appointment procedures in OHCs

[Chi-RN]

I am employed in a large industrial activity by the federal government. One of my primary roles is as liaison between my command and the medical command that provides Occupational Health Services for our federal civilians.

I have a dilemma I would like to share with other OHNs to see if anyone has run into this problem before.

The Occupational Health Clinic I deal with performs preplacement physicals and surveillance/certification physicals (with the exception of respirator & hearing) on a 2-appointment basis. In other words, each employee must have a preliminary appointment with the nurse to complete tests (bloodwork, spirometry, EKG, etc.). Then, the employee is scheduled again at a later date to see the physician and complete the exam. This process was started by a clinic department head about three or four years ago. That department head has since retired.

The result of the 2-appointment process for physicals is that surveillance examinations take up to two weeks to complete. Some of the surveillance lab results take a while to be returned from a mail-out lab. Physicians in the clinic will not perform the physical until all lab results are in the record.

For new hires, it get worse. It takes longer for preplacement exams to be completed using the 2-appointment system. Then, once new hires are onboard, I must still request they be scheduled for required surveillance examinations, with a resultant delay of several weeks before the new hire can be productively working. This is very costly for my command.

Until about 4 years ago, physicals were completed in this clinic during just one appointment. The same is true, of course, when you visit a private physician. Tests are performed, you see the physician, and you are called back for a second appointment only if there is a problem. The change to 2-appointments was made to accommodate clinic staff, but it was at the expense of customer commands.

I understand there are circumstances when the clinic would want to see an employee twice, such as when a written opinion or a referral to a private provider is required. Those, however, are exceptions.

My command would prefer the process be streamlined to save money in lost production time. For my command, as the customer command, the 2-appointment process means each employee requiring a physical must shut down processes, lock toolboxes, & report for the physical a miniumum of twice. In addition to cost savings for my command, I think my command's no-show rate would improve (not having to keep a minimum of 2 appts for each physical), which would result in a cost-savings for the clinic.

Unfortunately, this 2-appointment process for physical exams seems firmly implanted at the clinic. They like the ability to organize this way.

I would like to know if other Occupational Health Clinics use this 2-appointment process and if it presents problems for other OHNs.

Thanks.

[Sharon]

Chi-RN,

Are you in a Federal Occupational Health administered clinic? Are you truly stand-alone and do you have to comply with Health and Human Services and Office of Personnel Management standards?

Typically the federal government clinic standards and how preplacement and surveillance exams are administered are based on Health Human Services standards of care, Office of Personnel Management Standards of Care, collective bargaining agreements and letters of agreement with different federal employee unions.

In the Federal clinics where I have worked we did the tests on day one and they see the physician the next day. Why can't yours be done in two days back to back? The only time that the exams took weeks was when the agency did not want the physician hours required to accomplish the faster completion of the exam. I have done thousands of preplacement exams the same way. All surveillance exams are done during the preplacement physical so that there are no additional days. It is more cost effective to do all baseline surveillance exams at the preplacement physical even in agencies with high exam failures like Federal law enforcement agencies.

In my experience with federal workers, just as much critical information and education has been received from discussing normal results as abnormal results. There are many times in which information received during discussion of abnormal results triggered further referral and evaluation that identified a disease process that would have been caught much later.

Remember the optimal standard of care for health evaluation is to do the exam over two days so that all test (positive and negative) results can be discussed in person with the screener. This is a standard for both Physicians and Nurses in a variety of specialties. This standard is usually adapted based on resources. If your goal is to streamlining the process it can be done without moving away from the two-visit model.

[Chi-RN]

I am not in the clinic at all. My position is strictly administrative and I am trying to work with clinic staff to improve/streamline the process. The most delay occurs when waiting for cadmium and/or lead levels to be returned from mail-out labs (2 weeks). Other labs are performed on-site. The cadmium standard requires a Physician's Written Opinion to be delivered to the employee, but I am not certain this needs to be included during the preplacement process.

[Sharon]

In order to streamline the process the clinics I worked in stopped using mail out labs 10 years ago except for rare test usually provided by a single lab. In the past I have negotiated with labs to change the days or frequency of lab runs even with mass spectrometry testing. This is usually more effective at the time contracts are negotiated but has worked at other times.

I was curious what the turn around time is for Cadmium and Lead with our local labs.

Cadmium is 96 hours and depending on the test, they are run Monday -Friday

Lead is between 48 hours and 96 depending on the test and is sometimes run two mornings a week. (I suspect this reference was published before the increased media coverage of Lead exposures.)

After I got your reply I contacted a couple of physicians who both drafted some of the sandards for different agencies and one actually happens to be a former Department of Energy Medical Director. Both have Cadmium experience. For those reading this string and who are not familiar with Cadmium Standards: The Cadmium level is to be done after 30 days of initial assignment (exposure) to a position that has levels at or above the action level. The written opinion is after exposure to the Cadmium and is an opinion on whether the employee is using safe work practices based on biologic monitoring levels.

We don't think you are going to be able to combine your visits to less then three.

Visit one Preplacement testing including blood, urine, PFT's etc. (Lead baseline which the discussion can be deferred to visit three).

Visit two Physician exam and review of test results

Start work

Visit three The first 30 days of exposure to Cadmium, and review of hygiene and work practices based on results.

I would go back to your vendors and try to push for quicker turn around time on your labs.

[SharonH, RN]

I am employed in a large industrial activity by the federal government. One of my primary roles is as liaison between my command and the medical command that provides Occupational Health Services for our federal civilians.

I have a dilemma I would like to share with other OHNs to see if anyone has run into this problem before.

The Occupational Health Clinic I deal with performs preplacement physicals and surveillance/certification physicals (with the exception of respirator & hearing) on a 2-appointment basis. In other words, each employee must have a preliminary appointment with the nurse to complete tests (bloodwork, spirometry, EKG, etc.). Then, the employee is scheduled again at a later date to see the physician and complete the exam. This process was started by a clinic department head about three or four years ago. That department head has since retired.

The result of the 2-appointment process for physicals is that surveillance examinations take up to two weeks to complete. Some of the surveillance lab results take a while to be returned from a mail-out lab. Physicians in the clinic will not perform the physical until all lab results are in the record.

For new hires, it get worse. It takes longer for preplacement exams to be completed using the 2-appointment system. Then, once new hires are onboard, I must still request they be scheduled for required surveillance examinations, with a resultant delay of several weeks before the new hire can be productively working. This is very costly for my command.

Until about 4 years ago, physicals were completed in this clinic during just one appointment. The same is true, of course, when you visit a private physician. Tests are performed, you see the physician, and you are called back for a second appointment only if there is a problem. The change to 2-appointments was made to accommodate clinic staff, but it was at the expense of customer commands.

I understand there are circumstances when the clinic would want to see an employee twice, such as when a written opinion or a referral to a private provider is required. Those, however, are exceptions.

My command would prefer the process be streamlined to save money in lost production time. For my command, as the customer command, the 2-appointment process means each employee requiring a physical must shut down processes, lock toolboxes, & report for the physical a miniumum of twice. In addition to cost savings for my command, I think my command's no-show rate would improve (not having to keep a minimum of 2 appts for each physical), which would result in a cost-savings for the clinic.

Unfortunately, this 2-appointment process for physical exams seems firmly implanted at the clinic. They like the ability to organize this way.

I would like to know if other Occupational Health Clinics use this 2-appointment process and if it presents problems for other OHNs.

Thanks.

Chi, I work in a FOH clinic and we use the 2 appt system for pre-placements and annuals except in cases where the individual is coming from out of town in which case we do them in 1 visit. Generally, we schedule the physician visit 24 to 72 hours after the work-up because most of the agencies mandate it in order that we may discuss labwork with the client. Also, the client usually has to return anyway if they had a PPD. This works pretty well for all involved.

The problem may be physician availability. Our clinic uses physicians 4 days a week but this is unusual as a lot of the other clinics only have a doc who comes in 1 or 2 days a week. Also, it depends on the other agencies they are dealing with. We have the Feds_Heal contract which means we are also performing Army and AirForce Reserve physicals and they must do everything in one visit so we have to schedule around them also.

One other problem that we have infrequently is that some of the agencies like to call and schedule their clients with very short notice, for instance with less than a week's notice. We are usually booked 3-4 weeks ahead due to the Army and sometimes it is not possible to get their person seen on very short notice.

All in all, I will admit that 2 weeks turnaround on a surveillance is somewhat unreasonable. Generally we send them out on the same day they see the physician unless we are waiting for a sendout lab and the only one we usually have to wait for is lead which we have in 48-72 hours. I agree with Sharon about pushing the vendors for faster turnaround times.

[Chi-RN]

Thank you. You have really helped me a great deal. I'll let you know how it goes over the next few days! -ga