ATLANTA-When it comes to work-related illness and injuries, the operative rule is that everything that happens will happen again.

That is the moral of a long story learned by Earl Williams, safety and loss control officer of a hospital in Illinois and a speaker at the Risk & Insurance Management Society Inc. conference last week.

Mr. Williams, who works at OSF-Saint Francis Medical Center in Peoria, a 750-bed acute care hospital, has drawn attention for his outspoken opinion that hospitals and employers in general need to drastically step up their attention to risks to employee safety and become more sophisticated in the way they investigate the source of workers' illnesses and injuries.

The biggest problem facing companies with employees who are missing work is that root causes of the problems are left unidentified, leading to what Mr. Williams called "yo-yo medicine": The worker lapses in and out of work, over and over, with the employer oblivious or apathetic.

To understand Mr. Williams' proposed solution, he first sketched how one industry, the hospital field, has to a great extent ignored employee safety until very recently.

"Years ago, safety was not very much thought of at all or mentioned, except perhaps by maintenance staff," he said. Even when so-called safety engineers or security personnel later became responsible for aspects of employee safety and health, they rarely had much time to devote to it.

"The problem with all the hospital systems was really no one was directly responsible for safety," he said. "We all do safety, but there is a very driving need for someone who specializes in safety."

Even today, many hospitals have only a one- or two-person safety office or none at all, relying instead on a safety committee consisting of workers donating their time, he said.

"As you move about health care, you find more and more that safety is an added-on task or duty to someone that's already wearing 25 hats," he said. "You see more and more people picking up the duties of safety or the title of safety."

If hospitals devote time to risk management, it is mainly in the area of malpractice and not accident or illness prevention, Mr. Williams said. When fee-for-service indemnity coverage was the prevailing form of health insurance, doctors too often treated ailing or injured employees repeatedly for the same problem.

"Even today, in an enlightened field, many hospitals do not have a driving need for safety," he said.

A better approach, he said, would be akin to dispatching a private eye to get to the bottom of employees' complaints, without acting like the company is being investigated.

"Let's say the worker has some sort of respiratory difficulty," he said. "The worker is then referred to the doctor, the doctor looks at him and says, 'I can fix this, no problem.' The doctor gives him some sort of treatment and he's returned. Where does he go to work? Do you think he goes to a different company? They go back to the same company, the same place where he got sick the first time."

In this scenario, the doctor who examines a hurt or sick worker could request a specially designated "health care safety professional," who could be an outside consultant or a representative from an insurance company, to investigate the cause of the problem. The consultant would visit the specific worksite of the employee to see what could be causing problems and, if necessary, go to the worker's home to scout for clues.

"This is very patient-focused," he said. "Right now, if something similar happened, they'd call in an industrial hygiene firm or industrial engineers and they'd look at the whole work site or the whole plant. But this safety investigator would only look at the specific work site itself."

An example, Mr. Williams said, is an employee who does furniture stripping at home without good ventilation and has breathing difficulties. The cause probably would never be discovered in a typical workers compensation examination, he said.

The worker and employer would have to sign a release to authorize the investigation, he said. The results would become part of the medical records, which could be used for workers comp or group medical purposes depending on the origin of the problem.

"The doctor then has the license to go to the patient and say: 'We know what's making you ill. You're stripping furniture in your basement at night. You've got some options here. One, you can quit. We're not telling you to do that. You can change the way you're doing it-increase ventilation in your basement, wear a respirator. If you choose to do nothing, your health care costs are going to double. So instead of paying $150 for your health care, you're going to pay $300. Because we know you're going to be sicker more repetitively than anyone else.'*"

Such a process would cut both workers comp and insurance costs and raise productivity, he said.

Several questions remain unanswered about Mr. Williams' approach, and he raised many of them himself. For instance, who will pay for the new expense of an independent investigation of the claim? Employers should not be expected to foot this bill, he said, and he would like to see the cost added to the medical bill received by the patient if he is responsible. But Mr. Williams admitted he is far from certain how such a charge could be incorporated into statements from private insurers.

Also, it is not clear what the qualifications of the special investigators should be. They should be well-versed in managed care, and any qualifications should be uniform throughout programs, Mr. Williams said.

There is also the question of what to do about employees who refuse to sign the release form and halt any investigation in its tracks, though he said such cases will likely become rarer as workers become more interested in wellness and improving their own health in a preventive way.

Despite the uncertainties, such investigations are a good solution to the safety problem facing many smaller companies that have no safety staff and little incentive to make preventive changes in the working environment unless prodded by agencies such as the Environmental Protection Agency, he said.

Norm Parsley, risk manager of the Peoria, Ill., Park District, moderated the session.