The Fit Between Ergonomics: the Job and the Worker Human Diversity - - PDF document

1

Ergonomics

Marge McFarlane, PhD, MT(ASCP), CHSP, CHFM, CJCP, HEM, MEP

Learning Objectives

• Define what a musculoskeletal disorder

(MSD) is and provide healthcare-related examples.

• Describe the ergonomic assessment process

and the tools involved.

• Identify strategies that can reduce MSD risk

to healthcare workers.

2

Ergonomics: Human Diversity and Change

The capacity to perform physical work demands varies considerably not only from individual to individual, but within any given individual over time… the limitations of this capacity are complex and interrelated.

(NIOSH)

3

The Fit Between the Job and the Worker

When there is a mismatch between the physical requirements of the job and the physical capacity of the worker… Work- Related Musculoskeletal Disorders can result (WMSD’s).

4

2 Common Terminology

• ASTD – Activity-related Soft Tissue Disorder
• MIS – MusculoSkeletal Injury
• OEI – Over-Exertion Injury
• WMSD – Work-Related MusculoSkeletal

Disorder

• RSI – Repetitive Strain Injury
• CTD Cumulative Trauma Disorder
• RMI or RMD – Repetitive Motion Injury/Disease

5

OSHA Definition

An injury or an illness of the muscles, tendons, ligaments, peripheral nerves, joints, cartilage (including interverterbral discs), bones and/or supporting blood vessels in either the upper or lower extremities, or back, which is associated with musculoskeletal disorder workplace risk factors and which is not the result of acute or instantaneous events (e.g., slips or falls).

6

OSHA National Emphasis Program

• CPL 03‐00‐016, June 2015
• Ergonomics related to patient handling
• HCW 6.4 work related injuries/100 FTE 2013
• 3.3/100 FTE all U.S. industries combined
• 2013, 34% of recorded HCW injuries

nationwide with days away from work were associated with patient interactions

7

“What factors contribute to WMSDs?

• The task is not designed to accommodate

the physical and/or cognitive limitations of the worker

• Poor body mechanics and personal

physical/health limitations

• Gradual wear and tear

8

3 Common Susceptible Areas and Disorders

9

Common Denominators to WMSDs in Healthcare

Affected Body Region Cervicothoracic Spine Scapulae / Proximal UE Distal UE / Wrist - Hand Lumbosacral Spine Activity and /

• r Posture

Repetitive and /

• r Sustained

Flexion Scapular Stabilization and / or Retraction Forceful and /

• r Sustained

Pinch / Grip

• Rep Motion

Patient Handling Unsupported Sit Repetitive and /

• r sustained flex

Healthcare Examples Surgery Lab Radio / Spec Dx Business Office Patient Care Materials

• Env. Services

Dietary Surgery Lab Bus Office Patient Care Patient Care Lab Transport

• Env. Services

Common Physiological Predisposition Postural Fatigue Deconditioning Reduced Stress Tolerance Accessory Weakness Postural Fatigue Deconditioning Overuse Onset >1 yr Inflexibility Deconditioning Postural Fatigue Onset > 1yr. 10

Healthcare Work and Workforce Characteristics

Work

• Wide diversity of

situational exposures

• Handling of unstable load

(human beings)

• Extended work hours

commonplace.

• Shift work commonplace.

Worker

• Career duration.
• Typically hired by skill

level vs. physical ability.

• “Self‐sacrificing”

mentality.

• “Western Medicine”

mentality.

11

Healthcare Lifting

• Lifting inanimate objects as done by support

staff versus

• Lifting a patient/resident
• Completely different set of problems
• patient movement
• patient fear/ apprehension

12

4

Cumulative Trauma Syndrome i.e. Overuse Injury

• Carpal Tunnel
• Disc Injury
• Shoulder Strain

Sources of Stress @ Work Contributors to Diminished Adaptability Patho- Mechanics Symptoms Injury Primary Stressors

• Force
• Posture
• Fatigue

Secondary Stressors:

• Environment
• Tools
• Processes

Other Stressors

• Conflict
• Culture

Environmental

• Temperature

Biological

• Strength
• Fatigue

Behavioral

• Habits
• Skills
• Attitudes
• Expectations
• Decreased

Circulation

• Tissue Irritation
• Overstrain of

Structure Systemic Tenderness Swelling Tightness Behavioral Compensate Posture Weakness Disuse of injured area

The CTD (Cumulative Trauma Disorder) Stress Response Model

Accumulation of Trauma

Compression

3400 – 6400N Limit

Anterior/Posterior Sheer

1000N Limit

Lateral Sheer

1000N Limit

14 One-Person Two-Person

Wheelchair w/o Arm to Bed Bed to Wheelchair w/o Arm Wheelchair to Bed Bed to Wheelchair Chair to Commode Commode to Chair 2000 3000 4000 5000 6000 7000 8000 9000 Minimum Compression Tolerance Limits Maximum Compression Tolerance Limits Adapted from Marras et al 1999

Ergonomics and Lifting

• ACGIH has proposed lifting guidelines in the

2001 TLV booklet

• Based upon
• duration of task
• frequency of lifting
• lifting height zone
• location of lift in relation midpoint of the body

16

5 Ergonomics Horizontal Location of Lift

• Midpoint - between the inner ankles to the

midpoint between the hands.

• Close lifts - origin <30 cm from midpoint
• Intermediate Lifts - origin 30 to 60 cm from

midpoint

• Extended Lifts - origin >60 to 80 cm from

midpoint lifting tasks should not be started at a horizontal reach more than 80 cm

17

Ergonomics Lifting Height Zones

• 30 cm above to 8 cm below shoulder
• Knuckle height to below the shoulder
• Middle shin to knuckle height
• Floor to middle shin
• No routine lifting tasks greater than 30 cm

above the shoulder or more than 180 cm above the floor

18

Ergonomics and Lifting

• Based on the location of the lift a acceptable

weight to be lifted can be determined

• However there are some limitations
• no factorials for age
• no factorials for sex
• based on lifting well defined static objects

19

• “The revised equation can be used to calculate a recommended weight limit

for many patient‐lifting activities when the following conditions are met:

• The patient can follow directions and is not combative.
• The amount of weight the caregiver handles can be estimated.
• The lifting is smooth and slow.
• The geometry of the lift ‐the body and hand positions in relation to the
• bject being lifted ‐and the amount of weight lifted are not subject to

change.

• For most patient‐lifting tasks, the maximum recommended weight limit is 35 lbs.‐but

even less when the task is performed under less than ideal circumstances, such as lifting with extended arms, lifting when near the floor, lifting when sitting or kneeling, lifting with the trunk twisted or the load off to the side of the body, lifting with one hand or in a restricted space, or lifting during a shift lasting longer than eight hours.”

NIOSH Lifting for Healthcare

20

6

Lifting Guidelines (Weight) For A Single Individual

Sex/Age No Restriction? Training Required? Lifting Aids Required? Not Recommended Male <50 0-40 lbs. 41-60 lbs. 61- 130 lbs. >130 lbs. Male =>50 0-30 lbs. 31-50 lbs. 51-105 lbs. >105 lbs. Female* <50 0-25 lbs. 26-40 lbs. 41-80 lbs. >80 lbs. Female* =>50 0-20 lbs. 21-30 lbs. 31-60 lbs. >60 lbs. * females who are pregnant should not lift more than 25 lbs. References: Applications Manual for the Revised Lifting Equation, US Department of Health and Human Services, DHHS (NIOSH) Publication 94-110, NTIS, Springfield, VA 1994. Grandjean, Etinne Fitting the Task to the Man, A Textbook of Occupational Ergonomics, 4th edition, Taylor & Francis Inc., Philadelphia, Pa 1988. The Ergonomics Group, Health and Environmental Laboratories, Eastman Kodak Company, Ergonomic Design for People at Work, Volume 2, Van Nostrand Reinhold, New York, NY, 1986.

at Work, Volume 2 ,Van Nostrand Reinhold, New York, NY, 1986.

21

Other References for Lifting Calculations and Solutions

• Cornell University Ergonomics
• Alan Hedge
• http://ergo.human.cornell.edu/
• Healthcare Specific Tools
• http://ergo.human.cornell.edu/cuHealthcaretools.html
• University of South Florida
• Tom Bernard
• http://personal.health.usf.edu/tbernard/ergotools/index.html

22

Ergonomics Program Elements

• Management Leadership
• Employee participation
• Ergonomic Assessment and Corrective

Measures

• Education & Training
• Medical Management
• Program evaluation

23

Management Leadership

• Management must commit to the program!!!!
• Personnel
• Funding
• Medical resources
• Corrective actions
• Early reporting
• No disincentives

24

7

25

Employee Participation

An effective ergonomic program is a two way venture

• Management willing to find and correct

problems

• Employees willing to accept honest evaluation

and corrections Employees must feel that the program will empower them to facilitate their

• wn wellness

Employee Participation (cont.)

The employee must feel confident that if they raise a concern that

• It will be taken seriously
• It will be evaluated without bias
• That appropriate corrective actions

will be implemented

• That there will be no repercussions

26

Education & Training

Education & training should be designed to impart the information you want the employees to know

• How to register a concern
• What procedures will be followed
• The likely outcomes
• How successful is the program

27

Education & Training

Education & training should also be one of the interventions (corrective measures) implemented based on your assessments. We’ll revisit this later!!!!

28

8 Red Flags

• Changing workforce due to turnover,

seasonal patterns, aging, handicapped employees, operations with staff shortages.

• Work pace factors such as high overtime use

and/or shift work.

• Job task factors such as material handling,

repetitive motion, fine motor and/or static postures.

29

Ergonomics Plan Benefits to Healthcare

• Reduction in costs associated with lost time, lost

productivity and employee turnover due to injury.

• Improved patient care systems thereby

enhancing overall output and safety.

• Improved employee morale and well-being.
• Avoid unnecessary exposure to regulatory

pressures.

30

Ergonomics Survey

• The survey should start with an explanation of

the purpose and the procedures that will be followed

• An explanation of the ergonomics principles

should be discussed

• Observations should be made in a manner so as

the employee’s actions are not modified

31

Direct Observation Document the …

• Weights of materials handled
• Facility and process flow using a rough sketch*
• Workforce employed
• Scheduling of tasks (i.e. variable, constant,

rotation, full-time, part-time)

• Awkward/repetitive/stressful positions
• Pace of the work performed
• Time in a certain position

*2 individuals, still photos and/or video optional. 32

9 Direct Observation Document the …

• Tools used including grips, handles,

weight, texture, frequency of use

• Heights of applicable work surfaces and

reach distances

• Names of tasks, jobs, and departments in

the order they appear on the video

• Work-site conditions (operating space,

lighting, noise)

• Easy corrections made
• Any other relevant information

33

Easy Corrections

Fix the easy things first

• Allows for employee feed back on the

changes being implemented

• Budget and trial costly items lift equipment
• Ask the sales rep for demos to try for

several days Let me adjust your chair for you?

34

Documentation Tips

• Standard forms in a format agreeable to

treating physicians

• Include risk rating
• Summary of survey findings
• Write the standard job procedure
• Review the analysis periodically

35

Risk Rating

• Rate the relative ergonomic risk based on
• the findings of the survey
• the facility’s incident, work injury
• production output history variances
• The ranking should be performed by or in

conjunction with a person with credentials and training to evaluate the findings

• The risk ranking procedure should be well

documented

36

10

37

• Tape measure
• Scale/Force Meter
• Camera/video camera
• Light meter/Noise meter
• Goniometer
• Other devices as appropriate

Ergonomics Assessment Tools Needed Ergonomics Assessment Report

The report should be directed to the supervisor or administrator with a copy to the physician if that is in the arrangement

• Report not routinely shared with the employee

directly

• Includes controls for the hazards/problems
• Avoid recommending a specific brand of device
• Recommendations should be such that they

can be easily extrapolated from the remainder

• f the report if necessary

38

Job Analysis by Discussion

• Method useful for…
• New jobs
• Jobs done infrequently
• When it would be hazardous or impractical

to observe a job

• Follow the same procedures for direct
• bservation, except:
• Select several workers with appropriate

knowledge and experience

• Talk over the job and agree on the

sequence of steps

39

Ergonomic Assessment

• Worker-Based Assessment
• Process-Based Assessment
• Worksite-Based Assessment

Another form of job hazard analysis!

40

11 Worker‐based Assessment

Human Factors

• Age
• Gender
• Size / Shape
• Strength
• Flexibility
• Endurance
• Mental Capacity
• Attitude

Risk Factors

• Poor fitness level
• Arthritis
• Diabetes
• Past injury
• Obesity
• Stress
• Poor Technique
• Lack of Training

41

Example: Behavior Patterns

The method employed vs. the tool Keyboarding Style

• Wrist Position
• Typing Proficiency/Economy
• Force of Strike
• Extensive vs. Limited Use of Mouse

42

Keying and Keyboards

43

Worker‐Based Assessment

• Head Bent
• Head turned left or

right

• Shoulders hunched
• Elbows Bent <70

degrees

• Wrists bent up or down
• Arms not supported
• Arm working at angles

left or right

• Low back not supported
• Feet not flat on floor
• Infrequent change of

position

44

12 Bad Posture Affects Multiple Areas At Once

45

Posture? Support?

46

Somewhat better posture but chair back is not supporting back!

47 48

13 Process‐based Assessment

Risk Control Factors

• Controlled work pace?
• Are handlings and

distances traveled minimized

• Are pinch/grip tasks

and/or awkward positions minimized?

• Are difficult tasks

performed by teams?

• Is process intuitive?

Typical Situation

• Dictated by medial status and

caseload

• Patient privacy concerns

dictate segregated space

• Surgery, medication delivery,

diagnostic and laboratory environments can have pinch‐ based issues

• Staffing considerations and

emergencies may preclude multiple team members Has the process and equipment been designed to minimize risk of WMSDs?

49 50 51 52

14

53 54

The Questions to Ask

• Can this be engineered out?
• Is this a value add to the output?
• Is there solutions on the horizon?
• What is the ultimate cost (both equipment and

risk)?

• Who has influence over this work?

55

Worksite-Based Assessment Checklist

• Is equipment operating at maximum capacity?
• Is equipment in good operating condition?
• Is equipment serviced regularly?
• Has the proper safety equipment been provided?
• Is the machine the best for this operation?
• Can you make use of the machine’s or operator’s

“idle” time?

56

15 Worksite-Based Assessment Checklist (cont.)

• Are proper equipment and tools available?
• Have they been supplied to operators?
• Are equipment and tools properly pre-

positioned to permit effective work?

• Is all available space used?
• Are aisles wide enough?
• Are work areas and storage areas clean and
• rderly?

57

Worksite-Based Assessment Checklist (cont.)

• Is the surface of the work area or equipment okay

as far as hardness, elasticity, color, smoothness, etc.?

• Is lighting sufficient?
• Is there glare?
• Are controls, dial, panels, displays, etc., legible,

understandable, and adequately lit?

• Are there sharp edges on tools and equipment?
• Does the ambient temperature, sound levels, air

quality, etc. affect operations?

58

Workstation‐based Assessment Examples

Risk Control Factors

• Is adequate space available

to perform task?

• Is work surface design

suitable to task?

• Is proper safety equipment

available? Utilized? Typical Situational

• Work area congestion due to

equipment, lines, monitors, etc.

• Rapid technology evolution in

aging facilities = retrofit

• Labor‐saving equipment often

neglected due to added time factor and “informed incompetency”

59

Program Interdependency Design/Redesign is Key

• If the work-site is designed poorly, hiring fit

people will not help...

• If physically capable people are hired, but

choose unsafe work practices, their safety cannot be assured...

• Education in the face of work that is too

physically difficult will not help...

60

16 Work‐Station Design: Basic Elements

61

Chair Design and Adjustments

• Seat Height
• Seat Angle
• Back Angle
• Lumbar Adjustment
• Back Height
• Seat Slide
• Tilt Tension
• Tilt Stop Control
• Arm Height/Width
• Arm Tilt
• Comfortable Fit
• Height Adjustable
• Large/Small Enough
• Comfort over time
• Support in Recline
• 5 pedestal base
• Armrest? Needed?
• Chair Covering
• Footrest
• Adjustable pan tilt

Adjustments Considerations 62

Keying and Keyboards

63

Workstation Design

64

17

Monitor too high? Chair too low? Arm extended unsupported? Legs tucked?

65

EKG probe – pinch grip?

66 68

18

Pistol grip “add‐on” to microtome handle.

69

Automated Microtome

Hierarchy of Control

• Engineering Controls
• Patient/material

handling devices

• Ergonomic tools
• Equipment ratios
• Lift teams
• Programs
• Purchasing policies
• Proactive design
• Administrative/Work

Practice Controls

• Job rotation
• Job enlargement
• Break schedules
• Length of shift
• Staff levels
• Adequate training
• PPE (e.g., footwear)

Primary Solutions Secondary Solutions

Adapted from Health Care Ergonomics Dec 2005, Lynda Enos; www.humanfit.com. 71

19 Primary Solutions Programs & Policies

• Bariatric Programs
• Fall prevention programs
• Purchasing policies (proactive)
• Proactive facility design

Adapted from Health Care Ergonomics Dec 2005, Lynda Enos; www.humanfit.com. 73

Skills Training

• Identify Objective
• Develop Collaborative Training
• Complete Training
• Evaluate Initial Success
• Rounding Program
• Re-Evaluate

74

Secondary Solutions Training

• Job/task rotation
• Equipment use/Postural Awareness/Body Mechanics
• Adjust chair and computer to proper alignment
• Break Utilization / Exercise Performance
• Alternate work activities throughout the day,

changing tasks every 2 hours for a period of 10 minutes

• Take 1 minute breaks every 20 minutes of

continuous work to relieve stress and perform exercises

• Use of algorithms / patient assessment methods
• Healthy Lifestyle Participation

75

Task Rotation

• Within Job Title:
• Interpose movement between static postures.
• Break up stressful activities into smaller

episodes of time

• Coincide daily personal peak performance

times with most difficult tasks

• Amongst Job Titles:
• Pool similar activities and rotate persons to

complete

• Incorporate essential and peripheral duties

philosophy towards reducing overuse

76

20

• Evaluate work, injury records, survey staff
• Develop training specific to identified risk

Practical Example of Training

• Implement Training and Evaluate
• Implement Follow Up Plan
• Reevaluate work, injury records, survey staff

Practical Example of Training (cont.) Other Secondary Solutions Medical Management

• Medical treatment alone just like corrections

to the work-site alone may not correct the employees problems but a coordinated effort has proven to be successful

• Coordination of efforts gives the physician

insight into the work-site situation and corrective actions recommended

79

Return to Work Evaluations

• Provide the physician with detailed

information regarding work capacity to encourage early work release

• Identify the disposition of the worker as

putting forth maximal effort, magnifying pain levels, or malingering

• Identify the magnitude of physical impairment

to assist with case progression

• Assist with identifying possible

accommodations necessary for work return

80

21 Assess Actions Document Improvement

• Were the recommendations carried out?
• Continue to monitor decision
• Is the problem resolved?
• Complete a behavioral audit to see if trained

changes are taking place

• Measure impact: postural changes,

productivity/quality improvements, reduction in worker’s comp costs Supervisor should be involved!

81

The Action Plan: A Repeatable Cycle

• Set a foundation attaching ergonomics to all

major new products by creating task forces that do ergonomic design and review

• Spread the training in a cascaded format to

as many employees as possible

• Embed the program by having employees

participate in all levels of ergonomic function that directly affect them

82

Program Evaluation

Periodic evaluations of the whole program should be conducted by the HEM, ergonomist, safety professional, industrial hygienist, human resources and/or medical personnel to ensure that the program is providing the necessary information and

• utcomes desired

83

Questions?