NOTE: This document is provided for historical purposes only.
Presentation by Paula Bohr, Washington University School of Medicine
DR. RODGERS: Paula Bohr, who is a Ph.D. and is an occupational therapist whose practice in research interests focus on evaluation of workers and analysis of work tasks and assessment of work environments.
She received her B.S. in occupational therapy from the University of Kansas and her doctoral degree in industrial engineering from the University of Oklahoma. Dr. Bohr has served as consultant to businesses and industry. Currently she is overseeing implementation and evaluation of participatory ergonomics teams in health care.
She is a Director of the Occupational Health and Ergonomics Laboratory in Washington University School of Medicine, St. Louis, in the program in occupational therapy, where she serves as a faculty member.
I might just make a comment relative to this. If anybody has not had an opportunity to see what opportunities there are in ergonomics in the health care system, you have a real eye-opener coming to you. It is similar to construction and industries where you don't have much control over your workplace and the situation. So I am looking forward to hearing Paula's talk.
DR. BOHR: Thank you. I am excited to be here to talk about this project today, because we really have been surprised by a lot of our outcomes.
This project, funded through a cooperative agreement with CDC/NIOSH, is now in its second year. It is taking place in a large medical center that is a part of a larger health care corporation. The health care corporation has 16 acute care hospitals and 7 long term care facilities. And overall that system employs over 25,000 employees and 6,000 medical staff. So we are talking about a significant population of workers here.
They are going through the restructuring and the downsizing that is very typical in health care these days, and that is resulting in increased work loads for the workers in many of the departments.
My slides were on a handout. I am not sure that everyone got those, but if you are frantically taking notes, there are handouts around.
We targeted several groups in the hospital to look at implementing a participatory approach to ergonomics. We identified the groups because of the diversity of their hazards and also because of the educational backgrounds of the workers in those areas.
We also had to have willing participants, and we identified those participants in an intensive care unit, which was general medical intensive care, that had employees numbering around 50. We had a dispatch service which consisted of orderlies and transporters, and this was the group of individuals who were responsible for lifting and moving patients throughout the hospital and also for picking up blood samples and things from various patient rooms and going to the laboratories.
Our third group was clinical laboratory workers, and this was for the entire hospital, 450 workers in a variety of jobs.
We targeted the clinical laboratories because of the upper extremity risks that we were able to identify; the dispatch services because of the back and lower extremity problems that they were experiencing; and the intensive care nurses because of a variety of symptoms of unknown origin, back, upper extremity, lower extremity, a very mixed bag of complaints.
We developed teams, employee-management advisory teams, that consisted of four to six workers but had both worker representation and management representation. To those teams, the three of us who were involved with the project acted as technical advisors. We have an M.D. on the project who provided medical expertise; we have a certified ergonomist who is also a technical advisory; and I serve as the third technical advisor to those teams.
We started out with how in the heck do we train all of these people to do the jobs that we want them to do. We started looking at the literature and realized that many of the training sessions were very long and extensive, and that was not going to be possible for our population of workers. They were under time constraints. If we pulled too many workers out of one area for long periods of time, then we would have problems with coverage and getting the services provided in the hospital system.
So we were able to provide eight hours of training for the ICU and the dispatch teams, but our laboratory team could not get the work done and be out of the labs for more than four hours at a time. So we acknowledged that these were less than idea situations. We focused the training for these teams on team process and team-building kinds of activities because we thought that was more critical to the process.
We did provide some basic technical information to them as a part of the training, but we tended not to focus on detailed evaluation techniques and chose to provide that type of training in the context of the problems that they were identifying. I will talk about those in a few minutes.
We had videotaped many of the jobs, and we had the opportunity for them to do some actual hands-on analysis of the videotapes as a part of the training session.
The problem identification, initially we looked at all of our records, workers' comp, accident on duty logs, medical records, and did a record review. That was performed by the technical advisors to the teams.
We also had a process of sending out worker questionnaires. And the worker questionnaires had a number of components, including symptom reporting, and the psychosocial factors involved with the jobs. The symptom reporting, I will say we found very valuable in having three levels of reporting. First of all, did they experience discomfort by body part. If they did, how uncomfortable was it. And the third level was if they experience discomfort or pain, how much did it interfere with the performance of their job. And that was very useful information when we started looking at the problems.
We also relied on a lot of observation from the team members and the team members' measurements.
The observation and measurements really relied on training in context with the individual teams. For example, when our nursing group started looking at poor lighting in patient rooms, as technical advisors we took the light meters in, trained them how to use the light meters to do the measurements. And they took it from there and did a beautiful job. But we used that type of in-context training.
We did utilize some personnel with expertise in areas. We involved some of our safety people when we were looking at noise evaluations for all the alarms that were going off in ICU. So we did have access to them.
We provided each of the teams with a basic measurement kit. And that consisted of things like a camera, tape measures, goniometers, the little clicker counter instrument, but very basic kinds of tools for these kits. We provided those to the teams. And because they were available, the teams really have made good use of those kits.
The expensive pieces of equipment, like the Chatillon gauges, the sound meters, the light meters, we have available to those teams, but it is on a request basis. We didn't put them in the actual team's kit that they keep with them.
We have provided them in their training materials a notebook, forms or formats for looking at analysis. We provided those as guidance only. What we have found is that they really haven't used any of the forms that we thought were so wonderful and provided to them, but they have made their own forms and have actually been much more productive using their own forms than they would have using ours.
The problem really determined what type of data collection these teams did. The methods that they selected have varied with the teams and with the teams' expertise. I will mention those when we look at the problems, but they picked the methods that they were most comfortable with and that they thought would give them the best information.
From an engineering background, I questioned why are they doing that, why aren't they doing this, and it was very hard to sit on my hands and let them evolve this process. But what we found is that they didn't approach it the same way as an ergonomist would from an engineering perspective, but they came to the same conclusions. And their methods were much simpler than what we could have anticipated doing. I was ready to go do all the biomechanical analysis, and it wasn't necessary for the identification of the problems.
The worker groups tended to select the things that they knew would be accepted by their co-workers when they went out to make measurements. They knew whether or not they could take photographs or videotapes, and that played an important role.
The priorities were reached by group consensus. In some parts they were based on the number of workers who were impacted by that problem. They were based on the severity of the hazard as the team saw that severity. And they initially were based on the complexity of the problem defined and, as we have heard this morning, reaching for the low hanging fruit. That is basically what we did. We went for the simpler problems to get some success behind us, although we found one of our groups tackled their major problem and did a beautiful job first thing off.
The dispatch team: All of our teams have been productive in their work, but the dispatch team has probably been our outstanding team at this point. They identified problems first related to not having standard procedures for lifting and moving patients. They also identified the fact that there were inconsistent training procedures. Not all new workers were trained in techniques to lift and move patients.
They were using mechanical lift equipment either improperly or it was sitting in the corner because they didn't know how to use it properly. They were doing standing pivot transfers with patients under unsafe conditions, things like not having shoes or some kind of footing under the patient to move them. They were transferring in stocking feet and patients were slipping.
They also identified a problem with the lower extremity discomfort from their worker surveys. They did not identify that problem from injury rates, but the symptom surveys. The single, most reported complaint that the transporters had, was that they were having knee and foot and ankle problems. The team is now investigating that problem in terms of whether or not they need shoe requirements for these people who on average, they are estimating, may walk up to ten miles a day throughout the hospital on concrete floors.
They also had injuries from moving hospital equipment. This actually is quite a humorous issue. It was incidents such as running the gurney wheel over their foot when they were trying to put it on the elevator. The solution was simple in some ways, but the injuries were still happening.
The methods that this team used or relied on:
1) They relied heavily on interview of workers. This did tremendous things for developing the communication within that group. This group now has such a pride in working in the hospital system that we have really seen a morale boost, and especially now that they have done some of their problem solving. Other parts of the hospital and other hospitals are contacting them and wanting to know what their procedures are for lifting and moving patients. But a lot of that information they got from interviewing the workers.
2) They did do a lot of incident investigation. What did you do wrong with this procedure, that you ended up hurting your foot?
3) A lot of observation, and they were on target 99 percent of the time. I would be wanting to measure the angles, and they are going, "No, he is bending his knees too much." So it was much simpler than what I had envisioned the analysis to be.
4) They also reviewed the documentation of procedures, which they didn't have. They looked at equipment usage patterns and then they started evaluating mechanical lifts and other equipment that could be used.
The ICU team identified low lighting levels in patient rooms, noise from the alarms at the front desk, which were borderline up there with being out of compliance, uncomfortable computer chairs with no back supports (all of their record keeping was computer-based systems in the ICU), and potential injuries from lifting and moving patients. But the big area, and we are still struggling to define this with this group, is stress associated with ICU work.
This team employed some additional measures. They used many of the measures the dispatch team did, but they additionally added meter readings, both light and sound meter readings. They did workstation measurements, getting down with the tape measures and looking at computer work heights and that type of thing. They did a lot of photographing of work postures, because they really didn't believe, and their work force didn't believe, that they were using bad postures to lift and move patients or to change I.V. bags and that type of thing. So they did a lot of taking pictures, and that was really helpful for their analysis.
They evaluated a lot of seating options, actually got chairs in to look at, to evaluate. And with the stress issue, they found themselves doing a lot of literature review, which there's extensive literature out there but no real solutions. But we know there is a problem.
The laboratory team identified fatigue from prolonged standing on tiled floors, workstation discomfort in the transcription area, discomfort in sitting for performing laboratory procedures, poor body mechanics, particularly with the phlebotomists who are drawing blood, and poor design of laboratory areas that required awkward postures.
Additionally, they used worker evaluation of products, particularly anti-fatigue mats and seating options. They did cost benefit analysis of their equipment choices, and they did a wonderful job on that. They did do some detailed task analysis for some of the procedures with the help of the technical advisors. They used a lot of photography and videotaping. And they started looking for standards for laboratory equipment and procedures. And in some cases those do not exist.
So what we have found at this point, being that we are just starting into our second year of this project, we have seen significant decreases in low back symptoms among the ICU nurses and the orderlies. We have seen significant increases in time pressures for the laboratory workers. We have had approximately a 50-percent decrease in back injuries for the orderlies, and we have had an 88-percent decrease in lost days for the orderlies.
So we have had some significant changes, and it is a process that is working in the health care system at this point. The process will be expanding to go to those other facilities within the health care system.
Thank you.
DR. RODGERS: Thank you very much.
