What is a ‘reportable’ injury?

I was asked last week to compare injury rates from two jurisdictions. I had to explain that this is not easily done. Economic mix, demographics of the workforce, differences in benefit terms (waiting periods, employer deductibles) and other factors can impact such a comparison. One factor, in particular, came up that is often overlooked: injury reporting requirements.

Before a workers’ compensation or prevention organization can act on an injury, illness or incident, there must be a report to the organization. What is reportable will have a large impact on key statistical measures including time-loss injury rate (injury frequency). There are two aspects to reporting requirements:

• What is required to be reported as a work-related injury or disease

  The degree of compliance with reporting requirements
  

So, what is reportable? That varies by jurisdiction. For WorkSafeBC with its dual role as the workers’ compensation and prevention agency for the province, a reportable injury is (or is claimed to be) an injury arising out of and in the course of employment with any of the following immediate or subsequent characteristics:

1. The worker loses consciousness following the injury.
2. The worker is transported or directed to a hospital or other place of medical treatment, or is recommended by such persons to go to such place.
3. The injury is one that obviously requires medical treatment.
4. The worker has received medical treatment for the injury.
5. The worker is unable or claims to be unable by reason of the injury to return to his or her usual job function on any working day subsequent to the day of injury.
6. The injury or accident resulted or is claimed to have resulted in the breakage of an artificial member, eyeglasses, dentures or a hearing aid.
7. The worker or WorkSafeBC has requested that an employer's report be sent.
   
   

Some incidents require immediate reporting whether or not an injury occurs:

• Any incident that kills, causes risk of death, or seriously injures a worker
• Any blasting accident that results in injury, or unusual event involving explosives
• A diving incident that causes death, injury, or decompression sickness requiring treatment
• A major leak or release of a dangerous substance
• A major structural failure or collapse of a structure, equipment, construction support system, or excavation
• Any serious mishap

Ontario’s WSIB (with its primary role on the workers’ compensation side) has the following reporting requirements written into policy:
Employers must report a work-related accident to the WSIB if they learn that a worker requires health care and/or

• is absent from regular work
• earns less than regular pay for regular work (e.g., part-time hours)
• requires modified work at less than regular pay
• requires modified work at regular pay for more than seven calendar days following the date of accident.

In Alberta, reporting requirement of injuries for occupational health and safety purposes is different than for workers’ compensation purposes. According to the Alberta OHS Act, injuries and incidents have to be reported to the Government of Alberta if they:

• result in a death
• cause a worker to be admitted to hospital for more than two days
• involve an unplanned or uncontrolled explosion, fire or flood that causes or has the potential to cause a serious injury
• involve the collapse or upset of a crane, derrick or hoist
• involve the collapse or failure of any component of a building or structure necessary for the structural integrity of the building or structure.
  

My point is simply this: injury rate comparisons are complex. The injury rate in any jurisdiction is the result of many factors. Reporting requirement and the level of compliance with those requirements can have a significant impact on the apparent injury rates. When comparing injury rate data between jurisdictions, understanding what is reportable and how well reporting requirements are met are essential to understanding reported injury rates.

What factors encourage OH&S compliance?

Recently, I’ve been thinking about compliance with safety and health requirements of law and regulation. What factors encourage compliance among workplace players (employers, supervisors, workers)? I think there are three main categories of organizations to consider:

• those with strong safety cultures,
• those who are uninformed, and
• everyone else.

The easiest category to consider is the first one. Many workplaces are safe and secure form injury, illness and disease because of a pervasive safety culture. By this I mean that those present in the workplace put safety and health top-of-mind all the time. Supervisors continually incorporate safety-oriented content in 75% or more of their interactions with those they work with; workers are constantly alert to hazards and empowered to act to correct and control them; managers view violations of health and safety requirements as defects in their processes, training or supervision; firms act to eliminate safety and health risks to the vital human resources and the reputation of the firm. This shared culture is the predominant motivator and compliance is a natural byproduct of that culture.

The second category is characterized by a lack of safety culture without any malice or intention to violate health and safety requirements. In a sense, this group has the most to learn and gain from an intervention such as an inspection by an occupational safety and health officer. Often, these are newer firms struggling to gain markets, to expand or just to keep the business going. For this group, it is a lack of knowledge or skill rather than an active or willful disregard for health and safety that characterizes the lack of compliance. I include in this group those who may be well intentioned and even striving to develop a strong safety culture but ill equipped with the necessary knowledge, skills and abilities to make this happen.

The final category includes everyone else. Members of this category have knowledge of the health and safety requirements, the skills and abilities to comply with the health ans safety standards, but lack the internal motivation to act on what they know. For this group, compliance is more of a risk calculation:

Is the Cost of compliance less than [the probability of being caught in non-compliance times the cost of sanction(s)]? If so, comply... If not, continue in non-compliance.


A roofing firm might know that fall protection is required and even have the equipment and training to use it; however, if the risk of an inspection is negligible or, if an inspection does occur, the value of any penalty is low or non-existent, compliance may be seen as an added cost. (I shall assume that the value of non-compliance results in little or no increase in production).

For this category, there are few routes to compliance. Compliance may come as an unintended consequence or benefit of a change in process (a new machine comes with an automatic power off feature built in, for example) or if the cost equation makes non-compliance very costly.

Simple consequences of the equation follow:

• If there are no penalties, there would be no motivation for this group to comply.
• If the penalties are substantial but the probability of detection is very low (there are no inspectors in the region or the workplace is not easily observed), then there is little or no incentive for compliance.
  

There are much more complex equations in the literature but this simplified version leads to a couple obvious conclusions. Workplaces in this last category will move toward compliance as their perceptions of the cost of non-compliance increases. The perceived cost of non-compliance will increase if either or both the perceived probability of detection of non-compliance and cost of sanctions rise.

One way to increase the perceived probability of detection is announce an inspection blitz of a region or industry. Another is to increase the publicity around detected violations and penalty assessments. This does not increase either the number of inspections or the value of individual penalties for detected violations but it does increase the perception or expectation about the cost of non-compliance.

Another strategy is to increase the cost of non-compliance by a broader interpretation of penalties and sanctions. Loss of reputation through higher-profile sanctions may achieve this. OSHA in the US posts inspection reports on line. You enter a firm name and a state; you get a list of inspection reports and can determine if there are any penalties for serious violations of health and safety standards. To the extent that potential customers of a firm use this information to decide on whom they will do business with, the perceived cost of non-compliance will rise.

Ideally, we can move all workplaces into the first group—those with great safety cultures. Hopefully, a using these concepts to design compliance strategies will more workplaces toward that goal.

Why Compare Performance?

This past week I was in Victoria speaking at a conference on Performance Measurement. I have been asked to present at this conference about a half dozen times and it is a real credit to the strong performance measurement culture of WorkSafeBC that this organization continues to ask for our participation.


One of the BC Reporting Principles, adopted by the BC legislature, states the following:

Public performance reporting should provide comparative information about past and expected future performance and about the performance of similar organizations when it would significantly enhance a reader’s ability to use the information being reported.

Comparative data provides stakeholders with a context to understand if what we achieved is good, bad or indifferent.


Some of our key performance indicators do have direct comparators. Thanks to the AWCBC, we can plot our administrative costs, injury rate, duration and premium against other workers’ compensation systems in Canada. Not all the comparisons are perfect. One has to take into account that jurisdictions such as Manitoba, Ontario, and Saskatchewan cover a much lower percentage (~70%) of the employed labour force than we cover in BC (~93%).


Some of our key performance indicators have no direct comparison. Our ‘voice of the customer’ program has no direct comparator in Canada regarding overall satisfaction levels for workers and employers. Some jurisdictions report on return to work at the aggregate level but none in Canada publish a statistic comparable to our indicator that measures the success of RTW for cases referred to vocational rehabilitation for that purpose. While our key performance indicator for assessing our funding status is unique, there is an industry standard that can provide another context for comparison. This AWCBC measure is reported on their website and in the Appendix to our Annual Report and Service Plan. True the the principle, this additional context is included so stakeholders have another way to judge how WorkSafeBC is performing even though there is no direct comparator to our 'Percent of Target Capital Adequacy Reserve' indicator.


WorkSafeBC also reports on a public contribution index. This measure reflects the percentage of 800 surveyed British Columbians expressing an opinion who rate WorkSafeBC as making a somewhat or very positive contribution to BC. Scores in the mid 80% range in the last four quarters are a reflection of the commitment of staff to making a difference for each and every human being they encounter. No other workers’ compensation system I know of measures performance in this fashion (or, if they do, they are not telling anyone about their results). From some historical data from firms who used to ask this question and report, we have a scale that suggests our current level is near the top of the observed range for some other BC corporations. Still, having some current external comparator in the workers’ compensation business would help our stakeholders properly evaluate our performance.


All of this is not to say we have performance measurement ‘solved’. Measurement is essential to improvement. If you can’t (or chose not to) measure something, it is debatable that you can understand it or improve it. That said, not every jurisdiction can or should measure the same things nor should they necessarily measure similar things in the same way. Performance Measurement should be strategic as well as meaningful and useful to stakeholders and those accountable for the system. More importantly, every person working within the system should be able to see how what he or she does contributes to organizational goals and influence the key indicators of the system.

Whenever possible, I encourage comparison. Sometimes that means WorkSafeBC has to generate measures for others to use; at other times, we are asking jurisdictions in Canada, the US, Australia, or New Zealand to restate their data in a way that helps us understand our own performance better.

Why compare performance? Comparison leads to understanding and that leads to questions that can make all our systems better for those we serve.

How do you measuer return to work success?

Over the weekend, I received an email from Australia seeking information regarding return to work (RTW) programs and outcomes in North America. One question asked was regarding the percentage of injured workers who RTW. One might think there was a simple, common measure that would allow direct comparison across all workers’ compensation jurisdictions. In reality, however, there are few jurisdiction using the same method to measure RTW success.

The vast majority of injured workers who file workers’ compensation claims in BC and elsewhere experience a successful RTW. What percentage and how durable a return depend on the population being studied, the denominator uses and how RTW is defined. It also depends on the law and economy in the jurisdiction under study.

Many jurisdictions suggest they achieve 85-90% RTW for time-loss injuries. Most injured workers RTW with their accident employers anyway so the high percentage may not indicate anything about the effectiveness of the law, policy or program in a particular jurisdiction.

The 2008/09 Australia & New Zealand Return to Work Monitor examines these questions in detail. Using a common survey methodology that samples from the population of claims with “10 days or more compensation (including any excess) paid”, the reported statistics are among the most comparable around. The ‘employer excess’ refers to an employer deductible where the employer is responsible for paying wage loss benefits and medical costs up to certain limits. This is a common, (although not standardized) provision in Australia. Most jurisdictions in this study have legislation that requires the accident employer to return an injured worker to employment.

The Monitor reports on both ‘durable’ and ‘non-durable’ RTW. The results are summarized in that report as follows:

The RTW rate showed steady improvement between 2002/03 (83%) and 2005/06 (87%) returning to pre 2000 levels (mid 80%). There has been no further improvement, with the 2008/09 national RTW rate similar to all previous years (83%). The durable RTW rate has gradually declined over the last four years, with a lower durable RTW rate being recorded in 2008/09 (72%) to 2007/08 (75%).

More commonly, a report on RTW will be designed to meet the needs and data of a single jurisdiction. For example, a report out of the Texas Department of Insurance Workers’ Compensation Research and Evaluation Group in November 2008 reported on ‘initial’ RTW rates. The research found 74% -78% of claims (injury year 2004-06) had an initial RTW within two quarters post injury. This climbed to around 83%-88% by four quarters and topped out at 90-93% by 12 quarters (the longest category studied). These results have to be taken in the context of the unique Texan workers’ compensation context. For a variety of reasons, it is likely the study population in Texas is more severely injured than in the Australian & New Zealand Monitor’s data.

There is no standard for measuring RTW in Canada. Many jurisdictions in Canada have mandatory reinstatement laws that require an employer to return an injured worker to employment (although BC does not have such a provision). All have some form of RTW program.

New Brunswick 2008 Report to Stakeholders states:

Ninety-six percent of injured workers who lost time from work returned to employment or their pre-employment status following their injury. Two percent were not employed immediately following their claim closure, and 2% were fully disabled and incapable of employment.

At WorkSafeBC, RTW is not just another program; it is an integral part of our strategy and linked directly to the goal of improving satisfaction, accessibility and public confidence. While most workers return to their accident employer, the focus of BC’s vocational rehabilitation efforts is on those who face significant barriers in achieving a successful RTW.

A key indicator of RTW success for WorkSafeBC is the percentage of cases referred to Vocational Rehabilitation assistance who achieve a successful outcome. Measured as a percentage of all closed cases, the results have been as high as 81.7% in 2008. Although the current economic conditions in the province are likely to result in a lower level, the importance of RTW will not diminish.

We know from research that work is good for health and well-being. Regardless of how an agency decides to measure RTW, supporting every injured worker to achieve a safe and durable RTW is and should continue to be a priority for every workers’ compensation system.

Is Bullying (Psychological Harassment) a workplace OS&H issue?

A recent article noted that threats and intimidation by supervisors have risen during the current financial crisis. Whether or not this true, threats of violence or intimidation should never be tolerated. Many jurisdictions rely on a ‘general duty provision’ in their occupational safety and health regulation to require employers to assess risks and protect workers from harms that would include violence. Other jurisdictions (Federal government, BC, Alberta, Saskatchewan, Manitoba, PEI, Nova Scotia and most recently Ontario) have gone further and created specific provisions regarding violence. Part 4 of WorkSafeBC’s Occupational Health and Safety Regulation defines violence this way:

4.27 "violence" means the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker, and includes any threatening statement or behaviour which gives a worker reasonable cause to believe that he or she is at risk of injury.

More recently, the trend has been towards more explicitly dealing with the issue of what is commonly termed ‘bullying’. Quebec and Saskatchewan lead the way in this area with specific provisions that addressed ‘psychological harassment’. Bill 168, occupational Health and Safety Amendment Act (Violence and Harassment in the workplace) 2009 was given third reading by the Ontario legislature last week. Definitions in these provisions vary but the following extract from the Ontario Bill 168 captures the main elements:

"workplace harassment" means engaging in a course of vexatious comment or conduct against a workers in a workplace that is know or ought reasonably to be known to be unwelcomed.

Quebec’s provision in its Labour Standards 81.18 is even more inclusive:

"psychological harassment" means any vexatious behaviour in the form of repeated and hostile or unwanted conduct, verbal comments, actions or gestures, that affects an employee’s dignity or psychological or physical integrity and that results in a harmful work environment for the employee.

Saskatchewan’s definition is a little more complex:

(l) ‘harassment’ means any inappropriate conduct, comment, display,action or gesture by a person:
(i) that either:
(A) is based on race, creed, religion, colour, sex, sexual
orientation, marital status, family status, disability, physical
size or weight, age, nationality, ancestry or place of
origin; or
(B) subject to subsections (3) and (4), adversely affects
the worker’s psychological or physical well-being and that the
person knows or ought reasonably to know would cause a
worker to be humiliated or intimidated; and
(ii) that constitutes a threat to the health or safety of
the worker;

Note, these provision govern workplace safety and health; they do not speak to the issue of compensability of any psychological injury that may arise. By most definitions, "harassment" or "bullying" implies a series of actions or behaviours and not "an acute reaction to a sudden and unexpected traumatic event arising out of and in the course of the worker's employment", as may be required for a mental stress claim. (See Workers Compensation Act, section 5.1(1)(a).

Is an harassment provision more effective than the general duty clause? I don’t think there is a definitive researched, evidence-based answer to that questions. On the other hand, the issue of workplace bullying is real and increasing in profile as a workplace safety and health issue. Whether through specific regulation or active education, protecting workers from harassment should be a priority.

Ontario Labour Critic calls for Competition with WSIB

One might assume legislation that makes a Canadian WCB the exclusive workers’ compensation provider would extend some certainty to that status. Recent developments in other jurisdictions could dispel that assumption.

A few years ago, West Virginia was an exclusive state fund workers’ compensation insurer. Today, it faces competition from private insurers in that state. The New Zealand Accident Compensation Corporation is about to have its exclusivity removed for the workers’ compensation portion of its mandate.

Ontario’s Workplace Insurance and Safety Board (WSIB) has been under financial pressure for some time. It currently has an unfunded liability of about 47%. In other words, WSIB has about half (53%) the money it needs to cover the liabilities—the health care, permanent disability and other benefits injured workers are entitled to.

The way out of this hole is not easy. Clearly, reducing the number and severity of workplace injury and disease cases is part of the solution but unlike BC, which has the main legislated responsibility for occupational safety and health, WSIB is only one player in the prevention role. The Road to Zero strategy requires substantive and continuous reductions in the injury rate in order to have any impact on the unfunded liability.

Other options for WSIB include increasing premiums and cutting benefits. With current premiums among the highest in Canada, there is little appetite for any increase in premiums. In a sense, employers in the WSIB system are already experiencing an intergenerational transfer of costs. The unfunded liability of today is predominantly a result of injuries that occurred in the past. Slashing benefits would clearly hurt those who already are bearing the entire human and much of the financial costs of work-related injury, illness and disease.

What about improving the return on investments? As every investor knows, investments that offer higher returns carry increased risk of large losses. With market volatility and economic uncertainty the way they are today, becoming more aggressive with investment strategies is probably not a great idea.

Recently, the Labour Critic for the Official Opposition in the Ontario legislature introduced a private members Bill to open WSIB to competition. Randy Hillier, who recently sought to lead the Progressive Conservative Party of Ontario, saw his Bill 219 debated in the legislature on November 19, 2009. An explanatory note contained in the Bill states:

The Bill amends the Workplace Safety and Insurance Act, 1997 to allow an employer, at any time, to opt to participate in an insurance plan that is offered by a private-sector insurer, instead of the insurance plan established under the Act, if the alternate plan offers benefits to the employer's workers that are comparable to those offered by the insurance plan as it exists under the Act as of the date that the amendments to the Act come into force. To exercise the option, an employer is required to file a notice with the Workplace Safety and Insurance Board containing the particulars specified in the regulations made under the Act.

As with most private member Bills, this proposed legislation was defeated after some debate. It is clear that the idea of opening the WSIB to competition has resonated with some. While research would suggest that competitive workers’ compensation systems are, on average, higher cost for employers, it is likely that the large unfunded liability in Ontario will keep this issue alive for some time to come.

Ergonomic Considerations for Older Workers

The idea of fitting the job to the worker is not new...but the increasing numbers of older workers in the workforce requires a fresh look at workplace standards and design.

Older workers may have very different needs from their younger counterparts. Many tables that record body measurements and ratios are based on military populations and may not be representative of the working population in general or of a particular worksite with many older workers.

What sort of considerations should one make for older workers? In a recent presentation J.M. Haight offered the following advice:

Consider older workers limitation in workspace and task design:
· Improve illumination
· Reduce heavy lifts and elevated work
· Design smooth solid flooring
· Remove control panel and computer screen clutter
· Reduce noise levels
· Focus on error reduction tools such as three way communication
· Additional time spacing between task steps
· Increase decision making time
· Reduce necessary reaction time
· Understand accommodations being made
· Educate, Educate, Educate

The Australian Public Safety Commission produced a similar
checklist of strategies and activities for an aging workforce
(Australian Public Service Commission, 2003):

Improve work task design
· Promote employees’ control over their work depending on agency needs and employee preferences
· Reduce physical loads
· Ensure good visibility of task-related information
· Improve posture
· Set reasonable work rate standards, production targets or workloads

Improve job design and work organization
· Avoid monotony, short cycle times
· Improve work scheduling
· Allow flexibility in taking rest breaks
· Allow individuals time to adapt to new tasks
· Support flexible employment conditions

Improve the physical work environment
· Minimise glare
· Ensure good lighting levels
· Minimise noise levels
· Eliminate hazards that may cause slips, trips and falls
· Make allowances for working in heat and encourage sun-safe behaviour

Support and improve people’s performance capacities
· Develop best practice performance standards
· Improve training programs
· Develop and maintain support systems
· Improve employee morale and expertise

Interestingly, this resource follows each strategy with specific recommended activities and provides a small bibliographic reference section to support each recommendation.

Zurich, another large insurer, recently published an even more elaborate listing of practical steps (Zurich Services Corporation, 2008). The listing includes engineering and administrative solutions for physical, physiological and psychosocial changes.

With same level falls (slips, trips and falls) identified as a major source for injuries in older workers, the slips, trips and fall prevention program evaluated by Bell et al. (Bell, J. L., Collins, J. W., Wolf, L., Grnqvist, R., Chiou, S., Chang, W.-R., et al. Evaluation of a comprehensive slip, trip and fall prevention programme for hospital employees. Ergonomics , 51 (12), 1906-1925) is a good resource for ergonomic strategies that have collectively been validated in a healthcare setting. The main intervention strategy elements are:

· Keep floors clean and dry
· Prevent entry into areas that are contaminated
· Use slip-resistant shoes
· Keep walkways clear of objects and reduce clutter
· Provide adequate lighting in all work areas including outdoor stairwells and parking garages
· Secure loose cords, wires and tubing
· Eliminate outdoor surface irregularities
· Eliminate indoor surface irregularities
· Check stairs
· General awareness campaign

There are other resources like Designing for Older Adults: Principles and Creative Human Factors Approaches is one such reference (Fisk, Rogers, Charness, Czaja, & Sharit, 2009). Another is “Extra-ordinary” Ergonomics: How to accommodate small and big persons, the disabled and elderly, expectant mothers and children (Kroemer, 2006) where Chapter 6 is specifically about designing for aging.

These general guidelines and resources are a start. For any particular jobsite, safely fitting the actual job tasks to the the workers who actually perform them deserves consideration.