Good morning, everybody. Thank you for being here this morning. Today we're going to be talking about medical surveillance and the nuts and bolts of that. So for some of you, this is going to be a broad review of what medical surveillance is and how to establish a medical surveillance program. For others of you who may be new to the occupational medicine field or maybe you're trying to implement a new medical surveillance program, we're hoping today to give you not only the elements of a medical surveillance program, but also the tools that you will need for this. So we have a handout that I want to bring your attention to that is stacked with a bunch of tools. We also have a matrix that was developed with various common medical surveillance programs and what elements need to be included in that. It is not an official OSHA handout, but it is based on the OSHA medical surveillance guidebook. So just want to make sure you're aware of that and take that and use it as you see fit. My name is Melanie Hayes. I am a family practice nurse practitioner. And today, in the spirit of collaboration and interdisciplinary teams, I'm going to be presenting with a variety of colleagues. I have Scott Forler, who is an industrial hygienist. We have Jackie Rodriguez-Valdez, who is a nurse practitioner, and Pam Snyder, who is also a nurse practitioner with Firelands Health. I should also say Jackie owns her own business, Summit Healthcare. And then we have Dr. Erlinda Singarajah, who is with the VA Medical Center in Phoenix, Arizona. Standard disclosures. I think the primary thing that I just need to say is that our opinions are our own and do not reflect those of our employers. So today, we're going to describe the elements of a medical surveillance program and discuss the components that are included in that and, as I mentioned, give you the tools. So why is this important? Although this data is a little bit dated, we know that occupational illnesses and injuries cost at least a quarter of a billion dollars a year. Cardiovascular diseases, obviously, a half a billion dollars. Cancer, $219 billion. But this doesn't really account for the quality of life that can be affected by occupational illnesses and injuries or the fatalities and those family members who are left behind. So if we do medical surveillance well, we can increase our compliance with legal requirements. We can detect and manage and treat diseases early. And then we can also prevent diseases in their coworkers. That's really what medical surveillance is designed to do, is to really increase awareness of how those injuries and illnesses are occurring. We can reduce the bottom line for employers by reducing workers' comp costs. We can check to make sure our exposure controls are adequate. And then, on occasion, we can detect previously unrecognized health effects from hazards. So I've mentioned that the primary goal is to improve worker health and safety and prevent work-related illnesses and injuries. But with medical surveillance, we do that by identifying the relationships, the circumstances, and the patterns around occupational illnesses and injuries. We can also use this data then to guide policies and regulations, education and research priorities, and develop new prevention strategies. We have to get the information out to the people that can use it. That may include enforcement and regulatory agencies or public health agencies, as well as clinicians and researchers and the people who are designing engineering controls and PPE products and other measures and processes to help protect workers. So, pardon me for a moment here. I got mixed up with my notes slide here. All right. So, medical surveillance and medical screening. We often hear this used interchangeably, right? And we're going to help define the differences between those two. Medical surveillance is an ongoing systematic collection, analysis, interpretation of health data that is essential for planning, implementing, and evaluating public health practice. So the targets of medical surveillance, or rather the purpose, is to detect and eliminate the underlying causes from the exposures. We want to do that in at-risk workers with known or potential exposures. And we do that through that systematic ongoing assessment of workers who are or may be exposed to hazards in the workplace. Medical screening is really a subset, a complementary activity, sometimes considered a form of medical surveillance. It is designed to detect the early signs of work-related illness by administering tests to apparently healthy workers in a cross-sectional approach for the purpose of early diagnosis and treatment in those individuals, hopefully with better health outcomes. So we target diseases or body dysfunction before the individual would normally seek medical care. And we do that through our medical and occupational histories, our physical exam, and various biological testing. This is an interdisciplinary approach. We need our industrial hygienists, engineers, physicians, MPs, PAs, other nurses, as well as technicians. We may have an ergonomist in the mix, or athletic trainers. So we really are not working in a silo. We're doing this as a team, all with the goal of preventing workplace illnesses and injuries and reducing the risk for employers, as well as advancing workplace health and safety and increasing productivity. So when you're developing a medical surveillance program, it's helpful to have a model. And this is the model we will be using today as we go through. You're going to be looking at assessment, planning, designing, implementing, and evaluating your program to ensure that it's doing what you expected it to do. To do that, I'm going to introduce you today to Scott Forler to talk about assessment. I think you can do this by yourself. Yeah. Good morning. My name is Scott Forler. I am the chief of occupational safety and a senior industrial hygienist for the Phoenix Veterans Administration Hospital. So I'm going to talk to you about industrial hygiene this morning. As I said in my introduction, I am an industrial hygienist. And there is a little bit of a caveat with that. Generally, throughout my career, I've been doing this about 18 years now, I talk about being an industrial hygienist. I introduced myself as an industrial hygienist. And generally, nobody ever knows what that is. So unless you work with an industrial hygienist, generally, you just don't know what that profession entails. And it's not like a doctor, an attorney, a carpenter, something that you can tell from the title, you know what this person does. A hygienist, by definition, is a specialist who promotes clean conditions for health purposes. And that's absolutely true. That's generally what I do. But most people seem to think I have something to do with teeth when I introduce myself. But simply, industrial hygienist broken down, we measure things. That's it. We measure contaminants. We measure hazards. We measure exposures. And you know, I'm not sure what to call it myself. I can't really go back and say I'm an industrial measurer. That just doesn't do anything. Oops. Okay. So I'm going to talk to you about the three components of occupational surveillance that have to do with industrial hygiene. The first one is hazard assessment. And hazard assessment is really just surveying the site, the processes, the materials that people are working with. And we determine what needs to be measured by doing that to determine if there is the possibility of a hazard. So exposure assessments. Exposure assessments are measuring this hazard. We need to know what type of sampling is needed to measure it. What am I going to compare it to? You can't measure something unless you have a baseline previous sampling data to compare it to. Health conditions. Obviously, this is the one thing that we're trying to avoid, these negative health conditions. We want to negate the levels of the exposures. And we need to know if we're going to be re-sampling, if this is going to be ongoing medical surveillance, and we need to go back and check, re-testing, re-evaluating. All right. Principles of industrial hygiene. And this is the role of an industrial hygienist, this circle that we're looking at now. We generally start with anticipation, although that is not always where we start on this. Anticipation is, how is this job done? How do we know what to look for? How do we know that we have a hazard? And really, that's through hazard recognition. And we learn hazard recognition through education, through research, and then mostly experience. So, the IH, that's me, has to recognize if there is a hazard, what this hazard is. We have to ask questions. We have to know about processes. What chemicals are involved? What environment are we working in? And I always go back to the questions, and I always talk to people as much as I can about the jobs to find out what the hazards are. But what I find a great deal of the time is many people don't know what hazards they're dealing with in their day-to-day jobs. You know, they don't look it up. We need to educate them, all of this, myself, you, everybody, on what types of hazards and what are the ramifications of being exposed to those hazards. Evaluation. And we go back to measurements. And I'm going to go back to measurements multiple times here. We need to have the knowledge of how to measure these hazards. We need to know what sampling methodology we need to use. And if I don't know the sampling methodology on what I'm evaluating, NIOSH is an absolutely fantastic tool. I go back to it time and time again. You know, we can't use cellulose, ether, asbestos cassettes to measure hexavalent chromium fumes. So we're not getting any data. It has to be relevant. Oops. Controls. Controls are basically, obviously, controlling the exposure. Put potential solutions in place, follow up, and retest. And this leads into the next slide. So I know that everybody has probably seen this before or use it daily, like me. The hierarchy of controls. Elimination is a tough one because a lot of times we have the job task. It has to get done. We don't have an alternate to do. And while you can use elimination and it's the first step to do it, to go through, it rarely seems like that this is the answer. Sorry, I lost my place. Yeah. Substitution. And this is something that is very effective. Substitution, it's replacing a hazard, something that is a hazard, with something that's less of a hazard or not a hazard at all. And an example I use is our corrosives. So a lot of times I see corrosive detergents, corrosive this, corrosive that. And if we can have something that replaces this corrosive with a different product, it helps us out a great deal. Another one is volatile organic compounds. A lot of solvents, mastics used in construction are high VOCs. And if we can replace those products with low volatile organic compounds that are less hazardous, we try to always do so. Engineering controls. So there's a wide range of different engineering controls. And my favorite one that always seems to come into play before others is ventilation. And if we have airborne hazards and can apply localized ventilation, we can apply negative air, use HEPA filters to filter the contaminants out of the air, we can do so. And that is one of the go-tos of an industrial hygienist. Administration. Administration is controlling the limits of the exposure. And if we can substitute or rotate job tasks, rotate people, that's the way that we can reduce the time spent in that hazard. And then finally, PPE. And unfortunately, it always comes down to the PPE. Not because it's not effective, but it's the last item on the list. And the thing about PPE, and I have a tough time with this, is a lot of people don't see the value in it. And I see this every day. And it's especially in respiratory hazards. It's in wearing eye protection. And I think that the way that to make people understand what hazards they're faced with, we have to educate them. And we have to keep educating them. All right. So industrial hygiene to medical surveillance. We're understanding the job, the processes, the associated hazards. We're doing exposure assessments. We're identifying the significant hazards. We're measuring, again, we go back to measurements. We're measuring these exposures, these hazards, the contaminants. And we're comparing them to, like Melanie said, permissible exposure limits from OSHA. We're measuring them with short-term exposure limits, with threshold limit values. And then I go back to the NIOSH handbook, too, when OSHA does not have clarification. So we determine if we have an overexposure. We recommend and apply controls, maybe apply, recommend medical surveillance, depending on what the hazard is. And then we're always resampling and starting that cycle again. Other agencies. Now, we talked about OSHA. I was an OSHA compliance officer for a short time as well. And OSHA is really the end-all, beat-all that we're measuring ourselves against when employer-employee relationships. There are other agencies out there. We have MSHA. We have ANSI. And ANSI is a private organization that tries to set standards, worldwide standards. And then also USP-800, and to do with hazardous pharmaceutical drugs. So these are some examples of OSHA standards. This isn't the full list, but this is something that you may or may not have these hazards where in your place of work. But when I go through this list, about half of them are something that apply to at least my hospital and probably most hospitals. So I refer to OSHA almost every single day. So right now, I would like to introduce Jackie, who is going to go over plan and design. Good morning, everyone. My name is Jacqueline Rodriguez-Valdez. I am a family nurse practitioner, also CEO of Summit Healthcare Solutions. I am also certified as a project manager. So I'm going to kind of integrate a little bit of project in here, because I am sure you guys are very familiar with medical surveillance. This is also a guideline, guidance. We also want to provide some resources for you guys. So did it go? Oh, no. It didn't. Now it did. All right. So in the planning phase, it is vital to define the medical surveillance program as a roadmap, as all aspects are thoroughly assessed prior to implementation. Lewis Carroll stated, if you don't know where you're going, any road will take you there. So taking some time in the beginning of implementing a medical surveillance program is essential to understanding what possible barriers and challenges you're going to be presented with. Expect the unexpected, prepare, take a step back, and proactively design your program. When planning a successful medical surveillance program, one must also be methodical and strategic during the development phase, ensuring that the assessments of requirements and be proactive to anticipate the potential challenges. Managing a medical surveillance program without planning and setting objective goals is like shooting aimlessly and claiming that whatever you hit was your target. Start thinking about what tools you're going to utilize to measure a successful medical surveillance program. All right. The primary goal of the medical surveillance program is to protect the health of the worker from inherent hazards of the occupation. As such, it is codified by the federal regulations, which OSHA provides oversight and guidance. Please be aware that when planning your medical surveillance program, you must be aware of OSHA's minimum safety and health standard. Requirements are self-set forth by state regulations and standards. However, the employer may choose to supersede OSHA and implement more stringent standards, but never go below that. OSHA currently has 24 standards requiring medical surveillance. Please be also familiar with state-specific standards, which may have additional requirements above the OSHA minimum standard, particularly if you're managing interstate medical surveillance programs. For instance, 22 states have private sections and government-specific regulations. Government states also cover only state and local governments. So this is really important, not only to focus on federal OSHA, but also the state-specific as applicable. How many of you in this room have utilized this tool? Okay. All right. Yeah, the majority of them. For those of you who have not, this will become your best friend. It is a great tool, high level. It's about 30,000 feet in the air. It basically gives you very summarized key points of these surveillance programs. I recommend to use this, but also dig a little deeper and visit the OSHA website for additional information. The primary goal of the medical surveillance is to protect the health of our workers. Definitely utilizing this tool case will assist you in navigating the OSHA website, because sometimes it could be a lot of information. This guide provides a helpful plan, and I particularly recommend this when you are implementing a medical surveillance program that has several surveillance programs within your robust program. So this is an example, and you're seeing the respiratory protection. You also see that it can have either general or specific. For instance, general is 1910, or for construction, 1920. As you can see, it also provides the exam types you may be required, such as pre-placement or periodic. It also gives you the list of components, such as any diagnostic testings that are required or laboratory. It also provides some special equipment. In this case, perhaps a port account machine or a hood. Education. So having education within your medical surveillance program is essential. Providing that education to your examinee and ensuring that you're documenting this education. But who's providing this education for the examinee? Is it safety? Is it the physician? Is it your nurse? The OSHA General Duty Clause, each employer shall furnish to keep each employee at the workplace free from recognized hazards that are likely to cause serious physical harm or death. In cases where a specific standard is not formulized, the employer still has the responsibility to protect the worker. Consider including a plan on providing a proactive safety culture. Creating a safe and healthy work environment is the responsibility of everyone in the organization, and I think that's important to implement in your plan. Begin thinking on how you are going to implement a safety work culture. Establish trust within the team to ensure that they feel that they're able to report potential health or safety concerns without fear of retaliation. How to start. As Scott discussed earlier, the IH role and the regulatory requirements and hazard identification and performing a risk assessment to evaluate the severity and the likelihood of identified hazards and prioritizing actions based on the level of risk posed to the employee. One should identify what is your medical surveillance need. So identifying this is essential to have a team to include industrial hygienists, the frontline worker, having them integrated within your plan because they are boots on ground. They're seeing what the potential hazards are and going back, building that trust so that way they can raise their hand and say, I have this concern without fear of retaliation. Also keep in mind to be familiar with the regulatory requirements behind this medical surveillance program. Also identify who else may need to be involved and what role they may play. Like I stated, IH, the safety manager, the director, HR. Often we overlook something as simple as a site visit. When we are drafting our plan, go out and see for yourself, ask questions, anticipate potential barriers to your program. Identify gaps perhaps in your hierarchy of controls. Identify strengths and potential weaknesses. Identify key leaders. Who is going to take ownership of this program? Who's going to be your stakeholder? Who's going to raise their hand and say, you know what, maybe you didn't think of this? Understanding the professional scope of practice. Making sure that you understand what you're about to embark. They're going to throw curve ball at you. You can plan as much as you want and there's going to be things that are going to throw you off. Try to anticipate that. Try to assess who is your target population? What are their risk factors? Health effects of the workplace hazard. Work tightly with your team. Have frequent meetings, workshops, stand-ups. Assess the workforce knowledge. Ensure the information you're providing is at the level of education that they're going to understand and also the language. You can go to a work site and give a wonderful presentation in English and people are going to nod and say, yep, no, I got it. Ask questions. What did they say? What's going on? So ensuring that you're taking that into account into your plan. Understanding your state, local, and federal laws. Making sure you understand the wonderful world of managing your medical records. Ensuring that the primary care physician or the primary care information is not wrapped up into your occupational health care. Ensuring ADA, HIPAA, and privacy. All right. Design. All right. So now we're going to talk about the needs. So what is it that you need to implement a successful medical surveillance program? So let's think about the space. So before you start drawing all these wonderful plans, go to your space. See what you have. Think about your workflow. Are you going to do your physical exam before you do your vital signs? How is that going to work? When you do your physical exam, do you have the appropriate privacy so the other examinees are not listening to everything that's going on? And my favorite, look at not doing an audiogram next to a spirometry. Because I don't know about you, but I get really excited when I do my spirometry and I'm yelling and then, you know, they're like, Jackie, shh, there's a test over here. So just think about that. Think about the lighting when you're doing your vision testing. Do you have enough lighting for them to actually see? Think about the temperature. Think about the workflow. The equipment requirements. What are you going to need for your program? And think about the time and the frequency of exams, trying to cluster components as you could. Optimize scheduling of the components. You know, employers will be upset if you're scheduling a chest x-ray on this side of the town and then you're doing your audiogram over there. If any of you are familiar with Orlando, Orlando is an hour away from Orlando. So any examinee that has to kind of do the different exams everywhere is going to just take a lot longer. Think about your specialty labs. Some labs have special considerations when you're obtaining the lab. Think about processing time. Don't draw it on Friday if it has a 24 or 48-hour turnaround time. What are we going to do with critical lab values? Who are we referring these examinees to? How are they obtaining the information to know that they need to follow up? Who's managing that care? Do you have medical removal requirements? And how are we communicating these results going back to the language? Are we providing written documentation in their language? And then cost. Are we performing these exams in your brick and mortar? Are we performing them off-site? Think about all those considerations of performing these exams off-site. Maybe you're having a mobile vendor come in to do some exams. Think about the initial cost of implementation. Think about the cost of equipment, the supplies, the pharmaceuticals, and then have a separate column for the recurrent cost, which will be tightly grouped with your burn rate or how many examinees you're seeing. Think about the cost of staff and labor. Do these components require specific training, such as CAOC or NIOSH training? And then think about your license and certs. Here in Florida, we need an ACA license. Are you doing a point-of-care test? Do you need a CLIA waiver? And then also your application turnaround time. As you know, anytime we need a special cert for these type of programs, you have to also consider how long it's going to take to get your certification. And then management of records, making sure that you understand what the record retention policy. Many times it's the duration of employment plus 30 years. Who is responsible for these records? And also ensuring that you're developing a quality assurance program checklist to ensure before you archive that record, ensuring that all those requirements were performed and all your notes and all your documentation is up to date. Thank you so much. And now I would like to turn it over to Dr. Snyder. Thank you, Jackie. So as she mentioned, we're going to turn our attention now to implementing the Medical Surveillance Program. Implementing the Medical Surveillance Program. Many of you in this room are currently doing this portion, so we're just going to kind of go over some of the highlights, the important things. So we want to be aware of the OEM provider responsibilities. We perform and we oversee the medical surveillance examination. When performing an evaluation, we need to be knowledgeable about the employee's job duties, their work practices, the conditions that they're working in, the potential or the existing hazards, and any of those exposure controls. We want to be cognizant of the worker education. Training for the worker is a key function for both safety and health. During your evaluations, it's a great time to really assess the worker's level of knowledge. What do they know about the things that they're being exposed to? You have that private time to talk about that. We want to educate them on the signs and symptoms of the exposure that they may be potentially experiencing. Let them know the things that they should bring back to your attention. It's a time to not only educate, but really empower the worker. We're going to provide our report of medical findings to both the employer and the employee, and of course provide our recommendations. We want to take this opportunity to have a one-on-one opportunity to really engage our stakeholders. In a culture of safety, the goal is to proactively identify and respond to potential hazards before any negative consequences occur. We can suggest our actions to employers, the things that they should take in order to identify and respond to hazards, in order to protect their workers. OSHA standards often require employers to provide a number of things for us to do our job. They want to provide a copy of the applicable standards so we know what it is we're doing for this evaluation. They should provide the job description, typical duties. They should provide the exposure levels of the specific hazard. This may be that time to engage with industrial hygiene to really understand what it is that they're being exposed to. Along the same lines, what PPE are they currently using? If applicable, they should arrange for the transfer of the worker's prior occupational medical records. Do we have previous information that we may need to consider? Again, we're bringing those stakeholders all together, making sure everyone is on the same page, we're educating the employers why it's important that we have this information. It's really, it's difficult to provide optimal care for workers when this information is not available to us. So there are a couple of aspects of the exam process that we need to consider. First, the exam and appropriate testing are based on exposure or post-exposure. The regulations help to define aspects of the exam and who should be enrolled into the surveillance. Triggers for surveillance exams can vary. In the general industry, it could be an exposure that's at or above an action level of 30 plus days a year. Perhaps in the construction industry, it's just that they worked one day in that field and they may need an exam. Emergency exposures could trigger the need for exams and of course, if a worker is exhibiting signs or symptoms of an exposure. Next, we look at the frequency of our exam. Again, this is gonna vary based on the hazardous exposures and exams can occur at a variety of times. We have our initial or pre-placement exams which should be occurring before the potential exposure is encountered. Your exams might be periodic such as annually, every two to three years or perhaps based on the results of their lab values. Some hazards do require a termination exam. When that hazard is no longer a concern, it's time to complete an examination. Exams may be necessary due to emergency exposures and they perhaps, they may be driven by age or considered based on disease latency. We wanna use our available tools to help us determine the necessary exam frequency. We may need to work collaboratively with IH to determine the appropriate process because it does vary based on the hazards they're encountering. Regardless of the timing of our exam, it should be offered during work hours or a time convenient for our worker and of no cost to the employee. So we can refer back to the respiratory protection standard that Jackie introduced to kind of go that step further. So if we're looking at this exam, we can decide, okay, when do our exams need to take place? So we see a pre-placement exam requires an evaluation questionnaire or an exam plus a follow-up exam when required. That's followed by little superscript five. So if you go back into the back of the document, we refer to the five. It tells us the standard requires a specific protocol. See standard for details. That is your cue to really dive into that OSHA standard. Read what it says about your medical evaluation because it's gonna give you the information. It's gonna give you that bottom line that you need to be performing. With periodic exams, it says yes in specific situations. Again, this is denoted with the superscript five indicating to go back to those standards and review. You can see that neither an emergency exposure exam or testing nor a termination exam are required for our respiratory protection standard. As previously mentioned, myself and others, OSHA standards detail our bottom line requirements by law. That doesn't mean to say that companies can't go above and beyond. So it's always important to keep that in mind. When there's not a standard available for the type of exposure or the surveillance that we need, we have other sources out there, other guidance that we can turn to. The contents of the medical exam are gonna be varied based on their exposure or surveillance type. First is the evaluation of the information that we have, your detailed history, assessing the medical conditions and symptoms anyone may be experiencing. And again, we're gonna focus on the occupational history. History is often one of the most important elements that you can gather from that one-on-one conversation with the employee. Next, you're gonna conduct your physical exam, which is gonna focus on the hazard and the health conditions that are specifically related to that. You'll place your emphasis on the target organ systems. And keep in mind, some of the standards require multiple physician review. So it's very important, again, to be aware of what the standard says. We're gonna interpret our diagnostics, and this is gonna include, or perhaps it could include biological monitoring, things such as blood or urine levels. It's gonna maybe physiological data. We're gonna have PFTs or audiograms or chest x-rays to review. Additional testing then is often done according to the physician or other licensed healthcare professional's discretion. Again, targeting those specific organ systems is when we are gonna utilize those additional tests. And unless you're obtaining your baseline data, you're gonna compare the results that we retrieve to their prior results. We're looking for those changes and trends in data among the group. We're gonna provide our referrals as indicated. And this, again, can vary by standards. Couple examples, if you have a benzene exposure and you're having changes or abnormalities seen in their blood work, they may need a referral to hematology for further evaluation. If we're dealing with a silica exposure and we're seeing changes or slow changes in the trending of their PFTs or changes in their B-read, they're gonna need to either see your occupational medical specialist or referral to pulmonology for further evaluation. And then we're gonna ensure that our recommendations are additional requested and required information. Make sure everything is followed up on, reviewed, and documented as appropriate. We placed up here the link for Medical Matrix online. This is listed in our tools and resources handout. This is a great tool that's available. It's available online. It's particularly helpful if you're new to developing medical surveillance programs. It's not foolproof, but it does, you can utilize it as a guide to kind of create a form, to kind of create those pieces. So some other considerations. Data analysis is an important aspect of medical surveillance. Medical surveillance, of course, is intended to be active, ongoing. It's a preventative process. It's inherently linked to corrective and preventative action. If medical monitoring is collected merely to satisfy our compliance and the requirements that set forth, our surveillance efforts are ultimately ineffective. We wanna really look at the data. We wanna look at your trends and the biological data and the physiological data. We're looking within that similarly exposed groups. A worker who develops an occupational disease or for certain standards, perhaps a recordable injury, such as a threshold shift under the OSHA noise standard, may have a valid compensable workers' compensation claim. So we wanna ensure that that worker has the necessary tools and resources available to them. If there is a recordable illness or injury, communication with the person responsible for logging on the OSHA 300 form is vital. And as Jackie mentioned, medical removal requirements are found in some standards. Examples of those, benzene, beryllium, cadmium, cotton dust, formaldehyde, methylene chloride, they all have medical removal requirements, so you need to be aware. These may include temporary or permanent restrictions. They may include modifications of work practices or assignments. So be aware of what's out there. And then when we look at our documentation, obviously in our occupational medical record, we're gonna have the complete history, your physical, the diagnostic results. We're gonna include any specific standard requirements. For example, asbestos 29 CFR 1926.1101 states a statement indicating that the employee has been informed of the increased risk of lung cancer attributed to the combined effect of smoking and asbestos exposure. We're gonna relay this, we're gonna educate the worker, but our standards indicate that we need to have this documented. So again, we may be doing it one-on-one with our worker, but we also wanna satisfy the requirements that are put forth. And then keep in mind with our written opinions, limited information is generally provided to employers. They need to know what they need to know. So the occupational results. Our reports should reflect that the worker's been evaluated according to the OSHA mandated requirements or perhaps whatever standards guidance that you've developed for your program. And then provide any restrictions or limitations to the PPE or exposures. And as always, review those standards. So next I'm gonna turn this back over or turn it over to Orlinda, and she's gonna discuss the importance of evaluation and a quality audit. Thank you. I just woke everybody up. Good morning, everyone. I hope you're enjoying the conference. This is my third year attending the conference. And I just wanna let you know, the people around here except for Scott are my colleagues that I've met through the conference. So a lot of the tools that we'll be sharing today especially the medical matrix are a result of our collaboration and networking within the conference. So say hello to the person in front of you. There's gonna be a lot of collegiality going on and hopefully we'll see in the next conference. Before I forget, I wanna commend Jackie. Jackie is not Heather. For those of you that have been monitoring the swap card, Heather was going to be our other speaker for today. Pam is our section secretary for the NP. And this is our first time meeting Pam, but we've met online. Jackie, I met her through the conference and Melanie the past two years since the Utah conference. And so it is my pleasure to speak. I'm sensitive to the time as well. So I'm just gonna hit the basics of evaluation. And then we have multiple handout in the swap card. The medical OSHA matrix was developed. I am a visual learner and so for me to go through I think 35 pages of the OSHA medical matrix, it didn't make sense to me. And I learned that from my chief, Dr. Lee, who was a retired Navy and we created a medical matrix that says if it was this program, what are the requirements? Do we need a baseline, periodic, termination? What are the laboratory elements? Who should be providing the exam? There are limitations of what we can do as nurse practitioners, but at the same time, the language of the standard says you have to have a supervisory physician to have that discussion and to meet the OSHA requirements. So those are the things that I want you to go ahead and while waiting in line queuing for your flight, log on to your swap card, log on to those links because those are valuable tools. And again, hopefully as you spend more time in the conference, we'll have more time to do some evaluation. And know with time, we'll be more than happy to stand back of the room outside the hallway to answer any questions that you may have. I've been an occupational health nurse practitioner for since 2007. I've been an occupational health nurse since early 1991. I believe that we spend most of our waking hours at work, living, breathing at work. We have an extended family when we're at work. And where we make a biggest impact is at the workplace. So having worked in an acute care environment, when I started nursing, it was when you have to be in the hospital, not in public health, you have to be in the hospital to be perceived as a true nurse. So I was fortunate enough to have been recruited to work for a semiconductor company. And that is when I realized that I can make a better impact. I can respond to an emergency as well as understand what are the workplace health and safety hazards. Your employees are gonna have the biggest respect for you when you do site visits. And I know my colleagues have mentioned that already. So I urge you, if you're new to occupational health nursing or occupational environmental medicine, get to know who your employees are. They are the experts in what they do. And when you have the interest and the passion to understand what they do, they will be your best friend. They will work with you and they will look forward to seeing you every year. That is when you make a pause and said, what have we done? I will look forward to seeing you next year. I wanna see your newborn. I wanna have pictures of your newborn. Because what you're doing then is that setting the stage of what they can do differently tomorrow and then the next six months to make that lifetime, life health changes to impact their health as well as within the workplace. So I am going to start my presentation. Sorry, that was a bit of a long introduction. So as I said, I'm a visual learner. And when we started to develop the program for the content of this presentation, I needed to know how we can then, in a formal pattern, how we can embed evaluation as a key component in developing your medical surveillance program and the center of this framework is your engagement with your stakeholders. So identify who your stakeholders are. When I started the VA, I was an observer. That was me. It's a different organization from what I was accustomed to in an aerospace company. It was, I consider it to be a hierarchical, it doesn't matter whether you've had a military background, but ultimately when you're going to a VA organization, you kind of have to know what that culture is and how you can make some changes by understanding what the culture is. So understanding who is in power, informal and formal leadership power, who would be your major stakeholders, what incentivizes people. I mean, a piece of pen, a paper, a jacket, those are the key things. And I tell you, that makes a big difference. And understand what your role, what the limitations of who your function is, as well as understanding your swim lane. Don't cross it over. So understand getting to know your IH, what they can and cannot do, what you can and cannot do, what their programs, because that varies within different organization. And so with the evaluation, with the evaluation, understanding who your stakeholders are, it could be that safety representative of that department that's going to make or break that compliance program. Your manager, your IH, you may want to include how often are we going to evaluate this program? Is it going to be quarterly? Well, if it's going to be yearly, well, if it's yearly, you're going to miss those folks that needs to have a termination exam. Your IH may be that person that will say that, hey, I own the training program, but I've only got 25 people that completed a training program. When the standard says we have to have a training component, a medical component, and an exit termination exam. I'm not going to belabor the issue about data analysis, but that is something that we as providers of clinicians, as we see our patient day a yearly, or certainly if you have an occupational injury, you have some discussions of what are the parameters? Have there been an increase in their blood pressure, their weight? And in the realm of medical surveillance, you're understanding the patterns in their health, their behaviors, and what their value is. And that's something that I talk to my patient about. You're retiring, but what is it that you want to do when you retire in five years? When if they're diabetics and they're not on meds, well, why is it? If you love to spend time with their grandkids, then that's when you start talking about their health belief behaviors, and have that discussion and ongoing relationship, professional relationship with your patient. The program out audit. Let's see, oftentimes in my experience, with the audit, it's very limited in scope, right? When we have our site and environmental auditors, it's only a safety auditor and an industrial hygienist, but they oversee the OEM portion that they will be auditing. And so for me as a trained, I was fortunate to have been a trained auditor for my organization in the past. And so I've learned to just not say anything, right? You just answer the question, do you have a hearing conservation program? Yes. Okay, but what do you do? Yes. But it's never verified. But I think for the OEM, for ACOM, that certainly I think is an opportunity. How can we grow the organization to one, meet the compliance requirement, at the same time, how can we move forward beyond compliance to certainly do a holistic approach in improving the health and safety of our workforce? Let's see. Audit, according to the ISO, which is the International Organization for Standardization, how defined audit is that it's a systematic method, it's an onsite, independent, you verify by review of records or a process, product, or system. The scope may be the whole site, like the joint commission. They come to you, they descend upon you, and everything seems to be on high alert during their visit. You have your functional audit, you have a process audit going on, and the purpose of that audit could be one, to identify the recent off time deaths, what our environmental health safety auditors are doing, is they do what are the potential risks that they may identify, and they may come back in six months and conduct a follow-up on the corrective actions to make sure that you've had a plan in place, and how to avoid that non-conformance, and hopefully it's never going to happen again. When I was preparing for my slides, there were two quotations that kind of stood out for me. I'm going to let you spend a few minutes of your time to kind of read through it and kind of pause. But those are the things that kind of stands out. So the impact for being non-compliant, and I think as OEM professionals, we've heard this over and over time. My colleagues have looked at what are our roles of OEM providers, ultimately advocating for our workers' health and safety, as well as how can we minimize the risk, and us providers, we work in the model of prevention strategy, public health, primary, secondary, and tertiary, and I think when we can anticipate how we can avoid negative health outcomes, that is where we can then demonstrate our value, our return on investment to our employers. So poor employee health outcomes, individual and company liabilities, and the citation by OSHA may depend on the infraction, the negative public image, economic impact, impact on stock, loss of employees, and more importantly, I think the effect on employee morale. We've discussed this over and over again. Take a look at that handout. It is an element. If I was doing a peer-to-peer audit, that is something that I would do. I will pull the standards. If I have a lead program in place, I want to make sure that I cross the Ts and the Is, and if I find some findings, I would certainly have a document it and work on the examiner to make sure it doesn't happen again. This is one thing that I gathered or gained from attending the AOHC conference, the Occupational Medical Program Assessment, and we do have our military men and women here. Thank you for your service, but that is something. They have great tools that is available for the public and the private sector as well. They have a high level. When you look at their checklist, they look at, do I have adequate staffing? Is it a red, yellow, or green? Are they trained? Are they educated in terms of doing the exam? And then the second level of that checklist is, do we have a medical surveillance program? And beyond the medical surveillance program, there is a next level of tool that talked about the medical certification component. Beyond the compliance of audit, the International Organization for Standardization, the ILO, the International Labor Organization, under the umbrella of United Nations, had a committee that looked at what can we do to reduce the number of deaths among our workers globally. There's about 7,600 deaths related to workplace injuries and diseases, and so they came up with the ISO 45001, titled the Occupational Health and Safety Management Systems. It's the first international standard for occupational health. It's applicable to any industry, and those of you that work with bigger companies, I'm sure you've heard about the ISO 14001, which deals with the environmental management systems, and the ISO 9001, which is the quality management systems. When I was reading this, is anyone from Samsung in this group? Okay, well, okay, so I was hoping that we would, at the end of the talk, would talk to this attendee, but in 2022, all production sites within Samsung Company had been certified to 45001, and that is a stringent certification that they've done such a good job in terms of reducing their health and minimizing the risk for their employees. We have run over time, I apologize. As you can see, I'm very passionate about OEM. But the tools, we have a listing of tools, of laws and regulations, very comprehensive, sources for guidance, professional organizations, and being a member of AECM is one of the main things. Government and military entities, we talked about the OMPA is here, the medical matrix is here, other relevant guidance, and again, in summary, we have identified the drivers, we've created a framework that will help you. I'm a visual learner, that's something that I'm going to take with me when I talk to my colleagues, and we've identified multiple tools and resources. And with that, we thank you, and I apologize for taking a lot of your time, and we'll be more than happy to stay over and answer any questions that you may have. If there are questions, there is a mic in the middle of the room. If you would come to that, just so we can hear what your questions are. I have a question. So I work with two global chemical manufacturers, and we recently went through a global update for our medical surveillance programs. One of the questions that came up a lot, it's been a tough one, is EPA's new existing chemical exposure limits. And we're talking ones that are 200, maybe 1,000 times lower than our existing exposure limits. So when designing a medical surveillance program, we typically use these exposure limits to guide what is going to be our action level, and also just our controls in general. Any insights into being proactive and trying to follow these ahead of time, or, you know, because I know there's an enforcement question to this, a feasibility question, will they finally be approved? No pressure for OSHA, but what your memorandum of understanding eventually will be for enforcement on these things. But when you are designing these programs, are we looking at levels that low, or are we trying just to stick with what we know with ACGIH and our other kind of trusted authorities at this time? I'll let Scott address that. So thanks for the question. And this sounds like a much longer discussion. You know, it's a much deeper dive. And yeah, if the EPA has more stringent, it's going to be recommendations, right? But, you know, it's something that definitely has to be looked at. And I think that engineering trolls are going to have to — you're going to have to find a way, your team is going to have to find a way to implement those to try to meet those. I think that's the best way. You're not going to — if you said 100 times greater or 100 times more stringent, then we're not going to be able to do that with PPE or administration controls alone. It's going to have to be engineering controls. And, you know, it's going to take a team to dig into this. If you're going to meet that, you're going to need a lot of help. So fair enough? Thank you for this opportunity. My name is Khalid Saadi. I am Chief Medical Compliance Officer from Inukun, United Arab Emirates. I have one question regarding medical surveillance, which is I am very much into it. Are we talking about occupational health surveillance or medical surveillance? Because for me, they are totally different. Because if I am talking about occupational surveillance, I am starting from occupation. So there are things if related to the occupation, I am looking at the result of the medical surveillance. However, most occupational medicine or occupational health, sorry, occupational health service, they jump from occupational surveillance, then they talk about medical surveillance, then they go back to occupational surveillance. I think occupational surveillance is more potent and more polite and provide huge, more valuable information with regard to the concept, if we are talking about occupational surveillance. So could you, I think if I will refer the question to Scott, because he's industrial hygienist, I think that will be of value. But one other question I have, industrial hygiene report to me, right? The current issue with industrial hygiene, the misunderstanding that you stated, clearly that there is a misunderstanding of what people look or understand from industrial hygiene. There is only one question that I try to use to verify that. When I start my practice in occupational medicine, I ask each employee to bring along his job description, right? So the importance of HR, right, was with me from the beginning. I didn't hear it was mentioned anywhere in this presentation, which is, I believe, a strong stakeholder in the value of occupational medicine comes from HR. Thank you. So this is a difficult one. And I do see this every day as our staff, our employees, the people that we're trying to protect, always lacking education. Not their education, but education in the hazards that they're dealing with. And it's something that I continuously come across. And again, I can't emphasize training more for people. And even those discussions, those talks we have with people about their job tasks, they're not necessarily adequate. And sometimes, and I haven't done it in a long time, I have another industrial hygienist that works underneath me now. But going through the motions with, and this is something that maybe you can't do, but maybe an industrial hygienist, maybe safety personnel can, to see exactly what they're doing and exactly what they're exposed to. Because again, if you're a welder and you're welding stainless steel, I'll tell you that 8 out of 10 of them do not know that welding stainless steel, cutting stainless steel produces hexavalent chromium vapors. They don't. And they don't look into it. So we need to educate the people, and we need to put it back on them, too. It's their responsibility to know what they're being exposed to. But it's our responsibility to help them understand it. And I would just add to that, that one of the things that you brought up, it is extremely important to identify those stakeholders. We do believe HR is one of those important stakeholders, the safety managers, the supervisors, the workers. But you have to have information from all of those stakeholders. And doing a site visit really helps you establish who those stakeholders are, build those relationships with them, so that when questions come up, you have those relationships to go back to and say, hey, I'm seeing this in a worker. Can you give me more information here? Or I need some information on what this worker's doing. Can you explain that a little bit more? So you're exactly right. They are an important stakeholder. Can I also clarify? We put emphasis on medical surveillance as pertaining to the higher, to meet the regulatory body of OSHA and other local standards, such as ANSI. There's also a difference between, we don't want to confuse you more, but there is what we call medical certification. So the medical certification comes into play when you have your job description, you're doing an examination based on, can that person do the physical demands of the job? So for example, within our organization, within the VA, it's a mandate that anybody who is required to drive a government-issued vehicle will need to have an incidental driver exam. We know the supervisor identifies who are their workers that requires a medical certification that requires for them to be able to drive the car safely. So that's where the medical certification comes in. But our talk today certainly is emphasizing more on occupational medical surveillance. So thank you. Go ahead, Dr. Chaudhry. This is Dr. Chaudhry. Thank you for the presentation. And I do have a question regarding the asbestos program. And the question is to the industrial hygienist. Is your industrial hygienist, are they part of your asbestos medical surveillance? And if so, like, is your facility already being, or when do you enroll them, or basically who are the people whom you are enrolling these people into the asbestos program? Thank you. Oh, I'm sorry. Can you mention the first part of the question? I didn't quite hear it. Is your industrial hygienist, are they a part of asbestos program? Part of a specialist program? Yes. Being an industrial hygienist, are you, since you are an industrial hygienist, are you considered to be included into your asbestos program? Asbestos. Oh. So, okay. Okay, I understand. For myself, yes, but that's not true in every instance. Industrial hygiene is a very wide field. It's like maybe being a general practitioner where, you know, you know a little bit about everything, but maybe not a specialist in that item. I got my start in industrial hygiene doing asbestos, and the toughest test I've ever taken in my whole life was passing the California asbestos test to be a consultant, but not every industrial hygienist is going to know about asbestos or be an expert about asbestos. So did I answer your question? Are you enrolled in asbestos medical surveys? Oh, am I? Personally? Okay. I was. I am not now, but I have been many times in the past. I did asbestos for about 12 years and was enrolled in the program, yes. Did we not answer your question? I'm sorry. So the question is, like, basically, what I get. Actually, we are right at 945, and I know that the speakers that will be arriving for the next session in this room will need to come up. We'll be happy to meet you in the back outside and answer any other questions you might have. Thank you all so much for coming.

medical surveillance program

collaboration

interdisciplinary teamwork

program development

assessment strategies

industrial hygienists

HR personnel

data analysis

regulatory standards

exposure limits

occupational health initiatives