Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention (2014) / Chapter Skim
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Part I A Transit Workplace Health Protection and Promotion Practitioner's Guide
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1TRANSIT OPERATOR HEALTH T Transit Operator Health: Introduction and Explanation The Background ransit sector employees, and bus operators in particular, are more likely to have certain serious and chronic health problems, compared to other workers (Witters 2013)
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activities in the transit industry. TCRP Project F17, "Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention," updated and extended that knowledge.
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3TRANSIT OPERATOR HEALTH and only one out of three among smaller agencies. (Organizations with programs may have been more likely to respond to a survey on the topic, so the actual proportion of transit agencies with programs could be lower.)
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The Practitioner's Guide The Practitioner's Guide is built around six chapters, each made up of best practices and elements that illustrate how to achieve them, as shown in Figure 8. Each chapter and element is accompanied by real transit agency practice examples by tools, links, and resources and by references to journal articles and other sources.
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The Model According to the World Health Organization (Burton, 2010) , a healthy workplace is one in which workers and managers collaborate to continuously improve, protect, and promote the health, safety, and well-being of all workers.
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6 FIGURE 2 Total Worker Health™ ESSENTIAL ELEMENTS OF EFFECTIVE WORKPLACE PROGRAMS AND POLICIES FOR IMPROVING WORKER HEALTH AND WELL-BEING Organizational Culture and Leadership 1. Develop a "human- centered culture." 2.
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7example) and leisure activities (powerlifting, for example, frequently causes back strain)
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Maintenance and vehicle noise Leisure activities Past work exposures: Veterans Other trades HEARING LOSS Safety and operators working afternoons or nights frequently have "dinner" at times that increase insulin resistance. Occupational health hazards come into play as well, as work at night and sleep disturbance have been linked to diabetes (Szosland, 2010)
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an integrated approach is to address concerns about asbestos or diesel exposure at the same time as providing support for quitting smoking. Respecting workers' concerns is more likely to be trusted and more likely to lead to health improvements.
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Transit Workplace Health Protection and Promotion Roadmap Preparing the Organization and Making the Commitment • Culture of health and safety • Organizational needs assessment • Organizational resources • Meeting needs with resources Setting Targets in Transit Health Protection and Promotion • Setting priorities • A comprehensive health risk focus • Effective components • Transit-specific programming Building the Team • Taking the lead • Putting the team together • Management support • Labor support • WHPP committee • Champions and ambassadors • Vendor integration Implementing and Integrating an Effective Transit Program • An inclusive range • Transit-specific implementation • Effective communications • Training supports the program • Equitable incentives Evaluation, Return on Investment, and Ongoing Improvement • Evaluation framework • Integrated data management • Process measures • Impact and outcome measures • Cost-benefits and return on investment • Data-driven ongoing improvement Maintaining Effectiveness with Growth • Maintaining • Growing • A realistic perspective FIGURE 8 THE PRACTIONER'S GUIDE MAP The Practitioner's Guide relies on the practical examples provided by US and Canadian transit agency staff, union leaders, and bus operators. Enormous thanks are due to all those who provided their information, opinions, and input to make the F-17 research project and this Guide possible.
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Chapter Background Operator Health Bushnell, P
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13GETTING STARTED Chapter Getting Started: Preparation and Commitment CHAPTER MAP CULTURE OF HEALTH AND SAFETY The organization maintains a healthy and safe culture based on leadership and organizational commitment. • Recognize the importance of WHPP for the agency.
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14 Just as each organization has a culture of safety, positive or negative, the culture of health is formed by the environment, polices, practices, and participants. Are health problems considered an individual responsibility, or do work conditions figure in?
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15GETTING STARTED United Transportation Union -- Los Angeles County Metropolitan Transit Authority Wellness Program: Organizational Leadership and Commitment The United Transportation Union -- Los Angeles County Metropolitan Transit Authority (UTU-LACMTA) Trust Fund joint labor-management collaboration began in 2007 focusing on ways to control escalating costs without reducing benefits.
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16 to understand clearly the organization's culture of health and safety and what support there is across the organization. Assess the organizational culture: The initial organizational assessment identifies the current health protection and promotion culture, and suggests ways to improve it.
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17GETTING STARTED TOOL 1.1 RATING THE HEALTH PROTECTION AND PROMOTION CULTURE How would you agree with the following statements about your organization's worksite health and safety culture? (If you do not know, mark "Neither agree nor disagree.")
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18 FIGURE 1.1 WORKPLACE HEALTH PROTECTION AND PROMOTION ADVANTAGES TRANSIT WORKER EMPLOYER UNION • Increased knowledge about factors affecting health • Increased opportunity to take control of health and medical treatment • Improved health and quality of life through reduction of risk factors • Increased morale because of organization's interest in health and well-being • Increased opportunity for support from coworkers and environment • Reduced presenteeism related to productivity loss • Reduced out-of-pocket medical costs • Reduced pain and suffering from illness and injuries • Informed and healthconscious workforce • Healthier and safer work environment • Improved labor-management relations • Support recruitment and retention • More productive workforce • Improved morale • Positive public image • Opportunity for cost savings via: • Reduced sick leave absenteeism • Decreased overall health benefit costs • Decreased health care utilization • Reduced disability claims • Reduced workers' comp • Reduced premature retirement • Fewer accidents and on-the-job injuries • Lower casualty insurance costs • Improved health and quality of life for members • Improved occupational safety and health of members • Increased participation in joint decision making • Improved labor-management relations • Reduction of health care premiums or fund costs • Increased opportunity for workers to influence health, safety, and medical treatment Establish top leadership buy-in and commitment: The connection between operator health and transit services that are safe and reliable should be acknowledged by leaders and communicated widely. It is important to keep management and labor leadership involved to maintain momentum.
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19GETTING STARTED WHPP program, makes budget and resource decisions, and addresses organizational and collective bargaining issues, but does not run the program. The steering committee meets on a regular basis and contin- ues to assess progress and adapt goals and strategies as necessary.
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20 USING DATA TO SET TARGETS In one active agency with an individual health focus, the main data drivers for deter- mining the program's focus each year are group data on blood pressure, glucose, cholesterol, and diabetes; a pharmacy report on the categories of medications prescribed; dental and vision plan summary data; cause of death data (listing the five main causes of mortality) ; and aggregate data from voluntary health risk assessments and quarterly biometric screening.
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21GETTING STARTED Qualitative approaches to assessing need can be especially useful in under- standing the work environment. Carry out site walkthroughs and observa- tions of the workplace to identify health risks and health-promoting charac- teristics.
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22 TOOL 1.2 BUS OPERATOR ROUTE CHECKLIST ROUTE DATE TIME NAME/BADGE LOCATION/ DESCRIBE THE PROBLEM, INCLUDING ACTUAL HAZARD TIME OR POTENTIAL HEALTH OR SAFETY IMPACT Roadway issues (ex. potholes)
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23GETTING STARTED personality or power conflicts, a run-down physical plant, or a stressed or mistrustful management or hourly workforce. These problems need to be taken into consideration as you go forward.
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24 How can existing structures and programs contribute? Many transit agencies have safety and health committees or location subcommittees.
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25GETTING STARTED TOOL 1.3 CHARTING THE ORGANIZATION AND FINDING PARTNERS DEPARTMENT WHPP-RELATED CONCERNS RELATED PROGRAMS CONTACT AND RESOURCES AND POLICIES Communications Internal and external newsletters, Other: Data management Access to health and injury data, Other: Facilities Planning and construction, Other: Human resources Hiring, Work-family, Employee Assistance Program (EAP) , Disability, Return to work, Benefits, Other: IT Employee dashboard, Other: Labor relations Benefits negotiations, Other: Occupational safety and health Fatigue, Stress, Ergonomics, Accident, Heat/cold/weather, Other: Operations Availability, Vehicle safety, Scheduling, Other: Public relations Passenger interactions, Community support for transit, Other: Purchasing Costs, Vendor contracts, Other: Risk management Worker's compensation, Vehicle safety, Other: Union Knowledge of workforce, Union Assistance Programs, Health activities, Other:
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26 FIGURE 1.4 EXTERNAL WHPP PARTNERS GROUP WHAT THEY CAN CONTRIBUTE Health insurance providers HRAs, data, health coaching, funds, care management, classes Disease and case management For-fee support Occupational health clinics Diagnosis, treatment, and referrals for work-related illness and injury, group screenings, interface with researchers, consultation Physical fitness vendors Programs at work or offsite, ideally adapted to the transit workforce Primary care centers Disease management and health care directed at your workforce's needs Vendors for health risk appraisals and other health evaluations Targeted data collection and reports to build your case and track success Behavioral health vendors (e.g., Employee Assistance Programs, work-life) Services for specific problems identified Local health and wellness consultants Programs tailored for your situation Local and state government: Department of Health Training materials, workshops, special events Community organizations Social service opportunities Area transit agencies Shared experience, partnering on developing a transit-specific program Local business community and nearby businesses Support for developing healthy food choices, exercise areas, and other health-friendly local changes National agencies: CDC, NIOSH Training, research, materials Educational and research institutions: universities, hospitals Partners in identifying and addressing workplace health issues, in a controlled research collaboration Health promotion associations (Wellness Council of America)
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27GETTING STARTED contributes incentive items; several transit agencies have received public grant funds from local, state, or national sources. Some transit agencies explicitly commit the savings derived from the WHPP activities to supporting and expanding the program.
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28 Program Name Agency Worksite Health Protection and Promotion Program Program Year 2013 Mission Statement The mission of the WHPP program is to improve employee health and wellness, improve morale and work productivity, and reduce health care and other related costs by building a positive workplace health culture and establishing and maintaining activities, policies, and environmental supports that foster a healthy workforce. Long-term Goals -- Health, Safety, and Wellness Long-term Goals -- Work Organization and Environment Improve employee health, safety, and wellness, including reduce CDL medical disqualifications and bus operator MSDs by 20% per year.
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29GETTING STARTED Gold Award for Bus Security in 2013. Typically, cost outcome savings from sustained individual health risk factor reduction are seen in the long term.
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30 TOOLS + RESOURCES Workplace Culture Assessment Safewell Practice Guidelines. An Integrated Approach to Worker Health.
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31GETTING STARTED Chapter Background Baicker, Katherine, David Cutler, and Zirui Song. Workplace wellness programs can generate savings.
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33BUILDING THE TEAM Chapter Building the Team: Coordinating Health Protection and Promotion CHAPTER MAP TAKING THE LEAD The organization designates dedicated staff to coordinate and implement the workplace health protection and promotion program. • Identify an onsite staff person with WHPP knowledge and skills.
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34 CHAPTER MAP (continued) WHPP COMMITTEE The organization sets up and supports a group to take action on workplace health protection and promotion.
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35BUILDING THE TEAM Employees' health is important to all areas of a transit organi- zation. Despite this, in the TCRP F-17 Bus Operator Health, Wellness, and Retention survey, less than a third of the transit agencies said that their programs used resources from or influenced other departments or programs.
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36 Respondents realized that better coordination across departments would be valuable, but they typically did not take advantage of their available resources to make that possible. Many described organizational silos, with the WHPP program isolated from important decision makers, sources of information, and the operating staff.
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37BUILDING THE TEAM Dallas Area Rapid Transit Wellness Program: Building the Team Dallas Area Rapid Transit (DART) is a good example of how an agency can make chang- es within a program to bring people together and start a team.
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38 DESIGNATING DEDICATED STAFF continued A small agency contracts out the wellness coordinator position. It reports increased participa- tion due to fewer concerns about confidentiality and the coordina- tor's more flexible schedule.
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39BUILDING THE TEAM in the program should help integrate it into the workplace culture, policies, and procedures. Identify organization partners: Resources could be people who can bring a needed skill set to the program or departments that can develop products and activities to be included in the program.
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40 FIGURE 2.2 WELLNESS PROGRAM COMMITTEE PROJECTS DEVELOPMENT: AN AGENCY EXAMPLE The 2012 Wellness Committee Project plan was developed to support Wellness initiatives. Each project should state what is proposed for the 2013 Wellness Program.
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41BUILDING THE TEAM FIGURE 2.2 WELLNESS PROGRAM COMMITTEE PROJECTS DEVELOPMENT: AN AGENCY EXAMPLE NUTRITION Project -- Nutritional Health Assessment Project Details: Project plan should include suggestions to find out why good nutrition and a balanced diet are not being achieved by the majority of employees. PRODUCTS Project -- Select Threshold Prizes and Kick-Off Items for 2013 Project Details: Provide suggestions for Wellness Program products that will help employees become healthier.
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42 OPERATIONS MANAGEMENT INVOLVED IN PLANNING In a large western agency, Division Manag- ers actively participate in their division-based Health and Wellness committees. While this is a requirement, it also helps them influence and tailor activities to limit any conflicts with operational demands.
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43BUILDING THE TEAM Labor Support Union leadership can effectively influence policies, programs, and front- line workers. Union input and opinions are valuable to the members, and the union is a forum for important concerns and information about front-line worker health.
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44 Maintain communication with leadership: If union designees are selected for the WHPP committee or other program roles, they should have regular contact with the elected leaders to make sure that support and input continue. Union representatives sitting on committees and involved in program plans and activities should communicate all program progress (or failures)
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45BUILDING THE TEAM FIGURE 2.3 COMMITTEE CHARTER: TRANSIT AGENCY EXAMPLE PURPOSE The 2012 Wellness Committee will focus on the program initiatives of the current year. MEMBER ESTABLISHMENT Membership on the committee is voluntary and shall be established by written invitation and acceptance by December 31 of the previous calendar year.
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46 COMMITTEE EXAMPLES The 14-member wellness committee represents all departments, with at least three transit operators. The committee charter provides members details about the meeting schedule and the roles and responsibilities of the members.
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47BUILDING THE TEAM Plan ahead to make meetings effective: A focused agenda that is sent to team members in advance will allow time for review and sugges- tions, and to collect more information from the field if needed. Minutes should be kept and circulated after each meeting to confirm next steps and actions items and document program progress.
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48 Provide champions and ambassadors with schedule flexibility: Management should schedule paid release time for champions to partici- pate in and promote WHPP program activities and events. The champi- ons are the face and the boosters of the program, so it is important that they have the flexibility to actively support and promote the program.
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49BUILDING THE TEAM Find out what data is available and ask for data t h a t you need: When partnering with health insurance vendors, talk to them about the kinds of data that will help target your WHPP program strategy and activities. Define a consistent schedule for information to be made avail- able to you, the contact person that the data should be released to, and how to discuss any changes to the data that is to be provided.
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50 Promote use of e x i s t i n g vendor programs: Useful examples of specialized vendor programs include HRAs for high-risk individuals, online health coaches, and onsite or mobile health services. During the F-17 research project it became clear that employees and even WHPP program staff are not always aware of the resources that are available.
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51BUILDING THE TEAM FIGURE 2.5 QUESTIONS TO ASK VENDORS Customer Service How quickly are questions answered? How much does the vendor support implementation and delivery process?
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52 TOOLS + RESOURCES Who is going to take the lead? Partnership for Prevention (2001)
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53SETTING TARGETS Chapter Setting Targets: Effective Transit Health Protection and Promotion CHAPTER MAP SETTING PRIORITIES The organization establishes what matters and what can be done with available resources. • Use planning and needs assessment data to define program targets to match the organization's strategic goals.
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54 Bus operators and other transit workers experience some of the highest rates of health problems of any industry, as discussed in the introduction. There is not complete agreement on what the biggest problems are: As shown in Figure 3.1, agencies in the F-17 survey consistently reported the top health concerns of bus operators to be chronic diseases and musculoskeletal problems, followed by achieving healthy behaviors and general wellness.
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SETTING TARGETS Edmonton Transit System: Moving Toward Integrated Health Protection and Promotion A key element in transit workplace health protection and promotion is the range of contributors to operator health. Edmonton Transit System (ETS)
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56 avoiding illness. But to protect transit workers' health, organizations must also acknowledge and address contributing factors in the work environment.
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57SETTING TARGETS Use planning and needs assessment data to define program targets that match the organization's strategic goals: Target priority should be based on an assessment of the number of operators affected and how severe the impact is on worker health, on organizational success, or on finances. Tool 3.1 can help you prioritize your targets by comparing this information.
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58 TOOL 3.1 SETTING PRIORITIES Health problem Number of How severe How hard will it Priority Notes operators is the impact be to achieve im- affected (on health, provement? operations, finances)
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59SETTING TARGETS A Comprehensive Health Risk Focus Extensive research and the practical experience of agencies, bus operators, and health care providers demonstrate how closely connected the individual, the organization of work, and the home and work environments are when it comes to common health problems. An effective WHPP program uses this evidence to establish a comprehen- sive approach.
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60 gyms, walking trails, showers, and bike racks. These activities are all parts of an effective WHPP program, but they do not reduce the occupational components of risk.
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61SETTING TARGETS a small weight loss can improve insulin response and increase energy. Improving access to healthy food at work can help control the precur- sors to heart disease and diabetes and improve sleep.
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62 REDUCING CONFLICT BETWEEN OPERATIONS AND WHPP ACTIVITIES One agency, recognizing that front-line operator involvement is a challenge given the work schedules of the operators, collects operator feedback through a comment box in the fitness room and satisfaction forms following activities. Program planners make an effort to schedule activities to Figure 3.3 shows how you can apply this information to your health concerns and targets, as explained in detail in the Practitioner's Guide introduction.
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63SETTING TARGETS Where you start filling in the map does not matter -- you may know people have a health risk and want to explore what impact it might have or how you could limit its effects, or you might have an organizational issue such as commercial driver's license (CDL) disqualification and want to work out what is contributing to it.
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64 workplace health promotion on an ongoing basis. Figure 3.5 lists the intervention methods that the Task Force has determined to be reliable.
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65SETTING TARGETS FIGURE 3.5 TASK FORCE ON COMMUNITY PREVENTIVE SERVICES RECOMMENDATIONS AND FINDINGS INTERVENTIONS TO PROMOTE SEASONAL INFLUENZA VACCINATIONS AMONG NON-HEALTH CARE WORKERS Onsite, Reduced Cost, Actively Promoted Vaccinations Recommended 2008 Actively Promoted, Offsite Vaccinations Insufficient Evidence 2008 ASSESSMENT OF HEALTH RISKS WITH FEEDBACK (AHRF) TO CHANGE EMPLOYEES' HEALTH AHRF Used Alone Insufficient Evidence 2006 AHRF Plus Health Education with or without Other Interven- tions Recommended 2007 PREVENTING CHRONIC DISEASE Skin Cancer Prevention: Education and Policy in Outdoor Occupational Settings Insufficient Evidence 2002 Diabetes Prevention and Control: Self-Management Educa- tion at the Worksite Insufficient Evidence 2000 Obesity Prevention: Worksite Programs to Control Overweight and Obesity Recommended 2007 PROMOTING PHYSICAL ACTIVITY Point-of-Decision Prompts to Encourage Use of Stairs Recommended 2005 Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities Recommended 2001 Smoke-Free Policies to Reduce Tobacco Use Among Workers Recommended 2005 INCENTIVES AND COMPETITIONS TO INCREASE SMOKING CESSATION Incentives and Competitions when Used Alone Insufficient Evidence 2005 Incentives and Competitions when Combined with Additional Interventions Recommended 2005 Source: www.thecommunityguide.org/worksite/index.html, accessed May 6, 2013
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66 BEST PRACTICE The program planning and content addresses transit-specific risks, exposures, and conditions. Transit-Specific Programming There are many excellent health promotion packages available from local or state health departments and nonprofit health groups, and WHPP program managers may find it efficient to adopt generic health information and activities.
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67SETTING TARGETS Health Protection and Promotion Targets and Transit-relevant Practices FIGURE 3.6A Goal: To help diagnosis, treat, and manage health problems Objective Approach Best-Practice Examples Help workers identify health problems early Health risk assessments and supportive follow-up Health professional consults Screening HRA with follow-up from health system -- may be coordinated by health plan Schedule a nurse at locations monthly to answer questions confidentially Improve retention and availability CDL concerns (high blood pressure, diabetes, sleep apnea) Arrange with health plan to provide full coverage and waive copays for CDL-related health issues Campaign of CDL-supportive health promotion activities and rewards participants who requalify Improve treatment Educate physicians about how work affects wellness and health decisions Work with health plans to identify operator health issues and share with care providers Hold meetings to discuss treatment implications of diuretics with plan physicians Enhance access to care Screenings and care provided on paid time or at the workplace New York State law requiring time off for mammograms and prostrate screening publicized by employer Mobile MD allows operators to schedule physician visits Arrange for a mobile dentist at locations Prevent infectious diseases Decrease illness Decrease transmission at work Flu vaccine provided at work Accommodating sick leave policy does not penalize ill workers or encourage coming to work ill (Department of Homeland Security recommendation)
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68 FIGURE 3.6B Goal: To improve safety and health at work and at home Objective Approach Best-Practice Examples Vehicle safety Safe driving Investigate red light run-throughs and other infractions as indicator of schedule problem Left hand turn training Driver safety training and refreshers discuss car as well as bus safety Winter driving program Noise and hearing Screening, diagnosis, and treatment Screen at health fairs and special outreach programs with vendors, for employees and family members Training and information Work and home exposures are addressed in training Hearing protection provided for use at home Comprehensive hearing protection program Screening, follow-up and protection provided for all workers exposed at or above 85 dB Reduce noise at work Improve maintenance practices to limit bus noise Include internal and external noise specification in bus design and procurement Shield operators and others from noisy maintenance practices Chemical exposure Eliminate or reduce toxic chemical exposure Training on material safety data sheets and labels Recycling and waste disposal programs collect home waste Worksite green cleaning program Mental Health Improve mental health, treat disease, and accommodate workers Canadian workplace standard covers comprehensive approach to integrate prevention, diagnosis, treatment Substance use Eliminate illegal drug use WHPP program supports and promotes Union Assistance Program and Employee Assistance Program Eliminate tobacco use (smoking, snuff, and chew) No smoking policy applies to workplace and events Tobacco cessation support programs, including patches Tobacco cessation incentives Referral to health plan, community groups, or health department for tobacco cessation support Promote safe alcohol use "Driving Buzzed Campaign" around holidays and Super Bowl reminds drivers how a little alcohol can have a large impact No alcohol at agency or union-sponsored events
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69SETTING TARGETS FIGURE 3.6C Goal: To improve healthy food access and choice Objective Approach Best-Practice Examples Nutrition education Illustrate relevant healthy food choices Explain the impact of food choice on health Provide information about food timing and insulin response/discourage night-time eating Develop nutrition programs for transit workers Hold nutritional workshops that focus on cooking in a culturally relevant way Nutrition coach available to respond to questions Recipes and healthy food promotion in newsletters Improve food access at locations Provide and subsidize healthy food choices in vending machines, cafeterias Subsidize healthy food in machines and cafeteria Help operators carry healthy food Make it easier to carry healthy food Provide healthy bag lunch options in cafeteria in early morning so operators can carry them on route In bus-cab design process, provide space to store food and other personal items (discussed in the development of the European "Recommendation for a code of practice of driver's cabin in line service buses") Improve food access on routes Identify healthy food outlets (stores, restaurants, and trucks)
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70 FIGURE 3.6D Goal: Increase physical activity Objective Approach Best-Practice Examples Improve individual exercise opportunity Make exercise opportunities available for all work schedules Bicycle loan program Hula-hoops and jump ropes onsite Exercise DVDs and a player are freely available so people can fit their exercise in Identify safe and interesting exercise and walking circuits at the workplace and stopover areas Encourage group activity Provide access to classes, gym, and coaches onsite and within the work schedule Gym with trainer 4 days/week at each base 24-hour access to gym Popular exercise classes are provided by a motivated champion Walking clubs are run by operators to match schedules, swing shifts, etc. Make exercise part of the regular day Identify and take natural opportunities -- stairs, along the route, house, or yard Stair access and stair competition (but many transit buildings are not multilevel, and security concerns can block stair access)
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71SETTING TARGETS FIGURE 3.6E Goal: Improve ergonomics and reduce musculoskeletal disorders Objective Approach Best-Practice Examples Improve work environment Driver's seat and controls Vibration Safety team involved in pedal and wheelchair seats redesign Wellness, operations, and maintenance redesigned control toggle based on tendinitis cases. Operators and ergonomists worked together to develop improved seat design A peer assessor observed operators while they drove, and provided support and input about adjusting equipment and working more comfortably Workstation assessment of operators with MSDs or concerns by trained ergonomist; shared with others and used in training Improve work practices Assess and improve how tasks are done Signs, mirrors, windows Wheelchairs Maintenance An ergonomist evaluated work processes, and used ergonomic assessment to produce manual of good practices for operator tasks.
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72 FIGURE 3.6G Goal: Eliminate or reduce the impact of hazardous and stressful working conditions Objective Approach Best-Practice Examples Develop coping skills Public work Passenger interaction Screening and recruitment alert applicant to intense public contact Classes on public interaction, including "Reality training" developed to help operators prepare for customer conflict situations Create contact points for WHPP Provide access despite solitary work Telephone health consults and coaching provided by phone in addition to work locations to enhance use by mobile workforce Schedule routes to reduce stress Identify and correct problem schedules Informally, schedulers at various agencies reported including restroom access time and looking at routes that operators bid out of to adjust schedules Eliminate stressors Restroom access Establish policy to assure access to convenient, clean, safe restrooms Limit trauma Policies that protect workers from trauma after an accident or assault Comprehensive workplace violence program includes treatment and support for operators involved in accidents or assaults Find and eliminate hazards Proactive safety plan Confidential near-miss reporting system Inspections to include road hazards as well as vehicle safety and onsite Be realistic about the results you expect: When selecting the components and activities to make up your program, you may find success with methods that have not been proven scientifically. Still it is best to choose activities that will reasonably achieve your goals.
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73SETTING TARGETS FIGURE 3.7 MATCHING ACTIVITIES TO GOALS AND OBJECTIVES: AN EXAMPLE USING PHYSICAL ACTIVITY Goal: To increase activity among bus operators Sample Description Timeframe Measurable Objective 1 50% of operators exercise one or more times a week Jan-Dec Measurable Objective 2 25% of operators participate in work-based exercise Jan-Dec Planning Locations Activity 1 Identify safe, attractive walking area around each base Jan-Feb Activity 2 Contract outside health center for family pass Jan Activity 3 Provide hoops, bands, and weights for on-base activity September Programming Participation Activity 1 Weekly walking group April-Oct Activity 2 Family exercise passes Jan-Dec Activity 3 Lunchtime exercise class Nov-Mar Summary According to the Senior Medical Officer of NIOSH's Total Worker Health™: It is not enough for all of our health efforts in the workplace to be focused only on individual behavior change programs. These are expensive, time-consuming, and often have limited success.
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74 TOOLS + RESOURCES Driver Health Spotlight on Sleep Apnea. The Federal Motor Carrier Safety Administration (FMCSA)
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Chapter Implementing and Integrating: Balanced Workplace Health Protection and Promotion CHAPTER MAP• AN INCLUSIVE RANGE The WHPP program offers varied activities and resources. • Set up activities to engage the range of needs and interests of the workforce.
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76 I CHAPTER MAP (continued) TRAINING SUPPORTS THE PROGRAM Training is designed to promote the program goals, not just deliver information, and is integrated into other agency training.
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77IMPLEMENTING AND INTEGRATING Orange County Transportation Authority (OCTA) : Organizational Support OCTA aims for transit-specific implementation of its WHPP program by addressing physical activity and health education along with work conditions: • Scheduling: recovery time built into the schedules.
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78 BEST PRACTICE The WHPP program offers varied activities and resources. An Inclusive Range A successful program provides a wide enough variety of activities to interest the range of people in the organization, with differing health needs and varied ability and interests.
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79IMPLEMENTING AND INTEGRATING Include workplace inspections that look at occupational health and safety as well as the health-promoting environment. Figure 4.1 lays out many of the activities reported by US and Canadian transit agencies in the F-17 study, and by other key informants.
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80 FIGURE 4.1 F-17 INDUSTRY PRACTICES Health target Activity Disease management and prevention • "Ask A Nurse": blood pressure checks, stroke risk assessment, and health questions. • "Tri-Fit Summer Tour" ( mobile biometric testing and incentives)
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81IMPLEMENTING AND INTEGRATING Health target Activity Medical self-care and medication management • Blood donation & typing • Health coach • Holistic wellness vendors • Registered nurse on site • Wellness consultant lunch and learns • Wellness mobile: biometric screening, health risk assessments, and telephone follow-up Mental health • Counseling service for employees and family members • Onsite EAP training • Peer support for mental health following accidents or assaults Nutrition • 30 days nutrition training • Fresh fruit and vegetable market • Organic food display at health fairs • Healthy cafeteria and vending machine programs • Onsite nutritionist for consults and advice • Subsidized access to healthier food • Healthy cooking demonstrations • Healthy menu coupon program Responsible alcohol use • Drunk and buzzed driving campaigns • No-alcohol policy at agency events Safety • Reduce distracted driving campaign • Monthly injury prevention and disease management presentations • Onsite CPR Training • Walk-around representatives identify and help resolve safety and health hazards • Recovery time built into the schedules • Slip and fall campaign • Safety training enhanced to emphasize health and wellness, and shift work • Fatigue Smoking/tobacco product cessation • No smoking policy • Tobacco cessation class for employees and family Stress management • Incentive contests for stress management • Stress management seminars • Stress screening from insurance provider Threat assessment and management/violence prevention • Safety rules on bus operator/customer interactions to enhance operator safety • Fare policies to eliminate conflicts • Workplace Violence Policy • Comprehensive workplace assault program • Training on operator-customer conflict minimization • Bus cab barriers Weight management • Weight loss challenges • Weight loss programs (onsite, offsite, and online)
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82 ACCESS TO FITNESS One agency has two onsite 24 hour fitness centers with free personal training and health assessments Another has a trainer available at the fitness center during lunch hours four days a week, providing individual assessment and training plans along with nutritional advice. The trainer provides help to employees to achieve a safe blood pressure before participating in demand- ing activities.
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83IMPLEMENTING AND INTEGRATING FIGURE 4.2 INVOLVING FAMILY MEMBERS: TRANSIT EXAMPLES UTU-LACMTA's wellness program has initiated a pilot six-week family exercise plan. Employees who commit to exercising weekly receive a basket full of exercise aids and encouragements, paid for by the group health vendor: basketballs and soccer balls, fitness bands, MP3 speakers to allow the family to exercise to the same music, a jump rope that counts calories, a paddle ball that doubles as a chess and backgammon board, sticky mitts and cloth balls to let the little ones join in.
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84 A popular weight loss program geared toward the work e n v i r o n m e n t was strongly supported in many transit workplaces. But they all reported that participation was typically limited to office staff and downtown locations.
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85IMPLEMENTING AND INTEGRATING comfortable with hard copy information and reporting, others prefer electronic means. Despite the advantages, technology can be a barrier to effective program implementation.
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86 EXAMPLES OF ELECTRONIC OUTREACH One agency runs its point- based incentive program to encourage healthy behavior, learning, and fitness activity via a web-based portal. In an online wellness program tracker, each participant provides data about five broad categories: physical fitness, weight management, stress management, tobacco cessation, and related wellness areas.
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87IMPLEMENTING AND INTEGRATING Training Supports the Program Education and training underpin most WHPP activity and are key to program success. In addition to health information workshops, WHPP should be integrated into the organization's other training practices, such as new hire orientation, safety classes, and benefits open enrollment periods.
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88 BEST PRACTICE The organization utilizes equitable, nondiscriminatory incentives that encourage active involvement and a healthy workplace culture. Equitable Incentives Incentives for health promotion activity, reported by 70% of transit workplaces respondents, include cash prizes, health-related merchan- dise, health club memberships, reduction in health insurance premiums or copays, and recognition or time off.
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89IMPLEMENTING AND INTEGRATING The near-term goal is to increase participation in an effective program. An incentive structure that looks punitive or unfair can limit participation.
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90 At one agency, the vendor agreed to lower the insurance premium when employee partici- pation goals are achieved for activities such as gym member- ship, aerobics classes, cardio workout, nutri- tionist visits, and smoking cessation support groups. As a result, the health premium for all employees has been reduced by 2% for the upcoming year.
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91IMPLEMENTING AND INTEGRATING from policies to promote occupational safety and health and other factors that protect and enhance employee health. The strategies must include appropriate training and an effective communication plan to share information among all levels of the organization.
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93EVALUATING Chapter Evaluating: Return on Investment and Ongoing Improvement CHAPTER MAP• EVALUATION FRAMEWORK The organization establishes a comprehensive workplace health protection and promotion program evaluation plan. • Collecting baseline measures.
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94 T CHAPTER MAP (continued) COST-BENEFIT AND RETURN ON INVESTMENT Cost savings are quantified to show how the program supports the bottom line.
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95 Capital Metropolitan Transportation Authority: An Example of Program Evaluation and Return on Investment In the early 2000s, Capital Metropolitan Transportation Authority (Capital Metro) was confronted with record high health care costs, especially among operators, and greatly increased absenteeism.
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96 plish something important?
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97 FIGURE 5.1. SAMPLE PROGRAM GOALS AND MEASURES Program Goals Type of Measures Detailed Measures Measures Increase fitness/ health Process Program Reach # eligible, # participating, # successful, # maintaining Implementation measures (# courses, meetings, targets hit)
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98 BEST PRACTICE The organization establishes a comprehensive workplace health protection and promotion program evaluation plan. Evaluation Framework Program evaluation is a complex, multilevel challenge.
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99EVALUATING Baseline measures can also be used to describe the current level of program activities and allow measurement of the program's progress over time, such as the number of new physical activity classes offered to employees, the frequency of worksite health and safety inspections, or the establishment of a new health benefit. Involve stakeholders in evaluation: A comprehensive evaluation initia- tive involves many actors.
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100 engage potential agents of change who may start by opposing the program. At the same time, use caution when engaging with critics: there may be conflicting interests or motives that can undermine your program, unrelated to the program itself.
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101EVALUATING tional priorities. As part of the approach, consider collecting data on the work environment, organizational policies, and individual health risks into a coordinated system.
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102 Number of employees with targeted health issues by division, job title, and other groups Per case and total treatment cost for a specific health issue Trends in health problems or health care use Groups of employee at particular risk -- by age, title Health insurance premiums compared to similar organizations or groups -- for example, statewide Health insurance premium changes over time, and compared to others Target cost areas that could be addressed to reduce premiums Actions to be taken to reduce premiums As an active partner in an agency's WHPP program, one large health plan provided sophisticated and flexi- ble data reports. A nearby agency, with the same provider, had not negotiated a similar arrangement and was not aware it was possible.
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103EVALUATING Process Measures Ongoing evaluation supports continuous improvement by helping you see how well you are implementing your activities even before they have had a measurable impact. Processes to measures include the steps and activities taken in implementing a program and the outputs generated, such as the number and type of educational materials for a stress management class that are developed and given to employees.
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104 FIGURE 5.3 SAMPLE TASK TRACKING TOOL Target Date Tasks Description Lead Support Completion Completed Status Operator workstation assessment and training Workstation assessment and training of operators with MSDs or other concerns by trained ergonomist OSH Coordinator Operations 3/31/2013 3/15/2013 Completed Prepare for walking clubs Identify safe, attractive walking area at each base Base Champions Committee 3/31/2013 3/13/2013 Completed Family pass program centers Contract outside health center for family pass Wellness Manager 2/1/2013 4/1/2013 Completed Family pass program Register families HR Coordinator Shop Stewards 4/1/2013 Ongoing Base exercise workshops Provide hoops, bands, and weights for on-base activity Trainer Purchasing 9/15/2013 Ongoing FIGURE 5.4 SAMPLE PARTICIPATION AND REACH TRACKING TOOL % of # of % of Eligible Partici- Partici- Employ- Eligible # of pants pants ees Cost Employ- Partici- Reach Reaching Reaching Reaching Total per Par- Activity ees pants % Goal Goal Goal Goal Costs ticipant Operator Workstation Assessment 1350 150 11.1% Complete full assessment and training 130 86.7% 9.6% $9000 $60 Walking Club 1350 210 15.6% Walking five miles per week 100 47.6% 7.4% $5000 $24 Base Exercise Workshops 1350 350 25.9% Attend at least one workshop 150 42.9% 11.1% $5000 $14 Family Pass 1350 250 18.5% Sign up 250 100.0% 18.5% $9000 $36
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105EVALUATING Use process evaluation to make time-sensitive adjustments: Target the identified bumps and barriers that may limit your program effectiveness to improve your activities selection, scheduling, communications, and other areas, Convene the WHPP committee or even the top-level planning group to review the analyses, interpret the findings, and discuss what actions to recommend. A summary of the assessments should be prepared and shared before this meeting.
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106 Evaluation and tracking activities in the F-17 case study sites • Capital Metro: The program tracks an extensive list of measures to gauge program outcomes against yearly goals, beginning with program participation and penetration rates. To calculate gym participation, badge reports are provided by security and logged into a customized spreadsheet.
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107EVALUATING Impact and Outcome Measures Important as it is to be sure you are doing what you planned, and to make mid-course corrections as needed, what your organization cares about most is, "What difference did it make? " Impact measures are the areas you target for change because they can lead to a healthier person or environment, such as knowledge, attitudes, behaviors, skills, or policies.
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108 FIGURE 5.6 TYPES OF IMPACT MEASURES Metric Definition Changeability Example of Change Knowledge Acquired facts and information Easy Understanding decibel levels and hearing loss Attitudes How someone feels about a topic Moderate Support seatbelt use Skills Ability to carry out a specific action Difficult Learn to use a pedometer Behaviors Actions someone takes part in Difficult Eating five fruits or vegetables most days Vigorous exercise 30 minutes 3-4 days per week Impact metrics can be tracked using methods such as: • Pre- and post-event tests or surveys -- used to measure changes in attitude, knowledge, and current eating, physical activity, and mental health status from an initial assessment to completion of a program or campaign. Could be group or individual changes.
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109EVALUATING These outcomes, like the common target areas of WHPP programs, can fall into three major improvement categories: health, work conditions and environment, and operations and productivity. Associated cost savings can be identified within each area.
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110 Figure 5.7 shows an example of using the Planning, Evaluation, and ROI Template to track injuries. FIGURE 5.7 EXAMPLE OF OCCUPATIONAL INJURIES TRACKING Change Injuries in Inju- # Injuries per per 1,000 # ries per Number Employ- 1,000 Number of # Employ- Differ- 1,000 Type of of Injuries ees - Employees - Injuries – Employees ees - ence Employ- % Injury Before Before Before After After After in Injuries ees Change Neck Strains 5 1350 3.70 4 1359 2.94 -2 -0.76 -20.5% Slips and Falls 8 1350 5.93 7 1359 5.15 -3 -0.78 -13.1% Hip Strain 5 1350 3.70 3 1359 2.21 -3 -1.50 -40.4% Back Strain 10 1350 7.41 8 1359 5.89 -4 -1.52 -20.5% Knee Injury 4 1350 2.96 2 1359 1.47 -3 -1.49 -50.3% Total 32 1350 23.70 24 1359 17.66 -14 -6.04 -25.5% 3.
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111EVALUATING the attendance policy. WHPP programs that boost operator health and include policies to encourage responsible sick leave not only help agencies achieve the desired performance, but also relieve the pressure on operators to choose between coming to work sick and accumulating absent days.
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112 FIGURE 5.8 HEALTH-RELATED TURNOVER Num- # Number # Employ- Loss ber of # Employ- Loss Differ- % Im- of Exits - ees - Be- Rate – Exits - ees – Rate - ence in Change in prove- Exit Reason Before fore Before After After After Exits Loss Rate ment Work Stress 5 1350 0.4% 3 1359.0 0.2% -2 -0.1% 40.4% Medical Disqualification 7 1350 0.5% 3 1359 0.2% -4 -0.3% 57.4% Work Schedule 4 1350 0.3% 4 1359 0.3% 0 0.0% 0.7% Other Health Issues 3 1350 0.2% 2 1359 0.1% -1 -0.1% 33.8% Total 19 1350 1.4% 12 1359 0.9% -7 -0.5% 37.3% 100 80 57% 60 40 40% 34% 37% 20 0 Work Stress Medical Disqualification 1% Work Schedule Other Health Issues Total
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113EVALUATING Figure 5.9 provides examples of data sources for the impact and outcome metrics of transit WHPP programs. FIGURE 5.9 EXAMPLES OF WHPP METRIC SOURCES Category Sources Health Status or Behavioral Changes Smoking: class graduates, nicotine replacement therapy claims, and tobacco- free cash incentive figures Exercise: gym participation, challenge participation, 10K steps programs Biometrics Aggregate Health Risk Assessment (HRA)
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114 BEST PRACTICE Cost savings are quantified to show how the WHPP program supports the bottom line. Cost-Benefit and Return on Investment For many businesses, the key indicator of WHPP program success is costs to benefit ratio or return on investment (ROI)
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115EVALUATING supporting this Practitioner's Guide is simplified and streamlined. Although the template allows you to enter a wide range of variables, you should focus on evaluating the items that are most pertinent and that are reflected in your goals and objectives.
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116 FIGURE 5.10 SAMPLE COST-BENEFIT AND ROI SUMMARY Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Total Program Benefits -- Overall $350,773 $415,909 $434,000 $490,000 $510,000 $2,200,682 Total Program Benefits -- Due to WHPP Program $272,380 $330,357 $332,000 $430,000 $442,000 $1,806,737 Total Program Costs $210,000 $239,000 $220,000 $240,000 $220,000 $1,129,000 Net Program Benefits -- Overall $140,773 $176,909 $214,000 $250,000 $290,000 $1,071,682 Net Program Benefits -- Due to WHPP Program $62,380 $91,357 $112,000 $190,000 $222,000 $677,737 ROI Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Annual ROI Achieved -- Benefits Overall 67.03% 74.02% 97.27% 104.17% 131.82% 94.92% Annual ROI Achieved -- Benefits Due to WHPP Program 29.70% 38.22% 50.91% 79.17% 100.91% 60.03% Annual ROI Goal (Optional) 50.00% 70.00% 90.00% 100.00% 120.00% N/A Goal Achieved?
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117EVALUATING $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 0 Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Benefits Overall Benefits Due to WHPP Program Program Costs FIGURE 5.11 ANNUAL AND CUMULATIVE PROGRAM COSTS VS. BENEFITS 140% 120% 100% 80% 60% 40% 20% 0% Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Annual ROI Achieved -- Benefits Overall FIGURE 5.12 ANNUAL ROI ACHIEVED Annual ROI Achieved -- Benefits Due to WHPP Program
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118 BEST PRACTICE The organization communicates the impact of the program. Data-Driven Ongoing Improvement Your ROI calculations ideally will show that it is worth running your program and even expanding it.
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119EVALUATING Summary Calculating costs and showing a strong return on investment is not easy. Some of the very impressive results shown in the literature go far beyond the typical ROI found in most business practice.
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120 Cost-Benefit and ROI SAMPLE WHPP COST-BENEFIT AND ROI CALCULATORS Tool Description Source Link Health and Work Performance Questionnaire (HPQ) An internationally supported tool for investigating health care costs and business decisions, indirect costs of untreated and under-treated employee health problems, and ROI of employee health benefits and programs.
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121EVALUATING Tool Description Source Link Alcohol Cost Calculator Online cost calculator that shows how common alcohol problems are in each sector, how many work days are lost due to alcohol problems, the extent of alcohol-related hospital and emergency room visits of employees and their families, and the costs of missed work days and health care of employees and their families. Center for Integrated Behavioral Health Policy, The George Washington University Medical Center www.
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122 Chapter Background Adams, T
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123CARRYING ON T Chapter Carrying On: Maintaining Effectiveness with Growth CHAPTER MAP• MAINTAINING Workplace Health Protection and Promotion is essential to the organization, not an extra. • Justify organizational support.
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124 Transit Workplace Health Protection and Promotion Roadmap Preparing the Organization and Making the Commitment • Culture of health and safety • Organizational needs assessment • Organizational resources • Meeting needs with resources Setting Targets in Transit Health Protection and Promotion • Setting priorities • A comprehensive health risk focus • Effective components • Transit-specific programming Building the Team • Taking the lead • Putting the team together • Management support • Labor support • Committee • Champions and ambassadors • Vendor integration Implementing and Integrating an Effective Transit Program • An inclusive range • Transit-specific implementation • Effective communications • Training supports the program • Equitable incentives Evaluation, Return on Investment, and Ongoing Improvement • Evaluation framework • Integrated data management • Process measures • Impact and outcome measures • Cost-benefits and return on investment • Data-driven ongoing improvement Maintaining Effectiveness with Growth • Maintaining • Growing • A realistic perspective FIGURE 6.1 WORKPLACE HEALTH PROTECTION AND PROMOTION PROCESS BEST PRACTICE Workplace Health Protection and Promotion is essential to the organization, not an extra. Maintaining Justify organizational support: As described in Chapter 1, on setting up the program, and especially in Chapter 5, covering evaluation and return on investment, you will need to keep making your case to the organization.
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125CARRYING ON United Transportation Union -- Los Angeles County Metropolitan Transportation Authority: Maintaining Excellence with Growth The UTU-LACMTA program in Los Angeles, described in Chapter 2, exemplifies how an agency can start with a pilot project in two locations and over time develop it into a comprehensive program that serves almost all job titles in one of the largest transit agencies in the country. Extensive union and management commitment, a skilled and respected lead, vendor support, and careful planning and evaluation have all contributed.
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126 COLLECTIVE BARGAINING LANGUAGE EXAMPLE Letter of Understanding re Wellness Program The parties discussed the benefit of an enhanced wellness program (including the potential to reduce employee injury and sickness) during the current round of bargaining.
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127CARRYING ON recommendations are likely to be revised over the next few years. The new Federal Transportation Administration oversight of transit agency safety management systems and training are expected to have an impact.
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128 organization and evaluating results will lead you to set new priorities with stakeholders. A comprehensive WHPP program can expand by covering more titles and supporting a wider range of organization priorities.
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129CARRYING ON Summary "Develop a "Human-Centered Culture." "Start small and scale up." "Eliminate recognized occupational hazards." "Make sure the program lasts." These elements of a Total Worker Health™ culture are tall charges for any organization. Public transit faces some of the highest rates of chronic disease of any workforce in the US, along with a schedule-driven system, expanding demand, and shrinking funding.
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Appendix A NIOSHTotal Worker Health™ Elements 130
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A National Institute for Occupational Safety and Health Initiative October 2008 Page 1 of 4 Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Wellbeing Introduction The Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Wellbeing is a resource document developed by the National Institute for Occupational Safety and Health (NIOSH) with substantial input from experts and interested individuals.
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October 2008 Page 2 of 4 Mid level supervisors are the key to integrating, motivating and communicating with employees. Program Design 4.
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October 2008 Page 3 of 4 12. Adjust the program as needed.
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October 2008 Page 4 of 4 Acknowledgments We appreciate the contributions of the following individuals who participated in the 2007 workshop leading to the development of this document: David Benjamin Amick, PhD, Scientific Director, Institute for Work & Health (Canada) Anderson, PhD, Vice President, Program Strategy and Development, StayWell Ron Goetzel, PhD, Vice President, Consulting and Applied Research, Thomson Healthcare Nico Pronk, PhD, Vice President, Health and Disease Management and Executive Director, Health Behavior Group, HealthPartners Bonnie Rogers, DrPh, Director, North Carolina, Occupational Safety and Health Education Center and Director, Occupational Health Nursing Program, University of North Carolina at Chapel Hill Martin Sepulveda, MD, Vice President, Global Occupational Health Services Health Benefits, IBM Seth Serxner, PhD, Principal, Mercer Health and Benefits Michael Silverstein, MD, MPH, Clinical Professor, Department of Environmental and Occupational Health Sciences, School of Public Health and Community Medicine, University of Washington Glorian Sorensen, PhD, MPH, Director, Center for Community-based Research, Dana-Farber Cancer Institute and Professor, Department of Society, Human Development, and Health, Harvard School of Public Health Laura Welch, MD, Medical Director, Center for Construction Research and Training Department of Health and Human Services Centers for Disease Control and Prevention National Institute for Occupational Safety and Health This document is in the public domain and may be freely copied or reprinted Disclaimer Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH)
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Appendix B Sleep Disturbance and Sleep Apnea for Transit Drivers 135
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Sleep Disturbance and Sleep Apnea for Transit Drivers Sleep problems lead to fatigue, irritability, and errors. Sleep debt can cause you to fall asleep briefly when you should be awake, even when driving.
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What can transit vehicle operators do about sleep disturbance? Establish the best possible sleep schedule: You need time to sleep enough between work shifts.
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Key Terms
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