The scope of practice of occupational and environmental medicine has undergone important changes over the last century as a result of changing expectations of society, employers, and workers, as well as evolving federal and state regulations. The role of the occupational and environmental physician has expanded to enhancing the productivity of the worker with absence management and increased emphasis on the overall health and wellness of the worker – not just at the work site but also at home and in the community.

The provision of occupational health care has also expanded from the industrial in-plant clinic to university and community hospital-based clinics, multi-specialty group clinics, occupational medicine clinics, as well as private and government consultants. In many of these settings, the emphasis is on preventive interventions and policies rather than treatment. It is important that the practitioner be fully informed of all significant occupational and environmental health activities, problems and concerns in order to provide necessary advice to assure a safe, healthful environment. These changes are reflected in the transition of terms from “industrial medicine” to “occupational medicine” and finally to “occupational and environmental health.” 

There is increased recognition by the organizations and regulatory agencies that occupational and environmental medicine (OEM) physicians and other licensed health care professionals have expertise in the analysis and development of programs and policies that protect the worker. The occupational and environmental physician often designs programs and manages health services directed toward defined populations, as well as engaging in clinical care that emphasizes the evaluation and treatment of individuals. The ability to interact with diverse stakeholders to prevent and manage injury and illness, and to promote health, wellness and productivity of working populations, gives occupational physicians a unique perspective and role in the medical community. 

The field of occupational and environmental health continues to be impacted by a variety of regulatory matters and agencies and public health issues such as federal and state Occupational Safety and Health Administration, Nuclear Regulatory Commission, Environmental Protection Agency, Mine Safety and Health Administration, and Department of Transportation. Issues as diverse as bioterrorism, ergonomics, toxic exposures, in-door air quality, work place violence, wellness, productivity, and absence management all come under the realm of the occupational and environmental health physician. 

Additionally, as the United States’ workforce is increasingly part of a global workforce, requiring occupational and environmental (OEM) physicians to understand and foster the needs of the international worker and build ties with the occupational, safety and health care community internationally and encourage best practices. Communities are increasingly in need of qualified medical professionals to advise them on risk assessment as it relates to the environment and to develop programs to protect the health of workers and other populations potentially exposed to environmental injury. 

Appropriate training for participation in occupational and environmental health programs provides skill in clinical, environmental and occupational medicine, toxicology, epidemiology and biometry. In addition, practitioners understand how to enlist and collaborate with the skills of colleagues from industrial hygiene, toxicology, occupational health nursing, safety engineering, industrial relations, health physics, ventilation engineering, mechanical engineering, biomechanics, law, public policy, and health education. 

The change in practice location in occupational and environmental medicine within the past decade has added another needed set of skills, those of business management. Computerization of medical information necessitates a sophisticated degree of “computer literacy” on the part of the occupational and environmental health professional. Knowledge of data management for occupational health and safety purposes is required. 

Lastly, occupational health professionals are advancing the field of health and productivity. Integrated health and productivity is a component of occupational health, safety, loss and risk management, absence and disability management, health promotion, disease management, injury prevention, hazard control, and health care benefits management that includes evaluation of personal health care. 

This document identifies services that are considered essential components of comprehensive occupational and environmental programs that meet a standard of excellence. The specific contents of any particular occupational and environmental health program is determined by the nature of the work organization, the products produced or services provided, the nature of the workforce, job tasks, activities and potential hazards and specific workplace or community activities. Occupational health programs must comply with all relevant laws and regulations. 

The following components are further defined and expanded in the Resource Guide developed by the Corporate Health Achievement Award (CHAA) program of the American College of Occupational and Environmental Medicine (ACOEM). To learn more about each component and to have a clearer understanding of measuring these components, please refer to the CHAA Resource Guide which can be found at www.chaa.org. 

LEADERSHIP & MANAGEMENT

Organization and Administration
Employers should assure that occupational medicine, safety, and environmental health professionals have input into the decision-making process related to health and safety issues. In all settings, this requires close alliance among occupational health providers, safety and environmental personnel all reporting to a level in the organization that will have a broad influence and global impact. 

Occupational and environmental professionals, working in collaboration, then implement improvements to enhance health and productivity of the workforce and help maintain a safe workplace. Involvement of occupational health professionals assures necessary protection to worker and community populations in a manner that best utilizes professional workplace safety, health personnel and other resources. 

Organizational Commitment, Innovation and Change Management
Occupational and environmental medicine programs are most effective when there is organizational support with commitment to the health, productivity and safety of the workforce. Management must be willing to provide appropriate resources, encourage innovation and support positive change. Occupational medical professionals must collaborate with management to meet the challenge of designing and disseminating cost-effective health, safety and wellness programs to an increasingly diverse and aging population, often at widely dispersed national and international sites. 

Health Information Systems
Effective occupational and environmental programs use information systems to promote worker health and safety. Occupational health information systems (OHIS) are needed to generate metrics to identify problems, track compliance, manage programs, assure quality and effectiveness and wisely allocate health resources.

Program Evaluation and Quality Improvement
Program evaluation is necessary to assure that programs meet objectives and operate effectively and efficiently. Data collection is not sufficient. The information must be collated, validated, tracked, and trended and used in planning appropriate, specific interventions for quality improvement.

Privacy, Confidentiality, and Health Records Management
Occupational health programs must maintain occupational medical records on each worker, documenting the reasons for and results of all evaluations. Ideally, these records should contain data sufficient to reproduce a chronology of the worker’s medical history, workplace exposures, medical evaluations, illnesses, and injuries. All health data must be maintained confidentially. Procedures for preserving confidentiality, while allowing access to those with a bona fide need to know, must be developed. Occupational medical records may also be affected by government regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Americans with Disabilities Act (ADA). Occupational health professionals must remain current and informed on regulatory issues affecting medical records.

Systematic Research, Statistics and Epidemiology
Occupational and environmental health programs often perform formal research into scientific, regulatory, occupational health care delivery and financial aspects of worker health and safety. Excellent worker health and safety programs assure that data on worker and community exposures, medical illness and injury are accumulated and retained and when appropriate, this data is analyzed in epidemiological studies to assess the effects that the environment, job design and workplace may have had or are having on workers or inhabitants.

Occupational health professionals work in collaboration with many other departments within an organization (human resources, safety and risk management, security facilities, as well as the community medical, police, and fire department resources) to maintain a healthy community.

HEALTHY WORKERS 

Health Evaluation of Workers
Appropriate evaluations should be performed and workers should be fully informed of results of each health evaluation, whether normal or if abnormalities are detected. Those performing health evaluations must be familiar with the workplace, understand any potential hazards and have access to worker job descriptions. Evaluations should be carried out on the following occasions: 

• Pre-assignment/pre-placement: Health status, both physical and emotional, should be assessed before making recommendations regarding the assignment of an applicant or current worker to a job to assure that the individual can perform the essential job functions safely and without endangering the safety of others. This recommendation shall be based on any or all of the following:
• complete medical history;
• occupational history (complete work history), including past job exposures;
• assessment of the organs or systems likely to be affected by the assignment;
• evaluation of the description and demands of the job to which assignment is being considered;
• compliance with federal, state, and local laws and regulations.

• Medical monitoring: The health status of the worker should be reviewed periodically where there is possibility that workplace exposures or job activities could have an adverse health effect. Medical monitoring of workers may be required by an employer or regulatory agency directive because of potential exposure to hazards in the work environment. OEM specialists are often involved in defining and developing medical monitoring programs that identify early signs of potential hazard exposure and thus protect workers.

• Post-illness or injury, fitness-for-duty evaluations and independent medical examinations: The health status of the worker should be reevaluated following prolonged absence from work due to illness or injury, whenever there are concerns of ability to perform all job tasks, and for globally assessing worker’s allegations and claims. The goal is to assure that the individual has sufficiently recovered from the illness or injury to perform the job without undue risk of adverse health or safety effects to the individual or to others. It is important for occupational health professionals to be involved in return-to-work planning, as they can help determine if workers are able to return to restricted or full time work, on a temporary or permanent basis.

• Termination of assignment – Health status may need evaluation when exposure ceases or employment terminates. The worker should be informed concerning health status and advised of any adverse health effects due to work or environmental exposures.

Occupational Injury or Illness Management
Occupational and environmental injuries and illnesses should be diagnosed and treated promptly. Occupational and environmental physicians are best qualified to diagnose occupational illnesses and injuries because of their knowledge of the workplace and environment. The occupational health physician should objectively resolve issues about occupational causation of illness, be knowledgeable regarding available rehabilitation programs and facilities, and interact with program administrators as appropriate to facilitate post illness or injury return to work based on familiarity with the worksite and input from supervisory/management personnel. 

Non-Occupational Injury and Illness Management
The occupational health physician can design a comprehensive program that provides treatment for emergency conditions, including emotional crises that occur among workers while at work. This treatment may only be palliative and to prevent loss of life and limb or, where personnel and facilities are available, may be more definitive. Many employers are moving toward an employee health model of expanding onsite or near-site clinical services by using physician and/or n urse practitioner or physician assistant personnel with appropriate physician oversight to render diagnostic, treatment, and chronic disease maintenance, and preventive medicine. These services are convenient for the worker and enhance productivity in the work place by helping to reduce time away from the work site for minor injury or illness. Care at the workplace should be consistent with local standards of patient-physician relationships. 

Traveler Health and Infection Control
Occupational and environmental medicine physicians should have a method to advise travelers concerning various travel-related issues such as prevention of jet lag, food borne and waterborne diseases, local outbreaks of illness, motion sickness, and the need for medical care abroad. Immunizations and information should be made available to workers who may be exposed to an infection for which there is an effective immunization (e.g., hepatitis A and B virus exposure in travelers to certain areas and health care workers). 

Mental and Behavioral Health/Misuse of Substances
The occupational and environmental medicine physician should be able to assist companies/corporations in writing policies for worker education, prevention and recognition of substance abuse, mental health issues and violence in the workplace. Training of management and supervisors to be skilled in the identification and recognition of troubled workers and to refer them to occupational health professionals also should be a component of the occupational physicians’ responsibilities. Occupational and environmental medicine professionals are involved in mandated (e.g., DOT or military) or private sector drug screening and testing of workers, serving as medical review officers (MROs) who receive, review and interpret drug test results as part of drug-free workplace programs. 

Medical Screening and Preventive Services
Periodic health screening examinations, immunizations and education aimed at maintaining and promoting the health of workers are important aspects of a comprehensive worker health and safety program. Evidence-based approaches are used to develop the content and periodicity of preventive services and are reviewed regularly by knowledgeable professionals. Although employee participation is typically voluntary, these programs help maintain and promote the health and productivity of the worker, improve morale, and foster the perception that the employer is concerned for workers’ general welfare. 

HEALTHY ENVIRONMENT 

Workplace Health Hazard Evaluations, Inspection and Abatement
Occupational and environmental health programs should routinely inspect and evaluate the workplace to identify potential health and safety hazards and suboptimal work practices. Environmental health professionals such as industrial hygienists, safety professionals, ergonomists and toxicologists, should be involved as needed. Occupational and environmental health and safety professionals are familiar with worker job descriptions, potential chemical, physical/emotional, and biological agent exposures that may result from their jobs. 

Education Regarding Environmental Hazards
Occupational and environmental health (OEH) programs identify and educate workers about potential hazards at the worksite and in the community. Every worker should know the potential hazards involved in each job to which he or she is likely to be assigned. The OSHA Hazard Communication Standard (“right-to-know”) stresses the importance of worker knowledge of chemical usage. 

Personal Protective Equipment
Occupational and environmental health programs should ensure that workers who need personal protective equipment (PPE) are clearly identified, provided with proper selection and fitted with personal protective devices such as hearing protection, safety glasses, gloves and respirators. The occupational and environmental medicine physician should determine that the devices provide adequate protection to workers, and educate the workers in proper utilization and care of equipment for all potential uses at all sites. Occupational health professionals should encourage worker compliance with proper care and use of equipment. 

Toxicologic Assessment
OEH programs should include procedures to incorporate advice on the nature, adequacy, and significance of toxicological test data pertinent to the workplace. Toxicological assessments include advice on chemical substances that have not had adequate toxicological testing. Where adequate data does not exist, the occupational and environmental medicine physician should recommend appropriate medical monitoring and testing practices. Occupational and environmental medicine physicians should recommend protection and monitoring of workers in keeping with data available or until appropriate data are received. 

Environmental Protection Programs
Environmental protection programs should support a scientifically based process to evaluate and prioritize the potential public health and environmental risks posed by exposure to various hazards. The goal is to identify whether any specific chemicals or other hazards generally pose an unacceptable risk and the conditions and uses under which they pose such risks, using a risk management process that follows a preventive health model and which employs a full range of pollution prevention options (e.g., substitution, source reduction, recycle and reuse, and treatment). 

Emergency Preparedness, Continuity Planning, and Disruption Prevention
Occupational health programs should have a plan for managing health-related aspects of disasters, including terrorism and public health hazards. This is important for the safety and welfare of the employees and community, as well as for continuity planning and prevention of disruption of corporate initiatives. Since community facilities and health and safety personnel are an essential part of dealing with an emergency at the work place, such planning should be done in conjunction with the local community (Title III – Superfund Amendments and Reauthorization Act [SARA]). Under Title III, companies covered under the Hazard Communication Standard are required to make their chemical inventories known to emergency response groups of local community. 

Healthy Organization
Occupational and environmental medicine physicians are instrumental in designing and assuring implementation of company/corporate programs. Health Promotion and Wellness Health education and health promotion programs are considered vital to the health of worker populations. Health risk appraisals can be used to identify and prioritize beneficial health behavior change programs. Occupational health professionals can motivate and educate workers to take responsibility for making wise, healthier choices in lifestyle behavior and personal health care decisions. 

Absence and Disability Management
Disability management programs assess reasons for workers’ poor performance or absence from work due to illness or injury and determine when the individual is well enough to return to work safely. Closely related is the primary role of evaluating illness conditions that render work unsafe and require job modifications. This role is expanding to identifying individuals and worker populations who are at increased risk of poor performance because of health issues and finding positive means to enhance health and productivity in the workforce and decrease absenteeism.

Health Benefits Management
Organizations are challenged to skillfully manage and maximize the health, safety and productivity of the workforce. Health benefits management includes assessing and identifying specific health care needs of a given worker population and helping to maximize available resources to have the largest impact on delivery of high-quality care to workers, retirees and their families. Occupational medicine specialists can provide valuable assistance in evaluating worker health benefits, benefit costs and the adequacy of care provided. They are in a unique position to apply epidemiology, statistics, and information systems to assure quality of care and to identify the most effective opportunities to improve the health of a defined population of workers/beneficiaries. 

Integrated Health and Productivity Management
Integrated health and productivity management measures the link between worker health and productivity and directs employer investments into interventions that improve health and organizational performance. With this approach, managing the health of a population is incorporated as an important component of the organization’s business strategy. Organizational resources are aligned to support an integrated approach to strategically investing in worker health and performance. 

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Links

Agency for Health Care Research and Quality 
www.ahcpr.gov/

Agency for Toxic Substances and Disease Registry 
www.atsdr.cdc.gov

ACOEM Position Statements and Guidelines
www.acoem.org/guidelines.aspx

Centers for Disease Control
www.cdc.gov/

Corporate Health Achievement Award
www.chaa.org/

Occupational Safety and Health Administration
www.osha.gov/

National Library of Medicine
www.ncbi.nlm.nih.gov/entrez/query.fcgi

The National Institute for Occupational Safety and Health
www.cdc.gov/niosh/homepage.html

U.S. Department of Homeland Security
www.dhs.gov/dhspublic/  

This document was developed by the Corporate Health Achievement Award (CHAA) Committee and approved by the ACOEM Board of Directors on November 4, 2004. It was reaffirmed with minor revisions by the CHAA Committee and approved by the ACOEM Board of Directors on July 27, 2008.

List of Contributors 2004 (in alphabetical order): Melissa A. Bean, DO, MBA, MPH, FACOEM; Faiyaz A. Bhojani, MD, DRPH, FACP, FACOEM; Emmett B. Ferguson, Jr, MD, MPH, FACOEM; Elizabeth C. Frenzel, MD, MPH; Julia Halberg, MD, MS, MPH, FACOEM; Doris Konicki, MHS; Vernon A. Maas, MD, MPH, FACOEM; Julie Ording, MPH; Kent W. Peterson, MD, FACOEM; William J. Schneider, MD, MPH, FACOEM; Gregg M. Stave, MD, JD, MPH, FACOEM; Jeffery T. Thompson, MD, MPH; William S. Wanago, MD, MACOEM; and Charles M. Yarborough III, MD, MPH, FACOEM. In addition, the following physicians contributed to the 2008 revision:: Bruce Sherman, MD; Elizabeth A. Jennison, MD, MPH, MBA, FACOEM; Fikry W. Isaac, MD, MPH, FACOEM; Thomas B. Faulkner, MD, MHA, FACOEM; and Carl N. Zenz, MD, MPH, FACOEM.