Corporate Travel Medicine—Priorities & Models - Panel Discussion, April 27, 2000

Ron Joines, MD, MPH, Medical Director, SmithKline Beecham

DR. LIESE: The next speaker will be Ron Joines, who is the Medical Director of SmithKline Beecham. He is board-certified in preventive medicine and public health as well as in occupational and environmental medicine. His experience includes toxicology, medical surveillance, and industrial hygiene for infectious diseases in the workplace, so he has broad-based experience. He will present a case study on another organizational approach to primary prevention.

Ron, you have the floor.

DR. JOINES: Thank you very much for the introduction.

To validate one of your earlier comments, after traveling from my seat to the podium, what was the first thing I took a look for? My laptop. Right?

In the next 15 minutes, I really have a yeoman's task, I think, to leave you with a clear picture of how SmithKline Beecham is beginning to understand the impact of travel on the physical and psychosocial health of our employees. We'll take a brief look at how SB is applying a population-based health approach to define the key areas of risk for our travelers and to use a multidisciplinary approach as discussed by Dr. Ivancevich earlier to identify really the greatest opportunities for prevention at the individual and the organizational level.

One of the most exciting things I'll talk about is to discuss the potential application of some strategies, diagnostic tools, and behavioral interventions that were originally developed for general workforce, work-life, and organizational resilience strategy that might be able to be applied in the at-risk traveling group.

I think the best place to start, though, is with the story of the company, who are the people that make up SmithKline Beecham, what are our key products, and I think that will give you an understanding of our core businesses and how travel is a part of that and how travel affects our employees.

SB really is a truly global company, one of the world's leading pharmaceutical and consumer health care companies. Just taking, for example, pharmaceuticals, if you look at a typical Phase III clinical trial, a late-stage clinical trial that would be conducted to support a new drug application in a single market, that trial and all of the coordinating personnel and processes oftentimes span five to seven countries, even though the new drug application is in a single country; in turn, the product itself may be manufactured across two, three, or four countries and shipped around the world. It's really a global effort.

In that global effort, SB employs about 47,000 people in about 160 countries. In 1999, rather, we had sales of about $12.5 billion of 400 branded products. Among them are Paxil, the leading antidepressant, probably fairly frequently used among some of our travelers; Augmentin, a broad-spectrum antibiotic; and a broad portfolio of adult and pediatric vaccines. We also have a very strong over-the-counter medicine program with brand names you might recognize: Aquafresh, Tums, Nicorette, Nicoderm.

As a result, we have probably, I would say, one of the best company stores in the industry, and if you ever come to Philadelphia, I'll take you.

Following the proposed merger, the conclusion of that, which is likely to be this summer, with Glaxo Wellcome, Glaxo SmithKline—I actually got the name right, no Freudian slips there—we'll employ about 107,000 people in 165 countries. So our challenges will continue to multiply, I think.

Within the organization, I am privileged to work in a great group—Corporate Health Management. Our group serves our country, our company, rather—and our country—with a multidisciplinary team: 47 people in the U.S. and the U.K., who really utilize a population-based approach to health management that really integrates activity across a broad variety of disciplines. From the outset, our group has been chartered with a fairly unique mission, I think, in a corporate sector, a mission to prepare both individuals and the organization to meet physical and psychosocial challenges and demands of work and life.

We have long recognized that health is really multidimensional, and our strategy has been to take a vertically integrated approach to the design and delivery of health care services in conjunction with key organizational partners. This is not a silo approach of an occupational medical function. We actually really are very, very integrated with our human resources colleagues, the generalists, the organizational behavior change specialists, our recruitment specialists, and, of course, our safety colleagues.

Built into the design and delivery of all of our programs are various measures, process measures: health and financial outcomes measures, measures that we use to identify the impact of our programs on employees, to identify new health management opportunities, as well as continuous improvement.

Our group's end goal is really twofold: enhanced individual and organizational capability. We focus on reducing costs to the business, both direct costs attributable to ill health, such as sickness and absence, health care benefits claims, retraining, replacement of ill and injured workers, and also indirect costs by enhancing the productivity, focus, commitment, and probably ultimately the innovation of our employees who are really the critical element in this knowledge-based business.

Our activity really follows a public health approach. As a first step, we, of course, seek to define the health issues and its organizational impact. I think Dan Thomas had mentioned the importance of that earlier. Not only do you have to look at the prevalence incidence of the condition, but what is its impact in terms of productivity, cost, and organizational capability? And from that data, can we identify the key determinants of risk and intervene in those areas of risk?

Linking—it's also important—I think this has been mentioned a couple times—to link this to the business objectives and to raise awareness of the issue and its impact to the business leaders. That is how you gain management commitment, certainly.

Our focus and our areas of activity are quite broad. It's really almost a systems-based approach. Our population-based health efforts include initiatives in health care benefits design and quality assurance, and we use the benefit plan to promote prevention and to address key health and cost drivers. A second major focus of activity is work-life and resilience programs and strategies which are directed at improving both the personal and organizational resilience at SB. These programs include such diverse items as personal and team diagnostics to define key sources of pressure and counterbalancing coping mechanisms, resilience and skill building workshops, employee community involvement programs, and elder and child care assistance. A very broad package of services and programs.

We also, of course, act in the area of wellness and health promotion activities. Some of the most notable centralized programs that we have are a centralized health risk appraisal process, which I'm sure many of you also utilize. We use that transnationally, U.S./U.K. And, actually, one of the interesting things that we're doing, particularly in the wellness and health promotion area, is using the data derived from the health risk appraisal process to identify high-risk individuals. Those high-risk individuals are then contacted actually by an external vendor and offered access to disease management programs that overlay what they may already receive in their benefits plan or supplement what they already receive through their benefits plan.

Of course, we also offer comprehensive occupational health services and disability management services.

Our efforts are really focused at both the primary, secondary, and tertiary prevention level. The green arrow is intended to signify the fact that our efforts are concentrated, to the extent where it's possible, in the areas of primary and secondary prevention and in the areas of wellness. We want to stop illness and injury, of course, from occurring.

So I think the most important thing to know about where we're focusing our activities in this area is to start with who are our travelers, who are our target audience that we want to address and support and provide tools to.

Our frequent SB travelers really fall into two major groups. The first is expatriates, about 400 or so families that post overseas for two or more years on assignments. We also have a large group of episodic travelers, about 1,200 in the U.S. and the U.K. They average about six trips a year to one of 130 countries There was an interesting question earlier about what knowledge do we have, organizational knowledge, about the impact of this travel on physical and psychosocial health, and we did a very interesting survey back in 1996 of these frequent travelers. Five hundred of our travelers were surveyed. We had a response of about 70 percent. And 35 percent of our travelers indicated that they regularly experience physical or psychosocial issues that drain their productivity while they're away on business.

The primary drivers that they reported were at that time were actually physical health issues, establishing efforts to createf programs and services to address physical health issues our number one priority.

So as part of our integrated approach to supporting the employee, we have recognized that physical health is really the cornerstone of stamina, energy, performance, and psychological well-being. Using literature reviews, our focus groups, and survey data of frequent travelers, we've designed a program for that that's got components to prevent and manage the most common travel-related illnesses that we see. Sixteen clinics in the U.S. and the U.K. that offer comprehensive primary and secondary prevention services, pre-trip counseling, chemoprophylaxis, immunizations, and traveling fitness center kits and fitness center passports. I can explain that more later.

Also, of course, we've got a tertiary prevention model designed to support the ill and injured traveler's emergency needs abroad.

I think that one of the most daunting challenges we've had in putting a traditional program together has been promoting timely access to pre-trip travel health advice. We have had our fair share of people showing up at the door with a ticket to Africa in hand saying, "I'm on the way to the airport. Should I be getting something before I go?"

So we examined the key organizational barriers to be overcome to get information to people in a timely manner. And some of those barriers include things like a culture of invincibility. There's almost a road warrior culture. Raise your hand if you've seen that in a corporation.

I think there's a lack of awareness of the real health risks associated with travel. We've seen that in our business travelers and from our surveys. There's uncertainty about initially where to go for travel services. And people really need access to information on their terms. In other words, they can't, wait for a clinic to be open or necessarily visit us, , during our 8:00 to 5:00 clinic hours. They need access to information when they need it.

We have attempted to address these issues through two approaches. The first is a targeted educational approach to legitimize their health as a business issue and to raise awareness about how to access services, what type of services are available,etc. We've done this through presentations to line management, HR, key work groups that have been identified as frequent travelers based upon our in-house travel reservations programs and systems.

We have also, secondly, developed some tools to provide our travelers with access to a comprehensive body of knowledge and information that's available through their desktop at home or at work when they want it. We've found these resources to be very effective over the last couple of years in driving a personal perception of risk and getting people to take preventive steps prior to a trip.

I'll highlight one of the Web-based tools that we use for our frequent episodic international travelers, which is a part of a website that we Corporate Health Management, have built that actually outlines all of our services and programs that are available.

Through the Wellness Web, as we call it, frequent travelers and expatriates can access information 24 hours a day on local and out-of-country health resources, both inside and outside SmithKline Beecham; continuously updated, country-specific health risk information on over 220 destinations; along with immunization information, other pre-trip recommendations. And much to the delight of some of the somaticizers in our organization, we have descriptions of common tropical and tropical-related illnesses. I've seen a couple of people with Mediterranean sandfly fever and leshmoniasis who have actually never left the state of Pennsylvania. It's very interesting.

[LAUGHTER]

The program also includes information on how to access emergency medical assistance as well as routine payments and administrative issues, relieving another source of stress for them.

I think it's important to step back and look at how we approach travel health issues from a little bit of a different perspective, bringing in some of our other capabilities and resources. And a really exciting new set of opportunities, which I really think is directly applicable to the prevention of mental health illness in travelers is the application of our group's company-wide efforts in the arenas of work-life and resilience. Many of the strategic approaches, tools, and work-life programs have a really direct application in this group.

As a first step in understanding what these tools and resources mean in an organization, I think it's important to understand the organizational and individual context in which the SB culture views the concepts of work-life and organizational resilience. One of the first and I think most important things we have done is to build a business model, a business case for why organizational resilience is important. And this is really a business case for optimal psychosocial health and its impact, positive impact on the organization, and on individuals' discretionary effort. In other words, what are people going to give you above and beyond because they want to?

The business goal, clearly, of enhanced resilience is to enable employees to remain effective in a constantly dynamic, demanding, changing workplace. You get superior focus, commitment, productivity, retention, and recruitment. In keeping with the classical public health model, we recognize that resilience is shaped by both environmental and individual factors. Some of the critical environmental factors you see are senior executive practices: How well are objectives, goals clarified? What kind of balanced behaviors are being modeled and reinforced in their direct reports?

Jim Striker talked a lot about how the work gets done. Management practices, once again, in terms of clarifying objectives, supporting experimental ways of doing new work, flexible work, improving processes, or just doing things completely different, and that willingness to experiment is critically important, I think, in reducing stress in an organization and maximizing resilience in a group.

And, of course, the cornerstone, once again, is individual practices: choices that impact adaptability, health and stamina, and work-life balance. And by work-life balance, we actually frame the concept a little bit differently. We frame it as really drawing energy and enthusiasm from all aspects of life—your life outside of work feeding your life in work, and vice versa.

Now let's take a look at how this business concept, I guess, can be represented at the individual level, and I think it will become immediately apparent to you how these initiatives and tools are applicable to mental health issues in business travelers.

Central to the concept of creating a resilient workforce, I think, is an understanding of that relationship between pressure and performance at the level of the individual. Having said that, we all recognize that pressure has both positive and negative effects, and some degree of pressure is needed to perform well.

You've probably seen this graph or one like it before. The concept is that at very little levels of pressure, we all tend to be a little on the bored side and our performance is kind of low. As pressure increases, we move into our comfort zone, and new experiences, significant changes, work challenges really push us into the stretch zone, which is where we truly perform best.

However, we have to recognize there's a very think line between stretch, I think, and strain for both individuals and organizations. There is a rapid decline in performance. When people feel strained, they become fatigued, have poor judgment, impaired decision making, and this is not a position that we want to put a critical scientific or business leader in when they are abroad, making a resource decision that impacts the movement of an investigational product from a Phase II to a Phase III study. That's oftentimes a $300 to $500 million organizational commitment, and a commitment that could affect the lives of potentially millions of people.

When people have reached the panic zone, that's when we see them, of course, with illness—mental illness, physical illness, and burnout. We've all seen it, I think. We don't want people to get there.

Just to set realistic expectations, I don't want to leave you with the impression that being resilient does not mean that an individual can withstand infinite amounts of pressure and have an unlimited increase in performance. As much as we would like that, I think it's pure fantasy.

What we are trying to achieve through our resilience interventions is really pushing this curve upward and to the right, increasing an individual's ability to cope with greater amounts of pressure and remain in that stretch zone for a longer period of time before performance and personal well-being begin to suffer. We recognize that the optimal time to intervene, be it the physical, mental health, social health interventions are when people are in this zone. When they get here, it's too late. They're not receptive to the message. They don't incorporate it. And they've already progressed to illness and/or injury.

These interventions importantly, I think, have to be applied at both the individual level, the level of the working team, and the management level. And in the next slide, we'll begin to examine how we are starting to apply some of our resilience approaches in the general population to address the psychosocial impact of frequent travel on health.

Every presentation has an eyesight test, and this is the eyesight test slide. Fortunately, I just got new glasses yesterday, actually, so it's helped me.

Our resilience efforts really have their genesis in some work that we began about three or four years ago when began to examine the impact of stress on our organization. Using our U.S. benefits claims data, we determined the burden of illness and associated costs that could be attributable to stress-related illness across the organization. That was presented to senior management in a White Paper, and that White Paper generated quite a bit of controversy, excellent dialogue, led to a lot of leadership input, focus groups, trying to quantify the impact of stress on the organization and also beginning to understand the impact of stress on our ability to recruit and retain the best and the brightest.

From there, it recently led to a workforce engagement survey. This was a survey of the top 5,000 managers in our company. The goal of this survey was to determine the relative importance of various factors in influencing a manager's decision to either join SmithKline Beecham or to remain with SmithKline Beecham through chaos and change.

The preliminary results of the survey are in, and the most important determinant of commitment on the work-life balance scale, and the work-life balance scale was a very important determinant of commitment was, probably not surprisingly to this audience—the degree and extent of travel. And I think that this represents another one of potential organizational impacts that Dan Thomas was challenging us with.

So this has led us to the conclusion that we may be able to apply many of the individual and organizational diagnostic tools and interventions that we currently use in our general population and the management cadre and to our frequent travelers is a risk group.

I've just been given the one-minute mark, so I'll be very brief. I'd be happy to discuss further in questions. We have a number of very interesting risk and disease identification tools that we can use at the individual and the organizational level. The pressure management indicator, a PC-based mental health, health risk appraisal almost, looks at the sources of pressure, key coping skills people rely on, how out of balance they are and where they need to build coping skills.

Where work-life issues are identified as critical sources of pressure, we have work-life organizational assessment tools that can be used with intact work groups. We can, in turn, link that information to the physical aspects of the health risk appraisal.

Interventions are where it's at. Jim Striker talked earlier about how the travelers at the World Bank rely on themselves to cope, but also expect the organization to meet them halfway. It's a shared responsibility. We think that education and behavior change support in the form of change mastery programs, organizational, individual resilience training, and associated programs and resources are critical. And, of course, we think it's important to measure our key outcomes, such as recruitment and retention, and then conduct a follow-up of various key pressure indicators with the pressure management indicator and the work-life organizational assessment tools.

I'll leave you with four, critical success factors, at least in our corporation, for any effective health strategy. I think it's important to link the health issue to the business goal, deliver a practical solution, and use a population-based health approach. You can target interventions, make the most cost-effective intervention possible. You need to identify and mobilize multidisciplinary resources, work outside of the Medical Department to collaboratively achieve change. And you need a centralized strategy that shares best practices globally.

Thanks. I know it's been a brief and frenetic overview. I'll be happy to take questions at the break.

[APPLAUSE]

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