disability management and organizational change: the ... report 2009-2010 final report.pdf ·...

Disability ManageMent anD OrganizatiOnal Change: the Disability ManageMent aCtiOn researCh PrOjeCt

2009-2010Final report

national institute of disability management and research


national institute of disability management and researchdmar final repor t march 2011

Copyright © 2011 National Institute of Disability Management and Research

The views expressed in this document do not necessarily reflect those of the National Institute of Disability Management and Research, and the National Institute of Disability Management and Research does not assume responsibility for the views expressed and the information provided in this document nor in any of the references included.

All rights reserved. No part of this publication may be produced, stored in a retrieval system, or transcribed, in any form or by any means – electronic, mechanical, photocopying, recording or otherwise – without the prior written permission of the National Institute of Disability Management and Research.

ISBN: 978-0-9738181-4-7


national institute of disability management and research 3dmar final repor t march 2011

The Disability Management Action Research Project (DMAR) was reviewed by senior management at both Vancouver Coastal Health (VCH) and BC Nurses Union (BCNU) and was approved to proceed on March 16, 2009 with a one-year term to end mid-February 2010. The DMAR team consisted of Catherine Kidd as corporate sponsor; Sharon Saunders, representative of BCNU; Dr. Donal McAnaney (University College Dublin) methodological expert; Blake Williams, External Action Research Coordinator; and Dino Villalta as VCH internal Action Research Coordinator (previously Adrienne Hook). The team of Early Intervention and RehabilitationProgram (EIRP) Advisors also took an active role in the project. Since its initiation in March 2009, other actors that agreed to participate include the Health Science Association (HSA) and the Health Employees Union (HEU).

This report was prepared by Donal McAnaney on the basis of substantial contributions from Catherine Kidd, Anne Harvey, Dino Villalta and Blake Williams. Thanks should also be extended to all staff and management who assisted in the implementation of the DM Action Research project.


national institute of disability management and research

table OF COntents

PreFaCe: Origins of the DMar Project ...................................................................................................................................... 7

ChaPter 1: introduction to the Disability Management action research Project ............................................................. 15

ChaPter 2: the DMar Methodology ............................................................................................................................................... 21

ChaPter 3: the early intervention and rehabilitation Program .............................................................................................. 29

ChaPter 4: Outputs, Outcomes and lessons learned ................................................................................................................ 40

ChaPter 5: summary and Conclusions ........................................................................................................................................ 66

annex 1: DMar Materials ............................................................................................................................................................ 74

annex 2: DMar gantt Chart ...................................................................................................................................................... 78

annex 3: summary of the DMar journal Content ................................................................................................................. 80

annex 4: Pre and Post eirP Case studies .............................................................................................................................. 89


national institute of disability management and researchdmar final repor t march 2011

list OF Figures anD tables

Figure 1 the DM action research Project structure ............................................................................................... 22

Figure 2 the DMar action research Process ............................................................................................... 26

Figure 3 the organizational and individual dimensions of good DM Practice .......................................................... 30

Figure 4 the absence and return to work process prior to change ........................................................................... 35

Figure 5 the new process before an ltD claim .......................................................................................................... 36

Figure 6 the VCh early intervention and rehabilitation Program .............................................................................. 38

Figure 7 the increase in referrals to the eirP using Q2 2007 (eirP) as a comparison ............................................. 41

Figure 8 a comparison of participation rate pre- and post-eirP ................................................................................ 43

Figure 9 Comparison of time elapsed from date of disability to first contact with advisor ..................................... 44

Figure 10 Comparison of time from receipt of medical assessment to grtW .......................................................... 45

Figure 11 Comparison of duration from first day of absence to return to full duties ............................................... 46

Figure 12 Comparison of active duty to accommodate cases pre- and post-eirP ................................................... 47

Figure 13 Pre-post comparison of the proportion of Dta requests by union ............................................................. 48

Figure 14 Pre-post comparison of the number of Dta requests broken down by insurer ..................................... 49

Figure 15 number of new ltD claims by union Q1 2008 to Q1 2010 ........................................................................... 50

Figure 16 Participation status of eirP referrals as at the end of Q1 2010 ................................................................. 51

Figure 17 Proportional distribution of eirP referrals by status as at the end of Q1 2010 .......................................... 52

table 1 a comparison of the demographics of the participating unions and eirP participants ............................. 53

table 2 a case study comparison of the DM process pre- and post-eirP ................................................................ 55

table 3 Qualitative analysis of responses from eirP advisors .................................................................................. 57

table 4 Challenges and issues that emerged in the start-up phase of eirP ............................................................ 60

table 5 summary of positive results achieved by the eirP ................................................................................ 66



PreFaCe

Origins OF the DMar PrOjeCt

the disability management action research (dmar) project arose from an opportunity, which opened up as a result of the disability management excellence initiative in british columbia. this initiative, funded by the bc government, targeted employers across a range of sectors and offered them the chance to review their job retention and return to work policies, processes and procedures by means of the international disability management standards council (idmsc) consensus based disability management audit (cbdma). the province of bc awarded nidmar funds to launch the disability management excellence initiative to assist both private and public organizations to better manage disabilities in their workplaces.

ida goudreau, the former ceo of Vancouver coastal health, the largest health authority in bc providing medical services to a population of over one million people with a staff of 22,000 (of whom 7,000 are nursing staff), volunteered for Vch to participate in the consensus based disability management audit (cbdma). the intent was to both better understand the dm process in Vch and to glean any insights that might result to help improve its approaches to building on wellness and in helping its employees with disabilities.

Vch’s involvement in the dm excellence initiative was driven by a process of review of concerns regarding long absences of its employees undertaken by Vancouver coastal health (Vch) and the british columbia nurses union (bcnu). a number of key issues including rising costs, extended staff absences, addressing nursing skills shortages, and the role of the external provider, health-care benefit trust (hbt), motivated the Vch and bcnu to proactively address the issue of long-term absence and return to work.

the cbdma was completed and commented positively on the skill and commitment of Vancouver coastal health’s disability management team, and the commitment of Vancouver coastal health and its health promotion and Wellness efforts to assist disabled workers.


national institute of disability management and research8 dmar final repor t march 2011

its key findings included recommendations that Vch: • integrate the varied and sometimes “maze-like” Vch program approaches and policies into a clearly communicated and unified process to support employees with disabilities in returning to work.• review and revamp current early intervention strategies.• move from an externally based dm process with an insurer to an internal bipartite process managed by the employer, and conduct a cost-benefit analysis to evaluate its effectiveness.

after a thorough review of the audit recommendations by both bcnu and Vch senior leaders, an agreement was reached to design and implement a pilot project to address them. the principle participants had both personal and professional insights into this process gained by many years of collective experience dealing with disability issues facing their employees and union members.

leadership from the union had seen negotiations and systems created over the years that were problematic due to either unclear “duty to accommodate” language or by employers having no budgetary resources to support return to work efforts. often, shop stewards were kept out of the process and the systems developed were bureaucratic with inadequate evaluation mechanisms. the bcnu decided it wanted a problem-solving method in dm to help create a “dialogue that makes sense to their members”.

Vch leadership had experienced first-hand over the years the challenges their disabled employ-ees faced when they did not return to work (rtW), were subsequently cut off benefits, and lost their intrinsic sense of self and value. efforts to improve processes for employees with third party providers were frustrating. skilled staff losses were occurring during a time of skills scarcity, long term disability (ltd) costs were rising exponentially, and surprisingly Worksafebc assessments were decreasing. it was difficult to understand what was really happening and the information provided by third parties was less than helpful. When the audit report was shared with the unions, third party providers, and other health authorities, the bcnu leadership offered to set aside the collective agreement in order to help re-design the rtW model with processes that built trust for their members.

a new collective agreement was formed whereby Vch would undertake early intervention and all dm steps internally. northern health authority also expressed interest in monitoring the Vch pilot project as it prepared for its own cbdma.

through this collaborative effort, meetings took place to plan the enactment of a year long pilot project that would change the current way of “doing business” and forge new processes that were employee-centered and employer led. the positive trust relationship between the Vch and bcnu



leadership including catherine Kidd, regional director for Worksafe and Wellness at Vch, and sharon saunders, senior officer, health and Welfare benefits at bcnu was a key ingredient to the courses of action that were reviewed and undertaken. early agreements on data collection and sharing, voluntary participation by employees in the pilot, and measurement of employee satisfac-tion within the pilot were important stepping stones. the pilot project was to include the following elements:• Vch assumed responsibility for the early intervention program, taking it away from hbt and bringing it in-house• Vch assumed responsibility for rehabilitation and return to work for Vch employees who have a claim that is less than two years old • Vch worked directly with the insurer greatWest life (gWl)• hbt, as payer, was to pay for rehabilitation and retraining determined by Vch and gWl• a joint union-management committee was to meet to share data and outcomes

the decision was taken to fund through the dm excellence initiative an action research project to follow the pilot program’s progress through both an internal and external means to capture data and the organization’s learning processes while implementing change. in addition to the dmar data collection, Vch management determined what key indicators would be employed in consulta-tion with the ministry of health.

periodic project coordination team meetings were planned to help keep the research moving and to address issues and any barriers as they arose. the focus of the dmar project for Vch was to capture the data and the lessons learned in implementing the cbdma audit recommendations.

the principal “conceptual change” led to the need to create a legal framework with the healthcare benefit trust (hbt) so that direct communication by case managers with the insurer could begin.

the Vch presentations to all three unions about disability management allowed them to see the value of the new dm model to their members.

in all the tremendous amount of changes to get the pilot project off the ground, team members needed to keep up the momentum and enthusiasm with staff.

given the significance of the changes planned and the competition among different health au-thorities, senior management support that did not flinch when the heat was on was crucial to the success in starting the pilot project at Vch.



A Summary of the CBDMA recommendations

in the summer of 2008, Vancouver coastal health participated in a consensus based disability management audit (cbdma) and, through this process, Vch hoped to find ways in which it could improve its performance in managing the disabilities of its staff, whether related to occupational or non-occupational illness or injury.

over the previous years, Vch had invested increased time and attention to management of disabilities, but felt frustrated by what seemed to be less than best practices in relation to early intervention for non-occupational injury and illness, as well as rehabilitation for staff on long term disability. there was also much dissatisfaction expressed by the unions in relation to the services being provided for their members in the existing early intervention program and long term disability plan. there was more satisfaction in relation to the effectiveness of the management of staff with occupational related disabilities.

the audit results confirmed the beliefs of the Vch disability management staff. the audit results were shared with the three major healthcare unions. one of those healthcare unions, the british columbia nurses union, approached Vch, and together developed a letter of understanding in which the current terms of the collective agreement were put aside. the letter of understanding established an agreement whereby both the early intervention program and the rehabilitation as-pects of the long term disability plan would be managed by Vch instead of a third party provider. this pilot project commenced in april 2009.

in order to fully understand the background of this action research project, the following informa-tion is extracted from the executive summary of the cbdma audit report.

it was clear during the audit that Vch had put significant time, effort and resources into the devel-opment and implementation of their disability management program and many areas of strengths were to be found in this program, three of the most significant were: • skill and commitment of Vancouver coastal health’s disability management team • commitment of Vancouver coastal health to assist disabled workers• health promotion and Wellness

based on the results of the audit the following areas presented the most significant needs:

1. Policy Development and Integration: one of the areas of concern that was most obvious was the lack of integration of policies and procedures related to the disability management



program. Vancouver coastal health and third party insurers offered a wide range of programming and services to workers with disabilities; however, there seemed to be an overall lack of planning and integration. in reviewing the evidence, it was apparent there was a maze of programming related to disability management, which was almost impossible to fully comprehend. rather than having one set of policies and procedures, each of the separate programs (e.g. early intervention program, pears, transitional Work program, etc.) had their own. as such, it was unclear as to where the responsibility of one program started and stopped and where the next one took over. these numerous programs, all with separate areas of responsibility, were running the risk of not providing optimal services to the disabled worker. this in turn could create significant ethical, legal and financial implications for the organization.

2. Disability Management Service Provision: the delivery of disability management services for non-occupational illness and injury at Vancouver coast health involved a number of players including: the internal Vch disability management program, healthcare benefit trust and greatWest life (ltd insurance provider). this “layering” of providers created an environment where there was less than optimum service to workers with disabilities.

the Vch system appeared to be a “hybrid”, whereby some of the responsibility for disability management service delivery belonged with the workplace; but major components of the de-livery of service rested with third party providers (i.e. healthcare benefit trust and greatWest life). the separation of the worker with a disability from a workplace-based solution added additional difficulties to an already complex process.

the difficulties associated with this type of service delivery model demonstrated itself in a number of ways, including:

• the average time between a worker leaving the workplace due to a disability until they were first contacted by the early intervention program was 38 days in comparison to most common practice for organizations with effective disability management programs where this is a maximum of 14 days to contact a worker after their leaving the workplace due to a disability (with immediate contact if it is apparent the worker will be off for an extended period of time).

• the early intervention program was undertaken in isolation from Vch and it was not meeting the needs of the workplace.



• the return-to-work programming of Vch reflected the approach of an earlier era where interventions were solely directed at the worker; whereas more recent approaches to return- to-work programming attempts to rehabilitate not only the worker but the workplace.

• due to the nature of the system, return-to-work personnel from healthcare benefit trust and greatWest life worked outside of the workplace environment. they provided direct rehabilitation services to the disabled worker, but had only indirect influence on the rehabilitation of the workplace.

• a lack of effective communication between the Vancouver coastal health return-to-work personnel and the third party providers was also apparent. Vch did not feel they were able to obtain the breadth of information they needed to make decisions beneficial to their disabled workers.

3. Disability Management Cost/Benefit Analysis: in examining the documentation provided by the organization, it was noted that very significant expenditures were made towards the direct costs of disabilities in the workplace. it was estimated that approximately $35 million was being expended on occupational and non-occupational assessment rates each year. it should be noted that the canadian department of labour estimates that for every dollar that is expended for the direct costs of disabilities, the workplace conservatively expends another dollar on indirect costs (e.g. rehiring, retraining, overtime, additional supervision, etc.). on this basis, Vch was expending $70 million per year on costs related to disabilities in the workplace not including sick time benefits or the cost of staff replacement for those off on sick time.

With such a financial impact on the organization, the audit noted a number of areas of concern:

• there were a number of key participants in the dm process (Vch, hbt, gWl and service providers). this led to a significant level of risk that expenditures were being duplicated.

• even though there was a very significant expenditure on dm at the workplace, there was a noticeable lack of organizational cost/benefit analysis. it was found that the workplace did track such things as injury rate, type of injury, length of time on claim, etc., but not the costs associated with these expenditures (i.e. direct and indirect costs). there was no methodology in place to track the savings to the organization by having a dm program in place.

• it was estimated that approximately 800 to 900 individuals were at that time on permanent long term disability. Vch had no access to a useful list of workers with permanent disabilities and as such, there was no process in place to inform these workers of the potential



opportunity to re-enter the workplace with an accommodation. it could be assumed that many if not most of the workers who were on permanent disability would not be able to return to work due to the residual effects of their disability. however, there could be some who would relish the opportunity to return to work if they were made aware of the possibility of being accommodated at the workplace (e.g. shorter hours, graduated return to work, different job, etc.).

4. Lack of Knowledge of Disability Management: a survey was undertaken of over 900 employees of Vancouver coastal health, which revealed that approximately one-half of these individuals were not aware of Vch’s dm program or its benefits. in addition, over 60 percent of the respondents had either no idea or a vague idea of what would happen to them if they were ever to become disabled.

as a result, a number of recommendations were made including:.(a) development of policies and procedures – it was strongly recommended that a process be put in place to examine all return-to-work programs and to develop a policy and procedures manual which encompasses all of these activities. it was also recommended that a policy manual be developed and jointly developed and approved by both labour and management.

(b) re-examination of disability management services (non-occupational) – it was recommended that Vch re-evaluate its relationship with hbt and gWl to make a determination if it would be feasible to deliver some or all of the services they are currently providing internally.

(c) cost/benefit analysis – it was recommended that:

• a process be put in place to track and report both the direct and indirect costs related to disabilities at the workplace.

• a process be put in place to document the costs and savings attributable to the disability management program.

• Vch examine the possibilities of streamlining its processes to ensure that both staffing and resources are utilized in the most effective manner possible.

• Vch’s return-to-work program be given access to pertinent information regarding the permanent long term disability cases.

• it was further recommended that a process be put in place to examine the possibility of offering those workers who were medically able the opportunity to return to work.



(d) education – it was recommended that Vch develop an education program to inform all employees about the availability of the program, its benefits and the process used to assist them if they ever become disabled including:

• orientation training – at the time of hiring, every employee should be given training about the disability management program, its benefits and the process/services that are used if they ever become disabled.

• ongoing education – education should be provided to all employees on a regular basis. this can either be done as an addition to the current safety program, or as a “stand- alone”. this education could include brochures, website information, mail-outs, etc.

• satisfaction survey – a satisfaction survey should be given on a regular basis, not only to those individuals who have participated in the disability management program, but to all employees.



Chapter 1:intrODuCtiOn tO the Disability ManageMent aCtiOn researCh PrOjeCt

intrODuCtiOn

it is important to clarify the dm action research project is not about addressing the needs and recommendations of the cbdma. it is rather about documenting the things that worked and the challenges faced when Vch attempted to respond to these recommendations and particularly to internalize its dm processes and procedures. Vch is going about addressing the issues raised in the audit particularly through its early intervention and rehabilitation program (eirp). this is described in detail in chapter 3 of this report. the dmar project attempted to capture the change process as it was being implemented in Vch in order to document not only the corporate impact of the eirp but also the implementation process from the perspective of those with responsibility for making it work in the organization and those who were the intended beneficiaries and their representatives. one of the aims of the disability management (dm) excellence project is to document good prac-tice in dm. organizational change and continuous improvement projects are central to such good practice and thus it was essential to document the results and impact of the change process in Vch. however, Vch went further than this, and agreed that documenting the change process itself could help to provide guidance for other similar organizations who wish to embark on this path. the dmar project documented not only the benefits and risks of implementing an in-company dm program but also described how taking ownership of the processes of absence and return to work can best be done using action research methods. the change project in Vch is notable in that it had the cooperation of two unions at a very early stage. both the british columbia nurses union (bcnu) and the health sciences association (hsa) were committed to participating in the Vch change process from the beginning.

brieF DesCriPtiOn OF aCtiOn researCh the origins of action research can be traced back to the work of Kurt lewin, one of the founding fathers of social psychology, in paolo freire’s work of consciousness-raising (1970) and in various schools of liberation thought, notably marxist and feminist. more recently, it has been used in a variety of settings, but its growing popularity as a research approach owes much to its use in areas such as professional practice, organizational management and community development.



the purpose of action research is, always and explicitly, to improve practice. from a philosophical perspective, action research has been described as epistemologically objectivist. theory is particular rather than general, and reflexivity is epistemic in that it attempts to generate learning and new knowledge and the role of the researcher is close to the data (Coghlan & Brannick, 2005). action research can include all types of data gathering including qualitative and quantitative tools. however, the planning and use of these tools must be well thought through with the participants and clearly integrated into the action research process. the action research paradigm requires its own quality criteria. in other words, it is not possible to judge action research by the criteria of positive science but only within its own terms and as a mechanism for system change. martyn denscombe (2004) identifies four defining characteristics of action research: • action research is involved with practical issues and is aimed at dealing with real-world problems and issues, typically at work and in organizational settings. the purpose of action research is to improve practice by being part of practice rather than an addition to it. • action research is about change, both as a way of dealing with practical problems and as a means of discovering more about the phenomena that cause them. change is seen as a good thing and regarded as a valuable enhancer of knowledge in its own right, rather than something that is undertaken after the results of the research have been obtained. • action research involves a cyclical process in which initial findings generate possibilities for change, which are then implemented and evaluated as a prelude to further investigation. it rejects the concept of two-stage process in which research is carried out first by researchers and then implemented by practitioners. instead the two processes of research are integrated. the research feeds back directly into practice and the process is ongoing. • the active participation of practitioners is crucial in the action research process and is probably its most distinctive feature, since it hits at the heart of conventions associated with formal research. ideally in action research all actors involved in the research process are equal participants and must be involved in every stage of the research.



coghlan & brannick (2005) provide an illustration of the differences between certain researcher processes based on whether or not there is an intention for self-study in action by the researcher and by the system. by placing the system and the researcher on separate axis and specifying the presence or absence of an intention to self-study in action, the researchers produce four quadrants: • Quadrant 1 where there is no intended self-study in action either by the researcher or the system. this is where traditional research approaches such as collection of survey data, etc., are located. • Quadrant 2 where there is no intended self-study in action on the part of the researcher, but there is on the part of the system. this is where pragmatic action research such as internal consulting and action learning is located. • Quadrant 3 where there is no system self-study in action intended but where the researcher intends self-study in action and the focus is upon individual reflective study of professional practice and development. • Quadrant 4 where both the researcher and the system intend self-study in action and is located large-scale transformational change projects.



1. Professional Self-development

though it is by no means uncontested, action research is an increasingly popular approach among those working in professional areas such as education, health and social care. for example, the teacher who is concerned to improve performance in the classroom may find action research useful because it offers a systematic approach to the definition, solution and evaluation of problems and concerns (McNiff, Lomax & Whitehead, 2003).

this marks a significant shift in the locus of knowledge production about professional practice and entails a certain degree of reflection, which needs to be systematic if it is to qualify as action research. thus an action researcher is more than a reflective practitioner because he/she uses research techniques to enhance and systemize that reflection.

this type of research works on the assumption that professionals already have a good deal of knowledge, and are highly capable of learning for themselves. What they need in their professional learning is an appropriate form of support to help them celebrate what they already know, and also generate new knowledge. a number of models are available in the literature. most of them regard practice as non-linear, appreciating that people are unpredictable, and that their actions often do not follow a straightforward trajectory.

it is not enough simply for the research to be undertaken as part of the job, as this could include all kinds of data gathering and analysis to do with remote people and systems, the findings from which might have no bearing on the practitioner’s own activity. to accord with the spirit of action research, the researcher needs to investigate his/her own practices with a view to altering these in a beneficial way.

2. Organizational Development

the form of action research most often adopted in organizational development has been built largely from the work of Kurt lewin and his associates and involves a collaborative cyclical process of diagnosing a change situation or a problem, planning, gathering data, taking action, and then fact-finding about the results of that action in order to plan and take further action (Lewin, 1948; Dickens & Watkins, 1999).

this approach distinguishes between first person tasks (those taken by the action research coordinator/facilitator) and second person tasks (those taken by the people in the organization or clients), (Coghlan & Brannick, 2005).



the action research cycle begins with a critical entry point or “pre-step” that outlines the context and purpose of the project. this is about collecting information about the factors that will be influencing the organization such as economic, political and social forces, internal forces such as cultural and structural forces and understanding why the project is necessary or desirable. an important element of the pre-step is to establish collaborative relationships with those who have ownership or need to have ownership of the key questions.

once the pre-step is complete, the main steps of action research are diagnosing, planning action, taking action and evaluating action. such cycles can happen up to 20 or 30 times within any action research project.

in addition to the learning that is taking place within the organization, the authors introduce a reflection cycle, which they term meta-learning, which occurs when the action researcher reflects upon their own practice. thus, those involved in action research must be continually checking on their assumptions or the premise for the study, the process and the content. this meta-cycle of enquiry is taking place in an interactive but parallel way with the actual action research itself. important questions to be answered are “What happened?”, “how do you make sense of what happened?” and “so what?”

the dmar project offers a unique opportunity to gather evidence about the impact and implica-tions for an organization implementing a dm program. in consultation with the national institute of disability management and research (nidmar), Vch agreed to participate in a research project to document the impact of such an organizational change process.

initially a pre-post research design was considered which would illustrate the cost-benefit of being more proactive in dm based on indicators gathered during, and subsequent to, the audit and measured over a two year period. the limitation of this approach is that the processes and challenges that arise in carrying what is effectively a major organizational change project would not be documented. in addition, at this point there is ample evidence that adopting a dm approach to respond to absence and return to work makes good business sense in most systems of regulation.

the bigger question is, “What is the best way for an organization to plan and implement a change process that effectively internalizes responsibility for dm?” this cannot be documented using traditional research methods. it requires an action research model in which the staff members of the organization become engaged in data gathering as researchers into the issues, challenges and best practice that emerge during the change process required to create a coherent organization-wide



dm policy and practice. Vch were very positive about this approach and the dmar project was born. Very soon after-wards, a number of other key actors became involved including senior management, labour representatives, the regional directors for Worksafe and Wellness in each health authority in british columbia and the regional managers with casework responsibilities in Vch. this gave dmar access to a range of perspectives representing the critical stakeholders in an in-company dm process including workers, supervisors, managers, hr, Quality and occupational health and safety practitioners.

nevertheless, the analysis of pre-post data has a lot to offer in determining the impact of the changes made. on this basis it was agreed that the first year of dmar would adopt an action research methodology and also to review a number of key performance indicators. the aim of this report is to provide an overview of the progress achieved. chapter 2 presents an overview of the methodology adopted by the dmar project. chapter 3 describes the Vch early intervention and rehabilitation program which is at the heart of the dmar project. chapter 4 provides a review of outcomes and outputs of the project from a qualitative and quantitative perspective. chapter 5 concludes with observations about the progress made and the conclusions that can be reached on the basis of the results.



Chapter 2:the DMar MethODOlOgy

aiMs anD ObjeCtives

the aims and objectives of the dmar project are to document:

1. the issues, challenges and things that work when internalizing dm into an organization.2. the outcomes, impact and implications of an internalized dm system after 12 months.

PrOjeCt Partners

the partners in the dmar project are:

Vancouver coastal health (Vch)bc nurses union (bcnu)health sciences association (hsa)national institute of disability management and research (nidmar)

PrOjeCt struCture

at the heart of the dmar project are internal action researchers in each of the participating health authorities. these are senior members of staff with responsibility for the change project in their own organizations. these internal action research coordinators (iarcs) are facilitated by an external action research coordinator (earc) who has responsibility for bringing the two iarcs together to engage in action learning and collaborative enquiry and in making sure that the partners are fully engaged in the project.

the structure of the project is presented in figure 1 and a more detailed description of the procedures is presented below.

the highlighted elements of the figure represent the elements of the dmar project. they include:

1. The Project Steering Group (PSG)the psg was comprised of leaders from the partner organizations and relevant experts. the role of the psg is to overview progress in the project and to take ultimate decision making authority in relation to issues that may arise and that cannot be resolved at other levels of



the project. thus where a problem arises that cannot be resolved by the project coordination team (see below) the psg takes responsibility for resolving it. the psg is the internal governance group of project partners and the proceedings of the psg are confidential. stakeholder involvement is facilitated through the expert reference group (erg) described below.

Figure 1: DM action research Project structure



2. The Project Coordination Team (PCT)the pct is at the centre of the ar process. it is the forum for support and information sharing between the action researchers. it is where the day to day procedures for the project are generated, agreed and where appropriate adapted. it comprises of the earc and the iarcs working together. it is intended that the pct will meet regularly, often using electronic means, and review the action plans and ageing changes in response to the experiences of the ars. the pct is organized and minuted by the earc. any issues that cannot be resolved by the pct will be referred by the earc to the methodological consultant or the psg as appropriate.

3. The Expert Reference Group (ERG)the erg provides a forum through which the findings of the dmar project can be dissemi-nated and through which expert opinion can be accessed. the membership of the erg is at the discretion of the psg and membership will be agreed at its first meeting. the member-ship of the erg can include academics, researchers, dm professionals, peer organizations or funders. the erg is not scheduled to meet during the project timeframe but will be kept abreast of work in progress electronically and will be consulted as required where advice is required based on their expertise. the erg will also be invited to comment on the final de-liverable of the dmar project, i.e. the final report/how to manual produced by the project.

4. The Methodological Consultantthe role of the methodological consultant is to design and monitor the action research methodology. he works closely with the psg and the earc to ensure that the methods, materials and techniques which have been adopted for the dmar project are properly implemented and that any changes to the methodology that are required during the course of the project are within the spirit and the intent of the original project proposal. specific responsibilities include:

• development of the project specification including objectives, actions and interpretive mechanisms.• briefing of the leaders of the organizations and gaining agreement on the final action research plan.• training of the external action research coordinator (earc).• monitoring the training of the internal action research coordinators (iarc).• regularly monitoring progress during the project.• trouble shooting where challenges arise.• facilitating a multi-perspective valuing of the project outputs.• managing the production of the final report.



5. The External Action Research Coordinator (EARC)the earc has a pivotal role in the dmar project. he reports directly to the psg. he is responsible for liaising with the iarcs in each of the participating organizations, bringing them together as members of the project coordinating team (pct), facilitating the work of the psg, keeping the erg up to date and aiding the production process for the final report.

the responsibilities of the earc include:

• liaising with the iarcs • providing initial training to the iarcs • providing support and guidance to the internal iarcs as required• monitoring project progress • holding regular joint debriefing meetings with the iarcs to – – gather process data about the implementation process – identify any threats or risks to the project and facilitate resolutions – provide additional training to the iarcs as required – facilitating creative problem solving on the part of the iarcs from both organizations – re-design data collection tools as required• being available between meetings to answer queries that arise • organizing and documenting meetings of the pct • preparing reports for the psg and attending meetings • coordinating communications with the erg • producing the first draft of the final report

the earc will be supported by the methodological consultant.

6. The Internal Action Researcher Coordinators (IARCs)each organization has one iarc who is in effect the coordinator of the action research plans generated and the primary source of data generated during the change process. they have been chosen because of the key role that they are playing in the internal change strategy. the iarcs report directly to the senior management of their respective organizations on all issues arising during the change process, lead an internal implementation team, liaise with all internal stakeholders and colleagues, and document the results, implications and impact of the actions taken as part of the organizational change process.

the iarcs are trained and supported by the earc and meet together periodically as the project coordination team (pct). all issues arising during the action research project can be initially addressed to the earc. if this does not resolve them, then they can be placed on



the agenda of the pct so that collaborative problem solving can be applied. if this process fails to resolve the issues, the pct can agree to refer the issue(s) to the psg for a final judgment. throughout this process the advice of the methodological consultant can be accessed by the earc if required. the knowledge and information generated by the iarcs is privileged and confidential and can only be distributed beyond the project by the approval of the psg.

the iarcs have been provided with a number of tools to assist them in their roles as action researchers. these include an action planning template and a review and reflection Jour-nal. these will be updated on at least a weekly basis and will form a substantial part of the data to be used in anonymised format in the final report.

the main responsibilities of the iarcs include:• leading the organizational change project within their own organizations• developing and documenting an initial action plan using the template• recording their views of the results, implications and impact of the implementation of the change plan using the action research Journal• reviewing and revising the action plan based on their experiences and the data they have collected• acting as members of the pct• contributing to the production of the final report

other key actors in the project include:

the dmar project is not in itself an organizational change project. as the figure illustrates it operates within the context of the change projects being implemented within the participating organizations and aims to document good practice and potential challenges in implementing dm in each organization. thus the dmar project elements must maintain excellent communica-tions with the main internal part of the change process. in particular, the iarcs must manage their dual roles as organizational change agents and action researchers. this needs to be made explicit and sensitively managed in relationships with the senior management of Vch, the change consultant(s), if any, who are brought on board to assist the organizations with the change process, the project implementation teams within their own departments, the internal stakeholders including worker representatives and the staff members in each of the pillars in which the change project is implemented (e.g. in-house care, community care, accident and emergency). these will differ depending on the model adopted for the pilot change process by each organization.



PrOjeCt PrOCesses

the process adopted by dmar is a mainstream ar approach. it is based on a series of planning, acting and reflecting cycles which involves diagnosing the current situation, planning ways to move things forward, implementing the planned actions, gathering evidence of how effective or ineffective the actions were and on this evidence making a re-diagnosis of the situation.

it is envisaged that this cycle will take place at least four times during the 12 month deployment of the dm process in each organization.

it is inevitable that external factors will impact on this timeframe but these are also variables to be documented within the dmar frame.

the basic process is illustrated in figure 2. it should be evident from figure 2 that it is envisaged that each cycle will lead to an enhanced level of knowledge.

it is important to emphasize that the process diagram only relates to the activities of the pct and iarcs. all other elements of dmar are supportive of the process.

Figure 2: the DMar action research Process



PrOjeCt Materials

to assist the iarcs to engage effectively in their action research role and to provide an approxi-mate time frame for the project, a number of support documents have been developed. these are:

1. an action planning template2. a review and reflection Journal3. a survey of eirp advisors4. a feedback from for employees participating 5. an initial time schedule

these documents are annexed to this document.

PrOjeCt PrOCeDures

Data Collection

1. the iarcs are the primary actors in dmar. they are central to the organizational change process and they have committed to collect data about the implementation of the change process.2. initially they will meet with the earc and be introduced to the methodology and the materials of the project.3. they will develop an action plan based on their reading of the current circumstances and record this in the action planning template.4. on a regular basis (at least once a week) during the implementation they will complete the review and reflection Journal.5. they will meet as a pct at least four times during the project to engage in collaborative enquiry.6. in the interim they have the right to consult with the earc or each other about issues. this consultation will be documented.7. at the mid-point of the project they will agree on the Key performance indicators (Kpis) to be used to document the results of the dm programs being established and how these should be measured.8. the action plans (and amendments), the journals and the Kpis will provide the basis for a presentation to the psg and members of the erg. the outputs of this meeting will inform the production of the final report.



Collaborative Enquiry

it is essential for the dmar project to work effectively so that the ethos of collaborative enquiry is promoted and maintained throughout the project. to ensure that this is the case, a number of safeguards have been put in place. these cover issues such as confidentiality and support.

the information collected by the iarcs is privileged and will not be released to anyone without being anonymised. the report and conclusions of the study will be proofed by all parties and no identifying references will be permitted apart from those approved by the psg.

during the ar process the iarcs can access the earc confidentially on any issue. the earc can consult the methodological consultant on any research matters arising and the psg on any substantive issues.

through the pct the iarcs can share experiences and generate insights. the action plans, the Journals and the minutes of the meetings will document this.

Project Management

the day to day management of the dmar project is carried out by the earc in consultation with the pct in the first place and then if required in consultation with the methodological consultant or the psg as appropriate.

iarcs will keep their senior management informed and brief their teams and other participants as required.

the psg has ultimate responsibility for the effective implementation of the project.



Chapter 3:the early interventiOn anD rehabilitatiOn PrOgraM

intrODuCtiOn

internalizing dm processes within an organization operates on two key dimensions. at the organizational level it requires a change in the approach adopted by the leadership of the organization. this commitment must be embodied in the establishment of organizational policies to support job retention and reintegration of absent workers. this involves not only developing new policies reflecting the change of approach but also integrating the ethos of dm into existing policies including hr, Workplace health promotion, occupational health and safety, non-discrimination, communications, absenteeism management, legal and Quality policies. at the level of the individual worker, the return to work process must operate in a seamless manner. this requires enhancing the knowledge and skills of key staff and making resources available to assist in the return to work process.

the two primary axes around which successful integration of an organization’s dm strategy revolves are the organizational and the individual dimensions. this is illustrated in figure 3. it is essential that dm gets incorporated into the organizational ethos, policies and procedures but it is equally important that the return to work experience of the absent employee is customized and responsive to individual needs.



Figure 3: the organizational and individual dimensions of good DM Practice



Key policy objectives must aim to achieve broad support for the dm project. for this to be achieved:

• hr polices must embrace the principle that retaining an employee in their job is not only more beneficial to the worker but also makes sense financially for the organization. the cost benefit equation needs to be accepted by line management and supported by access to information and services such as employee and family assistance programs.

• the target of Workplace health promotion needs to be spread to incorporate a priority for maintaining the “workability” of the workforce and to engage at both program and individual levels to offer options to protect and maintain health in the workplace.

• occupational health and safety policies must be expanded beyond a narrow focus on risk management to include a proactive approach to adapting work conditions to support a more health protecting work context responding to the individual functional capacities of each worker.

• non-discrimination policies need to go beyond legalistic compliance with current legislative requirements to cover situations where an employee is at risk of developing a physical or mental impairment that may impact upon productivity on the basis that every case of illness or injury could result in a case of discrimination on the grounds of disability.

• changing communications policies is particularly crucial in putting in place an effective dm organizational strategy. if job retention and reintegration principles, procedures and ethos are not assimilated within organizational communications, it is unlikely that the integration of dm into an organization will be a success. communication polices must address not only the internal channels both vertically and horizontally within the organization but also communications with those external to the organization such as insurers, legal entities and importantly service providers.

• absenteeism management policy and information management systems must be reviewed and refocused to move away from a compliance approach to a facilitative one. this requires not only redesigning short term absence procedures but also extending absence management to intermediate absence so that employees who require assistance are provided with it in a safe and timely manner.

• the legal policy of the organization needs to focus on resolution of claims as opposed to contesting claims. the presence of a legal case has been documented to interfere with return to work processes on the part of the worker and the employer. an emphasis on resolution can help to increase the likelihood of reintegration and save the organization the often significant costs of contesting a claim.



• Quality policies in many organizations frequently privilege productivity and profitability goals. it is essential that maintaining the health and workability of employees becomes an integral part of the quality strategy of the organization so that monitoring and continuous improvement processes reduce barriers and enhance facilitators of job retention and return to work.

in organizational change terms, the internalization of dm processes into an organization must be accepted and integrated into general management values and performance indicators. this requires both information management systems which monitor absence and return to work in dm compatible metrics and procedures to guide managers and supervisors in the most appropriate way to respond to employee absence.

finally, changing organizational and individual behaviour requires trust. an essential ingredient of trust is cooperation and consensus. introducing organizational change to support dm needs a cooperative approach at the level of the organization and the absent employee. Working with employee representatives and hr to establish clear ground rules for the internalized dm program is essential but the principle of consensus must be deployed also at the level of the absent worker. the principle of consensus is central to an effective dm program at all levels.

the operation of effective dm policies requires the implementation of effective processes and procedures which support early monitoring and intervention and a proactive approach to case management. these are central to effective return to work.

specific dm policies and procedures must support:

• early intervention, assessment and referral to appropriate services – early intervention involves a continuum of actions that begins with early monitoring after three days, the offer of assistance at six weeks, the offer of a return to work assessment at twelve weeks and the assignment of a case manager to coordinate the interventions indicated by the assessment, including referral to appropriate services.

• engagement with the treatment process – the organization should work constructively with its absent employees and where appropriate the treating professionals to ensure that a safe and timely rtW is achieved.

• the opportunity for mediation between the absent worker and the organization – if necessary, there should be an option for negotiation to resolve differences between the employer and the absent worker, conducted by some impartial party, for the purpose of getting the employee quickly and safely back to work.



• access to a person to advocate for the worker with medical professionals, the supervisor or family where required – in some situations, e.g. if the person suffers a brain injury, they may not be able to “speak up for themselves”. in this situation the ill or injured worker should be given access to an independent person who looks after the interests of that individual and tries to ensure that they get the help and supports they need.

• the right to a customized and flexible individual return to Work plan for the absent worker – in order to develop a relevant effective return to work plan for an individual, a back to Work threshold specification would first be produced, which would include a list of inhibitors and enhancers, effecting the individual’s decision to return to work (see assessing the threshold section for more information). a return to Work intervention plan for the individual can then be drawn up, to tackle the inhibiting factors and to draw on the enhancing factors, in order to facilitate a timely and safe return to work for the individual.

• the provision of stable and appropriately individualized, supported accommodations and adjustments – company responses, although based on the policies and procedures of the company, should still be flexible and customized to the individual’s needs. for example, the individual may need a workplace adjustment such as a specially adjustable chair and a different table or they may need more breaks during the day.

• measures for a gradual resumption of work – for example, three half-days for a period of time, increasing to five half-days and so on.

• an active case management system for overseeing the reintegration process – a case manager is a trained rehabilitation professional in the coordination of the reintegration process for an ill or injured individual. they engage with the worker at whatever stage in the disability process that person is in and coordinates appropriate interventions, supports and resources in order to get them back to work in as safe and timely a manner as possible.

• opportunities for ill/injured workers to build their capacity through retraining – the policy should spell out that retraining will be provided where appropriate and that these opportunities are a significant part of the overall return to work policy.

• opportunities to obtain experience in an alternative, transitional work position – the policy should state that transitional work arrangements, i.e. temporary jobs and tasks



that are appropriate to the capacities of the employee, will be made available. it should also specify the circumstance under which they will be made available.

• use of technical support and advice – ergonomics, universal accessible design and technology adaptations.

• role integration between internal actors including hr, line management, occupational health and external providers.

• all departments or personnel should be aware of their roles and responsibilities in the rtW process and how their roles interact with each other. this would also include liaising with external services providers, e.g. training organizations, physiotherapists, etc.

The Challenges Facing VCH

at the level of the organization, Vch had many challenges to overcome. some of the policy chal-lenges have been described. this chapter concentrates on the implementation process at the level of the organization and the individual.

at the level of the organization, a crucial challenge was creating an alternative procedure for deal-ing with absence and return to work. the legacy procedure was heavily based on externalizing responsibility not only in terms of dealing with individual cases but also in terms of disability pay-ments and case closure. figure 4 illustrates the long term disability process that existed prior to the implementation of the change process.

figure 4 illustrates the original process that was utilized for individual employees at Vch who were proceeding towards qualifying for ltd. in this process, the healthcare benefit trust played the key role in the “case management” of the claim. specifically it was responsible for ensuring the individual was receiving appropriate and timely services towards the end goal of rtW. they held responsibility for coordinating with the insurer greatWest life to ensure that medical information was clear and consistent as well as providing quality control to ensure that all claims were moving forward in a concise manner. at the point where there was case consensus that a person was able to return to work in a job that was suitable and sustainable, the advisors at Vch were provided with a set of standard precautions and a graduated return to work plan was developed and imple-mented.

the focus of the pilot redesign of the dm process was to internalize procedures that were origi-nally supplied by the third party, i.e. hbt. in the previous approach, hbt was responsible for case management and Vch had responsibility for identifying potential candidates and delivering return



to work services. in this process, Vch referred absent workers to hbt which determined whether they were eligible for service. this referral procedure resulted not only in delays and left absent employees with a sense that there was a bias towards organizational imperatives but also resulted in some individuals receiving service while others did not.

by internalizing, and in essence, referring to Vch rather than external resources, communication delays were eliminated and contact with the employee was direct. the most important change was that the dm process could be offered to all individuals regardless of claim or even if they were struggling at work.

the case management process was also internalized and allowed the advisors to have added in-sight into the details and medical information specific to a claim. this created clarity when it came to the identification and elimination of rtW barriers. With this added insight rtW programs were better constructed and flags were raised on issues that were once unknown.

one of the major principles of the program was transparency. communication with employees, unions and managers was central to the success of the program. by internalizing the dm process, a layer of communication was removed and direct communications enhanced.

arbitration too often takes a “post-mortem” look at the process, useful for identifying what went wrong but not very helpful in procuring a workable solution.

Figure 4: the absence and return to work process prior to change



Figure 5: the new process before an ltD claim

While keeping personal confidentiality in the forefront of communications with the stakeholders, barriers to return to work could be discussed in a more open manner. the information deficit about workplace issues surrounding an absence was eliminated and organizational advisors who were previously only privy to physical precautions could engage in open and frank communication with the employee and relevant stakeholders.

figure 5 presents the new approach to managing absence and reintegration. it represents the pro-cess prior to a claim for long term disability benefit.

eleMents OF the eirP

the early intervention and rehabilitation program is presented in figure 6. this not only illus-trates the way in which the organizational processes were re-engineered but also the key activities targeted at the absent worker.

the goals of eirp included:

• decreasing the time lost due to work and non-work related injury and illness.• reducing the loss of valuable employees who exit into long term disability and never return.• increasing the engagement of the employee with the workplace through employer driven case management.• providing an employee centered bipartite approach with a focus on return to work.



eirp values were:

• employee centered in that it focused on maintaining connection with the employer.• employer driven in that the employer was proactive in maintaining employee contact and leading the case management process.• union participation in a partnership to develop and manage the program.

the main program elements of the eirp were:

• early intervention services (for both occupational and non-occupational illness and injury)• transitional Work programs• gradual return to Work program• Workplace accommodation• Vocational rehabilitation• program marketing and communications• program measurement, evaluation and reporting

the key eirp individual dm processes were:

• early intervention, assessment and referral to appropriate services.• engagement with the treatment process.• the opportunity for mediation between the absent worker and the organization.• access to a person to advocate for the worker with medical professionals, the supervisor or family where required.

in many of these cases the dispute focuses on the question of undue hardship. management simply takes the position that, whatever the root cause of the problem, the proposed solution is too onerous. this appears to simply duck the important root issue of whether the person is in fact suffering from something that falls within the definition of a “disability.” Without that, there is no duty to accommodate. arbitrators appear to be vexed by the difficulty of defining this increasingly-suffered disability and of determining just what, if anything, the duty to accommodate requires of an employer (and indeed at times other employees) faced with such claims. this is not to deny such medical disabilities exist; they do, but with precious little medical science to define their boundaries.



Figure 6: the vCh early intervention and rehabilitation Program

• the right to a customized and flexible individual return to Work plan for the absent worker.• the provision of stable and appropriately individualized, supported accommodations and adjustments.• measures for a gradual resumption of work.• an active case management system for overseeing the reintegration process.• opportunities for ill/injured workers to build their capacity through retraining. • opportunities to obtain experience in an alternative, transitional work position. • use of technical support and advice.• role of integration between internal actors including hr, line management, occupational health and external providers.



procedures were more clearly delineated and assistance was more readily available. it appears that the Vch model has incorporated the main elements of good dm practice.

having a supportive organizational policy and a blueprint for delivery at the individual level is only half the battle. the roll out and deployment of the program is also critical. this is the focus of the disability management action research project. it is designed to capture the process of implementa-tion and in particular the challenges and solutions on the road to effective internalization of the dm process. the reality of implementation is reflected in the subsequent chapters.



Chapter 4:OutPuts, OutCOMes anD lessOns learneD

intrODuCtiOn

the early intervention and rehabilitation program pilot has been in operation since the end of march 2009 and this report covers the period up to march 2010. it presents a comparison of the performance of the eirp to the program that was in operation prior to that date, the early inter-vention program in terms of output, outcomes and costs. there are many differences between the two approaches but the primary difference is that the eip was externalized to the healthcare benefit trust while the eirp is internalized and operated by the case management centre (cmc) within Vch. these comparisons are presented in the first section of this chapter. the second sec-tion provides a summary of the overall qualitative impact of the programs from the perspective of the internal stakeholder including the unions, the case managers and participants.

finally, as described in the methodology, the internal action research coordinators kept a journal of the issues and challenges which arose during the first year of implementation of the eirp. this provides qualitative data collected in real time about how the pilot operated and the kinds of things that needed to be addressed to ensure that it remained on course. the contents of the Vch jour-nals were subjected to a qualitative analysis and key themes and topics were extracted. these are presented in sections 3 and 4 of this chapter.

seCtiOn 1: the iMPaCt OF eirP On DM PrOCesses in vCh – PrOgraM inDiCatOrs

comparisons can be made between the two programs in terms of both output and immediate out-comes. from the point of view of outputs, it is possible to examine the extent to which referrals to the new program increased; the proportion of those referred to the program who actually agreed to participate or take up the program; the time it took for the advisors to contact employees after absence; and the time it took for participants to progress to a graduated return to work program (grtW). indicators of immediate outcomes include the length of time to achieve a return to full duties and the extent to which participants required to access the duty to accommodate (dta) program. a lower number of participants accessing the dta program is an indicator of a greater number of employees returning to their own jobs.



the eirp was established on march 18, 2009, effectively the end of the first quarter. in general, the results discussed relate to the end of the first quarter 2010, which is effectively a 12 month period. comparisons have been made to the most appropriate time period during which the previ-ous program was in operation. in some cases this was the previous 12 months including Q1 2009 and in other cases it was the calendar year 2008 and in some cases the comparison was between specific quarters.

Output Indicators

referralsthe number of referrals is an indicator of the attractiveness of the program to employees. the total number of referrals to the eirp at the end of Q1 2010 was 448. figure 7 compares the number of employees referred to eip in Q2 of 2007 (the first bcnu referrals were sent to hbt on or around february 27, 2007 and hsa became involved on may 17, 2007) with eirp referrals from Q1 2009 to Q1 2010. it should be noted that the first bcnu referrals were received by the eirp on march 18, 2009 (the end of Q1) and the first hsa referrals were received april 17, 2009.

Figure 7: the increase in referrals to the eirP using Q2 2007 (eiP) as a comparison



the combined referrals from both unions in Q2 2007 were 57. combined referrals to eirp rose from 17 in the final two weeks of Q1 2009, to 70 in Q2 2009, 115 in Q3 2009, a slight dip to 103 in Q4 and 143 in Q1 2010. in comparison to referrals in the 12 months prior to the establishment of eirp, referrals have increased overall by 89 percent.

Participation Rates

the number of employees participating is a further indication of the accessibility and attractive-ness of the program. the number of employees actually participating provides an indication of how effective the program was in gaining the trust of absent workers and the appropriateness of the services offered. figure 8 presents a comparison of the proportion of employees referred to each program who actually participated in the final quarter of the previous program with the par-ticipation rate in the first full quarter of the eirp. participation rates increased by 25 percentage points. this represents an increase of over 36 percent on the previous program. non-participation was over five times lower than in the previous program. this increase was sustained over the 12 months that are within the scope of this report.

the basis for comparison differs for each program. participation was registered by the eip on behalf of an employee when his or her doctor had returned the requested medical information to hbt. participation in the eirp was only recorded when an employee was receiving services, regardless of whether or not a request for medical information had been made. for example, a disability management advisor may coordinate a graduated return to work (grtW) program that does not require the collection of medical information. the substantial increase in the participation rate supports the view that the eirp approach is perceived as less threatening and likely to meet the needs of those who have been referred.



Figure 8: a comparison of participation rate pre- and post-eirP

non-participation in the eip was calculated on the total number of cases closed due to non-partic-ipation as a proportion of total appropriate referrals. hbt defines non-participation as “employee not interested in eip services” (January 2008). non-participation also includes pending cases.

in the case of the eirp, the proportion not participating is represented by the total number of cases classified as refused and not participating as a proportion of total appropriate referrals. a refusal is defined as an explicit indication from the employee that they will not participate. this includes employees who fail to return their consent and medical within 21 days of the information package being sent. the proportion participating is calculated by subtracting the proportion not participating from 100. in this approach, participation also includes pending cases.



Time to First Contact

one indicator of efficiency is the time it takes for an employee to be contacted after they withdraw from work. however, it is also an indicator of the potential for early intervention which has been demonstrated to be strongly associated with more successful return to work outcomes.

figure 9 presents the average number of days between an employee’s date of disability and the first phone call from the disability management advisor to the employee. it compares the last quarter in which the eip (hbt) processed bcnu and hsa members to each subsequent quarter up to and including Q1 2010. the decrease in duration from referral to first contact from Q1 to Q2 2009 was substantial and was generally sustained over the period covered by this report.

Figure 9: Comparison of time elapsed from date of disability to first contact with advisor(average number of days)

Time to Graduated Return to Work

a further indication of efficiency is the time required to put in place a graduated return to Work plan.

figure 10 shows the average number of days from the time an employee’s medical is received from the doctor to when the employee starts their grtW plan. it compares the last quarter in which eip (hbt) processed bcnu and hsa members to the first and second quarters in which eirp



Immediate Outcome Indicators

in addition to significant improvement in the efficiency of the dm program in terms of the number of employees referred and participation, and in the time it took to respond to them from first contact and to prepare a grtW, the eirp program was found to be more effective in achieving positive outcomes for those who participated. the duration of absence was decreased, the proportion of participants returning to their own jobs increased, and requests under the duty to accommodate decreased.

duration of absence

the time it takes to get a person to return to full duties in their original job without accommoda-tions can be considered an indicator of the effectiveness of a dm service in restoring employees to full productivity and capacity to carry out their responsibilities. figure 11 presents a comparison

took over (accessed on september 22, 2009). once again the decrease in duration between the previous program and eirp is remarkable. on average the duration between receipt of the medical report and the establishment of a grtW reduced from 41 days for the previous program to 17 for the eirp, a reduction of almost 170%.

Figure 10: Comparison of time from receipt of medical assessment to grtW(average number of days)



of the average number of days from the employee’s first day off to their return to full duties, for those employees who were ready to return to full duties. the figure presents the average duration of absence for employees who returned to full duties in each quarter, comparing the last quarter in which the eip (hbt) processed bcnu and hsa members, to the four quarters during which eirp was in operation.

the average duration of absence for those who returned to full duties during the first year of implementation of eirp was 87 days compared to 113 days for the final quarter for the previous program. this represents a 23 percent decrease in duration. the duration to full duties was rela-tively consistent over the four quarters during which the eirp was in operation, ranging from 81 to 91 days, supporting the view that this is a relatively stable indication of the greater effectiveness of the eirp in comparison to the previous program.

Figure 11: Comparison of duration from first day of absence to return to full duties(average number of days)



duty to accommodate requests

a decrease in formalized duty to accommodate (dta) procedures can be interpreted as an indica-tion that more employees are being accommodated into their own jobs. this is a significant imme-diate outcome indicator. this comparison is presented from three perspectives. figure 12 provides an overview of dta applications comparing the last quarter of the previous program with each of the four quarters in which eirp was operating and the average over these four quarters. figure 13 provides a breakdown in percentage terms of the dta requests by union. only the participat-ing unions are specified. figure 14 provides a breakdown in terms of the way in which the dta

requests are allocated to insurers.

Figure 12: Comparison of active duty to accommodate cases pre- and post-eirP

the reduction in active dta cases is particularly noteworthy (see figure 12). on average, active dta cases were reduced by 52 percent. this was relatively consistent across the four quarters in which this data was gathered. this can be extrapolated to the number of employees who managed to return to work to their original positions with minimal accommodations. the cost implications of this for the organization and for employees must not be underestimated.



figure 13 presents the proportion of dta requests in the quarter immediately before eirp (January to march 2009) and the average of the four quarters after implementation of eirp broken down by union. What is clear from figure 13 is that the pattern of dta requests from hsa was unchanged while the proportion of requests from members of the bcnu decreased by eight percentage points, and requests from other unions increased accordingly. given that the overall number of dta re-quests reduced during eirp implementation, these results support the view that this reduction was systematic and favoured employees who were participating in the eirp program.

Figure 13: Pre-post comparison of the proportion of Dta requests by union



figure 14 illustrates the same data from the perspective of the insurers. the reduction in dta requests was over 67 percent for Worksafe bc claimants. ltd claimants for dta decreased by 35 percent, and dta claims for all other insurers were reduced by 85 percent.

Figure 14: Pre-post comparison of the number of Dta requests broken down by insurer

ltd claims accepted

the majority of positive outputs and outcomes reported for the eirp are by their nature short term. it is the long term and sustainable impact that the program makes upon long term disability claims that will produce the most significant savings for the organization. it is difficult over the short period of time that is covered by this report to come to any strong conclusions about the extent to which the program will reduce ltd claims in the longer term. figure 15 presents the trends in new ltd claims by quarter over a 20 month period for the participating unions. during this time the level of new claims varied only slightly from 32 in the first quarter of 2008 to a high of 45 in the second quarter of that year. ltd claims tend to peak at the end of a qualification period as indicated in the figure. further, the number of new claims, during the period in which the eirp was operating cannot be attributed solely to those who were participating in the program because earlier cases contributed to the number of claims. it is important to note, however, that while the number of ltd claimants for all absent employees was relatively stable up to the final quarter of 2009 (between 35 and 40 for 2009), the trend for participants in the eirp project had begun to drop. this is clearly represented in figure 15.



it is difficult to draw any strong conclusions from the current data with regard to the downstream im-pact to the program on ltd claims at this point in time not only because the time frame is limited but also because the number of claimants per quarter is relatively low statistically although significant in cost terms. for example, the number of new ltd claimants affiliated to the hsa varies between three and six, except at the end of a qualification period. nevertheless, if the trend that appears to be developing continues, the cost benefit of the eirp could well be substantial. in the first quarter of 2008, ltd claims from members of the participating unions accounted for the majority of new claims (55 percent). in the final quarter of 2009 after 9 months of eirp implementation, the proportion of claimants from the participating unions had reduced to 42 percent.

Figure 15: number of new ltD claims by union Q1 2008 to Q1 2010

the current status of eirp participants

in order to provide a clear overview of the way in which the eirp impacted over the period covered by this report, the status of the 448 participants at the end of the first quarter of 2010 is presented in figure 16. these figures are presented as percentages in figure 17.



Figure 16: Participation status of eirP referrals as at the end of Q1 2010 (n=448)

the number of participants that has returned to work was 134, representing 30 percent of all par-ticipants; 86 (19 percent) were actively participating in the program; 92 (21 percent) were pending or had not been assigned a status; 26 (6 percent) had refused or were not participating for various reasons; and 3 percent were being reviewed, had resigned / retired, or were assigned another status. the number of referrals which were considered not to be suitable for the eirp for a variety of reasons was 92 (22 percent).



Figure 17: Proportional distribution of eirP referrals by status as at the end of Q1 2010

the cost benefits of eirp

given the difficulties in estimating the long term cost benefits of the eirp program at this junc-ture, it is worthwhile examining the cost savings that have accrued as a result of the pilot in terms of the costs of sickness absence and the eirp intervention costs. the cohort selected for analysis consisted of those who had more than 150 hours of sick time. the approach adopted was to calcu-late the cost of absence for a group of 225 employees who were in this category in the prior year. the calculation included paid sick time, backfill costs (pro rated by area of service) and overtime costs. it is important to note that replacement costs were not taken into account.

the total cost of sick time for all bcnu members during this period was $17.3 million. the total cost of sick time for the selected cohort was $8.3 million representing over 50 percent of the total cost of sickness absence for the period. paid sick time accounted for $5 million, backfill cost $3 million, and overtime amounted to $300,000. based on these figures, which do not include replace-ment costs or ltd cost avoidance, the average cost per absence in the year prior to the introduc-tion of eirp was $25,425.



as reported earlier, the duration of absence, as calculated from first day of absence to return to work, was reduced from 113 days to 87 days through the implementation of the eirp. using this metric to estimate the average savings accrued by the program, the average cost per absence reduced to $19,575. this represents an average saving of over $5,800 per absence and a total saving of over $1.3 million. there is little doubt that this is an underestimation of the short and intermediate cost impact of the program.

since the completion of the initial pilot, additional evidence has emerged to support the view that the eirp program is cost effective from a Vancouver coastal health perspective. it has been estimated by hbt that Vch is on track to a reduction of 8.9 percent in its total premium cost for long term disability from $32,483,000 in the previous year to $29,620,000 for fiscal year 2011-2012. this is the first time that a reduction occurred year on year and can be compared to increases of 26.6 percent and 7.8 percent for 2009-2010 and 2010-2011 respectively.

Section 2: Qualitative PerSPectiveS on the effectiveneSS of eirP

the profile of eirp participants

another key question is the extent to which the participants were typical of the population of employees that were targeted by the eirp. table 1 presents a comparison of some key demographics of the participating unions and 344 eirp participants. the table shows that the participant profile was very similar to the broader union reference group in terms of average age, gender and the areas in which they worked. there was a 10 percent differential between the number of participants who were over 50 years of age, which would be expected, as older workers tend to experience more health related problems.

table 1: a comparison of the demographics of the participating unions and eirP participants

union Profile eirP Participant Profilenumber of Members (excluding Casuals) 4,415 344average age: 46 years 45 yearsClinical areas: acute 70% 70% residential 22% 18% Community 8% 12%



union Profile eirP Participant Profile

Male: 10% 10%% by age Category 20 – 30 16% 13% 31 – 40 27% 21% 41 – 50 26% 25% 51 – 60 26% 32% Over 61 5% 9%

a case study insight into eirp

another way to highlight how the eirp achieved its positive results is to present the pre-eirp process and the post-eirp process from the perspective of individual employees. case study 1 pro-vides a description of the process for a 46 year old registered nurse (rn) prior to the introduction of the eirp. case study 2 is a 50 year old rn who participated in the eirp. the comparison of the process is presented in table 2 and a fuller description of the case studies is provided in annex 4.

from the perspective of Vch, it only became involved in the pre-eirp process two months prior to claim closure. at this point it required additional medical information regarding limitations and restrictions and needed to re-do the rtW plan with the medical provider. additional rehabilitation consultation was required. post-eirp, Vch knew the reasons for the employee’s absence at an earlier stage, was aware of a likely return to work date, and the dm advisor was able to work with the employee, who was unrealistic with her own expectations of when she could return to work. the advisor was also in contact with the manager, who informed the advisor of the change in the workplace. the advisor was able to take those changes into consideration during the rehab plan-ning, as well as keep the employee informed of the changes.



table 2: Case study comparison of the DM process pre- and post-eirP

Pre-eirP Post-eirPgender Female Female

age 46 years 50 years

Occupation rn rn

referral

to eiP on tenth consecutive day of absence after informing

her of the program

Contact made by DM advisor eighth consecutive day of

absence and explanation of eirP

Case Process 1. Manager informed of referral 1. Agreement to participate

2. Occupational Fitness Assessment OFA and Consent Form sent out

2. OFA and Consent Form sent out

3. Physician completed formand returned

3. Manager informed of participation in the EIRP

4. VCH DM informed that she was off sick but not why or what

treatment was being provided

4. Union informed and contacted employee to clarify any issues

5. Manager informed but no RTW date set

5. OFA received

6. After 4 months VCH informed that employee was to go on LTD

and that the appropriate forms were to be completed

6. DM Advisor contacted employee, discussed the

challenges, and engaged in counselling

7. Accepted to LTD 7. Mental health and physical rehabilitation provided

8. Intermittent contact from insurer and no referral to rehabilitation services

8. Employee was kept informedof development in her workplace

as a result of restructuring

9. Employee cleared to RTW two months before her LTD was due to end

9. Manager kept up to date in employee’s progress and targeted

RTW date

10. A very simplistic RTW plan was proposed only at this point

10. DM Advisor assisted to complete all necessary forms

11. No information was available about limitations or restrictions

11. Claim was accepted by the insurer

12. Only at this stage were referrals made to rehabilitation services

12. DM Advisor met with insurer, employee, and union to agree to a

rehab plan while on LTD which took into account the restructuring



from the perspective of the employees in question, the processes also differed significantly. in the pre-eirp case, the employee was frustrated by the different messages coming from the rehabilitation provider and the employer about grtW. employee was mentally prepared for one plan, when it was changed. there were lengthy delays in accessing services and getting rehabilitation set up. there was frequent confusion regarding who to contact and who the various providers were and who was doing what. in the post-eirp case, the employee, despite very challenging health issues, continuously expressed her thanks to the dm advisor for thehelp and support, as well as the realistic advice she was given. she felt that she was listened to and was an active participant in her rehabilitation and return to work planning. she felt that everyone knew what they were doing.

from the perspective of the union in the pre-eirp case, it only became involved during the rtW meetings and had no knowledge of the member prior to that point. they had concerns expressed around issues that their member shared with them but were not in a position to act effectively. they believed that they should have been involved earlier in the process. in the post-eirp case, the union appreciated the regular contact with stewards, and were made aware as soon as the employee was in the program. they became involved in the early stages of the return to work planning and knew what was going on and were also able to reassure the member regarding how the restructuring would affect her.

the eirp undertook a survey of those who had participated in the program. there is no pre-post survey comparing the previous eip to the eirp. the response rate was less than 20 percent. Key findings were: • the majority of survey respondents indicated that their dm advisor understood their issues and were caring and concerned for the employee (>70%). • employees felt they were able to express their feelings and views to the dm advisor (>80%). • respondents indicated that they had a greater understanding of the supports available to them after participating in the eirp (>70%).

there were also some comments received; many of which reflected that they felt they had to wait too long to hear back from the dm advisor, or had to frequently contact the dm advisor them-selves. this seems to be related to the previously identified issue of increasing workload for the dm advisors, which was a result of the increased number of participants in the program com-pared to the eip.

dm advisor feedback

another useful insight into the operation of the eirp can be gained from the views of the dm advisors on working with employees to assist them to return to work. for 15 selected cases,



the dm advisors completed a structured questionnaire, providing the opportunity for the dm advisors to indicate any obstacles they experienced in case managing the employee back to work, to indicate the things that were particularly useful and things that would have made the process easier. these were open-ended questions. the selected cases ranged from six days to over two months but no case required more than five hours of advisor input. most employees were over 40 years of age and the majority were working in acute patient care. the length of time the employees were working for Vch varied widely from one year to over 20 years. the reason for absence was evenly split between work related and non-work related illness or injury.

table 3: Qualitative analysis of responses from eirP advisors

Obstacles 1 access to appropriate services and assessment2 Previous history of absence3 inappropriate initial plan

4 Pre-absence work record5 reservations of manager6 employee difficulty in progressing to full time

return to work7 Presence of another health condition8 employee not wishing to participate

9 intervening while the person was back at workthings that worked 1 graduated rtW 2 time – extending the grtW (several cycles) 3 Communication with employee

4 access to internal resources5 early intervention6 Face to face meetings with manager and employee

things that would have made the process easier

1 getting the recommendations right from the outset (more effective assessment)

2 Further rehabilitation prior to rtW

the most frequent length of absence was between one and four months and all but one of the em-ployees had returned full time. advisor ratings of their satisfaction with the process were generally satisfactory.



a content analysis of the dm advisor response is presented in table 3. the obstacles encountered arose from three main sources. firstly, system problems were indicated in terms of a difficulty in accessing appropriate services and inappropriate initial plans. secondly, workplace issues arose in relation to manager cooperation and intervening after the person returned to work. thirdly, personal characteristics such as previous absence or work record, lack of participation, and the presence of another health condition were specified.

the grtW was frequently cited as something that worked. the option of extending the timeframe for grtW was considered useful. communication strategies including face-to-face meetings and flexible communication with the employee were important. getting in early and getting access to internal resources were also seen as things that worked.

advisors suggested that the process could have been more effective if the recommendations had been right from the outset. this suggests that more effective assessments could improve the way things work for the employee. in some cases, there was a view that further rehabilitation prior to returning to work would have helped.

seCtiOn 3: Making the eirP WOrk – results FrOM the aCtiOn researCh jOurnals

underpinning the implementation of the eirp pilot was a very systematic and analytical approach to planning and execution. a 17-point action plan was developed and is being executed. the dmar methodology introduced an extra dimension to this in the form of a journal in which the internal action researcher recorded on a regular basis what was going well, what challenges arose, and what solutions were generated in the course of the implementation. the intention of this procedure is to capture in real time the problem solving process that occurs when policies and procedures are being changed within an organization. the contents of the journal were analyzed in terms of the themes and topics that emerged.

the main areas that required effort were:• building capacity for and integrating dm data collection and information management.• establishing a set of dm processes and procedures.• establishing and executing a communications plan for the centre for case management (cmc).• establishing a plan to creatively implement vocational rehabilitation within the organization.• developing the transitional Work program.• establishing a single point of contact for the program.• developing a plan for engagement in the dm process for:



– managers – unions – employees• establishing a process for resolving cases where an employee’s ltd claim has been denied.• establishing an efficient and effective case management process.

the challenges that emerged during the start-up phase are presented in table 4. they can broadly be classified as “legacy challenges”, i.e. dealing with existing practices, programs and process challenges that arise during the roll-out of the program

the legacy challenges arose from the fact that a number of previous solutions to the problem of absence were already in existence. the problem was how to streamline or change these solutions so that they worked effectively alongside the eirp or in some cases were replaced by the eirp. this required a significant effort in communicating the intentions of the eirp, distinguishing it from previous approaches and putting in place alternative procedures and tools where this was appropriate.

the process challenges ranged from managing the success of the program from the perspective of the workload of the advisors to addressing issues of stigma associated with participation in the program. particularly difficult was managing absence information and standardizing referral procedures and sources. it was clear at a certain point that the knowledge and experience of the advisors and managers needed to be upgraded and this was dealt with through education and introducing mentoring for the advisors.

it was essential that the respective responsibilities accruing to the employee and the program were clarified and that the distinction between the hr function in relation to absence management was clearly distinguished from the dm program.

the unions played a very important role in identifying issues that needed to be resolved. some of the challenges identified by the unions included:• differences in geographical access to the transitional Work program• managers contacting employees who were off work• the role of union stewards in the rtW process• employee confusion about the respective roles of the eirp and Wsbc• the need for a dispute resolution processthe journal also highlighted a number of mechanisms that worked well in overcoming the chal-lenges and making for a more effective program.

these included:• clarifying the roles of the key actors:



– union stewards – managers – hr – service providers• using an action planning approach, which allowed changes to be made to the plan in response to emerging issues.• dealing with the workload issue for the team by re-defining roles and bringing in extra resources.• using logic models to specify the aims, actions and intended outcomes of the program.

table 4: Challenges and issues that emerged in the start-up phase of eirP

legacy Challenges Process Challenges1. existing hardware and software 1. the distinction between hr and DM processes

2. Organizational precedents – the way we did it before

2. the workload of the advisors

3. existing programs – a. aPPb. Clear/arlc. Dtad. gWle. WsbCf. hbt

3. Communication with:a. employeesb. Unionsc. leadersd. Managerse. external Providers

4. existing responsibilities a. hrb. Managersc. employeesd. external agencies

4. Fragmentation of responsibilities and information sources

5. existing understandings and agreements 5. Knowledge and experience of the team

6. Developing trust with unions and employees

7. Coordination with internal and external actors, e.g.a. hrb. Managersc. gWld. WsbC

8. stigma associated with special programs

9. information managementa. Data collectionb. Client tracking

10. referral source and processes

11. lack of clarity about what the program provides

12. the geographical spread of the organization



• establishing a small “think tank” representing all interests in the process to identify and resolve problems.• creating marketing material targeted at employees to attract them to the program.• using existing internal resources such as learning and development to develop new supports and interventions.• responding to concerns in real time – taking issues raised by the “think tank” and dealing with them immediately.• bringing in external expertise to complement the team in terms of mentoring and dispute resolution.• providing education to managers and advisors to upgrade knowledge, skills and attitudes.• making the process more accessible and efficient by introducing new and more easily understood formats.• using access to create data management tools to unify and streamline the information management system.

seCtiOn 4: key issues anD Persisting issues

some of the factors, processes and mechanisms that were identified in the journal analysis, per-sisted or re-emerged toward the end of the review period, i.e. Quarter 1 of 2010. a more in-depth description of some of these issues can help to provide an insight into the operation of the eirp.

the role of meetings

one particularly noteworthy strategy was the “think tank”. this was a small group representing all parties to the original agreement. it was a problem-solving forum to which any party could bring issues and where possible resolutions could be explored. the think tank helped to build trust by resolving issues in a direct and timely manner. some examples can help to illustrate the role that the think tank played in the success of the eirp. at one point the unions requested that union steward roles and responsibilities be organized in terms of the logical stages of the program. a clearer specification of the union role in the case management process was developed and a draft specification of roles and responsibilities was prepared for discussion at the march 2010 think tank. at an earlier juncture, the unions drew attention to the possibility of confusion for employ-ees in relation to the difference between the eirp process operating in parallel with the Wsbc process. as a result, the eirp contact letter was revised to provide the employee with information about what he or she needed to do to initiate the Wsbc process. another issue raised was the need for a dispute resolution process to be put in place for eirp. a framework of small, medium and large issues was proposed. for small severity issues, the union stewards would consult with the union office level (and the advisors, the equivalent for the employer). for medium severity



issues, a mutually agreed upon third party would be asked to assist. larger issues would go through existing grievance/arbitration channels.

the system was put under pressure with the need to respond to the incorporation of new partici-pating unions. the greater diversity in larger unions revealed a need to build a culture of diversity and extra education. this required more meetings and extra “nurturing” of relationships. this diverted resources and time from the pilot implementation, which resulted in less than consistent progress. one solution considered was to create a number of think tanks customized to each participating union. this was proposed by one of the unions that had entered the program at a later stage. the plus side of this approach was that such meetings could help to build trust. the downside was that more meetings would mean that dm advisors could experience serious time management issues. another possibility was a tripartite think tank with all unions involved. it was not clear that this type of meeting could cope with the issues raised or whether customized meetings were required given that issues differed between unions and required multiple processes to resolve.

the success of the tripartite meetings with the bcnu and hsa was put at risk at one point when the issue of dta was raised by the union representatives. it was felt that this issue could represent a threat to the sustainability of the program. this raised questions about the effectiveness of the meeting as a problem-solving mechanism but also what practical steps could be taken to address the issues raised such as the production of guidelines and the establishment of a smaller commit-tee to resolve the problems. the key is still to resolve issues as early as possible and work is ongo-ing in finding ways to engage the more recent unions to join a tri-partite think tank.

case meetings were held with the occupational health nurse and physician. the view was that these meetings were taking up more time than necessary in re-examining details unnecessarily and resulting in inefficiencies and possibly increasing the duration of absence for the employee. there was a need to provide greater clarity on the roles of the dm advisor and the other occupational health professionals, and to provide better summaries of the cases to be discussed. a referral form was developed in consultation with occupational health staff, which provided a case summary and specified medical and other case questions. dm advisors were trained on how to distinguish between medical and non-medical criteria.

the role of communications

a review of the communications plan revealed the need to refresh the strategy and to develop a communications bulletin to go out to all Vch managers to gain macro level acceptance of the values and mandate of the eirp. this required a review of the overall organizational position of the program, the development of revised literature and message, and a Vch community-wide message that was approved by the unions. this was implemented during february and march 2010.



both employees and union representatives drew attention to confusion on the part of employees about specific payments, medical benefits and services. based on a review of past practice, a number of solutions were proposed including revising the employee engagement brochure and the development of a work and wellbeing website. the program has managed to maintain a distinc-tion between decisions about payments and the services it offers. it acts as a volunteer advocate in cases where appeals are required. this has helped to build trust.

complaints were received from employees about incorrect wages and benefits, which could be at-tributed to poor communication between the case management centre, records and benefits, and payroll. this was inefficient and placed the reputation of the program at risk. this disconnect was addressed by creating a cmc database which could be accessed by the other two functions and which recorded case updates.

confusion around the meaning of the different eirp services and interventions persisted well into the second quarter of the operation of the program. as a result, the need for standardized defini-tions and terms of reference for the eirp became clear.

the role of managers in maintaining contact with the absent employee was another issue that needed to be resolved. it emerged that some managers contacted their absent employees as a mat-ter of course. this raised the issue whether this practice should be formalized as part of the eirp approach, as it would assist in maintaining contact with the workplace. the issue was raised at a think tank by the hsa. the key question was whether such a call would upset the absent worker particularly if the call was not handled well by the manager. it might also confuse the boundaries between the attendance promotion program (app) and the eirp and would certainly require a training program for managers. it was decided that the practice of managers contacting their absent employees would be kept distinct from the eirp process, which would be initiated by first contact by the dm advisor.

early intervention

there were persistent difficulties in making sure that all employees that would benefit from the program were offered it in a timely manner. one mechanism to achieve this was a 30-day audit report, which was intended to bridge the gap arising from multiple referral sources. however, the report was not being used effectively and additional effort was required to identify discrepancies, contact employees who had been missed, and update the caseload.

the use of the absence reporting line (arl) was around 50 percent compared to the required 100 percent. higher use of the arl should transform into more referrals to the eirp. strategies to address this issue were in development at the end of the period covered by this report.



Vocational rehabilitation and transitional Work

one element of the eirp that was particularly difficult to establish was the internal vocational rehabilitation program. as of february 2010, the vocational rehabilitation component of the eirp was on hold mainly because most employees who had reached maximum medical recovery did not need this service. as a result there was little motivation to develop internal resources. the referral of employees to the external program for which participants were still eligible was a possibility, but this raised the issue that workers could lose their connection with the workplace. in addition, there were resources available internally to respond to the needs of employees who needed re-training.

it was decided to liaise with the learning and development function to identify resources within Vch that would be useful and to establish a process to support the reintegration of disabled work-ers using these resources. the strategy was to put in place a stepped response where participa-tion in an internal program was the first option utilized and referral to the external program was accessed only when this was required.

the services provided by external private service providers came into question. firstly, not all providers offered a complete range of services and as a result, Vch ended up providing additional services to employees who had been cleared to return to full duties by external providers. the response to this was to develop organizational criteria for selecting providers and a system to track providers for completeness of services and eventually develop a preferred provider list.

it was challenging to find transitional work opportunities in remote areas, which have less work in general. Workplace rehabilitation advisors were engaged to identify jobs and reorganize duties to create opportunities.

relationship with other programs

the attendance promotion program (app) is a parallel program that operates in tandem with the eirp. the app is intended to reduce intermittent sick absences, not absences related to single significant illnesses, which is the focus of the eirp. if an individual identified as having high sick time indicates that this is related to a chronic disability, then the individual is referred to the eirp for assistance.

it was necessary to clearly define the processes and objectives of the app and the way in which it related to the eirp and to develop training for all new teams on how the two programs related. the benefits of this were that all Vch teams involved had clear responsibilities assigned and potential long term absence was responded to appropriately and at an early stage. a process was developed which clearly separated the two programs in terms of hr and the case management centre (cmc). additionally, the cmc began working on referrals and gathering information. referrals needed to be screened to determine next steps in order for the resources required and



likely workload from app referrals to be managed. managers and designates needed to be briefed to understand that the program was crucial to the success of their employees.

the duty to accommodate program (dta) was the subject of a review because it had been criticized by the unions for its low return to work rate (10 percent). it was estimated that the cost associated with each person who failed to return to work was about $100,000 each year. the review identified the need for the cmc to develop and maintain a more cohesive relationship with the hr team responsible for the revised program. proposed changes included prioritizing dta partici-pants when vacancies arose, and changing the role of managers in the dta process while provid-ing them with training and support.

another issue arising in relation to the dta program was the need to define the program more clearly and to clearly specify the sources of intake, as discrepancies arose in the numbers being reported. a distinction was required between dta in one’s own occupation and dta in any oc-cupation. a process map was needed to illustrate how people were referred to the program and an employee tracking database was needed.

the role of the dm advisors

referrals to the eirp increased steadily over the 12 months that are the focus of this report. as a result, dm advisors reported difficulties coping with the increased workload, which had an impact on program deliverables such as time to first contact and the duration of disability. a new team structure was introduced at the end of the first quarter of 2010, which included a dm advisor, an occupational health nurse, a Workplace rehabilitation advisor, a dm associate and a dm assis-tant to help with communications and other issues. the introduction of the new team structure and members, which occurred at the end of the first quarter 2010, brought the number of dm advi-sors/case managers to 11 for 40,000 hsda staff. While this was welcome, the quality of service was put at risk because of the need to shuffle teams. this required rebuilding relationships and the knowledge base of the dm advisors.

a lean review was initiated of the role of dm associates to identify where they could provide sup-port for the dm advisors. additional assistance was seconded from Wsbc to review outstanding cases that were over 150 days old. this amounted to 50 cases.

peer mentoring was introduced for dm advisors to share knowledge and build competencies. the need for enhanced mentoring was raised during dm advisor meetings. dm professionals external to the organization were brought in to meet with the dm advisors on a one-to-one basis, and relevant allied health professionals, e.g. a psychologist, were invited to meet the team in a round table. the aim was to improve the understanding of the dm advisors on how to identify risk factors for employees, interpret assessment results and be more constructive in identifying workplace accommodations.



Chapter 5:suMMary anD COnClusiOns

Summary of EIRP Achievements to Date

impact indicators for the eirp in its first 12 months of operation were very positive. in comparison to the previous program (eip), the current program stands up very well on all metrics. the results are summarized in table 5.

the eirp proved to be more efficient in dealing with employee absence when compared to the previous program. the eirp outperformed the previous program in terms of referrals with an almost 90 percent increase, and in agreement to participate, which increased by a factor of two in comparison to the previous program. actual participation rates increased from 69 percent to 94 percent. this represents an increase of 34 percent. the efficiency of the program improved in terms of a 50 percent reduction in time to first contact and a 23 percent reduction in time to full return to work.

table 5: a summary of positive results achieved by the eirP

Output indicatorsreferrals 89% increase in referrals

agreement to participate increased by over 200%

Participation rate increased from 69% to 94%

time to first contact reduced by 50%

time to full return to work reduced by 23%

immediate Outcome indicatorsDuty to accommodate requests reduced by over 50%

return to full duties 30% increase in return to full duties

ltD claims accepted reducing – but too early to determine as a result of pilot

estimated cost savings (excluding replacement and ltD costs)

Over $1.3 million.

Union participation Ongoing

the eirp was also found to be more effective than its predecessor. requests for duty to accom-modate were reduced by 50 percent, and return time to full duties increased by 30 percent. the estimated cost savings achieved by the introduction of the eirp in its first year of operation were



well over $1.3 million. this is clearly an underestimate given that it does not take into account replacement costs or the impact on ltd premium costs, which are on track to reduce by almost 9 percent from the previous year in the 2011-2012 fiscal year, which should be substantial.

the continued cooperation with both bcnu and hsa in jointly managing the program is a testament to both the importance that all parties assigned to the program, and the extent to which the program was perceived as meeting the needs of the organization and its employees. the fact that the heu also agreed that its members will participate in the program is evidence of its attractiveness and relevance. even in the context of such a changing and challenging context, the relationship with the original unions remained positive and the initial agreement and the original framework remain intact.

While these are very positive initial results, they are mainly output and immediate outcome indicators for the program itself. there is a need to gather corporate information to reflect the intermediate impact of the eirp on the organization in terms of enhanced productivity and reduced costs of absence and the sustainability of outcomes. the data should be available at the level of each site in order to identify environmental issues that arise for particular types of services or geographical location (e.g. remote areas and smaller scale services). this is a challenge for the organization moving into the future.

it would also be useful to be able to break down the data on the basis of demographics (e.g. age, gender, length of employment, previous absence record, etc.), job role, and type of condition. this type of information could be used to fine tune the program to the needs of specific target groups who are identified as facing more substantial barriers in the reintegration process.

the case study analysis provided an insight into why the eirp process was superior to the previous program on all metrics.

the key determinants for Vch were:• early involvement.• clarity on the reason for absence and a likely return to work date.• direct involvement in mediating between the manager and the employee.• a more systematic approach to the development of rehabilitation plans and grtW.• control over the process from beginning to the final conclusion.• greater transparency and accountability in monitoring the process.

the employees benefitted from the revised process in terms of:• clear messages from the dm advisors and the managers about the proposed return to work date and the rehabilitation plan.



• easier access and less delay in getting services required and in setting up the rehabilitation plan.• the removal of confusion about who to contact and who the various providers were, and who was doing what.• being able to have available the support and advice of the dm advisors in relation to health and other challenges faced in the recovery and return to work process.• playing an active role in the rehabilitation and return to work planning.

from the perspective of the union, the benefits of the new program included: • involvement in each case from its initial stage.• Knowing what the issues and concerns of employees were at an early stage.• being able to get employee concerns shared with the employer and to act effectively to resolve them.• having regular contact between the union stewards and the employees throughout the process.• being in a position to reassure their members regarding how the process might affect them.

the results presented in this report should be seen as interim in nature in that the period of the study was 12 months, which in organizational terms, is relatively short. in the intermediate term it will be necessary to gather data to provide evidence of the impact of the program in reducing the number of new ltd cases. While there was a downward trend in the final two quarters covered by this report, it is too early to come to any firm conclusions. in addition, other objectives of the eirp can only be evaluated after a longer period of time including the increase in the number of ltd claims successfully closed, the number of employees returned to work and accommodated into positions, and a reduction of the number of employees lost from the healthcare sector because of ltd conversion to “any occupation”. the eventual goal of the eirp is to save $7 million in ltd premiums over three years. there are many challenges facing the program if it is to achieve this target including developing an appropriate cost benefit model to assess the impact on ltd and putting in place accurate and relevant metrics to assist in this analysis. nevertheless, based in the very positive results achieved to date there is reason for optimism that these objectives will not only be achieved, but surpassed.

Conclusions

one of the final entries into the action research journal was a retrospective comment, which sum-marized the previous 12 months. it noted that a significant amount of effort was spent in playing “catch up” after the eirp had been launched and put forward the view that this might have been



avoided to some extent by putting the processes in place first. nevertheless, it must be noted that the parties involved in the eirp played “catch up” pretty effectively.

another critical limiting factor that impacted on the efficiency and effectiveness of the eirp was the fact that the processes that were in place were not operating as efficiently as they should because of developments and changes in the external context such as the amalgamation, which absorbed substantial energy and concentration. the view was expressed that all the ingredients for a successful program were in place but the recipe to replicate them in new contexts was required.

despite the many challenges faced by the eirp, it was very clear that, on all metrics gathered dur-ing the pilot, the eirp outperformed the previous program. the action research journal provided a unique insight into how these results were achieved and it is fair to say that they were not arrived at easily. there were constant challenges and often issues that appeared to have been resolved that required to be addressed again in a changing context.

Viewed against this background, the positive outputs and outcomes achieved by the eirp seem to be relatively robust. the external environment was indeed less than ideal, if not antagonistic towards, the introduction and piloting of a new dm procedure. the constantly changing organi-zational environment, personnel and management structures often meant that some elements of the eirp had to be re-engineered during the implementation process. even some of the positive developments, such as the rapid increase in demand for the program created stresses and strains for the eirp team in terms of increased workload. due recognition has to be given to the commit-ment, ingenuity and effort of the cmc staff and the consistent support from senior management and the union partners. in some respects, it is a testament to how robust the model upon which eirp was based that it succeeded in achieving the majority of its goals given the context in which it was tested.

critical success factors for eirp

it is useful to review the major success factors in these achievements. it is not possible on the basis of the data available to rank these factors in order of importance and there well may be other fac-tors that were not evident in the results nor in the action research journal. nevertheless, there is clear evidence that the following elements played an important role in the success of the program. • disability management advisors called employees who had been off work for more than five or seven shifts depending on the collective agreement. this work had previously been done by non-certified clerks and was more effective when performed by a nidmar trained advisor.• a clear and well-designed model for the eirp in advance of implementation that was shared



and understood by all parties. the development of a logic model for the program was an important element in achieving this consensus.• the design of the eirp itself, its service elements, and its employee processes proved to be generally fit for purpose and robust in the face of changing circumstances.• the strong and enduring commitment from senior management to the program and its implementation in the face of many challenges.• the commitment and support of the participating unions and their proactive and positive contribution to identifying potential risks and generating effective solutions.• the development of a 17-point action plan in advance of the implementation and the regular adaptation of the plan to meet new challenges and redesign processes.• the speed and efficiency with which identified challenges were addressed by the cmc and Vch leadership.• adherence to the principle of consensus throughout the process and commitment to the three values of the eirp, i.e. employee centered, employer driven and union participation.• the careful analysis carried out of each of the challenges faced as the basis for designing solutions. this was particularly important in addressing communication, data management and increased workload issues.• the prioritization of effective communications with partners, managers, other organizational functions such as hr, stewards and the absent employees.• making sure that the eirp had its own identity and was clearly distinguished from complementary programs, such as the attendance promotion program, which operated in parallel.• through careful system analysis to develop processes and procedures to ensure that the relationship between programs was synergic. • the use of training and staff development to raise awareness of the program amongst management and to upgrade the skills and competences of the cmc team and the dm advisors in particular.• the use of interim solutions to deal with problems that could not be resolved in a timely manner at an organizational level. of particular note was the use of access to create information management tools to improve the tracking of employees and to ensure that all organizational functions were aware of the status of the employee at any given time.• a particularly effective strategy was the establishment of the think tank. this was a smaller group of the partners than the overall monitoring committee, which acted as an early warning system for possible risks and a rapid response unit to resolve these problems before they became critical.• the motivation and commitment of the cmc team and its dm advisors to achieving the



objectives of the eirp and to provide quality services to its clients.• the capacity of leadership to maintain a strategic perspective on the development of the program while at the same time responding to the needs of individual absent employees and frontline staff. • making the process more accessible and efficient by introducing new and more easily understood formats. • a number of interventions that added to the success of the program were highlighted by the dm advisors in their feedback including: – the graduated rtW process; – the accommodation of disabled employees into their own jobs; – giving sufficient time for recovery and return to work by extending the grtW through several cycles; – maintaining clear communications with employees; – having access to internal organizational resources; – early intervention; and – holding face-to-face meetings with the manager and the employee.

outstanding issues

twelve months is a relatively short period in organizational change terms. as a result, there were still a number of important aspects for which action was required at the end of the period covered by this report. it is clear from the action research journal that the implementation process en-countered a number of potential barriers, which could have reduced its impact if not derailed the process. it is a tribute to all actors and an indication of the commitment of both management and unions that the majority of these issues were dealt with in real time and serious challenges were averted. nevertheless, there were still many issues that needed to be fully resolved, and sustained effort will be required moving into the future.

• the amalgamations resulted in a workforce of 40,000, a new management structure for all integrated hr services, changes in management, and the creation of new jobs. the response to this requires a revised operational strategy, the education of new dm staff, training and information for the new management, and basically re-doing a lot of the work that had been completed for the smaller scale organization. • a particular challenge is the expansion of the concept of the think tank to incorporate all unions now wishing to become involved. the issue is the scalability of the think tank approach, which is based on the principle that a small group of key individuals adopting a proactive



problem approach to address potential risks before they become critical. the question is whether a larger tripartite version of the think tank could achieve similar results and whether the diversity of issues being brought to the table by the other unions can be addressed within this forum.• rationalizing the multiple sources of data and record systems, including payroll and records and benefits, is critical. the problem of multiple data sources and parallel databases continued to be a challenge. the amalgamations contributed to the complexity and as a result, significant time and resources were being absorbed in managing the problem.• speeding up the referral process is essential. there were still outstanding issues in ensuring that all employees who could benefit from the eirp were identified at an early stage. two particular elements were identified as needing improvement – the utilization of the absence reporting line by employees who only had a 50 percent participation rate, and the accuracy of the 30-day audit of absent employees.• dealing with older referrals that have been delayed significantly. over 1,000 outstanding cases that were involved with other (external) providers were identified.• getting across to all managers the role of the cmc process. this is likely to be a continuing challenge given the constant change in management and organizational structures due to the expansion of the organization. it will require ongoing awareness raising procedures combined with continuing professional development. • dealing with the implications of the success of the program and the expansion of the organization by building the capacity of the cmc team in terms of staff numbers, knowledge and skills. this will also require the maintenance of support mechanisms such as the peer mentoring program and the use of external support and expertise.• other areas for improvement include: – making the eirp process more efficient by re-designing forms, meeting formats, tools and problem solving mechanisms; – putting in place internal rehabilitation interventions and supports and improving the transitional Work program; – making sure that all employees and managers have a clear understanding of the eirp in order to avoid inappropriate referrals; – building the role of managers and union stewards in the gradual return to Work program; and – improving the performance and services delivered by external service providers.



Concluding Comments

in conclusion, a lot has been achieved in the 12 months of the eirp and it is safe to expect that this success will be sustained into the future. its success cannot be attributed to one or two posi-tive factors but rather to a multi-level and fine-grained analysis of processes, and the development of appropriate responses. in this regard, the lean approach adopted by the cmc seems to have proved to be very effective. all was not “plain sailing” and without the commitment of all parties, the systematic approach to action planning adopted by the cmc team and the motivation of dm advisors and union stewards at the front line, the level of success achieved would not have been possible.

nevertheless, on the basis of the eirp results, it is possible to conclude that internalizing the dm process is the right thing to do and that the major challenge is making sure that it is done in the right way. based on results of the study, the approach adopted is shaping up to be an effective and appropriate approach. there is also little doubt that the qualitative findings of the dmar study and learning from the dmar project can be generalized not only to other health providers but also to other large distributed multi-site organizations wishing to internalize dm processes.



annex 1: examples of the DMar Materials

DMar action Planning template

DMar review and reflection journal



DMar eirP Case Manager advisor Feedback Form

Please provide the following case information on the volunteer by completing the form provided below. Where appropriate, circle the relevant number to indicate your response

1. Date employee entered the EIRP

2. Duration 5 days or less 6-30 days 1 to 2 months Over 2 months of the Case 1 2 3 4 3. Estimate the 1 hour or less 2-5 hours 6-10 hours 11 hours or more effort you allocated to 1 2 3 4this case in person hours

4. Age of the 20-29 years old 30-39 years old 40-49 years old over 50 years oldemployee 1 2 3 4 5. Length of his/ 1 to 14 15 to 28 1 to 4 5 to 12 12 to 18 Over 18her Absence days days months months months months 1 2 3 4 5 6

6. Length of time Under 12 12 to 35 3 to 5 6 to 10 11 to 15 16 to 20 Over 20 employed by months months years years years years yearsVCH (if known) 1 2 3 4 5 6 7

7. What is your Administrative Acute Patient Community Supervisoryjob role Support Care Patient Care 1 2 3 4

8. Please provide a brief description of the reason for absence below



DMar eirP Case Manager advisor Feedback Form

Please provide the following details by circling the relevant number for each item.

1. Age 20-29 years 30-39 years 40-49 years over 50 old old old years old 1 2 3 4 2. Length of 1 to 14 15 to 28 1 to 4 5 to 12 12 to 18 Over 18Absence days days months months months months 1 2 3 4 5 6

3. Length of Under 12 12 to 35 3 to 5 6 to 10 11 to 15 16 to 20 Over 20 time employed months months years years years years yearsby VCH 1 2 3 4 5 6 7 4. What is your Administrative Acute Patient Community Supervisoryjob role Support Care Patient Care 1 2 3 4

5. Please provide a brief description of the reason for your absence below



6. Please rate your overall satisfaction with your participation in the VCH Early Intervention and Rehabilitation Pilot by circling the relevant number on the scale provided.

7. Please indicate the current status of your participation on the scale provided by circling the relevant number

8. What obstacles, if any, did you encounter in attempting to return to work?

9. What kinds of things worked best for you?

10. What things would have made it easier for you?

11. What changes would you recommend to the VCH Early Intervention and Rehabilitation Pilot return to work process to make it work better?

Very Dissatisfied

Full Returnto Work

1

1

Moderately Satisfied

The process is still

ongoing

3

3

Dissatisfied

Partial Return to

Work

2

2

Satisfied

The process has ended without

Return to Work

4

4

Very Satisfied

The process was not

appropriate for me

5

5



annex 2: DMar gantt Chart



annex 3: summary of the DMar journal Content

Objective Issues Arising SolutionsOb.1) To articulate in writing, the redesigned disability management program – process and desired outcomes.Ob.2) To articulate in writing, the key DM program performance indicators and determine a reporting plan.Ob.3) To build capacity for and integrate DM data collection and management.

1. Multiple sources (11)a. Accurate and timely data difficult to getb. A single source is not possible

a. Narrow the sources to 2 or 3i. Create Access database as an interim measure

2. Attendance Promotion Program leads to delays in referralsa. Excessive response timesb. Managers don’t trust APPc. APP is perceived as ineffectived. 1 Advisor managing thise. APP is cyclical and missing a cycle leads to delayf. APP is high profile and needs resultsg. Loss of key data when tracking referralsh. Disagreement between HR and Unions on new APP procedure

b. Develop a process for intake and communicationi. Centralize data collection and sharingii. Single point of contactiii. Caseload divided between sev-eral Advisorsiv. Screen referrals to determine next steps based on 3 criteria – re-ferral to OHNP if physician’s note is completev. Policy change in requirement for physician’s note after 3 days – k. Physician’s note to be sent to CMC rather than HRvi. New process for intake and tracking notesvii. APP process re-defined (process map, inputs and exits and database)viii. Responsibilities clarified, timeframes standardizedix.Coincided with other CMC programsx. Clear distinction between HR and DM issues



Objective Issues Arising Solutions3. HR Team confused about CMC processa. HR expectations need to be adjusted

4. Older referrals are already delayed significantlya. This may result in grievances

c. Adjust HR expectations with a process flow in each HSDA

d. Introduce a “patch” process for older referrals

5. 30-day audit report of absences not being used effectivelya. Referrals of employees up to two months absence

e. New process for reviewing 30 day report to ensure timely referrals

Ob.4) To establish a DM policies and procedures manual.

1. Concerns about the need for Advisor mentoring by external experta. Need for a better understanding of support servicesb. Need to provide Advisors with greater insight into issues and scope of support servicec. Need for Advisors to distinguish between personal and workplace based issuesd. Potential to improve efficiency of the case management process

a. DM expert and other professional to be brought around the table with the teami. Individual mentoring to be made available to Advisors



Objective Issues Arising SolutionsOb.5) To establish a budget monitoring, forecasting and financial reconciliation plan for the RTW cost centre (71206001).

Ob.6) To establish a general communications plan for CMC.

1. Miscommunication of specific payment and medical benefits, etc.a. Loss of trustb. Confusion on the part of em-ployees and unionsc. Need for centralized information (including website)d. Revising information brochure for clarity

a. Definition of termsb. Making sure everyone gives the same messagec. Establish clarification on referral processd. Communication plan signed off by senior management

Ob.7) To develop a business plan for CMC.



Objective Issues Arising SolutionsOb.8) To establish a plan to creatively implement vocational rehabilitation within VCH.

1. The duty to accommodate places 10% of employees back to worka. Union complaints about the programb. Costs are around $200k per year per employee not returnedc. Exclusion of the worker with all its consequencesd. Possible resistance from unions to changing the title of the programe. Stigma of the DTA label may result in low participationf. Need to define DTA and its intake sourcesg. Intake statistics to DTA are inconsistenth. DTA Reports are inaccuratei. Accurate numbers are required for every stage of the program

a. New program needs to be developedb. Build relationship with HR who will lead the programc. Terms redefined (e.g. DTA own job; DTA any occupation)d. Referral sources identified and mappede. Access tracking database createdf. Include provisions for bumping and preferences for vacanciesg. Enhance manager role in the process and provide training and HR support

2. VCH lacks an internal program for training LTD employeesa. Currently carried out by GWLb. Increased LTD cost for VRc. VCH does not control the pro-gram or communicationsd. Learning and Development team have the expertise to do thise. Could result in more employees returning to their chosen careers

a. Identify current Learning and Development resourcesb. New process for the reintegration of disabled workersc. Two step process – internal program first, then GWL program



Objective Issues Arising SolutionsOb.9) To establish a continuous improvement process system within CMC.

Ob.10) To develop the VCH Transitional Work Program.

1. Confusion around services offered in Transitional Work Programa. Need for standardized definitions and termsb. These would help in marketing the programc. There are geographical differences in access to the Transitional Work Program (raised at think tank)d. Remote areas have less opportunities

a. Work plan for generating standardized definitionsb. Working group selectedc. Engage workplace rehab Advisors to identify jobs in smaller areasd. Develop a structure for reorganizing duties to create more opportunities

Ob.11) To establish a single point of contact (SPOC) for CMC.

1. The Call Line for Absence Reporting (CLEAR) system not being used consistentlya. Diversity of referral sourcesb. This results in delayed intervention2. The Absence Reporting Line (ARL) not being fully used by employees (51% in one period); 100% requireda. Higher use; more referralsb. Geographical spread of VCH is a challenge

a. A consistent procedure to ensure consistent and early reporting is requiredb. Measures needed to raise compliance



Objective Issues Arising SolutionsOb.12) To develop a plan for manager engagement in the DM process.

1. Referrals made by managers to the wrong programsa. Managers and designates need to understand that the program is crucial to the success of their employeesb. Existing relationships between CMC and managers need to be strengthenedc. This will result in better referrals and earlier intervention

a. Manager resource about EIRP/EIP createdb. Education sessions for managers planned

2. Some managers contact their employees who are off work – should this be formalized? (Raised by HSA at think tank)a. If this is not handled properly, it may upset the employeeb. Managers may not have the skills to handle the conversationc. Sometimes the EIRP and APP intersect; could this create a problem?

a. Managers will continue to contact employees if this is their practice but this will not be part of the EIRP processb. Advisor contact will maintain connection to workplace

Ob.13) To develop a plan for union engagement in the DM process.

1. Tripartite meetings could be more effectivea. Finding the right people for the meetingb. Finding the right size of meetingc. Introducing dispute resolutiond. Developing trust

a. Resolve issues earlyb. Create think tank (3 members from each group)



Objective Issues Arising Solutions2. Union Steward role and responsibilities in case management need to be clarified (raised by BCNU in tripartite meeting)a. This is not formalized in the Letter of Understandingb. Questions about this are regularly raised with Advisorsc. More clarity will enhance communications and decrease misunderstandings

a. 1 Advisor and 1 BCNU steward to work on a draft specification and bring to think tank

3. Employees can be confused about the respective roles of the internal EIRP and the external WSBC processa. The employee should initiate the WSBC process but may think the Advisor will do so (raised by HAS at think tank)b. Clarity will benefit the employer and employee and reduce stressc. If both processes begin early, there is a greater chance of success

a. Revise EIRP letter to the employeeb. Advisor needs to remind the employee if the injury is work related



Objective Issues Arising Solutions4. A dispute resolution process needs to be put in place for issues arising from EIRP and its supports and interventions (raised by HAS at think tank)a. This will protect trust and improve communicationsb. If third party intervention is required, medical and non-medical expertise may be required

a. A framework for different levels of issues to be developedi. Small issues: Union steward and union office with Advisors and Managerii. Medium issues: Mutually agreed third partyiii. Large issues: Existing grievance proceduresiv. Contacts with DM expertise to be identified and reviewed by both parties

Ob.14) To develop a plan for worker engagement in the DM process.

Ob.15) To establish a processfor resolving cases where anemployee’s LTD claim hasbeen denied.

1. Worksafe and wellness associated with decisions on payment or nota. Interferes with relationship with employee

a W&W to act as bufferi. External agents decide on payment – W&W acts as advocateii. Refocuses employee anger and frustration externallyiii. Cornerstone for building trust

2. Questions raised about the purpose of ARL and confusion about its name a. This can result in lower intake to CMC with resulting increased costs and durationb. ARL needs to be separated from APP to encourage staff to use the program

1. Inefficient communicationwith Payroll, Records andBenefits re employee statusa. Incorrect wages and benefitsb. Delays in correcting employeedatac. Reputation of the programsuffers

a. Re-brand ARL to create about inputs and outputsi. Memo sent to employee in pay stub to announce the new program

a. A system to update employeestatus in real timeb. CMC Access database for caseupdatei. Tabs and permissions for P,R&B to view relevant information



Objective Issues Arising SolutionsOb.16) To establish an efficientand effective case managementprocess.

1. Inefficient meetings andtoo longa. Re-examining case detailsunnecessarilyb. Need case clarityc. Increased duration of disability

a. Develop a Referral Form withOHNP to provide case summaryand key informationb. Train Advisors to distinguishbetween medical and non-medical

Ob.17) To establish ateam-building plan for the CMC.

2. Increased workload pressurefor Advisorsa. Referrals increasing and thusworkload increasingb.This leads to a delay in programdeliverables and duration ofdisability

a Peer to peer Advisor meet-ings to exchange experience and knowledgeb. Define workload in qualitative and quantitative measuresc. Temporary support from assistant and 1 additional Advisord. A review of the role of Associates to see how they can be better usede. A review of Advisor role

3. Some service providersnot providing what is required(discharge report, GRTW planand follow up services) a. VCH providing additionalservices to those cleared for fullduties by service providerb. Increased costs and services toemployer as a result of incompletework by service providers

a. Establish an objective processto clarify expectations and identifyunmet needsb. Require providers to completeservice contract



annex 4: Pre and Post eirP Case studies

Case study 1 – Pre Disability Management redesign

• Joan is a 46 year old rn who met the criteria for referral to the third party eip provider when she had her fifth consecutive day off sick. • Vch referred Joan to the eip provider on day 10 of her absence, after connecting with Joan and informing her of the program. • Vch informed Joan’s manager that she was being referred to the eip.• the eip contacted Joan and sent to her the occupational fitness assessment form and consent as per the program design.• Joan’s physician completed the ofa and returned it to the third party provider.• Vch disability management staff were informed that Joan was off with a medical issue, but were not provided with any information regarding the nature of the illness or the expected return to work date. • there was no information provided as to whether or not services or programs were being provided to Joan.• the Vch dm staff informed the manager that Joan was off and that there was, at this time, no known rtW date.• approximately four months after the first day of sick leave, the employer was notified that Joan was to go on long term disability, and the appropriate forms were to be completed. the dm advisor informed the manager and Joan was accepted on ltd.• there was no communication about Joan’s progress or rehabilitation plan while on ltd.• Joan continued on ltd until she and the employer were informed that her ltd would be ending in two months and that she was cleared to return to work. • the rtW plan was very simplistic – and did not reflect the work that Joan did.• at that point, Vch became actively involved as Joan’s benefits were coming to a close, but there was limited information regarding limitations or restrictions. • on speaking with Joan, the dm advisor learned that there had been only intermittent contact from the ltd insurance provider and there had been no discussion regarding return to work prior to receiving the information from the provider that her claim was to close in two months. there had been no referral for any type of rehab services until two months prior to claim closure.



Case study 2 – Post Disability Management redesign

• lesley is a 50 year old rn who was off sick for five consecutive days.• a disability management advisor contacted Joan on her eighth day off and explained the early intervention and rehabilitation program and what was offered through the program.• lesley was interested in the program, and the dm advisor had the consent and occupational fitness assessment form sent to lesley, who then took it to her physician.• the dm advisor informed lesley’s manager that she was in the program and that once we had an idea of how long lesley would be off, we would let the manager know.• the dm advisor informed the union representative of lesley’s absence and the anticipated rehab plan and rtW date, and the union contacted lesley and indicated to her that if she had any questions, to be sure to contact them.• medical information was received by the dm advisor, who then contacted lesley.• lesley’s case was very complex and required a great deal of counseling by the dm advisor as to how quickly lesley would be able to return to work.• rehabilitation services were arranged with both mental health and physical rehab provided, and there was also a compounding variable in that there was restructuring going on within lesley’s workplace. the dm advisor kept lesley informed of the changes, and how those changes would impact her.• the dm advisor kept the manager informed as to the anticipated rtW date.• lesley did need to apply for ltd and the dm advisor ensured that all of the appropriate documentation was completed, and the claim was accepted by the insurer.• the dm advisor met with the insurer, employee, and union to agree to a rehab plan while lesley was on ltd. Knowledge of the reorganization that was going on in lesley’s work area helped to develop a rehab plan that was realistic.

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