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Employer Based Risk Management Of Work-related Musculoskeletal Disorders With A Concentration On Employment Testing
David Hoyle, DPT, MA, OCS, CEASNational Director Select Medical: WorkStrategies
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Disclosures
The following presentation is meant to give an overview of published regulations and laws but should not be construed as legal advice. When developing policies and procedures surrounding employment testing consultation with employer’s counsel is recommended.
Mention of specific testing companies or processes are not meant as endorsements of any specific company or process but to inform attendees of some companies who provide employment testing services.
Lack of mention of a specific company or process is not a reflection on the quality or competency of that company or process.
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Learning Objectives
Learners will• understand the importance of functional based job descriptions.• have an awareness of laws that impact the ability to perform
testing on employees (new hires and incumbents).• know the difference between essential and non-essential job
functions.• have an awareness of testing which can and can not be used to
qualify an individual as cable or not cable to perform a specific job.
• understand the responsibility of “reasonable accommodation” when it comes to new hires and returning workers.
• Review an example of the value of post offer employment testing.
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Multi-discipline HealthCare Company
Select is the leading provider of outpatient physical therapy in the US.
Select Outpatient Division is comprised of a family of eight brands that operate under a single management team.
Select has a network of more than 1,000 wholly owned facilities in 33 states and the District of Columbia.
Select employs over 400 licensed athletic trainers and 2,000 licensed physical and occupational therapists and assistants and serves more than 1,500 payors, employers and networks.
Select also is comprised of divisions which own and operate specialty hospitals and contract services.
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National Presence
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Prevention and Management of Musculoskeletal Disorders
Prevention of owning a work related musculoskeletal disorder starts at the time of job posting and lives with the employee through job transfer or retirement.
Hiring
POETPost-Offer
Employment Testing
Safety
Prevention/Behavioral
Programs/Early Symptom
Intervention
Injury
Acute & Sub-Acute Injury
Management
Recovery
Job Simulation Programs/Functional
Capacity Eval/Fitness for Duty
Testing
Closure
Outcome & Data Analysis
Process Improvement
UMS System
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Comprehensive Services to Employers
Post Loss Services• Functional rehabilitation • Work Conditioning• Work Hardening• Return to work programs
• Job Coaching• Work Reintegration
• Functional capacity evaluations
• Fit for Duty Testing• On Site Rehabilitation• Utilization Management
System
• Pre Loss Services– Physical Demand Job Descriptions– Post offer employment testing– Preplacement screening– Ergonomics/Job Analysis
• Physical Demands Analysis• Job Risk Assessments• Office Ergonomic Evaluation
– Injury Prevention education• “Exercise and Work Practices”
– Early Symptom Intervention• Triage
– Assessment– First Aid
• Job Coaching
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Our Experience Post Offer Employment Testing Experience
Over 25 years of Post offer agility testing experience Largest Single Provider of Post offer agility testing. 2014- Conducted over 50,000 POETs.
• 350+ Employers• 318 Select Medical Locations
• Tests are internally developed or in conjunction with:• Advanced Ergonomics Inc (AEI)• Atlas Ergonomics• BTE Employer Services• ErgoScience• IPCS• WorkSaver• WorkSteps• WorkWell• As well as employer and other company designed tests.
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Testing Overview Benefits of Post Offer Testing include:• Identifying candidates who aren’t medically stable• Gathering baseline data regarding motion, strength
and functional status• Identifying candidates who cannot perform physical
requirements for the essential functions of the job (force exertion, climbing, bending, repetitive lifting, etc.)
• Cost savings through • Injury prevention (hiring physically qualified individuals) • Musculoskeletal Baseline that can be utilized post injury • Apportionment savings (having baseline data in case of
injury)
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Three Stages of Ability to Test by Employer Under ADA/EEOC First Stage/Pre-offer
• prior to an offer of employment• the ADA prohibits all disability-related inquiries and medical examinations,
even if they are related to the job. Second Stage/Post-offer
• after an applicant is given a conditional job offer, but before s/he starts work• an employer may make disability-related inquiries and conduct medical
examinations, regardless of whether they are related to the job, as long as it does so for all entering employees in the same job category.
Third stage/Employee• after employment begins• an employer may make disability-related inquiries and require medical
examinations only if they are job-related and consistent with business necessity. http://www.eeoc.gov/policy/docs/guidance-inquiries.html
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EEOC Regulations
Post-offer stage is when employers may collect the greatest amount of data, including baseline medical and physical capacity measures.• Once they begin the job, cannot legally collect
post-offer baseline information because they are considered an employee.
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EEOC Regulations
Post-Employment (Fit for Duty)• With the exception of public safety professions Post-Employment Testing is
limited to times when a trigger is documented. What are triggers?
• Difficulty performing essential functions• Known medical condition/injury that creates ‘reasonable
belief’ employee will have difficulty performing essential job functions
Limited scope: Medical measures collected must be ‘job related and consistent with business necessity’.
Interactive process for possible accommodations is mandated.• Employer responsible for determining if possible accommodations are
reasonable.
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Post Offer Test Development
JSA •Essential Job Functions•Physical Requirements
Test Development •Construct/Content Validity•Predictive Concurrent/Criterion Validity
Test Validation •Review by Employer•Testing of successful employees
Testing •Begin Testing
Adverse Impact Analysis •Assess effect of testing on protected employee classes•If unexplained adverse impact identified
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Job Description UsesThrough the life of an employee
Posting• Get applicants who
believe they are qualified. Interview Review• Applicants review so can
volunteer they qualify under ADA and may need an accommodation.
Develop and Perform Post Offer Testing
• Communication after an injury or illness.– Information for medical
providers to determine appropriate return to work.
– Rehab professionals to base rehabilitation on.
• Fit for Duty Testing and Functional Capacity Evaluations
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Essential vs. Non-essential Functions
Essential functions are the basic job duties that an employee must be able to perform, with or without reasonable accommodation. According to the ADA an employer should carefully examine each job to determine which functions or tasks are essential to performance.
(This is particularly important before taking an employment action such as recruiting, advertising, hiring, promoting or firing).
Factors to consider in determining if a function is essential include:• whether the reason the position exists is to perform that function, • the number of other employees available to perform the function or among whom the performance
of the function can be distributed, and • the degree of expertise or skill required to perform the function. • Employers judgement as to which functions are essential, and a written job description prepared
before advertising or interviewing for a job will be considered by EEOC as evidence of essential functions.
• Other kinds of evidence that EEOC will consider include:• the actual work experience of present or past employees in the job, • the time spent performing a function, • the consequences of not requiring that an employee perform a function, and • the terms of a collective bargaining agreement.
http://www.eeoc.gov/facts/ada17.html
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How are Physical Job Descriptions Developed?-Employee Interviews Recommend• Three levels of large
organizations• Field Based Employee• Field Supervisor• Management.
• Interview for– “Most Difficulty Tasks”
• Force Exertion• Awkward Posture• Repetition
– Essential vs. Non-essential (marginal tasks)
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How are Job Descriptions Developed?Field Measurements
Weights of objects to be lifted and carried.
Forces for Pushing and Pulling.• Include sizes of objects.• Handles• Frequencies
• Other Functions– Body Functions
• Reaching, bending, kneeling, crawling, sitting, standing, crouching, squatting, etc.
– Hand Functions• Fingering, grasping, handling,
pinching, etc.
– Sensory Functions• Hearing, smelling, tasting,
etc.
– Other such as confined space abilities.
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Job Site Analysis
WorkTask Analysis Identifies physical demands of
essential job functions Used for:
• Job descriptions with detailed physical requirements
• Development of Post Offer Employment Testing of new hires
• Accommodation of disabilities under the ADA
• Employee job specific exercise programs
• Stretch and Flex• Work Conditioning• Behavioral Modification Programming
• Behavioral audits• Training• Reinforcement
WorkRisk Analysis Identifies the ergonomic factors
that can lead to work related musculoskeletal disorders
Poses potential ergonomic solutions that can reduce tissue stress.• Administrative controls• Engineering controls
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WorkTask Analysis
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WorkTask Analysis
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WorkTask Analysis
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WorkTask Analysis
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WorkTask Analysis
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Job Description-Physical Demand Assessment
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Return to Work-Physical Demand Assessment
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Quick Word on Definitions
Constant- > 66% of the Work Day Frequent- 33% to 66% of the Work Day Occasional- < 33% of the Work Day
Example of Sitting, Standing, and Walking
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Goal of Job Description for Employment Testing
Establish Valid Job Specific Test Criteria Based on Essential Job Functions• Satisfying the ‘content validity’ criteria as established by the
Uniform Guidelines for EE Selection. • Capable/Not Capable Criteria should all be based on essential
job functions.• Non essential functions can be included but should not be
used as capable/not capable criteria.
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Test Development
WorkTask Analysis approved by Employer representative(s) Review of WorkTask Analysis for essential job functions with
the greatest physical stress related to injury trends. Development of Job Specific Test Protocol with Capable/Not
Capable Criteria. Job Specific Testing Protocol Approved by Employer
• A number of options are available for approval. Recommend documentation of sign off at three levels of organization.
• Content Validity. Validation Testing of Currently Successful Workforce
• Construct validity
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Post Offer Test Components
Components• Consent for Testing• Medical History
• General, Injury, Workers’ Compensation Claims, Lost Work Time• Assessment of Cardinal Signs
• Blood Pressure, Resting Heart Rate, Resting Respiratory Rate• Musculoskeletal Examination
• Range of Motion, Strength, Balance, Flexibility• Baseline Testing
• Aerobic Fitness, Grip Strength, Lifting Ability• Job Simulation
• Confined Spaces, Lifting, Pushing, Pulling, Positional Abilities
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Post Offer ComponentsConsent Consent and release of liability
• Consent for testing• Consent to release information to the employer including medical
information.• May include a hold harmless if the at increased but minimal risk.• May include physician consent for treatment if at risk due to:
• medical history – Prior surgical history– Cardiac history– Chronic Diseases
• baseline physiological measures above guidelines– Heart Rate– Blood Pressure
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Post Offer ComponentsMedical History
Complete Medical History• Chronic Disease• Prior Injury• Prior Workers Compensation Injuries• Prior Lost Time
Used to assure safe testing• May require a release
Attested to as true and complete by candidate• Occasional a stop point
• No release when required• Failure to disclose prior history
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Post Offer ComponentsCardinal Signs
Heart rate and Blood Pressure Used to assure safe testing• Require treatment prior to completing testing• May require a release
If employee subsequently completes testing start with a healthier employee.
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Post Offer Test ComponentsPhysical Examiniation Musculoskeletal Examination• Range of Motion, Strength, Balance, Flexibility, Special Tests
Can be used for additional testing of essential job functions that may not be tested in depth in standard protocol.
Can be used for apportionment in states that allow apportionment.• N.C. Gen. Stat. §97-33 (2007) “If any employee . . . has a permanent disability
or has sustained a permanent injury . . . in another employment other than that in which he received a subsequent permanent injury by accident . . . he shall be entitled to compensation only for the degree of disability which would have resulted from the later accident if the earlier disability or injury had not existed.”
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Post Offer Test ComponentsBaseline Testing Includes• Aerobic Fitness, Grip Strength, Lifting Ability
Not Generally a Capable/Not Capable Criteria May also be used for apportionment for some
subsequent impairments. Most importantly a means of controlled progressive
loading to ensure safety in testing.• Used to qualify for the next stage of testing, job specific
testing.• Example: Full Keg of Beer 160.5 lbs
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Post Offer Test ComponentsJob Specific Testing Job Simulation• Confined Spaces, Lifting, Pushing, Pulling, Positional Abilities• Often uses actual employer equipment or as close of
simulation as possible.• Examples• Confined space
– Coast Guard Marine Pilots License
• Climbing– Electrical Overhead Worker
• Lifting, Pushing, Pulling– Beer Distributor
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Recommendations(Post-Offer)
Capable• Met all physical criteria, no medical concerns
Not Capable due to physical demands• Lacks essential strength – no medical
Not Capable – Impairment• Physical demands not met, but there was a contributing
medical condition/impairment Not Capable due to Medical Risk• Physical demands were met, but clinician identifies ‘direct
threat’
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Disparate/Adverse Impact
Testing should be evaluated by the employer to determine unwarranted disparte/adverse impact on protected classes of employees.• Age• Sex• Race
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Disparate Impact Testing
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Return to Work Testing
Fit for Duty Testing1. Employment Test2. Ordered by Employer3. Paid for by Employer
Funds4. Can only include
medical testing related to current injury.
5. Not Capable needs to engage in interactive process for reasonable accommodation.
Functional Capacity Evaluation1. Medical Test2. Ordered by Physician3. Paid for by Work Comp Funds
from Carrier or Self-insured funds through Admin.
4. Often contains medical information outside of current injury.
5. Medical restrictions, need to engage in interactive process for reasonable accommodation.
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Fit for Duty Testing
Includes only business necessary medical testing and job specific testing.• Conducted after release for return to work by medical
provider of record.• Medical testing of the injured area only.• Baseline testing for safety purposes for progressive loading.• Job specific testing.• If not capable requires an interactive process to discuss the
need for accommodation.• Employer is responsible for determining the “reasonability”
of the required accommodation.
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Case StudySunCoast HospicePost Offer Employment TestingStewardship Report- Return on Investment
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Current Testing Statistics
• August 2011 through 9/9/2012– 7 Location• Bayonet Point, FL• Lakeland, FL• Largo, FL• Palm Harbor, FL• St. Petersburg, FL• Westland, MI• Victoria, TX
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Current Testing Statistics
• 5 Positions
– RN– LPN & CNA– Maintenance Tech and Team Leader– DME Tech– Chaplain*represents current positions tested, not potentially available positions
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Current Testing Results
• 182 Tests performed
ST City Position Tested
FL Bayonet Point LPN & CNA 2
FL Lakeland LPN & CNA 2
FL Largo LPN & CNA 11
FL Largo RN 13
FL Palm Harbor LPN & CNA 24
FL Palm Harbor Maintenance Tech and Team Leader 2
FL Palm Harbor RN 33
FL St. Petersburg Chaplain 1
FL St. Petersburg DME Tech / Driver 1
FL St. Petersburg LPN & CNA 44
FL St. Petersburg RN 45
MI Westland RN 1
TX Victoria Maintenance Tech and Team Leader 3
Tested 182
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Current Testing Results
ST City Position Tested Capable Not Capable(NC) Incomplete %ageNC
FL Bayonet Point LPN & CNA 2 2 0 0 0.0%
FL Lakeland LPN & CNA 2 2 0 0 0.0%
FL Largo LPN & CNA 11 11 0 0 0.0%
FL Largo RN 13 11 1 1 7.7%
FL Palm Harbor LPN & CNA 24 23 1 0 4.2%
FL Palm Harbor Maintenance Tech and Team Leader 2 2 0 0 0.0%
FL Palm Harbor RN 33 27 6 0 18.2%
FL St. Petersburg Chaplain 1 1 0 0 0.0%
FL St. Petersburg DME Tech / Driver 1 1 0 0 0.0%
FL St. Petersburg LPN & CNA 44 42 2 0 4.5%
FL St. Petersburg RN 45 41 4 0 8.9%
MI Westland RN 1 1 0 0 0.0%
TX Victoria Maintenance Tech and Team Leader 3 2 1 0 33.3%
Tested 182 166 15 1 8.2%
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Current Testing Results
• Total Tests 182– Capable 166– Not Capable 15– Incomplete 1
• Capable/Not Capable Rate 8.2%• Reason for Not Capable– Unable to meet lifting requirement or demonstrate job
specific activity/test
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Return on Investment
• Data Analysis for ROI Outcomes
– Assumption• The type of injury that would have resulted
– Fact• Not a matter of “if” the applicant will be injured, but a
matter of “when”– Majority of the time it will be years 1-5
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Return on Investment
• Cost of Test $175.00 per test
– 182 test X $175.00 = $31,850.00• Testing for approx. 1 year
• Return on Investment
– Compare to expected medical and indemnity cost
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Return on Investment
• Using OSHA Safety Pays Calculator
– http://www.osha.gov/dcsp/smallbusiness/safetypays/index.html
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Return on Investment
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Expected Savings 1 Strain Injury
• Direct Cost $30,551• Indirect Cost $33,606• Total Cost $64,157
15 Strain Injuries• Direct Cost $458,265• Indirect Cost $504,090• Total Cost $962,355
Return on Investment Total Cost of Testing
$31,850.00
Net Savings$930,505.00
