Keywords
occupational health, hospital, health risk assessment, occupational health services
-
Views
-
Downloads
How to cite this article
Kurniawidjaja LM, Susilowati IH, Lim YC et al. Development of an Instrument for Evaluating the Implementation of Occupational Health Programmes in Hospitals [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1009 (https://doi.org/10.12688/f1000research.165842.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
Export Citation
Sciwheel
EndNote
Ref. Manager
Bibtex
ProCite
Sente
▬
✚
Research Article
Development of an Instrument for Evaluating the Implementation of Occupational Health Programmes in Hospitals
[version 1; peer review: awaiting peer review]
PUBLISHED 29 Sep 2025
OPEN PEER REVIEW
REVIEWER STATUS
This article is included in the Health Services gateway.
Abstract
Corresponding author:
Indri Hapsari Susilowati
Competing interests:
No competing interests were disclosed.
Grant information:
This research was funded by the Directorate of Research and Development (Risbang) Universitas Indonesia through the Q1 International Indexed Publication (PUTI) funding scheme.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2025 Kurniawidjaja LM et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Kurniawidjaja LM, Susilowati IH, Lim YC et al. Development of an Instrument for Evaluating the Implementation of Occupational Health Programmes in Hospitals [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1009 (https://doi.org/10.12688/f1000research.165842.1)
First published: 29 Sep 2025, 14:1009 (https://doi.org/10.12688/f1000research.165842.1)
Latest published: 29 Sep 2025, 14:1009 (https://doi.org/10.12688/f1000research.165842.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
Hospitals play a vital role in the national health system, with comprehensive service delivery as their core business objective. To support this goal, various resources are needed, especially human resources—both health and non-health workers—who must not only be competent, but also healthy and fit to ensure productivity. However, as workplaces, hospitals pose numerous types of hazards and high levels of occupational health risks. The COVID-19 pandemic (2020–2022) revealed the vulnerability of healthcare workers, many of whom died while performing their duties. Research recorded 1,545 healthcare worker deaths during the first 18 months of the pandemic in Indonesia.1 Therefore, protecting hospital workers through the implementation of occupational health services is imperative. This aligns with the Alma-Ata Declaration and is supported in Indonesia by Government Regulation No. 88 of 2019 on Occupational Health, Article 70, which states that occupational health efforts aim to protect workers so they can live healthy lives free from harmful work-related impacts.
The goal of occupational health is to achieve healthy workers and a healthy workplace. This is achieved through risk management aimed at preventing workers from experiencing health problems or premature death, thereby ensuring productivity and supporting the sustainable growth of businesses or activities. In Indonesia, recorded cases of occupational accidents far outnumber those of occupational diseases (ODs). According to the Ministry of Manpower Republic of Indonesia, the number of reported ODs was 48 in 2019, 81 in 2020, and only 6 in 2021,2 followed by 94 cases in 2023.3 In contrast, BPJS-Tenaga Kerja reported the number of occupational accident cases as 182,835 in 2019, 221,740 in 2021, 234,370 in 2021, and 297,725 in 2022. Furthermore, Ministry of Manpower reported 370,747 cases in 2023 and 462,241 in 2024.3,4 Such rises are significant.
The number of recorded occupational accident cases in Indonesia is overwhelmingly higher than those of occupational disease, contrary to global data, which show that deaths from occupational diseases are higher than those from accidents. According to ILO and WHO estimates in 2016, of the 1.8 million work-related deaths globally, only 19% were due to injuries, while 81% resulted from work-related diseases.5
This situation is not conducive to worker protection, as unrecognised health risk factors continue to expose workers to health problems ranging from mild to severe, or even death. Therefore, risk management is essential, beginning with the identification of health hazards and followed by risk assessment in the workplace. Health Risk Assessment (HRA) serves as a foundation for occupational disease diagnosis and programme needs analysis, enabling the implementation of health risk control measures as part of corporate accountability in addressing workers’ social and health issues.6
Hence, it is necessary to assess how occupational health is implemented in hospitals. An instrument is needed to evaluate the extent of such protection for hospital workers, with a focus on the implementation of occupational health services based on identified health hazards or risk factors. This research is part of a broader research tree under the Department of Occupational Health and Safety (Departemen Keselamatan dan Kesehatan Kerja), Faculty of Public Health, Universitas Indonesia. It is expected to produce a comprehensive profile of occupational health implementation in Indonesia and to provide recommendations to inform national policy development.
Methods
This is a qualitative exploratory study. Data collection was conducted through an in-depth literature review to identify occupational health risk factors in hospitals, primarily drawn from studies involving health risk assessment (HRA) and/or reports of occupational disease cases or suspected cases. This was followed by in-depth interviews and field observations. The identified risk factors contributing to hospital workers’ mortality and morbidity were then analysed, and the results used as the basis for developing a semi-quantitative measurement instrument (scoring system) prototype to assess the implementation of an occupational health service programme in hospitals. The prototype was developed by adapting and modifying the Hospital Safety and Health Management System Self-Assessment Questionnaire from OSHA. The prototype was then subjected to validation through a 2-day FGD involving experts, practitioners, professional organisations, and other authorities in similar fields of study.
The study was conducted from May 2024 to March 2025. The focus was on accredited Type B general hospitals, based on the consideration that Type A hospitals are too large in scale, while Type B ones generally meet adequate standards in terms of resources and management compared to Type C ones. Three Type B hospitals were selected, chosen based on accessibility and in order to represent government, private, and teaching hospitals.
The following three research flow steps were taken to develop the prototype.
Step 1
In the instrument development process, qualitative interviews were conducted with informants comprising the heads of the Hospital Occupational Safety and Health Unit (Hospital OSH Unit); Infection Prevention and Control (IPC); general medical service managers (covering basic medical services, dental and oral health, and maternal and child health/family planning); emergency department managers, medical support service managers; nursing managers; and, where applicable, quality committee chairpersons. The number of informants was determined based on data saturation. The inclusion criteria were that they had worked in their current position for at least one year and had signed an informed consent form.
Step 2
The qualitative data collected were analysed using a thematic analysis approach. This method was chosen for its ability to explore and understand the various risk factors emerging from the qualitative data, enabling the identification and analysis of key aspects related to the research problem, namely five groups of health risk factors in the workplace (related to the environment, ergonomics, workers’ somatic conditions, worker behaviour, and work organisation and culture). Thematic analysis allowed for systematic organisation and interpretation of the data, facilitating in-depth insights from the respondents studied.
The identified risk factors contributing to hospital workers’ mortality and morbidity were then analysed, with the results used as the basis for developing a semi-quantitative measurement instrument (scoring system) prototype to assess the implementation of occupational health services programmes in the hospitals.
Step 3
The prototype was then subjected to validation through a 2-day FGD. The FGD participants included academicians, experts, practitioners, representatives from professional organisations, hospital directors and their teams, the Ministry of Health and Ministry of Manpower as the regulators. The number of participants was adjusted according to data needs and saturation. Inclusion criteria for the FGD participants were based on the principle of appropriateness to the study objectives, with a minimum of one year in their current position and having signed an informed consent form. The final result was an instrument consisting of indicators to assess the implementation of occupational health service programmes (Appendix 1), together with related guidelines (Appendix 2).
Ethical consideration
This study has gone through a review process and was approved by the Institutional Review Board from teaching hospital Rumah Sakit Universitas Indonesia (approval number: S-091/KETLIT/RSUI/VII/2024). Written informed consent was obtained from all participants, including informants for in-depth interviews and stakeholders in focus group discussions (FGD). The consent process ensured that participants were fully informed about the study’s purpose, procedures, potential risks, and their right to withdraw at any time without consequences. No animal or human biological materials were involved in this study. All data were anonymized, and identifiable information was securely stored to protect participant confidentiality.
Results and discussion
Analysis of Health Risk Assessment (HRA) implementation in Type B hospitals
The findings from the in-depth interviews, observations and focus group discussion (FGD) indicated that all the hospitals reported having conducted health risk assessments (HRAs). However, these were most likely to have been limited to hazard identification without progressing to actual risk level evaluation. The hospital results were presented as internal documents, but we were not allowed to have copies of these. The health hazards identified originated from five main sources: (1) the work environment, including significant physical, chemical, and especially biological hazards; (2) ergonomic factors, such as technical risks, organizational issues, task-related demands, individual factors, and psychosocial or psychological stressors; (3) the somatic conditions of workers, particularly their health status; (4) health-related worker behaviours, including lifestyle and work patterns; and (5) work organisation and/or workplace culture ( Table 1). All these identified health risks have the potential to negatively impact workers’ health. Therefore, it is strongly suggested that the next critical step for hospitals is to assess the risk levels and determine whether the risk factors are being adequately controlled. Risk control measures should be integrated into hospitals’ occupational health service programmes to prevent work-related health problems.
Table 1. Identified health hazards in hospitals.
Analysis of occupational health service programme implementation in Type B hospitals
The assessment of occupational health service programme implementation was conducted following the identification of health risk factors. Four key aspects of the programme were examined: (1) documentation of existing programmes; (2) analysis of programme adequacy using the 5-5 Model, a framework that integrates five sources of hazards with five levels of disease prevention, which assesses alignment with the identified risk factors and the needs for occupational disease prevention programmes across five levels of prevention — health promotion (HP), specific protection (SP) against risk factors from five sources, early diagnosis and prompt treatment (DT), disability limitation (DL), and medical rehabilitation including return-to-work (RW) programs; (3) recommended occupational health programmes (see Table 2); and (4) the decision-making process for programme development, assessed through hospital leadership’s commitment as reflected in policy, and worker involvement (see Table 3).
Table 2. Assessment of occupational health service programme implementation: Existing versus suggested programmes.
Table 3. Assessment of decision-making process for occupational health service programmes.
The data compiled from the hospitals studied indicate that the existing occupational health service (OHS) programmes for controlling identified hazards cover the five levels of disease prevention related to exposure. Following verification and confirmation through the FGD, we conclude that all hospitals should ideally be able to implement similar programmes. However, based on the findings and analysis, certain OHS programmes are recommended and have been arranged sequentially according to the five levels of prevention for effective hazard control (see Table 2).
1. Health Promotion
a. Enhance workplace health promotion by preparing communication materials, including hazard communication content and SOPs for critical tasks, as well as materials on healthy lifestyles and stress management.
b. Counselling materials on risk factors should not focus solely on biological hazards, which have been well-managed by the Infection Prevention and Control (IPC) teams, but should also include other risk factors such as chemical hazards, which have not been sufficiently detailed in hazard communication, together with physical risks such as radiation and heat.
c. Hazard communication tools should include a list of hazards and hazard maps; SEGs (similar exposure groups); and predictive area health mapping. Ideally, current area health maps should also be available. However, the findings show that only one unit has created individual body health mapping, which has not yet been aggregated into the collective data.
d. To improve workers’ physical and mental health status and their work capacity, management should involve health promotion officers, psychologists or employee assistance program (EAP) specialists, and psychiatrists. It was found that only some units employ psychologists and/or psychiatrists for workers experiencing depression, anxiety, or other forms of distress, which are usually only handled by direct supervisors. Periodic mental health screenings using questionnaires should be provided across all hospitals.
e. It is necessary to establish clear methods for socialisation, mentoring procedures, and supervision in the implementation of SOPs.
2. Specific Protection
a. Monitoring of microbial growth in ventilation system ducts and filters should be conducted, in addition to air sampling. This recommendation is based on findings in one hospital, where water stains were observed on the ceiling of a large outpatient waiting area (estimated at over 15 x 10 m2). Despite repeated annual repainting and even the replacement of rotted ceiling panels, the issue, suspected to be related to the piping system, has yet to be fully resolved. Water stains were also found on several walls and corridors. Water seepage, like stagnant water, serves as a breeding ground for microbes.
b. Measurement of hazard exposure levels, especially physical, chemical and ergonomic factors, needs to be improved. The measurement results can be used to assess risk levels and prioritise control measures. The study found that risk assessments were not conducted comprehensively and were limited to a few units, often performed by unit staff without the support of experts or the hospital’s OHS implementation unit.
c. It is suggested that ergonomic risk assessment use well-established measurement tools that are relatively simple and considered valid and reliable, such as REBA and RULA. It was found that only one hospital unit had conducted such assessment, in relation to mismatches between workers and work tools, equipment or workstations.
d. Implementation and supervision of SOPs, including PPE use, need to be strengthened, with a target of 100% compliance to prevent hazardous actions.
e. Engineering/technical controls, beyond administrative controls such as SOPs, should be enhanced in all relevant aspects, including environmental and ergonomic risk factors. It was found that advanced technical infection control measures have been implemented by two hospitals inspected, such as improved ventilation, HEPA filters, and specialised washing machines. However, technical controls for transferring bariatric patients were only found in one hospital, and the equipment was not functioning effectively because the European-made patient lifting equipment was too large for the Japanese-standard corridors. In addition, non-ergonomic desks and chairs were still found, especially in administrative areas where they were not typically visible, even though adjustable chairs were commonly used in other units.
f. Workers’ health behaviours need improvement through education on non-communicable diseases (NCDs), the Fit to Work concept, socialisation, and mentoring—ideally involving health promotion officers. The assumption that all hospital staff, both medical and non-medical, are well-versed in healthy lifestyles is not entirely accurate. The interviews and field observations revealed that health behaviour-related risk factors significantly affected workers’ health and capacity, such as obesity, poor sleep quality and duration, working while fatigued, and shift swapping between employees without notifying supervisors, despite the completion of digital attendance.
g. Specific protection strategies for both lifestyle and work behaviour should be considered, with targets established through consensus, and accompanied by defined evaluation methods and consequences. Behavioural risk factors should also be included in the risk register to ensure they are detected and addressed.
3. Early Diagnosis and Prompt Treatment
a. Periodic health examinations should be conducted regularly, especially biological exposure assessments, as these represent a primary concern for both healthcare and non-healthcare workers in hospitals. This recommendation is based on our findings that medical check-ups (MCUs) are sometimes only conducted for selected high-risk units, such as ICUs, operating rooms, haemodialysis, inpatient wards, and outpatient clinics, while workers in laundries, cafeterias, and administrative offices are not guaranteed annual check-ups, with some never having been given one. It is widely known that infection can be transmitted through airborne routes in hospitals, in addition to direct contact with patients or sharps, which potentially affect all workers, both clinical and non-clinical.
b. Establishing an employee clinic within hospitals in the form of a primary healthcare facility is strongly suggested. This proposal also emerged during the FGD and was supported by the health authorities and professional organisations. Comprehensive occupational health efforts, including promotive, preventive, curative and rehabilitative services, are implemented in such facilities. Furthermore, immediate treatment requires an accessible employee clinic within the hospital. However, under the current National Health System, hospitals are categorised as referral healthcare facilities, so workers must first visit a primary healthcare facility outside the hospital, navigate a lengthy process involving registration, wait for consultation, and then collect medication. This process is inefficient in terms of time, energy and cost, and causes discomfort and demotivation among hospital staff. Moreover, employees’ medical history data, regarding both occupational and non-occupational diseases, are poorly recorded within hospitals.
c. The involvement of an occupational medicine specialist is essential for a more accurate diagnosis of occupational diseases, given the complex risk factors affecting both healthcare and non-healthcare workers in hospitals.
4. Disability Limitation
a. Disability limitation is well managed by intensive treatment programmes within the hospitals. However, if the required facilities are not available, it is strongly recommended to make use of the referral system to another hospital, making the process more effective and efficient.
b. Immediate response to findings and reports should be ensured. The in-depth interviews with operational workers (both healthcare and non-healthcare staff ) and the field observations revealed complaints about delayed or even lack of responses to reports, despite the presence of a risk register system. Uncontrolled hazards may materialise and lead to health problems, disability or even death. In the long term, this undermines the development of a safety culture, in addition to causing short-term losses.
5. Rehabilitation
a. The return to work programme is essential, alongside medical or physical rehabilitation, with the presence of an occupational medicine specialist valuable, particularly for healthcare workers with health limitations due to occupational or non-occupational diseases. They can assist in determining appropriate tasks for such workers, especially in roles affecting patient safety, while also protecting their health from further deterioration; for example, nurses infected with tuberculosis, hepatitis B or HIV/AIDS.
Analysis of the decision-making process for occupational health services programmes
We continued the research by examining the decision-making process followed by the Hospital OHS Unit. The components assessed were (1) Policy; (2) Leadership; (3) Worker Participation; and (4) Contractor Involvement (see Table 3). Particular attention was paid to leadership commitment as reflected in hospital policies and worker involvement.
We found that written policies are in place. They require all hospital staff to report identified hazards through the risk register, whether from periodic assessments or unplanned findings. Each hospital has also issued written policies mandating the implementation of occupational health services for its personnel. Additionally, hospital accreditation policies in Indonesia have encouraged the implementation of occupational health programmes, including the obligation for leadership to demonstrate commitment in promoting and supporting these. This is the same as the neighbouring country such as Malaysia, whereby it is the responsibility of employers to have the occupational health program for the employees.
Leadership commitment is reflected in the implementation of leadership training aimed at reducing risks associated with work organisation and workplace culture. However, no monitoring or evaluation has been conducted to assess the impact of this training on leadership. In implementing general occupational health programmes such as workplace exercise, leaders are encouraged to participate actively on a rotating basis to promote staff engagement. Additionally, the development of health education materials should be needs-based, feasible, and accommodate workers’ preferences (in line with their needs). Therefore, material development should be led by the unit head, undertaken jointly with worker representatives, and facilitated by the Hospital OSH Unit.
In the process of hazard identification, planning, and determining occupational health service programmes, the Hospital OSH Unit receives reports and suggestions from all hospital workers and contractors, who can report hazards online via the risk register, or offline using a form. They can also propose occupational health service programmes through their respective unit leaders, who then submit these to the Hospital OSH Unit.
Development of an instrument for evaluating the implementation of occupational health programmes in Type B hospitals
Analysis of the implementation of HRA and of OH Services, together with the process of determining an OH services programme, has produced an instrument for measuring the implementation of such a programme (Appendix I). The format of the instrument was developed by adapting and modifying the Hospital Safety and Health Management System Self-Assessment Questionnaire, with written permission to do so obtained from the authorised OSHA party. As stipulated by OSHA, the scope of this document is recommendation-based and merely contains relevant information. The document is not a standard or regulation, nor is a legal obligation.
The instrument was designed in the form of statements to help Hospital OSH Units assess the implementation of occupational health services. The instrument consisted of 53 statements in seven sections, with a maximum total score of 159. Each question, divided into the seven groups below, was given a score of between 0 and 3.
1. Management Support in the Process of OH Services Implementation (6 statements)
2. Worker Participation and Leadership Involvement (6 statements)
3. Hazard Identification and Health Risk Assessment (12 statements)
4. Health Hazard Control (7 statements)
5. Disease Prevention (8 statements)
6. Education and Training (9 statements)
7. Occupational Health Service Programme and Evaluation (5 statements)
The statements cover the implementation of occupational health in hospitals in an effective occupational health management system.
To make it easier for the respondents to respond to the statements, they were asked to review the “Guidance for Completion” column carefully before giving their scores. The column explains what each hospital has done to make the programme effective; what it has failed to do, thus making the programme more ineffective; and what can be improved. Furthermore, the respondents could use Appendix II, which lists common workplace hazards in hospitals, as an additional guide indicating the hazards or health risk factors commonly found in each hospital.
To complete this instrument, circle the score 3, 2, 1, or 0 in the box provided to indicate the one that best matches the statement in the action item. You will have four choices:
• Strongly agree - indicates that the hospital routinely performs all the actions described and does so effectively (Three points given = 3).
• Partially agree - indicates that the hospital has performed all the actions as described, but only a few times effectively (Two points given = 2).
• Strongly disagree - indicates that the hospital has taken only some actions as described, and/or these have been ineffective or infrequent (One point given = 1).
• No action - indicates that the hospital has taken no action (No points given = 0).
The instrument allows Hospital OSH Units to calculate their own score and to summarise the scores for each section. The scores help users identify gaps and actions that, if taken, would improve the effectiveness of their hospital’s occupational health management system. It is recommended that hospitals complete the instrument periodically (e.g., annually or every six months) to track progress and improvement trends.
Conclusions and suggestions
The implementation of occupational health service programmes in hospitals is an integral part of the efforts to protect workers and improve the quality of health services as a whole. Hospitals as workplaces have complex and high risk characteristics, both for health and non-health workers. Therefore, a systematic approach is needed to ensure that all work risks can be identified, assessed and controlled effectively.
This study aimed to develop an instrument that can be used to assess and evaluate the implementation of occupational health service programmes in hospitals, especially type B general hospitals. The instrument development process was conducted through a mixed approach, starting with the identification of risk factors based on the literature review, followed by in-depth interviews and field observations. The resulting instrument was then tested for validity and reliability through an FGD involving various stakeholders, to ensure that the tool was suitable for implementation in hospitals.
The findings show that all of the hospitals already have occupational health programmes, but that their implementation has not been optimal. It was found that there remain gaps in aspects of hazard identification; implementation of risk assessments; technical and administrative controls; and the provision of comprehensive occupational health services, including health promotion, specific protection, early detection and prompt treatment, disability limitation, and rehabilitation in terms of return to work programmes. In addition, worker participation and commitment from hospital leaders and management also play an important role in determining the success of programmes.
The instrument developed covers seven main dimensions: management support, worker participation, risk identification and assessment, hazard control, disease prevention, education and training, and programme evaluation. It is designed to be used independently by hospitals to assess the status of their occupational health programme implementation and to design necessary improvement steps.
In conclusion, the instrument is a strategic tool that can be used by hospitals to improve the effectiveness of occupational health programme implementation in a sustainable manner.
Routine application of the instrument is expected to provide an objective picture of implementation conditions in the field; to support data-based decision-making processes; and to become the basis for policy formulation at the institutional and national levels. Regulatory support, management commitment, and involvement of all hospital elements are key to realising a healthy, safe and productive workplace for the whole hospital community.
Last but not least, a unified national dashboard (with collaboration between the Ministry of Health, Ministry of Manpower, and BPJS Ketenagakerjaan) should be developed to monitor workplace accidents, occupational diseases, and near-misses in real-time, supported by pilot projects and digitalization, which can be addressed by adapting the OSHA/EU-OSHA model to the Indonesian context.
Ethical consideration
This study has gone through a review process and was approved by the Institutional Review Board from teaching hospital Rumah Sakit Universitas Indonesia (approval number: S-091/KETLIT/RSUI/VII/2024). Written informed consent was obtained from all participants, including informants for in-depth interviews and stakeholders in focus group discussions (FGD). The consent process ensured that participants were fully informed about the study’s purpose, procedures, potential risks, and their right to withdraw at any time without consequences. No animal or human biological materials were involved in this study. All data were anonymized, and identifiable information was securely stored to protect participant confidentiality.
Download
Export To
metrics
| Views | Downloads | |
|---|---|---|
| F1000Research | - | - |
|
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Citations
CITE
how to cite this article
Kurniawidjaja LM, Susilowati IH, Lim YC et al. Development of an Instrument for Evaluating the Implementation of Occupational Health Programmes in Hospitals [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1009 (https://doi.org/10.12688/f1000research.165842.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
track
receive updates on this article
Track an article to receive email alerts on any updates to this article.
Open Peer Review
Current Reviewer Status:
AWAITING PEER REVIEW
AWAITING PEER REVIEW
Key to Reviewer Statuses
VIEW
HIDE
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations
A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Comments on this article Comments (0)