There is no simple formula for staffing an occupational health service but for industries without particular physical or chemical hazards the following rules of thumb will not be far out of line. A safety officer and access to medical care nearby is generally adequate for an employee population of less than 200, an occupational health nurse is usually needed for more than 300 employees and for every additional 750 employees, an occupational hygienist becomes justified as a permanent position at about 500 employees, and a plant physician on at least a part-time basis becomes cost-effective at about 1000 employees and on a full-time basis for more than 2000. These crude guidelines do not take into consideration the hazardous nature of some industries or requirements imposed by regulations, however. An occupational health nurse may be quite sufficient for several hundred employees in an office building but an occupational hygienist may be essential for a small company in a high-risk industry. There is no simple formula for staffing an occupational health service but for medium-risk industries the above rule of thumb will not be far out of line.
As with all medical facilities, the staffing of an occupational health service depends on several factors that reflect the mission of the organization and to the health patterns in the industry and community:
The last two factors should have the least weight. Any organization that lacks the resources to support or to contract for an adequate occupational health service relative to its needs is in serious trouble. Such programs are not disproportionately costly and they protect the organization from liability. Peak needs should never be the basis for full-time staffing projections, as they burden the operation with redundant staff during most of the year. It is more cost-effective to anticipate the peak load on the service and to employ part-time personnel for assistance during these times. For example, if all periodic screening tests, such as audiometric testing, are performed in a single month, temporary or part-time staff can perform these duties while the full-time staff deals with preplacement screening on an on-going basis throughout the year. Seasonal industries usually schedule screening tests during their lightest months to minimize disruptions to production.
Occupational health professions that should be considered in making decisions on staffing are profiled in Chapter 1.
The routine patient encounters handled by an occupational health service usually do not require the presence of a physician. A well-trained occupational health nurse is able to handle virtually all routine services and to triage cases requiring a physician's attention. Indeed, it is to the organization's advantage to protect the physician's time, which is expensive, by having routine services provided whenever appropriate by nurses or trained technicians and permitting the occupational physician to concentrate on more complex matters, including the intensive management of problem cases, the development of programs affecting large groups of workers, and handling issues of policy. Another reason for this approach is that most routine occupational health services, such as preplacement evaluations, are repetitive but require strict adherence to a set of criteria and procedures. Nurses perceive such duties as a professional challenge and often perform exceptionally well, taking pride in their skill on many details. Physicians often do not perform as well in conducting such routine tasks. An efficient occupational health service usually functions on a day-to-day basis through the efforts of an experienced head nurse who enjoys the confidence of a physician prepared to delegate routine duties.
The majority of occupational health services function solely or primarily with nurses. For office workers or in other low-risk settings a registered nurse with special training in administrative aspects of occupational health may be sufficient. For more complex situations, however, a certified occupational health nurse (COHN) is preferable and the additional cost is not great. (See Chapter 1 for a discussion of COHN preparation.) A COHN is more versatile and competent to handle most common occupational health problems with occasional physician back-up, but these specially trained nurses are in relatively short supply. At the end of the chapter is a sample position description for an occupational health nurse.
Physicians in occupational health services in industry are of two types, plant physicians and corporate physicians. Plant physicians are often part-time, supplementing their practice with service to a local employer. It is usually to the employer's advantage to have a contractual agreement with the plant physician to ensure access to medical services when needed and to encourage the plant physician to become knowledgeable about common or characteristic problems in the industry through continuing education. Depending on the types of hazards encountered in the industry, it is often desirable to identify specialists willing to provide services as needed in dermatology, lung disorders, orthopedics, or general surgery. Such specialists can also be engaged to review procedures and to set down guidelines for the management of routine problems in their specialty areas.
Corporate physicians may be full-time medical directors of large companies or consultants providing services as needed. The distinction between corporate physicians and plant physicians is that the former become involved in formulating policy and designing programs that affect groups of employees while plant physicians have a more limited range of activities and spend more time providing direct care to ill or injured employees or handling the administrative aspects of individual cases. A corporate physician is a substantial investment in a valuable human resource for a company. Considerable training in occupational medicine, and preferably specialization with formal certification as a specialist in the field is needed if the investment is to be worthwhile. The corporate physician represents the organization to regulatory agencies, to workers' compensation boards, and to the public and media and must have the credibility and credentials to speak with authority.
For clinics and medical groups with occupational health services the pattern of physician staffing is somewhat different. Here a trained occupational physician may direct a service in which care is provided by non-specialists or even, at times, locum tenens (doctors on short-term assignments) but must retain ultimate responsibility for the quality of care delivered and must be prepared to review the management of cases on a routine basis. This system works reasonably well because the physicians are in a group that allows interaction. In a company or large public agency, however, the plant physicians are usually dispersed among several sites and must be prepared to function fairly autonomously.
An occupational medical clinic may require the regular services of a dermatologist but may only need access on occasion to a pulmonary physician, a cardiologist, a neurologist, or to any of several other medical and surgical specialists. Table 9.1 presents recommended physician staffing patterns for occupational health facilities, depending on need and the type of services offered. Properly trained occupational physicians are in too short supply to comprise the entire clinical staff in most situations. A core of physicians with occupational training is essential but the medical staff may be augmented by family practitioners, internists, general surgeons, and evey by locum tenens temporary help. Quality assurance for occupational medicine practice is then maintained by frequent consultation, continuing education, records review, and spot-checking for quality control of case management. In this situation, continuing and in-service training is particularly important.
Other health care professions may provide special services to extend the capabilities of the basic unit of physician and nurse, such as audiometric technicians, who provide routine screening tests for hearing conservation. Many of these professions are discussed in Chapter 1. Others may be needed depending on the programs offered by the service, such as substance abuse counsellors in employee assistance programs (EAPs), physician assistants or nurse practitioners in large services with heavy acute care needs, physiotherapists in settings where musculoskeletal injuries are a problem, and fitness leaders in health promotion programs with exercise programs.
Table 9.1. Physician Staffing Suggested for a Large Clinic Serving Many Employers. 1. Staff in residence or in close proximity 1.1 Occupational physician (oversight and supervision) 1.2 Primary care (family or general practitioner or general internist) 1.3 Surgeon (general surgery and burns) 1.4 Dermatologist 2. Staff on call for consultation 2.1 Ophthalmalogist 2.2 Pulmonary specialist 2.3 Clinical toxicologist (access to laboratory important) 2.4 Cardiologist 2.5 Psychiatrist 2.6 Radiologist (should have particular interest in chest films and interpreting lung disorders)
Specialized occupational health professionals who do not provide direct patient care are essential to certain functions of a comprehensive occupational health service. Safety engineers are persons trained in the management of physical hazards, such as fire and accident prevention. They are usually workers experienced in the operations of a plant who receive their education in a series of short courses and become mid-level managers with responsibility for safety in their organization. Industrial hygienists, on the other hand, are usually university graduates or certificate-holders educated in special academic programs emphasizing toxic hazards, engineering principles and management skills. There is considerable overlap between the two in practice. Radiation protection or control officers (health physicists) have specialized training in that field and are usually limited to that function. The best way to judge the qualifications of each is by the relevance of prior experience to the organization they are joining and the quality of their work as reflected in reports and programs for which they have been responsible. Other special occupational health professionals, such as toxicologists and epidemiologists, are required on the staff of some large organizations with special needs but are usually brought in as consultants to deal with specific problems, as are experts in other areas such as acoustical engineering.
An occupational health service should be a team effort. The service should be organized as simply as possible to coordinate medical and administrative activities; all lines of administrative authority and responsibility should converge on one person, the director. Communication must cut across departmental lines but the service must possess sufficient autonomy to function efficiently to meets its own objectives consistent with the long-range goals of the organization.
As occupational health services expand, two problems in maintaining quality arise: control over increasing numbers of staff and the stress placed on the entire system by an increasing caseload. The problem of creating stress on the system with an increased case load can only be approached by anticipating demands and strengthening the weak points of the system.
There are several ways to minimize the burden of personnel costs until a facility is entirely self-supporting. These include the following:
Finally, the routine administration of an occupational health facility is usually best centralized under one person who has the time and the responsibility to learn the nuances of the system. Rarely is it satisfactory for occupational health services to be managed as part of the "span of control" of a manager entrusted with other responsibilities. A designated coordinator or administrator who knows how the system operates is of great assistance to the occupational health professionals working within the facility and can easily save enough in efficient management to justify the cost of a new position.
Because the key position in most organizations is the nurse, a sample position description for an occupational health nurse is given in the next section.
The nurse practitioner functions as a health professional under the administrative direction of ________________________.
Provides supervision and instruction for nursing or other health professions during placement within the organization.
Provides expertise to committes and units within the organization regarding occupational and environmental health matters.
Participates in epidemiological and other research that may be conducted.
American Board of Preventive Medicine. Certification in the specialty of occupational medicine. J Occup Med 1982; 24:546.
Arthur D. Little, Inc. Costs and Benefits of Occupational Health Nursing. Washington, Government Printing Office, National Institute for Occupational Safety and Health Publication DHHS (NIOSH) 1980, pp. 80-140.
Brown ML. Occupational Health Nursing: Principles and Practices. New York, Springer, 1981.
Gallagher PM. Occupational health nursing: Autonomy and interdependence. Occup Health Safety 1981; 50:43-47.
Knight AL, Zenz C. Organization and staffing (Chapter 6). Occupational Medicine: Principle and Practical Application. Chicago, Yearbook Medical Publishing, 1975, pp. 77-82.
Seaver ME. Teamwork: Industrial hygienists and occupational health nurses. Occup Health Safety 1982; 51:30-32.