Physical security Threats to the physical security of computer hardware may arise from theft, \201 re, \202 ood, power surges, or accidental damage All IT hardware (monitors, printers, CPUs) should be security marked and kept on an asset register An uninterruptible power supply should be provided \200 Building security should be at a level proportionate to local crime levels and the likely impact of loss of IT equipment on the OH service. This may include th e provision of alarm systems, \202 oodlighting, security patrols, etc. Particular care is needed when dealing with portable data storage devices such as data pens, detachable hard drives, lap tops and note books, or personal dig ital assistant (PDAs). Such devices are easily lost or stolen, and their contents should be protected using high quality encryption. Software security \200 Loss, corruption, theft, or unauthorized access to data should be guarded against Data should be backed up to a remote server on a daily basis, or saved on a detachable hard drive and stored in a \201 reproof safe. Small operations may be able to use CDs or other IT storage media to back up \201 les. Ideally, these should b e stored in a separate building Data back-ups should be checked for integrity, in case the back-up data is itself corrupt 17_Smedley_Chap17.indd 348 1/2/2013 1:26:44 PM MANAGING OCCUPATIONAL HEALTH RECORDS 1 349 All data should be password protected and the passwords should be regularly updated Passwords should not be written down, nor should computer user names or passwords be shared All computers should be locked when not in use \200 Computer users should log off any net work application after use. This is especially important where the computer is shared with others \200 Computer monitor privacy screen \201 lters should be used to keep con \201 dential data secure and prevent others viewing the screen \200\231s contents, e.g. clinic appointment lists Networked IT systems should have varying access levels, de \201 ned by operational need IT systems should provide an audit trail to identify unauthorized access, or attempts to access sensitive OH data. (Often the greatest threat to data securit y comes from within an organization) \200 IT support staff, whether in-house or contracte d to an OH department, should be asked to sign a con \201 dentiality agreement \200 Increasingly, s mart cards (an identi \201 cation card which carries an integrated computer circuit capable of holding personal data), are being employed to record health and safety data. Such cards require several layers of security to restrict access t o data and to prevent unauthorized changes to existing electronic records Systems that allow remote working via the Internet should employ the highest possible security. (cid:2) E-mail systems, where used for medical communications, should be secure and encrypt ed. Beware of similar e-mail addresses lest the wrong person receives the e-mail. Computer viruses \200 All IT systems should employ virus protection software to prevent computer viruses from compromising system operations Virus software must be kept up to date \200 IT systems that connect to the Internet are e specially vulnerable to infection with computer viruses, and this can lead to service loss for extended periods IT security by introducing viruses, and should be forbidden. Unauthorized use or installation of pirated software may compromise IT policy It is advisable for OH departments to have a written IT policy that covers the us e of computer technology. This should cover the security issues outlined here as well as ac cess to and use of stored data. 17_Smedley_Chap17.indd 349 1/2/2013 1:26:44 PM CHAPTER 17 Operational issues 350 Managing occupational health records 2: security, transfer, and archiving of records There are both legal and ethical issues around the security, transfer, and archiving of medical r ecords. The General Medical Council (GMC), the Faculty of Occupational Medicine, the Britis h Medical Association (BMA), and the Department of Health have all issued guidance on con \201 dential- ity. Concerns around con \201 dentiality are a recurring issue in occupation al medicine. OH professionals need to be aware of the many ways in which con \201 dentiali ty may be compromised. Security of occupational health records \200 All contacts between an employee and an OH s ervice should be recorded in the employee \200\231s OH record The medical records should be securely stored in a lockable cabinet or room or on a secure IT system Access to OH records should be restricted to OH staff \200 All OH staff should sign a con \201 dentiality agreement \200 It is unethical to allow access to OH records to non-OH staff, such as personnel managers. Transfer of occupational health records \200 Companies may outsource OH services, change OH provider, or go out of business. Independent occupational physicians may retire or chang e jobs. In all these cases, OH records will need to be transferred to an individual or orga nization that is in a position to maintain them for the appropriate period (this may be 50y rs after the last entry in the records in some cases, e.g. ionizing radiation records) The Faculty of Occupational Medicine publication Guidance on Ethics for Occupational Physic ians provides guidance on the transfer of OH records When it is proposed that OH records are to be transferred, employees should be informed and given the opportunity to request that their OH notes be ar chived, rather than transferred Where an organization closes, it may be appropriate to issue the OH records to the individu al or (with their consent) their GP. In some situations, statutory records may be offered t o the HSE for retention (again with the employee \200\231s consent). Archiving \200 Employees leave, are dismissed, or retire, and over time the number of ina ctive OH records held by an OH service will increase. Inactive \201 les occupy valuable s torage space. They can make it dif \201 cult for administration staff to locate current OH notes. As a result, all OH services need to have in place a standard operating procedure f or archiving OH records Archives may be held on or off site, but it is important that archiving medical records does not compromise medical con \201 dentiality 17_Smedley_Chap17.indd 350 1/2/2013 1:26:44 PM MANAGING OCCUPATIONAL HEALTH RECORDS 2 351 Readily accessible records detailing the location of all archived notes should be maintaine d. The location of records should be tracked to avoid the loss or mis \201 ling of records OH notes may need to be abstracted at a later date from an archive for a number of reasons, e.g. legal action, audit, or re-employment. Relevant legislation and guidance \200 GMC. Con \201 dentiality 2009: Disclosing informa tion for insurance, employment and similar purposes . Available at: M http://www.gmc-uk. org/Con \201 dentiali ty_disclosing_info_insurance_2009.pdf_27493823.pdf Faculty of Occupational Medicine (2006). Guidance on Ethics for Occupational Physicians , 6th edn. FOM, London. Revision to articles 3.37 \200\2233.40 of Guidance on Ethics for Occupational Physicians . Available at: M http://www.fom.ac.uk/wp-content/ uploads/m_gmcconf_ethicsrev1. pdf British Medical Association. Con \201 dentiality and disclosure of health information toolkit . Available at: M http://bma.org.uk/practical-support- at-work/ethics/c on \201 dentiality-tool-kit Department of Health. (2003). Con \201 dentiality: NHS Code of Practice . Available at: M http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidan ce/DH_4069253 17_Smedley_Chap17.indd 351 1/2/2013 1:26:44 PM CHAPTER 17 Operational issues 352 Quality and audit in occupational health practice 1: general principles OH practice is natu rally embedded within enterprises, or is supplied under contract. It faces scrutiny by purc hasers, users, and enforcing authorities, who all wish to see evidence of compliance with s tandards. Standards can be derived from a number of sources, such as: \200 The purchaser of services (e.g. contract speci \201 cations) \200 The professional body (e.g. good OH practice guidelines) \200 The statutory enforcing authority (e.g. standards for legal com pliance). Organizations strive constantly to improve the ef \201 ciency of their opera- ti on and also that of their suppliers of services. OH professionals must be able to show bene \201 t, constantly seek to justify and improve what they do, and demonstrate the use of e vidence-based best practice guidelines. Quality De \201 nitions \200 \200\230The degree and standard of excellence \200\231 \200 \200\230Fitness for a purpose \200\231 (Juran). 1 Customer-driven quality This is a useful approach which ensures that the OH service meets the needs of its customers. It \201 rst requires that the customers are de \201 ned. There are many who could be consider ed as customers or stakeholders, and they all have different (real or perceived) needs: \200 Service purchaser \200 Patients or clients \200 Legislative bodies \200 Trade u nions \200 Other health care professionals \200 Insurance companies \200 Pension fund trustees. The aim is to build a complex provider \200\223client relationship, through whic h the needs of the many stakeholders can be addressed. This should not be an entirely react ive process. Many of the stakeholders and customers of OH services may be ignorant of the r ange of services available, and each will have a different perspective. The art of OH servi ce practice is to meet the needs of the individual client (or patient), while at the same t ime tak- ing into account the needs of the organization in which they work. To be successfu l, the OH professional must engage in a continuing educational dialog with the various stak eholders of the service. Quality improvement Excellence in OH practice is not an endpoint, but is a continually movi ng target. Therefore, the pursuit of excellence requires continuous improve- ment. Juran su ggested that up to 40% of all activity involved correcting 1 Joseph Juran \200\224early proponent of benchmarking and quality costing. 17_Smedley_Chap17.indd 352 1/2/2013 1:26:44 PM QUALITY AND AUDIT IN OCCUPATIONAL HEALTH PRACTICE 1 353 iindividual or system failures. Quality principles provide a mechanism for continual improv ement, which requires: \200 Awareness of the need for improvement \200 A willingness to improve \200 A product or service \200 Measurements. Quality assurance Quality assuran ce encompasses all the planned and systematic activities needed to demonstrate that the OH service is meeting all its de \201 ned standards and customer requirements. It includes pr ocesses: \200 To eliminate faults \200 Maintain consistent performance. Audit The syste matic evaluation of the quality and effectiveness of OH service is a professional obligatio n. Audit is the process of observing the prac- tice and comparing it against a de \201 ned standard. It may also be a high- level process used to undertake a needs assessment of an organization or review of an OH service. \200 How many of your employees are sick? \200 Who gets sick and why are they sick? \200 How many accidents occur and what are the caus es? \200 Why do they retire? \200 What do your people die from? \200 What do you do? \200 Do you have a mission statement? \200 Do you have goals? \200 Do you have speci \201 c objectives for this year? Audit can be of the structure of an OH service, its proce sses, or its out- comes. An audit will compare practice against the standard as a means of establishing whether the standard is met or, if not, informing the need for change in eithe r the standard or the practice \200\224the audit cycle (see Fig. 17.1). Audit is an essenti al part of professional practice and is the tool that monitors and supports quality assuran ce and quality improvement. Set standard Implement change Observe practice Compare with standard Fig. 17.1 The audit cycle. 17_Smedley_Chap17.indd 353 1/2/2013 1:26:44 PM CHAPTER 17 Operational issues 354 Quality and audit in occupational health practice 2: systems and tools Quality systems A qu ality system requires that the OH service: \200 De \201 nes its processes \200 Ensures that all staff know and understand these \200 Ensures that the processes meet the needs of the customer \200 Reviews standards and procedures regularly \200 Improves continuou sly \200 Audits all the above regularly. Measurements Measurements are important in OH practice. However, many organiza- tions and i ndividuals collect data of little relevance to health improvement, such as the numbers of p eople seen and other activity analysis. The data that any occupational health service or OH professional should strive to gather are given in Table 17.2. Outcomes are always more imp ortant than process measurements. An effective OHS will be able to demonstrate positive change in some or all of the following: \200 Attitudes, knowledge, or behavior \200 Health status or s elf-rated health \200 Morbidity \200 Mortality \200 Occupational health process and p ractice \200 Effects on work organizations External quality standards Internationally rec ognized quality systems have developed to support the assessment and maintenance of quality in industry. Many organizations routinely require that their suppliers of services operate a quality system, including external audit of their service. Table 17.2 Data collection in OH Outcome Source Morbidity Sickness absence by location, occupation, function Mortality In service, pensioners Occupational disease Sickness absence by cause Accidents and incidents Reported accident statistics Health Health survey data Stress Employee Assistance Program data Litigation Analysis of compensation claims 17_Smedley_Chap17.indd 354 1/2/2013 1:26:44 PM QUALITY AND AUDIT IN OCCUPATIONAL HEALTH PRACTICE 2 355 Examples of external standards can be: \200 Speci \201 c: e.g. the UK Faculty of Occupat ional Medicine \200\230Safe Effective Quality of Occupational Health Services (SEQOHS) \200\231 and a German system for occupational physician practice Generic: industry standards, such as ISO 9000 and the European Foundation For Quality Management. These require that holders of their quality standard sys tematically apply all the principles described here. Holders of a recognized quality standard will usually have some advantage with potential cu stomers over their competitors who do not. However, possession of a quality standard will n ot necessarily ensure that the OH service is delivering the highest standards of occupation al health and safety or clinical service \200\224that still requires professional excellenc e and leadership. National audit A series of national audits of NHS occupational health services have been ca rried out by the Health and Work Development Unit of the Royal College of Physicians (see b p. 355, Further information). This work is also relevant to other (non-NHS) providers. At present audit cycles are ongoing in two topics, screening for depression in employees who a re on long term sickness absence, and the management of back pain. Clinical governance Clin ical governance is de \201 ned as management \200\231s responsibility for clinical perform ance. This requires that managers of a service ensure that the highest standards of clinica l performance are maintained by the consistent development and use of: \200 Evidence-base d guidelines (or consensus-based in the absence of evidence) Appropriate and ethical standard procedures \200 Continuing professional development of c linical staff \200 Peer review of clinical performance \200 Monitoring of clinical outc omes. Quality systems can encompass clinical governance processes. However, if the system d oes not apply to individual clinical performance, then sepa- rate procedures for ensuring c linical governance must be in place for the individual clinician or larger clinical team. Further information Royal College of Physicians. Back pain management audit. Available at: M http://www.rcplondon. ac.uk/resources/back-pain-management-audit Royal College of Physicians. Depression screening audit . Available at: M http://www.rcplon don. ac.uk/resources/depression-screening-audit-2008 Royal College of Physicians. Depression detection and management of staff on long term sick ness audit . Available at: M http://www.rcplondon.ac.uk/resources/depression-detection-and- manag ement-staff-long-term-sickness-audit 17_Smedley_Chap17.indd 355 1/2/2013 1:26:45 PM CHAPTER 17 Operational issues 356 Guidelines in occupational health Guidelines, governance, and quality The development of cl inical guidelines relevant to occupational health practice plays an important role in drivi ng up clinical quality in the spe- cialty. Guidelines form the link between scienti \201 c evidence (or profes- sional consensus in the absence of clear evidence) and agreed standar ds for care. Clinical standards provide a framework for assuring: \200 Consistency of pra ctice across OH providers \200 A baseline for continuous improvement in quality through r epeated cycles of audit (see b p. 352, Quality and audit). Guideline development methodology A number of guideline methodologies have been used to dev elop guide- lines in clinical medicine. These vary in complexity, but they have a com- mon aim to use standardized tools to: \200 Categorize evidence (peer reviewed papers, reviews or gray literature) \200 Summarize the implications for practice. 2 One of the main prob lems with the application of these methods in occupational health is the relative lack of e vidence from experimental studies (randomized controlled trials being the gold standard). M uch of the published research in OH is based on cross-sectional surveys and obser- vational studies, so will score at the lower end of the quality rating scales within most of the ag reed methodologies in Table 17.3. Nevertheless, a consistency of approach enables the reaso nable justi \201 cation of guidelines and the practice standards that are derived from the m. in terms of quality Table 17.3 Common methods for guideline development Method Web reference M http://www.sign.ac.uk/ Scottish Intercollegiate Guideline Network (SIGN) M http://www.ncgc.ac.uk/ Guidelines/Methodology/ M http://www.gradeworkinggroup. org/index. htm National Clinical Guideline Center (NCGC) Grading of Recommendations Assessment, Development and Evaluation (GRADE) Guideline development groups The most important points to note when setting up a guideline develop- ment groups (GDG) are: \200 Ensure all relevant stakeholders are included: professional groups from OH practice (including a representative from a primary care background if relevant) experts in the particular \201 eld (e.g. dermatology or microbiology) \200 users of a s ervice (employers, employees or their representatives) 17_Smedley_Chap17.indd 356 1/2/2013 1:26:45 PM GUIDELINES IN OCCUPATIONAL HEALTH 357 patient representatives (patients who have personal experience of the condition in question) enforcing or regulatory agencies (HSE, Department of Health (DH)). Training will be required if GDG members will be appraising evidence \200 Consider contra cting out the systematic review and/or evidence appraisal to an experienced research unit A clear dissemination and implementation plan for any output is essential from early in the process The budget for a guideline should be split; 50% for development and 50% for dissemination and implementation. Sources of occupational health guidance The main sources of guidelines that are relevant fo r OH practice are out- lined in Table 17.4. Table 17.4 Main sources of guidelines that are relevant for OH practice Source Web reference M http://www.bohrf.org.uk British Occupational Health Research Foundation (BOHRF) M http://osh.cochrane.org/ Cochrane collaboration: Occupational Health and Safety Review Group M http://www.nhsplus.nhs.uk Health and Work Development Unit (HWDU) M http://www.nice.org.uk National Institute for Health and Clinical Excellence (NICE) M http://www.nhsplus.nhs.uk NHS Plus Various other bodies including - Department of Health M http://www.dh.gov.uk M http://www.nhsemployers.org M http://www.hpa.org.uk M http://www.h se.gov.uk NHS Employers Health Protection Agency Health and Safety Executive Further information Although not speci \201 c for OH, the following are useful general evi dence-based resources. NHS (2011). NHS Evidence. Available at: M http://www.evidence.nhs. uk/nhs-evidence-content pathways.nice.org.uk/ NICE (2012). NICE clinical pathways section. Available at: M http:// 17_Smedley_Chap17.indd 357 1/2/2013 1:26:45 PM This page intentionally left blank 359 Chapter 18 Ethics Ethical principles in clinical occupational health practice 360 Con \201 dentiality, conse nt, and communication 362 Ethics in business and medico-legal work 364 18_Smedley_Chap18.indd 359 1/2/2013 12:28:52 PM CHAPTER 18 Ethics 360 Ethical principles in clinical occupational health practice Role The occupational physician is a registered medical practitioner (RMP) whose professional practice is concerned with t he interaction between health and work. Their role is outlined on p. 386. Although general ethical principles (which would be appropriate for all doctors) apply in occupa- tional med icine, special features of their role generate additional ethical issues for occupational p hysicians. These include: \200 Having a largely preventive or rehabilitative role, rather than the traditional therapeutic role of the GP, or hospital specialist \200 A need to maintain an objective and impartial position between various groups, including the employee (and his/her GP), the employer, and others (other em ployees, unions, local population). Principles The underlying ethical principles of medical practice (bioethics) for all RMPs, including occupational physicians are as follows: \200 Respect for autonomy: competent ad ults may make decisions for themselves irrespective of the consequences to themselves Non-malfeasance: the doctor shall do no harm \200 Bene \201 cence: the doctor shall do g ood and act in the best interests of the patient Justice: how rights and responsibilities are equitably and fairly distributed (Distributive Justice). In the UK and Europe respect for autonomy is the predominant principle. These ethical princ iples are further speci \201 ed by ethical rules such as truth- fulness, respect for priva cy, \201 delity, and con \201 dentiality. These principles place active, relevant respon sibilities on occupational physicians, which must be implemented even if not speci \201 ca lly required by law, rules or contract. Rules Occupational physicians are bound by \200\230the duties of a doctor \200\231 and Goo d Medical Practice , published by the GMC. 1 The Faculty of Occupational Medicine (FOM) has produced a speci \201 c version Good Occupational Medical Practice 2 that has been agreed with the GMC and comprehensively sets out professional practice. Occupational physicians a re required, inter alia, to do the following: Revalidate in accordance with the requirement s of the GMC: \200 Audit their work and demonstrate improvements in practice \200 Evide nce-based working must be at the heart of their activities \200 Seek the views of their c ustomers and clients and incorporate them 1 GMC. Regulating doctors, ensuring good medical practice. Available at: M http://www.gmc-u k. org/index.asp 2 . Faculty of Occupational Medicine (2010). Good Occupational Medical Practice . FOM, Lond on. 18_Smedley_Chap18.indd 360 1/2/2013 12:28:52 PM ETHICAL PRINCIPLES IN CLINICAL OH PRACTICE 361 Have an effective complaints procedure in place \200 Ensure appropriate arrangements for clinical governance in their work \200 Support specialist training. Ethical guidance United Kingdom \200 Faculty of Occupational Medicine (2006). Guidance on Ethics for Occupational Physicians (6th edn) FOM, London. ISBN 1860162800. It is recognized by the GMC as an authoritative source of guidance and is used by other occupational health profession als and lay people. 7th edition likely in 2012. British Medical Association (2003). Medical Ethics Today , 2nd edn. BMJ Books, London. Ethical guidance for all doctors is also published in the UK by the Brit ish Medical Association. 3rd edition likely to be published in February 2012. Nursing and Midwifery Council (2008). Code of Professional Practice. NMC, London. Available at: M http://www.nmc-uk.org/ Nurses-and-midwives/The-code/ . Other health care professionals publish ethical guidance, such as the Nursing and Midwife ry Council and the Royal College of Nursing. Royal College of Nursing (2005) Con \201 dentiality . RCN, London. Available at: M http://www.rcn.org.uk/publications/pdf/con \201 dentiality. pdf Other non-health-care professionals, such as the Institute of Occupational Safety and Health, also produce ethical guidance. International \200 International Commission on Occupational Health (2000). International Code of Ethics for Occupational Health Professional s. ICOH, Singapore. The International C ommission on Occupational Health (ICOH) publishes guidance that is recognized worldwide. Th e International Labor Of \201 ce of the World Health Organization produces wide-ranging gu idance for all those working in the \201 eld of health and safety. 18_Smedley_Chap18.indd 361 1/2/2013 12:28:52 PM CHAPTER 18 Ethics 362 Con \201 dentiality, consent, and communication General principles The principles of commu nication in OH are different from normal doctor \200\223 patient relationship. Explain this to clients when \201 rst referred. \200 The OH physician is impartial and aims to give objective advice to both employer and employee Personal information is kept con \201 dential. Information is only disclosed if justi \201 ed and then only with the employee \200\231s consent Any disclosure is the minimum required for the purpose, even if wider consent is available. Legal requirements In addition to the ethical requirement, con \201 dentiality is ensured by: \200 Data Protection Act 1998 (see b p. 578, Data Protection Act 1998) \200 Human R ights Act 1998 \200 Common law \200 Access to Medical Reports Act 1988. This gives addi tional rights to individuals where an OH professional requests medical information from a d octor who has provided the individual with clinical care. This is covered more fully on b p . 580, Access to Medical Reports Act 1988. 2 Breaches of con \201 dentiality may lead to a ction in the courts, by the GMC, or by the Information Commissioner. Consent In the setting of OH practice, consent may be required for any interaction with the client, including but limited to: \200 Preventative or therapeutic interventions (e.g. i mmunizations) \200 Assessment of risk to the employee or others (e.g. drug screening, assessment of immunity to infectious diseases) \200 Health surveillance and biological mo nitoring \200 Disclosure of con \201 dential information held by the OH department \200 Acquisition of con \201 dential information by the OH department. For consent to be ethi cally valid, it must be freely given by a competent individual who knows: \200 What actio n is proposed (including the content of proposed disclosure of information) By whom \200 To whom \200 The bene \201 ts and adverse consequences of giving/withhold ing consent. Consent may be: \200 Given explicitly: either in writing or orally, and reco rded in the contemporaneous medical record Implied: only used in obvious circumstances, such as a patient offering his/her arm for the taking of a previously explained blood specimen. Consent is freely given if no external pr essure is put on the individual to agree or decline a particular course of action 18_Smedley_Chap18.indd 362 1/2/2013 12:28:52 PM CONFIDENTIALITY, CONSENT, AND COMMUNICATION 363 The fact that there are consequences to a particular decision does not render the consent ethically invalid The fact that an individual has to agree to an examination in order to gain a particular be ne \201 t (gain a pilot \200\231s license or obtain an ill-health retirement pension) does not invalidate the consent. Consent is valid only for the purpose for which it was given. It may be withdrawn at any st age at which the change has practical effect (consent to disclosure cannot be withdrawn aft er disclosure has occurred). Withholding consent For assessment or treatment If consent for risk assessment, health scre ening, or interventions is with-held, the consequences must be explained to the individual and recorded in the OH record. These will depend on the situation, but might include refusa l to give health clearance for particular activities or jobs. The consequences of refusal t o participate in screening programs should be agreed in advance with employees \200\231 rep resentatives. Disclosing con \201 dential information without consent Rarely, con \201 dential informat ion may be disclosed without consent. Some examples include: \200 Over-riding public inte rest (avoiding serious harm to third parties) \200 Statutory requirement (terrorism, noti \201 able disease, GMC, road traf \201 c accident, Driver and Vehicle Licensing Agency (DVLA)) By order of a court. However, occupational physicians who disclose information without con- sent may be required to justify their decisions. It is prudent to seek advice from senior colleagues, medical defense insurer, or lawyers before taking such action. Individuals must be informed about what information will be disclosed and to whom, and the possible consequ ences. Communicating the output from OH assessments It is essential that the individual is informe d of the content of any reports that are generated by the OH department, and agree to their release. This applies even if the report does not contain sensitive or con \201 dential m edi- cal information. A copy of the report should be offered to the individual, and their r ight of access to it should be explained clearly. Further information GMC guidance on con \201 dentiality GMC (2009). Con \201 dentiality: guidance for doctors . Available at: M http://www.gmc-uk.org/static/ documents/content/Con \201 dentiality_0910.pdf GMC. Con \201 dentiality: disclosing information for insurance, employment and similar pur poses. http://www.gmc-uk.org/Con \201 dentiality_disclosing_info_insurance_2009. Available pdf_27493823.pdf Faculty of Occupational Medicine (2006). Guidance on Ethics for Occupatio nal Physicians , 6th edn. FOM, London. at: M 18_Smedley_Chap18.indd 363 1/2/2013 12:28:52 PM CHAPTER 18 Ethics 364 Ethics in business and medico-legal work Business ethics Globalization has increased divers ity in the workplace and companies increasingly operate their own ethical codes and values. Doctors should follow sound principles of business ethics where these do not con \202 ict with their duties as a doctor. \200 Occupational physicians remain as registered medical practitioners and are subject to the rules of the national medical regulator, the GMC in t he UK; the lack of a therapeutic relationship in many activities does not absolve doctors w orking in business of their biomedical ethical responsibilities Occupational physicians have a duty to promote health and wellbeing in the workplace regardless of geography Commercial pressures can impact on occupational physicians, but do not justify breaches of ethical or legal rules Occupational physicians must not contract for work outside their own or their organization \200\231s competence Competitors must not be denigrated, and information gleaned by OH staff through their work should not be used for personal advantage Care must be taken that contracts or agreements for services do not contain unethical provi sions such as a requirement to release con \201 dential medical information to the employe r When services are being transferred, the occupational health and safety of client organizations and their workforces must take primacy over commercial consi derations. Medico-legal work Occupational physicians may be required to give evidence: \200 As a fac tual witness, e.g. on some aspect of OH procedure or their personal input in a case. A fact ual witness does not give an opinion, just a statement of the facts or events as they occur red. As an Expert witness. An Expert witness gives an educated or expert opinion on a question e .g. the relationship between a workplace exposure and a particular health effect: \200 th e expert witness is responsible to the court, not to the party who has funded the report. independence and expert knowledge are paramount \200 never stray outside your area of exp ertise \200 expect to be challenged on your views; be prepared to produce evidence to justify your position. Legal report writing and giving evidence in court requires particular skills; ensure you ha ve the appropriate training. The Expert witness Institute provides training programs for do ctors (M http://www. ewi.org.uk). 18_Smedley_Chap18.indd 364 1/2/2013 12:28:52 PM 365 Chapter 19 Policies Writing a policy 366 Health and safety policies 368 Sickness absence policies 370 Wellness/ wellbeing policies 372 Immunization policies 374 Mental health policies 376 Substance abuse policies 378 Travel policies 1: general travel policy 382 Travel policies 2: expatriate po licy 386 Violence management policies 388 Workplace smoking policies 390 19_Smedley_Chap19.indd 365 1/2/2013 12:30:27 PM CHAPTER 19 Policies 366 Writing a policy The purpose of any policy is to set out how an organization plans to condu ct that aspect of its business in compliance with relevant legislation and current best pra ctice. Behind the organizational policy may lie one or more operational procedures/protocol s which document how the policy will be delivered. Well written, up to date, OH policies an d procedures are one element of good clinical governance (see Fig. 19.1). 2 To be effective , these policies must have support at the highest level of the organization. A comprehensiv e policy sets out organizational intention, and explicit arrangements (who does what, and w hen) with respect to the manage- ment of any given organizational risk. An effective policy should \200 De \201 ne the purpose of the policy \200 De \201 ne responsibilities from the top of the organization down the management tree Identify a director or senior manager responsible for that policy \200 Describe the respo nsibilities of managers and supervisors \200 Describe the responsibilities of employees \200 Describe the responsibilities of other parties where relevant, e.g. Occupational Health and Wellbeing service \200 Human Resources \200 Health and Safety D epartment \200 Training and Education Department Describe arrangements for: monitoring and review of the policy \200 monitoring of the effectiveness of the policy Allocate appropriate resources \200 Ensure the organization has access to competent advic e \200 Set a date for policy review. Relevant legislation and guidance \200 HSE (1997). Successful health and safety managemen t , HSG65. HSE Books, Sudbury. TSO (2003). Chapter 37. In: Health and safety at work, etc. Act 1974 . TSO, Norwich. HSE (2003). Management of Health and Safety at Work Regulations 1999. Approved Code of Prac tice and Guidance, 2nd edn, L21. HSE Books, Sudbury. 19_Smedley_Chap19.indd 366 1/2/2013 12:30:28 PM WRITING A POLICY 367 Define aims and objectives: why do we need this policy? Risk assessment Review current practice: what if anything do we currently do? Define best practice: what should we be doing? Identify legislative requirements, HSE, indu stry or other authoritative guidance. Draft policy 1. Agree and assign ownership of policy e.g. Health and Safety committee, OHS 2. Describe m anagers \200\231 and supervisors \200\231 responsibilities 3. Describe employees \200\231 r esponsibilities 4. Define how the desired aim will be achieved in keeping with best practic e 5. Agree the necessary resources (staff, equipment, maintenance) to deliver the policy \200\231s desired aims 6. Where there are specific, detailed, duties placed on one departme nt by the policy, this may be better defined in a related Standard Operating procedure (SOP ) 7. Describe audit and monitoring arrangements 8. Define review arrangements 9. Include ke y references e.g relevant legislation, other policies and procedures Consult key stakeholders: HR, OHS, line management, staff side representatives, legal advis ers on draft policy Revise policy in light of feedback Staff training Disseminate final, controlled, document in hard copy or, ideally, on the organization \200 \231s intranet Publicize Audit compliance with policy and monitor its effectiveness Fig. 19.1 Flow chart showing the key steps in drafting a policy. 19_Smedley_Chap19.indd 367 1/2/2013 12:30:28 PM CHAPTER 19 Policies 368 Health and safety policies The purpose of a health and safety policy is to set out how an o rganization plans to conduct its business in compliance with health and safety law. It expr esses commitment to sustained improvement in the management of health and safety risk. 2 Al l employers with more than \201 ve workers are required by the Health and Safety at Work etc. Act 1974 to have a written health and safety policy, and to communicate it to employee s. Under the Health and Safety Information for Employees Regulations 1989 employers must di splay a health and safety poster or provide lea \202 ets with health and safety informa- t ion for the workers. Health and safety policy 2 To be effective, a health and safety policy must have support at the highest level of the organization. The prevailing culture should give supervisors and staff a clear message that health and safety is an important organizational priority. A com pre- hensive health and safety policy sets out organizational intention, and explicit arran gements (who does what, and when) with respect to the management of health and safety risk. The policy should specify the owner of the policy, the scope, de \201 nitions/glossary, r elevant reference documents including legislation, regulations and other internal policies e.g. COSHH, First Aid, Noise. Many large organizations will require that draft policies are subject to Equality assessment prior to implementation. A health and safety policy should \200 Be signed (and dated) by the chief executive \200 De \201 ne responsibilities from the top of the organization down the management tree Identify a director/senior manager responsible for health and safety \200 Describe the re sponsibilities of managers and supervisors \200 Describe the responsibilities of employee s \200 Encourage the involvement of safety representatives \200 De \201 ne how health and safety issues will be communicated effectively \200 at board level: health and safety on the agenda of all meetings \200 to all staff: toolbox talks/team brie \201 ng, newsl etters, and circulars Describe arrangements for: