Employment Injuries: Compensation and Rehabilitation of Workers

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1 Employment Injuries: Compensation and Rehabilitation of Workers CHAPTER 4 Audited Entities : Commission de la santé et de la sécurité du travail (CSST) Ministère du Travail, de l Emploi et de la Solidarité sociale (MTESS)

2 Context The CSST is the organization to which the government entrusted the administration of the Occupational Health and Safety Plan Act respecting occupational health and safety (AOHS) Act respecting industrial accidents and occupational diseases (AIAOD). It compensates workers who have sustained an employment injury. It entitles workers to physical, social and vocational rehabilitation services. In 2013, 88,368 workers were admitted to the plan, and nearly $1.9 billion was paid in benefits. The plan is mainly funded by employer contributions. Its activities are divided into 20 regional branch offices. Ch. 4, Par. 1-14, 86 2

3 Context (cont.) Aside from the CSST, the main actors are: the Bureau d évaluation médicale (BEM) whose management is entrusted to the MTESS the attending physician the Commission des lésions professionnelles (CLP). The BEM oversees the application of the medical assessment procedure provided for in the AIAOD. It intervenes to provide medical advice in cases where there is a difference of opinion between the worker s physician and the physician designated by the CSST or the employer on one or several of the five matters provided for by the AIAOD. It can also provide advice on these matters at the CSST s request even in the absence of a contestation. Ch. 4, Par. 15, 16, 138 3

4 Our Audit Objectives: Obtain the assurance that the structure and mechanisms implemented by the CSST ensure good governance of activities related to compensation and rehabilitation Obtain the assurance that the CSST efficiently, effectively and fairly manages activities related to compensation and rehabilitation Obtain the assurance that the MTESS administers the medical assessment mechanism efficiently Our work was carried out at the CSST and the BEM includes, among other things, the examination of 60 files in 4 regional branch offices also includes the examination of 38 files related to workers who have died since 2009 from an employment injury. Ch. 4, Par. 22, 74, Appendix 1 4

5 Audit Results Good practice Deficiency Evidence Consequence 5

6 Compensation and Rehabilitation Process According to a CSST analysis based on a follow-up of the population that sustained an employment injury in 2007 a significant proportion of costs related to income replacement indemnities (74%) is attributable to a minority of workers who sustained a serious injury or who have risks of chronicity (7%). Ch. 4, Par. 21, 70, Figure 3 6

7 Governance The CSST does not sufficiently play the expected role of change agent with respect to updating the Occupational Health and Safety Plan in relation to modern labour market issues. Some important issues have been discussed over the years without coming to a clear and shared decision about them as to what orientation to favor. For example: Adaptation to the current health system: services offered by private and public organizations, availability of generic drugs Adaptation of the plan to modern labour market challenges: definition of employer, worker and employment relationship Evolution of injuries and occupational diseases based on current scientific knowledge Significant increase in the volume of CSST decisions contested, namely an increase of 49% between 1999 and 2014 Ch. 4, Par

8 Governance Structural Elements Elements of the CSST s governance structure complicate the reaching of agreements and the breaking of deadlocks on important issues for the organization. The BOD comprises 15 members: the president and chief executive officer, 7 members representing workers and 7 representing employers. Before each session, the parties meet in a caucus to agree on the position to uphold. Only the files that were the subject of a prior agreement between the parties are presented to the BOD for adoption. The exercise of the president s casting vote has rarely been used since the CSST was created. For example: regulation on the preventative management of asbestos Not debated by the BOD between 2006 and 2012 Required 10 years of work before it was adopted in Ch. 4, Par

9 Governance Organization of the BOD s Work The organization of the work carried out by the BOD and the technical committees is inadequate in some respects, namely with respect to work planning and follow-up. The BOD has not clearly determined priority issues or developed a work plan to reach consensus about them. For the technical committees, there are no set deadlines or targets to be achieved. No reporting is presented to the BOD unless the parties have reached middle ground beforehand. For example: regulatory standards on chronic exposure to noise in the workplace They have not changed since Discussions had been noted in the documents of a committee since 2005 without leading to clear positions as to whether there was a need to amend the current regulation. Ch. 4, Par

10 Return-to-Work Intervention Practices Interim Return-to-Work Solutions More effort must be put into education and promotion among employers and workers to encourage the implementation of interim return-to-work solutions. Few actions are implemented to inform employers of steps to follow, their responsibilities and the potential benefits of a interim solution (ex: awareness-raising campaign). Practitioners are not sufficiently equipped to raise employers awareness of the financial and social impacts of an employment injury (ex: potential cost savings). The practitioner did not play the expected coordination role between the employer and the worker and did not intervene in a sufficiently timely manner in more than half of the files examined. Ch. 4, Par

11 Return-to-Work Intervention Practices Return-to-Work Plan The return-to-work plan does not ensure the desired coordination and does not provide an overall view of the file, which would facilitate the choice of actions to be implemented. This plan aims to determine what the worker, the employer and the practitioner have agreed to do to ensure the best progression towards a return to work. It is often difficult to identify the worker s contribution to the plan, and nothing indicates that this plan has been clearly communicated to the worker and employer. Several practitioners see the return-to-work plan as an administrative or control tool; the pursued objectives are sometimes mere reminders of common tasks to be accomplished. In several of the plans examined, the means chosen are either insufficient to meet the pursued objective or inconsistent with the objective. Ch. 4, Par

12 Return-to-Work Intervention Practices Determination of Suitable Employment An employment is suitable if it respects the five criteria provided for in the AIAOD: (1) an appropriate employment (2) that allows a worker who has suffered an employment injury to use his remaining ability to work (3) and his vocational qualifications, (4) that he has a reasonable chance of obtaining (5) and the working conditions of which do not endanger the health, safety or physical well-being of the worker, considering his injury. The supervision measures in place at the CSST do not make it possible to ensure just and fair interpretation of the criteria nor compliance with them in determining suitable employment. In 8 out of 10 files examined, at least one criterion was not met or the documentation was insufficient to draw a conclusion. In 4 out of 10 files, no additional verification was made even though the suitable employment determined did not respect the worker s remaining physical abilities. Ch. 4, Par. 93, 96, 98, 99 12

13 Return-to-Work Intervention Practices Determination of Suitable Employment (cont.) For the worker, the practice of determining suitable employment is important because his income replacement indemnity shall be reduced by the amount of the weighted net income that he could derive from the suitable employment. Suitable employment income was overvalued in 3 of the 10 files examined compared to the information available in the file. The analysis does not take into consideration the precarious nature of the suitable employment determined (seasonal, part-time). If the worker cannot earn the anticipated income of the suitable employment, he will be penalized when compared to his remuneration before the injury. Ch. 4, Par. 94, 101,

14 Organizational Performance Performance Indicators The presence of many performance indicators can result in confusion about the CSST s priorities. Many indicators are produced and accumulate without their relevance being questioned. Five groups of indicators are commonly used regarding the compensation and rehabilitation of workers. There is a lack of coherence between them. Ch. 4, Par

15 Organizational Performance Performance Indicators (cont.) Conversely, certain essential components of performance are not sufficiently followed up on. The CSST does not know the cost per type of file (ex: with or without the right to return to work, by injury type) or intervention (ex: with or without risk). Few indicators are used to demonstrate the sustainable nature of the return to work and the quality of the rehabilitation intervention. No indicators are used to evaluate the proportion of workers with suitable employment who have not achieved the anticipated income that has been set for them. Despite the absence of such indicators, we calculated that out of the 20 files examined, only 9 workers were able to achieve the suitable employment income that had been set, including one who reached that salary only 20 years later. Ch. 4, Par. 104, 108,

16 Organizational Performance Regional Disparities The CSST s directives are not all understood or applied the same way from one region to the next. The CSST does not perform quality control to ensure that its intervention approach is applied in a consistent manner. It has not defined the key parameters of a sustained, quality intervention nor has it estimated the required efforts. In fact, there are significant variations in practitioners workloads depending on the region. An analysis of certain available statistics makes it possible to note other differences that the CSST should look into. Some regions have an eligibility rate that has been under the provincial average since 2003 while others have a rate that is frequently higher. The difference between these regions was about 10% in Ch. 4, Par

17 Organizational Performance Review Mechanism for Reduced Income Replacement Indemnities The CSST does not have a standardized review mechanism for reduced indemnities. It does not always adjust its calculation method to accurately evaluate the worker s situation. According to jurisprudence, 3 calculation methods can be used and should take into account the worker s situation particularly when he has a precarious, temporary or atypical job. It generally evaluates the situation on the date of the review rather than over a more representative period of time. The directives are not specific enough, and the practices observed are sometimes inconsistent with them. For example, considering the pay stubs of only the last 4 work weeks while a directive requires the consideration of the last 12 months. Disparities were noted in the assessment of the relevance, reliability and sufficiency of supporting documents. Ch. 4, Par

18 Organizational Performance Death Indemnities Some right-holders of workers who died from an employment injury have not received all of the indemnities they were entitled to. We identified 38 files concerning workers who died between 2009 and 2013 for which the CSST had not completed the analysis of rightholders or paid the indemnity they are entitled to. In 34 of those files, either the succession is known to the CSST, or notes in the file indicate that a loved one of the deceased worker has been contacted. We estimated that the amount not paid by the CSST to rightholders is at least $2 million. Based on the assumption that the State has not collected the worker s succession due to the absence of heirs or the renunciation of the succession. Ch. 4, Par

19 BEM Medical Assessment Mechanism Processing Times A major increase in the processing time of medical assessments has been observed since In , the published operational time was 49 days, an increase of 57% compared to However, this time frame is incomplete because it is calculated from the time the request is entered in the system and not from its receipt. We calculated a more significant processing time for the worker, which is 88 days on average. This is the number of days between the time the CSST sends a request to the BEM and the date the medical advice is mailed. The longer processing time contributes to increasing the risks of chronicity for the worker and the costs of the plan. According to the CSST s analyses, a 13-day decrease in processing times would make it possible to save over $2.7 million per year. Ch. 4, Par

20 Medical Assessment Mechanism Recruitment of Members The recruitment practices in place have not been revised in depth since 1998, which hampers the BEM s effectiveness. The BEM has not specified its quantitative needs or the specialties needed to ensure an appropriate level of services in an acceptable time frame. It has not conducted an analysis of current and future needs or identified solicitation strategies to be favoured. Since , the number of its members has decreased from 79 to 71, while the number of requests increased by 14%. The BEM faces a scarcity of health professionals in some specialties, which increases processing times. In the case of psychiatric evaluations, the time for issuing medical advice is 37 days longer than the overall average. Ch. 4, Par. 165, 166,

21 Comments of the Audited Entities The Audited Entities accepted all our recommendations. Ch. 4, p

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