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Occupational Safety Hazards in the Assisted-Living EnvironmentFourteen Steps to a Risk Management Model
October 2014 • Lockton® Companies
L O C K T O N C O M P A N I E S
LORI SEVERSONVice President
Loss Control Consultant303.414.6155
The direct and indirect costs associated with back injuries in the healthcare industry, adjusted for inflation, are estimated to be $7.4 billion annually.1 The assisted-living industry costs are a part of this $7.4 billion estimation. Considering the explosive growth of this industry and that the country will be entering an era of the smallest employment base to care for the estimated 76 million baby boomers, this industry is in great need of safety professionals within its ranks, armed with strategic risk management plans.
According to the National Center for Assisted Living (NCAL), the typical length of stay for a resident in an assisted living environment ranges from two and a half to three years.2 NCAL statistics indicate medication assistance is a number one driver of care.3
Aging In Place, a Market Trend
When, and if, the resident leaves the assisted living setting, it is commonly due to the need for higher care. A recent trend across the country in the assisted living market place is an “aging in place” practice. “Aging in place” simply is an agreement by the family/resident and the facility that the resident continues to live at the assisted living home. This can be through hospice care or even for what many see as skilled care but without the licensed-care costs.
The assisted-living industry is in great
need of safety professionals within
its ranks, armed with strategic risk
management plans.
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From a safety perspective, the “aging in place” trend is one of the leading causes of hazards in the assisted living workplace. The hazards are primarily experienced when the resident becomes more dependent on the staff to assist him or her with activities of daily living (ADLs) due to physical decline and increased cognitive issues. The staffing levels in the assisted living environment are not as high as skilled care, so a direct-care employee may have upward of 10 to 14 residents under his or her care during a shift. With the added demands of more dependent residents, the risk for occupational injury is compounded.
The assisted living industry experiences a negative financial impact on its bottom line from the direct costs of claims, both liability and workers’ compensation. It pays for these events with “after the fact” dollars because of the lack of investing in prevention in engineering solutions. It pays in the form of workers’ compensation, liability, and property claims occurring as a result of the physical demands of the work and the work environment. These “after the fact dollars” are estimated to be three to ten times greater than the initial investment that could have been made to prevent them.
Have well-written job descriptions and clearly define the physical demands of the job.
To ensure the best employees are hired to match the needs of the organization and limit all liabilities, have well-written job descriptions that clearly define the physical demands of the jobs. This will also help reduce turnover and the associated costs. Consider having the physical demands defined by a physical therapist or job demands expert to ensure ever-changing employment law requirements and safety laws/best practice standards are outlined.
Use preemployment screening tools to hire the best and place them with the most complex clients.
Hire the best staff you can by using affordable employment screening tools that establish the organization’s needs, with criteria that define the job demands and stay within employment laws. To reduce liability, match the best staff to service the organization’s most complex residents. This, along with the well-written job description and physical demand descriptions, can help reduce turnover and the costs associated with restaffing.
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The greatest risks arise during the assistance with bathing,
dressing, transferring, and assisting to ambulate, using, or
not using, their assistive devices, such as walkers, scooters,
and wheelchairs, due to the postures and the home-like
work environment.
We call these incidents/injuries, “safe resident movement”-
related claims. They are oftentimes very costly, and are the
longest-lasting claims of healthcare workers.
These 14 steps to implementing a comprehensive
Assisted Living Risk Management Safety Model
will assist assisted living employers in reducing
the total cost of risk in their organizations for
employee, resident, and property safety.
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October 2014 • Lockton Companies
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Develop management safety statements in line with the organization’s mission and value statements.
Safety management statements set the tone for how employees will perceive the culture of safety and how they can or cannot behave toward day-to-day safety. A successful safety program has safety statements that are developed by the management team and the safety committee members. An easy way to bring these statements into practice is by beginning all standing operations meetings with a one- to five-minute opener about workplace safety. These must be specific and relevant to the organization versus general in nature and keep attention to prevention and process improvement versus blame. Seasonal safety issues and specific incident trends are great ways to connect safety mission statements to practice.
Create a safety/risk management team for insurance program oversight.
In addition to written statements of safety, an effective risk management control is to have a multidisciplined risk/safety management steering team in the organization regularly reviewing, discussing, and monitoring the insurance program of the organization.
This can be a small team, sized appropriately, based on your operations. Keep it simple and meet as part of existing meetings that may be related, or alone to allow for adequate attention. Collectively, the team needs to establish a set of metrics, such as claim frequency and severity, claim trends for causes, and costs.
Insurance professionals can assist an employer in developing these oversight committees, helping
determine typical metrics, and helping benchmark an organization to its industry and peers in the state or country. They can also help determine who can generate the reports, the frequency of the reports, and what format to document the monitoring of the corrective action plans.
Emphasize a balanced culture of employee and resident safety.
Too often in healthcare, patient and resident’s rights and survey results rule over employee needs. The healthcare worker and his/her safety is too often seen as just part of the job and a secondary priority. Spend the same resources and dedicate equal meeting time to communicating about employee safety as you do patient safety. Employees, who see employers who care for them as equals to the patients and residents they care for, typically have stellar safety records. People need to be valued. 4
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Require safety be a measurement of job performance for all employees.
Establish a list of safety rules for all employees to follow, and set these as job performance expectations for all job descriptions. During annual performance reviews, make safety a topic of performance, and speak to each employee’s part in the success, or lack thereof, of his/her day-to-day and departmental safety performance. This sets the tone that as individuals, we all are responsible for the success of our own performance and the organization’s overall safety performance.
Develop leading and lagging indicators for organizational safety performance.
The organization’s safety performance must be measured annually to ensure progress is made toward safety and risk reduction. This can be measured by creating leading and lagging indicators for safety. Examples of leading indicators are establishing annual goals of holding a predetermined number of safety meetings with management and holding a certain type and number of annual safety training meetings with all staff. Lagging indicator tracking consists of measuring injury frequency and severity (costs) or OSHA 300 log statistics. Trends should be noted and corrective actions set in place if the goals are not met. Results should be reported to all employees and the board, if one is involved.
Establish new resident assessments to determine when to accept risk and when to practice risk avoidance/risk transfer.
Assisted Living employers should determine in their business plans which level of resident care they will provide, and through resident assessments make clinical business decisions as to whether services will allow them to do business or the service requested will place them in too high a risk for an incident. The organization’s
clinicians will always need to use their professional judgment in the new business assessment and develop the optimal care plan for residents based on the new business assessments which reduces risks for all involved.
Establish best practices of care.
Establish best practices of care, which define what are acceptable and unacceptable ways of providing services which reduce risks to residents and employees. There are comprehensive resources from the Canadian Interior of Health, British Columbia, and Europe, which you can obtain from the author, which spell out best practice care standards.
Use Job Hazard Analyses (JHA) to establish best care practices, educate all staff, and help hold employees accountable to follow the best practice standards.
The model of “job hazard analysis” is a practical format of defining the proper steps to a job, the hazards one may encounter in the steps, and solutions for optimal resident and employee safety during each step of the job/task. Contact the author for specific assisted living job hazard analyses for tasks such as bed making and bathing.
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The organization’s safety performance
must be measured annually to ensure
progress is made toward safety and
risk reduction.
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October 2014 • Lockton Companies
5
clinicians will always need to use their professional judgment in the new business assessment and develop the optimal care plan for residents based on the new business assessments which reduces risks for all involved.
Establish best practices of care.
Establish best practices of care, which define what are acceptable and unacceptable ways of providing services which reduce risks to residents and employees. There are comprehensive resources from the Canadian Interior of Health, British Columbia, and Europe, which you can obtain from the author, which spell out best practice care standards.
Use Job Hazard Analyses (JHA) to establish best care practices, educate all staff, and help hold employees accountable to follow the best practice standards.
The model of “job hazard analysis” is a practical format of defining the proper steps to a job, the hazards one may encounter in the steps, and solutions for optimal resident and employee safety during each step of the job/task. Contact the author for specific assisted living job hazard analyses for tasks such as bed making and bathing.
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11 Develop a customized safe-resident-handling program.
The market in safe-resident-handling equipment now offers many solutions for the assisted living industry and functions well in the home-like assisted living environment. Implementing an assisted living safe-resident-handling program can be done by determining the dependency levels of your residents. For those that may require hospice care or other issues that may cause the resident to not be able to help himself or herself, assisted living homes in the U.S. have been outfitted with (where licensure allows) ceiling track, floor-based lifts and sit-to-stands, and assistive devices, and incorporate therapeutic use of lift equipment successfully. Because incidents/injuries during care of residents are one of the leading causes of injury in this employment sector, it will be imperative to have a creative and multidisciplined team driving the initiative forward.
Provide regular safety communications to staff and in various formats.
“Safety toolkits” are a recommended format of communication. After each resident and home environment assessment, have customized “safety tool-kits” to address the hazards and risks identified in each assisted living home. The toolkits can then be placed in the “Care Plan” for employee and resident safety, which resides in the resident’s room. This way, it is an immediately accessible resource, not to be left to an annual in-service.
The best safety toolkits should be developed by a multidisciplined team of safety professionals from the carrier/third-party administrator/broker relationships, direct care staff, supervisors, and management to create the excitement and buy-in necessary to bring “new” tools into the workplace.
Provide safety education and reeducate staff. Use materials in writing, online, and in-services.
Well-trained staff in safety-hazard recognition and control practices is a valuable asset to company profitability. By implementing proper new hire training, coupled with frequent safety reminders on best practices for care, your employees will exhibit safer work habits. What they do not know, they cannot practice. It is up to the employers to establish their standards and teach their employees. Once effective safety training is in place, the organization should begin to see reductions in claim frequency and severity over time.
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Develop a comprehensive claims-cost-containment practice and written program with employee performance expectations.
Incidents and losses will occur. The best practice for employers “after the fact” is to have a strong comprehensive claims-cost-containment program that includes performance expectations for all employees in the organization. A successful program will have performance expectations for the executive director, the insurance administrative person(s), and all employees. True cost-containment practices require everyone taking an active role in managing incidents to closure. Here are the basic steps to an effective program:
A. Have well-defined job descriptions that include the physical demands of the job. This should be sent along with the injured employee to appointments so treating physicians understand the job demands.
B. Have excellent incident analysis education and training in place for all new employees and make it ongoing for all staff. Learn from mistakes, near misses, and incidents and communicate them across the system.
C. Have a strong injury management program for all claims. Establish best-practice standards with all carriers/third-party administrators/brokers. Set the expectation for all that you care about safety and preventing injuries.
D. Hold all employees accountable for job performance standards under workers’ compensation, leave of absence requests, and personal-injury or property-damage incidents. Set the expectation that leaves of all kinds are monitored and healthy employees and work environments are the goal.
E. Have a strong return-to-work and alternate and transitional-duty program and partner with occupational medicine clinics where you can for work-related injuries. Set the expectation that unless you are hospitalized, coming back to work will be very possible and welcomed when appropriate and safe.
F. Have a customized, predetermined list of “alternate/transitional duty tasks” ready to show treating physicians when alleged work-related injured staff seek medical attention. Establish relationships with treating providers; let them know that you are an employer who is prepared for these events and can offer relevant safe work for injured staff.
G. Remain in regular communication with all staff on work-related or personal leaves of absence. Silence kills relationships and deters successful outcomes. Speak to your injured employees and invite them to company events. Keep them informed and expect them to do the same for you.
H. Hold regular claim reviews (all lines), hold routine reviews to ensure claims are monitored for costs, and moving forward, develop action plans with carriers, third-party administrators, and brokers to resolve issues. “Out of sight, out of mind” and “knocking on wood” are not risk management strategies. Keep a pulse on all claims—it is time well spent.
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October 2014 • Lockton Companies
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This article has presented the compelling reasons why the assisted living industry needs to develop a risk management model for reduction of risk, business continuity, and market demands. By applying the program elements listed (Steps 1-14), this risk management model should reduce the negative impact on human and financial resources to this industry. Its purpose is to assist this industry in developing a multifaceted safety program which each assisted living employer can customize.
A comprehensive list of general safety and safe-resident-handling equipment and assistive devices is available from the author to help assisted living industry employers identify solutions for their specific safety hazards.
References 1. Waehrer G., Leigh J., and Miller T. Costs of Occupational Injury and Illness within the Health Services Sector, Intl. J. of
Health Services, Vol 35(2): 342-359, 2005. In 2008 dollars.
2. Wright, Bernadette, PhD, (2004), Fact Sheet Assisted Living in the United States, AARP Public Policy Institute, October 2004, retrieved September 25, 2010 from http://assets.aarp.org/rgcenter/post-import/fs62r_assisted.pdf.
3. Wright, Bernadette, PhD, (2004), Fact Sheet Assisted Living in the United States, AARP Public Policy Institute, October 2004, retrieved September 25, 2010 from http://assets.aarp.org/rgcenter/post-import/fs62r_assisted.pdf.
A longer version of this article appeared in HealthBeat (Volume 10, Number 3)
Develop a comprehensive claims-cost-containment practice and written program with employee performance expectations.
Incidents and losses will occur. The best practice for employers “after the fact” is to have a strong comprehensive claims-cost-containment program that includes performance expectations for all employees in the organization. A successful program will have performance expectations for the executive director, the insurance administrative person(s), and all employees. True cost-containment practices require everyone taking an active role in managing incidents to closure. Here are the basic steps to an effective program:
A. Have well-defined job descriptions that include the physical demands of the job. This should be sent along with the injured employee to appointments so treating physicians understand the job demands.
B. Have excellent incident analysis education and training in place for all new employees and make it ongoing for all staff. Learn from mistakes, near misses, and incidents and communicate them across the system.
C. Have a strong injury management program for all claims. Establish best-practice standards with all carriers/third-party administrators/brokers. Set the expectation for all that you care about safety and preventing injuries.
D. Hold all employees accountable for job performance standards under workers’ compensation, leave of absence requests, and personal-injury or property-damage incidents. Set the expectation that leaves of all kinds are monitored and healthy employees and work environments are the goal.
E. Have a strong return-to-work and alternate and transitional-duty program and partner with occupational medicine clinics where you can for work-related injuries. Set the expectation that unless you are hospitalized, coming back to work will be very possible and welcomed when appropriate and safe.
F. Have a customized, predetermined list of “alternate/transitional duty tasks” ready to show treating physicians when alleged work-related injured staff seek medical attention. Establish relationships with treating providers; let them know that you are an employer who is prepared for these events and can offer relevant safe work for injured staff.
G. Remain in regular communication with all staff on work-related or personal leaves of absence. Silence kills relationships and deters successful outcomes. Speak to your injured employees and invite them to company events. Keep them informed and expect them to do the same for you.
H. Hold regular claim reviews (all lines), hold routine reviews to ensure claims are monitored for costs, and moving forward, develop action plans with carriers, third-party administrators, and brokers to resolve issues. “Out of sight, out of mind” and “knocking on wood” are not risk management strategies. Keep a pulse on all claims—it is time well spent.
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