“My advice? Consider the worker as a person who has innumerable factors impacting on their presentation, and have an open mind as to rehabilitation measures to help them return to work and return to normalcy.” – Andrew McGarity, Rehab Manager

Concord and Rozelle Hospitals in Sydney’s southwest were losing nearly 6 days per full time employee per year to injury or illness, and had a high number of workers’ compensation claims, some of which had remained unresolved for five to ten years.

In terms of injuries sustained, there was little to explain the Hospitals’ poor rehabilitation performance. Similarly to other medical facilities, manual handling injuries were common, as were slips, trips and falls. A large number of workers’ compensation claims were made up of the classic back, neck and shoulder injuries.

Clearly, however, something was keeping claims active well beyond their expected endpoint. Rehab Manager, Andrew McGarity was appointed and elected to adopt a very new and fused approach.   

The results were:

• Lost time had dropped to less than half a day per full time employee per year;
• Claims costs were less than a quarter of what they were in the preceeding years and
• There were less than 40 active claims, down from a peak of nearly 110 

This case study examines how Andrew succeeded in turning around rehabilitation performance at Concord and Rozelle Hospitals.

The starting point: Ad hoc claims adding up

Andrew was too modest to tell us that he had spearheaded the remarkable rehabilitation turn-around at Concord and Rozelle hospitals. But he was clear about why claims had been dragging on and on. And on.

“It seemed to be a spiral downwards, as more and more claims came in and there weren’t any significant proactive measures to deal with the existing claims.”

“Our approach had been very ad-hoc, very retroactive. All we did was respond to the injured worker’s needs and respond to the medical certification that was provided—and this was very similar to other facilities I’d been at. There were no systems in place. There were no methods to try and facilitate the worker’s recovery and return to work.

“Because there were no systems in place, injuries and the subsequent rehabilitation seemed to go on for a very long period of time. When I started we had quite a number of claims that were over 5 years old and had never been resolved, never been finalised.”

While an ad-hoc approach may be appropriate for small organisations, it is not suitable for a large employer like Concord, which has 2672 staff on site, with one Rehab Manager. In 2007, Rozelle Hospital, a nearby mental health facility with 1529 staff, was relocated onto the Concord Hospital site. Two Rehab coordinators were appointed to assist Andrew with management of the additional staff. At both institutions, the workforce comprises around 50% nursing staff, 25% other medical workers, and 25% “admin” staff, including cleaners and food services staff.

Given the large staff numbers, the tiny rehab team, the backlog of claims and the organisation’s “culture of compensation,” Andrew decided that something had to be done.

“The impetus for change was partly from necessity. Having just one person in this role required a different approach to try and make it more proactive and also more time efficient.”

Having a hunch: psychological and social barriers

With a background in private consulting and OH&S, Andrew quickly developed a theory regarding factors that might be contributing to the backlog of claims at Concord and Rozelle.

“The key thing was that we weren’t identifying the barriers to the workers returning to work very well. The continuous feedback and systematic processes that you see in OH&S work just didn’t exist in the rehabilitation forum. I thought that was one of the reasons that there wasn’t any end-date on claims.

“In this field, it is very important to consider the problem holistically. We were making the mistake of medicalising the issues, rather than allowing for the fact that there might be “psychosocial” factors—things that aren’t to do with the injury itself, things that aren’t necessarily even to do with work—coming into play.”

Andrew’s hunch was that if the organisation took measures to identify workers who were at a high risk of having psychological and social barriers interfere with return to work, many drawn out work absences and claims could be avoided.

Friends in high places

With his hunch in hand, the next thing Andrew did was shore up executive approval.

“Luckily, the General Manager of the time had a psychological background. He was very supportive of the project, even though at that stage there wasn’t a lot of practical, workplace-based information out there.

“There was a lot of anecdotal evidence and guidance regarding the contribution psychosocial factors might make to poor rehab outcomes, but there wasn’t anything specifically for employers.”

With the GM’s approval and support, the Rehab team decided to undertake research of their own.

Adapting resources and identifying risk

Andrew and his team were familiar with the OREBRO questionnaire, which gathers information about psychosocial issues that may impact poorly on return to work.

This existing resource was helpful, but not ideal. Traditionally, the OREBRO questionnaire is used four to six weeks into a claim or work absence and Andrew felt that, from an employer’s perspective, four to six weeks was too long to wait.

“After doing a pilot and some further research, we remodelled the OREBRO into a questionnaire that could be used within 48 hours, mirroring the WorkCover requirements for notification of injuries.”

The remodelled OREBRO Questionnaire (which will shortly be uploaded to the Tools section of our site) was given to a group of 156 employees.

“Based on the results of that questionnaire we divided our workers into three groups: low, medium and high risk. We kept the low risk group as ad hoc treatment but put together a systematic assessment process for the medium and high risk group.

“The assessment processes involved utilisation of independent specialists to guide the rehabilitation process and it also included referral to an independent psychologist, to start management of any psychosocial issues that had been highlighted in the questionnaire.

“The screening tool allowed us to identify individual workers’ issues very, very early and very, very accurately. When we looked at our stats it was about 99% accurate.”

Becoming aware of non-medical barriers

“Instead of pursuing a medical model where you’re trying to identify pathology, we found that quite often there were non-work-related issues that were impacting on the worker’s presentation, that were far more important than any medical diagnosis.”

The two most common barriers preventing rehabilitation and return to work were:

1. The worker’s perception of pain. For example, if a worker had back problems and was friends with someone who’d had a bad back and never returned to work, their pessimistic beliefs about pain and their pain-related behaviours—for example, avoiding activities that cause pain, regardless of whether these activities are doing damage—could contribute to delays.
2. A disagreement with a supervisor or manager, that meant that the worker didn’t want to return to the workplace.

“Traditionally those sorts of things are ignored or downplayed, but they’re actually the key issues in the worker’s presentation. Once we’d identified these kinds of problems, we were able to overcome them very quickly and get the person back to work.”

Surmounting non-medical barriers

Andrew and his team found that there were effective ways of surmounting the two most common barriers, identified above.

1. Perceptions of pain:
   • An independent physician provided workers with knowledge about the injury that had occurred, including expected recovery periods;
   • The workers were given access to their medical reports, so that they felt they were part of the process; and
   • A psychologist assisted the worker with pain management and relaxation techniques.
2.  Workplace conflict:
   • The psychologist was able to identify anxiety and depression, and assist the worker in dealing with normal workplace issues; and
   • Mediation was provided where appropriate.

Providing workers with assurances of confidentiality is vital when tackling non-medical barriers to rehabilitation and return to work.

“The issues the psychologist deals with are confidential and we’re only informed if and when the worker is happy to have that happen. This set-up works quite well. It allows the psychologist to have a relatively free rein at identifying whatever barrier is there and overcoming it, without the worker feeling that their confidentiality is going to be compromised.”

Andrew's approach is systematic, but it also takes a holistic, 'human' view of the injured worker. Not only has it assisted the rehab team at Concord / Rozelle to resolve long term claims, it also enables them to intervene early in cases which exhibit psychological and social warning signs. This is good for the workers' comp costs at the hospitals and it is good for the people at the centre of RTW: injured workers.