916654
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WHSXXX10.1177/2165079920916654Workplace Health & SafetyWorkplace Health & Safety
vol. XX  ■  no. X
Workplace Safety
A Strategy for Enterprise Risk Management
Janet G. Jule, DNP, RN1,2
Abstract: Background: Injury and illness incidence rates
continue to be higher in healthcare facilities than in the
manufacturing environment despite improvement efforts
implemented by various organizations. The prevention of
workplace injury and illness is a challenge for facilities due
to reasons including exposure to body fluids, infectious
diseases, and patient handling activities. The purpose
of this project was to reduce workplace safety-related
incidents and prevent employee injuries through leadership
involvement in employment of preventive, directive, and
corrective controls. Methods: A tertiary medical center in
California experienced 114 accepted injury claims in 1
year. As a response to the problem, the medical center
developed a safety management system consisting of a
process for engagement between leadership and staff
members/employees to increase accountability and reduce
injury risks. Findings: The medical center achieved a 59%
reduction from 114 to 67 injury claims over a period of 2
years and a two-point increase in engagement scores from
both leaders and staff members. Conclusion/Application to
Practice: The development of a safety culture starts with
leadership behavior, establishment of clear safety processes,
and hazard mitigation activities. Workplace safety is a
shared responsibility between frontline staff managers and
leadership within an organization. Senior leaders must serve
as role models to promote a speak-up culture to support
safe work practices.
Keywords: workplace safety, risk management, work
injuries, work-related injury, workplace injury, patient
handling
Background
According to the Bureau of Labor and Statistics, U.S.
Department of Labor (2018), there were 2.8 million nonfatal
workplace injuries and illnesses reported by private industry
in 2017, and 51,380 of which were cases reported by
DOI: 10.1177/2165079920916654. From 1University of San Francisco, and 2Kaiser Permanente. Address correspondence to: Janet G. Jule, School of Nursing and Health Professions, University of
https://doi.org/
San Francisco, San Francisco, CA, USA; email: jgjule@usfca.edu. Kaiser Antioch Medical Center, Antioch, CA; email: janet.g.jule@kp.org.
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Copyright © 2020 The Author(s)
Workplace Health & Safety
Professional Pr actice
hospitals resulting in days away from work (Bureau of Labor
and Statistics, U.S. Department of Labor, 2018). Nursing
assistants and nurses had the highest injury rates, related to
patient handling and workplace violence, of all occupations
as reported by 112 facilities participating in the Centers for
Disease Control and Prevention’s (CDC) Occupational Health
Safety Network (OHSN) from January 1, 2012 to September
30, 2014 (Gomaa et al., 2015). Hospitals reported an injury
and illness incidence rate of 129.8 cases per 10,000 full-time
equivalent (FTE) workers in 2017 compared with 93 cases
per 10,000 FTE workers in the manufacturing industry
(Bureau of Labor and Statistics, U.S. Department of Labor,
2018). In addition, there were 4,674 injuries related to patient
handling and movement reported to the OHSN from 2012 to
2014, equivalent to a rate of 11.3 incidents per 10,000 worker
months, and lifting equipment was not used in 51% of the
reported patient handling incidents (Gomaa et al., 2015).
Studies have shown that increased access to ceiling lifts and
other patient handling equipment improves efficiency and is
directly related to a decrease in incidence of musculoskeletal
disorders (Enos, 2018). California’s safe patient handling
regulation requires every hospital to have adequate
equipment available for safe patient handling, have a robust
training program, and review the plan annually (California
Department of Industrial Relations, 2016). Every employer is
held responsible to comply with the Occupational Safety and
Health Act of 1970 and may be held legally liable for
employee sufferings due to violation of the Occupational
Safety and Health Administration (OSHA) standard (Pozgar,
2016). As of January 2018, the penalty fine is US$12,934 per
violation and US$129,336 per willful violations (OSHA, 2018).
Organizations are also at risk of criminal litigations if a willful
violation due to lack of prevention, despite knowledge of
risks, result in an employee’s death. The criminal penalty for
a willful violation of OSHA was amended to be punishable
by fines up to US$500,000 for organizations (Conn &
McMahon, 2016).
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Workplace Health & Safety
Applications to Professional Practice
Promoting a culture of safety is the responsibility of every
member of an organization. Leadership behavior and
employee engagement are key in supporting safety
processes and sustaining results. Identification of risks
and prevention of injury are important in the field of
occupational health and environmental nursing. It is
crucial for organizations to focus efforts on the reduction
of injuries experienced by healthcare workers. This
improvement project addressed how one medical center
dedicated resources to make employee safety a priority
and understand that results are obtained over a period of
time. It is important for the leadership team to set a
realistic target and support managers and frontline staff
members in achieving this targeted goal.
Nursing and residential care facilities continue to have the
highest incidence rate of workplace injuries and illnesses
despite safety initiatives that are currently in place (Bureau of
Labor and Statistics, U.S. Department of Labor, 2019).
According to a Northern California (NCAL, 2016) hospital
system’s workplace safety report, one of its facilities
experienced as high as 114 injury claims in a period of 1 year
from October 2015 to September 2016, at a rate of 10 injuries
per 1,000 employee productive hours (NCAL, 2016). Although
the injury claims decreased to 93 occurrences the following
year, the continued high injury rate is costing the organization
between US$3.6 million and US$4.4 million for both direct
and indirect costs using an estimated cost of a medically
consulted injury claim at US$39,000 per claim (National Safety
Council, 2019).
Workplace injuries continue to pose challenges to
healthcare organizations. Although hospitals have reduced the
rate of worker injuries over time, construction and
manufacturing industries have surpassed the improvements
made by hospitals (OSHA, 2013). There are unique hazards
inherent among healthcare workers and those who work in a
hospital setting. These hazards contribute to an increased risk
for injury and illness. Some of the hazards include exposure
to infectious medical conditions and contaminated sharp
instruments and devices, lifting and repositioning patients,
and caring for violent and combative patients (Bureau of
Labor and Statistics, U.S. Department of Labor, 2019). These
unique circumstances led multiple national groups and
associations to learn more about contributing factors and
promote safe practices for healthcare workers.
McCaughey et al. (2016) used the modified National Institute
for Occupational Safety and Health (NIOSH) framework to
analyze findings, specifically the organization of work that
includes both management or supervisory work practices and
work design. The authors endorsed the use of the NIOSH
framework in the identification of antecedents to injuries so
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Mon 2020
organizations can link their safety programs to injury prevention
approaches and leaders can support the development of safety
structures and facilitate performance improvement initiatives
surrounding workplace safety.
It has been shown that organizational and supervisory
support play an important part in the prevention of
workplace injuries and promotion of worker safety. Tveito
et al. (2014) emphasized the importance of having a
nurturing and supportive working environment and better
organizational practices and policies to reduce injuries and
disability costs for nurses. An analysis of the nursing
assistant survey showed that employee training on safety
practices is not enough to prevent injuries, and that
supervisor support and employee engagement have an
indirect relationship with injury incidence in the nursing
assistant group (McCaughey et al., 2014). Peer feedback,
combined with supportive empowerment and adequate
training on equipment use, has been proven to reduce injury
rates (Cortez et al., 2017). In fact, the direct relationship
between ethical leadership and occupational safety
outcomes is apparent in high-reliable organizations
(Freiwald et al., 2015). For example, the relationship
between an organization’s ethical climate and its employees’
safety motivation or engagement is one that can be changed
and influenced positively by the organizational leaders.
Leadership behavior is important in transforming the culture
through role-modeling of safe behaviors and deliberate actions. A
cross-sectional survey conducted in Belgium revealed that
transformational leadership had a positive impact on nurses’ safety
practices and compliance with safety (Lievens & Vlerick, 2014).
In 2011, the NIOSH launched the Total Worker Health
(TWH) Program. This program combines policies, programs,
and safe practices to integrate job hazard mitigation, and illness
and injury prevention (CDC, 2018). It emphasizes the
importance of a consistent process for job hazard identification
and oversight to promote and support personal and
departmental safety.
The Harvard Chan School Center for Work, Health, and
Well-being developed the Workplace Integrated Safety and
Health (WISH) assessment, which is an instrument to measure
an organization’s workplace policies and programs that includes
six constructs, namely, leadership commitment, participation,
policies and programs that foster supportive working conditions,
comprehensive and collaborative strategies, adherence, and
data-driven change (Sorensen et al., 2018). The purpose of this
project was to reduce workplace safety–related incidents and
prevent employee injuries through leadership involvement in
employment of preventive, directive, and corrective controls.
Methods
The continued high rate of workplace injury at a northern
California medical center posed a risk to the organization
and a challenge for the leadership team. This project aimed
to utilize evidence-based risk mitigation strategies to
vol. XX  ■  no. X Workplace Health & Safety

Table 1.  Workplace Safety Risks

Risk category Short term Medium term Long term

Financial
  1. C
 ost of workplace injuries 1. Days away from 1. Worker’s comp 1. Any associated fines;
work claims legal fees
  2. Expenses related to backfill and 2. Replacement 2. Contract/agency staff 2. Consultant/educator
retraining upon return to work fees fees
Infrastructure
  1. Presence/absence of processes 1. Training modules— 1. Adjunct training (i.e., 1. Annual or periodic
supporting safety such as training and up-to-date content hands on) training
education, leader support
  2. Job hazard analysis reliability 2. Software/database 2. Timeliness of analysis 2. Automation
Reputational
  1. Poor public perception of organization 1. Social media posts, 1. Ongoing press 1. Community safety
due to negative social media news release, public programs
relations
  2. OSHA compliance 2. Noncompliance to 2. Leader training on
regulations OSHA
Marketplace
  1. Competitors offering more safety 1. Presence of another 1. Part-time work in 1. EE transfer/resignation/
equipment and training hospital in area another facility loss of manpower
  2. Employees favor competitors or other 2. Other careers 2. Further education 2. Change of career
jobs

Note. OSHA = Occupational Safety and Health Administration.

decrease its worker injury rate of 10 injuries per 1,000
productive hours in 2016 by at least 20% to eight injuries per
1,000 productive hours by the end of performance year 2018,
from October 2017 to September 2018. The high-risk
departments in the medical center, including environmental
services, inpatient nursing departments, and perioperative
departments, were asked to participate in current assessment
and action planning to improve workplace safety and reduce
the incidence of the top 3 injuries: overexertion, contact with
objects, and patient handling.
To achieve The Joint Commission’s (2012) goal to promote
patient and worker safety, the medical center embarked on a safety
journey to assess its risks and other antecedents to workplace
injury. Table 1 describes short-, medium-, and long-term workplace
safety risks across risk categories such as financial, infrastructure,
reputational, and risks within the market place. One of the
initiatives implemented by the facility was the consistent and
thoughtful completion of job safety analysis (JSA) tools for every
employee in each job category within the workplace.
The previous process of JSA completion was inconsistent
and not purposeful. There was no engagement from the
employees and the hazards identified were generalized to a
larger population rather than specific to the department’s risks
and environmental factors. The JSA tools were made available
in the medical center’s intranet site and were preloaded with
set templates based on common tasks performed and
associated hazards. There was also an option to customize the
tool and add department-specific mitigation activities.
Managers identified potential job hazards and discussed
mitigation and prevention activities with each employee. In
turn, the employees’ acknowledgment of known risks
heightened their awareness to safe practices.
The newly implemented process engaged employees by
having them help identify their own job hazards and develop
action plans to decrease or eliminate them. Employee
engagement was reflected in the employee satisfaction survey
administered in the medical center 3 months after implementation
of new standards and structures for workplace safety.

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Workplace Health & Safety
In addition, the employee health and safety department, in
partnership with an ergonomist, assessed the work environment
for each job category to help identify ergonomic-related injury
risks and eliminate them. Prevention of accidents and injuries
was important in promoting the morale of staff and improving
productivity.
The previous training schedule was scheduled once a year,
typically in October, to capture all employees. This annual training
schedule created gaps. For purposes of this project, the medical
center put directive controls in place specific to safe patient
handling trainings. There was a regular cadence of training
sessions offered weekly and all direct care staff members were
required to attend each year near or prior to their annual
performance appraisal dates. Leaders and educators leveraged the
safety trainings to highlight policies and procedures on ergonomic
principles, proper use of personal protective equipment and safe
patient handling equipment, stretch exercises, and risk
identification and injury prevention. The clinical education
department and workplace safety champions partnered together
and provided training sessions to all direct care staff.
The medical center instituted corrective controls that were
exercised either after an incident had occurred and root causes
had been identified or as a proactive intervention when risks
were recognized. For example, environmental service workers
used visual signs and pop-up cones to caution staff of wet
floors or presence of biohazard or noxious substance. All
frontline staff members were required to use personal
protective equipment and safe patient handling equipment
with every patient mobility task, and the manager ensured the
rotation of staff assignment for fair distribution of work and to
prevent continuous exposure to physical activity and repetitive
motion. The inpatient units assessed safe patient handling
equipment inventory to inform purchase of additional
equipment as needed, resulting in the testing and purchase of
additional bed repositioning sheets. In 2017, ceiling lifts had
been installed with the goal of increasing convenience and
easy access to the lifts; leaders reinforced use of the lifts
through additional trainings offered in 2018.
The medical center conducted several safety stand down
events where senior leaders came to various units during
department huddles and had engaging conversations with staff
members on topics such as high hazard activities, safe practice
of pausing, planning, and preparing, and speaking up for safety.
All leaders, including the executive chiefs, incorporated daily
and weekly department safety rounds as part of their standard
work and documented them in the medical center’s rounding
intranet site. In addition to department rounds, leaders came
together every morning for a safety briefing where safety issues
were raised for the past 24 hours with the goal of raising staff
awareness.
Both outcome and process measures were monitored to
determine progress and opportunities for improvement. The
reported injuries, both first aid only and injury claim, were
monitored as outcome measures. The rate of injury was
defined as the number of accepted injury claims per 1,000
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productive labor hours occurring in the performance year for 2
years from October 2016 of the previous calendar year to
September 2018.
Findings
The baseline performance used for the improvement project
was the number of employee injuries from 2016 to 2017, with a
total of 114 injury claims at a rate of 10 injuries per 1,000
productive hours. The injuries ranged from being struck by an
object, needlestick or sharps injuries, eye splash, muscle strain
due to material or patient handling, and slips/trips/falls.
The medical center also monitored process measures such as
employee peer-to-peer safety conversations, occurrences of leader
safety rounds, JSA completion rate, and documented use of safe
patient handling equipment. The employee safety conversations
and leader rounds are reported through the medical center’s
database and have exceeded the target of 85% for safety
conversations and 90% for leader rounds every month for the past
year. The medical center’s current JSA completion rate was at 93%
as of May 2019, compared with a 45% completion rate in May
2018. Improvement in employee engagement as evidenced in the
employee satisfaction survey was represented by a two-point
increase in the employee engagement scores in comparison with
baseline. Finally, the electronic medical records showed a 175%
improvement of documentation of equipment use to 74% in April
2019, compared with 27% in March 2018.
At the end of performance year 2018, the medical center was
able to reduce its incidences of injury claims to 67 and
decreased the rate to 8.9 injuries per 1,000 productive hours.
The first quarter results for 2019 showed a total of 14 injury
claims at a lower rate of 6.6 per 1,000 productive hours.
Discussion
The promotion of workplace safety in this medical center
started with leadership commitment and support for a
speak-up and safe culture. The reduction in workplace injuries
was realized once leadership efforts were put in place to
implement combined preventive and corrective actions
addressing identified risks over a period of time. The leaders
modeled safe behaviors through safety messages and reminders
and purposeful safe actions. The result trend only included 2
years of data and will need to be monitored to ensure
sustainability. In the meantime, the heightened awareness of all
employees and leaders to existing job hazards was a change in
mind-set reflective of the developing safety culture and values.
Some of the key challenges in the culture change journey
included leadership turnover in multiple departments, which led
to inconsistent processes for hazard identification and
mitigation, and employee training on safe practices. Leader
standard work is a phrase that describes a set of established and
routine tasks where managers and supervisors engage in
proactive work to improve processes in the department,
mitigate risks, and support the frontline staff members rather
vol. XX  ■  no. X
than troubleshoot issues. The lack of leader standard work
played a role in the reactive practices rather than proactive and
preventive actions. The leaders were engaged in non-value-
added tasks and had daily variation in schedules. The
development of leader standard work allowed for coaching time
by leaders and rounding on the departments to meet and coach
frontline staff.
Conclusion
An engaging transformational leader who shares a vision of
safety will attract followers who ultimately develop a sustainable
commitment to injury and accident prevention.
Employee engagement, together with leadership behavior,
was necessary in upholding a culture of safety. Peer-to-peer
conversations and feedback also a role in fostering safe
behaviors and promoted a speak-up culture where everyone is
encouraged to stop the line and speak up if they feel that
safety of the patient or a coworker may be compromised.
Development of a safety culture leading to decreased patient
harm and decreased worker injuries was the result of a united
vision and the collaborative work between leaders, managers,
and frontline staff members. The role of the executive leader
was vital in shaping the future of safety in every organization
through role-modeling and positive reinforcement.
One characteristic of a highly reliable organization was its
preoccupation with failure, where every employee thinks of
ways their work processes may break down so this breakdown
can be prevented. This trait compels leaders, managers, and
frontline staff to constantly look for risks and mitigate them
before an accident occurs. Safety must be ingrained in the
organization’s culture where it serves as the driver of every
deliberate activity. Leadership was key to this goal.
Conflict of Interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Janet G. Jule https://orcid.org/0000-0002-7932-5881
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Author Biography
Janet Jule is the Chief Nurse Executive at Kaiser Permanente
Antioch Medical Center. She has over 25 years of nursing
experience in various roles as a bedside nurse and as a nursing
leader. She has a strong patient-centered focus and has been
effective in leading her teams to a culture of service excellence,
quality, and safety.