occupational safety and health program ...admninistration's (osha) evaluation of the department...

OCCUPATIONAL SAFETY AND HEALTH

PROGRAM EVALUATION

OF THE

VETERANS HEALTH ADMINISTRATION

U.S. DEPARTMENT OF VETERANS AFFAIRS

U.S. DEPARTMENT OF LABOR OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

DIRECTORATE OF COMPLIANCE PROGRAMS OFFICE OF FEDERAL AGENCY PROGRAMS

SECRETARY OF LABOR WASHINGTON

The Honorable Anthony J. Principi Secretary of Veterans Affairs Washington, D.C. 20240

Dear Secretary Principi:

Enclosed for your review and comment is the Occupational Safety and Health

Admninistration's (OSHA) evaluation of the Department of Veterans Affairs, Veterans

Health Administration's safety and health program. The evaluation was prepared by

OSHA as required by Executive Order 12196 and Department of Labor regulations 29

CFR Part 1960.

During the evaluation, OSHA staff received outstanding cooperation from their

colleagues at the Department of Veterans Affairs and the Veterans Health

Administration. With their help, we were able to prepare a report which we believe

will help make your occupational safety and health program more effective. While our

report suggests some changes to further improve the program, it also recognizes the

positive steps taken in safety and health during recent years.

We would appreciate your reply within 60 days concerning the actions that will be

taken on the various findings and recommendations in the report. It has been our

pleasure to work with your staff on a program that is so important to the welfare of the

men and women working to provide services to our veterans.

Sincerely,

Elaine L. Chao

Enclosure

EXECUTIVE SUMMARY

In 1997, the Veterans Health Administration (VHA) initiated a concerted effort to make

occupational safety and health a core value of the organization and its commitment has

continued unabated. VHA management regards protection and promotion of employee

safety and health as a fundamental value of the organization and applies its

commitment to safety and health with as much vigor as to other organizational

purposes. Safety and health policy and goals have been established and

communicated. Management has provided resources including budget, personnel and

information to facilitate the operation of the occupational safety and health program.

Management at all levels of VHA participate in significant aspects of the safety and

health program and are held accountable for supporting the goals of the program and

promoting efforts to achieve expected results.

Employees and their representatives have been encouraged to participate in all aspects

of the program, including program improvements and development, operations, and

evaluation as evidenced by this joint effort. They have in turn committed their insight

and energy to achieving the safety and health program's goals and objectives.

Procedures are in place for effective communication on safety and health matters,

including employee access to information and management-employee committees.

Employees and their representatives are included in oversight of the safety and health

program and participate in worksite evaluations.

The VHA has established a program which provides systematic policies, procedures,

and practices that are adequate to recognize and protect its employees from

occupational safety and health hazards. There are provisions for the systematic

identification, evaluation, and prevention or control of general workplace hazards,

specific job hazards, and potential hazards which may arise from foreseeable

conditions. The program holds compliance with safety and health standards as an

important objective and seeks to prevent injuries and illnesses.

Detailed procedures, guidance regarding program operations, and hazard controls for a

wide range of potential hazards have been provided. The VHA National Engineering

Services Center, Headquarters staff and other VHA safety and health professionals are

to be commended for the development of a high quality multi-volume Guidebook Series

that provides a comprehensive and consistent review process for the occupational

safety and health program at medical centers.

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Additionally, VHA developed a real-time automated incident management and

tracking system as well as a computer based oversight evaluation tool. A

comprehensive array of safety and health training and education for employees at all

levels, and their representatives, is available.

Work operations removed from patient care, such as confined space surveys and safe

work practices, hazard assessments for personal protective equipment needs, and

lockout/ tagout program operations require additional attention to ensure strict

compliance with requirements and hazard control. While VHA has established

adequate employee safety and health program guidelines and standard operating

procedures, there is a need to tailor that general guidance so that local hazards are

controlled, and employees adequately protected.

OSHA acknowledges the cooperation and support afforded this agency by VHA staff at

all levels at the Headquarters offices and sites throughout the country. Their

willingness to join with OSHA on an untested pilot evaluation process is to be

commended. Executives; managers, supervisors, employees and their representatives

joined together to ensure that the evaluation teams were provided information

requested, without exception. Their work to ensure that this evaluation effort was

successful is appreciated. Together, we have built a solid foundation of cooperation

that will serve our future efforts to promote Federal agency safety and health programs.

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ..........

I. INTRODUCTION .......................................................... 1 A. Regulatory Basis .................................................... 1 B. Focus of the Evaluation .............................................. 1 C. Previous Agency Evaluations ......................................... 1 D. Statistical Review ................................................... 4

1. Total Injury/Illness Case Rates .................................. 4 2. Lost Time Case Rates ........................................... 5 3. Lost Time Case Rate Expressed as Percentage of Total I/I Case Rate . 6 4. Workers' Compensation Chargeback Costs ........................ 8

E. Participation by the Department of Veterans Affairs Employee Unions ..... 9 F. Description of Protocol ............................................... 9 G. Follow up on Evaluation ............................................ 10

II. TOP MANAGEMENT SUPPORT .......................................... 11 A. Management Direction ............................................. 11 B. Program Documentation ............................................ 14 C. Resources ..................................... ................... 15 D. Accountability ........................ .................. 17

III. PROGRAM PLANNING ................................................. 19 A. Record keeping .................................................... 19 B. Goals and Priorities ................................................. 19 C. Emergency Planning ................................................ 20

IV. PROGRAM IMPLEMENTATION .......................................... 22 A. Employee Rights and Responsibilities ................................. 22

1. Right to be informed about the program ......................... 22 2. Right to report hazards ....................................... 22 3. Right to be protected from reprisal .............................. 23 4. Right to participate in inspections .............................. 24

B. Training ........................................................... 25 C. Inspections ........................................................ 27 D. Hazard Abatement ................................................. 29

V. PROGRAM EVALUATION ......... 31

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Appendix A - Agency Evalqation Grid

Appendix B - Program Revi Hazardous Materials Bloodborne Pathogei Tuberculosis Manag( Chemical Health Ha2 Confined Space Prog Fire Protection ..... Emergency Response Personal Protective E Violent Behavior Pre, Employee Complaint Ergonomics Program Facility Safety Comni Facility Director Invc Structural Analysis o Occupational Health

ws .............................

Management .......................... SManagement .......................... m ent .................................. ard Exposures ......................... am .............................

Planning............................ quipm ent .............................. rention ................................ Response Program ..................... ............... ol......................

Appendix B - 1 Appendix B - 1 Appendix B - 2 Appendix B - 3 Appendix B - 3 Appendix B - 4 Appendix B - 5 Appendix B - 6 Appendix B - 7 Appendix B - 7 Appendix B - 8 Appendix B - 9

ittee ................................. Appendix B - 10 lvement. ............................ Appendix B - 10

'the OSH Program at the Facility Level ... Appendix B - 11

Services .............................. Appendix B - 12

Appendix C - Best Practices Top Level Managemr Safety and Health To VHA Annual Safety . Violent Behavior Pre, Ergonomics Program Worker Compensatic Employee Training . Patient Safety and RiL Bloodborne Pathoger Tuberculosis Manage Chemical Health Ha2 Confined space .... Fire Protection .... Emergency Response Facility Safety Conur Contractor Safety ..

nt Support and Employee Involvement ... lhnical Resources ....................... nd Health Activities Evaluation Survey ... ,ention ................................ ; ... ....•o •....... ....................

n Program Management ................

k Management Program Integration ...... s Management and Control .............. ment ............................... ard Control and Management ............

Planning ......................... ittee................................

Appendix C - 1 Appendix C- 1 Appendix C - 1 Appendix C - 2 Appendix C - 2 Appendix C - 3 Appendix C- 4 Appendix C- 5 Appendix C- 5 Appendix C - 5 Appendix C- 6 Appendix C -6 Appendix C - 6 Appendix C - 6 Appendix C - 7 Appendix C- 7 Appendix C - 7

Appendix D - Recommendaions ............................. Appendix D - 1 Occupational Safety nd Health Program Training............ Appendix D -1

Personal Protective E~luipment Programs .................... Appendix D - 3 Confined Space Prog-am ................................... Appendix D - 4

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S........ Appendix A - 1

Fire Protection Programs ................................... Appendix D - 4

Lockout/Tagout and Electrical Safety ........................ Appendix D - 5 Occupational Safety and Health Program Written Requirements Appendix D - 5 Occupational Safety and Health Program Resources ........... Appendix D - 7 Ergonomics Programs ..................................... Appendix D - 8 Violent Behavior Prevention Programs ....................... Appendix D - 9 Opportunities to Share "Lessons Learned" ................. Appendix D - 9

Commonly Used Acronyms ...................................... Appendix E- 1

I. INTRODUCnTON

A. Regulatory Basis

The Occupational Safety and Health Act of 1970, Section 19, requires agency heads to

establish "effective and comprehensive" occupational safety and health programs.

Executive Order 12196 and its implementing regulations, Basic Program Elements for

Federal Employee Occupational Safety and Health Programs (29 CFR Part 1960) were issued

in 1980; these regulations require the Secretary of Labor to evaluate the agencies'

programs and describe the minimum elements a program must include to be effective.

Evaluations are carried out by the Department of Labor's Occupational Safety and

Health Administration (OSHA).

B. Focus of the Evaluation

This evaluation of the Veterans Health Administration (VHA) was conducted jointly by

OSHA, representatives of the Department of Veterans Affairs, staff from the Designated

Agency Safety and Health Official's (DASHO's) Office, VHA officials, and

representatives from five of the unions that represent VA-VHA employees nationwide.

The evaluation focused on the safety and health program as implemented at VHA

medical centers nationwide and encompassed both the medical centers and the

organizations that administer their safety and health programs at Headquarters. This

was a pilot project and was the first evaluation conducted with agency safety and health

managers and professionals and the unions representatives holding full membership on

the evaluation team.

C. Previous Agency Evaluations

The Department of Veterans Affairs (VA) is the second largest federal agency. During

the time of this evaluation, the VA's largest subagency, the Veterans Health

Administration (VHA), had 210,000 workers in 172 medical centers and 400 clinics

across the country. VHA was and remains the largest subagency in the VA. VHA is the

largest network of health care providers in the United States.

OSHA evaluations of the VA were previously conducted in 1983,1985, and 1992. The

findings from each of these past evaluations were provided to the Department Head

and safety and health officials. VA had not successfully implemented a number of the

recommendations from previous evaluation reports. While the VA Designated Safety

and Health Official (DASHO) is responsible for the overall occupational safety and

health program for the Agency, the Under Secretary for Health, who heads VHA, has

the authority and responsibility for directing programs and personnel required to

correct deficiencies. Thus, OSHA undertook this partnership to engage VHA top

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management officials in bringing about real and substantial change since the three

previous evaluations had not produced the desired results.

Leadership and support for significant safety and health program initiatives has been

evidenced by the VHA Office of the Under Secretary for Health and VA DASHO, with cooperation by their union partners. A number of long standing program deficiencies

have been corrected, or are actively undergoing positive changes. The following

examples illustrate some of their efforts:

In prior evaluations OSHA found that VA did not have a written OSH program compliant with E.O. 121%. VA's current written safety and health program was

issued in July 1998 as VA Directive 7700 and Handbook 7700.1. While a number of VHA medical centers had not implemented all the requirements of the Directive and Handbook at the time of our site evaluation team visits, both management and union representatives have initiated work to update, and thus facilitate final implementation, of a VA-wide safety and health policy and

program.

In previous evaluations, OSHA addressed VA's lack of adequate staffing to

perform oversight of OSH programs. At this time, the DASHO's Office of Safety

and Health has oversight responsibilities and VHA has implemented a detailed annual program evaluation initiative geared to maximize program effectiveness and efficiency. Additionally, VHA has implemented automated electronic software that has the capability to accurately identify, track, and evaluate

accidents, injuries and illnesses when they occur; this system allows VHA facilities and safety and health experts to better identify root causes of accidents

and implement preventive measures. VHA has developed a system for streamlined safety and health inspections that will improve nationwide consistency, improve reporting and tracking of inspection results, reduce paperwork and may result, in time, in improved utilization of professional safety

and health inspector time.

Previous OSHA evaluations had documented a lack of accountability for OSH

performance on the part of VA management officials. During our current evaluation efforts we found that VHA network and facility directors are held

accountable for the delivery of safety and health program services and goal

achievement. Supervisors also have written performance measures pertaining to employee safety and health obligations. To illustrate another facet of improved

accountability, OSHA's prior evaluations documented repeated failures to abate

deficiencies cited by OSHA and VHA inspectors. Each Site Evaluation Team reported that they found written abatement procedures, written procedures for tracking abatement and that abatement dates are set and met, or that required

procedures were followed when abatement could not be achieved within time limits. VHA's support for this evaluation and commitment to manage necessary

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program changes was further illustrated by the fact that the VHA management representative from the VHA Veterans Integrated Service Network Support Service Center (VISN VSSC) attended nine of the ten site evaluations.

In past evaluation reports, OSHA addressed the lack of effectiveness of the occupational safety and health portion of labor - management partnerships within VA. During our recent evaluation visits, we found that employee representatives and front-line workers participated in the occupational safety and health program. The VHA has taken steps to actively include the unions in all phases of the safety and health program; useful and effective relationships have been fostered. VHA has established a Partnership Council and facilitated the designation of VHA national safety representatives.

Members of the DASHOCs Office of Safety and Health have worked with VHA to take positive action on the prior OSHA findings regarding a lack of occupational safety and health training. Safety and health program training goals have been established and met, training has been developed, offered in a variety of userfriendly formats, and made available to employees. VHA has developed materials for training VHA employees.

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D. Statistical Review

1. Total Injury/Illness Case Rates

F'calYear W9 9 91 92 93 94 9 6 9 8 9

VA total injury/ illness case rate 5.71 5.23 5.01 5.01 5.00 5.01 4M5 4.65 4.49 4.42 4.54

Fed Gov't total injury/ illness case rate * I547' 5.10 15.11 15.11 15.37 15.73 ,5.63 5.58 .5.63 .5.46 .5.48

* U.S. Postal Service experience has been included in the above noted Fed Gov't total

inqury/iMness case rate.

Rates are expressed as injury and illness, claims filed with the US. Department of Labor

office of Workers Compensation Programs, per 100 employees.

Although this evaluation focused on the safety and health program in place at VHA,

governuent-wide uniform data for the range of years addressed was available only for

the entire Department of Veterans Affairs. In that VH-A employees make up the majority

of the VA population, and VHA is charged with providing a wide range of safety and

health program services within VA and VHA, we attribute a large part of the decline in

the number of injury and firness cases to changes implemented by VHA.

When we compare total injury and illness case rates for fiscal years 1989 and 1999, the

total injury and illness case rate at the Department of Veterans Affairs in Fiscal Year

(FY) 1999 was 20.5% less than the rate recorded ten years earlier. For the Federal

government, the rate remained essentially unchanged.

The last OSHA evaluation was done in 1992; the VA total injury and illness rate in FY

1999 was 9.4% lower than the rate in FY 1992. The Federal government's total injury

and illness rate in FY 1999 was 7.2% higher than its FY 1992 rate (includes U.S. Postal

Service data).

STotal Injury/Illness Case ....Rate 6

E. 5.5

5 At Fed Gov

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2. Lost Time Case Rates

Lost Time Case Rate

4

3.5

3 - AN Fed GOvI

.9 2.5

2

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

FiscalYear 89 90 91 92 93 94 95 96 97 98 99

VA lost time injury/ illness case rate 3.80 3.35 3.25 3.12 3.19 331 2.84 2.85 2.65 2.53 2.30

Fed Gov't lost time in,;ry/illness case rate* 2.71 2.41 2.43 239 2.70 3.05 2.80 2.67 2.51 2.40 2.13

* U.S. Postal Service experience has been included in the above noted Fed Gov't total

injury/illness case rate.

Rates are expressed as injury and illness claims filed with the US. Department of Labor

Office of Workers Compensation Programs, per 100 employees.


government-wide uniform data for the range of years addressed was available only for

the entire Department of Veterans Affairs. In that VHA employees make up the majority



the number of lost time injury and Illness cases to changes implemented by VHA.

The VA lost time case rate in FY 1999 was 39.5% lower than in FY 1989, and the Federal

government lost time case rate was 21.4% lower in FY 1999 than in FY 1989. The VA lost time case rate in FY 1999 was 26.3 % less in FY 1992, the year of the last OSHA

evaluation. For the Federal government, the lost time case rate in FY 1999 was 10.9%

lower than government-wide rate in FY 1992. Note that rates for the Federal

government include US. Postal Service data in this analysis.

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3. Lost Time Case Rate Expressed as Percentage of Total Injury/Illness Case Rate

U.S. Postal Service experience has been included in the above noted Fed Gov't total injury/illness case rate.

Rates are expressed as injury and illness claims filed with the US. Department of Labor

Offic of Workers Compensation Programs, per 100 employees.


government-wide uniform data for the range of years addressed was available only for

the entire Department of Veterans Affairs. In that VHA employees make up the majority



the percentage of lost time injury and illness cases to changes implemented by VHA.

Since 1989, the percentage of VA lost time cases has trended downward. In FY 1989,

67% of VA's total injury and illness cases involved lost time; in FY 1999 only 51% of

VA's total injury and illness cases were lost time cases. The percentage of lost time

cases for the Federal government also trended downward, from 50% in FY 1989 to 39%

in FY 1999, but this is not as wide a margin as that for VA.

We believe that the downward trend for lost time injury and illness rates may be

attributed to a number of factors:

In VHA there has been a trend to provide more care to veterans in outpatient

settings rather than in hospital settings. This means that there are fewer

employees working in the higher risk settings of hospitals.

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There has been a change in the way VHA administers its OWCP chargeback costs, which are now charged to the facility levels, giving each VHA Facility Director an incentive to reduce costs, as well as reduce the numbers of injuries and illnesses.

Reductions in costs and lost time case rates are a requirement documented in the performance plans for VHA network directors. These requirements, in association with VA and VHA goals for reductions in rates and costs, have provided incentive to reduce rates.

VHA staff have produced high quality tools to aid field safety and health staff in the implementation and delivery of the program and operations. Occupational safety and health programs and initiatives have received top level management support from the Office of the Under Secretary for Health and his staff.

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4. Workers' Compensation Chargeback Costs

I V A Workers' Compensation Chargeback Costs I

150 $145,470.924

145 "142.4.28 s14o17204272

/140 S ,I!O7- i 13,.N

S135 -$133,3$ l.023

1992 1993 1994 1995 1996 1997 1998 1999125

L .. �, m�hn&� � 3A% mom tt�an 1992 W�S I I � .�..�.��--.-.-----**-*-

- --

Although this evaluation focused on the safety and health program in place at VHA. government-wide uniform data for the range of years addressed was available only for

the entire Department of Veterans Affairs. In that V-A employees make up the majority



worker compensation chargeback costs to changes implemented by VHA.

In Chargeback Year 1999, VA experienced a 336% increase compared to Chargeback

Year 1992 in terms of workers compensation costs for medical expenses, disability

compensation and survivor payments (but not continuation-of-pay costs). For the

same two years, the workers compensation costs paid by the entire Federal government

were 14.5% higher in Chargeback Year 1999 than Chargeback Year 1992. The rate of

increase for VA was lower than that for the entire Federal government.

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$14D.118.132

f. A- -h-4,costsere336% Mon ;,;: I I NOTE 99 vgolpa- COMPe-- -- IV

[

E. Participation by the Department of Veterans Affairs Employee Unions

Five union representatives from the ranks of VHA were involved in the development and approval of the evaluation protocol and took active roles during the evaluations of

ten VHA Medical Centers and at VHA Headquarters. The union representatives are

associated with the American Federation of Government Employees (AFGE), Service Employees International Union (SEIW), American Nurses Association (ANA), National

Federation of Federal Employees (NFFE), and National Association of Government

Employees (NAGE).

F. Description of Protocol

The evaluation protocol was developed by staff assigned to OSHA, the DASHO's Office

of Safety and Health (VA), VHA, and the union representatives; it was formally approved by all parties. The evaluation protocol called for a review of the overall safety

and health program at VHA, including subject areas such as top management support,

accountability for occupational safety and health, compliance with training requirements and program implementation at the facilities.

The protocol provided for the use of "partnership evaluation teams" to perform the

evaluation. Site evaluation teams were directed by OSHA Regional Federal Agency Program Officers and were comprised of industrial hygienists and safety professionals from VHA and OSHA, one of the five national union representatives, local union

representatives and representatives of OSHA Office of Federal Agency Programs. The

site evaluation teams spent a week at one of the ten VHA medical centers and their work is described below. VHA sent a representative of the VISN Support Service

Center to nine of the ten facility evaluations; (two of the facility evaluations were

conducted during the same week. The DASHO's Office of Safety and Health sent a

representative to the first facility evaluation. The National Evaluation Team members included the Director of the Office of Occupational Safety and Health (VA), the Director of Safety for VHA, the Director of the OSHA Office of Federal Agency Programs, and a

national rdpresentative from each of the five unions listed above; this team developed this report..

During a week-long visit at one of the VHA medical centers, the Site Evaluation Team reviewed documentation of the Center's safety and health program for compliance with requirements contained in 29 CFR 1960, Basic Program Elements for Federal Employee Occupational Safrty and Health Programs and Related Matters, such as inspections, training,

hazard abatement, accountability, employee complaint and reprisal procedures,

recordkeeping and other specific elements addressed in detail in this report.

Additionally, teams conducted walkthroughs of the facility and interviewed employees, supervisors, facility safety committee members, and the Facility Director. They worked

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closely with facility safety and health staffs in collecting information and facility managers were briefed concerning team findings, and expected to timely abate hazards

identified. Findings were summarized for use by the National Evaluation Team.

Representatives of the National Evaluation Team interviewed VA and VHA staff at

Headquarters, reviewed work compiled by the site evaluation teams and written

program information provided by senior management officials, and developed this

report.

The VHA ten medical centers selected for onsite reviews were selected because they

represented a variety of strong and weak points: some had relatively high lost time case

rates, some were more typical of the VHA norm, others were selected based on size,

location, or past OSHA inspection compliance history. The sites were:

Little Rock, AR Iowa City, IA

Loma Linda, CA Detroit, MI West Haven, CT Albany, NY Lake City, FL Coatesville, PA

Miami, FL Beckley, WV

G. Follow up on Evaluation

The implementation of recommendations in this report will be monitored jointly by

OSHA, the DASHO's Office of Safety and Health, the unions and VHA.

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II. TOP MANAGEMENT SUPPORT

A. Management Direction

Leadership and commitment by management are essential for an effective health and

safety program. Top management officials in VHA have demonstrated their

commitment to making employee health and safety an organizational priority and core value: * Goals have been developed for the health and safety program and there are

action plans for meeting those goals. * Management has communicated with employees so that they understand the

results desired, plans for achieving results and employee and union roles in the

endeavor. * VHA management stays abreast of current activities and issues involving the

health and safety program and seeks ways to maximize opportunities and control potential problems.

* The responsibility for developing and managing a comprehensive program has been assigned to persons with expertise in occupational health and safety and management, and these individuals have decision making power through

designated procedures. • The health and safety program has been endorsed and supported through

provision of financial, human, and material resources critical to achieving goals. * Manager, supervisor, and employee accountability has been provided for, and is

expected.

Employee involvement is a vital part of an effective health and safety program. Employees possess first-hand knowledge of the workplace and their input should be a basic component of the program. VHA management has established mechanisms to facilitate employee involvement and motivate employees to participate in achieving program objectives and goals.

This evaluation project is an example of the VHA interest in building viable and

effective partnership with its employees. At the medical centers, we found that employees were free to report hazards, unsafe work practices, and occupational injuries

and illnesses and did so without fear of reprisal. The reviewers found that there was follow-up on employee health and safety suggestions and concerns. At each facility

visited by the site evaluation teams, safety and health committees were utilized to

enhance employee involvement. Committees from site to site varied slightly to

accommodate the needs of the local facility, but common responsibilities found in each

committee were: "* ensuring that program elements were implemented; "* reviewing and analyzing reports related to health and safety program activities;

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making recommendations related to program development, implementation, and revision; monitoring the effectiveness of the program; and

reporting activities to upper-level management on a regular basis.

The 1992 OSHA safety and health program evaluation found that the VA Designated

Agency Safety and Health Official (DASHO) position was placed four levels below the

Administrator. According to the 1992 report, the DASHO did not appear to have

ready access to the Administrator or to represent him in managing the safety and health

program. Since that time, the Assistant Secretary for Human Resources in the Office of

the Secretary of Veterans Affairs has been assigned the duties of the DASHO. The

DASHO is charged with assisting the Secretary in formulating and promulgating VA occupational safety and health policy and administering the VA OSH program. The staff of the DASHO is located in the Office of Occupational Safety and Health works

with the staff of the VHA Under Secretary for Health. It should be noted that although

there has been a change in the location of the DASHO, this evaluation did not focus on

the specific impact of that change on the VHA safety and health program. This evaluation focused on the VHA since it is the Under Secretary for Health, who heads

VHA, who has the authority and responsibility for directing programs and personnel

associated with providing the bulk of safety and health services. VHA has assigned the

occupational safety and health program and services to the Office of the Under

Secretary for Health. These activities are directly supervised by the Office of the Chief

Network Officer. Nationwide initiatives are coordinated at Headquarters and field

programs, services, and activities are delivered by 22 Networks. This organizational

placement of occupational safety and health in VHA has given the program visibility and support and enhances the VHA's oversight and advocacy efforts for the

occupational safety and health program.

Dr. Thomas Garthwaite, former Under Secretary for Health at VHA, was asked how he

fostered top management support for safety and health. In an organization where, due

to the nature of the work, potentially serious health and safety risks exist, VHA's goal is

for no unplanned event at any time, and to learn from every untoward event There are

34 inspecting bodies that go through the VHA every year, and VHA welcomes their

insights. VHA has put plans, people, and incentives in place and continues work on

plans to change the organization's culture to focus on the responsibility to meet

standards with exceptional accountability. VHA has identified strategies to move this

very large and complex agency: * Performance measures are put in place to accurately measure for outcomes, point

toward ways to do it, drive the attributes in the system. * Annual negotiated signed agreements are formulated between the Chief

Network Officer, who works directly for the Under Secretary for Health, and

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each Network Director. These performance agreements have safety/health goals. Education is combined with good systems to support people. Top level management has established a conscientious safety and health group at VHA Headquarters with staff reporting directly to the Chief Network Officer. That group is committed to supporting safety and health program systems, people and plans. In terms of establishing a core value, VHA is committed to be a place where employees feel safe and want to work.

The Chief Network Officer (CNO) advised the evaluation team of VHA's vision for safety and health in the future: VHA needs to be the health care provider, and employer, of choice. VHA recognizes the critical need to provide an environment where employees are secure and want to come to work and intends to be a place where employees can be safe and productive. Safety is not discreet, it is integral. The CNO has communicated his views and specific expectations to VHA managers and tracks compliance with requirements through performance indicators, measures and monitors made a part of network and facility directors' performance agreements. Performance is monitored quarterly, reviewed against established goals and corrective action is identified to ensure compliance.

The VHA Chief Consultant for Occupational and Environmental Strategic Health Care Group and the VHA Director for Safety advised that the Occupational and Environmental Strategic Health Care Group was established by Dr. Garthwaite's predecessor, Dr. Kenneth Kizer, in June 1997 to better coordinate safety and health issues across VHA. Multiple disciplines are involved in this coordination, geared to

enhance programs. The Occupational and Environmental Strategic Health Care Group strives to: • Improve management of injuries and illnesses. Each VHA Medical Center has a

process that draws together a diverse group of professionals that includes the

Director, workers' compensation program specialists, safety and health staff, and supervisors to address issues associated with an incident

* Better track injuries and illnesses. VHA instituted a safety and health information management system called the Automated Safety Incident and Surveillance Tracking System (ASISTS) early in 1999 that is compatible with VHA medical centers' computer language and has the capability to accurately identify, track and evaluate accidents or illnesses when they occur. Veterans Integrated Service

Network (VISN) and medical center safety and health employees can use this trend analysis capability to identify the root causes of accidents and help prevent future incidents.

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Promote education in safety and health. VHA encourages in service training for safety and health staff, sponsors annual training conferences and provides basic

courses in safety and health for managers, union representatives, staff.

Focus on health surveillance and provide expert technical advice for various

programs and problems. Promote collaborations with other agencies in a broader role. For instance, there

is a memorandum of understanding with NIOSH to utilize expertise and expand research ability in areas that include but are not limited to latex sensitivity,

needlestick prevention, TB control and education. Provide ongoing support for interagency education programs. These programs

are supported by FDA, CDC, NIOSH and VHA. Some projects have included latex, TB prevention and other smaller special projects. Provide support through the VHA St. Louis National Engineering Service Center.

Dr. Kizer directed the establishment of qualitative and quantitative performance

standards for network and facility directors to show top level management commitment. Dr. Garthwaite continued and refined this process.

B. Program Documentation

The 1992 evaluation documented that the VA did not have a written safety and health

program as required by Executive Order 12196. OSHA's 1983 and 1985 evaluation reports had recommended that VA correct this deficiency. In July 1998, VA Directive 7700, Occupational Safety and Health, was issued and established the policies and

responsibilities for managing and implementing the VA occupational safety and health

(OS-) program. Concurrently, VA Handbook 7700.1, Occupational Safety and Health,

was issued and contained the VA OSH program for preventing injuries and illnesses,

training, reporting, record keeping and recognizing outstanding OSH achievements. However, neither document had been fully implemented throughout VHA at the time

of the site evaluation team visits to medical centers. VHA had experienced two major

workforce reductions and had reorganized their regional structure shortly before these

documents were issued. Some VHA positions assigned responsibilities in the VA

Handbook had been eliminated so that work delegated in the policy had to be assigned

to other staff. Some terminology and requirements had been overtaken by VHA to the

point that the policy and guidance was in need of an update to enable the field to fully

implement its requirements. Since VHA is the organization assigned most of the

responsibility for delivering safety and health program services to VA facilities, these

programmatic disconnects presented operational problems.

Although there were implementation delays associated with VA Directive 7700 and

Handbook 7700.1, both the site evaluation teams and National Evaluation Team found

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policy and VHA guidance that predated the Directive and Handbook, with updated procedures and services incorporated when feasible. Officials in the VA Office of Occupational Safety and Health, VHA, and union representatives have agreed to work together to update and make recommendations to facilitate full implementation of VA Directive 7700 and 7700.1. In Appendix D, it is recommended that this work move forward.

C. Resources

In 1992, the OSHA evaluation found that VA did not have sufficient occupational safety and health staff to carry out the program at any organizational level. The DASHO had insufficient staff to carry out Central Office responsibilities; there were too few inspectors at the regional offices, and shortages of safety and health staff at the majority of medical centers. The VA Office of Occupational Safety and Health, much like VHA Headquarters, has a small staff. As noted previously, substantial program responsibilities associated with developing and delivering safety and health program operations have been assigned to and are accomplished by VHA at the Headquarters and network/facility levels. * VHA provides resources to its line management and holds operatives accountable

for delivery of required occupational safety and health services and attaining measurable program performance goals.

"• VHA safety and health program positions are funded and training is available. "* Safety equipment and.personal protective equipment is available. Employee

medical surveillance programs are in place. Health sampling equipment is purchased and samples analyzed; expert safety and health assistance is available. Safety and health information is collected, analyzed and disseminated.

"* Site evaluation teams confirmed that funding was available for abatement of identified workplace hazards.

VHA management officials planned, funded and implemented a number of initiatives to improve services and provide tools to the safety and health community: * The VHA National Engineering Service Center (NESC) in St. Louis and the

Regional Safety Advisory Committee issued a series of guidebooks based on the process for conducting Annual Workplace Evaluations (AWEs) of medical centers' safety, fire protection and industrial hygiene programs. The intent in adopting the Guidebook system was to provide a more comprehensive and consistent review process for all components of the occupational safety and health programs at medical centers. The Guidebook series provided guidance on how to comply with requirements of the various programs and supplied sample policies and procedures needed to meet standards. The policies, procedures and

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forms contained in the series were made available on computer disk to facilitate the customization of these documents for medical center use. In the past two years, VHA staff developed a real-time automated management and tracking system for injuries, illnesses and accidents that allows analysis for root causes. Future phases of this project will add the capacity to track safety and health issues such as medical surveillance, training, and other record keeping information. VHA has developed, tested and implemented an automated data entry system for Veterans Integrated Service Network (VISN) safety and health staff to use during facility occupational safety and health oversight inspections. This system is called the Safety Automated Facility Evaluation (SAFE) and it will promote evaluation process consistency, reduce hands-on paperwork requirements for inspectors, improve reporting and tracking and, ultimately, better use professional resources. VHA sponsors and develops the curriculum for the National Occupational Health and Safety Conference for safety and health professionals, clinicians, worker compensation and union personnel. In 1999 and 2000 these conferences provided high quality training in a wide variety of occupational safety and health and related topics and provided an opportunity for the VHA safety community to share experiences. "The site evaluation teams confirmed that safety and health programs receive support at the VHA VISN and facility levels. The VHA little Rock Education Center is a widely respected and frequently used training and education resource.

"* Staff from the Office of Occupational Safety and Health worked with VHA to promote employee training and education in occupational safety and health at all levels.

"* The Office of Occupational Safety and Health sponsored a week-long Workers Compensation Program Management Conference in 1999 and 2000.

VHA safety and health professionals assigned to the VISNs are responsible for performing Annual Workplace Evaluations (AWEs) at VHA facilities as well as work sites assigned to the Department of Veterans Affairs, the Veterans Benefits Administration (VBA), the National Cemetery Administration (NCA). Due to a major shift from inpatient to outpatient care, VHA has added over 370 community-based outpatient clinics in the last few years, greatly adding to the AWE workload. The number of sites for which AWEs must be conducted has increased to approximately 800

and includes over 170 VHA Medical Centers, over 370 community-based outpatient clinics, over 100 national cemeteries, over 60 regional offices, and other VA work

spaces. Due to a number of factors including, but not limited to, scheduling issues and sites that had not been in service for a full year, some AWEs were not completed in FY 1999. Many of the AWEs not conducted involved community-based outpatient clinics

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and other smaller facilities and VHA should focus on how to facilitate inspections at

these workplaces.

Facility-level safety and health staff perform hazard surveillance surveys that require

walk-around inspections and written reports, quarterly surveys of high hazard areas

and semiannual surveys of the facilities; however, they do not issue Notices of Unsafe

or Unhealthful Working Conditions or conduct AWEs for the medical centers to which

they are assigned. At least two site evaluation teams and members of the Headquarters

Evaluation Team were concerned that there may be an insufficient number of VHA

inspectors assigned to the VISNs to complete all AWEs. Further, it was recommended

that VHA ensure that both the safety and industrial hygiene portions of the AWEs are

performed by qualified professionals. Whether AWEs are completed by VISN staff,

other qualified staff to whom authority is delegated, contractors, or the processes

involved are adjusted for efficiency without compromising quality, it is recommended

in Appendix D that VHA management take appropriate action to ensure that goals

associated with completion of AWEs and other services are met.

D, Accountabiliy

In 1992, the OSHA evaluation found that the DASHO did not exercise oversight over

the program. The DASHO did not monitor safety and health activities carried out by

regional directors and there were no adverse consequences for failure to carry out

responsibilities (e.g., conducting annual inspections). Professional resources were

sometimes shifted from safety and health responsibilities to address other priorities,

such as support for engineering services. The OSHA evaluators also found in 1992 that

performance plans for VA regional directors, facility directors, managers, and

supervisors did not hold these officials accountable for carrying out their safety and

health responsibilities. This was not a new development since OSHA's 1983 and 1985

evaluation reports had pointed out the need to comply with this accountability

requirement

The VA Office of Occupational Safety and Health reviews a variety of safety and health

program evaluative efforts, including reports provided by VHA, VBA, and NCA. VHA

staff in the Office of the Chief Network Officer, in concert with the VHA Occupational

and Environmental Strategic Health Care Group, coordinate and evaluate program

delivery and functions. VHA network directors manage VISN safety and health

inspection staff and are held accountable for program services and support through

performance requirements.

VHA Headquarters managers, network directors and the senior managers who report

to them, and managers at medical centers are held accountable for the delivery of safety

and health program services and goal achievements. Their performance is tracked,

accomplishments are rewarded and deficiencies acted upon without delay. At most of

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the sites, the evaluation teams found that supervisors and managers are evaluated based on their safety and health performances.

Since 1997, VHA has performed an annual Safety and Health Activities Evaluation Survey to quantify the successes and areas for improvement of VISN-based safety and health programs.

This survey also enhances the partnership between employee representatives and V-IA management by requesting union members' input in concerning the value of the program. The data received is used as a baseline to measure and monitor future developments of VISN safety and health programs. The survey can be used by organizational units to measure progress of safety and health program activities and identify key areas of success as well as areas needing attention. The survey is a tool that VHA managers can use to make decisions that are based on objective needs of veterans, employees and visitors.

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III. PROGRAM PLANNING

A. Record keeping

The VA utilizes data collected through its management information system to identify unsafe and unhealthful working conditions and establish program priorities. The VA Workers Compensation/Occupational Safety and Health Management Information System (WC/MIS) provides detailed information for analysis of accident data. At VHA, their new real-time automated management tracking system for accidents and illnesses, ASISTS, is on line for internal tracking and trending. The version of the OSHA recordkeeping log of occupational injuries and illnesses generated by ASISTS at some sites did not consistently contain all of the required items; for example, some evaluation teams found that items such as employee occupational series were coded numerically, or missing. VHA and OSHA have agreed to work together to facilitate necessary system adjustments to resolve record keeping issues associated with ASISTS.

B. Goals and Priorities

The 1992 OSHA evaluation found that the VA did not set Agency safety and health goals for reducing occupational accidents, injuries and illnesses. Although the facilities developed goals and objectives on their own, the DASHO did not disseminate agency goals and objectives.

VA annual occupational safety and health program goals for all agencies in the Department are published and disseminated. We reviewed the DASHO's goals from FY 1994 until FY 2000. These goals were detailed and required specific actions for major subagencies: "* The VA DASHO set annual goals holding agencies accountable for reductions of

lost time claims rates since at least FY1994. "* Since 1994, DASHO annual goals have evidenced VA support for employee

participation in Federal Safety and Health Councils (FSHCs) or other professional organizations.

"* Occupational safety and health training goals were identified at all levels of the Department

"* Goals were established to ensure accurate coding and timely submission of occupational injury and illness claims to OWCP.

"* Specific goals based on recent safety and health experience and issues were identified.

Worker compensation injury and illness data are analyzed and utilized in planning safety and health goals and strategies. The VA Worker Compensation/Occupational Safety and Health Tracker System can be used to determine claim rates, frequency distributions for variables, and information for identifying trends, problem areas, and

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focus training needs. Data from this system are available for use in preparing reports on the performance of the VA occupational safety and health program, determining achievement of the Secretary's goals and recognizing occupational safety and healthrelated accomplishments.

VHA uses injury and illness data to establish occupational safety and health program priorities and objectives. The agency priority list is expressed in VHA as goals in the performance standards of the CNO, twenty-two VISN directors and the VHA Director for Safety. In addition, VHA has established specific areas of emphasis in occupational safety initiatives, which are also tracked as indicators of network directors' safety performance goals. Goals and indicators are evaluated quarterly by the CNO's Office. Injury and illness data have been used to set performance measures for VHA managers; to prioritize education and training objectives, health promotion and injury prevention goals; and to focus VHA occupational health research agenda. The former Under Secretary for Health made occupational safety and health a key component of VHA's reorganization efforts by establishing annual occupational safety and health performance measures for supervisors and managers. The implementation and uses for the VHA Annual Safety and Health Activities Evaluation Survey were addressed under the top management support, accountability section of this report.

C. Emergency Planning

Emergency response plans 'and programs instituted at VHA medical centers were reviewed by site evaluation teams VHA has established emergency preparedness requirements that address effective and safe responses to a wide range of potential crises. These requirements include: "* written procedures that address emergency response for hazardous operations

and maintenance activities; "* local product safety programs to ensure that hazardous chemicals and agents are

handled safely throughout their life cycle (including emergency response); "* local fire plans that contain evacuation instructions and procedures to be followed

during emergencies; "* employee education and training programs for employees who may be exposed

to hazardous chemicals, biological agents, or physical agents; specialized training must addresses the health hazards associated with the chemicals or agents, standard operating procedures, first aid procedures, and emergency actions;

• detailed emergency procedures that contain first aid information, spill clean-up, personal protective equipment, emergency reporting, evacuation, and waste disposal; and

* emergency procedures must be readily available to responding emergency personnel and comply with applicable Federal, state and local requirements.

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VHA officials undertake emergency event drills, evaluate responses and performance, update plans as needed and communicate findings to staff. One of the medical centers sponsored a volunteer Emergency Response Team, the first in VHA. The group received extensive training in emergency response and was equipped to respond to external disasters. The Site Evaluation Team who visited that Medical Center recommended that this effort be included in this report's "best practice" list at Appendix C.

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IV. PROGRAM IMPLEMENTATION

A. Employee Rights and Responsibilities

1. Right to be informed about the program

The 1992 OSHA evaluation found that workers did not participate in VA's occupational safety and health program. They did not routinely participate in health inspections,

were not questioned privately regarding their health exposures, and were not included

in the closing conference. The ten site evaluation teams associated with this effort found that employees were questioned during inspections and invited to speak with

VISN inspectors confidentially, if desired. On a larger scale, the VHA Safety and

Health Activities Evaluation Survey for FY 1999 reported that all 22 VISNs had

processes for informing employees of their job safety and health rights and all of them

invited employee representatives to accompany safety staff on employee complaint inspections and AWEs. For FY 1999, employee representatives surveyed reported: * 95% of the time, they were invited to participate in the AWE process; 0 94% found the closing conference useful for identifying safety and health

deficiencies; • 90% reported that there was an abatement plan submitted to the VISN for

correction of deficiencies; and * 89% reported that there was a process for resolving disputed deficiencies. a 74% of the time, employee representatives were invited to participate in the

employee complaint inspection process.

Procedures have been established for employee participation in safety and health committee meetings, training seminars, conferences and the like. This evaluation found

evidence that employees have been informed of the provisions of the program as well as their rights and responsibilities. The DASHOYs Office of Occupational Safety and Health uses their Websites and hardcopy document distribution systems to share information and employee training. Consultation with employee representatives

regarding a variety of occupational safety and health activities has opened an important channel of communication and has promoted cooperation in working towards common

goals.

2. Right to report hazards

Employee involvement in the identification and reporting of occupational safety and

-health hazards in the workplace is a key ingredient to an effective occupational safety

and health program. By providing a means for employees to report identified hazards

and by providing information to employees about how hazards have been abated, or

the current status of identified problems and the proposed course of action, the facility

can stimulate the degree of employee involvement and positively impact the

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•'-" effectiveness of the program. Site evaluation teams found a system for responding to employee complaints that was effective. Interviews with facility employees revealed that they generally understood and exercised their right to report unsafe or unhealthful working conditions, and the majority of staff were satisfied that their complaints were satisfactorily resolved. Site evaluation teams reported that it was routine for employee complaints, questions and inquiries regarding unsafe or unhealthful conditions to be acted upon by supervisors and safety and health officials promptly and competently. Hazard assessments for issues raised in complaints, and actions to correct or eliminate problems, were undertaken; site evaluation teams documented that imminent danger conditions were abated immediately.

VA and VHA have provided documentation of employee rights in a variety of sources. VA Directive 7700 and Handbook 7700.1 documented the right of employees to report unsafe or unhealthful conditions and the obligation of management officials to respond, evaluate and appropriately resolve employee complaints related to safety and health. The VA poster (VA Form 2180) delineated the rights of employees to report and request inspections of unsafe or unhealthful working conditions by giving written or verbal notice to the supervisor. The VHA National Engineering Service Center (NESC) Safety Program Administration Guidebook contained sample hazard reporting procedures to be used as a template for developing local reporting procedures, including anonymous complaints. However, the evaluators did not locate procedures that required managers to ensure employee reports and management responses to such complaints were documented in writing. See also our discussion regarding the employee complaint procedure in Appendix B and our recommendations for system improvements contained in Appendix D.

The 1992 OSHA evaluation found that VA did not have separate written procedures indicating specifically how workers' rights to report hazards anonymously would be implemented. Further, the 1992 evaluation documented employee representatives' beliefs that employees were not aware of procedures for submitting formal or anonymous reports of unsafe or unhealthful working conditions. The current VA Poster (VA Form 2180) describes the VA channel of communication for employees to submit anonymous safety and health complaints. If employees desire anonymity, they may contact the VA Safety and Heath Official directly to report and request inspections of unsafe or unhealthful working conditions. If an employee does not seek anonymity, reports may be initiated by a verbal or written notice to his or her supervisor.

3. Right to be protected from reprisal

The 1992 OSHA evaluation found that VA did not have separate written procedures indicating how workers would be protected from reprisal. During this evaluation, we found procedures that addressed these rights:

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The VA Poster 2180 contained a paragraph that informed employees that exercise of their rights under VA's job safety and health program is protected from discrimination, restraint, interference, coercion or reprisal. If an employee has reason to believe his or her rights were violated due to participation in the program, he or she may raise such concerns with the facility Director or designee for appropriate investigation and decision. VA Directive 7700 states that VA policy prohibits reprisals against employees who exercise their rights under the VA occupational safety and health program. The Deputy Assistant Secretary for Administration, who reports to the DASHO, is responsible for developing procedures to handle reprisal complaints from employees who exercise their rights under the occupational safety and health program; we were informed by VA staff that grievance procedures are utilized for handling these matters. VA Directive 7700 assigns responsibility to the VA Director of Occupational Safety and Health, who also reports to the DASHO, with ensuring that procedures are developed to handle reprisal complaints from employees who exercise their rights under the occupational safety and health program. The VHA National Engineering Service Center (NESC) Safety Program Administration Guidebook at 1-1, Management Support, provides detailed guidance to VHA on procedures for investigation and resolution of all allegations of reprisal.

Site evaluation teams found that the majority of VHA staff did not feel that reprisal was a substantive threat. It was not surprising that most of those employees did not know specific procedures to ensure protection of their rights against reprisal for participating in the safety and health program, and equally telling, they did not feel the need to seek out such procedures. Although most employees have not felt the need to investigate the "reprisal protection safety net" available to them, to ensure that any employee who may in the future have need to know of his or her rights, we recommend that details of the protections afforded employees, as well as where to locate current procedures to be used for allegations of reprisal, should be disseminated in a way that will facilitate employee access. Please refer to Appendix D, recommendations.

4. Right to participate in inspections

Among other rights, the VA Poster 2180 confirms employee rights to assist in inspections to assure a thorough safety and health inspection. Employees are authorized official time to participate in opening conferences, walkthroughs and closing conferences. They are questioned by inspectors during walkthroughs and encouraged to tell inspectors about unsafe or unhealthful conditions in the workplace, confidentially, if desired. Earlier in this section, we addressed employee representative reports concerning inspection participation per the VHA's FY 1999 Safety and Health Activities Evaluation Survey.

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B. Training

The 1992 evaluation report indicated that some of the regional inspectors and facility safety and health professionals, though minimally qualified for their jobs, needed basic OSHA compliance and required training to conduct asbestos monitoring. VA did not have a comprehensive training policy and career development program to ensure that personnel with safety and health responsibilities received necessary training. Collateral duty safety officers and employee safety and health representatives had not been trained for their responsibilities. Some employee representatives complained that they were not receiving training required under 29 CFR 1960. The evaluators in 1992 found that the supervisory safety and health training course in use at many of the medical centers was out of date.

This review at the VHA medical centers and Headquarters found evidence that a focused effort to improve training for the VHA occupational safety and health program has been successful. VHA now identifies and updates occupational safety and health training needs for employees, supervisors, and managers and training plans for VHA occupational safety and health personnel. This responsibility includes budget planning and execution for VHA-wide occupational safety and health training initiatives, support and consultation concerning training, and coordination of education activities through the VHA Occupational and Environmental Strategic Health Care Group to the Office of Employee Education.

Training and education has received support from the highest levels of VHA management. The Under Secretary for Health advised members of the National Evaluation Team that education, combined with good systems to support people, is one of the basic strategies relied upon to meet their goals. The VHA Occupational and Environmental Strategic Health Care Group has identified the promotion of safety and health education, including interagency programs, as a way to enhance the program.

The excellent work performed by the VHA National Engineering Services Center (NESC) has been recognized and VHA management provides ongoing support for NESC training and education products. VHA's integration of training efforts into routine performance is reflected in the materials and detailed guidance on training, training aides, reference materials and equipment found in the Safety Program Administration Guidebook published by the NESC. VHA's Little Rock Education Center resources and materials are used appropriately throughout the agency. As noted earlier, VHA sponsors and develops the curriculum for their annual National Occupational Health and Safety Conference for safety and health professionals, clinicians, workers' compensation staff and union personnel. This multidisciplinary conference brings VHA professionals from safety, fire protection, industrial hygiene, infection control, occupational health and workman's compensation programs together to share experiences and receive updates on a variety of training issues.

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The VA Office of Occupational Safety and Health staff has worked with VHA to provide introductory and specialized training materials to management officials at all levels to assist them in developing the skills necessary to manage the agency's safety and health program, recognize and eliminate or reduce occupational safety and health

hazards in their work units, and train and motivate subordinates toward ensuring safe and healthful work practices. The supervisory training addresses: ° supervisory responsibilities for providing and maintaining safe and healthful

working conditions for employees; • the Agency safety and health program; * Section 19 of the Act, Executive Order 12196, and 29 CFR Part 1960; * occupational safety and health standards applicable to their assigned work

places; • handling allegations of reprisal; * procedures for abating hazards; and * other appropriate rules and regulations.

There are 18 separate courses with videotape and downloadable slide presentations available at all medical centers. The VA Occupational Safety and Health Website provides an interactive version of the OSHA 600 Collateral Duty Course, as well as access to other electronic training programs, and program support tools.

The qualifications of VHA inspectors assigned to VISNs were reviewed during this evaluation and it was found that inspectors are well credentialed with, on average, 15 to 20 years of experience in safety and health fields. The Safety and Health Activities Evaluation Survey for FY 1999 listed VISN safety professionals who held a variety of

credentials: Professional Engineers, Certified Fire Protection Engineers, Certified Safety Professionals, and bachelors and masters degrees in safety and engineering specialties. VHA VISN industrial hygienists included staff who were Certified Industrial Hygienists as well as those who held professional degrees at the bachelors, masters and doctoral levels. There is a requirement for safety and health professional staff to take 40 hours of training per year.

Facility safety and health personnel benefit from the VHA educational programs which include course work, laboratory experiences, field study and other formal learning experiences. Due to the complexity of safety and health issues facing medical center

staffs, and based on some of the findings of our site evaluation teams, facility engineering and safety and health staff may benefit from focusing their annual 40 hours of training on hazard recognition, evaluation, and control. Review of protocols and

procedures recommended in the Safety Guidebook Series to ensure that program requirements are communicated, required and practiced, could facilitate front-line implementation of some safety and health programs and procedures. The Safety

Guidebook Series provided excellent information, procedures, protocol and boilerplate

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local program guidance and is a valuable program support tool. We have made recommendations regarding training in Appendix D.

The VA Office of Occupational Safety and Health staff have worked with VHA to sponsor employee representative education efforts. The VHA has dedicated substantial resources to continuing education for employee representatives as evidenced by joint labor-management training (e.g., The Union's Role in Workplace Inspections) and sponsorship of an annual union safety conference. Further, union safety representatives are invited to participate in VHA's annual Occupational Health and Safety Conference. The employee representative training program includes information on the agency's safety and health program, with particular emphasis on employee rights and responsibilities, and includes introductory and specialized courses and materials, such as the basic training course for employee representatives given at the Little Rock Education Center. The training enables these individuals to ensure safe and healthful working conditions and practices in the workplace and effectively assist in workplace safety and health inspections.

The employee safety training program in place at one of the Medical Centers visited by a Site Evaluation Team was identified as a "best practice" based on the level of employee accessibility to educational resources, integration of training into routine work processes and ral_.ge of issues covered in training. Similar support for employee training and educatiori was found during most of our other visits; VHA has made training widely accessible and convenient for employee use at all levels. VHA medical centers provide annual awareness training for employees in the areas of safety, health and security.

C. Inspections

In 1992, OSHA found that VA did not ensure that comprehensive annual safety and health inspections were performed at the medical centers and cemeteries. The VA plan in place at that time that provided for safety inspections and health inspections in alternate years did not meet OSHA's requirements. Currently, VA and VHA policy requires that all VA facilities be inspected annually. VHA has taken a number of steps to ensure that the internal safety and health inspection process is dependable and useful. VHA procedures require that annual workplace evaluations be performed by VHA inspectors assigned to VISNs, even if qualified local facility staff are available. The inspection process requires that "* Facility directors and their safety staffs maintain and make available all relevant

information necessary to evaluate a facility's safety and health program. "* Inspectors consult with employees (confidentially, as appropriate) during

inspections and employees have the opportunity to alert inspectors to suspected unsafe or unhealthful conditions.

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Representatives of establishment officials and recognized labor organizations are to be invited to participate in the annual occupational safety and health inspections and OSHA-conducted inspections at the opening conferences, walkthrough inspections, and dosing conferences. Inspectors conducting AWEs document deficiencies on VA Form 2165 (or its equivalent) and provide timely notice to facility directors that describes the nature of each hazard with particular detail and classified by degree of seriousness. Violated standards and requirements are referenced and notices are posted at the facilities. Deficiencies identified by AWEs are tracked by the facility directors, safety offices, safety committees and VISNs to ensure abatement plans are implemented. VISN staff conduct follow-up inspections. The evaluators who participated in site visits confirmed that deficiencies are abated.

In addition to the AWEs performed by VHA inspectors assigned to VISNs, VA Handbook 7700.1 requires that facility safety and health staff perform hazard surveillance surveys including walk-around inspections and written reports, quarterly surveys of high hazard areas and semiannual surveys of the facilities. While facility safety and health staff do not issue notices, they make recommendations for improvement and actively work with local staff to implement needed changes.

In fiscal year 1997, VHA had the responsibility to perform annual safety and health inspections at 547 VA facilities: 0 95% of the AWEs were completed in medical centers; 0 81% of the AWEs were completed at national cemeteries; and 9 65% to 67% of the AWEs were completed at community-based outpatient

centers, VBA regional offices and other VA workspace.

In FY 1999, the number of VA facilities subject to VHA inspection had risen to 800. a 92% of the AWEs were completed in medical centers; * 87% of the AWEs were completed at national cemeteries; and 0 84% to 90% of the AWEs were completed at community-based outpatient

centers, VBA regional offices and other VA workspace.

In FY 1997, there were 128 community-based outpatient centers in the VHA system. In FY 1999, the total almost tripled to 373. A number of the AWEs that were not performed in a specific fiscal year were postponed since the sites had not been operating for a least a year when the scheduled AWEs were to be performed. We have addressed this issue, and the issue ensuring the availability of personnel with expertise in both safety and industrial hygiene to conduct AWEs, earlier and in Appendices A and D.

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VHA has established a detailed inspection protocol that is widely available. VHA is in

the process of automating the system in its Safety Automated Facility Evaluation

(SAFE) system for use by VHA VISN inspectors in conducting AWEs. This system has

been designed to promote the evaluation process consistency, mitigate hands-on

paperwork requirements for inspectors, improve reporting and tracking and,

ultimately, better utilize professional resources. After testing the system and actively

seeking union input, VHA accepted recommendations made by employee

representatives. In fact, VHA delayed implementation of the system to ensure that

those recommendations arising from the St. Louis meeting with union representatives

could be incorporated in the SAFE programming. This system has now been endorsed

by all five unions.

D. Hazard Abatement

The 1992 OSHA evaluation at the VA found that regional inspectors often found the

same hazards upon subsequent inspections, particularly at the medical centers. Most

facilities needed major improvements in their hazard abatement systems. At that time,

facilities did not develop plans for correcting hazards that could not be corrected within

30 days. Further, in 1992 inspectors did not post notices of unsafe or unhealthful working conditions for hazards they identified, or conduct follow-up inspections to

verify abatement During this evaluation, the teams found that VHA has implemented

procedures to ensure the prompt abatement of unsafe and unhealthful conditions.

Accidents are investigated in a timely fashion and management officials are required to

institute or recommend corrective actions to avoid recurrence of similar injuries or illnesses. The VHA ASISTS safety and health information system has been implemented to identify, track and evaluate accidents or illnesses when they occur; this

system is in addition to the existing VA Workers' Compensation/Occupational Safety

and Health Management Information System.

Site evaluation teams reviewed facility abatement records and found that actions were

tracked and taken in a timely fashion. Where unsafe or unhealthful working conditions

cannot be corrected within 30 calendar days, facility directors and other establishment

heads are required to promptly prepare abatement plans that include an explanation of

the circumstances of the delay in abatement, a proposed timetable for the abatement,

and a summary of steps being taken in the interim to protect employees from injury.

VA procedures for correcting unsafe or unhealthful working conditions include the

requirement that a follow-up inspections be conducted to verify corrections. Further,

VA procedures require that the establishment head and the appropriate safety and

health committee be notified of all "failure to abate" notices resulting from follow-up

inspections.

In addition to VA safety and health program procedures and requirements, there are

other VHA checks and balances for oversight. The VHA Safety and Health Activities

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Evaluation Survey is used to advise network directors of program strengths and deficiencies, including hazard abatements. In follow up memoranda based on survey findings, VHA Headquarters staff in the Office of the Chief Network Officer provide network directors recommendations on options for resolving issues and receive and evaluate the directors' plans for addressing deficiencies and recommendations. The SAFE program has been developed to allow better tracking of deficiency corrections. This program was implemented in May 2000.

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V. PROGRAM EVALUATION

In 1992, the OSHA evaluators found that VA did not conduct qualitative assessments of the extent to which their occupational safety and health program had developed in accordance with OSHA requirements even though the 1983 and 1985 evaluations had pointed out the need to comply with this requirement. The evaluators involved in this effort found that the VA Director of the Office of Occupational Safety and Health monitors the accomplishment of annual safety and health goals, implementation of new initiatives and program operations VA-wide. The VA Director utilizes a variety of sources of information to evaluate the program and make recommendations to the DASHO regarding goals and priorities. Analysis of injury and illness data through the VA Workers' Compensation/Occupational Safety and Health Management Information System provides a basis for annual goals and initiatives. A number of DASHO goals are self-reporting goals. VA has consistently submitted detailed annual reports to the OSHA Office of Federal Agency Programs concerning annual VA-wide activities.

VHA staff at Headquarters assigned to the Office of the Chief Network Officer (CNO), in concert with the VHA Occupational and Environmental Strategic Health Care Group, coordinate and evaluate program delivery and functions performed by VHA staff to support the VA safety and health program. VISNs provide VA facilities occupational safety and health related suplort, including AWEs. Network directors manage inspectors assigned to VISNs and are held accountable for program services and support through performance standards and requirements.

In addition to the organizational accountability described previously, the VHA CNO has undertaken detailed assessments of occupational safety and health program delivery. Since 1997, VHA has participated in annual Safety and Health Activities Evaluation Surveys and reports that: "* Survey information is useful as baseline data on VHA occupational safety and

health activities and processes since the transition from regions to VISNs. "* VHA operatives including safety staff assigned to VISNs, facility senior

management, safety staff and employee representatives are queried about a wide range of program deliverables and value.

"* Each VISN is provided a detailed analysis of the responses received and the data are provided to each medical center as a stimulus for discussion between top management, safety and health professionals and employee representatives.

* Information distributed to each Network Director is used for improving occupational safety and health programs at the VISN level and for identifying future initiatives and educational needs in occupational safety and health programs. Each Network Director is required to respond to his or her report with plans for improving areas with an indicated deficiency.

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Appendix A - Agency Evaluation Grid

How VHA's Program Meets Requirements of 29 CFR 1960

Safety and health program requirements delineated in 29 CFR 1960, Basic Program Elements for Federal Employees Occupational Safety and Health

Programs and Related Matters, appear below in italics. The particular

section of 29 CFR 1960 is highlighted in bold italics. The assessment of

whether VHA's program meets, partially meets, or fails to meet each requirement appears in bold print. A discussion of the assessment is

provided in plain print. If the issue is discussed in detail elsewhere in the

report, we have referred the reader to that section of the report, highlighted with bold print.

1960.6(a) - Appoint a Designated Agency Safety and Health Official (DASHO) of the rank of Assistant Secretary with sufficient headquarters staff with training and experience to carry out this part.

Meets requirements VA Directive 7700 designates the Department of Veterans Affairs' Assistant Secretary

for Human Resources and Administration as the DASHO. The VA Deputy Assistant

Secretary for Human Resource Management and Administration, as well as the VA

Office of Occupational Safety and Health, carry out the work of the DASHO through

development of VA-wide policy and evaluation assistance. The Secretary for Veterans Affairs delegated to the Under Secretary for Health in the Veterans Health

Administration substantial Department-wide responsibilities to provide occupational

safety and health support, services and assistance to VA facilities, in addition to VHA facilities.

1960.6(b)(1) - Establish an occupational safety and health policy to carry out the provisions of Section 19 of the Act, E.O. 12196, and 29 CFR Part 1960.

Partially meets requirements VA Directive 7700 and VA Handbook 7700.1 were issued in July 1998 but had not been

fully implemented throughout the VA at the time of our site evaluation team and

National Evaluation Team visits. We have discussed this issue more fully in the report

at Top Management Support, Program Documentation and have made a

recommendation that staff of the VA Office of Occupational Safety and Health, VHA

and union representatives continue their work to update, and thus facilitate,

implementation of the VA and VHA policies and programs, see Appendix D.

Appendix A- 1

1960.6(b)(2) - Establish an organization to implement the occupational safety and health program at all operational levels.

Meets requirements Executive and management positions at each operational level, and on organizational charts, have been identified in the VA Directive 7700 and 7700.1. The Secretary of

Veterans Affairs named the VA Assistant Secretary for Human Resources and

Administration as the Designated Agency Safety and Health Official (DASHO). At the

Departmental level, three offices reported directly to the DASHO regarding occupational safety and health program implementation: per Directive 7700, section 3,

Responsibilities, the VA Deputy Assistant Secretary for Human Resources Management, the VA Deputy Assistant Secretary for Administration, and the VA

Director for Occupational Safety and Health. It should be noted that VHA does not report directly to the DASHO regarding occupational safety and health program implementation. The VHA Office of the Undersecretary for Health provides information to the DASHO. The VHA has assigned occupational safety and health

programs and services to the Office of the Under Secretary for Health. These programs are directly supervised by the Chief Network Officer. Nationwide initiatives are

coordinated at headquarters, and field program services and activities are delivered by 22 Veterans Integrated Service Networks (VISNs) located across the country; each

Network manages an occupational safety and health program. VHA management operatives are responsible and held accountable for delivery of services. The organizational placement of occupational safety and health in VHA has given the

program substantial visibility and support. As noted in the report under Top

Management Support, Management Direction and Resources the VHA Office of the

Under Secretary for Health provides substantive and effective leadership to this

program.

1960.6(b)(3) - Establish procedures to implement the agency program. Partially meets requirements

VA Directive 7700 and Handbook 7700.1 have not been implemented throughout the

agency, as noted above in 1960.6(b)(1). Our review of VHA medical centers and

Headquarters indicated that occupational safety and health programs have been implemented in practice that are, for the most part, in compliance with the

requirements in Section 19 of the Act, Executive Order 12196, 29 CFR Part 1960, VA

Directive 7700 and Handbook 7700.1, as well as with predecessor policy and

guidebooks: VHA has established systems and structures for the dependable delivery

of occupational safety and health program services. In Appendix D we recommend

that the written occupational safety and health program be finalized.

Appendix A - 2

1960.6(b)(4) - Establish goals and objectives for reducing and eliminating occupational accidents, injuries and illnesses.

Meets requirements We have discussed VHA occupational safety and health program goals in the report at Program Planning, Goals and Priorities.

1960.6(b)(5) - Establish plans and procedures for evaluating the occupational safrty and health program effectiveness at all operational levels.

Meets requirements VHA provisions for program evaluation are discussed in the report at Program Evaluation.

1960.6(b)(6) - Establish priorities for actions to address the factors which cause accidents, injuries and illnesses.

Meets requirements We have discussed VHA occupational safety and health program goals in the report at Program Planning, Goals and Priorities.

1960.6(c) - Ensure that safety and health officials at each level have authority to plan for and assure funding for necessary safety and health staff, equipment, materials and training.

Meets requirements VHA occupational safety and health initiatives are funded from existing funds, per VA Directive 7700. Program responsibility can be tracked from the Secretary's level to the

VHA Under Secretary for Health, through the management chain to VHA network and facility directors, and through the organization. VHA provides resources to line management and holds operatives accountable for responsible resource utilization, delivering occupational safety and health services and attaining measurable goals.

1960.7(a) - Ensure that the agency budget submission includes appropriate financial and other resources to implement the occupational safety and health program.

Meets requirements Safety and health program positions in VHA are funded. Training is available, as are safety equipment and personal protective equipment. Employee medical surveillance

programs are in place. Health sampling equipment is purchased and samples analyzed; expert safety and health assistance is available. Safety and health information is collected, analyzed and disseminated.

Appendix A - 3

1960.7(b) - Plan for and request resources for the safety and health program implement and evaluate the occupational safety and health budget.

Meets requirements See responses to 1960.6(c) and 1960.7(a), above regarding funding for day-to-day

operations and program functioning. The site evaluation teams confirmed that safety

and health programs receive support at network and facility levels. VA and VHA

officials planned, funded and implemented a number of initiatives to supplement and

improve the delivery of services; please refer to the section of the report under Top

Management Support, Resources for a full discussion of resource management.

1960.7(c)(1) - Ensure sufficient personnel to implement and administer the program at all levels.

Meets requirements, with recommendation We have discussed VHA staffing and program administration in the report at Top

Management Support, Resources and have made a recommendation regarding meeting annual workplace evaluation goals in Appendix D.

1960.7(c)(2) - Ensure sufficient funding for abatement of unsafe or unhealthful uorking conditions.

Meets requirements The site evaluation teams did not find evidence that limited funding prevented

abatement identified workplace hazards. The National Evaluation Team interviews

with VHA top level management confirmed that they are committed to providing

quality patient care to veterans while ensuring that employees are safe.

1960.8 - Furnish each employee employment and a place of employment free from recognized hazards that are causing or are likely to cause

death or serious physical harm.

Meets requirements The objectives of the VHA occupational safety and health program are to: reduce or

eliminate work-related injuries and illnesses, minimize the severity of those injuries and

illnesses that do occur, ensure compliance with applicible occupational safety and

health regulations and standards, implement safe work practices, and provide a safe

and healthful work environment for VHA employees in accordance with the Mission

and Goals Statement. VA policy states that OSHA standards are fully applicable to

agency operations and activities. VHA established a systematic plan for inspecting

employee work areas for hazardous and potentially hazardous working conditions, and

for ensuring their timely correction. VHA acquires, maintains and requires the use of

approved personal protective equipment, approved safety equipment and other devices

Appendix A - 4

to protect employees. The requirement for a viable safety and health program has been

communicated and VHA has committed resources and support to the program.

1960.9 - Supervisors shall furnish employees employment and place of employment free from recognized hazards that are causing or are

likely to cause death or serious physical harm. They shall comply with occupational safety and health standards, regulations and orders.

Meets requirements, with recommendations Site evaluation teams found that most VHA supervisors exercise their authority to

provide hazard-free work environments, provide employees the opportunity to obtain safety and health training, require safe work practices, and ensure quick abatement of

identified unsafe and unhealthful working conditions. Review of front-line implementation of a variety of programs indicated that supervisors needed to become

more aware of program requirements and more assertive in ensuring implementation

of protective measures. Appendix B provides summary reports on specific programs reviewed and Appendix D provides recommendations the safety and health program, particularly the need for additional training in various areas.

1960.10(a) - Employees comply with standards and regulations issued by the agency.

Meets requirements Safety and health information and requirements are communicated to new employees

during orientation. Routine safety training is available in a variety of formats (computer interactive, website, in-service, conferences, training fairs) and new process

and equipment orientation is provided. Site evaluation teams found that employees are aware of safety and health procedures and requirements, support efforts to control potential hazards, report suspected hazards and support efforts to improve working conditions and the safety and health profiles for workers, patients and visitors to

medical centers.

1960.10(b) - Employees use safety equipment, personal protective equipment, and safety procedures as directed.

Meets requirements, with recommendation Generally, evaluation teams found that personal protective equipment (PPE) and safety

devices were provided in sufficient number and kept in good repair. Employees were trained on the proper use of safety equipment and procedures. There were monitoring

programs to ensure consistent and proper use. At the time of the site evaluation team

visits, some VHA medical centers had not completed workplace-specific hazard

Appendix A- 5

assessments, or updates of existing assessments, for PPE. The PPE program is

discussed in detail in Appendix B and in Appendix D it is recommended that required hazard assessments be performed and appropriate action taken.

1960.10(c) - Employees report unsafe and unhealthful conditions to appropriate officials.

Partially meets requirements While most employees interviewed at the medical centers indicated that they were

satisfied that their complaints were satisfactorily resolved, aspects of the procedures

associated with employee reports of unsafe and unhealthful conditions should be

amplified and clarified. Please see our report at Program Implementation, Employee

Rights and Responsibilities, the Right to Report Hazards, as well as Appendix B for a discussion of findings and Appendix D for recommendations.

1960.10(d) - Employees are authorized official time to participate in the activities provided for in Section 19 of the OSH Act, E.O. 12196

and the agency occupational safety and health program.

Meets requirements VHA has established procedures for employee participation in safety and health committee meetings (including Environment of Care meetings), training seminars, subsafety committees, union repiesentative safety training, conferences and the like. During AWEs, employee representatives are invited to participate in the opening conference, the walkthrough and the closing conference. Facility employees are questioned during inspections and invited to speak with VHA inspectors confidentially, if desired.

1960.11 - Performance evaluations of management officials in charge of an establishment and supervisors measure performance in meeting requirements of the agency occupational safety and health program - superior performance should be noted.

Meets requirements, with recommendation We have discussed managerial accountability and performance monitoring in the report

at, Top Management Support, Management Direction and Accountability and have

made a recommendation regarding the VA managerial performance appraisal system in

Appendix D.

Appendix A - 6

1960.12(a) - Make copies of the OSH Act, E.O. 12196,29 CFR Part 1960, details of the agency occupational safety and health program and applicable safety and health standards available to employees for review.

Meets requirements These documents are available on the VA Office of Occupational Safety and Health website, in hard copy, and for employee review at most VHA facilities.

1960.12(b) - Make a copy of the agency written occupational safety and health program for the establishment available to each supervisor and to employee representatives.

Meets requirements Same as 1960.12(a).

1960.12(c) - Post a poster informing employees of the provisions of the Act, E.O. 12196, and the agency occupational safety and health program- each agency shall add details of agency procedures for responding to reports by employees of unsafe or unhealthful working conditions and procedures for responding to allegations of reprisal and where employees may obtain information about the occupational safety and health program.

Meetsr requirements, with a recommendation VA Form 2180 (issued March 1999) is the VA safety and health program poster. Posters were available at each location visited. Please refer to our discussion of the VA employee complaint procedure, Appendix B and Appendix D as well as Program Implementation, Employee Rights and Responsibilities, the Right to Report Hazards. The VA poster advises employees to use VA Form 2169 when giving written notice to supervisors, but that form has been discontinued (albeit still available on the VA website). Per VA poster instructions, if an employee wishes to appeal the supervisor's disposition of the complaint and wants a written reply, the employee must use the discontinued VA Form 2169. Directing an employee to find and use a discontinued form presents a barrier to the exercise of his or her right and should be corrected.

1960.12(e) - Promote employee awareness of occupational safety and health matters through ordinary information channels.

Meets requirements VA and VHA use newsletters, bulletins, handbooks, website postings, conferences, and the like to promote employee awareness of occupational safety and health matters.

Appendix A - 7

1960.16 - Comply with all occupational safety and health standards. Partially meets requirements, see recommendations

VA Directive 7700 states that it is the policy of the VA to maintain safe and healthful work environments for employees through the elimination of safety and health hazards

and through the development of safe work practices, and assigns responsibilities to management officials to ensure compliance with the policy. The site evaluation teams

were charged with reviewing specific aspects of 15 safety and health program

operations at the VHA medical centers. Summaries of the findings and recommendations are found at Appendices B and D..

1960.25(a) - Ensure that inspectors are qualified to recognize and evaluate hazards and to suggest abatement procedures and ensure that

safety and health specialists have experience and up-to-date training in occupational safety and health hazard recognition.

Meets requirements We have discussed qualifications of VHA inspectors assigned to VISNs in the report at Program Implementation, Training.

1960.25(c) - Inspect all areas and operations of each workplace at least annually - more frequent inspections shall be conducted where there is an increased risk of accident, injury or illness due to the nature of the work performed. Sufficient unannounced inspections and unannounced follow-up inspections should be conducted to ensure the hazard identiffication and abatement.

Partially meets requirements Please refer to the report at Program Implementation, Inspections for a discussion of VHA's program. At Top Management Support, Resources and Appendix D, we discuss the need to ensure that sharply increased numbers of work sites can be accommodated for annual workplace evaluations. Medical centers had the highest completion rates for annual inspections, and more frequent local reviews; these facilities represent some of the most complex and potentially hazardous work sites in VA.

1960.26(a) - Inspectors prepare by reviewing hazards reports, injury and illness records, previous inspection reports.

Meets requirements VHA facility directors and their safety staff members are required to maintain and make available all relevant information necessary to evaluate a the site's safety and health program.

Appendix A- 8

1960.26(b) - Employees participate in the walk around and closing conference. Meets requirements

Employee representatives are invited to participate in the opening conference, walk

through inspections, and closing conferences during VHA annual workplace evaluations. See also Program Implementation, sections about Employee Rights and

Responsibilities and the Right to be Informed Regarding the Program.

1960.26(c)(1) - Inspectors describe procedures followed during the inspection in writing. Meets requirements

VHA has established a detailed inspection protocol that is widely available. The VHA

SAFE automated facility evaluation system was discussed in detail in the report at Program Implementation, Inspections.

1960.26(c)(2) -Notices of Unsafe or Unhealthful Working Conditions shall be issued not later than 15 days after completion of the inspections for safety violations or not later than 30 days for health violations - Notices include written description of the hazard, including classification of seriousness, standard referenced and an abatement date.

Meets requirements VHA inspectors assigned to VISNs are required to document deficiencies on VA Form

2165 or its equivalent and in accordance with this section. The ten site evaluation teams

documented adequate performance at VHA facilities. This is discussed in detail in the

report at Program Implementation, Inspections.

1960.26(c)(3) - Facility directors immediately post the Notice at or near the hazard until the condition has been corrected or for three working days, whichever is later.

Meets requirements, with recommendation The majority of VHA facilities visited by the site evaluation teams posted notices in

accordance with this requirement, however, some facilities posted notices on nearby

bulletin boards or other areas where employee information is commonly posted. This

provided adequate notice to facility employees of the hazard and abatement activity, but it may not ensure the alert reached employees working in the immediate vicinity of

the hazard. VHA medical center directors should be reminded to post a copy of a

notice near the cited hazard unless the nature of workplace operations prevent such a

posting. See Appendix D.

Appendix A - 9

1960.27(a) - Safety and health inspectors are in charge of inspections and may interview employees in private, if necessary - representatives of the official in charge and employees shall be given an opportunity to accompany inspectors during the inspection to aid in the inspection and to provide representatives with more detailed knowledge of any condition - inspectors shall consult with employees to the extent necessary.

Meets requirements We have discussed communications between VHA inspectors assigned to VISNs and employees and their representatives in detail in the report at Program Implementation, Employee Rights and Responsibilities and in the section that addresses Inspections.

1960.28(c) - Any employee or representative may report unsafe or unhealthful working conditions- the report shall be recorded in writing and shall remain confidential if the employee so requests.

Partially meets requirements The requirements outlined in 29 CFR 1960.28(c) should be clarified in VA policy and VHA procedures. Please refer to our discussion of the employee complaint procedure, Appendix B and Appendix D as well as Program Implementation, Employee Rights and Responsibilities, the Right to Report Hazards.

1960.28(d)(1) - Reports of existing or potential unsafe or unhealthful working conditions are recorded on a log at the establishment and a copy of each report shall be sent to the establishment safety and health committee.

Partially meets requirements In the majority of the ten VHA facilities visited, safety committees or Environment of Care committees were advised of employee complaints and actions taken, but not all complaints were referred to establishment safety and health committees. Note that agency maintenance of a "log" of employee reports of unsafe or unhealthful working conditions is not required per 29 CFR 1960.28(d)(1) or (2), but such a log can serve as an information source to track and trend safety and health issues raised by employees. Please refer to Program Implementation, Employee Rights and Responsibilities, the Right to Report Hazards, Appendices B and D.

Appendix A - 10

1960.28(d)(3) - Inspections (to investigate employee reports) should be conducted within 24 hours for employee reports of imminent danger conditions, within three working days for serious conditions and within 20 working days for other than serious conditions an inspection may not be necessary if the hazard can be abated through normal management action.

Partially meets requirements While VA Directive 7700 requires that supervisors identify unsafe and unhealthful conditions and practices in the workplace and take prompt corrective action, required time frames for inspection activity do not appear in the VA Directive 7700 or Handbook 7700.1. Nevertheless, site evaluation teams reported that employee complaints, questions and inquiries regarding unsafe or unhealthful conditions were acted upon by supervisors and facility or VHA VISN safety and health officials without delay. Hazard assessment and actions to correct or eliminate problems were dependably undertaken in a timely fashion. Site evaluation teams documented that imminent danger conditions are abated immediately. The VHA NESC Safety Program Administration Guidebook Chapter 1-4, Hazard Awareness provided guidance regarding the delegation of authority to immediately stop work and the requirements for positive action in the face of imminent danger situations. Please see Appendix D for our recommendation regarding VA documentation of these requirements and need to disseminate information about the procedures.

1960.28(d)(4) - An employee reporting a hazard is notified in writing within 15 days if the official receiving the report does not plan to make an inspection. The inspection report, if any, is available to the employee within 15 days after the inspection for safety violations and within 30 days after the inspection for health violations.

Does not meet requirements We did not find documentation in VA occupational safety and health policies or VHA procedures that addressed the requirements of 29 CFR 1960.28(d)(4). Nevertheless, site evaluation teams were satisfied that employee complaints and questions regarding unsafe or unhealthful working conditions were handled promptly and competently by VHA management. Please refer to our discussion of the VA employee complaint procedure, Appendix B and Appendix D and Program Implementation, Employee Rights and Responsibilities, the Right to Report Hazards.

Appendix A - 11

1960.29(a) - All accidents are investigated. Meets requirements

VA Directive 7700 requires service chiefs and supervisors to investigate injuries and illnesses that occur to employees under their supervision and institute or recommend corrective actions to avoid recurrence of similar injuries or illnesses. The VHA NESC Safety Program Administration Guidebook part 1-5, Incident Management, provides guidance regarding accident investigation pertaining to all incidents and requires review of lost-time accidents which occur at the facility. The site evaluation teams that VHA facility safety committees were informed of accidents and subsequent associated actions.

1960.29(b) - Each accident resulting in afatality or hospitalization of three or more employees is thoroughly investigated to determine causal factors involved.

Meets requirements VA Directive 7700 describes Board of Inquiry actions in response to such an occurrence, and the VHA NBSC Safety Program Administration Guidebook provides guidance with regard to accident reviews.

1960.30(a) - Prompt abatement of unsafe and unhealthful working conditions is ensured.

Meets requirements Site evaluation teams reviewed VHA facility abatement records and found that actions were tracked and taken in a timely fashion. VA Directive 7700 assigns the responsibility for abatement to a variety of line management officials and supervisors. VA Handbook 7700.1 describes requirements for abatement plans.

1960.30(b) - Procedures for correcting Unsafe or Unhealthful Working Conditions include a follow-up inspection, to the extent necessary, to determine whether the correction was made - if correction was not made, the official in charge of the establishment and the appripriate safety and health committee shall be notified of the failure to abate.

Meets requirements Site evaluation teams found that abatements were tracked and accomplished at the ten medical centers visited.

Appendix A - 12

1960.30(c) - If abatement of a hazard is not possible within 30 calendar days, the official in charge of the establishment prepares an abatement plan explaining the delay in abatement, a proposed timetable, and steps taken in the interim to protect employees and a copy is sent to the safety and health committee.

Meets requirements Site evaluation teams found the ten VHA facilities in compliance.

1960.46(a) - Establish procedures to assure that no employee is subject to reprisal for filing a report of an unsafe or unhealthful working condition, or other participation in agency occupational safety and health program activities- these include, among others, the right of an employee to decline to perform his or her assigned task because of a reasonable belief that, under the circumstances, the task poses an imminent danger.

Partially meets requirements The majority of staff interviewed at VHA medical centers did not believe that reprisal or the threat of reprisal was a problem at their workplaces, and few people knew what the procedures were. Please refer to the report at Program Implementation, Employee Rights and Responsibilities, the Right to be Protected from Reprisal for a discussion of these matters and Appendix D for our recommendation.

1960.54 - Train top management officials to manage the occupational safety and health program of their agency - include Section 19 of the Act, Executive Order 12196, the requirements of this part and the agency safety and health program.

Meets requirement, with recommendation VHA has a training program for management officials. There is a basic safety course for medical center top officials available on the inter- and intra-net. The program provides orientation and learning experiences that support knowledges as outlined above. Some managers at the facilities did not recall taking this training course; they should refamiliarize themselves with the materials. See Appendix D.

1960.55(a) - Train supervisors in the following: responsibility for providing and maintaining safe and healthful working conditions, the occupational safety and health program, E.O. 12196, Section 19 of the OSH Act, 29 CFR Part 1960, occupational safety and health standards applicable, procedures for reporting hazards, reporting and investigating allegations of reprisal and hazard abatement.

Anmendix A - 13

Meets requirements, with recommendation VHA has a safety and health training program for supervisors that was addressed in detail in the report at Program Implementation, Training. Some staff assigned to the site evaluation teams recommended additional training for supervisors - hazard recognition and control, personal protective equipment assessment and use, handling reprisal, and administering local safety and health program requirements. Please see Appendices C and D for our discussions of VHA training as a best practice and with regard to some recommendations on the need for additional supervisory training.

1960.56(a) - Train safety and health specialists to perform monitoring, consultation, testing, inspections and other tasks - training includes hazard recognition, evaluation and control, equipment and facility design, standards, analysis of accident injury and illness data.

Meets requirements, with recommendation VA's educational program for safety and health specialists was addressed in detail in the report at Program Implementation, Training. Site evaluation teams documented a number of VHA safety and health program implementation issues that may be mitigated by advanced technical training. Please see Appendices C and D for our discussions of VHA training as a best practice and with regard to some recommendations regarding the need for additional training for VHA facility safety and health staff, including review of the protocols and procedures recommended in the NESC Safety Guidebook Series to ensure that program requirements are communicated, required and practiced. Note that the Guidebook Series provided excellent information, procedures, protocol and boilerplate local program guidance and is a valuable program support tool.

1960.56(b) - Implement career development programs for safety and health specialists to enable them to meet present and future program needs of the agency.

Meets requirements VA's educational program for safety and health specialists and the qualifications of VHA safety and health staff assigned to VISNs were addressed in detail in the report at Program Implementation, Training.

1960.57- Provide training for safety and health inspectors on standards, identifying and evaluating hazards and suggest abatement procedures, as well as preparing reports on inspection findings.

Meets requirements

Appendix A - 14

Most of the VHA inspectors assigned to VISNs (GS-12 and -13 levels) have professional degrees and credentials and many years of experience. Training on new field developments is provided.

1960.58 - Provide training for collateral duty safety and health personnel within six months of appointment to the position - training includes the agency occupational safety and health program, section 19 of the Act, E.O., 12196, 29 CFR 1960, agency procedures for reporting evaluating and abating hazards, procedures for reporting and investigating allegations of reprisal, hazard recognition and OSH standards.

Not applicable VHA medical centers do not appoint collateral duty safety and health personnel, thus the site evaluation teams did not review this in detail. It should be noted that VA has a training program for collateral duty safety and health personnel that provides information on VA's safety and health program, Section 19 of the Act, Executive Order 12196, 29 CFR Part 1960, and VA procedures for reporting, evaluating and abating hazards, recognizing hazardous conditions and environments, identifying and using occupational safety and health standards and other appropriate rules and regulations.

1960.59(a) - Provide job-specific safety and health training for employees such training shall also inform employees of the agency occupational safety and health program, with emphasis on their rights and responsibilities.

Meets requirements VHA's educational program for safety and health specialists and the qualifications of VHA safety and health staff assigned to VISNs were addressed in detail in the report at Program Implementation, Training. VHA has a job safety and health program for employees that provides general and specialized training appropriate to the work performed by the employee and is available in a variety of formats, including computer based and Website training. Specialized training is handled at the local level.

1960.59(b) - Provide training for employee representatives, including introductory and specialized courses and materials that will enable them to help ensure safe and healthful conditions and assist in conducting inspections.

Meets requirements The VHA Employee Representative training program includes information on the agency's safety and health program, with particular emphasis on employee rights and

Appendix A- 15

responsibilities, and includes introductory and specialized courses and materials, such as the basic training course for employee representatives given at the VHA Little Rock Education Center. The training enables these individuals to ensure safe and healthful working conditions and practices in VHA workplaces and effectively assist in VHA workplace safety and health inspections.

1960.66(c) - The agency utilizes information collected through the management information system to identify unsafe and unhealthful working conditions and to establish program priorities.

Meets requirements VHA management information systems were discussed in detail in the report at Program Planning, Recordkeeping and Goals and Priorities.

1960.67(a) - Maintain a record or log of all occupational injuries and illnesses for each establishment.

Meets requirements, additional work with DOL-OSHA pending VHA has developed a version of the OSHA log of occupational injuries and illnesses for each facility and copies were reviewed during the site evaluations. VHA ASISIS software program normally generates the log, but due to implementation issues, other software was used during some facility visits. Issues concerning information available on the log arose and will be addressed by the Agency and DOL-OSHA as part of the follow-up work for this evaluation.

1960.67(c) - Record any occupational injury, illnesses or fatality reported on a worker compensation form (OWCP Form CA-i, CA-2 or CA-6) on the log.

Partially meets requirements The electronic version of the log generated by the new ASISTS program did not consistently print all of the required items. For example, some site evaluation teams found that the employee occupational series was coded numerically, or missing. During the time of this evaluation, a number of other recordkeeping questions have come to light. VHA and OSHA have agreed to work together to facilitate necessary system adjustments to the VHA's new injury/illness data system as well as resolve other recordkeeping questions.

Appendix A- 16

1960.68 - Complete workers compensation form - (CA-l, CA-2 and CA-6 or OSHA Form 101) within six working days after the receipt of information that an injury or illness has occurred.

Meets requirements According to site evaluation teams, the majority of VHA medical center supervisors completed required paperwork for OWCP (CA-is and -2s) within six workdays from receipt of the OWCP claim form.

1960.69 - Compile an annual summary of injuries and illnesses based on the record or log of occupational injuries or illnesses.

Meets requirements The VA Directive 7700.1 requires that the Annual Summary be posted. At the nine VHA medical centers evaluated for posting of the annual summary, eight were in compliance with this requirement (one site posted in February).

1960.70 - Report to OSHA, within eight hours after occurrence any accident or illness which is fatal to one or more employees or any accident that results in hospitalization of three or more people.

Partially meets requirements VA Directive 7700 and Handbook 7700.1 do not require that the local OSHA Area Office be informed by telephone or in person within a time certain regarding a fatality or accident that results in hospitalization(s) described in the regulation. However, the evaluators found instructions and sample forms for reporting and investigating accidents in the VHA Safety Program Administration Guidebook under Incident Management, 1-5. The VA poster requires timely reporting of serious accidents and fatalities. Procedures calling for a Board of Inquiry to investigate employment accidents are contained in VA Handbook 7700.1. It should be noted that there was no indication that there have been problems with timely notification to OSHA in these matters. In Appendix D, we recommend that VHA establish written procedures for reporting such information to OSHA in accordance with 29 CFR 1960.70, and disseminate the procedures.

1960.79 - Agency heads develop and implement a program of self-evaluations to determine effectiveness of their occupational safety and health programs and compliance with requirements set forth E.O. 12196 and 29 CFR Part 1960 in allfield activities.

Meets requirements Program evaluation processes and efforts undertaken by VHA have been discussed in detail in the report at Program Evaluation.

Apendix A- 17

Appendix B - Program Reviews

Hazardous Materials Management

* Is there a written policy? * Is there a hazardous materials inventory? * Is there hazard commurdcation (material specific/work area) training for

employees? Are there records of the training?

At each VHA Medical Center visited by a Site Evaluation Team, comprehensive, written hazard communication programs existed that addressed required program elements. In most facilities, the programs were available for employee review in safety offices, as well as at individual work units. Material safety data sheets (MSDSs) and chemical inventories were available on a unit-level basis and master copies of MSDSs and chemical inventories were maintained in safety offices or similar access areas.

Employees at VHA medical centers received orientation and annual hazard communication information and training (via a lecture format or computer module). Training on the safety and health hazards of specific chemical products used by affected personnel was conducted at the department level or by safety staff.

Chemical storage was organized according to materials compatibility. Allowable quantities of flammable liquids were stored in properly labeled flammable storage cabinets or segregated in explosion-proof areas. The site evaluation teams generally found that containers of hazardous chemicals were properly labeled with the chemical identity and appropriate hazard warnings.

All the facilities routinely conducted exposure monitoring for hazardous materials; there were sites where the need for additional (exposure and/or follow up) monitoring was evidenced and has been addressed later in this Appendix as well as in Appendix D. Operational problems were evidenced during site evaluation team visits at eight of the ten VHA medical centers. At one facility, the evaluators recommended that services lines, including canteen, nursing and occupational therapy, improve their chemical inventories, collections of MSDSs and employee training. At the same site, they recommended that the facility's hierarchy of spill responses be clarified and communicated. One of the facilities needed to establish procedures for labeling associated with transferring hazardous chemicals during multiple workshifts and another needed to revisit work practices associated with labeling At least one hospital did not provide specific departmental training. At another hospital, the evaluators recommended upgrading training, implementing annual supervisory reviews of

Appendix B - 1

precautions and special hazards, and providing training as appropriate. Specific recommendations were acted upon by the facilities and we have made broader recommendations regarding this program in Appendix D.

Bloodborne Pathogen Management

Is there a written policy? Is there an adequate program design, for example, is it based upon a facility exposure determination? Is training performed, if so, when, and is the training material updated? Are employees with occupational exposure offered Hepatitis B vaccine? How does the facility handle exposures? Is personal protective equipment provided?

Each VA Medical Center visited had a written Bloodborne Pathogen Program and some centers had issued supplemental written plans, Universal Body Substance Isolation Precautions. The documents outlined VHA policy and identified program responsibilities. Also included in the plans were procedures describing methods of compliance, vaccination and post-exposure evaluation and follow-up, communication of hazards and recordkeeping. Proactive infection control processes supported ongoing programs.

In several instances, incidence data was being trended to identify and support corrective measures. New employees were trained during initial orientation and all employees were trained annually. Interviewed employees at most of the VHA medical centers knew their responsibilities related to bloodborne pathogens and infection control. Almost every site evaluation team found that Hepatitis B vaccine was offered at no cost to employees at risk for bloodborne pathogens exposure and following an exposure incident, source individuals were tested, and follow-up medical evaluation was provided to any affected employee. Nevertheless, at one VHA Medical Center, a group of housekeepers had not been offered the vaccine and health care professional written opinions were not given to employees participating in the pre-exposure Hepatitis B vaccination program or post-exposure evaluation and follow up efforts. Action was taken to correct these problems.

Appropriate personal protective equipment and safety devices were provided and used, however at two VHA medical centers visited, handling and disposal of contaminated materials presented problems. At the time of the site evaluation team visits (1999), new needleless intravenous systems were used at some VHA medical centers, and other systems were routinely evaluated for reduced exposure potentials. A national initiative to track needlestick injuries was included in the VHA new recordkeeping system, the Automated Safety Incident and Surveillance Tracking

Appendix B - 2

System (ASISTS). During the time of the visits to the ten VHA medical centers, at least two had established needlestick or bloodborne pathogen committees. One Site Evaluation Team recommended that specific attention be given to cases involving employees who had repeat needlesticks. Appendix C addresses best practices identified at the sites with regard to bloodborne pathogen management and control activities. Please refer to Appendix D for recommendations.

Tuberculosis Management

Is there a written risk assessment at the facility, based upon objective criteria? Is there a facility policy based on risk assessment? Is there implementation of facility policy?

All ten VHA medical centers visited as part of this evaluation effort had developed tuberculosis programs and policies based on the Centers for Disease Control and Prevention (CDC) guidelines. Two of the VHA medical centers were identified as "low risk" hospitals. The majority of VHA medical centers visited had more than one isolation room, and some used ultraviolet (UV) light as an additional control. Training was satisfactory at the facilities evaluated; both orientation and annual employee training included tuberculosis management. At one VHA Medical Center, the Site Evaluation Team recommended that the criteria for removal of isolation designation be clarified. The site evaluation teams found personal protective equipment (PPE) included in all TB Management Programs as well as purified protein derivative (PPD) tests. One hospital reported a 0.2% conversion rate with a 99.8% employee involvement. Most VHA medical centers performed exposure assessments. Appendix D contains a list of recommendations given to one VHA Medical Center that may prove useful at others. Similarly, Appendix C addresses a best practice that may prove useful at other sites.

Chemical Health Hazard Exposures

Is there a written plan for periodic assessments based on objective criteria? (e.g., formaldehyde management, ethylene oxide management) How are facility assessments performed, are they designed to accomplish desired tasks? Are records collected? Is appropriate action taken?

Each of the ten VHA medical centers visited had implemented occupational health programs which covered employee exposure control plans for chemical health hazards. Nine of the visited VHA medical centers had developed and implemented written policies for periodic assessments of chemical hazards based on objective criteria. Despite

Appendix B - 3

the lack of a written industrial hygiene plan for periodic assessment of chemical health hazards at the tenth VHA Medical Center, the site evaluation team members who visited that facility found that initial assessment, continuing, and follow-up monitoring of chemical hazards throughout the facility was evident. Substance-specific policies existed for certain chemicals.

The ten VHA medical centers conducted periodic air monitoring and analysis, including OSHA-required monitoring of employee exposure to chemical health hazards, per the local occupational health program. Centers initiated corrective action where sampling data and workplace assessments revealed the need for engineering controls or personal protective equipment. The VHA medical centers performed evaluations and personal monitoring for hazardous agents of employees whose exposure was representative of the workplace conditions routinely encountered, recorded hazard surveillance inspections and sampling activities and maintained the analytical results in accessible data systems, and provided the results of sampling activities to employees and their supervisors. Generally, employee protective measures such as engineering controls, administrative controls, and personal protective equipment (PE) were provided and utilized, and OSHA-required medical surveillance was provided. Nevertheless, at five facilities, site evaluation teams made specific recommendations for improvements in monitoring and sampling procedures. At three VHA medical centers, the site evaluation teams addressed the need for permanent eye wash equipment, or better assessment concerning emergency eye wash needs.

At the ten medical centers visited, VHA employees received general safety training and safety training specific to the health hazards in their work areas. Observations of onsite work practices indicated that appropriate policies were in place for the handling, use and storage of chemicals. Employee interviews revealed that they were fairly knowledgeable about safe handling practices, PPE use and emergency measures. However, additional training should be undertaken to provide a greater margin of safety, as recommended in Appendix D. Additionally, Appendix D contains a list of recommendations provided to various VHA medical centers while the site evaluation teams were at the facilities - it is important to note that a majority of the issues were resolved before the teams left the site. Appendix C documents some best practices identified by the site evaluation team who visited one of the Centers

Confined Space Program

Is there a written program to identify confined spaces? Was the assessment performed, are there records of the assessment? How many confined spaces were found, how many were incorrectly identified? Is the program updated, and if so, when? Is the appropriate action taken (employee training, signage, PPE available)?

Appendix B - 4

Nine VHA medical centers visited by evaluation teams had confined space programs that documented facility policies, written procedures and employee training requirements for entry and work in permit-required confined spaces (PRCSs). The tenth VHA Medical Center was required to develop a program. Site evaluation teams reported that VHA medical centers maintained sufficient amounts of personal protective equipment for employees entering and working in PRCSs. VHA employees received training under the confined space programs and interviews with employees indicated that they understood the hazards of PRCSs as well as control procedures. Rescue operation services at the VHA medical centers were provided through facility fire departments, or through contracts with municipal fire departments. Site evaluation teams reported that the VHA medical centers visited provided sufficient information to rescue personnel so that they were appropriately prepared to conduct successful rescue operations.

Most local programs identified the confined spaces at the VHA medical centers, however, some written procedures were not specific as to the location of the confined spaces, permit contents and review, or training. The site evaluation teams at five of the ten VHA medical centers found that a the local confined space programs were not complete. One Center was advised to revise its confined space program to comport with the requirements of 29 CFR 1910.146; another needed to clarify its assessments and program to differentiate between permit required confined space and non-permit required confined space. The need to document the results of sampling for toxic or explosive atmospheres was raised at one VHA Medical Center. The same facility was advised regarding the need to provide harnesses for employee use and folding stretchers for rescue use and to be cautious regarding permit duration times and proper signage to cover multiple shifts. In addition to the need to review and assess the needs for hazardous atmosphere testing in confined spaces, and keeping programs updated, there was an instance of a confined space not identified or listed. In each case, the site evaluation teams brought this information to the medical centers' attention for corrective action. Please see Appendix D for recommendations. Appendix C lists best practices associated with management of potential hazards in confined spaces.

Fire Protection

Is there a written facility fire policy and plan? Are fire drills performed as required? Are the drills evaluated in writing? Is training provided that is consistent with identified needs?

Each VHA medical center visited had a written, comprehensive fire protection program that established policies, standard operating procedures and training requirements to respond effectively to fire emergencies. Medical centers conducted fire drills in

Appendix B - 5

accordance with pertinent requirements, and performed written evaluations to assess program effectiveness enhance training. The fire drills were conducted at or above the required frequency for patient and non-patient care buildings. VHA employees received fire protection training during orientation, and annually thereafter, and were involved in the assessment of completed fire drills. Site evaluation teams reported that VHA employees interviewed at the ten facilities understood the local fire protection program and their responsibilities during fire emergencies. Generally, written reports of the fire drill were reviewed by the VHA medical center's Environment of Care or safety committees. Please see Appendix C for a best practice associated with one Center's fire protection program.

Site evaluation team found some operational problems. At two of the Centers, the site evaluation teams addressed the need to ensure that exit corridors are kept free from impediments such as temporarily stored equipment or supplies. At another VHA Medical Center, the staff was reminded to keep combustibles away from a designated smoking area. While one evaluation team was onsite, Center staff implemented interim life safety measures associated with the fire alarm control panel. Other problems such as

updating the fire pump flow annual testing (NFPA 25) or resolving questions concerning compartmentalization were resolved in a timely fashion. One of the VHA Medical Centers had a contractor performing renovations in an area that was still occupied by employees, and the contractor did not fully comply with fire safety practices; VHA management officials imm.ediately implemented a daily check of the construction area to ensure that safe practices were implemented. In fact, all of the Medical Centers visited took immediate action to resolve any problem brought to their attention and corrections were either immediately implemented or scheduled for abatement at the earliest possible time. Appendix D contains our recommendations with regard to the VHA fire protection program.

Emergency Response Planning (earthquake, natural disaster, etc)

Does the facility have a plan for responding to these events ? Is the plan written, when was it last updated? Has training on the plan requirements been performed?

Each of the ten VHA medical centers visited had written plans that contained emergency response planning elements. The plans were updated. Three of the VHA medical centers had emergency response activities that addressed Y2K contingencies. Facility plans addressed a wide variety of emergencies, including internal disasters. VHA medical centers critiqued their responses to various emergency scenarios and drills and tracked improvements for implementation. Training courses included semi-annual emergency drills, computer-assisted instruction, and personal instruction; new employees were trained and periodic retraining for all employees was part of this program. Discussions with VHA employees confirmed that information about the

Appendix B - 6

emergency response program was widely distributed and well supported by management and employees. See Appendix C for best practices recognized by site evaluation teams and Appendix D for recommendations with regard to the overall program.

Personal Protective Equipment (PPE•)

Does the facility have a policy on the selection and use of PPE? Is the policy written, when was it last updated? Have PPE needs assessments been performed? Was PPE made available on the basis of the assessments? Was appropriate training provided?

All ten VHA medical centers visited during this evaluation effort had written personal protective equipment (PPE) programs that were routinely updated. Three VHA medical centers had not fully customized the VHA Headquarters PPE Guide to ensure that their PPE hazard assessments were workplace-specific. This resulted in some problems: for example, at one facility, employees were using safety glasses and rubber gloves to handle corrosive chemicals and at another, the Site Evaluation Team raised issues about eye and hand protections for laboratory employees.

Of the ten VHA medical centers visited, the site evaluation teams at six of the centers recommended improvements related to the need to do detailed site-specific hazard assessments.

At three medical centers, site evaluation teams recommended revision and updates for local respiratory protection program to ensure compliance with current OSHA requirements. While all VHA medical centers provided PPE and employee training in the use, care and limitations of required PPE, one site evaluation team found that employee training on respiratory protective equipment lacked details such as how to perform positive or negative pressure checks or air flow checks on powered air-purifying respirators (PAPRs). Appendix D contains our recommendations.

Violent Behavior Prevention

* Is there a written facility policy? o Is the policy based on objective criteria?

The VA Secretary and VHA Under Secretary have issued letters concerning the prevention of violence. VA policy stated that written programs must contain procedures necessary to minimize employee exposure to violent behavior and all employees with potential exposure to violent behavior as part of their work assignments must successfully complete specialized annual violent behavior prevention training. • Please

Appendix B - 7

see Appendix C for our recommendations with regard to a local strategies that appeared to be successful.

Site evaluation teams found that violent behavior prevention efforts varied. The majority of VHA medical centers operated successful programs and identified prevention and control measures for potential exposure to workplace violence. Two VHA medical centers did not have facility-wide written violent behavior prevention policies in place at the time of the site evaluation team visits one Medical Center had workplace violence prevention plans in an unsigned, unnumbered, updated draft policy. At another Medical Center, only employees assigned to high risk areas had completed training at the time of our visit. See Appendix D.

Employee Complaint Response Program

Is there a written policy informing employees of their right to submit complaints? Does the policy inform employees of their rights regarding "reprisals"? Is there evidence that appropriate action is taken in response to complaints? Is feedback provided to the complainant? Is the safety committee informed of the complaint and facility action?

Interviews with VHA medical center employees indicated that the majority were confident that when they report unsafe or unhealthful working conditions, their concerns would be addressed in a timely and appropriate manner. VHA employees routinely reported complaints to their supervisors or staff in the VHA medical center safety offices. Most employees interviewed indicated they were satisfied that their complaints were being addressed. Almost all VHA employees at the ten medical centers visited reported they had no fear of reprisals. At one VHA Medical Center, the visiting team reported their observation that employees felt more comfortable giving their complaints to local Union representatives, in an effort to preempt any chance of reprisal.

Employee safety and health complaint processing procedures were addressed to some degree in documents such as newsletters, provisions of AFGE- or NFFE-negotiated Agreements, VA Directive 7700 and VA Handbook 7700.1 and the VHA National Engineering Service Center (NESC) Safety Guidebook. All ten VHA medical centers depended on the VA poster (VA form 2180) to inform employees about their rights to report unsafe or unhealthful working conditions. At a few medical centers, particularly those that had large campuses, site evaluation teams recommended that posters should be placed in more locations to facilitate employee access. Per the VA poster, employees could give verbal or written notice to their supervisors to report and request an inspection of an unsafe or unhealthful working condition. The VA poster indicated that VA Form 2169, a safety and health complaint form, was to be used for written notice to the supervisor, however, that form had been discontinued (albeit available on the VA Website). If an employee appealed the supervisor's disposition of the complaint and

Appendix B - 8

wanted a written reply, the employee was required to use the discontinued VA Form 2169, per poster instructions. Some changes to the VA poster may be in order, based on amplification and clarification of the VA employee complaint procedure.

Most of the VHA medical centers visited maintained complaint logs that documented employee reports. While such logs can serve as an information source to track and trend safety and health issues raised by employees, agency maintenance of a log of employee reports of unsafe or unhealthful working conditions is not required per 29 CFR 1960.28. Most VHA medical centers shared some portion of the complaints with the facility safety or Environment of Care committee. Typically, more serious complaints that required changes in operations or tracking over a period of time for full abatement were brought to the attention of the committees and complaints requiring simple housekeeping or engineering fixes were resolved sometimes were not reported. Most, but not all, supervisors and management officials at the ten VIA medical centers provided written responses to employees regarding reports of unsafe or unhealthful working conditions. As addressed in the report at Program Implementation, Employee Rights and Responsibilities, the Right to Report Hazards, the procedures should be clarified. Our recommendations can be found in Appendix D.

Ergonomics Program

Is patient lifting addressed? Is there a program for prevention of back injuries?

* Is there a program for prevention of repetitive stress injuries? * Does the facility have an ergonomics program? * Are employees trained to lift properly? * How do employees report injuries? 0 Does the facility have a back injury program? * Does the facility provide lift devices?

VA published a policy statement in the VA Handbook 7700.1 requiring an ergonomics program to be developed and implemented at all facilities based upon assessments of specific tasks that pose significant risk for injury. It required written procedures for proper lifting of materials and patients, video-display terminal use and tasks that involved repetitive motion. Employees who performed lifting as part of their assignments were required to successfully complete specialized back injury prevention training and general training in proper lifting procedures, operation of lift devices and prevention techniques.

Eight of the ten VHA medical centers involved in this effort had developed written ergonomics policies and programs at the time of our site evaluation team visits. All visited medical centers had focused attention on employee training about prevention of injuries when performing patient lifting and various repetitive motion tasks; the facilities

Appendix B - 9

supplemented training with onsite expert support and assistance. Each of the ten VHA medical centers provided lift devices, and training in their use and some centers had implemented ongoing back care programs. Training for medical staff on how to safely perform tasks and use devices, as well as training for the local ergonomic committee or teams in recognizing and evaluating work processes that could result in injuries, was an important component of these programs. Please see Appendix C for efforts recognized as best practices and Appendix D for recommendations.

Facility Safety Committee

Is there a facility safety committee? How often does the committee meet? Does it review the safety program activities throughout the facility? Does it monitor the performance of the safety program staff? Does it receive and act upon employee complaints? Does it report to the facility director on its actions?

All ten VHA medical centers visited by site evaluation teams had safety committees chaired by a variety of management officials including the Director, Associate or Assistant Director, Chief of Engineering or Safety Manager and all committees had employee representatives as members. Committees met monthly, and generally, subcommittees provided quarterly reports. The committees coordinated safety activities to ensure consistency, monitoired compliance with safety policies and directives and evaluated overall effectiveness of safety programs. Committee activities included: reviewing carelines or service lines safety issues, tracking employee complaints and follow-up actions; conducting accident investigations, reviewing the safety program annually to measure the performance of staff, reviewing performance standards, and conducting walkthroughs with facility safety personnel. Most committees were closely associated with Environment of Care Committees or Healthcare Leadership Committees (these may be one and the same). Please see Appendix D for recommendations and Appendix C for best practices associated with committee work.

Facility Director Involvement

Does the facility director. * know the status of the safety program; * establish annual program goals, if so, how do these relate to overall VA goals; * attend safety training; * take an active role in the management of the safety program; and * meet with Union leadership regularly to discuss employee safety concerns?

At all ten VHA medical centers visited, the facility directors were involved in the local safety and health programs. A policy statement, as well as implementation guidance

Appendix B - 10

At all ten VHA medical centers visited, the facility directors were involved in the local safety and health programs. A policy statement, as well as implementation guidance regarding the local safety and health program, had been issued at each of the ten VHA medical centers. The teams reported that top-level local management (the Director, Division Director or Associate Director) actively participated in the Medical Centers' safety programs. Nine of the ten VHA medical centers produced evidence of clear, measurable goals and objectives from their directors; six of the medical centers had developed site-specific annual safety and health program goals. At every VHA medical center visited, directors had designated top management officials to represent them on the local safety committee; in one case, the Director was the Chairperson. Half of the facility directors interviewed by the teams reported that they routinely met with local union leadership to discuss safety concerns. The majority of facility directors and their senior staffs attended training on the agency safety and health program, and three directors took steps to demonstrate support for employee safety training. The Fire, Safety and OSHA Standards Committee and a Healthcare Leadership Committee on Coordination of Environment of Care at two VHA medical centers had been empowered by their respective facility directors to manage the program and to implement appropriate action plan(s). Appendix D contains our recommendations.

Structural Analysis of the OSH Program at the Facility Level

Does the organizational structure of the occupational safety and health program adequately support the responsibilities and expectations of the facility? Are program staff qualified to perform their assigned tasks? Is the program adequately supported by facility management? Does the program play a visible role in the functional operation of the facility?

Site evaluation teams reported that the organization and placement of safety offices at VHA medical centers supported the responsibilities, and expectations, of those centers. Communications between the safety staff and facility directors were effective and medical, administrative and support staff at facilities were aware of, and supported, the safety office's work. VHA medical center management officials evidenced their support for the safety and health program through participation in the safety committees, training, correction of safety and health hazards, provision of personal protective equipment, routine walkthroughs of hospitals and the like. Site evaluation teams reported adequate cooperation and coordination between various functions, that is, between facilities management and safety staff member and between occupational health services and safety staff members.

The site evaluation teams documented that local safety and health programs were supported by management through an on-going and as-needed budget. In the majority of the VHA medical centers, the numbers of staff assigned to the safety offices, and their areas of expertise and training, were adequate and appropriate to handle program

Appendix B - 1

responsibilities. At some medical centers, contractors were hired to perform various aspects of the industrial hygiene work Facility safety personnel used expert support available from the VHA staff assigned to the Veterans Integrated Support Networks (VISNs). At one site, the evaluation team addressed the need for local industrial hygiene services since the servicing VISN did not have a regional industrial hygienist on staff for backup. Recommendations can be found in Appendix D.

Occupational Health Services

Does the employer offer occupational health services? How are services provided; on-site or off-site with a contractor? Does the facility provide health examinations as required for applicable OSHA standards?

All VHA medical centers offered on-site occupational health services by professional staff. The facilities' medical surveillance programs provided testing and medical evaluations as required by OSHA standards. Occupational medical services included, but were not limited to: tuberculosis testing, audiograms, medical exams, asbestos physicals, bloodborne exposures testing, blood lead monitoring, respirator clearance exams, purified protein derivative (PPD) testing, Hepatitis C screenings, and Hepatitis B vaccine. Employee participation in the program was tracked and follow-ups scheduled as appropriate. At some VHA medical centers, employees injured on the job were evaluated and monitored until recovery through the occupational health services groups.

VHA medical center safety professionals and Office of Workers' Compensation Program (OWCP) coordinators developed good working relationships with staff in the occupational health service groups and that cooperation facilitated services to employees. Interviewed employees had favorable comments concerning the occupational health services offered by the VHA medical centers, but at a few of the visited centers, employees and their representatives voiced concern about returning staff to work following an occupational injury or illness and ensuring compliance with attending physician restrictions. Please see Appendix D for our recommendations.

Appendix B - 12

Appendix C - Best Practices

Top Level Management Support and Employee Involvement

VHA has made a determined effort to promote employee safety and health. VHA management officials at the highest levels have demonstrated their commitment to make employee safety and health an organizational priority and core value. Goals and action plans have been instituted and communicated to all levels of the organization, program activities have been endorsed and supported through provision of resources critical to achieving goals, and accountability at all levels has been established. Key in terms of ensuring that the program remains visible and continues to receive support is the organizational placement of occupational safety and health in the VHA Office of the Chief Network Officer, directly supervised by the Office of the Under Secretary for Health. This organizational placement of occupational safety and health in VHA enhances the VHA's oversight and advocacy efforts for the occupational safety and health program.

Management has established mechanisms to facilitate employee involvement and encourage employees to participate in achieving program objectives and goals. This VAVHA OSHA-union evaluation project is an example of the viable and effective partnership developed between agency management and employees.

Safety and Health Technical Resources

Members of the National Evaluation Team had the opportunity to review materials developed by the VHA National Engineering Services Center (NEC) and were impressed by the quality and level of technical support evidenced in this series. NESC provides ongoing support for VHA safety and health education and technical resources and in the past few years they have developed, with input from safety and health experts in VHA and employee representatives, a series of guidebooks to enhance the VHA safety and health program and assist facilities in meeting the standards of OSHA, EPA, NFPA, and JCAHO. The intent in adopting the Guidebook system was to provide a more comprehensive and consistent review process for all components of the occupational safety and health program at medical centers. The Guidebook series provided guidance on how to comply with requirements of the various programs and supplied sample policies and procedures needed to meeting standards. The policies, procedures and forms contained in the series were made available to each medical center on computer disk to facilitate the customization of these documents for their use. Each guidebook contains sample policies and procedures that can be customized to meet facility needs. For example, the Safety Guidebook Series was developed to assist VHA facilities in implementing a comprehensive safety, fire protection, and industrial hygiene program. The Industrial Hygiene Guidebook provides implementation strategies for the various

Appendix C - 1

subjects covered; the Environmental Compliance Guidebook covers annual safety and health

evaluation work as well as the components of a complete environmental hygiene program. The Occupational Health Guidebook for the Industrial Hygienist covers medical

surveillance and the Emerging Pathogens Guide was developed to assist VHA medical

centers in tailoring programs to address their specific needs and meet guidelines published by the Centers for Disease Control. The JCAHO 2000 Environment of Care Guidebook was developed to assist VHA medical centers in complying with the latest JCAHO Management of the Environment of Care standards.

In the past two years, VHA has spent considerable time and effort in developing two computer based safety and health systems that will improve the safety and health

program substantially. The Automated Safety Incident and Surveillance Tracking System (ASISTS) program is a real-time automated management and tracking system for

injuries, illnesses and accidents that facilitates root cause analysis and is slated for programming enhancements that will add the capacity to track safety and health issues

such as medical surveillance, training and other recordkeeping information. The Safety Annual Facility Evaluation (SAFE) is an automated data entry system for use primarily by VHA inspectors assigned to VISNs in conducting facility occupational safety and health oversight evaluations. The system will promote inspection consistency, improve communications with facility management and union representatives, improve notice

documentation and abatement tracking after the inspection visit and generally improve professional resource utilization.

VHA Annual Safety and Health Activities Evaluation Survey

Since 1997, VHA has surveyed its 22 networks to quantify successes, and identify areas for improvement in the VISN-based safety and health programs. The data received are used as a baseline to measure and monitor future developments of the program and can be used by organizational units to measure progress in key safety and health activities. This survey also enhances the partnership of employee representatives and VHA management by requesting their input in regards to the value of the program.

Violent Behavior Prevention

The majority of VHA medical centers visited by the site evaluation teams had taken the

issue of violence in the workplace and protection of staff, patients and visitors seriously. Management commitment and employee involvement was evident at the sites. At all but

three medical centers, the site evaluation teams found written local programs, assignment of resources and responsibility for the program, and accountability. Employees were trained in understood and complied with the workplace violence prevention programs and were involved in the program through committee work. Numerous VHA medical centers had dealt with questions that have a wide base of interest in the field of violent behavior prevention, such as:

Appendix C- 2

use of physical barriers and alarm systems for various units (Little Rock and West Haven VAMC), need for evaluation of employees prior to returning to work (Coatesville VAMC), better coordination and use of 'report of contact' system (Detroit VAMC), how to ensure that patient admissions processes minimize employee exposure to potentially dangerous situations (Miami and Detroit VAMCs), managing potentially violent patients and/or visitors with legal bounds (Detroit VAMC) how to best control employee relations issues situations involving coworker conflict and training for supervisors in documenting and controlling problems (Detroit VAMC).

It is clear that most of VHA medical centers spent considerable time, effort and talent in identifying potentially useful strategies for meeting challenges associated with violent behavior programs. We understand that work to promote a nationwide prevention program for violence in the workplace has been instituted and are encouraged that VHA plans to promote this important work. In terms of workplace security analysis, hazard prevention and control and program evaluation, medical centers and other VHA worksites may benefit from the broader view and nationwide data that could be collected and disseminated from the VHA Headquarters level.

The violent behavior prevention program in place in Albany, New York has been recognized by their Network as a "best practice" and the site evaluation team was informed that the program was slated to be implemented throughout the New York upstate network The VAMC also shared its program with a number of outside entities, including two local Federal Safety and Health Councils.

Ergonomics Programs

The VHA NESC Safety Guidebook Series for Industrial Hygiene contains a chapter of general guidance on ergonomics that covers back injury as well as repetitive motion injury prevention. At the time of the site evaluation team visits, VHA was developing a source book on patient lifting practices designed to prevent back injuries. Further, nationwide policy is under development by VHA at the Headquarters level to facilitate implementation of successful and efficient programs and maximize local efforts. Appendix D suggests a number of components that should be considered in the development of ergonomic policies. We expect that each VHA Medical Center policy on ergonomics should be an overall policy, with specific program recommendations for work and divisions unique to that facility.

Considering the general success of using lift devices, it is important to ensure devices are available where needed, and maintained for use (e.g., charged batteries, repairs quickly

Appendix C - 3

reported and accomplished). Facilities are conducting reviews of work practices and staff continue to seek strategies to limit or prevent employee exposure to hazards. In Little Rock, a computer- based system had been introduced into the ergonomic evaluation process and the facility Injury Control Committee annually evaluates the effectiveness of the ergonomics program. In Coatesville, a new concept in manipulating/repositioning patients was being implemented during the time of our site visit A number of VHA medical center employees were being trained in the processes and were expected to help train other facility staff in the new program. Other VHA medical centers may wish to utilize these strategies and continue work to support local ergonomics programs.

Worker Compensation Program Management

In addition to controlling lost time case rates, VHA has made its management operatives accountable for controlling worker compensation costs. VHA managers have been given support from the highest levels of VHA. To illustrate, a few years ago, the practice of reporting worker compensation costs to organizational units was instituted; additionally, annual goals that including management of worker compensation claims and matters have been established and tracked. For the past two years, VA has sponsored week-long Workers Compensation Program Management Conferences. The VHA Occupational and Environmental Strategic Health Care Group has worked to identify better methods for improving management of injuries and illnesses including but not limited to the institution of ASISTS, support for education and training, coordination of support through the NESC, and the like.

There were substantial decreases in lost time case rates at the Albany VAMC. Our discussions with the Facility Director and staff responsible for workers' compensation program management, occupational health, and safety can provide a blueprint for others to follow. They attributed reductions in their lost time case rates to: • top management commitment to injury reduction; * supervisory involvement at the early stages of an accident and claim; * involvement of safety personnel in accident review and continuing involvement in

case management; • involvement of Employee Health Unit Nurse Practitioner in the identification and

implementation of appropriate light duty assignments; * development of a Network Office of Workers' Compensation Program (OWCP)

Task Group to ensure increased management of OWCP claims that included monitoring case progress, resolution of coding errors in the DOL-OWCP information systems, and leadership and coordination among Network hospitals.

Coordination of roles and work products identified interventions ensured that injured

workers received appropriate medical care and preserved VHA medical center resources.

In addition to the commitment by management to take active steps and put resources

Appendix C - 4

into administering the local workers' compensation program, the site evaluation team found that employee cooperation and support was encouraged through communication about goals and processes.

Employee Training

As noted earlier in this report, VA had been criticized in 1992 for a number of deficiencies associated with their safety and health training and education efforts. This review at the VHA medical centers and Headquarters found evidence that a focused effort to improve training has been successful. We found that training and education received support from the highest levels of VHA; the former Under Secretary for Health advised the evaluators that education, combined with good systems to support employees, was one of the basic strategies VHA focused on to meet their goals. VHA has promoted the excellent work produced by the NESC and VHA's integration of training into routine performance is reflected in the materials and detailed guidance available in the Guidebook series. VI-A has produced improved introductory and specialized training materials for managers at all levels to assist them in developing skills to manage the program, recognize and eliminate or reduce workplace hazards, and train and motivate subordinates. VHA has invested substantial time and effort into developing a well trained workforce; for example, safety and health staff are authorized to undertake 40 hours of training in their fields. Staff from the Office of Occupational Safety and Health have worked with VHA to sponsor employee representative education efforts as well as ensured employee access to'quality education resources. The site evaluation team who visited the VAMC in Iowa City, IA identified the local employee safety training program as a "best practice." Training was available in a variety of formats including computerized delivery, classroom and demonstration training, drills, and the like. Training typically was customized for local needs and interests and available at time convenient to employees on all three shifts.

patient Safety and Risk Management Program Integration

The Albany facility reported that their Network had implemented an integrated risk management program which included both unplanned clinical occurrences and Environment of Care incidents. This effort sought to improve patient safety in a way to that information could be identified for use in improving employee safety.

Bloodborne Pathogens Management and Control

At the VAMC in little Rock, AR, the site evaluation team identified the timely investigation of exposure incidents by the Infection Control Nurses to be a "best practice." This facility also uses a Single Use Detection System (SUDS) diagnostic test to provide a 30-minute result for HIV determination following an exposure incident that holds promise for application at other sites.

Appendix C - 5

At VAMC located in West Haven, CT, the site evaluation team identified the focused reviews for all needlesticks or mucous membrane exposures to blood or body fluids, and forms utilized following an exposure incident, to be a "best practice."

Tuberculosis Management

In West Haven, the VAMC implemented a PPD testing program based on the employee's birth date and the program's tracking process ensures that supervisors are notified and

held accountable for each employee completing the skin testing. (Note: an employee may decline the PPD skin test in writing after reading and signing a declination statement)

Chemical Health Hazard Control and Management

The site evaluation team who visited the VAMC located in Little Rock considered the onsite abatement program for asbestos unique to the VA system, and noteworthy. Asbestos is a significant hazard at the North Little Rock facility due to the number of historic buildings. The facility-wide assessment of all asbestos containing material locations is

used extensively by the on-site asbestos abatement team and the assessment facilitates the implementation of effective protocols for abatement project design. The assessment documentation at the site provided an example of a thorough, easily accessible and readable system. The facility is designated by EPA as an approved training facility.

This VAMC also has invested in industrial hygiene equipment. The fully equipped calibration laboratory enables industrial hygiene monitoring of a wide variety of contaminants. This level of capital investment to support the occupational safety and

health program at the local level should be considered a "best practice" for VHA.

Confined space

Our site evaluation team who visited the VAMC in Coatesville, PA identified two "best practices" associated with management of potential hazards in confined spaces. At the

Coatesville facility, all confined spaces are treated as permit-required confined spaces to eliminate potential confusion as to whather permits are required. This VAMC's second "best practice" is its support for its Fire Department, the group is well trained and well equipped to perform confined space rescue.

Fire Protection

The VAMC located in Coatesville was credited with a "best practice" associated with its

fire protection programs. This Medical Center conducts fire drills once per shift per

quarter for each healthcare ward. This practice is in excess of the VHA and JCAHO requirements that call for such drills once per shift per quarter for patient care buildings.

Anvendix C - 6

The increased frequency provided a higher level of fire drill exposure and practice to the

staff in patient care areas.

Emergency Response Planning

The facility in Little Rock sponsored a volunteer Emergency Response Team, the first in

VHA. The group has received extensive training in emergency response and is equipped

to respond to external disasters.

The VAMC located in Albany, NY developed a written emergency preparedness plan

that has been used as a model plan throughout Network 2.

Facility Safety Committee

The site evaluation team who visited the VAMC located in Beckley, WV reported best

practices associated with the facility safety committee called the Fire, Safety and OSHA

Standards Committee. The Committee reviews safety program activities with special

emphasis on accident review, workers' compensation and OWCP case management,

particularly those involving lost time claims.

Contractor Safety

The site evaluation team who visited the facility in Little Rock reported that contractors

are screened and monitored on their working habits. Contractors have been directed to

leave the facility because of unsafe or unhealthful work practices.

At the VAMC in Beckley, contractors are advised of safety policies and guidelines in

place at this facility. Only licensed contractors are hired to perform work at the facility.

Appendix C - 7

Appendix D - Recommendations

Progress on implementation of recommendations in this final agency-wide report will be monitored jointly by the National Evaluation Team. Based on input from the partners regarding timeframes for implementation of each recommendation, final implementation timeframes will be developed by OSHA. The status of progress will be included in the Department of Veterans Affairs annual report to OSHA and the Secretary's Annual Report to the President.

Occupational Safety and Health Program Training

Site evaluation teams found that most supervisors in VHA exercise their authority to provide hazard-free work environments, provide employees opportunities to obtain safety and health training, require safe work practices, and ensure timely abatement of identified unsafe and unhealthful working conditions. Nevertheless, there were a sufficient number and range of program implementation problems to indicate that training is necessary to assist supervisors in meeting their obligations. Half of the site evaluation teams recommended additional training for VHA supervisors in safety and health subjects such as hazard recognition and control, PPE assessment and use, handling reprisal, or administering local safety and health program requirements. Site evaluation teams findings indicated a trend that when the work was not in direct patient care areas,

recurring operational problems emerged such as the lack of lockout/tagout safe work practices in a number of work settings (including laundry operations), confined space safety measures, electrical system safe work practices, construction oversight for safe work practices and the like. Although a great amount of the work at VHA medical centers is associated with patient care and in a health care environment, general industrial-type processes and associated potential hazards are also a large part of the support systems in place at these campuses. In addition to ensuring that supervisors are assertive advocates of safe work practices, employees at all levels must carry out their assignments in compliance with systems and procedures established to protect their safety and health. A renewed commitment to ensuring safe work practices be required throughout all VHA campuses would lend support to proactive and preventative measures. Training in the technical areas would ensure that all staff are cognizant and clear about safety and health requirements; compliance is a matter of support, enforcement and cooperation.

* VHA management should provide training for supervisors to ensure that local program requirements are understood, communicated, required and practiced. This should facilitate front-line implementation of safety and health programs and procedures.

Appendix D - 1

VHA supervisors, as well as other employees, should attend initial, refresher and followup training on safety and health hazard controls and options for protective measures associated with local operations

In addition to the recommendations concerning supervisory training in both the provisions of 29 CFR 1960 and specific safety and health subjects such as hazard recognition and control, control of violent behavior in the workplace, and resolving allegations of reprisal, site evaluation teams recommended additional training for all involved personnel regarding control of hazardous materials and bloodborne pathogen management programs. A few site evaluation teams found that employee responses to specific questions were not consistent with policies associated with hazardous materials management. Further, there was evidence at some VHA medical centers that, although bloodborne pathogen management policies were generally well written and established, some aspects of the program were not adequately communicated, required, or practiced.

"* VHA management should evaluate the effectiveness of training pertaining to hazardous materials management programs and procedures. VHA management should also ensure that written programs for hazards chemicals (e.g., gluteraldehyde, ethylene oxide, and other materials covered by expanded standards) are written in plain English to facilitate efforts to communicate safeguards to be followed.

"* Local bloodborne pathogen management program training content must mirror VHA medical center policies.

"• Protocols must be developed so that the policies can be followed precisely as written.

This report delineates a variety of program implementation issues that may be mitigated by advanced technical training for safety and health personnel per 29 CFR 1960.56(a). The evaluators noted, and commended, VHA for developing a high quality set of guidebooks and training materials developed by VHA NBSC and the VHA Little Rock Education Center. These products should continue to be used at VHA facilities, in fact, they should be put to greater use than was evidenced through some of the findings during the site evaluation team visits. The Safety Guidebook Series provided excellent information, procedures, protocol and template language for local program guidance and is a valuable program support tool.

* VHA facility safety and health staff should attend technical training that incorporates review of the protocols and procedures recommended in the VHA Safety Guidebook Series. Supervisors and managers must ensure that program requirements are communicated, required and practiced.

Appendix D - 2

Some managers at the facilities did not recall taking the VHA basic safety course for medical center officials.

VHA managers that are unclear regarding the VHA safety and health program operations, or their responsibilities, should utilize training resources available to them to review safety and health program requirements.

Personal Protective Equipment Programs

Six of the ten site evaluation teams made recommendations regarding local personal protective equipment (PPE) programs and use of safety equipment and procedures. Three of the ten VHA medical centers did not fully customize the VHA Headquarters PPE Guide to ensure that hazard assessments were workplace specific. Teams recommended that local revisions should cover a variety of potential hazards, including but not limited to identification of confined spaces, identification of potential stored energy and electrical hazards (including spreaders operations in at least two laundry operations), placement of safety devices, efficacy of local ventilation systems and the like. Updates to the respiratory protection program were needed at three VHA medical centers, as well as improvements to employee training.

There are several resources for further information on PPE. The VHA National Engineering Service Center (NESC) Guidebook Series has a chapter on PPE in the General Safety Guidebook, and there is an entire VHA Guidebook devoted to PPE, the Personal Protective Equipment Guidebook and can assist staff in determining hazards that could be addressed by PPE. It outlines employee training and development of local policies regarding the scope of protective clothing, respiratory devices, and other protective equipment. The Guidebook provides hazard assessment checklists for a number of departments and is user friendly.

* VHA medical centers that have not customized the VHA Headquarters PPE Guide must do so.

* VHA management must ensure that qualified personnel perform required local job and workplace hazard assessments, document the findings and identify options for engineering controls, administrative controls and PPE and safe devices to abate or control current potential worksite hazards.

• Review of local respiratory protection procedures and programs must be undertaken to ensure that the programs are sufficient to meet the requirements of 29 CFR 1910.134 and 1910.139 (as appropriate), including employee training. Laboratory and research area hazard assessments should be undertaken in a timely fashion, with particular attention given to placement of emergency eyewash and shower equipment. When

Appendix D - 3

processes and materials used in these labs change, new hazard assessments and appropriate changes to operations must be made. Additional supervisory training in hazard assessment, and PPE selection and use, would likely promote program efficacy at operational levels. Supervisors must ensure that employees are trained and utilize PPE as indicated.

Confined Space Program

Five site evaluation teams identified a variety of shortcomings problems with local implementation of their confined space programs as addressed in Appendix B. This is problematic and further supports the need for renewed vigor in ensuring that facility support and engineering functions adhere to safety and health requirements. The VHA National Engineering Service Center (NESC) Industrial Hygiene Guidebook provides substantial guidance for local confined space program management as well as a detailed implementation strategy and a sample permit-required confined space entry program. This resource is available to VHA facilities.

"* Local implementation of confined space programs in VHA medical centers must be reviewed in detail, procedural or operational corrections identified, implemented, and monitored to ensure compliance.

"* VHA supervisors of safety and health personnel, as well as front-line engineering staff, must be held accountable program implementation to include delineation of specific roles and guidelines for working in confined spaces; hazard assessment, identification and marking of all permit required confined spaces; atmospheric testing requirements; permit requirements and alternate procedures; records, entry and rescue procedures; advice to contractors; employee training; and sampling procedures.

Fire Protection Programs

Four site evaluation teams addressed problems associated with local fire protection programs and practices. At least two VHA medical centers were advised of the need to control hallway storage and ensure that equipment and materials did not impede egress.

VHA medical centers must implement procedures to routinely check for and remove any items, mobile or semi-permanent, that could be impede egress. VHA medical centers must communicate with staff (on a routine basis if necessary) the importance of not leaving unattended or stored items in corridors and enforce this requirement.

Appendix D - 4

Facility engineers and contractors must ensure that placement and installation of high storage shelving does not interfere with sprinkler head water distribution patterns.

Lockout/Tagout and Electrical Safety

Although the site evaluation teams were not given specific items to review with regard to VHA medical centers' lockout/ tagout programs or electrical safety practices, site evaluation teams made a number of recommendations with regard to problems evidence during their visits. At three medical centers, a means of lockout for the laundry spreader-feeder needed to be developed. Staff at two VHA medical centers were improperly using tags instead of locks. In four VHA medical centers, recommendations for equipment-specific procedures, and employee training, were made by site evaluation teams. At one Center, a variety of electrical safety issues were addressed, including the proper use of extension cords, marking of electrical circuits at circuit breaker boxes and clearance in front of the circuit breaker boxes.

"* If there is no lockout/tagout program in place at any VHA medical center, action must be initiated to develop and implement one.

"* Site- and equipment-specific procedures to control hazardous energy must be developed, implemented, and employees trained.

"• Review of electrical safe work practices should be conducted routinely.

Occupational Safety and Health Program Written Requirements

VA Directive 7700, and detailed implementing guidance contained in the VA Handbook 7700.1, were issued in July 1998 but had not been fully implemented throughout VHA at the time of visits to Medial Centers and Headquarters. 29 CFR 1960.6(b)(1) requires that the Designated Agency Safety and Health Official (DASHO) assist the Agency Head to establish an occupational safety and health policy to carry out the provisions of Section 19 of the Act, E.O. 12196, and 29 CFR Part 1960.

• The written occupational safety and health program must be revised as appropriate to facilitate implementation at medical centers.

Site evaluation teams documented that at VHA facilities, most employees were satisfied that their complaints regarding unsafe or unhealthful working conditions were satisfactorily resolved.

Site evaluation teams reported that VHA employee complaints, questions and inquiries regarding unsafe or unhealthful conditions were acted upon without delay by VHA supervisors and facility or VHA safety and health officials assigned to VISNs. Hazard assessment and actions to correct or eliminate problems were dependably undertaken in

a timely fashion; site evaluation teams documented that imminent danger conditions are

Appendix D - 5

abated immediately. The VHA NESC Safety Program Administration Guidebook Chapter 14, Hazard Awareness provided guidance regarding the delegation of authority to immediately stop work and the requirements for positive action in the face of imminent danger situations. Nevertheless, the site evaluator teams (and the evaluation group who worked with Headquarters staff) did not find procedures that delineated all of the requirements per 29 CFR 1960.28 associated with handling and documenting employee complaints.

Safety and health program procedures must delineate employee rights with regard to reports of unsafe or unhealthful working conditions, including the right to have the report documented in writing, that copies of the report are sent to local safety committees, and that reports are investigated and processed in accordance with timeframes listed in 29 CFR 1960.28. These procedures must be communicated to management officials and employees. VHA should consider whether procedures for filing anonymous complaints require further clarification and dissemination.

The majority of VHA staff interviewed did not feel that reprisal was a substantive threat Based on that level of confidence, it was not surprising that a majority of staff interviewed did not know what procedures were in place to ensure protection of their rights against reprisal. The VHA NESC Guidebook contained a detailed procedure for investigating and handling allegations of reprisal compliant with 29 CFR 1960.46(a), however those procedures were widely unknown.

Details of the protections afforded employees, as well as where to locate current procedures to be utilized for allegations of reprisal, must be implemented in a practical sense and disseminated in a way that will facilitate employee access.

A few of the VHA medical centers posted Notices of Unsafe or Unhealthful Working Conditions on bulletin boards or other areas where employee information is commonly posted instead of at or near the hazard. This provided adequate notice to facility employees of the hazard and abatement activity, but it did not provide the on-site alert to employees working in the immediate vicinity of the hazard.

* VHA management must remind facilities to post at least one copy of Notice(s) near the cited hazard(s) unless the nature of workplace operations prevent such postings (then post in a prominent place frequented by affected employees).

The site evaluation teams did not find VHA procedures that required that the local OSHA Area Office be informed by telephone or in person within eight hours of any accident fatal to one or more employees, nor of any accident resulting in the inpatient

Appendix D - 6

hospitalization of three or more employees. From our discussions with VHA managers and safety and health staff, appropriate and timely notification to OSHA has not been a problem.

VHA should establish written procedures for reporting information to OSHA in accordance with 29 CFR 1960.70 and disseminate the procedures.

Two site evaluation teams reported that a new VA-wide supervisory performance appraisal system has been interpreted at some VHA Medical Centers to require incorporation of safety and health performance requirements into general supervisory and administrative standards.

* The VA-wide performance appraisal system should provide sufficient flexibility to facilitate safety and health accountability in supervisory and managerial performance standards.

Neither VA Directive 7700 or Handbook 7700.1, or materials available from VHA, clearly delineated safety/health obligations involving Canteen operations at VHA facilities. Some Canteen operations could have direct effects on the safety status of VHA sites and employees.

* The relationships between Canteen operations and VHA safety and health programs, inspections, and operations should be clarified.

Occupational Safety and Health Program Resources

29 CFR 1960.7(c)(1) requires that federal agencies ensure that there are sufficient personnel to implement and administer the agency's occupational safety and health program at all levels and 29 CFR 1960.25(c) requires annual inspections and more frequent inspections where there is an increased risk of accident, injury or illness due to the nature of the work performed. At least two of the site evaluation teams documented that qualified VHA-Network level personnel with expertise in both safety-fire protection and industrial hygiene were not available to conduct AWEs at all sites. As discussed in the report at Program Implementation, Inspections and Appendix A, all AWEs are not completed each fiscal year.

VHA management must ensure that required safety and health services are delivered, including obtaining sufficient resources to perform this work

Whether AWEs are completed by VISN staff, other qualified staff to whom authority is delegated, contractors, or the processes involved are adjusted for efficiency without compromising quality, the decision is that of VHA management.

Appendix D - 7

Ergonomics Programs

At the time of the site visits, VHA was developing a source book on patient lifting practices designed to prevent back injuries.

To facilitate implementation of successful and efficient programs and maximize local efforts, a nationwide policy should be developed by VHA at the Headquarters level. Individual VHA medical center policies with specific program recommendations for work and divisions unique to each facility would be necessary.

* The National Engineering Service Center (NESC) Safety Guidebook Series for Industrial Hygiene contains a chapter of general guidance on ergonomics that covers back injury prevention as well as types of repetitive motion injuries. The following list of program elements for inclusion in facility policies is suggested, however, this general list must be tailored to the needs of VHA and individual facilities: • issuance of a written policy and program that confirms

management leadership and encourages employee participation;

• an effective injury reporting system and prompt responses to reports;

* clear program responsibilities; * regular communication with employees about the program; "* employee participation in the program (as demonstrated by

the early reporting of injuries) and active involvement by employees and their representatives in the implementation, evaluation and future development of the program;

"• effective management of back injuries and repetitive stress injuries;

"* job hazard analysis and control, including evaluation of controls to assure that they are effective;

"* training of managers, supervisors and employees (at no cost to these employees) in the ergonomics program and their role in it, and

"• program evaluation, as demonstrated by regular reviews of the elements of the program and of the effectiveness of the program as a whole, using such measures as reductions in the number and severity of employee injuries, increases in the number of jobs in which hazards have been controlled, or reductions in the number of jobs posing hazards to employees, and the correction of identified deficiencies in the program.

Appendix D - 8

Questions arose during the site evaluation visits regarding "light duty" and the problems that can arise when uninjured members of a staff are assigned to take on an increased amount of physically challenging duties as part of a plan to accommodate staff on "restricted or light duty." VHA management should identify and exjlore options that may mitigate potential adverse effects associated with shifting physically demanding duties among staff members. A substantive amount of attention has been directed to issues that affect members of VHA medical staffs. VHA should continue to address ergonomic challenges faced by food service and laundry staffs.

Violent Behavior Prevention Programs

Of the ten VHA medical centers visited by site evaluation teams, three did not have written programs in place and another site could benefit from training more staff in local the Violent Behavior Prevention program.

* VHA medical centers that have not issued written programs that delineate local progranxi provisions and procedures to minimize employee exposure to violent behavior should do so.

* VHA management should ensure that required employee training is completed.

* Employee involvement and representation should continue in the development and adaption of facility programs.

Opportunities to Share "Lessons Learned"

Seven site evaluation teams made recommendations regarding Chemical Health Hazard E. As noted earlier in our discussions and recommendations for additional training, the majority of requirements were documented in local programs and procedures. The issues were addressed at the medical centers during the visit or in follow-up work. Below is a list of the various recommendations; generally each recommendation applied to one of the ten specific sites visited. As appropriate, consideration should be given to implementing these, or similar, work practices at VHA medical centers. These site evaluation team recommendations could be used in the

development of safety and health program checklists, "lessons learned" pieces, and content for supervisory, safety and health professional, and front-line worker training (addressed earlier).

* Notify new employees at orientation training about their rights to access medical and exposure records under 29 CFR 1910.1020.

• Develop chemical laboratory inventory lists for review and approval by safety offices prior to establishing new laboratories (including research laboratories), projects, or work under new grants. This practice encourages

Appendix D - 9

early identification of hazardous chemicals to be used, need assessments for and placement of emergency eyewash and shower stations, hazard communication program updates and necessary employee training. Assess the need for and placement of permanently plumbed eyewash stations and emergency showers in various laboratories, clinics and morgues, and update facility assessments routinely. Complete all sections of the form used to document monitoring activities, including employee job descriptions and personal protective equipment (PPE) designated for use. Collect multiple samples during industrial hygiene surveys. Implement written plans when employee exposures exceed permissible exposure limits (PETs); forward written notices to employees regarding corrective actions taken to decrease exposures. Conduct noise sampling for employees working in kitchen or ground maintenance groups to determine if those employees should be included in the hearing conservation program. Review facility needs to determine if new or revised emergency spill procedures are necessary; train emergency spill teams as needed. Ensure proper labeling of hazardous waste containers. Ensure weekend emptying of biomedical waste management containers.

Formaldehyde: • Ensure formaldehyde sampling records document a description of the task

being evaluated, PPE used by the sampled employee, the employee's social security number (SSN), and job classification.

* Review and reassess engineering controls such as local exhaust systems, standard fume hoods, tissue grossing tables, particularly when employee exposure monitoring levels indicate that a short-term exposure limit (STEL) has been exceeded.

* Ensure documentation of in-service training. a Ensure appropriate labeling and signage in areas where formalin is used.

Nitrous Oxide: * Routinely conduct personal air sampling for compound contaminant in

operating rooms and dental suites. Ensure follow-up personal and area air

monitoring to evaluate corrective measures and efficacy of engineering controls. Performing leak checks on the recovery systems may be a useful supplement to current monitoring.

Asbestos: * Adopt Resilient Floor Tile Institute procedures as the standard operating

procedures for in-house floor tile removal.

Appendix D - 10

Methyl methacrylate: Conduct persohial and area air monitoring to verify the efficacy of engineering controls in the dental labs based on previously documented

employee exposure.

Methylene chloride: 0 Perform exposure monitoring in areas where employee exposure occurs.

Waste anesthetic gases: * Provide follow-up monitoring of halogenated anesthetic exposure where

the recommended exposure limit was exceeded, e.g., in the operating room during maintenance of anesthesia machine vaporizers.

Ethylene oxide: * Provide annual training in the areas required by the standard.

Lead: * Conduct facility-wide lead surveys, to include bulk sampling of paint (with

an analysis completed for both cadmium and lead) to identify paint containing lead.

* Conduct personal air sampling for maintenance employees performing cutting, grinding or sawing of metal door frames painted with lead paint.

Provide appropriate PPE. Naphtha: • Perform exposure monitoring in areas where employee exposures occur.

• Select PPE in accordance with workplace hazard assessment and PPE

selection guidelines.

Liquid nitrogen: * Ensure employees wear proper hand protection when dispensing liquid

nitrogen.

Ethanol: a Perform personal monitoring to determine exposure levels to ethanol.

As reflected in Appendix B, local emergency response programs met the needs of the

sites visited. Some of the recommendations from the site evaluation teams could be used

as a "lessons learned" piece:

0 The number of "disaster codes" in a VHA medical center plan should be

kept to a minimum to enhance employee use. When emergency response plans are developed, they must be finalized, signed and distributed.

Appcndix D - 11

Most of the local VHA safety and health or Environment of Care committees at facilities visited by site evaluation teams operated effectively. Further, the site teams found VHA medical center facility director support was at a level that facilitated local safety and health programs. A number of site evaluation teams had recommendations for local facility safety committee programs and facility director involvement and that may be useful for other VHA medical centers in terms of "lessons learned":

* The safety committee chairperson should be a top management official. * Committee members should be trained in general occupational safety and

health, the requirements of 29 CFR 1960, and the VA-VHA safety program. * Where not already in place, ad hoc groups of staff such as supervisors,

safety and health officials, workers' compensation coordinators, employee health staff and the like can be brought together to investigate accidents and illnesses on behalf of committees and VHA management.

"* Issues brought before committees should monitored and tracked with information about the problem, the person responsible for managing problem, the status of the problem, the date the problem is corrected and the results of post-correction monitoring.

"* Each member of the committee should receive a copy of the minutes of the meetings.

"* There should be a feedback mechanism to inform employees of actions taken by the committees.

* Facility directors should continue to involve employees and their representatives in finding solutions to employee safety concerns.

Site evaluation teams found that on-site occupational health services provided a wide variety of useful services. Recommendations were made by a few teams:

"* VHA occupational health services staff should work with the safety office and management to ensure provision of services to support the occupational health needs of employees (e.g, implementation of a comprehensive hearing conservation program for employees based on noise exposures, updating the respirator medical surveillance questionnaire).

"* When VHA employees are returned to work following a occupational injury or illness, maintenance of work restrictions determined by attending medical professionals should be ensured.

"• VHA supervisors and facility management should ensure that employees respond to appointments in a timely manner.

Appendix D - 12

Commonly Used Acronyms

AFGE ANA ASISTS AWE CDC CFR CNO DASHO EO EPA FAPO FDA FSHC JCAHO MSDS NAGE NCA NESC NFFE NFPA NIOSH OSH OSHA OWCP PEL PPD PPE PRCS SAFE SEIU STEL VA VAMC VBA VHA VISN VSSC WC/OSHMIS

American Federation of Government Workers American Nurses Association Automated Safety Incident and Surveillance Tracking System Annual Workplace Evaluation Centers for Disease Control Code of Federal Regulations Chief Network Officer Designated Agency Safety and Health Official Executive Order Environmental Protection Agency Federal Agency Program Officer, OSHA Federal Drug Administration Federal Safety and Health Council Joint Commission on Accreditation of Health Care Organizations Material Safety Data Sheet National Association of Government Employees National Cemetery Administration, US. Dept of Veterans Affairs National Engineering Service Center National Federation of Federal Employees National Fire Protection Association National Institute for Occupational Safety and Health occupational safety and health Occupational Safety and Health Administration, US. Dept of Labor Office of Workers' Compensation Programs, U.S. Dept of Labor Permissible Exposure Limit Purified Protein Derivative Personal Protective Equipment Permit-Required Confined Space Safety Automated Facility Evaluation Service Employees International Union Short-Term Exposure Limit U.S. Department of Veterans Affairs Veterans Affairs Medical Center Veterans Benefits Administration, U.S. Dept of Veterans Affairs Veterans Health Administration, US. Dept of Veterans Affairs Veterans Integrated Service Network Veterans Support Services Center Workers Compensation/Occupational Safety and Health Management Information System

Appendix E - 1

occupational safety and health program ...admninistration's (osha) evaluation of the department...

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