Public Risk August 2016 by Moire Marketing Partners

PUBLISHED BY THE PUBLIC RISK MANAGEMENT ASSOCIATION AUGUST 2016

BROWARD COUNTY RISK MANAGER NAMED

2016 PUBLIC RISK MANAGER OF THE YEAR

Meet JOHN BURKHOLDER PAGE 6

ALSO IN THIS ISSUE

SELF-FUNDED HEALTH PLAN MANAGEMENT: Direct Contracting with Medical Providers PAGE 11

INDUSTRIAL HYGIENE Using Science in Risk Management PAGE 14

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AUGUST 2016 | Volume 32, No. 7 | www.primacentral.org

CONTENTS

The Public Risk Management Association promotes effective risk management in the public interest as an essential component of public administration.

PRESIDENT Terri L. Evans Risk Manager City of Kingsport Kingsport, TN PAST PRESIDENT Dean R. Coughenour, ARM Risk Manager City of Flagstaff Flagstaff, AZ PRESIDENT-ELECT Amy J. Larson, Esq. Risk and Litigation Manager City of Bloomington Bloomington, MN DIRECTORS Brenda Cogdell, AIS, AIC, SPHR Risk Manager, Human Resources City of Manassas Manassas, VA

BROWARD COUNTY RISK MANAGER NAMED 2016 PUBLIC RISK MANAGER OF THE YEAR

Meet John Burkholder

Scott J. Kramer, MBA, ARM City/County Director of Risk Mgmt Montgomery County Commission Montgomery, AL Jani J. Jennings, ARM Insurance & Safety Coordinator City of Bellevue Bellevue, NE Scott Moss, MPA, CPCU, ARM, ARM-E, ALCM P/C Director Oregon Public Entity Excess Pool Salem, OR Lori J. Gray Risk Manager County of Prince William Woodbridge, VA Donna Dolinger-Capria, CRM, CIC, AINS Risk & Insurance Coordinator WaterOne of Johnson County Lenexa, KS

By Jennifer Ackerman, CAE

NON-VOTING DIRECTOR Marshall Davies, PhD Executive Director Public Risk Management Association Alexandria, VA EDITOR Jennifer Ackerman, CAE Deputy Executive Director 703.253.1267 • jackerman@primacentral.org

11 Self-Funded Health Plan Management: DIRECT CONTRACTING WITH MEDICAL PROVIDERS

14 Industrial Hygiene USING SCIENCE IN RISK MANAGEMENT By Chris Witty, MSPH, CIH

By Hal K. Luttschwager, ARM, CPCU, CLU

IN EVERY ISSUE

| 4 NEWS BRIEFS | 19 ADVERTISER INDEX

ADVERTISING Courtney Blackford 888.814.0022 • courtney@ahi-services.com

Public Risk is published 10 times per year by the Public Risk Management Association, 700 S. Washington St., #218, Alexandria, VA 22314 tel: 703.528.7701 • fax: 703.739.0200 email: info@primacentral.org • Web site: www.primacentral.org Opinions and ideas expressed are not necessarily representative of the policies of PRIMA. Subscription rate: $140 per year. Back issue copies for members available for $7 each ($13 each for non-PRIMA members). All back issues are subject to availability. Apply to the editor for permission to reprint any part of the magazine. POSTMASTER: Send address changes to PRIMA, 700 S. Washington St., #218, Alexandria, VA 22314. Copyright 2016 Public Risk Management Association

AUGUST 2016 | PUBLIC RISK

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MESSAGE FROM PRIMA PRESIDENT TERRI L . EVANS

You Want to Do WHAT?

Or, How PRIMA can help you survive.

o you ever find yourself as the last to know about a project? Sometimes, our coworkers only think of us as post-mortem problem solvers, not the global-thinking planners that we are. Take, for example, our winner of the prestigious PRIMA Public Risk Manager of the Year award, John Burkholder, director of risk management for Broward County, Fla. While he is consistently lauded for his many accomplishments in Broward County, including saving $12 million in workers’ compensation and $11 million in property insurance premiums, John has faced the same challenges of communicating the value of risk management. John has a few words of wisdom for us:  Get Involved – internally and externally. Position yourself to help, not hinder. Increase your resources by networking with other local risk managers, including those from private industry.  Increase your knowledge by becoming a certified risk management professional (ARM, CIC, etc.), attending PRIMA conferences and PRIMA Webinars and PRIMA chapter meetings.  Know your numbers. Evaluating your underwriting data, using insurers to help as needed, will help you develop your plan. You have to know where you have been and where you are, to know where you need to go.  Have Fun! Accept that this is a challenging profession, but face every challenge with a positive attitude. Participating in PRIMA’s ERM training allowed for more thorough integration of the risk management process throughout John’s organization. A regional project on climate change, presented in the enterprise risk management framework, provided engagement of several entities senior leaders and allowed communication of the value of risk management, likely resulting in

No matter how well versed we are in our jobs, we cannot know everything. That is why it’s important to realize that the best overall resource for you is PRIMA… When faced with a totally new concept, we rally together. I could not have survived in the Stone Age—pre-Google—if not for my PRIMA risk management contacts, vendor partners and liability pool.

improved risk management throughout the region. THAT is an accomplishment!

that I have seen, with interesting shops, restaurants, music and art.

No matter how well versed we are in our jobs, we cannot know everything. That is why it’s important to realize that the best overall resource for you is PRIMA. I have found that risk managers are very supportive of one another. We share knowledge. We share policies. We share stories. Occasionally, we share a good laugh, or cry. When faced with a totally new concept, we rally together. I could not have survived in the Stone Age—pre-Google—if not for my PRIMA risk management contacts, vendor partners and liability pool.

Finally, have you ever wondered how one gets to be on the PRIMA Board of Directors? Board members are chosen by a panel of PRIMA members called the Leadership Development Committee (LDC) and then sent to the membership at large for a ratification vote. If you are interested in serving on the LDC—another way to give back, network with your peers, share information, learn from others—applications are being accepted until September 2. The LDC application form is on the web site—www.primacentral.org.

The good news is that PRIMA is your go-to source for knowledge and support. We ARE a supportive group. Questions can be posted on PRIMAtalk and answers will come from all over the country. In addition to the annual conference, we also have PRIMA Institute. This year it will be held October 24–28 in Pittsburgh, Penn. It is an intense, week-long learning experience, oriented toward the newer pubic risk manager but with lots of information that would benefit even the most seasoned. I strongly encourage everyone to go. In addition, Pittsburgh is one of the best examples of successful urban redevelopment

So, the next time you get a call on Wednesday, advising you there is a model rocket competition scheduled to launch from your stadium on Friday, you know to go to PRIMA members for help. And commiseration.

Terri L. Evans 2016–2017 PRIMA President Risk Manager City of Kingsport, Tenn.

AUGUST 2016 | PUBLIC RISK

NEWS BRIEFS

NEWS Briefs

INSTEAD OF SELLING GUNS, SEATTLE POLICE WILL START DESTROYING THEM The Seattle Police Department will begin melting down its unused guns rather than selling them, ending a practice that brought in about $30,000 a year, reports the Seattle Times. The resolution was a slight change of plans— the City Council was expected to vote on a resolution saying the guns would be sold only to other law-enforcement agencies, but Councilmember Tim Burgess amended the resolution, which then passed unanimously. “We don’t want the city in the business of distributing and selling firearms,” Burgess said.

The original resolution presented said the council hoped to ensure guns from the department aren’t “diverted into an illegal market” and sought “to increase responsibility and improve firearm safety in the community.” Burgess said the amendment was passed primarily to keep gun-disposal policies consistent. The department also destroys firearms that are either surrendered to or seized by police. The decision comes months after the fatal shooting of Che Taylor, who was killed by two Seattle police officers who feared he was reaching for a gun that was later traced back to a former King County sheriff’s deputy. The resolution and Burgess’ amendment is unrelated to the case, Burgess said. “That was never discussed in this at all,” he said.

PUBLIC RISK | AUGUST 2016

Dave Workman, spokesman for Second Amendment Foundation and senior editor of TheGunMag, called the decision a “terrible waste of money.” “We’re talking about the taxpayer’s money,” he said. “City Council doesn’t own those guns; the taxpayers do.”

“

SPD spokesman Sean Whitcomb said he supports the decision “full-heartedly.” “Really, this is a small cost to the department and the city to ensure that a gun no longer in use by the Seattle Police Department is not going to be used irresponsibly or fall into the wrong hands,” he said. “Ultimately, I think there’s general peace of mind.”

Really, this is a small cost to the department and the city to ensure that a gun no longer in use by

“

The resolution affects up to 100 guns per year, said a spokesperson from his office. Previously, the department would sell guns back to the manufacturer.

the Seattle Police Department is not going to be used irresponsibly or fall into the wrong hands… Ultimately, I think there’s general peace of mind.

Sean Whitcomb, Seattle Police Department spokesman

LAWSUIT CHALLENGES CALIFORNIA’S STRICT VACCINATION REQUIREMENTS With California’s strict vaccine mandate now in place, opponents are fighting to overturn the law in court, reports The Associated Press. The new law, which took effect in July, bars parents from citing religion or other personal beliefs as reasons to not vaccinate their kids. SB 277 is one of the toughest mandatory vaccination laws in the country and drew many protesters when it was debated in Sacramento. A group of parents and the nonprofit Education 4 All filed a suit to overturn the law in U.S. District Court in San Diego. The suit claims that the law violates California children’s right to an education under the state’s constitution. “SB 277 has made second class citizens out of children who for very compelling reasons are not vaccinated according to the CDC schedule,” the plaintiffs’ attorney, Robert T. Moxley, said in a statement. “We are hoping the court will grant us an injunction while the judicial process takes place to see if this law is constitutional, which it most certainly does not seem to be.” The plaintiffs are seeking a preliminary injunction to suspend the law while the case is being decided. In September, opponents of the law failed to gather enough signatures to put a referendum on the November ballot to overturn the law. The new law requires children entering school or day care be vaccinated against measles, mumps, whooping cough and other diseases. There are exceptions for people with documented medical conditions, like immune system deficiencies or allergies.

GETTING DIVORCED NOT A FIREABLE OFFENSE, RULES NEW JERSEY SUPREME COURT Employers cannot discriminate or terminate workers for going through a divorce or separation, the New Jersey Supreme Court said in a ruling. The decision stemmed from a case in which an employee of the Millville Rescue Squad in Cumberland County said he was fired in 2006 after telling a supervisor he was divorcing his wife—who also worked there—and having an affair with another coworker. Mario A. Iavicoli, who represented the former employee, Robert Smith, said that the ruling was critical for the broader workforce in New Jersey. It is the first time state courts have defined “marital status” to include divorces and separations, reports the Philadelphia Inquirer. “That’s a very, very important decision in the workforce, extremely important, because of the amount of divorces that occur in our society,” Iavicoli said. Smith is now married to the woman with whom he had an affair. Iavicoli said they married between six months and a year after Smith’s divorce was finalized, in September 2006.

The legislation gained momentum after a measles outbreak at Disneyland in 2014 that infected 150 people. State health officials said that vaccine refusal partly fueled the outbreak.

Smith was the director of operations at the rescue squad, where he had worked for 17 years. His then-wife, Mary, and her mother and two sisters also worked there, according to the suit. They reported to the top person in charge, rather than Smith, who was second in command, Iavicoli said.

About 80,000 California students claim personal belief exemptions for vaccines annually.

Smith had an affair with a volunteer he was supervising in 2005. He and his wife, who

found out, both separately alerted their supervisor. The supervisor, according to the suit, said he could not promise that the affair would not affect Smith’s employment, and said, “All depends on how it shakes down.” Smith moved out of the home he and his wife shared on New Year’s Day 2006, and then told his supervisor the marriage had collapsed. The supervisor, the suit said, was worried that Smith and his wife would have an “ugly divorce,” and notified the rescue squad’s board. The board then chose to terminate Smith, though it cited poor performance rather than the separation. Iavicoli said the Supreme Court’s ruling in his opinion does not exclude divorced workers from discipline if they wreak havoc or cause disruption at work. Rather, he said, it means someone cannot be fired simply because they are going through a divorce or separation. Iavicoli said Smith is now an EMT at a hospital in Gloucester County and still lives in Cumberland County. The ruling means Smith’s suit for damages can now be heard again in Superior Court in Bridgeton. Iavicoli said that if the suit goes to trial again—or a settlement is reached—Smith will seek remuneration for his termination. Iavicoli said he believed Smith’s salary at the rescue squad was in six figures, but he did not have an exact amount.

AUGUST 2016 | PUBLIC RISK

BROWARD COUNTY RISK MANAGER NAMED

2016 PUBLIC RISK MANAGER OF THE YEAR BY JENNIFER ACKERMAN, CAE

PUBLIC RISK | AUGUST 2016

Meet JOHN BURKHOLDER

ROWARD COUNTY, FLORIDA, faces many unique challenges including a prime spot in “Hurricane Alley,” a massive seaport, a diverse workforce including many volunteers, and the uncertainty

of climate change. Luckily, the second largest Florida county employs John Burkholder as the

director of risk management. Burkholder has created some of the country’s most lucrative and

money-saving risk management programs. His success has earned him accolades from his peers. It has also earned him the title of PRIMA’s 2016 Public Risk Manager of the Year.

SEAGRASS TO SAWGRASS

Broward County is made up of 31 municipalities, has a population of more than 1.8 million people, and is governed by nine commissioners. It runs from the ocean to the Everglades— seagrass to sawgrass, they say. In 2015, Broward County celebrated its 100-year anniversary. The County provides traditional county government administration services such as budget services, tax collection, human resources, planning, human services, technology services, fleet services, cultural centers, and communications services. Broward County also provides public works such as water and wastewater, traffic engineering, waterway bridges, canal maintenance and building services. According to Burkholder, Broward’s specific risk management challenges include an

owner-controlled insurance program (OCIP) that has completed $1.3 million of capital construction at 60 projects, utilizing more than 700 contractors and subcontractors over the last five and half years. Other challenges include the Port Everglades seaport, with approximately 3.6 million passengers annually on 41 cruise ships and more than 4,000 cargo ship calls per year. As director of risk management, Burkholder administers Broward County’s self-insurance programs and develops its policies and procedures in order to meet established goals. He regularly advises the Board of County Commissioners, the County Administrator, department heads, and division heads on the identification of risk, the application of methods to minimize or eliminate risk and the implementation of means to transfer or accept those risks.

AUGUST 2016 | PUBLIC RISK

2016 PUBLIC RISK MANAGER OF THE YEAR: MEET JOHN BURKHOLDER

of Broward County is extremely challenging on many levels… Risks include

seasonal storms, an ever-changing global insurance market, preparing for

“

Managing a risk management program in a county of the size and diversity

potential climate change, Federal Emergency Management Agency (FEMA) post-disaster rule changes, workers’ compensation changes and deviations, large capital growth, and construction infrastructure.

John Burkholder, 2016 Public Risk Manager of the Year

“Managing a risk management program in a county of the size and diversity of Broward County is extremely challenging on many levels,” said Burkholder. “Risks include seasonal storms, an ever-changing global insurance market, preparing for potential climate change, Federal Emergency Management Agency (FEMA) post-disaster rule changes, workers’ compensation changes and deviations, large capital growth, and construction infrastructure.”

RISK MANAGEMENT IN HURRICANE ALLEY

Broward County is located on the Atlantic Ocean in south Florida and is part of “Hurricane Alley,” an area that has birthed many historic hurricanes that have landed in Florida. The fluctuating property insurance market in this geographical area requires market knowledge and property expertise in order to maximize the ability to provide acceptable and sufficient property insurance coverage for the County. “We knew we had to augment the property program with GIS information to better map all of our properties and add more outside appraisals, including professional surveyor-supplied threshold elevations to obtain better COPE data to analyze the County properties,” said Burkholder. “These efforts have lowered the Probable Maximum Loss (PML) since 2012 by $274 million (or

PUBLIC RISK | AUGUST 2016

49 percent) and reduced the County’s annual property premiums by over $11 million. The property program alone has saved over $35 million by vastly improving our risk profile to underwriters while almost doubling our named windstorm coverage.” The uncertainty of climate change, in low areas such as Florida, is being addressed by the County’s Environmental Planning and Community Resilience Division, a leader in advancing climate resiliency nationally. By combining expertise and merging knowledge, Burkholder helps the county respond to climate resiliency at a higher level and adapt to potential cost changes in property insurance. The improved GIS data is providing the location and elevation of every county building in graphical representations in order to map and analyze all of the properties and prepare the county for resiliency studies or to provide protection for these properties in the case of adverse conditions.

WORKERS’ COMP WIN

In the workers’ compensation program, Burkholder hired a new manager in 2012 and they led the changes that resulted in the Broward County Risk Management Division being one of three recipients for the National Underwriter’s 2015 Workers’ Compensation Risk Management Award for Excellence. The substantial reduction of

workers’ compensation open claims (from 668 claims to 235 claims), pharmacy and medical cost savings of more than $4.5 million, and savings of over $7.5 million in settled claims during the last three years has improved the risk program and set new goals for future success. Other improvements included workers’ compensation adjuster metrics for job performance and functional capacity analysis for light or modified duty for injured workers by the Safety and Occupational Health Section in every claim. Burkholder’s efforts also resulted in the Broward County Board of County Commissioners recognizing the Risk Management Division with a County Proclamation for its efforts and savings.

OTHER RISK MANAGEMENT CHALLENGES

The Broward County Transit system operates more than 350 buses, covering three counties and over 410 square miles of routes, with 41.5 million annual trips. “In the future, the Broward County Transit Division will debut a new modern streetcar system, ‘The Wave,’ which will add more riders to our already robust transit system,” said Burkholder. “The transit system offered many challenges from a hiring, liability and workers’ compensation standpoint.”

Burkholder has worked to incorporate new risk management and loss control systems that allow risk management liability adjusters immediate access to the video database of all bus cameras and audio files, and to allow the Safety and Occupational Health Section personnel to assist and test potential commercial driver candidates, ensuring that those candidates meet minimum job requirements. A large and diverse workplace has prompted the use of “embedded risk managers” in potential high loss or complex departments in order to address specific loss potential or other multifaceted risk issues that are specific to one department. There are four embedded risk managers in and funded by four departments, but are mentored, supported and trained by the County’s Risk Management Division. The goal of the process is to provide consistent awardwining policies and procedures throughout the entire County organization. “John is a consummate professional who is always focused on customer service,” said Monica Cepero, assistant county administrator for Broward County. “He is very inclusive of all of our departments and all of the entities within the county government.” The county’s current OCIP is now completely managed by risk management. Its projects include a 20-floor courthouse as well as

an elevated runway at the airport, where planes land over a railroad track and a divided federal highway. These construction projects have been completed with a loss ratio of only 18 percent, with a projected savings of more than $24 million using the broker’s calculations and savings of contractor-proposed insurance costs. After various issues with the management and direction of the OCIP, Burkholder instituted a complete restructuring, changing third-party administrators, the agent/broker, the safety personnel, legal counsel, and most of its other vendors. All of these changes occurred after the OCIP was transferred to risk management.

“John is deserving of the Risk Manager of the Year award for 90 million reasons and that’s the total savings he’s saved the county—over $90 million,” said Kevin Kelleher, Deputy CFO/ deputy director of the finance and administrative services department for Broward County. For more than four years, Burkholder has been making a difference in Broward County, with both his passion for risk management and his desire to help others. PRIMA congratulates John Burkholder on his career of risk management excellence!

The success of the OCIP restructuring encouraged Burkholder to expand capital project insurance options and one airport terminal project recently saved almost $2 million by utilizing a hybrid insurance remedy for the project. The accomplishment of this project insurance funding has created a new Controlled Insurance Program (CIP) that will analyze all of the insurance bids and apply the best insurance product to the project. These changes have had a dramatic effect on the more than 700 contractors and subcontractors working on county projects, including the project initially with the most claims rebounding to a project that received the first Broward County OCIP safety award.

AUGUST 2016 | PUBLIC RISK

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Self-Funded Health Plan Management:

DIRECT CONTRACTING WITH MEDICAL PROVIDERS BY HAL K. LUTTSCHWAGER, ARM, CPCU, CLU

RECOMMEND BEER. That was my response to a

question posed by an audience member at a health

care purchaser conference held in Casper, Wyoming,

in the summer of 2014. Our health plan has, for its hip

and knee replacements, bundled pricing arrangements

with a hospital. He was curious to hear how we began the

process that led to these arrangements. The larger scope of my presentation prior to that question was more directed

at using data analytics to reduce health care expenditures via negotiated fee agreements i.e. direct contracting. The

comment about beer was true. We launched our mission to obtain better pricing from providers based, in part, upon a conversation with another health plan administrator, who

opined, over that beer, that hospital discounts were not the way to control medical trend. He was right.

AUGUST 2016 | PUBLIC RISK

SELF-FUNDED HEALTH PL AN MANAGEMENT: DIRECT CONTRACTING WITH MEDICAL PROVIDERS

Our definition of direct contracting is simply this: the health plan has contracts with the medical providers who form our network of preferred providers. Those providers who have a contract with our health plan are in-network providers while those who do not are out-of-network. The contract determines what the health plan pays for services. We have, for the most part, fixed pricing for services rather than discount agreements. Imagine a self-funded, government-sponsored health plan, formed in 1980, with current enrollments of just over 1,000 employees and retirees and fewer than 2,000 total covered lives. This plan operates in a community with two hospitals and a county population under 120,000. The nearest larger community is 200 miles away. This is Missoula, Mont., and the health plan is the Missoula County Employee Benefits Plan. Our payment strategy, until five years ago, was designed to keep our administrative costs and participant friction very low, to pay any willing provider accurately and promptly, and to negotiate all large claims. This strategy was easy and it worked reasonably well, until it stopped working. It quickly became clear that a new strategy must be developed before any further ground was lost. But letâ&#x20AC;&#x2122;s back up now and engage in some explanation of the process that we used then, and still use today. Our medical claims expense trend was high, resulting in annual premium increases

frequently in double-digits. We ran our claims data from our data warehouse through a software modeling program developed by a well-known actuarial firm that was recommended by our broker. The data analysis showed clearly that we were paying more than most of the payer market in our market area. It was no longer viable to be passive on the fee billing front. What to do? Naturally, we looked at a lot of plan data and we considered multiple options, including reference based pricing and buying a more robust preferred provider network to constrain the ever increasing expenditures. We deemed that direct contracting held the most promise in our service area. We took the idea to our benefits committee and to the plan sponsor. Upon gaining their approval, we engaged the services of a contractor who then began the process of negotiating contracts with our top fifty providers (based on annual spend). We later expanded that network to include contracts with key providers outside of our usual service area, those essential for certain transplant and other special medical situations. We then expanded our use of pilot programs for developing models for treatment protocols useful to both our members and our providers. Our wellness plan has become more involved in population health initiatives and has begun a new strategic plan based on expanding the base of those who participate, by determining their wants and identifying any barriers to those wants.

New challenges in paying for health care present themselves often, but there are also new methods to respond to them. Affiliate with high quality brokers, consultants and data analytics professionals and then go talk to those who provide the services as well as those who consume medical services. With these tools and strategies, you can change the shape of your health plan and its results. 12

PUBLIC RISK | AUGUST 2016

We did encounter some obstacles among those with whom we sought to contract, but most providers readily agreed to contracting with our health plan directly, rather than through an intermediary. A few providers required extra time and attention to work through the changes in their business practices. Most often, an extra meeting to explain our need to change the payment model was sufficient to calm concerns raised. As always, a few providers refuse to contract with any payers, but the number was small in our case and we are very satisfied with our experience and results. We now pay less for administrative services related to network contracting than we did prior to these changes. More importantly, we saved over 20 percent in the first direct contracting year over medical claims paid, when comparing actual claims to the direct contracting prices, versus the old model of payments which were based on usual and customary, with discounts. The savings have continued into the second year and our premium increases have dropped to four percent in this plan year, and were zero in the last plan year. In addition, we now have added surplus in the trust account. Narrowing our network to pay fewer providers was appropriate for us. With good data and more transparency in provider billing, we have tools to locate low and high cost providers, and to review quality metrics. The direct contracting efforts also led us into better relationships with our provider community. We were able to meet many of them in person and learn how they want to practice and what we can do to make our relationships better. This led us into very favorable and beneficial bundled pricing arrangements (with warranty periods, but that is a different topic). We also obtained better pricing on high frequency, lower cost diagnostic procedures and are making headway on a model that further distances us from fee for service plan design. New challenges in paying for health care present themselves often, but there are also new methods to respond to them. Affiliate with high quality brokers, consultants and data analytics professionals and then go talk to those who provide the services as well as those who consume medical services. With these tools and strategies, you can change the shape of your health plan and its results. Hal K. Luttschwager, ARM, CPCU, CLU, is the risk manager for Missoula County, Mont.

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INDUSTRIAL HYGIENE

USING SCIENCE IN RISK MANAGEMENT BY CHRIS WITTY, MSPH, CIH

ONSIDER THE FOLLOWING SCENARIOS: You just received a phone call from the local wastewater treatment plant. An employee was opening a valve and wastewater splashed in her face. Sheâ&#x20AC;&#x2122;s concerned that the

wastewater could be toxic and that she will become ill. Or, an employee from the

public works department stops by to ask you if he needs to wear a respirator when grinding pavement to lay new asphalt. What are the hazards of this dust?

PUBLIC RISK | AUGUST 2016

These are just a few examples of questions you may hear as a safety director or risk manager for public sector operations. So where do you turn for answers to questions regarding potential employee exposures to chemical, physical, or biological agents? This is where an industrial hygienist can help. Industrial hygiene (IH) services can assist you with your risk management programs to proactively evaluate potential workplace hazards. Industrial hygienists can equip you with the knowledge to understand and evaluate possible hazardous exposures in your workplaces and help you respond and communicate articulately when such exposures are publicly identified. Occupational injuries, such as cuts and fractures, can result from a work-related event of a single instantaneous exposure in the work environment. Occupational illnesses include any abnormal condition or disorder, other than one resulting from an occupational injury, caused by exposure to factors associated with employment. They include acute and chronic illnesses that may be caused by inhalation, absorption, ingestion, or direct contact with chemical, biological or physical agents. Claims or injuries associated with overexposure to occupational hazards while on the job continue to be a concern in many work environments. Skin diseases, hearing loss, respiratory conditions and poisoning claims have consistently been the most frequent type of occupational illness claimed over the years and should be addressed in your workplace. How do you address the potential increase of occupational illnesses is the question at hand?

Proof that an illness and/or disease process was caused by inhalation, absorption, ingestion or direct contact with a physical, chemical, or biological substance, typically requires a wellfounded, scientifically established conclusion about a cause and effect relationship. Otherwise, the relationship between illness and/or disease and substance may be considered speculation. Industrial hygiene monitoring can provide this needed objective data. According to Ronald Gots in his 1993 book, Toxic Risks â&#x20AC;&#x201C; Science, Regulation and Perception, proper principles of causation analysis methodology can be summarized as follows:

The fields of toxicology and IH are founded upon dose-response principles. When an exposure is less than that known to produce an injurious response, scientific data cannot support a claim of a causal connection. For example, the American Conference of Governmental Industrial Hygienists (ACGIH) promulgates Threshold Limit Values (TLV) that describe the minimum exposure levels that create an unreasonable risk of disease or injury (https://www.acgih.org/tlv-beiguidelines/policies-procedures-presentations/ overview). Unfortunately, claims are often seen where so-called experts testify to causality notwithstanding exposures well below levels known to be injurious.

Can the identified toxicant in question produce the illness/disease at issue? Are there substantial and properly relevant animal data? Is there human evidence, epidemiological support? Once it has been determined it can be causation, the next question that needs to be answered is: Did the identified toxicant cause the illness in this case? Have other causes been properly considered and ruled out? Has the exposure been confirmed? Was the exposure sufficient in duration and concentration?

What comes to mind when you hear the term toxic? What route of entry into the body? How much? Over what period of time? From a science perspective, toxic is a relative term that has little meaning without further qualification. Even a chemical generally considered harmless, safe, or non-toxic in small doses can be toxic at some level. Even water can be harmful when consumed in large quantities as is widely reported in the literature, potentially resulting in water intoxication or water poisoning where

Employment by ownership and nonfatal injury and illness case data from 2010 shows that while 11 percent of the total employed population in the U.S. is employed by local governments, 16 percent of the total recorded injuries and illnesses requiring days away from work across the country are directly related to local government operations (Bureau of Labor Statistics, U.S. Department of Labor, October 20, 2011, http://www.bls.gov/iif/oshwc/osh/os/osch0044. pdf). These numbers underscore the importance of local governments taking action to reduce the frequency of worker injuries, illnesses and associated costs.

AUGUST 2016 | PUBLIC RISK

INDUSTRIAL HYGIENE — USING SCIENCE IN RISK MANAGEMENT

your electrolyte levels are dangerously low (Case proven: exercise associated hyponatraemia is due to overdrinking. So why did it take 20 years before the original evidence was accepted?, British Journal of Sports Medicine (July 2006; 40(7): 567–572), for example). Consider that the dose makes the poison. Two aspirin relieve a headache, while a bottle taken all at once can be lethal. Most prescribed medications similarly have precise safe dosage regimens. Deviations may produce medication levels that are toxic. There is a correlation between what the person was exposed to and acute and chronic toxic effects. These can be two separate issues when allegation of exposure-related illness is made.

will anticipate and recognize by conducting a qualitative assessment to map potential exposures and identify operations that require further evaluation. Next, the industrial hygienist evaluates or conducts quantitative data collection through monitoring to better understand exposures. Lastly, the industrial hygienist develops solutions to control exposures, which include process engineering controls, administrative controls including programs and procedures like employee training and education and/or the use of personal protective equipment (PPE). When assessing potential workplace exposures, industrial hygienists typically investigate three main categories of hazards: biological,

radiation, temperature extremes and vibration. Biological hazards include bacteria, fungi and viruses. The most common workplace biological hazards include bloodborne pathogens, typically viruses like Hepatitis A. In public sector workplaces, bacterial hazards may also include communicable diseases such as tuberculosis. In assessing potential hazards, we must understand how these agents enter the body. Four main entry routes include: inhalation (breathing in a gas), absorption (the agent may enter the body by being absorbed through the skin), ingestion (some employees fail to wash their hands before taking a break) and injection (introduction of an agent through a puncture).

When evaluating the potential for exposure to a hazardous agent,

first determine if a source for the agent is present. Determine if there is a path for this agent to reach workers. If so, confirm that it actually reaches them and then determine if the workers are overexposed…

When we talk about concentration and duration of exposure, we are

looking at the dose—similar to when you take a dose of medicine. If you follow directions, you are exposed, but not overexposed. If you take it too frequently or take too much at a time, you are overexposed.

Industrial Hygiene is anticipation, recognition, evaluation and control of occupational exposure hazards. We leave scientific determination of cause and effect relationship between a toxicant and an illness or disease process to toxicologists. Industrial hygienists are trained and educated on how to accurately quantify these type exposures by implementing sampling strategies of the hazards. Industrial hygienists conduct sampling for the exposures identified, compare results to established safety thresholds and develop documentation recording the results. This data is crucial for effectively controlling the risk and potentially, the defense of non-meritorious claims. This assessment for exposures is best accomplished in these phases that are the basis for Industrial Hygiene. First, the industrial hygienist

PUBLIC RISK | AUGUST 2016

chemical and physical agents. Industrial hygienists may also look at ergonomic hazards. Biological agents include living organisms that cause adverse effects on humans. Chemical agents involve various toxic chemicals that can cause an immediate reaction, a long-term negative response, or both. Health hazards affect the whole body or a particular organ. Physical agents are various harmful physical circumstances, for example, acoustic, electric, or thermal, that can have a negative impact on the body, even without necessarily touching it. Ergonomic issues address how employees interact with their workspace. Common chemical hazards include dusts and fumes, gases, mists and vapors. Physical hazards include ionizing radiation, noise, nonionizing

Acute effects are immediate; whereas chronic effects typically develop over time. Examples of acute health hazards include dermatitis and headaches. Lung disease and hearing loss are examples of chronic health hazards. Local effects occur at the exposure site. With systemic effects, exposure occurs at one site, such as inhalation into the lungs, but the toxic effects occur elsewhere in the body, such as liver. Latency period is the period of time between exposure and onset of illness. Mesothelioma is a lung disease that develops after 15 to 20 years of asbestos exposure. When evaluating the potential for exposure to a hazardous agent, first determine if a source for the agent is present. Determine if there is a path for this agent to reach workers. If so, confirm

that it actually reaches them and then determine if the workers are overexposed. Consider the concentration of the agent. How much of the agent is present in the air? For how long are workers exposed to this concentration of the agent? Is it briefly, one day a week, or is it continuously everyday? When we talk about concentration and duration of exposure, we are looking at the dose—similar to when you take a dose of medicine. If you follow directions, you are exposed, but not overexposed. If you take it too frequently or take too much at a time, you are overexposed. Once hazards are identified, evaluation of exposure degree can be conducted. Air and noise monitoring are common exposure evaluation methods. For maximum resource usage efficiency, a sampling strategy can be developed. Define the scope of the survey and sampling reason. To interpret the data there should be an occupational exposure limit (OEL) for comparison to the results. Example OELs include Occupational Safety and Health Administration Permissible Exposure Limits, ACGIH TLVs and National Institute for Occupational Safety and Health Recommended Exposure Limits. Elimination, substitution and engineering controls can be the most effective and sustainable controls within the hierarchy of controls because they involve physical changes to work areas and do not rely on human behavior. Elimination means eliminating the risk by replacing a piece of machinery with something safer, for example. Substitution may also significantly reduce exposures, such as replacing toxic chemicals with less hazardous ones. Engineering controls involve physical changes to work areas. Example engineering controls include local exhaust ventilation, installing guards between the worker and the hazard and using mechanical equipment. Administrative controls involve policies or procedures that reduce risk factors. These typically can be less effective than engineering because they rely on the human decision making. Example administrative controls include worker training and job rotation to lessen exposure time.

Personal Protective Equipment can be considered a last resort after exhausting all other controls. Heavy reliance on PPE can limit its effectiveness. PPE examples include hard hats and respirators. In some situations administrative controls or PPE solutions may need to be implemented first to provide interim employee protection. Look at some of your operations. Then take a look at the tasks and work processes your employees handle. Examine the chemical and/ or physical exposures and determine the length and time employees are exposed. Conduct IH sampling to determine the amounts of chemical or physical hazards. Are you using PPE? What type? Is it appropriate? What would be the safest work practice possible? Consider some examples of possible occupational exposures in the public sector: • Water and wastewater treatment facilities: fecal-borne organisms, bloodborne pathogens (BBPs), chemical hazards, gases like chlorine, confined spaces, laboratory hazards, noise and temperature extremes. • Public works operations (such as street maintenance): hazards include chemicals, dust, noise, silica and temperature extremes. • Trash services: BBPs, diesel fume, dust, gases, noise, temperature extremes and insect-borne diseases. • Vehicle repair shops: carbon monoxide, diesel and noise. • Police: BBPs, evidence handling/ storage hazards, lead at firing ranges, methamphetamine laboratory hazards and noise. • Jails: BBPs, communicable diseases and fecal-borne diseases. • Fire departments: smoke inhalation, biological agents, dusts, noise and temperature extremes. • Public schools (kindergarten through 12th grade): asbestos, communicable diseases, dust, indoor air quality, laboratory hazards, lead and radon.

• Swimming pools: BBPs, chlorine, bromine, temperature extremes, non-ionizing radiation and insect-borne diseases. • Park and recreation: insect-borne diseases, pesticides, herbicides, BBP from discarded needles and chemicals in pressuretreated wood. Public sector entities sometimes overlook indoor environmental quality (IEQ) issues. IEQ issues may include employee complaints in offices, the general public visiting buildings to get permits, or inmates in jails. Typical complaints include stale air possibly related to inadequate fresh air, temperature complaints, sore eyes related to screen glare and allergyrelated sneezing. An evaluation of the facility’s heating, ventilation and air-conditioning systems often prove valuable in assessing these issues. Strive to obtain accurate, quantitative data in the event of a reported injury for the claims professionals and physicians to, not-only effectively treat the injury, but also to accurately determine compensability. Without it, it may prove difficult-at-best to determine injury causation. Without good quantitative data you may be paying for injuries that your doctors and claims professionals could have determined did not occur in the course and scope of employment. Chris Witty, MSPH, CIH is a senior industrial hygiene specialist with Travelers Risk Control.

AUGUST 2016 | PUBLIC RISK

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• September 14 – Implementing an Effective Return to Work Program • October 19 – Cyber Threats Faced by Public Entities • November 2 – ERM: Mandate & Commitment in 60 Minutes • December 14 – Communicating ERM Progress

PRIMA ANNUAL CONFERENCES June 4–7, 2017 PRIMA 2017 Annual Conference Phoenix, AZ Phoenix Convention Center June 3–6, 2018 PRIMA 2018 Annual Conference Indianapolis, IN Indiana Convention Center June 9–12, 2019 PRIMA 2019 Annual Conference Orlando, FL Gaylord Palms June 14–17, 2020 PRIMA 2020 Annual Conference Nashville, TN Gaylord Opryland

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