A Tale of Two Accommodations

It was the best of accommodations, it was the worst of accommodations….

All apologies to Charles Dickens for stealing his famous opening line but over a very short time period several years ago, we were sent two claimants who fell at the extremes of what can happen during workplace accommodations following a workplace injury.

In both cases, accurate job descriptions could have prevented these issues.

The first of the two cases was an employee at a county run mental health facility.  Unfortunately, we evaluated this claimant after they were injured in the position that was used as an accommodation after their first workplace injury.  The employee’s second injury was a reinjury of their right rotator cuff, which had been injured in the first injury.  At the time of the employee’s first injury, she worked as a Certified Nurses Assistant.  While transferring a patient, she suffered a tear of her right rotator cuff for which she underwent surgical repair of the rotator cuff.  She attended physical therapy for approximately 3 months following surgery.  At the conclusion of physical therapy, the claimant was accommodated through placement in a different position after the treating physician suggested that she was not able to safely return to her previous position as a CNA.  An FCE to determine her physical abilities at the end of treatment was not performed.  The employer chose to accommodate the employee by offering her a position within the housekeeping department of the facility, specifically in a position that was responsible for distribution of clean linens and collection of dirty and/or used linens.

Within 4 months of being switched to the housekeeping department, the employee was lifting a bag of dirty linens into a tall rolling cart when she tore injured her right rotator cuff for the second time.  She underwent a second surgical repair and was sent for an FCE after completing physical therapy.  She provided a consistent effort during the FCE and qualified at the light work level (20 pounds occasional, 10 pounds frequent, negligible constant).  In both cases, the employer did not have customized job descriptions for either of these job titles.   

The Dictionary of Occupational Titles places the CNA position and the linen staff for housekeeping in a hospital at the medium work level (50 pounds occasional, 25 pounds frequent, 10 pounds constant).  While lacking a customized description that accurately and objectively defines the minimum essential physical demands, a cursory look at the DOT entries would indicate that this accommodation was a transfer to a position with a similar physical demand level as the position that the physician had recommended against.  Having measured the physical demands for both positions at several facilities, while the overall tasks performed are different, the forces required to push, pull, and lift in performance of tasks is similar.  Employees working in linen services in most hospital facilities face overstuffed bags of dirty linens that have to be lifted to shoulder height or above when placing in laundry carts as well as several other physically demanding tasks.

The second case started off slightly different.  He had been sent for an FCE due to injuries sustained in a vehicle based accident at work.  Based on the customized job description that was provided by the employer, his FCE results indicated that he did not meet the essential minimum physical and postural demands of his position.  The employer identified a variety of tasks that could be performed by the employee in an accommodation based on his demonstrated physical abilities during the FCE.  They asked us to perform an onsite visit to measure the physical demands and postures of the tasks that would be offered as an accommodation to the employee.   As we were evaluating tasks, the supervisor showed us the equipment on which the employee had been injured.  As we were looking at the equipment, I dug into my notebook where I had a copy of the provided job description. 

The onsite equipment did not match the job description that we had been provided with for the test.  The equipment used for the employee’s job title provided ground level access with handrails and required only an 8 inch step to climb onto the equipment.  The job description had indicated a step height of 22 inches.  We brought this to the attention of the supervisor who looked at the description that I had brought with me.  He realized that they had been using a company wide description that did not accurately reflect the equipment at each of the sites.  The description had been based on a location in another state. 

We continued to evaluate the proposed accommodations but we also measured the demands for the position that the employee held at the time of injury.  After collecting all of the data, a review of the employee’s FCE performance versus site specific equipment measurements indicated that the employee could return to his full duty position with no restrictions.  Fully documented addendums were sent to the case manager and the treating physician.  The treating physician returned the employee to full duty.

While the second case had a successful outcome for both the employer and employee, the case could have been resolved about 1 month earlier had the provided job description been accurate for the specific worksite.  In the first case, a second injury with subsequent surgery may have been prevented if the accommodated position had been validated against the individual’s physical abilities.  In both cases, accurate job descriptions could have prevented these issues.

You Can’t Have Good Work Conditioning Without Good Job Descriptions

Recently**, a physical therapist who I’ve known for years reached out to me for some advice. She had two patients that were being sent for “work conditioning” to her. The problem was that job descriptions weren’t provided for either of the two patients. She knew that the “I only have to do this…..I never have to do that” wasn’t the whole story. She also knew that I had been involved in writing job descriptions for those positions for some of our clients. Having performed Functional Capacity Evaluations with us in the past, she also knew that having a solid job description is key in matching up demonstrated performance to essential physical and postural demands.

Work conditioning is defined by the American Physical Therapy Association as “work related, intensive, goal-oriented treatment program specifically designed to restore an individual’s systemic, neuromusculoskeletal and cardiopulmonary functions. The objective is to restore the injured employee’s physical capacity and function for return to work.”

Without understanding what the functional demand is for a specific position, it is difficult to define the goals of a work conditioning program. One of the patients that she had inquired about was a school bus driver. He had told my friend that he “really didn’t have to do much beyond sit in the driver’s seat and drive. Maybe, open the door every so often to let the kids on in the morning or off in the afternoon.” He was returning to work from a lower extremity injury that resulted in a joint replacement. Having performed FCEs for school bus personnel before, she knew that the demands were more but was unsure of the other tasks.

School bus drivers are tasked with performing pre- and post- inspections of their vehicles. This involves checking in and around the vehicle, checking storage compartments (if the bus has one), ensuring that all emergency exits (including the roof exits) are operational, and being able to check under the seats for both children and their belongings. Also, in some districts, bus drivers may be switched to different routes based on employer needs. Switching routes may require drivers to pick up students who may be in wheelchairs. When the wheelchair lift malfunctions, drivers use a manual, hydraulic pump to elevate and lower the lift as needed. This task requires the driver to be able to squat or kneel to a level to operate the manual pump. Drivers, if an aide is not present, may have to secure wheelchairs to floor mounted devices, which requires the ability to kneel while reaching. With demands such as those listed, she needed to work with this patient on being able to step up/down to get into and out of the bus, to be able to kneel to perform tasks, and make sure that the driver demonstrated the ability to perform the overhead tasks of checking the emergency exits. The ability to perform these demands are even more important as a result of the NTSB school bus driver recommendations that I mentioned in a January blog post.

Based on the APTA definition, work conditioning covers a larger swath than when the patient was being treated solely for the injury that brought them to physical therapy. During that initial portion of the treatment, therapy focused on the needs of healing for the specific body part along with improving range of motion and strength as appropriate based on the healing process. Work conditioning helps to pick up to make sure that the other aspects of the injured worker such as their cardiovascular endurance, strength, power, and muscular endurance are not impaired when they are returned back to work. As a result, work conditioning includes activities to improve physical capacity in all of these areas. When an individual begins a work conditioning program, their initial status in these components should be documented – both as a baseline as well as for comparison to the essential postural and physical demands. This will help the therapist communicate to the patient, the case manager, the physician, and the employer as to where the patient is in regard to return to duty.

When quarantine/shelter in place orders begin to be lifted, work conditioning is going to play an important role in returning workers that had been out on workers comp prior to the pandemic to their previous roles. For many of these patients, they may have been shifted over to telerehab as clinics closed for safety issues. Telerehab and “virtual physical therapy” are great for keeping in contact with the worker and moving them along in their rehab journey as best as can be done in these circumstances. However, they may not have access to the resources or guidance to recondition themselves for work prior to returning to their job. Correcting this deconditioning is going to be vital to their success upon return to work as well as for reducing their risks for suffering another injury after return to work.

Yellow school bus. Vector illustration
Yellow school bus. Vector illustration

** – I had started writing this several weeks before all of the “shelter in place” orders started to come down from the different states and it sat in a draft folder for a while. As I revisited the draft after a little over 3 weeks in quarantine, it made me think about the fact that some injured workers currently in PT may be deconditioned if not by now, but definitely by the time the shelter in place orders are lifted. Getting these workers into a work conditioning program at the soonest appropriate time point may be the best chance for a successful return to work process.

Importance of Job Rotation, Job Title, and Essential Demands (and baseball)

I have had two separate discussions this week involving job titles, job descriptions, and when employees are required to do jobs that are outside of their “specific” job title – but still essential job demands of their overall “job title”.  During both discussions, a key detail to the “specific” job title in question was that the specific job title falls under a much broader category.

I try to avoid sports analogies when meeting with clients because they can sometimes be cliché, especially depending upon the setting.  However, a recent Phillies game went into extra innings and became a great example of the situation that both clients were questioning.   While we refer to most major league baseball players by the position that they play, the overall job title that applies to them is baseball player.  During this extra inning game, the Phillies manager had to make some adjustments in the 13th inning (not really different than unplanned overtime) which included moving an outfielder to pitching and having a pitcher play in left field.  While not uncommon, moves like this don’t happen in every extra inning game.  What made this game memorable is that Vince Velasquez, the pitcher who was placed in left field, made two highlight worthy throws to throw runners out.  Each of these players were moved from their “normal” job to a different job, but still under the same title, and were able to fulfill their role – well maybe not for the outfielder who pitched because the Phillies lost the game.

We have several clients that use a system similar to this, in that when a person applies for a position with the company, they will apply for Job Title “A”.  For these clients, Job Title “A” will have several sub-titles or location areas that the employee may be directed to work within after company specific training.  They may have been hired with experience in other sub-titles or locations but these companies, much like the military, will place these new employees where they have a demand.   One of the companies uses a title of Mechanical for the position.  Those within the Mechanical position may work in carpentry, plumbing, electrical, rigging, welding, etc.  While an employee may be placed in one of these areas dependent upon company needs, they are all trained to be able to perform the tasks of mechanical employees so that when the need arises they can fill that particular need.  On the public sector side of this issue, we have seen similar job descriptions that require staff of public works departments or the buildings and grounds department within a school district have to be able to perform multiple roles as needed.

Cross job utilization can allow for companies to identify modified duty accommodations that an employee may be able to fill, help to spread out overtime over a larger group of employees if an individual employee is injured or ill, and allows some employers to reduce the amount of different job titles that they need to perform post-offer pre-employment tests for – if the job demands to be able to perform across multiple roles can be demonstrated to be an essential demand.

**  Of note for the diehard baseball fans, prior to these highlight reel throws Vince Velasquez was famous for throwing out a runner using his left arm after being struck in the right arm by a 96 mph line drive during the 2018 season.