2012 USPHS Scientific and Training Symposium CDR Scott J. Salvatore [email protected] Safety of examinee Co workers and other military and federal employees Public citizens Liability/legal Provider’s actions license U.S. Army Medical Research Institute of Infectious Diseases Mission: core mission is to protect the warfighter from biological threats and investigate disease outbreaks and threats to public health Personnel- approximately 800 • 25% Military • 37.5% Civilian Employees • 37.5% Contractor Employees Professional staff • > 150 Ph.D.’s • > 20 DVM’s • > 15 MD’s approximately • Nearly 300 laboratory technicians Personnel registered with CDC BSAT: >500 Personnel with access to BSAT: 30 % of USAMRIID employees Biosurety is defined as the combination of security, biosafety, agent accountability, and personnel reliability needed to prevent unauthorized access to select agents of bioterrorism. 1. Army Regulation 50-1 – Biological Surety 2. MEDCOM Regulation 40-55, latest edition - Guidance on occupational health practices for the evaluation and control of occupational exposures to biological select agents and toxins (BSAT) 3. Army Regulation 40-6 – Medical Record Administration and Health Care Documentation 4. 42 USC 126 - Equal opportunity for individuals with disabilities (to include reasonable accommodation) 5. H.R. 493 - Genetic Information Nondiscrimination Act (GINA) 6. 42 CFR (Code of Federal Regulations)-pertaining to release of drug/substance abuse records. Identifies the purpose, concept, and responsibilities for the biological surety program Establishes procedures for the biological personnel reliability program Reliability assessment Persons who do not meet BPRP standards will not perform BPRP duties. The certifying official will make a judgment on the reliability and suitability of an individual for a BPRP duty position. The following sources of information the certifying official will use to determine that the individual is qualified for the BPRP: (1) Initial interview. (2) Personnel Security Investigation (PSI). (3) Personnel records review. (4) Medical evaluation. (5) Drug testing. The following are the general suitability and reliability standards expected of all BPRP members: “Individuals will be mentally alert, mentally and emotionally stable, trustworthy, physically competent, and free of unstable medical conditions. This includes dependability in accepting responsibilities and effectively performing in an approved manner, flexibility in adjusting to changes in the working environment, good social adjustment, ability to exercise sound judgment in meeting adverse or emergency situations, physical ability to perform duties required by the position, and positive attitude toward BPRP duties and the BPRP.” Current diagnosis of drug/substance or alcohol dependence Alcohol-related incidents/abusing alcohol Medical condition. (1) Any significant mental or physical medical condition, medication usage, or medical treatment, which may result in— (a) An altered state of consciousness. (b) Impaired judgment or concentration. (c) Increased risk of impairment if exposed to biological agents. (d) Impaired ability to safely wear personal protective equipment required for the biological surety position (e)Suicidal Behavior Inappropriate behavior: attitude, conduct, or “Poor attitude or lack of motivation. Poor attitude can include arrogance, inflexibility, suspiciousness, hostility, flippancy toward BPRP responsibilities, and extreme moods or mood swings.” Aggressive/threatening behavior Issue of judgment and reliability in context of safeguarding classified national security information/material Guidelines do not require a formal diagnosis of a disorder for there to be a concern Examination to determine whether incumbent employee is able to safely and effectively perform his or her essential job functions. (IACP, 2009) Threshold for examination • Ruling out issues retaliation, organic physical causes, administrative issues • Identify relevant clinical questions • Unfitness v. unsuitability or misconduct • Higher threshold for civilian FFD exam to link fitness to a psychological condition • OPM: two prongs to determine fitness: inability to perform job essential job functions or posing a direct threat 5 CFR Federal Agency may order an employee to submit to a psychiatric or psychological examination only when: 1. “…physical exam indicates no explanation for behavior or actions…” 2. “psychiatric or psychological examination is specifically called for in a position having medical standards or subject to an established medical evaluation program” In FFD of police officers, public safety and direct threat are always implicated in the judgment of fitness. Employer may preemptively require an FFD without showing that an employee’s job performance has suffered as a result of health problems (Brownfield v. City of Yakima, Cody v. CIGNA Healthcare of St. Louis). Obtain Informed Consent and Authorization for Release of Medical Information Describe nature, scope of evaluation, limits of confidentiality, and who will receive findings. Methods of evaluation Multiple sources information (behavioral and clinical) Standard of Practice in Forensic Evaluations Central (not collateral): o Medical records Performance evaluations Interviews with informants (supervisor, spouse, co worker, etc.) Personnel Security Investigation (PSI) Supervisor /co worker questionnaires o Job description/analysis o o o o Clinical Interview: • Pertinent History • Symptoms (if relevant) • Individual psychiatric history (per GINA) • Personal/developmental, Educational, Legal, Military, Marital, Occupational, Social, Work Relations, Habits, Substance Use, Stress Management • Mental Status Gambling Sexual behavior Finances Safety attitudes/practices Threats to co workers Grudges toward U.S. Govt. Allegiance to U.S./Foreign influence/preference Passive v. active threat Violence risk assessment Additional Concerning Behaviors from National Science Advisory Board for Biosecurity: • Working off hours • Security Breaches, accessing computer/email passwords • Unexplained absences • Mention of plans to commit acts of violence to persons, property • Lab work that doesn’t correspond to official project • Sabotaging colleagues’ research • Risk taking behaviors • Unexplained, significant decline in performance • Merit Systems Protection Board Psychological Testing MMPI 2, MMPI-RF, PAI, CPI, MCMI-III, 16PF. Self Report Measures (e.g BDI) Employee Referral Safety Inventory (e.g. ESI) to specialist (e.g. neuropsyche) National Academy of Sciences and the National Science Advisory Board for Biosecurity: Lack of efficacy for personality assessment tools, polygraph and integrity tests for identifying ‘insider threat.’ Genetic Information Nondiscrimination Act of 2008 Prohibits use of genetic information and tests to discriminate in employment Applies to applicants and employees Military v. civilian evaluations Assess Response Style • Reliable/honest • Malingering • Defensive • Dishonest • Uncooperative Existence of a mental disorder or condition. Pattern of behaviors relevant to guidelines Qualified for BPRP (fit) Medical Restriction (qualified with accommodations) • When performance of BPRP duties may be impaired by a temporary medical condition (including medication for the condition) or psychological condition including short term stress. • Restriction is a caution based on possibility of impairment and not assessment of unreliability (not to exceed 180 days) • Suspension Certifying official determines that the individual’s reliability is suspect. When medical condition becomes prolonged Later option for reinstatement or disqualification Disqualification Certifying Official determines that an individual does not meet the reliability standards (including medical conditions. Separation from employment /service may be appropriate if BPRP certification is a condition of employment. • Reinstatement/requalification – reevaluation Reinstated or request for requalification (substantive evidence that the cause of disqualification no longer exists) Remission of symptoms Treatment and supporting documentation Special Procedures for alcohol abuse/dependence *The individual successfully completes an initial intensive rehabilitation, if prescribed, followed by a 1-year period of strict compliance with aftercare requirements, regular and frequent participation in meetings with Alcoholics Anonymous or a similar organization, and abstention from alcohol. • *Mental health evaluation and a favorable prognosis by the CMA. Consult Consult Consult Finally, document consultation. Americans with Disabilities Act of 1990— --pursuant to the federal ADA (ADA) employers may require a preemployment medical examination to determine if an applicant can effectively and safely perform the job requirements of the position they are seeking. --if employer requires applicants to undergo pre-employment psychological screen, the evaluation must be given to all applicants in that job class --for medical examination about potential impairment, exam may administered only applicant has received conditional offer of employment -- v. American Airlines Designed to assess worker’s psychological resilience and attitudes toward lab safety and personal responsibility who work in BSL 4. Four behavioral areas identified for potential risk of accidents/injuries: clinically elevated levels of depression, anxiety (stress), substance abuse, and high risk safety attitudes. Positive screen may necessitate more comprehensive psychological evaluation.