occupational and Operational Medicine-Related Law and Regulations: Knowledge and skills necessary to comply with regulations important to occupational health and operational medicine. This most often includes those regulations essential to workers’ compensation, accommodation of disabilities, public health, worker safety, emergency medical services, and environmental health and safety.
- Hazard Recognition, Evaluation, and Control: Knowledge and skills necessary to assess the risk of an adverse event from exposure to physical, chemical, or biological hazards in the workplace or environment, to include knowledge of ergonomics, industrial hygiene, and radiation safety. If there is a risk with exposure, that risk can be characterized with recommendations for control measures.
- Environmental Health: Knowledge and skills necessary to recognize potential environmental causes of concern to the individual as well as to community health. Environmental issues most often include air, water, or ground contamination by natural or artificial pollutants.
- Work Fitness and Disability Integration: Knowledge and skills to determine whether a worker can safely be at work and complete required job tasks (for additional information, see the section on readiness assessment in Chapter 3). The physician has the knowledge and skills necessary to provide guidance to the employee and employer when an employee with a disability needs to be integrated into the workplace.
- Toxicology: Knowledge and skills to recognize, evaluate, and treat exposures to toxins at work or in the general environment. This most often includes interpreting laboratory or environmental monitoring test results, as well as applying toxicokinetic data.
- Disaster Preparedness and Emergency Management: Knowledge and skills to plan for mitigation of, response to, and recovery from disasters at specific worksites as well as for the community at large. Emergency management most often includes resource mobilization; risk communication; and collaboration with local, state, or federal agencies.
- Medical Management of Chemical, Biological, Nuclear, and Radiological Events: Knowledge and skills to play a senior role in national-level efforts to reduce the risk of such events, recognize when a surreptitious event has occurred, and mitigate the population or individually targeted effects of these events.
- Health and Productivity: Ability to identify and address individual and organizational factors in the workplace in order to optimize the health of the workers and enhance productivity. These issues most often include absenteeism, presenteeism, health enhancement, and population health management.
- Public Health, Surveillance, and Disease Prevention: Knowledge and skills to develop, evaluate, and manage medical surveillance programs for the workplace as well as the general public. The physician has the knowledge and skills to apply primary, secondary, and tertiary preventive methods.
- Medical Quality Management: Knowledge and skills required to develop and manage programs designed to ensure high-quality care when measured against industry-standard norms, including credentials management, professional privileging, and medical quality assurance activities.
- Medical System Management, Administration, and Control: Administrative and management knowledge and skills to plan, design, implement, manage, and evaluate comprehensive occupational and environmental health and operational medicine programs and projects. Included in these skills should be the ability to communicate effectively regarding health-related issues to both internal leadership and the public.
Elements for Federal Employee Occupational Safety and Health Programs and Related Matters.
Implementing an Aligned Organizational Structure
The committee recognizes that alignment of all workforce health protection functions under the CMO would substantially increase the scope of responsibilities of that position. Transfer of responsibilities would need to be accompanied by simultaneous transfer of the budget and personnel currently allocated to execution of those functions in order to meet the demands of the increased workload. Specifically, the three headquarters-level occupational safety and health program management personnel and the DHS workers’ compensation program manager and policy advisor would need to be transferred from OCHCO to OHA. Additionally, the title and responsibilities of the DASHO would have to be reassigned to ensure that the person with those responsibilities and authorities would be in the same reporting structure as the CMO and the safety program manager. According to 29 CFR 1960, Basic Program Elements for Federal Employee Occupational Safety and Health Programs and Related Matters, “the headquarters [safety and health program] staff should report directly to, or have appropriate access to, the Designated Agency Safety and Health Official, in order to carry out the responsibilities under this part.” With the alignment of the occupational safety and health program under the CMO, the CMO would need to be designated as or report to the DASHO. There are examples of federal agencies in which CMOs (or their equivalent) are also the DASHO (e.g., NASA, Department of State), and the committee considers this a reasonable arrangement for DHS. However, assuming that the DASHO responsibilities would be assigned to a leader with sufficient authority and budgetary influence to ensure that health and safety programs were appropriately implemented and resourced (as required by executive order), the committee views a structure where the CMO reports to the DASHO as a viable option as well.
The committee refrains from recommending specific reporting relationships within OHA but suggests that the organizational structure of the Coast Guard’s Health, Safety, and Work-life Directorate (see Appendix A) could serve as an appropriate model for the alignment of occupational safety and health, health promotion, and medical services functions under a single health and medical authority. The establishment of Associate CMOs with the experience and authority to provide leadership in the execution of specific responsibilities would help offset the significant increase in the workload of the CMO.
Ensuring Adequate Oversight Authority
The committee believes the designation of a lead agency official for all occupational safety, health, and medical programs is necessary but not sufficient to achieve needed improvements in coordination and integration. The CMO, as the lead official, will require the authority, influence, and resources necessary to ensure the execution of department-wide policies and programs.
In the 2008 Delegation to the Assistant Secretary for Health Affairs and Chief Medical Officer, the Secretary delegated to the CMO the authority to exercise oversight over all of DHS’s medical and public health activities. In the course of this study, however, it became apparent that, in practice, the CMO lacks the authority to exercise oversight over all medical and public health activities for DHS. The committee attempted to obtain clarity on the meaning of the term “oversight.” Senior Advisor to the Secretary the Honorable Judge Alice Hill told the committee that “the word oversight in 2013 probably does not mean that OHA will be its most effective if it just issues directives to the components…. OHA will need to prove its value and that is how these changes will be made” (Hill, 2013). The committee agrees that OHA must lead and not just direct components, but certain critical functions, such as medical quality management, need to be standardized and implemented consistently throughout the department. When the committee asked whether OHA has the authority to ensure that components comply with the policy set forth in the Medical Quality Management Directive (see Appendix B), it was told that the directive is an unfunded mandate and that OHA provides the components with guidance and tools but lacks the authority to ensure implementation (Leslie, 2013). “It’s sometimes not very clear what we have the authority to do,” said Occupational Health Branch Chief Ingrid Hope during the committee’s first meeting (Hope, 2013). The CMO cannot be effective in fulfilling the responsibilities of the position in the face of such ambiguity.
Recommendation 3: Ensure that the Chief Medical Officer has authority commensurate with the position’s responsibilities.
The Secretary of the Department of Homeland Security (DHS) should review the organizational context of the Chief Medical Officer (CMO) position and make necessary changes to ensure that the CMO has adequate authority, influence, and resources to carry out the essential function of ensuring the health, safety, and readiness of the more than 200,000 members of the DHS workforce.
The committee recognizes that giving individuals more authority will not effect change unless they are also given the tools, administrative resources, and full institutional support needed to carry out their assigned responsibilities. In addition to ensuring that budget and personnel are reallocated, as described following Recommendation 2, the DHS Secretary will need to demonstrate clear support for the alignment of critical health protection functions under the CMO. To empower the CMO, the Secretary will need to establish clearly through both policy (revision of Delegation #5001) and action (holding component heads accountable for compliance with policies and standards promulgated through OHA) that the CMO has oversight responsibility for all DHS health and safety programs. Further, the CMO’s role should extend beyond policy making to ensure that DHS’s health and safety programs are aligned, prioritized, and implemented. To this end, the CMO should be included as a member of DHS enterprise-wide governing bodies, such as Investment Review and Program Review Boards.
The organizational context of the CMO position needs to support these interactions and should be evaluated in this regard. In some of the organizations considered by the committee (e.g., J&J, P&G), the medical director is organizationally located within human resources. This arrangement may help promote integration between health and human resources activities, which is essential to the effective management of integrated workforce health programs (McLellan et al., 2012). However, the committee does not believe this organizational arrangement would improve the effectiveness of DHS’s overall health and safety policy, programs, or practices, for the following reasons:
- In those private-sector organizations, the human resources leader reports directly to the chief executive officer. Consequently, the medical director is only two levels down from the company’s senior official. The committee recognizes that the DHS Deputy Secretary is responsible for the day-to-day operation of the agency, so in accordance with the structure of those private-sector organizations, the CMO should be no more than two levels below the Deputy Secretary. That would be no lower than reporting to the Under Secretary for Management, a reporting relationship that would still be consistent with the CMO’s designation as an Assistant Secretary and would ensure that important health and safety issues could be raised to the Secretary unfiltered and expeditiously.
- Congress has stipulated that the DHS CMO should serve as the principal advisor to the DHS Secretary and head of FEMA on medical and public health issues.14 To carry out this responsibility,
14Post Katrina Emergency Management Reform Act.
the CMO needs greater visibility, autonomy, and influence than could be achieved within OCHCO. Moving the CMO under the Chief Human Capital Officer would reduce rather than raise the perceived importance of health and safety as an essential factor in mission readiness.
- The CMO would face competing priorities within OCHCO that would make it impossible to resource and execute the strategies and programs the committee deems necessary for DHS.
Although the committee cautions against placing the CMO under the Chief Human Capital Officer, there would be notable benefits to having the CMO, as the leader of an aligned health system, report to the Under Secretary for Management instead of reporting directly to the Deputy Secretary, as is currently the case. The committee noted that this type of organizational arrangement (i.e., a health-related office located within a management or human capital entity, at the same level as a human resources office) has been adopted by other federal agencies (e.g., Department of State and DOI). As suggested by the Chief Human Capital Officer, ensuring that health protection functions remain closely linked to related human resources functions such as benefits and labor relations enables a desirable synergy.15 This arrangement would not only ensure close coordination between the CMO and Chief Human Capital Officer but would also facilitate increased engagement of other relevant line-of-business chiefs (e.g., Chief Human Procurement Officer, Chief Financial Officer, Chief Information Officer), thereby promoting integration of workforce health protection into the larger DHS management infrastructure and governance processes. Additionally, if the CMO were located within the Management Directorate, the Under Secretary for Management would be the logical choice for assignment as the DASHO, as the Under Secretary for Management has the necessary budgetary authority to ensure that adequate resources are allocated for program execution. However, these benefits would need to be weighed against the decreased access of the CMO to the Secretary that could accompany such a move. Given the specialized, technical nature of health and medical information, there would be a risk of information loss during translation if the Under Secretary for Management were to brief the Secretary on behalf of the CMO. It would need to be understood that the CMO was still responsible for providing guidance and updates to the Secretary on all health- and medical-related matters. Additionally, the committee acknowledges that other considerations outside the scope of this
15E-mail communication, K. Emerson, DHS OCHCO, to A. Downey, Institute of Medicine, regarding integration of occupational health and operational medicine infrastructures at DHS, December 24, 2013.
study (e.g., responsibilities of the CMO beyond those related to workforce health) may be important to the decision on the best organizational placement of the CMO. Consequently, the committee cannot make a recommendation on this topic and suggests that this decision be left to the DHS Secretary after review and consideration of the benefits and disadvantages of the alternative reporting relationships for the CMO. Regardless of the CMO’s organizational placement, the Secretary’s clear empowerment of a strong leader in the CMO position will be required for success.
Since its creation in 2002, DHS and its component agencies have struggled to retrofit a large set of distinct legacy and nascent organizational structures into a single cohesive operational and management framework that meets the diverse requirements of the DHS mission. The same is true of the organizational structures supporting health protection; each component agency has developed a different infrastructure for carrying out its health, safety, and medical functions. These functions include, but are not limited to, fitness for duty, employee assistance, health promotion, medical screening, immunizations and travel medicine, medical threat assessments, operational medicine, quality monitoring, hazard identification and remediation, injury and illness investigations, automated external defibrillator (AED) programs, ergonomics assessments, regulatory compliance, health and safety training, return-to-work programs, and reasonable accommodation. In some components, these functions are carried out internally, whereas in others, some of these services are outsourced to other federal agencies (e.g., Federal Occupational Health), private contractors, or academic organizations. The committee found that the placement of occupational health programs supporting these functions is fragmented in some agencies and centralized in others, and their organizational location differs across the components (with locations including offices of human resources, training, administration, law enforcement services, and global strategies—see the component organizational charts in Appendix A). For example, health promotion programs may be operated out of medical program offices or separate human resources offices. The same is true for workers’ compensation programs. The committee was unable to gauge whether these locations in and of themselves are the cause of, or related to, inefficiency and lack of coordination within some components.
As discussed previously, the committee believes that organizational alignment of workforce health protection functions into one reporting structure would ensure effective coordination, collaboration, and accountability. While acknowledging that other options for coordination of these
functions can be effective, the committee was not provided sufficient evidence of matrix alignment to support the fragmented approach. In components with aligned or partially aligned organizational structures in which health, safety, and/or medical programs and functions are collocated, the committee found evidence of increased information sharing through regular meetings and coordination processes, encouraging communication and synergy in support of mission requirements. The case study of the integrated medical program of the Federal Air Marshal Service (FAMS) presented in Chapter 4 (see Box 4-4), demonstrates the value of organizational alignment. Notably, when the workers’ compensation program management function was removed from the FAMS reporting structure, coordination with the medical unit was degraded and workers’ compensation costs increased (Lewandowski and Weeks, 2013). The Coast Guard provides another example of improved integration through alignment of prevention and health protection functions under its CMO, but most other component agencies lack an equivalent single point of accountability for all health, safety, and medical activities.
Not only does fragmentation of workforce health protection functions at the component level impact intracomponent coordination, but oversight from the headquarters level also is more challenging when there is no single responsible leader or even consistency in what are considered medical, occupational safety and health, and human resources functions. Vertical integration has been less of a problem for occupational safety and health functions because well-established processes for oversight are in place to ensure compliance with regulations for federal agency occupational safety and health programs. Each component has a Designated Safety and Health Official and occupational safety and health program managers with clear responsibilities and minimum core performance metrics established by the Occupational Safety and Health Administration (OSHA). Vertical integration of medical programs has been far more challenging. Prior to the development of the Medical Liaison Officer (MLO) program, few of the components had a physician on staff, and there were few formalized routes of communication or mechanisms for information sharing between OHA and component medical and health offices.16 The MLO program represents an encouraging step forward, but vertical integration challenges remain. The MLO program has placed Senior Medical Advisors in only four of the DHS operating components.17 Additionally, the fragmentation of medical
16The Emergency Medical Services Training and Education Advisory Committee discussed in Chapter 4 is a notable exception.
17OHA is working to expand the MLO program into other component agencies. As benefits are realized in those components that have piloted the program, OHA hopes this will engender interest from other components.
and health functions across component human resources, workers’ compensation, occupational safety and health, medical, operational, and training offices means that even in components in which Senior Medical Advisors are located, there is still no one person accountable for medical and health activities. Senior Medical Advisors may be assigned to guide occupational health or operational medicine activities and may not have oversight over other medical programs. The result has been situations in which medical functions have been outsourced with no oversight from internal medical authorities.
The committee concludes that the current fragmented organizational structure and the distribution of health, safety, and medical authorities within DHS component agencies will impede the ability of the CMO to orchestrate a comprehensive and integrated workforce health protection strategy to ensure the health, safety, and resilience of the entire DHS workforce. The effectiveness of the CMO would be enhanced by having a single point of accountability within the operating components, an individual who could ensure the integration of component occupational health and operational medicine functions.
Recommendation 4: Establish Component Lead Medical Officers to align and integrate occupational health and operational medicine functions.
The Secretary of the Department of Homeland Security (DHS) should direct each component agency head to design and implement a single reporting structure that effectively aligns and integrates all component occupational health and operational medicine functions and assign oversight responsibility for these functions to a Component Lead Medical Officer. That individual would be responsible for ensuring that these functions are implemented in a manner consistent with DHS-wide standards and policies. The Component Lead Medical Officer, through a clear position description, should be held responsible for the following:
- reporting to the component head and/or component Designated Safety and Health Official on the execution of health, safety, and medical policies and programs within the component;
- applying the policies and standards promulgated by the Chief Medical Officer (CMO) in the context of the unique operational requirements of the component;
- developing a reporting structure and coordination processes to ensure the integration of occupational safety and health,
medical, workers’ compensation, and health promotion efforts; and
- ensuring that a federal medical officer, under the guidance of the CMO, is responsible for all component health, safety, and medical services, including those services provided by contract and/or interagency agreement.
Because Component Lead Medical Officers (CLMOs) would need to lead the development and coordination of the full spectrum of occupational health and operational medicine programs, encompassing health promotion, occupational safety and health, occupational and operational medicine, and disability management, the same core competencies described in Box 6-1 for the CMO should be represented on their team. Initially, as the CLMOs work to become established and address pressing gaps, it will be important for the CMO to ensure that they have adequate reachback support (program management staff and subject-matter experts) within OHA.
The Case for Alignment of Health, Safety, and Medical Functions Within Components
The committee was asked to provide recommendations on how occupational health and operational medicine infrastructures within component agencies can be better integrated into a coordinated, DHS-wide system. As discussed in Recommendation 2 (alignment under the CMO), the committee acknowledges that organizational realignment of all workforce health protection functions (e.g., fitness-for-duty determinations, health promotion and monitoring, record keeping and credentialing, safety inspections, injury and illness investigation and management) into a single reporting structure will present some challenges in terms of recasting authorities, particularly for components that already have one or more medical officers. In the short term, this process may even lead to inefficiencies as adjustments are made. However, the committee believes that aligning these functions under a CLMO as proposed in Recommendation 4 would result in long-term benefits, including
- improved communication and information sharing among health, safety, and medical activities, fostering a more cohesive environment for workforce health protection to support mission readiness;
- development of a comprehensive strategy for operational integration at the component and, where appropriate, the subcomponent levels;
- improved communication with line leadership, which would ensure that health programs are driven by component mission
requirements and that line leadership is kept informed regarding the health concerns and needs of the workforce and those in care or custody;
- development of an efficient system for integration of health data for internal analysis and transmission to and from DHS headquarters;
- development of clearer roles and responsibilities and scope of authority within components;
- improved communication with DHS headquarters, with CLMOs serving as conduits for information from their respective organizations to the DHS CMO and vice versa; and
- identification of staffing and skill shortages that can be addressed by a workforce development strategy to better meet health, safety, and workforce protection requirements.
Considerations in the Designation of Component Lead Medical Officers
Component-specific circumstances (e.g., field- versus facilities-based operations) may drive the organizational location of the CLMO—a determination the committee believes would best be left to component leadership. Regardless of where in the organizational structure CLMOs are established, however, they should have high-level visibility with component operational leadership to (1) advise on the allocation of adequate financial and other resources, (2) advocate within the component for health protection as essential to mission readiness, and (3) motivate line managers to undertake appropriate prevention activities. By designating a CLMO and ensuring that the position has sufficient visibility, component leadership would set the expectation that the CLMO is the medical authority across the component, which is critical to obtaining broad support and buy-in for component health, safety, and medical programs.
In designating the CLMO, component leadership would have to decide whether to assign the title and responsibilities detailed above to a Senior Medical Advisor or to a medical officer employed independently by the component (direct hire). Senior Medical Advisors are funded through cost-sharing agreements between OHA and their assigned component, and their performance expectations are developed by the Director of the OHA Workforce Health and Medical Support Division, who receives input from component supervisors. The implications of this decision for the following possible CLMO reporting configurations should be considered:
- CLMOs would report to and their performance be monitored by both component line management and the DHS CMO centrally (Senior Medical Advisor model). The benefits of this option include continued cost sharing and a stronger link between the CLMOs
and the CMO, which might improve information exchange and increase the likelihood of component adoption of department-wide standards. However, under this arrangement, CLMOs might have more difficulty earning the trust of their component leadership than would a direct hire counterpart.
- CLMOs would report to line management within the component but have performance requirements to consult and coordinate with the DHS CMO for department-wide policy and program development and oversight. This option might increase the sense of ownership over component medical programmatic activities and improve trust between component medical and line leadership, but it could impede information sharing with the CMO if CLMOs were not held accountable for participation in coordination activities.
Challenges Associated with Dual Reporting
Regardless of which of the two above options were chosen, the CLMOs, by design, would have a dual reporting relationship under the DHS matrix management authority structure. For component operational matters, they would report to the component leadership, but for medical matters, their implementation of health and medical programs, guidelines, and practices would fall under the oversight of the CMO. This point is critical because medical authorities, not line leadership, need to set medical training and certification requirements and ensure that they are met, and oversee the quality and scope of medical practice across DHS components. DoD has successfully implemented a similar dual reporting structure between line military commands and the senior departmental health authority to ensure that force health services, capabilities, and occupational risks are fully and authoritatively considered in preparing for and executing component operations. However, this arrangement works best when, as for DoD, both component and department medical authorities are able to plan, budget, and distribute funding to support implementation of their respective component/medical policies, programs, and practices. Otherwise, dual reporting could potentially cause problems for CLMOs should the priorities of the two leaders diverge. Without the ability to fund directed programs, the CMO might face pushback from components against such unfunded mandates, and CLMOs could be left in a position of responsibility without sufficient resources for policy execution. Although some cost-sharing initiatives have been implemented and others proposed, OHA generally is unable to provide funding to help components meet medical requirements. One way to help ensure that CLMOs would receive adequate budgetary support would be for the Secretary to require that component heads, as well as
CLMOs, be held accountable for successful execution of department-wide standards and policies.
Oversight of Outsourced Health, Safety, and Medical Services
An important role for the CLMO would be to ensure that all occupational and operational medicine program activities, including those that are outsourced through contracts and interagency agreements, are overseen by a component federal medical officer under the guidance of the CMO. The responsibilities delegated to the CMO by the Secretary include assurance of the quality and efficiency of all DHS medical services. The integration of DHS medical services, including coordination of occupational safety and health, workers’ compensation, and medical support for high-visibility, high-consequence, and nationally significant events, clearly falls within the responsibility of the CMO. The committee noted significant reliance on outsourced providers for occupational health and medical services (e.g., fitness-for-duty evaluations, health promotion services, ergonomics assessments, medical surveillance services). Federal Occupational Health alone provides hundreds of thousands of examinations and other various clinical services to DHS employees annually at health units across the country. The committee learned that two operational medicine programs within DHS currently are using a contracted medical director (Tang, 2013), whose scope of authority regarding programmatic direction and resource allocation is unclear.18 Furthermore, although one of the CMO’s delegated authorities is to provide medical guidance for departmental personnel programs, including return to work (DHS, 2008), the committee learned that an acquisition process has been initiated for a contracted DHS-wide medical case management program to be managed by workers’ compensation program staff at both the headquarters and component levels (Myers, 2013). In addition to nurse case managers, the vendor is to provide the medical reviewing physician. The committee was informed that OHA has not been involved with the development of this program since participating in initial discussions more than 3 years ago.19 Although the committee recognizes the value of early case management for workers’ compensation claims, this contract in its current form bypasses the internal medical assets and authorities of DHS. In so doing, it potentially impedes both medical situational awareness
18The role of contractors in the direction and oversight of medical operations should be delineated more clearly following analysis by DHS General Counsel to ensure compliance with legal requirements set by Federal Acquisition Regulations prohibiting contractors from carrying out inherently governmental functions, such as the supervision of federal employees.
19E-mail communication, I. Hope, DHS OHA, to A. Downey, Institute of Medicine, regarding a DHS medical case management program, August 12, 2013.
and integration with other workforce health protection functions, most notably occupational safety and health and fitness for duty.
The use of contracted medical direction may have arisen out of necessity in the past, but Senior Medical Advisors and a CLMO could provide in-house expertise to meet these needs. To ensure that such services are integrated into the larger DHS health protection infrastructure, technical oversight of outsourced services should be delegated to DHS medical officers at the component level. An example of these activities is monitoring revalidation of licensure for contracted medical practitioners (ICE, 2013).
Going forward, when contracted medical services are considered, they should be well delineated, task specific, and approved by the CMO. Administration of contracts and interagency agreements is the responsibility of trained procurement specialists, but a mechanism is needed to ensure that contracts and agreements are consistent with the overarching health policies and standards of the department. In private industry, stringent contract language is used to ensure that the company’s professional standards and practices are met (Christensen, 2013). Accordingly, the CMO should set minimum requirements for contracts and agreements and, where appropriate, work with acquisition authorities at DHS to establish a common vehicle for use by components in procuring occupational health and medical services to achieve efficiencies unless a business case demonstrates the need for a component-specific service agreement (see Recommendation 9 on centralization of common services). Another private-industry practice applicable to DHS is to require components to report on standardized core metrics using a data collection tool such as a global scorecard (see Recommendation 10 on collecting core metrics), regardless of whether services are provided in house or outsourced (Christensen, 2013; Isaac, 2013).
Establishing a Coordinated Approach to Workforce Health Protection Across DHS
Prior to establishment of the MLO program, the CMO had limited visibility on health and medical programs and challenges within component agencies. This limited visibility interfered with the CMO’s ability to address cross-cutting and department-wide health and medical issues through policy and program initiatives and to ensure that the Secretary’s agenda is assimilated at the component level. The committee learned that directives and proposed standards from OHA sometimes are disconnected from the needs and realities within the component agencies (Leffer, 2013), possibly contributing to the observed uneven compliance with OHA policy, most notably the Medical Quality Management Directive (Kosh-Suber, 2012).
The committee concludes that a mechanism is needed to enable the CMO to collect information on operational requirements from the
component level, to engage components in the development of medical and public health policy, and to provide senior-level direction for an integrated DHS workforce health protection strategy. OHA already has taken laudable steps toward developing this capability with the MLO program, but the role for Senior Medical Advisors in building and sustaining an integrated health protection system has yet to be clearly defined and formalized. In addition to serving as a source of information on drivers of health and medical policy within the components, Senior Medical Advisors and other medical officers within DHS have diverse backgrounds and represent a valuable source of knowledge and experience that the CMO should tap. The committee heard that the Senior Medical Advisors meet regularly (once or twice a month) with the MLO program Branch Chief but that these meetings are attended infrequently by the CMO (Maycock, 2013). This networking among medical officers is critical to the identification of commonalities in mission requirements that could be addressed with DHS-wide health, safety, and medical policies, standards, and services, but the committee believes the network’s value would best be realized through regular and formal direct interaction with the CMO. Other DHS Management Chiefs lead a council of representatives from each component that meets regularly for these purposes (e.g., the DHS Chief Human Capital Officer meets regularly with a council of Human Capital Officers from component agencies). An equivalent council of CLMOs to support and advise the CMO might facilitate a coordinated (top-down and bottom-up) approach to the development of policy, increase the agility with which emerging public health and medical issues can be addressed, and clarify the individual and collective roles of CLMOs in the department’s overarching health protection strategy while generating esprit de corps.
Recommendation 5: Establish a Medical and Readiness Committee to promote information sharing and integration.
The Chief Medical Officer (CMO) should establish and chair a Medical and Readiness Committee with membership comprising the Component Lead Medical Officers to promote information sharing and integration. Responsibilities of the proposed committee should include, but not be limited to
- recommending and validating department-wide health and medical standards;
- providing briefs on the specific health and medical issues/needs of the components;
- identifying best practices and sharing lessons learned;
- advising the CMO on resource needs for program implementation and execution;
- contributing subject-matter expertise to aid the CMO in providing medical guidance to the Secretary and component leadership;
- identifying and sharing education and training resources to help all component agencies achieve strategic goals;
- identifying opportunities to achieve efficiencies through consolidation and centralization of common services, including outsourced services (see Recommendation 9); and
- developing new tools and recommending core metrics for evaluation and trend analysis of health and medical programs (see Recommendation 10).
As envisioned by the committee, the Medical and Readiness Committee is key to the development of department-wide medical standards and policies that are responsive to the operational requirements of the components. The proposed committee, which should meet regularly (e.g., monthly), would establish formalized channels for information sharing among components and with the CMO; the resulting horizontal and vertical integration would help ensure that the health and medical needs of all DHS employees, and those in their charge, are met while also facilitating improvements in efficiency, interoperability, and harmonization. Although the proposed committee should play a key advisory role, the CMO should retain sole authority for setting DHS-wide medical policy. The recommended membership of the Medical and Readiness Committee currently is limited to CLMOs and the CMO; however, the scope of issues that arise could necessitate its augmentation and the participation of other medical or multidisciplinary representatives from DHS headquarters or component agencies. For example, participation and regular briefings by OHA Branch Chiefs and the DHS Safety Manager could help ensure that all OHA activities are supportive of and complementary to, but not redundant with, CLMO-led activities.
The committee believes that, to promote the continued maturation of the DHS health protection infrastructure and ensure that the CMO and CLMOs have the knowledge and experience required to provide occupational and operational health leadership to DHS, the CMO and CLMOs would benefit from regular peer review and input. This review and input would support the identification of best practices implemented in other organizations and succession planning in the face of inevitable leadership turnover. The committee believes that the Medical and Readiness Committee would provide a useful vehicle for convening outside peer experts for this purpose. These experts should come from within the federal
government and might include other federal medical directors and representatives from the Office of Personnel Management who could advise on personnel-related medical issues such as fitness-for-duty policies. Such peer experts, in conjunction with DHS clinical/administrative leadership, could orient new CMOs and CLMOs on topics including but not limited to readiness assessment, continuous quality improvement, and operational medicine, as needed.
Governance structures are used to support collaboration and decision making on organizational plans, actions, and resource commitments, particularly when conflicting priorities among component entities must be resolved in making decisions for the good of the institution. When DHS was initially established, the Government Accountability Office designated its formation as high risk, in part because of the foreseen management challenges associated with merging 22 component agencies and the serious consequences of failing to achieve integration. In working to address these concerns, DHS has established a tiered governance structure (GAO, 2012b) to facilitate integration and oversight of interrelated programmatic activities that support mission outcomes across the department (see Figure 6-1). In this structure, which is still being implemented, governance bodies and processes are established at the program level, the portfolio level (related sets of programs), and the enterprise level. Strategic priorities flow down from higher to lower governance bodies, and issues that cannot be resolved at lower levels flow up.
Portfolio-Level Governance of Health, Safety, and Medical Programs
The committee is unclear as to whether or how workforce health protection programs would be managed within the DHS governance structure shown in Figure 6-1 but identified a need for portfolio-level governance20 of such programs to ensure alignment and efficiency. Multiple headquarters offices and component agencies have shared responsibilities for the complex programs supporting the health, safety, and mission readiness of the workforce. Whereas heads of DHS components are responsible for the
20“The 13 planned portfolios are: Benefits Administration, Continuity of Operations, Domain Awareness, Incident Management, Information Sharing and Safeguarding, Intelligence, Law Enforcement, Screening, Securing, Enterprise Financial Management, Enterprise Human Resource Management, Enterprise IT Services, and Enterprise Business Services” (GAO, 2012b, p. 15).
FIGURE 6-1 DHS’s integrated enterprise governance structure.
SOURCE: GAO, 2012b.
health and mission readiness of all component employees, the CMO has responsibility for setting department-wide policies that promote health and mission readiness. Many workforce health protection functions span the intersection between health and human resources and therefore also require the involvement of the Chief Human Capital Officer. Input from other
members of the DHS management team21 may be required as well to ensure adequate resourcing of occupational health and operational medicine programs and effective management of these programs within the larger DHS financial, acquisitions, and information management architecture. The DHS Health, Safety, and Medical Council was established as a governance body to facilitate the necessary ongoing coordination, collaboration, and participation of these various headquarters- and component-level stakeholders in the development of health, safety, and medical policy. However, the Council has been inactive for more than a year.
Recommendation 6: Create a governance framework to engage Department of Homeland Security management officials and component leadership in employee health, safety, and resilience to support mission readiness.
The Secretary of the Department of Homeland Security (DHS) should develop and implement an effective governance framework for workforce health, safety, resilience, and readiness programs to ensure coordination, collaboration, and participation of DHS management and component leadership. This framework should include reconstitution of the existing, but inactive, Health, Safety, and Medical Council.
Reinvigoration of the inactive DHS Health, Safety, and Medical Council is critical to achieve department-wide consensus on strategies for addressing overarching and cross-cutting health, safety, and medical issues, and to engage component leadership in the development of policies that support the readiness of their workforces. Council membership should include the CMO, the DASHO,22 key members of the DHS management team, and component leadership.23
To function effectively, the Council will need to be part of a larger formalized governance structure. Figure 6-2 illustrates a tiered governance approach to workforce health protection.
21The management team (located within the Management Directorate) consists of the Chief Human Capital Officer, Chief Financial Officer, Chief Procurement Officer, Chief Information Officer, Chief Security Officer, and Chief Administrative Services Officer and is led by the Under Secretary for Management.
22If the DASHO title and responsibilities are assigned to someone other than the CMO when the aligned reporting structure proposed in Recommendation 2 is created.
23While component leadership representatives do not have to be component heads, these individuals should have budgetary authority within their organization (e.g., DSHOs).
Reconstitution of the Health, Safety, and Medical Council
In the framework shown in Figure 6-2, the Health, Safety, and Medical Council, which should meet quarterly or semiannually, would be responsible for assessing and prioritizing investments, eliminating redundancies among programs, and ensuring program alignment. The committee envisions that the Council could also be used as a mechanism for streamlining the issuance of management directives, a process the committee learned takes several years because of the current unwieldy mechanism for soliciting concurrence from components and other headquarters units. To ensure that the Council does not become inactive again in the future, the committee suggests that Council members be held accountable for participation through specific requirements set in their performance plans. Additionally, a clear charter from department leadership would help to ensure that the Council can effectively address cross-cutting policy issues and keep members engaged.
In its vetting and decision-making process, the Council should draw on recommendations and other information provided by program-level committees with varied subject-matter expertise, including but not limited to the Health Care Quality Committee, the Medical and Readiness Committee proposed in Recommendation 5, and the Safety Managers Committee. These committees are responsible for developing tools, standards, processes, and best practices for individual programs. Strategic decisions would be passed down to these lower-tier working bodies, which would be responsible for developing coordinated implementation plans. Execution would be overseen by the CMO and CLMOs. The CMO, who, as discussed in Recommendation 3 (CMO authority), should also sit on enterprise-level review boards, would be responsible for informing department leadership regarding resource needs for safety and health program execution, as well as potential consequences of underresourcing such programs.
Governance structures themselves need to be managed. To ensure successful implementation of the proposed governance framework, the Secretary should establish mechanisms for securing stakeholder buy-in, an implementation plan, and processes for evaluating effectiveness and capturing lessons learned (GAO, 2012b).
Enabling a Coordinated Approach to a Unified DHS Workforce Health Protection Strategy
A reinvigorated Health, Safety, and Medical Council would be instrumental in the coordinated development of the department-wide workforce health protection strategy discussed in Recommendation 1. The Council should advise the Secretary on consensus strategic objectives and
performance measures for each strategic goal, and CLMOs then should lead the development of annual operational plans detailing component-specific actions to be taken toward meeting these goals and related objectives. Updates on progress toward the Secretary’s strategic vision and goals for workforce health protection, as demonstrated through the performance measures outlined in the strategy, should be presented and discussed in regular meetings of the Health, Safety, and Medical Council. The related objectives and performance measures should be reviewed by the Council continually to ensure that the strategic plan is adaptable and meets the evolving needs of the department.
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