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  • ACOEM Comments on National Agenda for Advancing Total Worker Health (TWH)

    December 19, 2014

    National Institute for Occupational Safety and Health
    NIOSH Docket Office
    1090 Tusculum Avenue, MS C–34
    Cincinnati, Ohio 45226–1998

    Re: NIOSH Docket-­‐275 To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) applauds the efforts of NIOSH to create a National Agenda for advancing Total Worker Health (TWH). Bringing focused attention to TWH research, practice, policy and training is essential to advancing this initiative. We fully concur with NIOSH that the integration of health protection with health promotion in the workplace is key to achieving the healthiest workforce possible.

    Creating a culture of health and safety in the workplace is a fundamental building block for a national culture of health and safety, which ACOEM believes will require better integration of health in the workplace with health in homes and in communities. Health strategies in these three sectors -- workplace, home and community -- must be closely aligned if we are to optimize the health and safety of our citizens. And promoting the health and safety of our citizens is foundational to the future economic sustainability of our country.

    A 2011 ACOEM paper titled Workplace Health Protection and Promotion: A New Pathway for a Healthier -- and Safer -- Workforce, described the integration of health protection and health promotion as a continuum, in which “health promotion interventions contribute dynamically to improved personal safety in addition to enhancing personal health, while occupational safety interventions contribute dynamically to improved personal health in addition to enhancing personal safety…The two factors, personal health and personal safety -- each essential to a productive  worker and to a productive workplace -- are effectively combined in a symbiotic way that increases their impact on overall health and productivity. The whole becomes greater than the sum of its parts.”  We are pleased to see that ACOEM’s paper is included in the references that helped in the development of the proposed national agenda.

    In the years since the publication of the report, the chorus of voices advancing health and safety integration has certainly grown, but the number of employers actively exploring this concept remains small. Though employers have made great strides in creating separate cultures of health and safety in the United States, and many theorize that they could be more powerful if integrated, the two have yet to meet and merge into a truly sustainable and integrated culture.

    In an effort to better understand how the environment for integrating health and safety in the workplace has changed over the last several years and to seek new ways of advancing the concept, ACOEM and UL hosted a summit meeting during the summer of 2014 comprised of experts from a wide range of corporate, not-for-profit, educational and research organizations.

    In these comments, we would like to share several consensus viewpoints from that summit meeting that we believe should be taken into account as you continue to shape the national agenda.

    The first is the continuing need for more research demonstrating that health promotion programs can positively influence workplace safety; just as health protection programs can positively influence workplace wellness – creating synergy between the two.  As workplace health professionals, we are seeing increasing signs that this is the case, but we need more empirical, evidence-­‐based research proving it to be so. The various workplace health communities are increasingly united behind the idea of integration – but we must show the evidence for it.  To the extent that this specific research need can be articulated in the national agenda, we believe the document will be strengthened.

    Second, we believe a key gap continues to exist in terms of a commonly shared set of metrics that could place demonstrated economic value on integrated health protection and health promotion programs.

    The draft agenda rightly notes that the “business case for prevention” remains a key question for employers.  Most often, the economic value of health promotion and protection programs has been based on a consideration of whether a return on investment (ROI) has been achieved.    However, published articles that report on the ROI of workplace health interventions usually fail to detail the methodology used to calculate the ROI.  ACOEM believes that the specifics of this methodology  must be articulated.  For research purposes, standardization of an ROI methodology should be pursued.

    In addition to better methodology for calculating ROI, we believe a better suite of metrics for the determination of ROI is needed. Too often, health interventions are assessed by their cost-effectiveness alone, using limited endpoints such as Quality of Life Years (QALYs).  True measurements of the impact of health interventions in the workplace should be much broader. ACOEM believes that other measures of the value of TWH should be encouraged by NIOSH.  For example, NIOSH could establish an agenda to identify a suite of metrics that affect the economic sustainability of a business.  These metrics might then contribute to a universally accepted index of the economic value of health promotion and health protection.

    During our summit meeting, there was great agreement on the need for practical advice that can help bridge activities in the health protection (safety) community with those in the health promotion (wellness) community within workplaces.

    While there is widespread agreement that these activities should be integrated, health and safety professionals yearn for hands-on, practical advice aimed specifically at the concept of integration of programs and how it can occur from an operational standpoint. Participants at our summit meeting strongly agreed that there is dearth of information aimed at this particular need.

    We applaud the draft agenda’s goal #2, which calls for the development and dissemination of best practices – and urge a strong emphasis be placed on management practices that can help integrate health strategies across operational silos in the workplace.  To maximize the practicality of adoption of best practices, NIOSH should consider creating a standardized template for collecting and web-publishing best practices, which would provide users sufficient detail to be actionable. Templates for disseminating best practices have been developed by the business community and could easily be adapted by NIOSH for this purpose.

    We concur that advancing policies supportive of total worker is vital to the success of efforts to achieve the healthiest workforce possible. In particular, exploring opportunities to transfer concepts of TWH to the general health care delivery system holds the potential for more rapid adoption of TWH.  For example, group health insurers might team with Workers’ Compensation insurers to provide new incentives – such as premium reductions or discounts -- for workplaces with strong health strategies in place, thus encouraging policyholders to promote TWH. Workers’ Compensation insurers might offer TWH support as part of their risk management services.

    Finally, ACOEM agrees that the future of TWH ultimately depends on training future practitioners. As TWH becomes a recognized approach to improving worker health, TWH training courses, practitioners and services are likely to proliferate in the marketplace. NIOSH should help define parameters of this training and education as well as the defining basic competencies of TWH practitioners to assure the availability of a uniform product.

    ACOEM is a long-time partner with NIOSH and our efforts on behalf of worker health are closely aligned. As always, we want to offer any resources we can make available to help with this important project.  Again, we commend NIOSH on this draft, which moves our national efforts in the right direction.


    Kathryn Mueller, MD, MPH, FACOEM


    1Workplace Health Protection and Promotion A New Pathway for a Healthier—and Safer—Workforce