Public Risk March 2016

PUBLISHED BY THE PUBLIC RISK MANAGEMENT ASSOCIATION MARCH 2016

BUILDING TOMORROW’S WORKFORCE:

HOW TO MANAGE THE

GROWING

DIABESITY

EPIDEMIC PAGE 6

ALSO IN THIS ISSUE

HELP! MY INJURED WORKER IS ADDICTED TO NARCOTICS! PAGE 10

PUBLIC SECTOR SAFETY CULTURE PAGE 14

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MARCH 2016 | Volume 32, No. 3 | 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 Dean Coughenour, ARM Risk Manager City of Flagstaff Flagstaff, AZ PAST PRESIDENT Regan Rychetsky, ABCP Director, HHS Enterprise Risk Management and Safety Texas Health and Human Services Commission Austin, TX PRESIDENT-ELECT Terri Evans Risk Manager City of Kingsport Kingsport, TN DIRECTORS Lori J. Gray Risk Manager County of Prince William Woodbridge, VA

BUILDING TOMORROW’S WORKFORCE:

6

Jani J. Jennings, ARM Insurance & Safety Coordinator City of Bellevue Bellevue, NE Scott Kramer Risk Manager Montgomery County Commission Montgomery, AL Amy Larson, Esq. Risk and Litigation Manager City of Bloomington Bloomington, MN Scott Moss, MPA, CPCU, ARM-E, ALCM P/C Trust Director CIS Salem, OR

How to Manage the Growing Diabesity Epidemic

Tracy Seiler, ARM-P Director of Risk Management Services Texas Association of Counties Austin, TX

By Michelle Despres, PT, CEAS II

NON-VOTING DIRECTOR Marshall Davies, PhD Executive Director Public Risk Management Association Alexandria, VA

PUBLIC SECTOR

SAFETY CULTURE

EDITOR Jennifer Ackerman, CAE Deputy Executive Director 703.253.1267 • jackerman@primacentral.org

10 Help! My Injured Worker is Addicted to Narcotics!

By Fernando Branco, M.D.

IN EVERY ISSUE

14 Public Sector Safety Culture

By Dr. Rick Wakefield

4 NEWS BRIEFS | 19 ADVERTISER INDEX | 20 MEMBER SPOTLIGHT

ADVERTISING Donna Stigler 888.814.0022 • donna@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

MARCH 2016 | PUBLIC RISK

1

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MESSAGE FROM PRIMA PRESIDENT DEAN COUGHENOUR, ARM

“Y

Vison-Plan-Action or Action-Plan-Vision?

our” PRIMA vision is to provide you with focused educational opportunities coupled with valuable peer interactions that will help you to continue to excel at our profession of helping people. The Speaker Bureau, Annual Conference, online interactions, PRIMA Institute, Podcasts and more are provided by PRIMA to meet that vision. Nowhere else can you get all of this in one place that is focused on the public sector and the unique challenges we face. PRIMA is special and is made even more spectacular by your presence either in person, online or in spirit.

In sharing with you this month, I think of the risk management process and whether the essence of success is a process of Vision-PlanAction or Action-Plan-Vision? When I think of what it takes to be successful in managing risk and what it takes to be an effective risk manager, I would say it is both.

Establishing a vision of the future often comes from taking an objective look at what has happened historically, where the greatest opportunities lie today and then drawing up an action plan that is driven to meet that vision of the future.

As risk managers, reaching the vision is like going on a cross country trip in a 10-year-old recreational vehicle. We have a vision of how the trip will go, a plan to get there and a commitment to action. But as each mile of the journey unfolds, things change. We have to address the present, consider its impact and then refocus on our destination. Risk management is a lot like that. We are but a phone call or email away from a change in our priorities for the day, the

In sharing with you this month, I think of the risk management process and whether the essence of success is a process of Vision-Plan-Action or Action-Plan-Vision? When I think of what it takes to be successful in managing risk and what it takes to be an effective risk manager, I would say it is both.

week and sometimes our long-term vision. But that is the FUN part. Risk is not an assembly line of redundancy but rather a journey through the unexpected while continually refocusing on the vision of what controlling risk looks like for each of our entities.

That is why we are truly blessed to be in our profession. Sometimes we get lost along the way.

Relationships are stressed; we get stuck in a rut, take a side road on our journey and struggle to get back on track to meet the vision of when we first started out.

That is exactly where PRIMA comes in. PRIMA is like the road map, mechanic and parts supplier for what we need to be successful on our journey, to a vision of controlled risk. The more we fine tune our profession, the more we are prepared for the journey and all of the challenges and joys we will experience along the way and the more successful we will be.

are sure to be energized and have one of the best “tune ups” for your risk management journey to speed you on your way to being the best risk consultant for your entity. I look forward to saying howdy at the opening reception.

Keep driving toward your vision and enjoy the adventure every day.

You’re the BEST!

Dean Coughenour, ARM 2015–2016 PRIMA President Risk Manager City of Flagstaff Flagstaff, AZ

So plan to be involved and come to the PRIMA Annual Conference in Atlanta this June. You

MARCH 2016 | PUBLIC RISK

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NEWS BRIEFS

NEWS Briefs

AS UBER’S OUTCOME LOOMS, LYFT SETTLES LAWSUIT WITH DRIVERS Lyft drivers suing for employee status have agreed to remain independent contractors under the terms of a settlement agreement reached with the ride-hailing company, reports the San Francisco Chronicle.

The resolution of the proposed class-action case, one of many pending against the on-demand industry, allows Lyft to continue its core business model with few disruptions.

“We are pleased to have resolved this matter on terms that preserve the flexibility of drivers to control when, where and for how long they drive on the platform and enable consumers to continue benefiting from safe, affordable transportation,” Kristin Sverchek, general counsel at Lyft, said in a statement.

“We believe this is a fair settlement and adequate resolution of the claims we brought, given the risks we faced in the litigation against Lyft,” the drivers’ attorney, Shannon Liss-Riordan, said in a statement.

Those risks included provisions in Lyft driver contracts requiring arbitration and effectively banning class-action cases.

Lyft’s much bigger rival Uber has similar contract language but a judge hearing a case by Uber drivers ruled that its arbitration clause is unenforceable. That opened the door for the Uber drivers seeking employee status to proceed as a class action. Liss-Riordan represents the drivers in that case as well. It is set to be heard by a San Francisco jury in June in federal court.

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PUBLIC RISK | MARCH 2016

That case, O’Connor v. Uber Technologies, makes a variety of high-ticket financial claims, including that drivers are entitled to expense reimbursement and tips, both dating back to the founding of Uber five years ago.

The Uber and Lyft cases reflect a nationwide debate about whether the growing cadre of freelancers, including workers for a new generation of on-demand companies, should be entitled to the rights and benefits of employees.

“

Lyft said it supports new hybrid models that would give contractors more benefits.

“Apart from this settlement, we continue to explore a variety of ways to provide services and support for our driver community, including the potential for portable benefits, because we believe it is important to preserve the flexibility drivers cherish while also strengthening their safety net,” the company’s statement read.

Lyft said about 80 percent of its drivers put in 15 hours a week or less behind the wheel.

We are pleased to have resolved this matter on terms that preserve the flexibility of drivers to control when, where and for how long they drive on the platform and enable consumers to continue benefiting from safe, affordable transportation.

“

Lyft agreed to pay the drivers $12.25 million and make two changes in its terms of service for drivers. It will list specific reasons that allow it to “deactivate” drivers—previously it could terminate their service for any cause. Lyft also agreed to pay fees and costs for future arbitration claims.

Kristin Sverche, general counsel at Lyft

PENNSYLVANIA GETS RID OF GRADUATION TESTS, FOR NOW Pennsylvania Gov. Wolf signed a bill that would delay for two years the use of high-school graduation exams, thus allowing time to study whether such tests should be a requirement, reports the Philadelphia Inquirer.

The bill would make the 2018-19 school year the earliest the state could administer the so-called Keystone Exams, which have been marked by logistical and cost issues and criticized as being overly burdensome on school districts.

“While we should have high academic and educational standards in the commonwealth,” Wolf said, the state needs to look at Keystone alternatives.

“My administration is currently engaging teachers, administrators and students, community leaders, stakeholders and advocates from around the state to develop a comprehensive school accountability system that will support schools and help Pennsylvania students succeed,” he said.

The legislation passed the General Assembly unanimously.

The administration said the reasons for the delay included the fact that higher numbers of students are failing to demonstrate proficiency in the Keystone subject areas, which are algebra 1, biology, and literature.

The superintendent of the West Chester Area School District said during the summer that the exams could cause some struggling students to give up on being able to graduate.

Wolf said that school districts are shouldering the financial burden of helping students pass alternative tests.

Wolf said he believed testing has a place in determining student readiness, but agreed that the Department of Education should investigate other methods for students to demonstrate proficiency for graduation.

The bill he signed requires the department to study that very question and report its findings within six months to the legislature.

ILLINOIS REFUSES TO ADD CONDITIONS TO MEDICAL MARIJUANA LIST Illinois will not expand the list of conditions that qualifies people to get medical marijuana, Gov. Bruce Rauner’s administration announced.

The announcement came despite pleas from patient advocates and medical marijuana business owners who say they need more patients to make the industry viable in the state. So far, only about 4,000 people have been approved to use the drug, far below early estimates, reports the Chicago Tribune.

The decision was announced by the Illinois Department of Public Health’s director, Dr. Nirav Shah.

Melaney Arnold, department spokeswoman, said the program “remains in its early stage.”

“As patients have just started purchasing medical cannabis, the state has not had the opportunity to evaluate the benefits and costs of the pilot program or determine areas for improvement or even whether to extend the program beyond its pilot period,” she said in an email. “At this time, it is premature to expand the pilot program before there is the ability to evaluate it under the current statutory requirements.”

The move went against the state’s own Medical Cannabis Advisory Board, which

had recommended that eight conditions—including autism, irritable bowel syndrome, post-traumatic stress disorder, osteoarthritis and several pain-related conditions—be added to the list of about 40 ailments that can qualify people for medical marijuana.

Advocates had said they had delivered about 25,000 signatures on a petition asking the governor to expand access.

The first medical marijuana dispensaries opened in Illinois in November.

Dr. Leslie Mendoza Temple, chairwoman of the state Medical Cannabis Advisory Board, said she was “reeling” from the decision.

“I’m deeply disappointed,” she said. “But I’m not surprised. The governor’s office hasn’t shown much support for this pilot program, and it shows in this blanket rejection again.”

Mendoza Temple hopes to get more feedback as to why the conditions were rejected. She remained optimistic that the governor will reconsider after the board makes recommendations at its next meeting in May.

MARCH 2016 | PUBLIC RISK

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PUBLIC RISK | MARCH 2016

BUILDING TOMORROW’S WORKFORCE: HOW TO MANAGE THE

GROWING

DIABESITY

EPIDEMIC

BY MICHELLE DESPRES, PT, CEAS II

besity has been recognized as one of the greatest challenges being faced

in today’s workforce, with some studies estimating that nearly 70 percent of Americans are overweight.1 And, obesity leads to a number of significant

health problems, including diabetes, which impacts nearly 30 million Americans

(or 9.3 percent of the population).2

It is at the intersection of these two major health issues that we find one of the most significant health risks impacting workers’ compensation today: diabesity. Diabesity is the health issue marked by the occurrence of both diabetes and obesity in a person that, among injured workers, is commonly associated with increased medical costs, frequency of injury and illness, higher indemnification costs, slower recovery times and heightened risk for re-injury.

Unfortunately, this trend is not unique to today’s workforce. An estimated 17.5 percent of children and adolescents ages 3–19 are obese3 and more than 200,000 Americans under the age of 20 have been diagnosed as diabetic.

Clearly, this is a trend that will continue into the workforce of our next generations.4 As we look to maintain a healthy workforce, today and for the future, we must seek to better understand and manage issues resulting from the “diabesity” epidemic. Through proactive

management of diabesity cases, risk managers can help reduce time away from work, lower indemnity costs and improve overall recovery for injured workers. And, importantly, improved prevention, understanding and management of these cases allows employers to empower this growing population of workers to continue to make substantial, positive contributions to the workforce.

THE IMPACT OF DIABESITY ON WORKERS’ COMPENSATION It is well established that health issues related to diabesity have contributed to the everincreasing healthcare costs nationally. In fact, it is estimated that complications and conditions directly related to obesity (such as diabetes) cost the American healthcare system up to $200 billion a year, which is more than 10 percent of all healthcare costs. Unfortunately, this number is anticipated to rise in coming years where obesity has the potential to account for as much as 20 percent of all healthcare costs by 2020.5

MARCH 2016 | PUBLIC RISK

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BUILDING TOMORROW’S WORKFORCE: HOW TO MANAGE THE GROWING DIABESIT Y EPIDEMIC

In jobs requiring high levels of manual labor, it is important to consider that nearly one in two adults with diabetes reports physical limitations on stooping, bending or kneeling, and more than one in three adults reported limitations on standing for two hours.7 Among workers with diabetes, the workforce has seen the indirect costs as a result of increased absenteeism and overall reduced productivity while at work.

Beyond the financial impact on society, diabesity bears a substantial impact on workers’ compensation through increased claim volume, absenteeism, medical costs and greater indemnity costs.6 According to one study, morbidly obese workers (BMI 40+) are responsible for a 45 percent higher claim volume with an 800 percent increase in missed work days than workers who were not obese. The study also found that obese worker claims were associated with medical costs five times higher than non-obese workers and eight times greater indemnity costs.

In jobs requiring high levels of manual labor, it is important to consider that nearly one in two adults with diabetes reports physical limitations on stooping, bending or kneeling, and more than one in three adults reported limitations on standing for two hours.7 Among workers with diabetes, the workforce has seen the indirect costs as a result of increased absenteeism and overall reduced productivity while at work.

Further, medical costs for people with diagnosed diabetes are, on average, 2.3 times higher than costs related to non-diabetic workers.8 Due to the prevalence of claims involving both diabetes and obesity, it is clear that the diabesity trend will continue to play a major role in the daily responsibilities of risk managers across the country.

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THE ROLE OF PHYSICAL THERAPY IN MANAGING DIABESITY AND CLAIMS

Diabesity bears an impact on a person’s physiology and biomechanics, which contributes to the particularly high volume of claims requiring physical therapy among this population. In fact, the condition physically alters the biomechanics of a person’s spine making them more susceptible to injuries in the lower back.

Studies confirm this with workers who suffer from diabesity also demonstrating a greater frequency of musculoskeletal injuries, especially to lower back, knees, hips, wrists and shoulders.

And, when placed in physically demanding jobs, these workers demonstrate a particularly high rate of claims as compared to sedentary jobs.9 According to the authors of one study that was published in the Journal of Occupational and Environmental Medicine, of all risk factors impacting workers’ compensation claims, “obesity contributed the most to the risk to both low back and non-low back non-work related musculosketal disorders when associated with physically demanding work.”10 (Tsai, SP, Bhojani, FA, Wendt, JK) The increased frequency of claims requiring physical therapy can be attributed to a variety of factors, such as poor level of fitness, general muscular de-conditioning and decreased flexibility. In addition to the presence of co-morbidities, diabesity claims are also often complicated by the presence of arthritis, lower back pain, joint problems or even cancers. All of

these contribute to an increased risk for injury likely to involve physical therapy, slower healing rates and extended therapy durations leading to higher indemnity costs.

A ROADMAP FOR PREVENTION AND PROACTIVE MANAGEMENT OF DIABESITY

Prior to the placement of new workers, many employers are engaging post offer/pre-employment programs that screen new employees and match the demands of their bodies to their duties.

These programs consider a worker’s physical abilities and limitations to establish realistic work demands and goals. Through successfully implementing these programs, employers have demonstrated significant reductions in medical and workers’ compensation costs and overall claim volume for workers suffering from diabesity because they ensure that employees are appropriately matched to their jobs from the outset.

Once a worker with diabesity is injured, it is important to utilize clinical guidelines or benchmarks (such as ODG and APTA) as tools for identifying treatment utilization needs.

Still, because these guidelines are focused on immediate treatment results, it is important to corroborate these guidelines with any internal data analytics available to a risk manager, as well as his/her experiences and understanding of larger trends and clinical outcomes to ensure the best long-term results for an injured worker.

Given the prevalence of physical therapy in the treatment plans for injured workers with

diabesity, it is important for risk managers to remain proactive and involved in the therapy elements throughout a patient’s recovery. Proactive management and engagement with a patient’s physical therapy program is proven to improve diabese patient outcomes with reduced medical and indemnification costs (see “Case In Point”).

Physical therapy programs for patients with diabesity should include a number of key elements for success: • Increased balance considerations, addressing a patient’s biomechanics as appropriate.

• Education for fall prevention and appropriate sitting/standing postures.

• Joint protection and mobility improvements, such as aquatic therapy and increased strengthening exercises.

• Discussion of appropriate management of diabetes and suggestions for incorporating daily monitoring and management into an employee’s specific job function.

• A treatment plan with goals unique to the patient based on his/her exercise tolerance, diabetes management, return-to-work requirements and other clinical evidence of delayed healing.

• Oversight of an employee’s job requirements upon return to work to ensure demands meet an employee’s abilities in light of any mobility restrictions due to diabetes, obesity and/or the injury.

Upon an injured workers’ return to work, risk managers should also work closely with their entity to provide recommendations and programs to reduce future injuries. Through identifying risk factors for additional injuries, such as diabesity, employers are able to consider employee wellness programs and body mechanics training that can reduce some of the risk factors before an injury occurs. After an injury that involves physical therapy, work conditioning may be warranted if additional endurance, strengthening or biomechanics training needs remain barriers to return to work. Further, regular employee evaluations and benefits such as gym memberships, functional capacity evaluations (FCEs), on-site physical therapy visits and ergonomic evaluations have proven successful in reducing re-injury rates among workers with diabesity.

With statistics showing that the diabesity trend isn’t a really trend at all—it’s here to stay—risk managers must seek to better understand and manage claims involving injured workers who suffer from diabesity. Collaboration among the stakeholders in the workers’ compensation industry should be aimed at adjusting the management of these claims to match the needs of this population to reduce the risks of heightened claim frequency, ballooning claim costs, longer recovery periods, and increased rates of re-injury.

Michelle Despres, PT, CEAS II, is the vice president and national product leader at Align Networks, a division of One Call Care Management.

FOOTNOTES

1 Obesity and Overweight: Fast Stats. 2011-2012.

Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/hus/hus14. pdf#059 2 2014 National Diabetes Statistics Report.

Centers for Disease Control and Prevention. http://www.cdc.gov/diabetes/data/ statistics/2014statisticsreport.html 3 Carroll, M, Navaneelan, T, Bryan, S, et al.

Prevalence of Obesity Among Children and Adolescents in the United States and Canada.

NCHS Data Brief. Number 211, August 2015.

4 2014 National Diabetes Statistics Report.

Centers for Disease Control and Prevention. http://www.cdc.gov/diabetes/data/ statistics/2014statisticsreport.html 5 Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ. 2012; 31:219-30.

6 Ostbye, T, Dement, JM, Krause, KM. Obesity and Workers’ Compensation: Results from the Duke Health and Safety Surveillance System. Arch Intern Med. 2007 Apr 23; 167(8):766-73.

7 Age-Adjusted Percentage of Adults with Diagnosed Diabetes Reporting Mobility Limitation, by Task, United States, 1997–2011.

Centers for Disease Control and Prevention. http://www.cdc.gov/diabetes/statistics/mobility/ health_status/fig1.htm 8 The Cost of Diabetes. American Diabetes Association. 2013. http://www.diabetes.org/advocacy/ news-events/cost-of-diabetes.html 9 Ostbye, T, Dement, JM, Krause, KM. Obesity and Workers’ Compensation: Results from the Duke Health and Safety Surveillance System. Arch Intern Med. 2007 Apr 23; 167(8):766-73.

10 Tsai, SP, Bhojani, FA, Wendt, JK. Risk Factors for Illness Absence Due to Musculoskeletal Disorders in a 4-year Prospective Study of a Petroleum-Manufacturing Population. J Occup Environ Med. 2011 Apr;53(4):434-40. doi: 10.1097/ JOM.0b013e3182128b12.

11 Align Networks. Data on File.

CASE IN POINT: CLOSE OVERSIGHT OF DIABESITY PHYSICAL THERAPY CASE LEADS TO APPROPRIATE RECOVERY, REDUCED COSTS11 A 58-year-old obese male worker with diabetes developed Herniated Nucleus Pulposus (HNP), a common injury among obese workers. Upon evaluation and diagnosis, the worker was prescribed 12 physical therapy visits, which is the maximum prescribed visits under normative conditions. While the worker demonstrated objective progress, compliance and responsiveness, due to his weight, diabetes and age, he required an additional four physical therapy visits in order to make a full recovery and return to work. Following the additional four visits, the worker was able to return to full duty in a job with mediumheavy physical demand levels.

Proactive management and oversight of this case impacted by diabesity enabled the following positive outcomes: • Upon the determination that the worker would need further physical therapy, he was prescribed an additional 12 visits.

With close oversight and communication, the case management team saved additional costs and visits by determining that the worker would only require four additional visits for full recovery.

• Recognizing that this case involved diabesity, the case management team was able to appropriately emphasize nutrition, weight loss and healthy living with the injured worker.

Upon his return to work, the worker joined an employee wellness program. He has shown overall improvement and is demonstrating healthier habits.

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HELP! My Injured Worker is Addicted to Narcotics!

BY FERNANDO BRANCO, M.D.

T

he narcotics crisis that we are living with today started several years ago with some well-intended measures (i.e., treat pain as the fifth vital sign, give more power to the patient and

demand a pain-free existence). Various groups took advantage of this new found medical mindset. One important force was the pharma-

ceutical companies that discovered the lucrative business of narcotics.

Medications are not only needed by millions of chronic pain sufferers, but their continued use will be ensured in the future based on their

metabolic and addictive potential. If a prescription was all that was

needed, physicians could see a greater number of patients. Extensive face-to-face contact was no longer necessary, which resulted in more efficient and profitable medical practices.

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Due to their normal metabolism, narcotics and other addictive substances (e.g., sedatives, sleep aides, etc.) cause several abnormalities independent of the patient’s will. Tolerance will almost always develop and the patient will have to take higher dosages to achieve the same level of pain control. These medications may cause physical dependency, in that patients may experience withdrawal symptoms even if taking their regular dosages. As tolerance increases, they can suffer greatly if the medications are suddenly stopped. This is the same kind of withdrawal we are familiar with in crack or heroin dependency.

Addiction is the inevitable next step. Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestation, as defined by the American Society of Addiction Medicine (ASAM).

Addiction is a clinical syndrome that includes: • Loss of control: The patient is unable to stop taking the medications even if he or she has the will to stop. Physical dependency plays a major role here.

• Compulsive use: As tolerance increases, more and more medication is needed.

• Continued use despite harm: Deterioration in function occurs at work and socially. Use continues in spite of knowing risks of overdose.

• Craving: Physical dependency will likely cause craving in almost all patients.

To diagnose a person with addiction is not difficult, since most symptoms are related to involuntary physical dependency and tolerance.

Unfortunately, labeling somebody an addict does not do anything to help them. I will focus on the tolerance and physical dependency that can be treated if the patients want and are given the right treatment.

Patients have to be followed closely particularly if any of the situations described below are present: • Complaints of more or specific medications needed • Drug hoarding • Doctor shopping (i.e., several providers prescribing addictive medications) • Unsanctioned dose escalation • Refusing other non-narcotic pain treatments • Illegal activities (e.g., forging prescriptions, buying on the street) • Changing route of use (e.g., injecting, snorting) • “Lost” or “stolen” prescriptions • Resistance to change therapies despite adverse effects (e.g., severe constipation, sedation, sleep disturbance, increased pain despite escalating dosages) • Refusal to comply with random urine drug screens (UDS), or unexpected UDS results • Abuse of alcohol or other substances Another major problem associated specifically with the use of narcotics is what is now

well-established: opioid-induced abnormal pain sensitivity.

Narcotics eliminate our own endorphins. This, associated with tolerance and physical dependency, may cause increased pain sensitivity and, consequently, higher levels of pain independent of the underlying medical condition treatment.

It is not unusual to find that when the narcotics are weaned, the pain actually improves.

Addiction is major problem, but other serious narcotics side effects have to be taken in consideration, including: • Severe constipation: This condition is likely resistant to most common laxatives and therefore highly expensive drugs are needed.

Doctors have become “specialized” in treating this “disease,” but there is only one solution.

Stop the narcotics. Some of these patients have such serious constipation that bowel obstruction is not uncommon and surgery is needed.

• Hypopituitarism: Narcotics depress the pituitary gland that provides the body with hormonal balance. It is common to find individuals with hypogonadism (sexual hormone deficiency) and dangerous forms of replacement are used. Hypothyroidism (low thyroid hormone) is also common, causing increased weight (already inactive individual) and lethargy (already heavily sedated).

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HELP! MY INJURED WORKER IS ADDICTED TO NARCOTICS!

Narcotics are powerful muscle relaxants and their overuse can cause urinary incontinence as our sphincters are muscles. It is not unusual to find patients diagnosed with urinary incontinence from nerve injury to be able to control their bladder normally after weaning from narcotics.

What is the solution? There is no magical answer nor a silver bullet medication or procedure that will “fix” the chronic pain and narcotics addiction issues.

Only hard work from the patient and providers will resolve or improve the situation.

The main goals of treatment should always be to:  Improve the quality of life.  Restore optimum levels of function.  Reduce or eliminate pain.  Reduce or eliminate addictive medications.  Enable the person to become independent of the health care system (related to pain or associated side effects).

These goals can be achieved by an aggressive functional restoration program with a strong psychosocial emphasis.

The weaning process should occur in conjunction with functional restoration to maintain a drug-free future.

Rapid detoxification for a few days, whether inpatient or outpatient, will not be effective in the long term as the body and mind of the patient has not had time to adapt to the drug-free state. Therefore, recidivism is high.

Substitution narcotics therapy (e.g., methadone, buprenorphine) is not ideal as it does not treat the underlying pain problem.

Methadone was successfully used during the heroin epidemic of the 70s and 90s. It was effective because methadone has a metabolism in which only 50 percent of the substance is cleared by the body in 12 hours, maintaining a steady state that helps patients avoid severe withdrawal.

It was scheduled to be given once or twice each day. Unfortunately, when the narcotics epidemic first raised its ugly head in the early 90s, providers thought that methadone could be

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the silver bullet that would “fix” this problem.

Methadone has an analgesic effect (pain control) of only 3 to 4 hours and most patients ended up taking the medication multiple times per day. This resulted in a buildup of methadone and, consequently, overdose became a common occurrence. By the late 90s, methadone was the biggest killer due to overdose in the narcotics family. As its use waned, other narcotics took its place, such as hydrocodone (easy to prescribe and not considered “dangerous”).

Buprenorphine (Suboxone, Subutex, Butrans), was the next narcotic to come to the forefront.

Buprenorphine is not a new drug and has been used for decades with a well-documented history of abuse. It was repackaged with naloxone with the hope that it would discourage intravenous use or snorting. Buprenorphine is a partial agonist of the morphine receptor; its performance for pain control is weak. It does help to avoid the dreaded side effects, but most patients end up continuing to take narcotics to control pain if not used in conjunction with a functional restoration program. Buprenorphine is a narcotic and, eventually, has to be weaned off or it will cause all the same problems as any other narcotic.

The epidemic reached its peak in the last couple of years. The Centers for Disease Control suggests that prescription opioid sales in the United States increased by 300 percent since 1999 and, in 2013, there were 16,000 overdose deaths, four times the number in 1999.

Unfortunately, medical providers did not take charge of this epidemic. Law enforcement made the paradigm change, arresting providers that ran pill mills (prescribing narcotics without a detailed exam or any quality control) and changing public perception of narcotics when faced with the social and personal consequences.

The immediate reaction was a drop in narcotics prescriptions by some physicians without providing any other options. Now we see a heroin epidemic fueled by narcotics users that can no longer obtain them legally or illegally.

The solution will not come in the form of another silver bullet (e.g., spinal cord stimula-

tors, intrathecal pumps, spine intervention) but returning to the basics of improving the quality of life through hard work from the patients and the providers.

There are few effective functional restoration programs and they are expensive but, in the long run, will have great cost savings considering the costly consequences of not having programs.

Even more important, the patient will have a longer, more fulfilling life and hopefully be a productive part of society.

Treatment should include:  Aggressive physical therapy should focus on one-on-one treatment, direct supervision, hands-on stretching, education for selfstretching and exercise.  Occupational therapy should focus on activities of daily living (ADLs); work on posture, biofeedback (reminders to correct problems) and ergonomics (how to perform activities to avoid injury); gait training and increasing endurance.  Cognitive behavioral therapy should focus on changing behavior and mindset to improve pain. It is not psychotherapy and it should have a focused goal and limited sessions.  Neuromuscular massage should be aggressive enough to actually treat areas of pain instead of only soothing them. In this case, “no pain, no gain” as trigger points (knotted areas of muscle pain) will be painful when being treated.  Alternative medical practices should be used, such as acupuncture, as long as the benefits are greater than the risks to the patient.  Trigger point injections should be used in select cases. Even spinal injection could be helpful in a few instances as long as there is a functional goal in mind (i.e., what will the patient be able to do better after the injection and what are the risks).

Overall, the treatment has to be comprehensive and offer clear guidelines after discharge to include an exercise program, psychological tools to avoid recidivism and strategies to handle pain without the use of narcotics.

Dr. Fernando Branco is the Medical Director for Midwest Employers Casualty Company, a W. R. Berkley Company.

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PUBLIC RISK | MARCH 2016

SECTOR PUBLIC SAFETY CULTURE

BY DR. RICK WAKEFIELD

I

njury and illness risk is an integral or implicit element in the execution of all public sector missions.

While the cultural and environmental framework is unique to each organization, there exist common elements that form the foundation of risk management techniques.

Ultimate safety in the work place is a goal in modern organizations for which all strive, but which is impossible to accomplish. The risk management profession has grown and matured in a turbulent litigation environment that has resulted in a dichotomy of methodologies and strained the relationships between the business management style that emphasizes productivity as opposed to a culture that emphasizes worker safety.

People make mistakes and always will. Hence the term ‘being human’ means fallible, imperfect or error prone. The inevitable individual error cannot be eliminated, but it can often be intercepted, mitigated or compensated by a robust safety culture within the organization.

Safety culture characteristics include the perception of the values, beliefs, attitudes,

principles, morals, ethics and philosophy of the entire organization concerning safety. In this case, the perception is the reality and defines the safety culture. This perception varies considerably from one organization to another but also among groups and individuals within the organization. The administration and management perception (macro-culture) has its basis in a more scholarly approach involving overall staff training, cognitive understanding of the needs and fundamental necessity of safety, as well as its relationship to the success of the enterprise.

The frontline worker perception (microculture) is based on the individual attitudes and behaviors that ultimately result in the enterprise performance. The organizational macro-culture is the driving force, but the frontline worker can be immune to efforts at modifying this safety culture. This micro-culture is the most

MARCH 2016 | PUBLIC RISK

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PUBLIC SECTOR SAFET Y CULTURE

challenging to measure and modify. As James Reason concludes, “We cannot change the human condition, but we can change the conditions under which people work.” 2 Mearns et al.1 stated that “safety culture is an important concept that forms the environment within which individual safety attitudes develop and persist and safety behaviours are promoted.”

Unfortunately, there is such profound variation across the organization that it is difficult to evaluate the culture without substantial compartmentalizing. This helps with training design and implementation, but complicates the overall assessment of the organization.

Although the goal of a culture of safety is to lessen harm to workers and the public through both system effectiveness and individual behaviors, threats to safety will always be present and errors will occur throughout an organization.

ENVIRONMENTAL FACTORS

Environmental factors are not easily changeable. These factors form the context in which the individuals work and function. Such factors include the type of industry, service or product and by their nature are not modifiable. They also include unrelenting efforts to reduce costs, reduce the number of employees and trend toward outsourcing or technology.

In addition, environmental factors include increasing specialization among workers, high risk tasks, services or products and just doing more with less.

LATENT CONDITIONS

Public sector entities are not typically driven by profit but do suffer from the other latent condition pressures found in the private sector such as budget constraints, under staffing, and administrative pressure for quality and productivity.

Resolving latent system flaws will greatly increase the likelihood that the inevitable errors of individuals will be intercepted and prevented from causing harm to individuals, property or the organization.

INDIVIDUAL BEHAVIOR— THE MICRO-CULTURAL SAFETY ENVIRONMENT

Behaviors define the character of the worker; it is not what they are trained to do, what they say they will do, or what they are asked to do, but ultimately their job behaviors that characterize the safety potential of the individual. Their overall job behavior then, is a combination of their skill, attitudes and values.

Humans will make mistakes but they also voluntarily deviate (at-risk) from protocols and procedures of which they are aware and trained.

Workers also may engage in flagrantly reckless

Although the goal of a culture of safety is to lessen harm to workers and the public through both system effectiveness and individual behaviors, threats to safety will always be present and errors will occur throughout an organization… Some common obstacles to a safe system include: risk-prone activities; lack of standardized verbal, written, and electronic communication systems; tolerance of normalized deviation from policies and procedures; fear of retribution which inhibits reporting; and, lack of ownership for the task.

Some common obstacles to a safe system include: risk-prone activities; lack of standardized verbal, written, and electronic communication systems; tolerance of normalized deviation from policies and procedures; fear of retribution which inhibits reporting; and, lack of ownership for the task.

There is a natural bias for quality and production over safety both in management and individuals. The safest organization produces nothing and performs no service. This natural bias is the enemy of safety culture.

Individuals act in a system and two groups of factors comprise the macro-culture system; environmental and latent factors.

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PUBLIC RISK | MARCH 2016

Latent conditions are system faults that can be solved and act within the organization to increase the chances that individuals will make errors, and that those errors will cause injuries or property damage or both. These conditions often arise from decisions that affect organizational policies, are related to management, organizational culture, protocols/processes, and transferring of knowledge.

Examples include: • Inadequate procedures, protocols and resources; • Poor or inadequate communication; • Poor team compatibility; • Poor team coordination; • Poorly defined responsibilities; • Lack of training to back up coworkers; and • Failure to monitor coworkers for safety.

behaviors. These three behaviors—errors, at-risk and reckless—result in the majority of individually induced accidents.

Reasons for voluntary deviation or at-risk behaviors include efficiency, comfort, lack of knowledge, poor work ethic, and taking ‘shortcuts’.

Normalized divergence is the deviation from the safety policies and procedures that have become so common place at the worker level that the workers consider it to be normal behavior. This can lead to a “culture of low expectations”, in which workers come to expect a norm of unsafe practices.

Factors that increase the incidence of individuals making errors can never be completely elimi-

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PUBLIC SECTOR SAFET Y CULTURE

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PUBLIC RISK | MARCH 2016

nated. Individual performance can be improved; however, it cannot be perfected.

admission which inhibits safety implementation and quantification.

Coworkers respect their colleagues and mimic their behaviors which can contribute to normalized divergence. This is contagious and can become endemic. The same is true with safe work site behaviors. Good and bad behaviors spread by social coping, peer to peer transfer and emulation. Fostering this safety behavior through these methods is more likely to succeed than training in a classroom setting or online.

While “no blame” is the appropriate stance for many errors, some errors and deviations are blameworthy and demand accountability. The just culture response to an error, at-risk or reckless behavior is predicated on the type of behavior as opposed to the magnitude or severity of the event. Reckless behavior would result in punitive action even if no harm resulted.

Safety micro-culture is a slow viral spread among workers that can be initiated by workers with leadership qualities or supervisors.

THE ‘NO BLAME’ CONCEPT AND ‘JUST CULTURE’; A BLENDED SOLUTION

The no blame concept has been in use for decades and there is little published data on the success rate. It is extremely difficult to establish throughout an organization and often is found partially implemented. The concept of individual blame for errors is still dominant in today’s business world because it is a fundamental part of accountability, because consequences are a part of ownership of the task, and because it is part of the traditional management style. There is no doubt that punitive action and blaming contributes to a lack of voluntary

We need to accept the fact that errors happen and result in injury. Risk management professionals can mitigate the consequences and reduce the frequency of errors by continuing to be cognizant of the systemic flaws and behavioral characteristics of individuals.

Dr. Rick Wakefield is the CEO of International Healthcare Consultants, Inc.

FOOTNOTES

1 Mearns, K., Whitaker, S. M. & Flin, R. (2003) Safety Climate, safety management practice and safety performance in offshore environments Safety Science, 41, 641-680.

2 Reason J. Managing the risks of organizational accidents. Aldershot, United Kingdom: Ashgate Publishing; 1997.

3 Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch J., Johnson, J., Mitchell, P.,…Warren, J. (2007). Quality and safety education for nurses.

Nursing Outlook, 55, 122-131.

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TITLE MEMBER SPOTLIGHT

Yuma County Improves Health and Reduces Cost with Manual Therapy

M

ore than 70 million physician office visits each year are directly related to musculoskeletal pain, and such pain is also a significant factor in prescription drug use and frequent absences from work. In Yuma County, Ariz., the majority of the workers’ compensation claims are the result of musculoskeletal injuries. The county’s health insurance program costs are also greatly affected by employee pain.

In an effort to reduce the budgetary impact and personal costs associated with chronic pain, Yuma County partnered with Dorn Companies to institute a program of manual therapy called the Pain-Free Treatment Program (PFT).

“PFT is a system of non-invasive, deep tissue manual therapy consisting of more than 90 specific protocols for treating each different type of pain condition,” said Shannon Gunderman, risk manager. “It is designed to reduce or eliminate painful musculoskeletal conditions.”

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PUBLIC RISK | MARCH 2016

A local massage therapist was trained in the PFT technique and then the county simply paid the cost of the therapy sessions, which totaled $18,504 during the first year. According to Gunderman, the therapy provided during the pilot period saved the county approximately $87,500 by averting 25 potential claims, producing a net savings nearly $69,000 after costs.

The results of the workers’ compensation pilot program were so impressive that the trustees of the Yuma County Employee Benefits Trust unanimously recommended that a similar program be tested under the county’s health insurance, with the goal of including it as a fully covered wellness benefit.

Gunderman said that the program is easily transferrable to any entity. “Since Dorn Companies trains local therapists, any public entity with massage therapists in its community can easily implement the program. The fact that there are no up-front fees adds to the ease with which the program can be duplicated.”

For more information, contact Shannon Gunderman at shannon.gunderman@yumacountyaz.gov.

Each month, Public Risk features a member who has gone above and beyond in a feature column titled “Member Spotlight.” Do you know someone who deserves recognition, has made a contribution or excelled in their profession?

If so, we’d like to hear from you for this exciting column, as PRIMA shines the spotlight on its members. To be considered for the Member Spotlight column, contact Jennifer Ackerman at jackerman@primacentral.org or 703.253.1267.

Employee feedback has also been overwhelmingly positive, with employees stating that they are pain-free for the first time.

Since Dorn Companies trains local therapists, any public entity with massage therapists in its community can easily implement the program. The fact that there are no up-front fees adds to the ease with which the program can be duplicated.

Shannon Gunderman, risk manager

“

“

The PFT program was initially covered under the county’s self-insured workers’ compensation program. Since the therapy falls under OSHA’s definition of first-aid, it can be used as a preventative measure and does not have to be reported as a recordable event, said Gunderman.

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