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Healthcare workers are at increased risk of injury, compared to other industries. Controlling the associated costs requires a multipronged effort.
• The incidence and costs of workplace injuries may be underreported in the healthcare industry.
• Proper lifting and other safe practices must be not only taught, but enforced.
• Timely reporting of injuries is important to reducing long-term costs.
Workers’ compensation claims are a major concern for healthcare risk managers and can create tremendous liability for the healthcare organization, but careful attention to injury prevention and proper handling of claims can keep the costs to a minimum.
Most workplace injuries in healthcare facilities result in a formal complaint petition for workers’ comp, at least in New Jersey, says Matthew Gitterman, JD, partner with the Biancamano & Di Stefano law firm in Edison, NJ. He defends workers’ comp cases for hospitals, nursing homes, and rehabilitation facilities.
“Particularly in hospitals and nursing homes, I’m seeing a lot of claims involving nurses or nurse’s aides helping lift patients and sustaining back injuries,” Gitterman says. “I’d say over 50% of the cases I see are that specific fact pattern. There also are slip-and-fall injuries, repetitive motion, and occasionally something falling on someone, or a violent patient.”
Risk managers should focus much of their resources on preventing those back injuries, Gitterman says. That will involve formal training and ensuring that there are enough staff members available to help lift a patient, he says.
“Very often these organizations just don’t have enough staff to put three or four aides on task for moving a patient, and I think that can be a very big mistake. You should err on the side of more and not less when assigning aides to move a patient,” he says. “I see descriptions of a 110-lb. employee moving a 260-lb. patient, and that’s just a recipe for disaster. I’m sure most providers have policies in place but I would guess that on a day-to-day basis, due to staffing issues, they try to cut corners. That’s where injuries occur.”
That observation is seconded by Paul S. Mazeski, JD, shareholder with the law firm of Buchanan Ingersoll & Rooney in Pittsburgh. He encourages healthcare clients to establish policies that require a minimum two-person lift.
“The best thing you can do is provide good training for supervisors in the company’s policies, and then train the frontline staff as well,” he says. “If they are not complying with those policies, they have to be disciplined because otherwise you are going to run into problems down the road.”
Remember that it is not just nurses and aides who get hurt. Physicians can be injured as well, and that can expose the hospital to much greater liability for loss of income. (See the story in this issue for more on that risk and the perspective of an attorney representing injured workers.)
Once an injury occurs, proper documentation can be the key to limiting future liability, Gitterman says. Fully and carefully document what happened, why the injury occurred, and, most importantly, exactly what injuries were sustained, he says.
“I see cases all the time where you had someone injure their back and then six months later, all of a sudden, the neck or shoulder comes into play,” he says. “If the documentation was what it should be from day one, it’s very easy for me to have that documentation reviewed by a medical expert who can write an opinion that limits the extent of the claim to just what was initially involved. If you don’t have that documentation, it becomes difficult to defend the additional body parts.”
Gitterman also encourages risk managers to investigate suspicious claims, ensuring that disabled workers are not employed elsewhere or taking part in activities they supposedly cannot perform because of their injuries. Also, be sure to check a claimant’s health background thoroughly for previous conditions that were not divulged in the workers’ comp claim.
Be careful to include staff who work outside the facility, such as therapists or aides who visit patients in their homes, in any risk reduction policies, Mazeski says.
“It is imperative that the employers maintain control over the work performed in those homes, and also the travel between the homes. They should be trained in safe lifting and other techniques to reduce injuries, and they should be held accountable for complying with those procedures,” he says. “There also is a significant issue of when they are in the course of their employment — whether it begins when they get to the house, or whether they are in employment throughout the day — that might be decided on a state-by-state basis.”
Larger hospitals and health systems tend to use a more proactive approach to handling workers’ comp claims, sending injured workers to well-qualified physician panels for treatment and making work available to claimants, Mazeski says.
“Getting people back to work sometimes means you can avoid lost time claims. Healthcare providers can be more astute in this area with getting people to the appropriate treatment and back to work, better than what we see in some other industries,” he says. “We’ll see a lot of situations where people get with the wrong healthcare provider, don’t get the right treatment, and they’re out of work longer than they have to be. Healthcare providers tend to be better with that when their own people are injured.”
The incidence of workers’ comp injuries, and the associated costs, are growing with the healthcare industry, notes Christopher L. Pizzo, JD, an attorney with the LeClairRyan law firm in Newark, NJ. The healthcare industry is projected to grow substantially faster than the average rate compared to all occupations, with the Bureau of Labor Statistics (BLS) estimating that there will be 2.3 million new jobs in healthcare added between 2014 and 2024, which represents a 19% increase.
“With growth comes the added potential for work-related injuries and illnesses. Healthcare and social assistance employees already account for very high statistical rates of injury and illness in private industry, so growth will only add to that exposure,” Pizzo says.
He points to a recent BLS study showing that, due to the physical nature of hospital jobs, those employees face a higher incidence of injury and illness — six cases per 100 full-time workers — than employees working in other industries such as constructions and manufacturing, which are usually considered dangerous occupations. (That study is available online at: https://bit.ly/2KWyXT0.)
In 2014, workers in the hospital sector sustained 294,000 nonfatal work-related injuries from the more than 5.1 million employees in that category. The leading type of work-related injuries in healthcare are strains and sprains, which account for 35% of all workplace injuries, Pizzo notes.
Approximately one in five injury and illness cases reported by private industry employers in 2016 occurred in healthcare and social assistance industries. About half of all nonfatal injury and illness cases reported among private industry establishments in 2016 occurred in just three industry sectors: healthcare and social assistance, manufacturing, and retail trade.
“Healthcare workers involved in patient care have a specific exposure to injury in that manual lifting can injure caregivers and put them as well as patients at risk of falls, fractures, and bruises. A related risk that is not direct workers’ compensation exposure but can cross over from liability into workers’ compensation due to its impact on workers is that caregiver fatigue, injury, and stress are tied to a higher risk of medication errors and patient infections,” Pizzo says.
BLS data show that 48% of injuries resulting in days away from work are caused by overexertion or bodily reaction, including motions such as lifting, bending, reaching, or slipping without falling, and these motions often relate to patient handling, he notes. Sprains and strains account for 54% of injuries that result in days away from work and account for the largest share of workers’ compensation claim costs for hospitals, Pizzo says.
“The very nature of the healthcare environment creates a large exposure for injury and an array of potential dangers. The occupation can be very physical, requiring moving large and heavy patients into positions for proper care,” Pizzo says. “There is the possibility of encountering a patient who poses a physical threat of harm, whether they are affected by drugs or alcohol or mental and physical disorders. There are exposures to viral and bacterial substances which can cause unseen injury with latent manifestation. There are also many healthcare workers who are in the field and private homes, rendering care on a singular basis which creates the opportunity for situations to arise that cause injury and illness.”
Workers in hospitals, nursing homes, and other healthcare settings also face significant risks of workplace violence, Pizzo notes, and resulting injuries can become workers’ comp claims. Many factors contribute to this risk, including working directly with people who have a history of violence or who may be delirious or under the influence of drugs. (See the related story in this issue for more on addressing workplace violence.)
Workers’ comp claims related to workplace violence may involve more serious injuries and higher costs for the employer. From 2002 to 2013, the rate of serious workplace violence incidents (those requiring days off for an injured worker to recuperate) was, on average, more than four times greater in healthcare than in private industry, Pizzo notes.
“In fact, healthcare accounts for nearly as many serious violent injuries as all other industries combined. Many more assaults or threats go unreported,” he says.
The cost of medical treatment for healthcare workers’ compensation claims may be underestimated because unlike other industries, hospitals can treat their own injured workers onsite and hospital employees often are given an “employee discount” for treatment, Pizzo says. Many hospitals also are self-insured, so they bear the entire cost of workers’ compensation losses directly.
“From the healthcare risk management perspective, given the predicted growth in all healthcare sectors and the risks and exposures particular to that industry, there are numerous risk factors that can cause not only injuries but also cause increased costs of workers’ compensation claims when injuries do occur,” Pizzo says. “Some of the leading factors to be considered and strategies for reducing or even eliminating the exposure are cause of injury, age of the worker, health of the worker, and timely reporting of the claim.”
Regarding the cause of injury, Pizzo notes that heavy lifting is required for many healthcare workers because they are assisting patients who are unable to lift or move themselves. Sprains and strains can be minimized by proper and safe patient lifting techniques. Overall education is needed to improve loss prevention, but so is enforcement of use of proper techniques, he says.
“Too many times in the course of litigation defense, counsel is told by the injured worker and their co-workers that there were proper lifting techniques given by the employer, but that they were rarely enforced,” Pizzo says.
He urges risk managers to implement the following strategies:
• Train healthcare workers on safe patient handling guidelines. Safe Patient Handling and Mobility (SPHM) programs that set guidelines and promote best practices are critical to ensuring the safety of employees as well as patients.
• Provide education and training in using mobility equipment and assistive devices.
• Closely examine employee skill sets for proper job placement and assignment.
• Provide proper employee breaks.
• Consider equipment modifications, environmental improvements, and tools that can reduce injury.
• Enforce safe patient handling guidelines.
The relative age of workers is important because by the year 2020, many workplaces will have five generations of employees working alongside each other, Pizzo notes. Healthcare workers such as nurses are no exception, as research indicates nearly half of all currently registered nurses will reach retirement age by 2020, he says.
“Thus, this is a risk to the healthcare industry that exceeds the general aging population everywhere. Care must be given to avoid even the appearance of age discrimination, but the reality is that the workforce is aging and employers must be ready to cope with the needs of their workforce,” he says.
To address the age-related risk, Pizzo recommends implementing technology and tools that assist older workers, as well as designing ergonomic workplaces that reduce physical demands and eliminating trip, slip, and fall risks. He also recommends offering, or even requiring where permissible, participation in physical wellness programs to strengthen workers, including body mechanics, stretching, and team-building to help older workers teach younger employees and facilitate connection with the job.
Experienced employees also can act as mentors to younger healthcare workers, teaching them about the risk of injury and how to stay safe on the job, he says.
The health of the worker is another factor to consider. Research indicates that compared to 20 other industries, the U.S. healthcare industry has the second-highest rate of obesity, Pizzo notes. Although there are many factors that contribute to a worker’s overall personal health, there is statistically a direct relationship between body mass index (BMI) and workers’ compensation claims resulting in costs and lost workdays.
To address the risk factor related to worker health, Pizzo advises providing an onsite fitness center with instruction on proper mechanics and stretching. If this is not feasible due to size and/or cost, then access to offsite fitness programs and tie-ins with other incentives for participation can be effective, he says.
Healthcare employers also can offer nutritional guidance and promote healthier eating practices, with incentives for a healthier lifestyle and regular medical checkups, he says. The employer also can foster an environment of team-building with events like corporate fun runs and other group activities.
Timely claim reporting is important to reducing costs, Pizzo says. Because healthcare workers can be working inside an institution or in the field, it is important for all employees to be counseled by human resources and familiar with proper and timely accident reporting.
“It is absolutely necessary for employers to timely report claims to their administrators and/or carriers. Attempts by employers to handle claims themselves is an alarming recent trend, and often ends in loss of control of things like medical treatment within workers’ compensation rules — not to mention is a crime in many jurisdictions,” he says. “Regardless of the potential for fraud, however, it just makes sense to report all claims timely, and let the workers’ compensation-specific professionals engage and mitigate the exposure. Attempts to handle claims without reporting them often end in protracted claims and litigation — and more expensive medical care without the safeguards and defenses in place such as networks, fee schedules, and utilization review.”
Pizzo advises conducting annual training on rules and reporting time requirements, and the employee should acknowledge having received such training. Employees should know whom they need to notify when an injury occurs.
Healthcare employers also should consider a drug-free workplace program that includes, at a minimum, a post-injury drug-testing protocol with proper procedures on administering the correct tests and documenting chain of custody for legal purposes.
Risk managers also must understand the law and rules of the state in which the institution does business regarding “first aid” claims vs. true medical and/or lost time claims, he says. This distinction can dramatically reduce claim exposure and loss experience, he says.
The institution should be committed to a return-to-work program that is structured and allows for modified work restrictions during an employee’s recovery phase, Pizzo advises. Consider use of a third-party administrator to streamline claims efficiency and case management, he says.
“It may be an understatement to say managing workers’ compensation claims in the healthcare setting can be a costly and challenging process. However, with proper procedures, training, equipment, and engaging the employee in a team approach, these exposures can be mitigated or, in some cases, even eliminated,” Pizzo says. “And most importantly, in order for any of these strategies to work in the whole, employers and risk managers must engage and take ownership for their own roles in the process.”
• Matthew Gitterman, JD, Partner, Biancamano & Di Stefano, Edison, NJ. Phone: (732) 549-0220. Email: firstname.lastname@example.org.
• Paul S. Mazeski, JD, Shareholder, Buchanan Ingersoll & Rooney, Pittsburgh. Phone: (412) 392-2120. Email: email@example.com.
• Christopher L. Pizzo, JD, LeClairRyan, Newark, NJ. Phone: (973) 491-3372. Email: firstname.lastname@example.org.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.