In my experience, the on-site visit is usually requested in an effort to assess existing ergonomic or safety problems. As an example, I may receive a request from the human resource director of a company to evaluate the working conditions of a specific employee who has a reported disorder, such as carpal tunnel syndrome. Or, similarly, I may be asked to visit a particular location where there have been a high number of injuries or complaints. In addition, the on-site visit may be used for medico-legal reasons in determining a causal relationship between work-related factors and the presence of a medical condition. Increasingly, the on-site visit is being used proactively as part of an overall safety program. It may also be used as a means of complying with governmental or regulatory agencies. Whatever the reason for the on-site visit, the experienced clinician adds a valuable component to the safety process.
For the purposes of our discussion the on-site visit may be divided into several components; 1) pre-walk through preparation, 2) site walk through, 3) closing meeting, and 4) written report.
To begin, prior to actually touring the workplace, it is necessary to do some homework regarding the situation at hand. This preparation should provide the clinician with an understanding of the specifics of the facility, the nature of the work performed, the work force, and the types of injuries that are prevalent in such an environment. We gather much of this information from the industrial case history (ICH), a questionnaire we provide to our industrial clients prior to any worksite visit. Additional information may be extrapolated from general injury data. For example, certain occupations such as textile manufacturing or electronic assembly line production, are associated with a high incidence of hand and wrist injuries. Facilities such as loading docks or warehouses, where there is a large amount of manual material handling, will often have a high incidence of back injuries. More specific injury data may be found by reviewing the company workers' compensation records as was discussed in Part I of this column.
In addition to gathering information through the ICH, it is helpful to have an orientation meeting with company officials prior to the walk through. During this meeting it is important to establish the purpose of the walk through. This is a chance to review overall operations, to obtain a description of jobs to be analyzed, and to discuss company health and safety policies. It is also a time to gain a clear understanding of company priorities and budgetary considerations. It is important that the clinician and the company agree on the need for the on-site visit, the expectations for the visit, and the form of the final outcome. For obvious reasons, the more time taken in preparing for a visit, the more productive the time on-site becomes.
When the time comes for the on-site visit there are a number of factors that must be considered. The clinician should use appropriate safety equipment, such as hard hats, eye or hearing protection, steel-toed shoes, etc. Typically, the clinician will be accompanied by a company official. I like to take pictures of the site for future reference, so permission must be obtained. While this is not usually difficult, I have encountered areas that contain sensitive information, procedures or products and have, on occasion, been denied this request. At one site I was provided with a company photographer who accompanied my tour.
During the visit, I am particularly interested in observing the interaction between employees and company officials. The nature of the interaction provides a unique insight into the social environment of the company. As a general rule, the clinician should not engage in any extended conversation with employees without first asking the company official or tour guide. In some cases, employees may be reluctant to discuss problems in the presence of supervisors. In other cases, employees may be sarcastic or openly hostile. When employees and supervisory personnel interact in a friendly and open manner, the task of making positive changes in safety is made that much easier. In my opinion, understanding the attitude of workers towards company officials, and vice versa, is one of the most important aspects of the on-site visit.
While gaining an understanding of worker attitude is useful, the primary objective of the on-site visit is to identify health and safety hazards. Although the focus of the chiropractic consultant is on physical (i.e., biomechanical) hazards, it is important to remain alert for other potential problems. These may include chemical, environmental, biological or psychological factors. In evaluating a site for potential ergonomic problems, look for the following:
- unnecessary or repetitive motions
- poorly designed work stations
- poorly maintained equipment and/or work stations
- routine tasks that require non-neutral postures of the spine and/or extremities
- poorly designed hand tools
- cluttered or dirty areas
- factors which may distract workers
When looking at a specific work station or job, I find asking the employee what modifications would make their work easier often reveals valuable information. For example, I was once asked to assess the work station of a computer data entry operator who had a problem with carpal tunnel syndrome. When questioned, she responded that the "r" on her keyboard was broken and she had to strike it repeatedly. Part of the solution for her particular situation involved a replacement keyboard at a cost of approximately $50. Without asking her, I would not likely have discovered this problem. As noted earlier, however, employees may not always feel comfortable sharing information in the presence of supervisory personnel. We encourage employees to provide written suggestions and provide self-addressed, stamped envelopes for their use.
In addition to the information listed above, it is helpful to look for signs of psychological stress such as:
- crowded work stations and areas
- worker attitude
- work pace
- worker control over environment
It is also helpful to note such things as temperature and relative humidity, noise, lighting, ventilation, and housekeeping. I note the presence of signs, posters, safety messages and first aid kits. I also note employee behavior, such as eating, drinking, and smoking while on the job.
The walk through should be concluded with a brief closing meeting. This is an opportunity to organize data that has been collected. It is also a time to ask additional questions regarding work practices and situations that have been observed. It should be emphasized that this is not a time to reach conclusions and/or to offer opinions regarding changes that need to be implemented. Rather, the nature of the follow-up report may be discussed and clarified. Suggestions for improving safety and health should be contained in the final report.
The final phase of the on-site visit is a formal written report. I consider this to be similar to the report of findings that we provide new patients. It should provide the company with a clear list of problems that have been identified during the walk through. I find it useful to prioritize the problems noted, beginning with those areas that I am able to provide assistance with. For instance, my company specializes in reducing the incidence of musculoskeletal injuries. Consequently, if lifting techniques have resulted in a high incidence of back injuries, this will be at the top of the list. Likewise, if simple ergonomic changes may reduce the frequency of hand and wrist problems, these will be similarly positioned in my final report. Those problems that I am not comfortable addressing, such as high noise levels, improving ventilation, or major ergonomic redesign, will be placed at the end of the list. Each problem that is identified should be accompanied by suggestions for improving the situation. Once again, as with patient care, it is not necessary that the chiropractor be equipped to solve all problems that have been identified. The solution often involves professionals from other disciplines, e.g., ergonomists, industrial engineers, or hazardous material specialists. I view my role to not only provide advice regarding areas of my specialty, but also to assist companies to identify other individuals. In other words, I may refer the company to a specialist in a different field.
Finally, I would like to add a word about fees. In some instances, the opportunity to visit a worksite may be viewed as a chance to improve the relationship between the chiropractor and the employer. Under such circumstances, it is acceptable to provide the service at no charge in the name of public relations. The good will developed more than offsets any time and effort involved. However, when a specific request is made of the chiropractor to assist a company in the development and refinement of a health and safety program, serious consideration should be given to charging a reasonable fee for services provided. It is common for consultants to develop a fee structure that is based on time spent, similar to that of attorneys. Fees should be discussed prior to performing services and payment arrangements should be clearly agreed upon by both parties.
While there are many definitions of "consultant" (e.g., anyone out of work who owns a brief case), when clinicians are asked to visit a worksite they become problem solvers. As I have indicated in my past writings, it is my opinion that the chiropractor has a great deal to offer to the industrial community. Our understanding of the nature of musculoskeletal injuries, and our unique approach to health, make us extremely useful in the industrial community. In addition to helping industry with injury prevention, interacting in the business community will have a positive impact on our future. In a recent column in Dynamic Chiropractic, Dr. Joseph Sweere (the father of chiropractic industrial consulting) articulated the way into managed care was through our relationship with the business community. The chiropractic profession can only benefit from increasing our visibility in the workplace.
If you are interested in obtaining a copy of the forms that we use in our industrial evaluations, please send a stamped, self-addressed manilla envelope to:
Dr. Paul Hooper
Injury Prevention Technologies
2562 Castle Rock Road
Diamond Bar, CA 91785
I may also be contacted at Los Angeles College of Chiropractic, 16200 East Amber Valley Drive, Whittier, CA 90609. If you have questions, you may reach me at 909-598-6344 or at
Paul Hooper, DC
Diamond Bar, California
Click here for previous articles by Paul Hooper, DC, MPH, MS.