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EMPLOYEE HEALTH SERVICE T ' IN SMALL PLANTS OCCUPATIONAL HEALTH SERIES No. 6 Edition of June 1955 Safety and Occupational Health. Bureau METROPOLITAN LIFE INSURANCE COMPANY HOME OFFICE: NEW YORK Pacific Coast Head Office: San Francisco Canadian Head Office: Ottawa aaiiMiaiinifrf rffrPTi EMPLOYEE HEALTH SERVICE IN SMALL PLANTS ---------------------------------f--------------------------------- Objectives and Program The purposes of an employee health service are to promote a condi tion of health and well-being that will be conducive to contentment and efficiency; to prevent the occurrence of illness whenever that is possible, and to shorten its duration and lessen its severity when it does occur; to prevent injury, poisoning, and other mishaps; to give care for occupational ailments and injuries for which the employer is legally responsible; to give emergency care for minor nonoccupational injury and illness. In addition to the benefits of improved morale and better industrial and community relationships, the employee health program actually reduces the costs of compensation, illness absence, and labor turnover. According to Dr. Kenneth C. Peacock, in Practical Problems of Em ployee Relations (Personnel Series No. 149, American Management Association, New York, N. Y. 1952): Hundreds of plants--totaling 1,200,000 employees--in which med ical departments have been established have been surveyed on a national basis. "Before" and "after" figures show universal profits averaging $3.50 to $5.00 per $1.00 spent on medical departments. J Tor example, in compensation the saving was 50 percent; in turn over, 30 to 50 percent; in absenteeism, 30 to 40 percent; in lost time, 80 percent; in accident frequency, -45 percent,, and in occu- . .. pational diseases, 63 percent. An effective employee health service is an integral part of business administration. Although the needs of individual companies vary, and 3 employee health services should be planned to fit those needs, in gen eral the program will include (but not necessarily be limited to) the following activities. Physical examinations 1. For all employees when they are hired. On the basis of the examination and the applicant's medical and employment his tory, the physician can recommend placement in a job which the applicant is able to perform. When this procedure is fol lowed the employee is protected against assignment to work which would put undue strain on him, and the employer is assured of the best use of the skills of his employees. 2. For all employees, including executives, at regular intervals, preferably annual, and at the time of transfer from one job .to another. 3. For employees whose work exposes them to potentially toxic materials or to unusual hazards, at appropriate intervals de pending upon the degree and nature of exposure. Findings of all examinations should be kept confidential and discussed only with the employee, who should be advised to consult his personal physician if his condition requires care or further study. On-the-job medical care 1. Prompt and efficient medical care of all injuries and ailments of occupational origin. When treatment is required that the health service is not equipped to give, the employee is referred to a specialist or to a hospital for care and, if necessary, re habilitation. 2. Emergency treatment of nonoccupational injuries and ailments. This often forestalls complications or more serious illness and also protects other employees from possible exposure to com municable diseases. For more than minor ailments, the employee is advised to consult his personal physician. When disability continues over an extended period, the em ployee health service keeps in touch with the employee, his family, and his physician. Home nursing visits may be arranged through the local visiting nurse association if the family needs --- and wants professional instruction and care. Health education and counseling 1. Personal contacts. When the physician and nurse see employees individually for physical examinations, for treatment, or for the purpose of excusing them from work because they are ill, the interview presents an excellent opportunity to discuss health and safety practices or personal health interests and problems and to assist in finding solutions to problems. On such occasions, the health service staff can counsel the employee on matters which affect his health and efficiency, and give advice about obtaining needed treatment or other service. 2. Group programs. Group discussions and courses provide the health service with opportunities to help employees toward better health and safety. Properly used, health publications, ex hibits, and posters are also effective. Administrative responsibilities 1. Determining when employees shall be excused during the work day because of illness or injury and deciding, when an employee has been absent for such reasons for a predetermined period,, whether he is able to return to work. 2. Participation in management plans for recreation programs, meal service, safety devices and practices, sanitary conditions, and the removal of hazards in the plant. 3. Maintenance of adequate records and preparation of periodic analyses. Records should be kept in such a way that they will show how, when, and where in the plant illness and injury occur. They should also show the causes, nature, and duration of disability, and if the size of the group warrants it, data should be tabulated by department, age, and sex. 5 ifttSirin Coordination with community health and welfare resources 1. Contact with physicians, health department, hospitals, public health nursing organizations, and other agencies so that con__ suitation and assistance will be available when it is needed and ~ employees can be referred for care or assistance. 2. Cooperation with community health projects such as chest X-ray surveys and better breakfast campaigns. 3. Planning with civil defense authorities for plant disaster pro gram. Requirements The number and type of personnel, the space, and the equipment needed for an employee health service are determined in large measure by: 1. The type of industry and the potential hazards. 2. The extent and nature of health service given. 3. The number of employees and their age and sex. 4 The plant's injury and illness experience. 5. The availability of supplemental medical service in the community. . Personnel There can be no set rule for the amount of medical and nursing services needed. Where the program includes preplacement and pe riodic physical examinations, a rough scale is a full-time physician for 2,000 to 3,000 employees and a full-time nurse for 300 to 750 em ployees. The small plant with a similar program would probably need three hours of medical service and nine hours of nursing service per week per hundred employees. 6 The Physician An employee health service should be under the direction of a licensed physician with a special interest in industrial medicine and preferably with previous experience or postgraduate study in this field. He-should have regular and definite hours at the plant and have oppor tunity to become familiar with the plant processes, materials, and pos sible hazards. He should have cooperative relationships with manage ment and employees. The employment of an "on call" physician is not recommended because identification with the plant, which is very im portant, is almost impossible without regular attendance. Some State and local medical societies have industrial health committees which _ can guide and assist in the selection of a full-time or part-time industrial physician. The plant physician needs and must have the support of management He should be responsible to the president, plant manager, or some other official of comparable rank. The Nurse The nurse in a small plant should have mature judgment, a sympa thetic personality, and the ability to understand and get along with people. Her professional qualifications should be considered carefully, since she usuaUy works without direct nursing supervision. She should be a graduate of a school of nursing accredited by the State Board of Nurse Examiners and should be registered in the State in which she is practising. The American Association of Industrial Nurses recom mends that the nurse in a small plant should have at least five years of graduate nursing experience plus at least a year in an industrial medical department, in an emergency clinic of an accredited hospital, or in a community health agency, such as a health department or visiting nurse association. Postgraduate study in industrial nursing is desirable. Assistance in the selection of the right nurse for a small plant can be obtained from sources such as industrial nursing consultants or nurse counseling and placement services often sponsored, by State or district nursing organizations. Statements to guide local practices have been prepared by industrial nursing associations in many States; they are usually available through the industrial health division of the State 7 MMjjk department of health or labor. Committees of the American Association of Industrial Nurses have also prepared statements which are helpful to employers considering the employment of a nurse. Copies can be pur chased from the Association. The^ industrial nurse should be responsible to the plant physician, who determines standard procedures (standing orders) to be carried out in his absence and directs whatever treatment is given to employees. In a plant which has a part-time physician, the nurse should be responsible to the president, the plant manager, or some other company official for all matters not of a professional nature. Sharing and part-time plans Small plants sometimes find it advisable to share the services of a nurse and physician with other companies. Various sharing plans have been in operation for several years. Their practicality has been demon strated and they have met with approval from management, employees, and the medical and nursing professions. One of the first plans for sharing the services of physicians and nurses was organized in Philadelphia many years ago by the Philadel phia Health Council and Tuberculosis Committee. Under the original plan, several plants employing from 25 to 500 persons each, and located reasonably close together, were combined into a unit of 1,000 employ ees. Each plant sharing in a unit provided a first-aid or clinic room with necessary equipment. The Council supplied medical and nursing service, first-aid instruction, health instruction, and sanitary supervision. A physician with experience in industrial medicine and hygiene was assigned to two units (2,000 employees) or a part-time physician gave half of his time to one unit. A graduate nurse with industrial nursing training was assigned to each unit and divided her time in the plants according to the number of employees and the services needed. When the units were able to continue the service without supervision by the Council, they were turned over to plant management for further admin istration. At the present time the plan is operating under the super vision of private physicians. In some of the plants the Visiting Nurse Society of Philadelphia provides part-time nursing service on an hourly basis; in others, full-time nurses are employed directly by management. 8 inUaeUitOaHatm Another example of this type of service was developed in Hartford, Conn. Eight plants employing from 280 to 635 employees -each are served by one physician. Each plant maintains a dispensary, employs at least one full-time registered nurse, and is responsible for a certain amount of the_guaranteed annual salary of the physician. The nurse in each plant is responsible to the physician for all matters of a profes sional nature and to her own plant officers for other matters. Common standing orders and a common system of record keeping are used by all of the participating companies. In other plans the part-time medical service is given by a local phy sician who comes into the plant at scheduled hours each week. Reim bursement is on an hourly basis, and the rate varies in different local ities. Part-time nursing service can be provided in various ways. A group of plants may share the full-time service of an experienced industrial nurse, or the local visiting nurse association may provide the service on an hourly basis. Part-time Nursing in Industry, published in 1945 by the National Organization for Public Health Nursing and now available through the National league for Nursing, 2 Park Avenue, New York 16, N. Y., is a detailed and helpful report on part-time nursing service given by 25 visiting nurse organizations. Except that she is not available full time for emergency care, the part-time nurse can provide many of the same services as the full-time nurse. As the value of employee health service is demonstrated, many small plants are increasing the time the physician spends in the plant and are employing the nurste directly and full time, rather than through an organization on a part-time basis. First-aid workers Careful attention to first-aid service is necessary in any part-time program if emergencies are to be met adequately when neither the physician nor the nurse is in the plant. Two or more workers on each shift should be responsible for all first aid given in the absence of the physician and nurse. These workers should have a current certificate of proficiency from the American Red Cross or another acceptable organ ization and should take a refresher course every three years. They should be responsible to the nurse and physician and should have written instructions signed by the plant physician. Unless the injury demands treatment where the accident happens, first aid should be given in the dispensary rather than in the various departments, sinde facilities for handwashing, sterile supplies, and proper first-aid materials as well as records will be needed. Supervisors and employees should know the names and locations of the individuals who are responsible for administering first aid. When first aid has been given, a simple record should be made and left for the nurse, who will see the injured employee, if necessary, when she comes to the plant. She will also make the necessary entries on the health records. Space and Layout The industrial dispensary should be designed.to meet the specific needs of the plant and should be planned by management in consulta tion with the physician and the nurse. The following are minimum requirements: 1. A location easily reached from various parts of the plant, with an exit readily accessible to the street or driveway so that stretcher patients can be carried to an ambulance. 2. Quiet and privacy. 3. Windows for good light and ventilation. 4. Good general artificial illumination and a number of electric outlets for supplementary illumination, equipment, or other appliances. 5. Hot and cold running water and toilet facilities. 6. A floor of some impervious material such as tile, terrazzo, concrete, or linoleum. The walls should be made of tile or of well-painted wood or plaster, so they can be easily kept clean. 7. Provisions fot expansion. A desirable floor plan for a dispensary in a small plant employing less than 500 people, in the charge of a part-time physician and a full time nurse, is given in Figure 1. The plan includes a waiting room, treatment room, examining room, lavatory, and storage space. The area in this particular plan is about 350 square feet, but the space will of course vary according to needs. 10 amt seismsSuomi js^ifarfa The treatment room occupies the greater part of the floor area. A smaller room containing a table and bed may be used for physical examinations and treatments where privacy is required This room can also be used as a rest room for workers temporarily indisposed during the work: day Qi_for seriously ill employees waiting for an ambulance. Figure 1. Floor Plan for the Small Dispensary Adapted from a plan developed by the American Association of In dustrial Nurses in collaboration with the American Mutual Liability Insurance Company. 11 - - ;-j-  ri Equipment The plant physician, whenever possible, should select his 0wn e . ment and supplies. Because they will get heavy wear, they should b -of good quality. T1*"? equipment generally includes: An enameled metal or wooden treatment table Two metal or wooden chairs or stools A treatment chair with detachable basin and headrest A foot pedal waste receptacle A firm bed or examining table covered with washable material, pillow, pillowcases, sheets, and blankets Paper-towel rack Adhesive-tape rack Soap dispenser Magnifying glass Deep sink with single mixing faucet, two valves--vitreous porcelain or stainless steel Stretcher Sterilizer Screens Instrument and supply cabinet with lock Leg rest or foot stool Wastebasket Scale Electric plate Record file and lock Desk and desk chair Chairs or bench for the waiting room Telephone Wheel chair Bulletin board or information rack Infrared lamp 12 mm The physician setec^ drugs, instrument,, and other suppUes which wdl probably mdude hypodemnc syringes and needles, cymometers sterile gauze, cotton adhesive, tongue depressors, applicators, soap' ctoowveerlesd^ hjaorts-w,-mateedr ibciontetleg,laiscseesb,aigc,uernniaqmueetlsb, aasninds reancodrdpitfcohrmerss, eye tta7v' The nurse should be responsible for the maintenance of equipment. Records The keeping of accurate and complete medical records is one of the important functions in a plant dispensary. The records should be simple, particularly in a small plant where clerical assistance is not readily available. However, they must be adequate and accurate to meet the legal requirements of the State in which the firm operates and to be useful in placement and health counseling, analyzing and con trolling health problems, and appraising the value of the service. Although the physician and nurse together decide on the type and content of the records in a small plant, the maintenance of the record system is usually the responsibility of the nurse. The nurse and physi cian review and evaluate the data periodically and plan the type and content of reports to management. Types of Records Although the types of records may vary, it is generally agreed that certain basic ones are essential. They are: 1. Administrative records (a) Daily report form (sheet or book) (b) Periodic report form 2. Individual records (a) Personal health and accident record (b) Preplacement and periodic examination or health history forms (e) Occupational injury reports 13 nsnrrdifi 1. Administrative Records The daily report is a record of all daily visits to the medical depart ment and of all other activities of the professional staff. It is kept in one_of two ways: (a) The reason for the employee's visit and the service given are recorded directly on the employee's individual record at the time of his visit. On the daily report, the visit is recorded by department and reason for visit. Periodic summaries of such daily reports are particularly useful for interdepartmental dis cussion and for safety promotion because the problems and their locations are highlighted, but employees are not identified. (b) The employee's name, department, the reason for the visit, and the service given are recorded on the daily report. Later this information is transferred to the employee's individual record. The disadvantage of this method is the duplication of record ing and the possibility of posting errors. When this type of daily report is kept, a day book rather than a day sheet is recommended Periodically--usually once a month and once a year--the employee health service submits a statistical and narrative report to manage ment. The statistical information is taken from the daily reports. The narrative section includes comments on trends, recommendations, and all other information which will show management the significance of the health status of employees, the work of the service, and the need for further activities. 2. Individual Reports A record folder or envelope should be made for each employee, and all correspondence, records, and reports pertaining to. his health should be filed in it. The personal health and accident record is a cumulative chronological report of all visits to the dispensary for occupational and nonoccupational conditions, with notations of reasons for visits, treat ment, or other help given. Some firms use separate records for occu pational and nonoccupational conditions. The occupational injury re- 14 v$ t T ' 11 v ports must meet the legal requirements of the State. The preplacement examination record should include the medical and occupational history of the employee. Beside these basic records, it is also helpfulto have referral forms, return-to^work-permits, absentee reports, and other special forms, such as those required for company benefits. Many State bureaus of industrial hygiene provide sample copies of suggested record forms which meet State law requirements and which are patterned from records currently used in the State. Before final adoption of a record it is helpful to give the form a trial so that necessary changes can be made before a large supply is printed. The files of individual employee records should always be kept locked in the dispensary. The information in them, except as it applies to occupational injuries or illnesses, is confidential and should be available only to the health service staff. SOURCES OF MATERIAL ON EMPLOYEE HEALTH AND NURSING SERVICE American Association of Industrial Nurses 654 Madison Avenue New York 21, N. Y. American College of Surgeons 40 East Erie Street Chicago 11,11L American Medical Association Council on Industrial Health 535 North Dearborn Street Chicago 10, III American Nurses' Association 2 Park Avenue New York 16, N. Y. 15 SOURCES OF MATERIAL ON EMPLOYEE HEALTH AND NURSING SERVICE (Continued) Industrial Hygiene Foundation Mellon Institute 4400 Fifth Avenue Pittsburgh 13, Pa. (for member companies) Industrial Medical Association 28 E. Jackson Boulevard Chicago 4,11L ' Metropolitan Life Insurance Company 1 Madison Avenue New York 10, N. Y. National Association of Manufacturers 2 E. 48th Street New York 17, N. Y. National Industrial Conference Board, Inc 247 Park Avenue New York 17, N. Y. (for member companies) 1 * National League for Nursing 2 Park Avenue New York 16, N. Y. I U. S. Department of Health, Education, and Welfare * Public Health Service Division of Special Health Services Washington 25, D. G 16 t