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Workplace Violence in Healthcare

Disclaimer

The content and information presented in this program is intended to be used for general information and is not intended to be legal advice. Consult a licensed attorney-at-law to assist with specific situations that require legal advice or counseling.

The Big Picture

©2017 MagMutual Insurance Company. All rights reserved.

Workers in hospitals, nursing homes, and other healthcare settings face significant risks of workplace violence.

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Forms of violence to health care workers

• Biting• Kicking• Punching• Pushing• Pinching• Shoving• Scratching• Spitting• Name Calling


Joint Commission. Sentinel Event Alert. Issue 59, April 17, 2018. Jointcommission.org

• Intimidating• Threatening• Yelling• Harassing• Stalking• Beating• Choking• Stabbing • Killing

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Prevalence in Health Care

©2017 MagMutual Insurance Company. All rights reserved. 5

• A 2014 survey on hospital crime attributed 75% of aggravated assaults and 93% of all assaults against health care workers to patients or customers.

• According to OSHA, approximately 75% of nearly 25,000 workplace assaults reported annually occurred in health care and social service settings.

• Workers in health care are four times more likely to be victims than workers in private industry.

• The National Crime Victimization Survey showed health care workers have a 20% higher chance of being the victim of workplace violence than other workers.


Prevalence in Health Care


• Incidences are underreported

• Only 30% of nurses report incidences of WPV

• 26% of emergency department physicians report WPV

• Scope of WPV is difficult to recognize because of reporting mechanisms


The Joint Commission

• Emergency departments, behavioral health care settings, extending care facilities, and inpatient psychiatric units

• Common root cause of violence-lack of or inadequate behavioral health assessment to identify aggressive tendencies in patients.

• Sentinel event data show 68 incidences homicide, assault or rape of hospital staff workers over an eight-year period.

• Worker-to-worker as well as patient-health care worker verbal abuse is common

The Joint Commission Perspectives. Workplace Violence Prevention: Screening for the Early Detection of Risk of Harm to Self or Others. http://www.jointcommission.org


Unique Challenges


• Difficult to mitigate or prevent due to lack of information• “Do no harm”• Patient population• “Part of the job” mentality• Employees must react to unpredictable events with split-

second decisions• Compromises patient care

The faces of perpetrators


Most Common Characteristics


• Altered mental status– Dementia– Delirium– Substance intoxication– Decompensated mental illness

• Patients in police custody• Providing care for potentially violent individuals

Other factors


• Stressful situations• Lack of organizational policies and training• Gang activity• Domestic disputes• Presence of firearms or other weapons• Inadequate security • Long wait times or crowding

Other factors


• Understaffing• Staff working in isolation or areas without an escape• Poor lighting or factors restricting vision• No access to emergency communication• Unrestricted public access • Lack of community mental health care

Physician Practice Incident


• Parent and physician• Negative reviews• Response• Future care

WPV comes with a high cost


• Harms workers-physically and emotionally• Workman’s comp $$• Replacement cost in overtime, temporary staffing, recruiting

and training a replacement• Higher turnover• Deterioration of productivity and morale• Compromised patient care• Regulatory and accreditation requirements


• “The organizational culture, principles, methods, and tools for creating safety are the same, regardless of the population whose safety is the focus.”– The Joint Commission. Improving Patient and Worker Safety: Opportunities

for Synergy, Collaboration and Innovation.• Sentinel Event Alert 40: Behaviors that undermine a culture of safety• Sentinel Event Alert 57: The essential role of leadership in developing a safety

culture• Sentinel Event Alert 59: Physical and verbal violence against health care

workers

• Numerous standards that relate directly or indirectly to workplace violence.




• Leadership (LD) and Rights and Responsibilities of the Individual (RI)– Establish the framework for safety and security of all persons in the

organization• Provision of Care, Treatment and Services (PC)

– Provide guidance addressing patient assessment interventions• Environment of Care (EC)

– Address the physical environment and practices that enhance safety• Emergency Management (EM)

– Address planning for more extreme risks of workplace violence• Active shooters, community unrest and terrorist attack



DNV

• Det Norske Veritas Germanischer Lloyd (DNV-GL) quality management standards require accredited hospitals to "maintain safe and secure facilities that are designed and maintained in accordance with national and local laws, hospital policy, regulations and guidelines."

• Standards further specify that "the Security Management System shall address issues related to abduction, elopement, visitors, workplace violence, and investigation of property losses and [shall] be proportional to the risk." (DNV-GL, PE 4, SR 3)



Occupational Safety and Health Administration

• No specific standard on the prevention of workplace violence• General duty to “furnish to each of his employees employment and a

place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”

• Section 5(a)(1) of the Occupational and Health Act of 1970 (OSH Act)• Section 11(c) of the OSH Act provides protection for employees who

exercise a variety of rights under the Act

Occupational Safety and Health Administration: Workplace Violence Prevention and Related Goals. OSHA 3828-12/2015. www.osha.gov.

OSHA Issues Largest Workplace Violence Citation in 2017

Confined Space. OSHA Issues Largest Workplace Violence Citation in its History. Good Indication for the Future? http://jordanbarab.com/confinedspace/2017/08/22/workplace-violence-citation/

• $207,690 failure to abate citation and fine against UHS of Westwood Pembroke, Inc.-doing business as Lowell Treatment Center

• Failed to comply with multiple terms of a formal settlement to resolve violations identified in a 2015 inspection

• Follow-up inspection after hospital failed to provide documentation to show it had implemented a workplace violence program

OSHA-Citation for Violations and Notification of Penalty

Among other methods, feasible abatement measures include, but are not limited to the following:• Evaluation and modification to the workplace violence policy;• Review workplace violence incidents;• Develop reporting structure for WPV concerns• Provide employees with readily available means of communication;• Perform a workplace hazard assessment;• Develop a recordkeeping system designed to report any violent incident;

Time frame for response 15 days

It’s not a matter of if…it’s a matter of when

Comprehensive Workplace Violence Prevention Programs: Building Blocks

1. Management commitment and employee participation2. Worksite analysis and hazard identification3. Hazard prevention and control4. Safety and health training5. Recordkeeping and program evaluation

Building Block #1: Management Commitment and Employee Participation

1. Commitment by management

2. Environment of trust

3. Create a written WPV policy and post it visibly-include verbal abuse

4. Joint management-employee committee

5. Address employee’s safety concerns in a timely mannerOccupational Safety and Health Administration: Caring for Our Caregivers. Preventing Workplace Violence: A Road Map for Healthcare Facilities. OSHA 3827 12/2015. www.osha.gov.Joint Commission. Sentinel Event Alert. Issue 59, April 17, 2018. Jointcommission.org

http://www.osha.gov/

Building Block #2: Worksite Analysis and Hazard Identification

1. Risk factorsa) Patients, clients and settingsb) Organizational

2. Reviewing records, procedures and employee inputa) Anonymous employee surveysb) Work-related injury logsc) Incident reports (include near misses)

Occupational Safety and Health Administration: Caring for Our Caregivers. Preventing Workplace Violence: A Road Map for Healthcare Facilities. OSHA 3827 12/2015. www.osha.gov.Joint Commission. Sentinel Event Alert. Issue 59, April 17, 2018. Jointcommission.org


Building Block #2: Worksite Analysis and Hazard Identification

d) Procedurese) Look for trends or “hot spots”

3. Patient input4. Walk through assessment5. Include all locations



Building Block #3: Hazard Prevention and Control

Engineering Controls:• Improve sightlines for staff• Changing floor plans• Improving lighting in remote areas or outdoor spaces for better visibility• Installing mirrors• Controlling access • Enclosing areas or installing deep counters



Building Block #3: Hazard Prevention and Control

Administrative and work practice controls:• Procedures/tools for assessing and reassessing patients for violent behavior• Communicating information regarding patient behavior• Adequate staffing• Training on de-escalation• Emergency procedures



Building Block #4: Safety and Health Training

• Objectives– Increased confidence among workers in de-escalating aggressive

behavior and in managing aggressive behavior when it occurs• Topics

– Review of workplace violence policy– Risk factors that cause or contribute to assaults– Location, operation and coverage of safety devices/alarm

systems.Occupational Safety and Health Administration: Caring for Our Caregivers. Preventing Workplace Violence: A Road Map for Healthcare Facilities. OSHA 3827 12/2015. www.osha.gov.Joint Commission. Sentinel Event Alert. Issue 59, April 17, 2018. Jointcommission.org



• Topics– Proper use of safe rooms– Self-defense procedures when appropriate– Importance of early assistance– Progressive behavior control methods




• Who– Nurses and other direct caregivers– ED staff– Support staff– Security personnel– Supervisors and managers




• Format and frequency– Classroom plus hands-on instruction– Just-in-time training– Web-based training– Blended

• Evaluation and improving training programs



Building Block #5: Recordkeeping and Program Evaluation

• Reporting– Internal– External

• Injury Tracking Application-OSHA• https://www.osha.gov/injuryreporting/

• Recordkeeping

• Program evaluationOccupational Safety and Health Administration: Caring for Our Caregivers. Preventing Workplace Violence: A Road Map for Healthcare Facilities. OSHA 3827 12/2015. www.osha.gov.Joint Commission. Sentinel Event Alert. Issue 59, April 17, 2018. Jointcommission.org

https://www.osha.gov/injuryreporting/


Tools and Resources

ASHRM Workplace Violence Toolkit – www.ASHRM.org

ECRI InstituteViolence in Health Care Facilitieshttps://www.ecri.org/components/HRC/Pages/SafSec3.aspx

ENA Workplace Violence Toolkit– https://www.ena.org/docs/default-source/resource-library/practice-

resources/toolkits/workplaceviolencetoolkit.pdf?sfvrsn=6785bc04_28

http://www.ashrm.org/

https://www.ecri.org/components/HRC/Pages/SafSec3.aspx

https://www.ena.org/docs/default-source/resource-library/practice-resources/toolkits/workplaceviolencetoolkit.pdf?sfvrsn=6785bc04_28

Tools and Resources

How Safe is Your Hospital for Workers? • A Self-Assessment

– Total Case Incidence Rate (TCIR)– Days Away, Restricted, or Transferred (DART)– Injuries and Costs– Safety ProgramsOSHA 3690 www.osha.gov


Tools and Resources

OSHA Guidelines for Health Care– https://www.osha.gov/Publications/osha3148.pdf

Preventing Workplace Violence: A Road Map for Healthcare FacilitiesOSHA 3827 December 2015www.osha.gov

Sentinel Event Alert, Issue 59 includes actions suggested by TJC

https://www.osha.gov/Publications/osha3148.pdf

Teresa Kelly Phillips, MSA, BSN, CPHRM, LHRMRisk and Patient Safety Consultant

[email protected](229)308-4885

©2017 MagMutual Insurance Company. All rights reserved. Content may not be reproduced or redistributed, in whole or in part, without prior written permission.

mailto:[email protected]

References

Behnam M, et al. Violence in the emergency department: A national survey of emergency medicine residents and attending physicians. Journal of Emergency Medicine, 2011; 40(5): 565-79.

Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health (NIOSH). Violence in the Workplace. DHHS (NIOSH) Publication Number 96-100, Current Intelligence Bulleting 578. Atlanta, GA: DOL, July 1996.

Confined Space. OSHA Issues Largest Workplace Violence Citation in its History. Good Indication for the Future? http://jordanbarab.com/confinedspace/2017/08/22/workplace-violence-citation/


Joint Commission. 2012. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation. www.jointcommission.org/improving_Patient_Worker_Safety

Joint Commission Perspectives. Workplace Violence Prevention: Screening for the Early Detection of Risk of Harm to Self or Others. http://www.jointcommission.org

Occupational Safety and Health Administration: Caring for Our Caregivers. Preventing Workplace Violence: A Road Map for Healthcare Facilities. OSHA 3827 12/2015. www.osha.gov.

http://www.jointcommission.org/improving_Patient_Worker_Safety

References

Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers (OSHA, 3148-04R). Washington, DC: OSHA, 2015

Occupational Safety and Health Administration. Workplace Violence in Healthcare. (OSHA 3826). Washington, DC: OSHA, 2015.

Pompeii L, et al. Perpetrator, work and workplace characteristics associated with patient and visitor perpetrated violence (type II) on hospital workers: A review of the literature and existing occupational injury data. Journal of Safety Research. 2013; 44 (Feb): 57-64

Security Industry Association and International Association of Healthcare Security and Safety Foundation. Mitigating the risk ofworkplace violence in health care settings. Silver Spring, MD: Security Industry Association, August 2017.

Speroni KG, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing, 2014; 40(3):218-28

U.S. Department of Labor. DOL Workplace Violence Program-Appendices. Definitions. Washington, D.C.: DOL, no date.

Vellani KH. The 2014 IHSSF crime survey. J Healthc Prot Manage. 2014;20(2):28-35

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