A study of leading indicators for occupational health and safety management systems in healthcare

OHSMSs are a combination of planning and review, consultative arrangements, and specific program elements that work together in an integrated way to improve health and safety performance [11]. OHSMSs are distinguishable from traditional occupational health and safety (OHS) programs by being more proactive, better integrated internally and incorporating elements of evaluation and continuous improvement [12]. Organizations that adopt an OHSMS have a clear vision of health and safety goals, communicate these goals to their workforce, assess risk data, define corrective action more often, and exhibit improved attitudes towards employee training [13]. Research has linked low injury rates in organizations with elements of OHSMSs [14‐17]. However, in a systematic review examining OHSMSs, Robson et al. [12] identified a number of gaps in the research, more specifically a lack of rigorous research examining the effectiveness of OHSMSs interventions on employee health and safety outcomes. This gap will be addressed in this proposed project by developing and evaluating the effectiveness of a tailored intervention on improving health and safety workplace indicators.

Many organizations put programs in place, but do not develop an overall OHSMS. When an organization is focused on a program, lagging indicators are often used to measure the outputs of the program [18]. A lagging indicator is defined as a measure taken after events with a focus on outcomes and occurrences based on retrospective data [19]. Lagging indicators include accident and incident rates, disease statistics, frequency of accident investigations and costs associated with compensation systems [18, 20, 21]. Focusing on lagging indicators does not lead to sustainability or evaluate the quality of an OHSMS. Thus, there has been a movement away from lagging indicators, towards ‘leading’ or predictive assessments of an organization’s health and safety climate. A leading indicator is often associated with proactive activities and is a condition or measure that precedes an event. By identifying and using leading indicators, performance outcomes under current conditions of an organizational system may be anticipated and action taken.

Much has been written about leading indicators for OHSMSs, but there is inconsistent terminology, lack of uniformity, and little discussion on how to measure these indicators. The template of leading indicators identified by Bennett and Foster [10] was chosen for this project because the indicators are well-developed, measurable and based on an extensive literature review of other industries. Senior management commitment is about more than a policy being written and posted on a safety board. Health and safety goals must be ingrained in organizations with health and safety objectives required at the senior management level and included in all team-meeting agendas [10]. Continuous improvement within OHSMSs is never stagnant. Health and safety is an ongoing process that needs to change and grow with the employer being committed to improving the system. Managers set and review objectives which are integrated into operational management [10]. The committed organization has a process in place that implements audits, completes investigations, and deals with non-conformities quickly. It is not enough to keep track of incidents but instead understand how the system failed, and what led to the incident. Communication includes interactive discussions as well as company-wide messages supportive of OHS from a senior person within the organization. Employee communication and feedback are paramount to improved OHS [18, 22]. Competence includes an analysis of all jobs for competence requirements including OHS understanding. The front-end hiring and training of new personnel is the most effective step in the consideration of health and safety performance [23]. The expectation is that workers have received health and safety induction, and an individual has confirmed qualifications for the work being undertaken. Employee involvement focuses on the involvement of each employee in an OHS activity rather than the expectation that the health and safety department is solely responsible for OHS. This can include workplace inspections, incident investigations, or working on risk assessments. The goal is to stimulate everyone within the organization to take responsibility and understand various aspects of OHS. Occupational health management includes the monitoring of occupational health risks such as violence, musculoskeletal disorders, and infectious diseases.

To conduct a longitudinal study implementing six elements of the OSACH system identified as leading indicators and evaluating the effectiveness of this intervention on improving selected health and safety workplace indicators.

A quasi-experimental longitudinal research design will be used. There will be two phases of the project. The first phase will focus on assessing current OHSMSs in participating hospitals using the key leading indicators, determining potential facilitators and barriers to changing current OHSMSs, and identifying the leading indicators that could be added or changed to the existing OHSMS in place. Phase I will conclude with the development of an intervention designed to support optimizing current OHSMSs in participating hospitals based on identified gaps. Phase II will pilot test and evaluate the tailored intervention.

The setting will include two acute care hospitals in Eastern Ontario. Sites will be chosen based on size (small, medium, large) and location (urban and rural) to obtain a variation in types of hospital.

Data collection in phase I will include 1) semi-structured interviews and document reviews; 2) surveys; and, 3) administrative data.

To evaluate the effectiveness of the tailored intervention (research question #4), survey data will be collected at the beginning of phase I, and near the end of phase II using an online survey. Sample: A power analysis was conducted using G*Power [24] to determine the appropriate sample size. A paired t-test will be used to assess for statistical significance in the outcome variables pre- and post- intervention. For the paired t-test statistic with an alpha significance level of .05 and a power level of .95, it was determined that a moderate effect size (r = .50) between groups would be detected with a total sample size of 45 participants. Each site will be assessed separately. Therefore, 45 participants are required at each site with a total of 90 required participants. To compensate for a 50% response rate commonly found in survey research, a minimum of 180 participants is recommended. The number of employees in each hospital identified in the region varies with a range from 270 to 4000. Therefore, to ensure the appropriate sample size obtained, all employees (full-time, part-time and casual) and physicians in the participating sites will be invited to participate. Hospital volunteers will be excluded.

To evaluate the effectiveness of the tailored intervention (research question #4), administrative data will be collected at the beginning of phase I, and near the end of phase II. In a recent project, PSHSA [19] recommended a set of core, consensus-based health and safety workplace indicators. From this set, the following administrative data will be collected:

Following the completion and analysis of the interviews, document review, administrative data and survey results, an all-day face-to-face meeting will be held with the research team and participating sites. The purpose will be to review the results, identify gaps, identify which leading indicators need to be changed or added, and develop the tailored intervention for each site. Ultimately the objective is the implementation of all six leading indicators. However, it may not be realistic to address several missing indicators, given the time frame of this project. The research team, in collaboration with the OHS director/manager, will determine the indicators which could be improved, and how to address the gaps identified. A teleconference will take place with the research team, PSHSA, and knowledge users within two weeks of the intervention being implemented to finalize the plan.

The tailored intervention will be implemented and monitored over 12 months. The internal work will be completed by appropriate individuals within each site, while our team of consultants and RAs will provide support in the implementation. The implementation and monitoring will initially be a joint effort between the consultants and RAs. This initial monitoring time will also be used by the consultant to equip the RA with the necessary knowledge to monitor the intervention. All subsequent monitoring will be the responsibility of the RA. The intervention will deliver various elements of the leading indicators to each participating hospital; however, the elements will vary depending on the identified gaps, facilitators and barriers in phase I. The goal of the intervention will be to improve OHSMS in each hospital to meet the specific quantified benchmarks based on the assessment questions from phase I. Each RA will meet with the personnel responsible for implementation in each participant site monthly, answer questions, and ensure the intervention is being implemented as planned. Similar to phase I, participants will be asked to provide copies of documentation to illustrate examples of each indicator. The hospital documents will be reviewed by the RA and recorded using the same standard form to ensure consistent measurement. Similar to phase I, each indicator will be assessed at the end of the intervention with a rating of 0 (never completed) to 10 (100% completed) to compare to the rating in phase I. The data to assess each indicator will be collected over 12 months. During the 12-month intervention, teleconference meetings will take place with the researchers, PSHSA, and knowledge users every 5 months (e.g. 11th and 16th month) to provide updates on the progress of the project and discuss any issues that arise. At the end of the intervention (19th month), a teleconference meeting will take place between researchers, PSHSA, knowledge users, and collaborators to discuss the intervention overall and confirm questions for the interviews, document review, surveys and administrative data being collected to assess the intervention.

There is a great deal of focus in Ontario’s occupational health and safety system on compliance and fines. Occupational health and safety professionals believe focusing on managed systems and a health and safety culture within an organization, in most cases, is a more effective alternative to fines. This research proposes to give healthcare organizations an alternative to a compliance-based system.

Over the next decade, the healthcare sector faces several challenges which could have a significant impact on worker health and lost-time injury rates. These challenges include increased care requirements resulting from Ontario’s aging population, increased demand on health and community care services, and globalization of occupational health and safety issues such as emerging infectious diseases, pandemics and other environmental risks. Across Ontario, there are competing priorities faced by healthcare organizations with time and money at a premium. Enhancing a culture of healthy and safe workplaces across Ontario’s healthcare system is essential.