from Health Action- October 2012

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Ouality
and
Audit
inOccupational
Health
Jf QualitVis fitnessforpurposethenwhatispurpose?
IPurpose and excellenceare not necessarilyself-
evident.
In an occupationalhealth servicecontext,is the
purpose
for:
r Improvingthehealthof theworker(s).
o Reducingrisksto health,detectingdisease
or
assessing
risksto health,
o Increasing
theavailability,fitnessandproductivity
of the workforce (andhenceprofits)?
Perhaps
Qualityin Occupational
Healthis ,,in
theeyes
of thebeholder"'l
If so,who is thebeholder?
o Theemployer o Theemplovee(s)
o Theoccupational
healthserrice 'supplier'
o Theexternal
qualitysysrems
auditor
o The occupational
healthauditor/peer
rerieuer or
perhaps
rThe legislator
Worker'sPerception
o Goodhealth
o Stableandsatisfactory
employment
Mancrger'sperception
o Rapidresponse r Authoritativereporl
o Advicethatwill pennita managerial
decision
OccupatiortaI heet
Ith prctf'e.s
sicut
ctI's1t
erception
o Impartialadvice . Accuraterisk assessment
o Validadviceon risk reduction
Standards
of quality
If the perceptions
of quality are so diffbrent.is it
possibleto definea single'GoldStandard"l
Is therelikely to be a simpleunitary 'League
Table'
measure
of quality?
Given the complexityof the issues- the answersto
thesequestions
arealmostcertainly'NO'.
Inadequate
evidence-based
standards
of practicein
occupationalhealthare fundamentalweaknesses.In
many contexts, thereis a wide diversity of practice
betweenoccupationalhealth services,and between
differentcategories
of occupational
healthpractitioners
ostensibly
workingto achievethesameend. Debateis
neededabouthow Occupational
Healthis practised,
what the aims and purposesare (and hence the
measures
appropriate
to ensurequality). Often there
is inadequate
scientificevidenceto justify a particular
practice. If that practiceor policy is accepted
uncritically as a quality assurance
standardor as an
audit criterion, healthoutcomesin the long-termmight
suffer ratherthan benefit. Perhaps,thereis a casefor
Cochrane
type collaboration
in occupational
health,or
a firrmof evidence-based
occupational
medicine
to help
le.(rlve
thi. iundantental
ditficultr.
I n t h e . i b . e n . .
of n_crd
rl.rndrrd..
one nte hu c itr
C O n l p ; r c
o h . e r r e di
_ r - '
s t r u C t u r e . l n d . ' F
practiee.ucain:t"*"t "*!l
-suidelines as
follorr
s:
Assuring and measuring quality in
occupational
health
Ourresponse
tothedifficultiesoutlinedaboveshould
avoid the two opposingpitfalls of 'nihilism'
or of
measunnganythingthat can be measuredsimply
because
it can.
Severalapproaches
to assure
quality andto conduct
audit in occupational
healthhavebeenconsidered.If
all of thesewere pursuedto the extentto which they
are individually advocated,
a considerable
amountof
resourcewould needto be invested.and if this had a
HealthAction. October
2012
l 2

2. limited return, seriousinefficiency could arise.
Moreover, if an inappropriate choice of quality
assurance
standards
or of audit topics or methodsis
made,false(positiveor negative)conclusions
may be
drawn about an occupationalhealth service, and
ineffective, or even counter-productive,changes
implemented.
Education and professional competence of
occupational
healthprofessionals
aswell asof managers
mustnotbeoverlookedin thequestfor quality assurance
standardsand audit criteria. In a controlled study
investigating
changes
broughtaboutby cyclesof peer
reviewaudit,the effectof audition.theprocess
of care
waslimitedto oneaspect
of process.
resulting
in slieht
improvement.
uhen compared
to the much larger
differences
in theprocess
of careassociated
rrith pnor
trainingand standards
of competence.Thus issuesof
contlnuingprofessionaUmedical
education,
of so-called
"Clinical Governance"
andof professional
(re)validation
arecloselylinked to thepursuitof quality andits audit.
Issuesof quality andauditmust address
occupational
healththroughoutthe whole working organizationand
not merely within its occupationalhealth service. For
example,an audit of the managementof sickness
absenceby an occupationalhealth servicein isolation
will havea limited value,if it doesnot alsoaddress
the
extentto which theorganizationasa whole recognizes,
acceptsand implements appropriatereferrals as well
as the ensuingaction to prevent ill-health and to
rehabilitate.
It is essentialto developquality assurance
standards
andauditcriteriafor thosepolicies,structures,
processes
and outcomeswhich have a critical bearing on
occupational
healthcare.Al1toooftenquality standards
are devisedand audits undertakenin circumstances
merely whereit is easyto setarbitrary standards
or to
conductsimple audits. Thesemay prove to be very
poor surrogatesfor the true quality of care. For
example,in one study,essentiallyno co-relationwas
shown betweenresponsetimes following referral to
occupationalhealth serviceand the peer reviewed
qualityofthe response.It is relativelyeasyto establish
quality assurance
standards,
andto audit the useof, for
example,occupationalhygiene equipmentto measure
gases,
vaporsor respirabledustaswell aslung function
equipment.However,it maybemuchmorefundamental
andimportantto questionwhetherthecorrecthazardis
being sampled,how andwhy the samplingstrategyfor
the workplace has been determined,and whether and
to what extent appropriately sensitive and specific
Debateis neededabouthow
Occupational
Healthis practised,
whatthe
aimsandpurposesare(andhencethe
measures
appropriateto ensurequality).
Oftenthereis inadequate
scientific
evidencetojustify aparticularpractice.
questionnairesare being administeredto the workers
at significantrisk.
Example
Consider
theissueof industrialaudiometry.
aspartof
a hearingr-onservation
and monitoringprogramme.
Clearir it i: imporranrro help assurequality by
establishing
management
systems
for callingemployees
to undertaketheir audiomeffy,for regularly calibrating
theaudiometer,for recordingandstoringtheaudiograms,
for recallingthe employeesafteran interval,and soon.
Good professionaloccupationalhealth practice
requiresmuch more than thal the workplaceneedsto
be assessed
by suitableand sufficient noise surveys,
appropriateadvice must be given regardingreduction
of noiseat source,personalprotectionetc. Moreover,
the appropriate employees who need "Health
Surveillance"mustbe clearly identified. If impeccable
audiometryand systemsmanagement
is appliedto a
poorly selectedsubsetof employees(while othersat
equal or greaterrisk are overlooked) or if inadequate
stepsare taken to reduceexposureat sourceand/or
implement personalprotection,then sadly good
occupationalhealth standards
have not beenachieved.
It is essentialto searchfor the fundamentalo'weak
links" in thepursuitof auditandquality in occupational
healthboth within the disciplineasa whole and within
eachand every workplace,whereit must be practised.
Scientificresearch,
appropriate
professional
competence
and debatebetweenthe practitioners concernedwith
helpachievethis. Thepressure
for quality improvement
and the adventof third party auditsmay help in some
circumstances.However,if thesepressures
result in
arbitrary quality standardsor in auditing what can be
auditedratherthan what should,they may lead to
unwarrantedself-satisfaction
hiding fundamentalflaws
in occupationalhealthcare.l
(Clinical Instructor (Psychiatric Nursing), College of Nursing,
Jawarharlal Institute of Post Graduate Medical Education and
Research(JIPMER), Puducherry. The author acknowledges
various sourceswhich are available on request)
HealthAclion o October2012