Introduction to Surveillance and Certification Exams
Medical surveillance and certification examinations contribute to the overall goal of a healthy and safe work environment, the prevention of work-related diseases, and the maintenance and promotion of work ability of employees.
Medical surveillance and certification examinations are mandated by specific regulations. These programs are implemented to meet regulatory requirements, guidelines, or established standards of practice to help prevent occupational disease and to protect the health and safety of employees. Regulations include the Code of Federal Regulations, Department of Defense issuances, and Military Department issuances.
Surveillance examinations are performed in the context of work that involves known health hazards. Surveillance examinations should be linked to environmental surveillance. The process of medical surveillance involves the direct medical evaluation of individuals at risk for the development of disorders related to health hazards in the workplace. Surveillance examinations are a systematic monitoring of individual workers as well as a systematic approach for healthcare providers in order to recognize occupational disease and injury. The goal of surveillance examinations is prevention and is based on the principle that occupational diseases and injuries are preventable.
Medical surveillance examinations are designed to identify early evidence of work-related health effects while they are still reversible. They are a search for unrecognized disease at a stage at which intervention can slow, halt, or reverse the progression of the disorder. Effective surveillance examinations should identify disease at an early stage, before it would otherwise become evident. Early identification is important because interventions are more beneficial when applied early in the disease process.
In some cases, surveillance is designed to detect exposure rather than disease. In these cases, biological monitoring is used. Biological monitoring is the measurement of a chemical, its metabolite, or a biochemical effect for the purpose of assessing exposure. The purpose of biological monitoring is to detect exposures that are occurring even at levels that do not imply the presence of disease.
Effective medical surveillance programs not only target interventions of direct value to the affected individual, but to others at risk of developing the same disorder. A critical intervention is to control the environmental factors that are responsible for causing the disease. By recognizing work-related disease or injury, health professionals can initiate activities to ameliorate the hazardous condition.
A critical concept is that medical surveillance is one technique in a continuum for the prevention of occupational disease. Other techniques include: eliminating hazards from the workplace or substitution of a nonhazardous substance for a hazardous one; containing hazards with engineering controls including installation of engineering controls and devices; work practice alternatives; and protecting workers with personal protective equipment.
Another critical concept is that medical surveillance is an indicator of the effectiveness of existing workplace control measures. Detection of adverse health effects provides evidence of control failures in the workplace. Early detection of disease or abnormality can identify inadequate control measures, allowing them to be corrected so that other workers can be protected. Prevention starts at the workplace and not with medical surveillance. Medical surveillance examinations screen for the presence of disease that has already begun or for exposure that has already occurred. Medical surveillance is just one element of an effective safety and occupational health program.
It is important to note that medical surveillance is a secondary preventive measure in the control of occupational illness. The primary control measure is to reduce the hazardous exposure. To be effective, medical surveillance must be directly linked to preventive action in the workplace. Actions prompted by the surveillance system should be directed not only at the individual case, but also at the responsible workplace factors.
In summary, medical surveillance exams are part of a comprehensive process that helps to bring about changes that prevent exposure to health hazards, and enhance the quality of working conditions and the employee's health, well-being, and work ability.
Certification examinations are performed in the context of work that involves specific health requirements. Requirements can be found in the governing instruction for the work process or equipment. When they are not, the medical examiner will use the position description and knowledge of job functions. These exams are an individualized assessment of the employee’s ability to perform job functions and to perform those functions safely. The medical examiner correlates the individual’s medical conditions to job functions and makes recommendations based on the impact of the medical condition on the safe performance of the job functions. The goal is to place employees in work commensurate with their physical and emotional capacities, which can be performed without endangering the worker or fellow employees and without damaging property.
Types of Examinations
For each surveillance and certification examination, there can be up to three different types of examination. These types are baseline, periodic, and termination. Surveillance exams typically include all three, while certification exams typically include only baseline and periodic examinations. For each examination there will be specified, relevant medical history, physical exam elements, and laboratory tests. There will also be a specified exam periodicity. The content of the exams is in accordance with the objectives of the work and health requirements inherent in the work. Surveillance and certification exams are planned events that are part of broader programs and are not for situational exposures.
- Baseline Examinations
Baseline surveillance examinations are conducted prior to initiating work that might be reasonably anticipated to cause occupational exposure to a potential hazard. These examinations are also used to develop an individual baseline for use in assessing future changes. Baseline certification examinations assess whether the employee is physically capable of performing essential job functions safely. In both cases the medical examiner can make recommendations to adjust the work environment. Additionally, these examinations can be used to educate employees on the hazards of the work, prevention, and the connections between work and health. Ideally the final outcome of a baseline examination is the placement of an employee into a job that justifiably suits his/her health.
- Periodic Examinations
Periodic examinations are administered at regular intervals as dictated by regulations or the expected timing of health effects in relation to occupational exposure to a potential hazard. In the case of surveillance examinations, the medical evaluation is performed for the early detection of occupational illness. Periodic examinations are designed to detect, as early as possible, potential changes in health, the onset of diseases, and indications of problems in coping and the threat of lowered work ability. The medical examiner assesses work ability and recommends limitations when necessary. These exams can also be used to promote employee health and work ability. Outcomes of periodic examinations include: employees who are aware of the connections between lifestyle and health and work ability and of the influence of work on health; workplace managers who are aware of an employee's work ability and of problems arising from work; and workplace managers who make changes to working conditions to maintain healthy working conditions.
- Termination Examinations
Termination examinations closely mirror the other exam types. These examinations are frequently used by employers to document that the employee has suffered no adverse health effects from employment or to establish the extent of any such effects. Termination examinations are administered at the time of termination of employment or at the time the employee is no longer occupationally exposed to the potential hazard.
Occupational medical examinations are designed to be simple, noninvasive and safe. The examinations should be sufficiently comprehensive to achieve the goal of the examination. Only information that is necessary for achieving the goal of the examination is collected. The methods used by the medical examiner should be scientifically validated, correctly used, and their results correctly interpreted. Furthermore, the chosen methods must be used in the same way for each examination. The medical examiner should be provided with a description of the duties and physical abilities required by the job, protective equipment used by the worker, an estimate of the exposure level (in the case of surveillance examinations), and any other information pertinent to the clinical evaluation. Ideally, medical examiners should gain first-hand knowledge of workplace conditions by visiting worksites to observe job requirements. At the conclusion of the examination the medical examiner issues a statement on the work ability of the employee and, if necessary, clearly defined limitations and recommendations on restrictions. The medical examiner may also make recommendations for workplace improvement and/or suggest measures to support continued work.
Roles and Responsibilities
Successful safety and occupational health programs have good coordination between management, employees, and healthcare providers.
Roles and responsibilities of management include:
- Assessing workplace control measures and personal protective equipment
- Correcting conditions that lead to occupational health morbidity
- Managing restrictions imposed on an employee as a result of the medical examination that limit the employee from performing certain functions of a work-related task
- Ensuring employees are in the correct surveillance and certification programs and informing the employees of the requirement
- Communicating with employees and healthcare providers
- Ensuring employees report for medical examinations
Roles and responsibilities of employees include:
- Keeping all appointments with the healthcare provider and completing the required medical examinations and tests
- Taking an active interest in one’s health
Roles and responsibilities of medical examiners include:
- Being familiar with clinical medicine and toxicology
- Understanding the applicability of industrial hygiene exposure measurements
- Comprehending the importance of a standardized approach to exam performance
- Being cognizant of existing laws and regulations
- Interpreting results and presenting the findings to management and workers
- Making consistent and well justified decisions concerning employees’ suitability for work
- Determining causality
- Being responsible for quality control of the medical aspects of the program including the use of properly calibrated and functional equipment, using certified and proficient laboratories, and having appropriately trained staff
Tips for a Successful Program
- Assess the workplace - define the baseline situation, identify work and work processes, and identify equipment used
- Obtain the Industrial Hygiene Survey – excellent source of recommendations to improve the workplace
- Communicate with and involve employees and healthcare providers
- Know the regulations – in particular, service level instructions
- Set goals – improve the workplace and make is a safer place to work
- Take responsibility!