The Introduction of an Occupational Health Management System for Solving Issues in Occupational Health Activities in Japan

Industrial Health 2002, 40, 167 174 Original Article The Introduction of an Occupational Health Management System for Solving Issues in Occupational Health Activities in Japan Koji MORI 1 * and Toru TAKEBAYASHI 2 1 Department of Medicine and Occupational Health, ExxonMobil Group in Japan, New Pier Takeshiba, 1-16-1 Kaigan Minato-ku, Tokyo 105-8572, Japan 2 Department of Preventive Medicine and Public Health, School of Medicine, Keio University, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan Received November 28, 2001 and accepted February 18, 2002 Abstract: An important challenge to occupational health services in Japan is the necessary shift from regulation-based occupational health program to health risk-based program. The Occupational Safety and Health Management System (OSHMS) is an effective tool for introducing risk-based activities. To date, the Five Management system has been used to manage occupational health activities. This classification, however, does not show the interactions among the listed activities. Nor is it clear how this system contributes to the PDCA (Plan/Do/Check/Act) cycle for continual improvement. The category in the Five Management system called Roles of the Occupational Physician covers most of the occupational health services required in Japan. The items listed in the Five Management system were compared to the guidelines of OSHMS from the International Labour Office and issues that should be solved for occupational health activities with OSHMS were clarified. Seven issues are discussed in this paper; (1) occupational safety and health policy and audit that can drive the PDCA cycle effectively, (2) reclassification of occupational health activities with several different objectives, (3) set up of targets, (4) risk assessment methods that can prioritize health risks compared to safety risks, (5) exposure assessment methods for risk assessment, (6) flexibility of laws and regulations, and (7) development of talented professionals for risk-based occupational health activities. Key words: Occupational health, Risk-based program, Services, Occupational safety and health management system, PDCA cycle, The International Labour Office Introduction In 1972, the Robens Report was submitted to the British Parliament describing the limitations of occupational safety and health (OSH) activities based on regulations. It recommended, instead, that the government shift to a strategy of care based on existing risks 1). Since then, risk-based care has been promoted mainly in western industrial countries. Under the responsible care strategy in OSH, it is essential to implement the Occupational Safety and Health *To whom correspondence should be addressed. Management System (OSHMS) and to continually improve OSH performance with the system. Each company or site needs to develop its own OSHMS according to actual conditions. Still, some guidelines or standards are necessary to develop reliable systems. The International Labour Office (ILO) in 2001 issued guidelines for OSHMS. These guidelines were designed as a practical tool to help organizations achieve continual improvement in OSH performance. The guidelines were not intended to replace national laws or regulations and the application does not require certification. On the other hand, the British Standards Institutes published the Occupational

168 K MORI et al. Health Safety Assessment Series (OHSAS) 18001 and 18002 2), which can be used for certification. Some Japanese companies have already started to receive OHSAS 18002 certification. OSH activity in Japan today is similar to Britain s situation in the early 1970s, when adherence to detailed laws and regulations was required. The Labor Safety and Health Law enacted in 1972 has played a central role in the regulatory system of OSH and has contributed significantly to the reduction of occupational injuries and illnesses. The regulations, however, tend to encourage improvement of OSH performance only so far. And this system cannot adapt to rapid changes in the industrial environment. In addition, due to the globalization of Japanese businesses, it is important to have an OSH system that is consistent with global standards. With this in mind, the Japanese Ministry of Labor, currently the Ministry of Labor and Health, issued Guidelines on Occupational Safety and Health in 1999 3), which are consistent with ILO guidelines 4). Although the OSHMS guidelines have been developed by some industries 5) and companies, occupational safety elements predominate, whereas occupational health elements may be limited to lists of regulatory requirements. These programs often do not include health risk assessments, the monitoring of risk-based measures, or work consideration according to fitness for duty assessment. As a result, the Occupational Health Management System (OHMS) has not been implemented successfully as a part of OSHMS. If employers, with the cooperation of the workers, can effectively manage the occupational health risks on site, the workers health should improve. In order to achieve this goal, it is valuable to clarify issues in OHMS development and implementation. This paper examines the issues in promoting occupational health activities with OHMS and their effectiveness. Methods Occupational health activities in Japan are usually classified under the Five Management system, i.e., General Management, Work Environment Management, Work Management, Health Management, and Occupational Health Training. These activities at industrial sites are broad, ranging from prevention of typical occupational illness to personal health promotion. Moreover, risks and issues vary from site to site. To begin with, we listed the current Japanese standards for occupational physicians derived from a report called Roles of the Occupational Physician 6) in Table 1 to present an overview of occupational health activities required in Table 1. Items in Roles of Occupational Physician 1. General Management (1) Field Patrol & Assessment of Work Environment (2) Cause Analysis of Work-Related Diseases (3) Management of Information Related to Occupational Health (4) Establishment of Occupational Health Organization (5) Documentation of Occupational Health Procedures (6) Development of Occupational Health Plan (7) Development of Health Promotion Plan (8) Participation in Health and Other Related Committees (9) Collaboration with Safety Management (10) Participation in Work Design and Appropriate Assignment (11) Contribution to Introduction of New Technology and Machine (12) Contact with Governmental Authorities (13) Collaboration with Outside Resources (14) Budgeting and Stewardships for Site Occupational Health Services (15) Training of Successors 2. Health Management (1) Health Examination and Follow up (2) Illness Management (3) Prevention of Epidemics (4) Nutrition Management (5) First Aids Services (6) Health Counseling (7) Health Maintenance and Promotion 3. Work Management (1) Management of Hazardous Work (2) Management of Personal Protective Equipment (3) Management of Work Condition (4) Management of Labor Condition (5) Optimization of Work Condition 4. Work Environment Management (1) Management of Hazardous Chemicals (2) Management of Potential Oxygen Deficiency (3) Management of Hazardous Physical Agents (4) General Environmental Hygiene (5) Environmental Monitoring and Assessment (6) Improvement of Work Environment (7) Facility Maintenance for Better Work Environment (8) Optimization of Work Environment 5. Occupational Health Training (1) Industrial Hygiene Training (2) General Health Education (3) Education for Health Maintenance and Promotion Industrial Health 2002, 40, 167 174

OHMS FOR SOLVING ISSUES IN OH ACTIVITIES IN JAPAN 169 Japan. It was published in 1988 and revised in 1990 by the Committee for the Promotion of Occupational Physicians Activity, established by the Occupational Health Promotion Foundation. Since, under the Occupational Safety and Health Law and the Ordinance, the roles of occupational physicians are expected to cover the entire range of occupational health activities, including work environment management and work management, as well as health management from the viewpoint of medical professionals (Table 2), the report can be regarded as the entire picture of occupational health activities expected in Japan. To clarify issues in promoting occupational health activities and to verify the effectiveness of OSHMS, then, we compared the contents of Roles of the Occupational Physician to the ILO occupational health and safety guidelines 4). Results Table 3 showed the results of rearrangement of Roles of the Occupational Physician with headings of the ILO OSHMS guidelines. There are some blank elements, i.e., OSH Policy, Audit, Preventive and Corrective Action, and Continual Improvement in the OSHMS. Moreover, we summarized issues that should be solved for introducing OHMS into current occupational health activities in Japan in Table 4. Discussion Classification for occupational health activities in the Roles of the Occupational Physician is quite different from that in the OSHMS because, in the OSHMS management, activities are organized according to a system for continual improvement called the PDCA (Plan/Do/Check/Act) cycle as shown in Fig. 1. In other words, the former basically focuses on what kinds of activities should be done; the latter emphasizes how to drive the PDCA cycle. Traditionally, an entire picture of occupational health activities expected in Japan has been elucidated by the Five Management system. However, this goal has not yet achieved to date. According to a study by the Association of Kanagawa Labor Safety and Health in 1996 7) examining how often occupational physicians performed certain activities, the proportion of occupational physicians who performed these activities was as follows: 79.2% did specific health screening and surveillance, 45.0% managed the work environment, 33.0% did occupational health training, and 31.0% performed field patrols. Since Kanagawa prefecture covers the main part of the largest industrial area in Japan, the Keihin Industrial Area, and it has led OSH activities in Japan, these rates are probably higher than the Japanese average. According to the PDCA cycle, occupational health activities should be Planned based on existing risks or needs in each company or industrial site and be Done according to the plan. The performance and outcome should be Checked, and then each company or site should Act to make improvements. In the Five Management system concept, such a ascending spiral linkage between occupational activities is lacking. Therefore, introducing the OHMS is capable of improving the current situation that Japanese occupational health activities are confronted with and promoting risk-based occupational health activities. It is necessary to solve the problems that interfere with the introduction of OHMS as a part of OSHMS in Japan; thus, we would like to take up seven issues for discussion as follows: Table 2. Duties of occupational physician in the ordinance on industrial safety and health Article 14. The matters provided for by the Labor Ministry based on Article 13 of the Law (Industrial Safety and Health Law) shall be those requiring the specialized knowledge of the medicine, which are enumerated below; (1) Matters relating to the execution of the medical examination of the workers and execution of the health care program for the workers based on the result of the medical examination. (2) Matters relating to the maintenance and control of the working environment. (3) Matters relating to the control of the work. (4) Matters relating to the health care of the workers besides those matters set for the in the above three paragraphs. (5) Matters relating to the health education, health counseling and other measures for the maintenance and promotion of the health for the workers. (6) Matters relating to the health education. (7) Matters relating to investigation of the causes of the health impairment of workers and preventive measures. 2. An occupational physician may recommend to the employer or the general safety and health supervisor the measures deemed be necessary in regard to any one of the matters provided for by the preceding paragraph, and may give guidance or advice to the health supervisor.

170 K MORI et al. Table 3. Rearrangement of Roles of Occupational Physician with ILO Guidelines on OSHMS 3.1 OSH Policy (No Clear Related Items) 3.2 Worker Participation Participation in Health and Other Related Committees 3.3 Responsibility & Accountability Establishment of Occupational Health Organization Collaboration with Safety Management 3.4 Competence & Training Training of Successors Industrial Hygiene Training General Health Education Education for Health Maintenance and Promotion 3.5 OHS Management System Documentation Management of Information Related to Occupational Health Establishment of Occupational Health Organization Documentation of Occupational Health Procedures Contact with Governmental Authorities 3.6 Communication Participation in Health and Other Related Committees 3.7 Initial Review Field Patrol & Assessment of Work Environment Health Examination and Follow up Management of Hazardous Work Management of Work Condition Management of Labor Condition Management of Hazardous Chemicals Management of Potential Oxygen Deficiency Management of Hazardous Physical Agents Environmental Monitoring and Assessment 3.8 System Planning, Development and Implementation Development of Occupational Health Plan Development of Health Promotion Plan Budgeting and Stewardships for Site Occupational Health Services 3.9 OSH Objectives Development of Occupational Health Plan Development of Health Promotion Plan 3.10 Hazard Prevention 3.10.1 Prevention & Control Measures Field Patrol & Assessment of Work Environment Health Examination and Follow up Prevention of Epidemics Management of Hazardous Work Management of Personal Protective Equipment Management of Work Condition Management of Labor Condition Optimization of Work Condition Management of Hazardous Chemicals Management of Potential Oxygen Deficiency Management of Hazardous Physical Agents General Environmental Hygiene Environmental Monitoring and Assessment Improvement of Work Environment Facility Maintenance for Better Work Environment Optimization of Work Environment Industrial Hygiene Training General Health Education Education for Health Maintenance and Promotion 3.10.2 Management of Change Participation in Work Design and Appropriate Assignment Contribution to Introduction of New Technology and Machine Management of Hazardous Chemicals 3.10.3 Emergency Prevention, Preparedness & Response First Aids Services Industrial Hygiene Training Collaboration with Outside Resources 3.10.4 Procurement Contribution to Introduction of New Technology and Machine 3.10.5 Contracting Collaboration with Outside Resources 3.11 Performance Monitoring & Measurement Budgeting and Stewardships for Site Occupational Health Services Health Examination and Follow up Environmental Monitoring and Assessment 3.12 Investigation of Work-related injuries, ill health, diseases and incidents and their impact on safety and health performance Cause Analysis of Work-Retaliated Diseases Participation in Health and Other Related Committees Contact with Governmental Authorities Health Examination and Follow up Illness Management 3.13 Audit (No Clear Related Items) 3.14 Management Review Participation in Health and Other Related Committees 3.15 Preventive and Corrective Action (No Clear Related Items) 3.16 Continual Improvement (No Clear Related Items) 1) Use of OSH policy and audit to drive the PDCA cycle The functions that drive the PDCA cycle are included under General Management in the Five Management system. It is not enough for an employer to designate a general health and safety manager and participate in the safety and health committee. Employers should also affirm OSH policy, assure the effectiveness of the OHMS and its auditing process, and review the audit results, taking action when necessary. Although the OSH policy and audit are the key components in a management system that drive the PDCA cycle, they are not commonly part of occupational health activities in Japan and are not included in the Roles of the Occupational Physician, as shown in Table 2. Employers and occupational physicians should work together to develop effective OSH Industrial Health 2002, 40, 167 174

OHMS FOR SOLVING ISSUES IN OH ACTIVITIES IN JAPAN 171 Table 4. Summary of issues for occupational health services with management system in Japan OSH Policy It is not general that employers set out in writing definite Occupational Health policy. Competence & Training Training on Occupational Health Management System is insufficient. OSH Objectives Objective in Occupational Health is less clear than Zero incident in Safety. Prevention & Control Measures Health hazards that risk assessment is conducted are limited. There are some different objectives of occupational health services, including prevention of occupational illness, prevention of work-related diseases and promotion of workers health, but the differences are not clearly recognized in risk management Risk control activities are not always conducted based on risk levels. Management of Change Occupational health professionals are not involved enough in management of change. Procurement Evaluation from the health aspect is not sufficient in procurement process. Contracting Contribution to contracting from the health aspect is not sufficient when comparing with safety. Audit There is no auditing activity that is independent from audited organization. Preventive and Corrective Action Due to insufficient evaluation system for occupational health, the preventive and corrective actions are not well followed up. Continual Improvement Even if occupational health activities are continually improved, definite procedures don t exist. Fig. 1. ILO OSHMS Guidelines.

172 K MORI et al. Table 5. Classification of occupational health activities with objectives and flow Objectives Prevention of Occupational Prevention of Promotion of Individual Health Illness Work-Related Diseases Workers Health Information External Information Harmfulness of Agents Relationship between Parameters and Health Internal Information Environmental Monitoring and Spontaneous Health Consultation Exposure Monitoring Field Patrol Fitness for Duty Assessment General Health Examination Specific Health Surveillance Evaluation of Work Load Life Style Information Risk Assessment Work and Workplace Adaptability between Individuals and Works Individuals Risk Control Work Environment Alternative Materials Exhibition of Calorie at Cafeteria Management Enclosing Prohibition of Smoking in Offices Work Management Improvement of Work Procedures Reduction of Work Load Limitation of Significant Overtime Personal Protective Equipment Health Management Specific Health Screening Work Accommodation Health Counseling including Health Counseling including Induction to Treatment Induction to Treatment Risk Occupational Education for Health Industrial Hygiene Training Health Education Communication Health Training Maintenance and Promotion policy and audit standards and procedures. In addition, auditors should have appropriate skills and knowledge, and the people who conduct and receive the audit should understand its meanings and objectives. 2) Reclassification of occupational health activities with several different objectives The objectives of occupational health activities range from the prevention of occupational illness to the individual health promotion of workers. Each objective requires a variety of activities. For example, in order to diagnose occupational disease or to monitor biological effect, health screening and surveillance must be done. Similarly, to assess fitness for duty or personal health risks, physical examinations must be performed. Currently, however, the stress is on what kind of activity is done rather than the objective of that activity. In a simple occupational health system or regulationbased system, it is sufficient to clarify what is required and perform those tasks with minimal staff and expenditure. On the other hand, in a risk-based system, it is essential to clarify the objectives of the activities and to conduct activities according to the unique risks or needs at each company or industrial site. In the OHMS, occupational health should be a series of activities, i.e., collecting necessary information, assessing health risks, prioritizing activities according to their risk levels, and controlling the risks when they are not acceptable. So complex occupational health activities should be reclassified according to objectives and be arranged in this kind of flow. As an example, typical occupational health activities are classified into three objectives: 1) prevention of occupational illness with a single cause, 2) prevention of work-related diseases to which personal health factors contribute significantly as well as work-related factors and 3) promoting workers health. Then they are arranged in the flow of activities as shown in Table 5. 3) Set up of targets In OSHMS, it is necessary to establish clear and measurable targets of occupational safety and health activities. The targets can be used as standards to evaluate the effectiveness of the system at the step of Performance Monitoring and Measurement. In the measurement, both process measures and outcome measures are usually used. Outcome measures evaluate the effectiveness of an intervention. Safety activities are usually measured by severity ratio and frequency ratio. It is possible to use these measures to evaluate the effectiveness of programs to prevent occupational diseases also. However, the ratio of occupational illness to total work-related exposure is low and these ratios are not useful for chronic illnesses caused by long-term exposure to hazardous agents, such as noiseinduced hearing loss and chemical-induced cancers. Early Industrial Health 2002, 40, 167 174

OHMS FOR SOLVING ISSUES IN OH ACTIVITIES IN JAPAN 173 indicators for health effects need to be developed. For prevention of work-related diseases, process measures, such as the rate of employees who undergo health examination, are often used. There are few appropriate outcome measures in this area that are useful. 4) Risk assessment methods that can prioritize health risks compared to safety risks Risk assessment methods investigate various kinds of hazards in order to prioritize their importance. It is necessary to develop reliable risk assessment methods for all the objectives, i.e., prevention of occupational illness, prevention of work-related diseases, and promotion of workers individual health. They are especially important for the prevention of occupational illness, since the control measures are similar to those for safety risks. These measures include the improvement of facilities and procedures, the wearing of personal protective equipment, and the training of workers. Health and safety risks do not tend to be separated under OSHMS. The safety risk is usually expressed in a matrix of the severity of incidents vs. the possibility or frequency of the incident. The health risk can be expressed in the same kind of matrix, with seriousness of health effects vs. the possibility of disease. These matrices look similar, but it can not be said that their risks are comparable to each other. When considering which control measures to invest in, risk assessment methods that can prioritize health hazards compared to safety risks should be considered. 5) Exposure assessment methods for risk assessment The basic strategy of health risk assessment is to compare exposure levels with individual permissible levels. In Japan, however, area monitoring is much more common than personal monitoring because of governmental regulations. Area monitoring can assess the quality of the work environment but not the probability of health effects. It is also true that personal exposure monitoring or area monitoring should be chosen based on the situation. Area monitoring, however, must be done to comply with legal requirements and sometimes it is not practical to do both area and personal monitoring because of the cost. If the system of area monitoring is continued in Japan, a method to assess health risks indirectly using the data from area monitoring should be developed. The other option is to change the monitoring regulations so that personal exposure monitoring or the combination of personal and area monitoring is required. Furthermore, ergonomic hazards have assumed greater importance at the workplace. There are few practical monitoring methods for occupational hazards. 6) Flexibility of laws and regulations The development of an OHMS and the administration of occupational health activities must be in compliance with laws and regulations. The existence of laws and regulations, however, is sometimes an obstacle to effective strategies for risk reduction. In private companies, since management resources are limited, occupational health activities should be conducted according to the priority of health risks. For this purpose, risk assessment is an effective tool. If the laws and regulations lack flexibility, however, prioritization according to risk may be affected. Consequently, some risk controls that should be set up because of health risk levels may be canceled, and activities to meet legal requirements that are not necessary from the aspect of health risks are conducted instead. Therefore comprehensive standards and flexible administration of laws and regulations that holds employers responsible for outcomes are indispensable to effective programs. 7) Development of talented professionals for risk-based occupational health activities Risk-based occupational health activities require greater expertise than regulation-based activities. Occupational health professionals need to identify existing health hazards, to design and conduct monitoring, and to assess health risks using their knowledge and skills. In the United States, United Kingdom, and other countries, industrial hygienists or occupational hygienists play the main roles in risk assessment. However, there is no training system for these professionals in Japan. Instead, regulations rely on occupational physicians for all professional advice, but most of these physicians do not have sufficient training in occupational health. It is essential to establish training systems of professionals who can manage risk-based occupational health activities under OHMS. In this era of global competition, private companies must be accountable to all interested parties. The area of occupational health should not be an exception. It needs to shift from regulation-based activities to responsible care based on health risks. For this objective, OSHMS is a good tool to establish an effective occupational health system. The flexible administration of related laws and regulations, the development of professionals who can manage risk-based activities, and new evaluation techniques are critically important to establishing responsible occupational health programs with OSHMS in Japan.

174 K MORI et al. References 1) Robens L (1972) Safety and health at work, Report of the Committee 1970 1972. 2) British Standards Institute (2000) OHSAS 18002, Occupational heath and safety management systems Guidelines for the implementation of OHSAS 18001, 2001. 3) Ministry of Labor (1999) Guidelines on occupational safety and health management system (in Japanese). 4) International Labour Office (2001) Guidelines on occupational safety and health management systems. 5) Federation of Automobile Industry Management (1998) Safety and health management system (in Japanese). 6) Committee for Promotion of Occupational Physicians Activities (1990) Role of occupational physician (in Japanese). 7) Takeda T, Kaneko M, Hamaguchi T, Horie H (1997) Status of occupational physicians activities in industrial sites in Kanagawa Prefecture. J Occupational Health 39, S 125 (in Japanese). Industrial Health 2002, 40, 167 174