Prior to the Mayor's 2006 Shape Up at Work Strategies, most City departments had no formal program to promote employee health. In the April 2006 executive directive initiating the Shape Up at Work Strategies, the Mayor instructed City departments to incorporate their commitment to employee health and wellness strategies into their mission/vision/value statements by June 30, 2007.

Incorporation of Employee Health and Safety into Departments' Mission Statements and Strategic Plans

City departments did not uniformly respond to the Mayor's directive instructing City departments to incorporate their commitment to employee health and wellness strategies into their mission/vision/value statements by June 30, 2007. City departments function under a mission statement and conduct operations under a strategic plan. In general, a mission statement serves as the department's statement of purpose for employees, commission members, and the public, while a strategic plan outlines the direction and approach used to implement the department's mission. In San Francisco, the mission statement or strategic plan is the highest level at which a department's senior management can sponsor employee health promotion programs. However, in a survey of 49 City departments conducted by the Budget Analyst, only 22 of the 42 departments responding to the survey, or 52 percent, reported that the department's mission statement or strategic plan incorporated employee health and safety promotion. The list of City departments that were surveyed and that responded to the survey is attached to Section 2.

As shown in Table 2.1, nine of the City's ten largest departments incorporate promoting employee health and safety in their mission statements or strategic plans. These departments include the Department of Public Health, Municipal Transportation Agency, Police Department, Public Utilities Commission, Human Services Agency, Airport, Department of Public Works, Sheriff's Department, and Recreation and Park Department. The Fire Department does not include promoting employee health and safety in their mission statement or strategic plan, but as discussed below, successfully applied for a grant from the Federal Emergency Management Agency that will support the physical fitness of its employees.

Table 2.1
Incorporation of Employee Health and Safety in Departments' Mission Statements and Strategic Plans

Source: Budget Analyst Survey

According to the Adult Probation Department, the Department is currently developing a strategic plan that will incorporate a strategy for promoting employee health and safety.

Seven departments did not respond to the Budget Analyst survey question on the incorporation of employee health and safety programs in the department's mission statement or strategic plan. These departments include the Academy of Sciences, Office of the Assessor/Recorder, Board of Appeals, Department of Economic and Workforce Development, Department of Elections, Department of the Environment, and Mayor's Office.

City Departments' Implementation of the Mayor's Shape Up at Work Strategies

According to the Shape Up at Work website, the primary goal for Shape Up at Work is to "ensure that all City employees work in environments that support healthy eating and physical activity through the development and implementation of policy, programs, and events".

Shape Up at Work as Part of Shape Up San Francisco

Shape Up at Work is part of the larger City-wide Shape Up San Francisco initiative, which targets the entire San Francisco population, including youth and adult residents, and private and public employees. Four City departments have lead responsibility for Shape Up San Francisco, including the Department of Children, Youth and Their Families, Department of Public Health, Recreation and Park Department, and Department of Human Resources. The Department of Human Resources and the Department of Public Health have both played coordinating roles in Shape Up at Work.

Shape Up San Francisco has received approximately $220,000 in funding for programs. The Department of Public Health received $160,000 for Shape Up San Francisco programs for City residents, including $70,000 for the Walking Challenge, a ten-week program intended to engage employees and San Francisco residents to be physically active, and $90,000 to develop an awareness campaign. The Recreation and Park Department received $60,000 for events to promote active life styles and healthy eating for children.

Shape Up San Francisco does not have funding for dedicated staff, however. The Department of Public Health has two positions and the Department of Children, Youth, and Their Families has one position who allocate some time to coordinating Shape Up San Francisco as part of their broader job responsibilities.

City Departments' Participation in Shape Up at Work

Shape Up at Work is coordinated by a Steering Committee, consisting of representatives from six City departments, including the Department of Public Health, Public Utilities Commission, Department of Public Works, Recreation and Park Department, Human Services Agency, and Fire Department. The Shape Up at Work Steering Committee meets to discuss strategy and programming for the City-wide initiative on a monthly basis. Previously, the Department of Human Resources had a temporary intern position to support the Steering Committee and coordinate Shape Up at Work participation among City departments, but that temporary position no longer exists.

Thirty-three departments responding to the Budget Analyst survey reported participating in Shape Up at Work in 2007. Many of these departments have designated a department liaison who attends quarterly Shape Up at Work meetings to receive information, discuss programs within the individual departments, and coordinate future programs.

Most departments reported taking part in Shape Up at Work by organizing teams to participate in the Walking Challenge, set measurable distance goals, and track distance walked as a group.

Ten departments reported participating in another major employee health promotion initiative sponsored by the American Cancer Society, Active for Life, which was conducted from February 2006 through April 2006. These ten departments coordinated individual employees' and department teams' participation in Active for Life, including physical activity and eating healthier foods on a regular basis.

Eight departments did not report or reported that they do no participate in Shape Up at Work programs. These departments include Asian Art Museum, Board of Supervisors, Child Support Services, City Attorney, Emergency Management, Law Library, Mayor's Office, and Taxi Commission.

City Departments' Programs to Promote Employee Health

Few City departments allocate funding in their budgets for employee health promotion programs. The City departments that do allocate funding for employee health promotion programs generally allocate a small amount. Thirteen City departments responding to the Budget Analyst's survey reported total estimated FY 2007-2008 funding of $814,577 for employee health promotion programs. Eleven of the 13 departments reported small amounts of funding to pay program costs or partial funding of department positions.

• The Airport reported approximately $3,000 to $5,000 in the Airport's Health and Safety Unit's budget to promote health and wellness in the workplace. In addition, the SFO Medical Clinic, operated by a private contractor at the Airport, provides on-site annual medical monitoring exams and ongoing medical services, such as the flu shot program, to non-City as well as City employees at the Airport.
   
• The Asian Art Museum reported $4,000 in the budget of the Asian Art Museum Foundation, a non-profit organization, to pay for flu shots, Employee Assistance Program services, and other workplace health and wellness services.
   
• The Human Services Agency reported developing and implementing strategies to reduce employee stress and promote wellness in 2004, as a result of the Agency's strategic planning efforts. The Agency reported including approximately $2,000 in the FY 2007-2008 budget for training costs and materials and supplies for health promotion activities.
   
• Eight other departments, including the Department of Building Inspection, Commission on the Status of Women, Fire Department, Library, Public Utilities Commission, Recreation and Park Department, Sheriff's Department, and Rent Arbitration Board, reported small amounts of funding for employee health promotion programs or partial funding of Department positions to promote employee health programs as part of their broader responsibilities.

In total, these eleven City departments reported approximately $180,781 of the total estimated FY 2007-2008 funding of $814,577 for employee health promotion programs. Additionally, the Police Department reported an estimated $383,796 for the Department's physical fitness program for uniform personnel and the Municipal Transportation Agency reported $250,000 for the Agency's employee health promotion program, as discussed below.

The Police Department's Physical Fitness Program

The Police Department's physical fitness program tests uniform employees for a variety of physical fitness measures, including strength, endurance, body composition, and cardiovascular status, twice each year. Uniform employees who perform well in the physical fitness tests can earn up to 40 hours of paid time off each year.

The City's Memorandum of Understanding with the Police Officer's Association first included a provision for the Police Department's uniform employees to participate in physical fitness programs in 1993. Participation is voluntary for uniform employees hired prior to 1994 and mandatory for employees hired in 1994 and later.

As shown in Table 2.2, participation in the Department's physical fitness program and accrual of paid time off has increased between FY 2003-2004 and FY 2006-2007.

Table 2.2
Participation in the Police Department's Physical Fitness Program
FY 2003-2004 through FY 2006-2007

Source: Police Department Human Resource Information System

Not only are a larger number of uniform employees participating in the Department's physical fitness program, but a larger number are accruing the maximum hours of paid time off. In FY 2003-2004, 313 employees accrued 40 hours of paid time off and in FY 2006-2007, 435 employees accrued 40 hours of paid time off, a 39 percent increase.

Of the $383,796 estimated program costs in FY 2007-2008, approximately $60,000 are the costs of accrued paid time off. The remaining $323,796 estimated program costs pay for Police Department staff time to coordinate the physical fitness program, proctor exams, and take the physical fitness exams.

The Police Department tracks employees' compliance with the program requirements but does not track overall participation trends or the impact of participation in physical fitness programs on sick leave, disability leave, and workers' compensation leave. Consequently, the Police Department can not determine if the costs of the program result in savings from reduced sick leave, disability leave, or workers' compensation leave.

The Municipal Transportation Agency's Employee Health Promotion Program

The Municipal Transportation Agency provides an on-site back strengthening and comprehensive health awareness program to the Agency's employees. The Agency's program began as a two-year pilot program in 2002 to provide back strengthening to transit operators and reduce the incidence of workplace back injuries. Participation in the program is voluntary.

The on-site back strengthening and comprehensive health awareness program is currently provided through a contract originally awarded through a competitive process in 2003 to BackFirst and renewed in 2006 for three years in an amount not to exceed $300,000 per year. The Municipal Transportation Agency has reported that the FY 2007-2008 contract costs are $250,000.

BackFirst provides on-site back strengthening and comprehensive health awareness screenings, which include: blood pressure screening, cholesterol testing, yoga, massage and aerobic exercises at the Municipal Transportation Agency's Presidio and Cable Car Divisions. In April 2007, BackFirst added a mobile van to expand services to the remaining five Municipal Transportation Agency Operating Divisions. In addition to classes at these seven divisions, BackFirst also regularly holds classes at the Municipal Transportation Agency's administrative headquarters located at 1 South Van Ness Avenue.

The number of employees participating in the on-site back strengthening and comprehensive health awareness program has increased in the seven-month period from July 2007 through January 2008. In July 2007 the program had 1,107 participants and in January 2008 the program had 1,327 participants, an increase of approximately 20 percent.

Health Risk Assessments

BackFirst provides health risk assessments to employees through its mobile van. The health risk assessments include on-site blood pressure, blood sugar, and cholesterol screening. Employees are then provided an individualized risk assessment report, providing information about their health risks and what to do about them. Participating employees receive health risk counseling from BackFirst staff, who assist employees in developing individual action plans.

As of January 2008, 309 Municipal Transportation Agency employees had completed the health risk assessment, of whom 55 percent were transit operators, 14 percent were mechanics, and 27 percent were office and administrative staff. According to the Municipal Transportation Agency, health risk assessment information is confidential, and collected health risk assessment data does not contain information that could identify specific individuals.

The Municipal Transportation Agency has collected aggregate data for the 309 completed health risk assessments. This data has shown that approximately one-half of the participating employees have risks associated with nutrition, stress or depression, back pain, high blood pressure, and weight. The Municipal Transportation Agency intends to use the health risk assessment data and on-going onsite observations to develop programs targeting employees' health risks.

Measuring Program Outcomes

The Municipal Transportation Agency has not yet developed a system to measure program outcomes. The Agency's Workers' Compensation Division Manager, who oversees the back strengthening and comprehensive health awareness program, reports that the number of workers' compensation claims has decreased since the implementation of the program but the cause for the decrease can not be directly linked to the program. According to actuary reports, the Municipal Transportation Agency's expected workers' compensation payments decreased from $27.3 million in FY 2006-2007 to $25.3 million in FY 2007-2008, a decrease of 7.3 percent.

The Fire Department's Proposed Program

The Fire Department submitted a grant proposal to the Federal Emergency Management Agency (FEMA) to fund a wellness and fitness program for the Fire Department's uniform and civilian employees. In February 2008, the Fire Department received official notice that FEMA awarded the grant to the Department. Under the grant proposal, the Fire Department will receive approximately $1.2 million as a one-time grant for a proposed ongoing wellness and fitness program to mitigate the work-related injuries, absenteeism, cardiovascular disease, and the effects of aging.

Firefighter Health Risks and Potential Risk Reductions

According to national firefighting statistics, firefighters face a high risk of cardiovascular events due to the nature of their job, where sudden shifts from sedentary status to high activity pose a particular stress on the body. Over time, it is possible that, without attention, individual employees are "deconditioned" and fall into less than peak health condition. One additional risk factor germane to the Fire Department is age. As reported by the Fire Department, 66 percent of uniform personnel are over 40 compared to the national average of 45.6 percent, and 44 percent of uniform personnel are over 50 compared to the national average of 19.5 percent, which increases the department's likely incidence of illnesses and injuries due to age-related conditions like arthritis, deterioration in reflexes, flexibility, and range of motion.

From 2004 to 2006, the Fire Department spent over $39 million in workers' compensation costs and nearly $23 million in total sick pay. During the same period, Fire Department employees reported 1,205 serious work-related injuries or illnesses, of which 63 percent were due to strain, sprain, or muscular pain and 5 percent were due to cardiac conditions or strokes. The 2006 Department of Human Resources Report on the Status of Health and Safety reported that 38 percent of Citywide claims associated with cardiovascular disease were filed by Fire Department uniform employees.

Health and Fitness Program Outcomes in Other Local Fire Jurisdictions

According to the Fire Department, there is a movement within fire departments around the country to make wellness and fitness programs mandatory. In California, Los Angeles County Fire Department has a mandatory program. Following negotiations with their unions, the Orange County and San Diego County Fire Departments' health and fitness programs are now mandatory for new employees.

According to the Fire Department, the Department's goal is to create a mandatory and non-punitive wellness and fitness program for uniform employees. Creating a mandatory program requires meeting and conferring with the San Francisco Firefighters Union. The Department's civilian employees' participation in the program would be voluntary.

Mandatory participation has not always resulted in high levels of participation among firefighters. The Los Angeles County Fire Department manages an incentive program, providing a 3 percent pay incentive to employees who develop and adhere to a wellness plan. This new incentive program was instituted after measuring an employee participation level of 40 percent in the wellness program despite the program being mandated.

Fire departments in other jurisdictions have reported positive physical and financial outcomes of comprehensive employee health and safety programs. The Los Angeles County Fire Department has identified 42 cases of cardiovascular disease over the past three years as part of their cardiovascular screening, with savings estimates from $450,000 to $1.3 million due to return to work expediting and prevention of unnecessary workers' compensation claims. Over a ten-year period, the Phoenix Fire Department realized a reduction in injury by 26 percent, injury severity by 42 percent, and re-injury by 75 percent. The Orange County Fire Department saw a reduction in lost days due to lower back injuries by 59 percent in the second year of their program and recorded a reduction in workers' compensation by $1 million in FY 2003-2004.

The FEMA Grant Proposal

The FEMA Assistance to Firefighters Grant provides funding to local fire jurisdictions to support the physical health of their employees. The Fire Department has successfully applied to FEMA for grant funding for a comprehensive $1.5 million program focused on health and wellness for Fire Department employees, including $1.2 million in grant funds and $300,000 Fire Department matching funds. Activities included in the program are:

• Annual medical exam and fitness assessments for uniformed members,
• Formal fitness and injury/illness prevention programs, including exercise prescriptions and nutritional guidance,
• Durable exercise equipment for 45 fire stations, paramedic units, and administration uniform and civilian staff,
• An exercise physiologist, who will be accessible at no cost through employees' current health check provider, and
• Peer fitness trainers, with a goal of 25 certified trainers who receive 40 hours of training and are then able to provide one-on-one training for fitness and nutrition.

Currently, the Fire Department only provides medical screening for the Department's uniform employees but not broader wellness and fitness programs.

In 2006, the Fire Department submitted a grant application to FEMA for a wellness and fitness program. FEMA denied the grant, informing the Fire Department that the grant application was worthy of award but lacked compelling information on the costs and benefits of the proposed program. In 2007, the Fire Department submitted a new grant application, and in February 2008, the Fire Department received official notice that FEMA would award the Fire Department a $1.2 million one-time grant to implement an on-going wellness and fitness program. Although the grant application was successfully awarded, of note with this second grant submission, as with the first, was the absence of letters of support from elected officials which, according to the Fire Department, is encouraged by grant experts in the field.

In 2007, the Fire Department also formed a Joint Labor/Management Physical Fitness Committee consisting of four (4) uniform members, two (2) appointed by the Chief of the Department and two (2) appointed by the Firefighters Union. This committee will contribute to developing the Department's wellness and physical fitness program for uniform employees.

The City's Employee Assistance Program

The Employee Assistance Program, which is currently organized in the Department of Human Resources, offers free, confidential, and voluntary counseling and information to City employees and their dependents. The program is staffed by licensed mental health counselors.

In FY 2007-2008, the Employee Assistance Program has a budget of $338,814, which pays for rent, software licenses and other expenses, and salary and fringe benefits for three positions, including one Senior Employee Assistance Counselor, on Employee Assistance Counselor, and one Clerk Typist. In addition, several professional therapist interns are engaged during the academic year to provide practicum experience to local students.

The Employee Assistance Program serves a majority of City departments, their employees, and the employees' dependents. Some City departments, such as the Police Department and the Municipal Transportation Agency have contracts with private employee assistance program providers, although employees of these departments can also access the City's Employee Assistance Program services. Also, the Police Department, Fire Department, and Municipal Transportation Agency have their own peer counseling units.

To outreach to eligible City employees, the Employee Assistance Program conducts orientation to help employees understand the Employee Assistance Program services. From 2002 through 2007, the annual number of Employee Assistance Program orientations for City employees and dependents ranged from a low of nine to a high of 42 sessions.

The primary services provided by the Employee Assistance Program include:

• Brief solution-focused therapy sessions, a six session model that is solution focused and does not include ongoing mental health counseling,
• Employee Assistance Program referrals for City employees to access Employee Assistance Program services, and
• Outside referrals for employee support that requires more than six sessions or professional expertise beyond the scope of services provided by the Employee Assistance Program.

In addition, the Employee Assistance Program can refer City employees to community counseling agencies, such as family service agencies, culturally-targeted organizations, or services provided through local academic organizations.

Employee Assistance Program Utilization

The Employee Assistance Program's data management system, EAPISoft, is a customized management information system, designed by a former Employee Assistance Program professional, which tracks demographic and diagnostic information. The system has been in place since 1999.

Based on utilization reports from FY 2002-2003 through FY 2006-2007, the most prevalent issues assessed by the Employee Assistance Program, comprising nearly 75 percent of all primary assessed problems for clients include:

• Work-related issues,
• Family, marital, and relationship problems, and
• Psychological problems.

The components of the three primary assessed problems are listed in Table 2.3 below.

Table 2.3

Top Three Primary Assessed Problems for City Employees,
FY 2002-2003 through FY 2006-2007

 

Work-related Issues	Family/ Marital/ Relationship Problems	Psychological Problems
Job Stress Job Loss Safety/Accidents Roles and Duties Career Issues Customer/Vendor Relations Absenteeism/Tardiness Supervisor/Manager Relations Organizational Change Work Quality/Quantity Workplace Violence	Family significant other substance abuse Child behavior/ parenting Child abuse Relationship conflict/ communication problem Separation/divorce Extended/Blended family Domestic violence Childcare issues Elder care issues Other family/relationship problems	Psychosis Depression Adjustment Reaction Anxiety Personality Disorder Eating Disorder Depression Grief/ Loss Trauma Response

Source: Employee Assistance Program Reports and Staff

In FY 2006-2007, the Employee Assistance Program opened 292 client cases during the year, which is approximately 18.4 percent less than the 358 client cases opened in FY 2003-2004. This reduction in cases corresponds to Employee Assistance Program staff reductions. In FY 2003-2004, the Employee Assistance Program had 3.5 full time counselor staff, including 1.5 Employee Assistance Counselors, 1.0 Senior Employee Assistance Counselor, and 1.0 Employee Referral Program Director. In FY 2004-2005, the Employee Assistance Program reduced to 2.0 full time counselor staff, including 1.0 Employee Assistance Counselor and 1.0 Senior Employee Assistance Counselor. According to the Employee Assistance Program staff, the Program's clinical staff are currently focused on offering counseling sessions and are unable to focus on marketing efforts for the Program.

The Employee Assistance Program receives clients primarily through self-referral. The Program has not generally served as a tool for supervisors to assist employees with problems that impact work performance. The Employee Assistance Program staff identified three reasons given by City employers for low referral rates, including:

• The supervisor's hope for employee's self-resolution of issues rather than escalation;
• The supervisor's attribution of behavior to the employee's personal issues or an employee's own personality and attitude; and
• The supervisor's desire to not become a target of negative employee attention or legal liability by getting involved with an employee's issues.
• Anecdotally, clients who receive referrals on this basis tend not to cooperate with the Employee Assistance Program's counselors.

Employee Assistance Program Policies and Procedures

The Employee Assistance Program was transferred from the Department of Public Health to the Department of Human Resources in FY 2004-2005. Because the Department of Human Resources has not updated the Employee Assistance Program's Policies and Procedures since the transfer, the Policies and Procedures continue to describe the Employee Assistance Program as part of the Department of Public Health. Some provisions of the Policies and Procedures, including utilization meetings, organization strategy meetings, and staff training assessments are not currently conducted.

The City's Health Fairs

During the course of the Budget Analyst audit, two City departments conducted health fairs, one by the Health Service System and another by the Department of Public Works. Approximately 3,000 City employees participated in the two fairs, where they received a breadth of health plan information, flu shots, and health assessments on site. The Health Service System and Department of Public Works did not coordinate the health fairs despite significant overlap of information, services, and vendors between the two fairs.

Health Services System Member Fair

On October 31, 2007, the Health Services System held its second annual member health fair at the Hotel Whitcomb. The Health Service System reported that more than 2,500 members attended the event, which was approximately 54 percent more than the 2006 attendance of 1,600. This increased attendance resulted in part from increased outreach and visibility of the second annual health fair compared to the first health fair. According to the Health Service System, 1,500 members received flu shots, and more than 500 members patronized the health assessments on blood sugar, cholesterol, blood pressure, and body mass index. Members also received chair massages and participated in Qi Gong demonstrations.

Health plan representatives from Blue Shield, Kaiser Permanente, PacifiCare, United Healthcare, Delta Dental, Pacific Union Dental, and VSP Vision were present and provided health and wellness information and tools in printed format and online. Other attending organizations included City programs such as Shape Up San Francisco and the Employee Assistance Program, as well outside vendors like ING Financial Services, the San Francisco Employees' Retirement System, the Retired Employees of the City and County of San Francisco, the United Educators of San Francisco - Retired Division, and the Chinese Community Health Care Association.

According to the Health Service System, Health Service System staff solicited feedback throughout the event in efforts to mitigate the delays in accessing health screenings, flu shots and other activities, and to identify areas of potential improvement for future annual events. The Health Service System staff noted that health fair participants had long waits to access health screenings, in which wait times ranged from 30 minutes to over 2 hours depending on the number of screenings a member sought, and vendors, in which wait times ranged from 30 minutes to 4 hours.

The Public Works Department's Health Fair

On November 2, 2007, the San Francisco Department of Public Works held the first of what the Department intends to be an annual health fair with an estimated cost of $76,924. Several hundred Department of Public Works employees participated in the fair that targeted the Department's operations employees, who work in the field and were unable to attend the Health Service System downtown health fair. Department of Public Works management explained that employee health issues in recent years demonstrated the need for employee health promotion and preventive care.

Department of Public Works offered a variety of services to employees, including: body mass indexing, blood pressure reading, blood sugar level reading, total cholesterol measurement, diabetes testing, flu shot, and chair massage. The primary coordinators of the health fair were Department of Public Works senior management and General Service Agency health and safety staff. Participants in the fair included the Department of Public Works operations staff, the Department of Public Health/Nutrition Services, the Department of Emergency Management, the Employee Assistance Program, the San Francisco General Hospital, vendors Redback Shoes and 24 Hour Fitness, and healthcare provider California Pacific Medical Center.

To facilitate field employees' access to services, the City should consider providing standalone computer terminals in the Department of Public Works Yard and other difficult-to-reach employees who do not have access to a computer and the internet. Such access would enable field employees' participation in health risk assessments, accompanying incentive programs, and other online resources.