Violence: Health-scare in

Healthcare

Meg Garrett, Johns Hopkins Health System

Lauree Barreca, Johns Hopkins Health System

Karen Mathura, RCM&D

Goals / Objectives

• The attendees will understand and be able to articulate the scope and depth of the workplace violence problem as it relates to healthcare.

• The attendees will be provided tools to assess their organization for security risks.

• The attendees will be able to create a comprehensive plan to address the risks associated with workplace violence.

• Insurance concerns surrounding workplace violence will be explored and the attendees will be provided with options to better deal with insulating these exposures.

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It‘s a Violent World

• Visitor shoots and kills wife and wounds himself• Psychiatric patient shoots and kills caseworker

and injures physician. Physician shoots and wounds attacker

• 2 nurses are stabbed by patient, one critically injured

• Physician repeatedly slapped anesthetized patients, hospital fined

• Patient who became violent died after police used a Taser to subdue him

• All of these events happened this year 4

What is Workplace Violence?

• The National Institute for Occupational Safety and Health (NIOSH) – Any physical assault, threatening behavior or verbal

abuse occurring in the workplace. • The US Department of Labor

– An action (verbal, written, or physical aggression) which is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others, or damage to property. Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior, and threats

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Types of Violence

Assaults Suicide / Attempted Suicide

Shootings Threats

Stabbings Harassment

Rape Stalking

Hostility Aggressive Behavior

Verbal Abuse Bullying

Domestic Violence Psychological Traumas

Obscene Phone Calls or Texts Beatings

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The Stats

• 2010 data reports 11,370 assaults in healthcare entities which represent a 13% increase in reported assaults since 2009

• Of at least 154 shootings in hospitals 46% resulted in fatalities

• ED is the most frequent site of all shootings• Co-worker to co-worker violence is increasing• In one study it was reported that 13% of employees

describes at least 1 assault in the last year• From 2003-2009 8 RNs were fatally injured at work*

BLS, 2011

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OSHA

• OSHA requires employers to mitigate of prevent “recognizable hazards” which include workplace violence by:– Insuring employees are involved and educated on process– Evaluating worksites to ensure safety requirements are

met– Hazard prevention through the use of “panic alarms” or

metal detectors– Safety and Health Training is provided– Compliance with the program must be documented – OSHA fined hospital $78,000 for ‘dozens’ of incidents

involving patients and staff; one nurse sustained severe brain injuries

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CMS

• No formal regulations or policies issued• However, several CMS regulations are the basis

for sanctioning hospitals– Violence toward patients– Safety Restraint Regulations – Allegations of abuse or neglect

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TJC

• Requires that each hospital or organization have a code of conduct that defines acceptable and disruptive and inappropriate behaviors

• Leaders must create and implement a process for managing disruptive and inappropriate behaviors by:– Educating staff– Consistent and equitable enforcement– Implementing “zero tolerance” for disruptive or violent

behavior

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Exposure Resulting From Common Law

• Liability for failing to appropriately hire, supervise, train an employee who may commit a violent act

• Failing to act on known risks that result in injury or harm

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The Cost of Violence

• Direct Cost– Major cost is subsequent litigation which costs all US business an

estimated $120 Billion/year– Average jury award $3.1M*

• Indirect Cost – More difficult to calculate

• Lost time• Higher turnover• Stress related illnesses/request for medical leave• Decreased productivity• Physical injury/death• Reputation

*IMPACT 2006-200712

Patient Employee Violence

• Over 50% of the participating ED nurses experienced verbal or physical violence at work*

• Risk Indicators / Red Flags:– Patient behavior begins escalating or changing– During patient encounters especially in ED or high care areas– Situational events/Times of high stress

• Causes of violence• Patient cognitive impairments

– Patients demanding to leave– Restraints– Transitions in the care process / “Bad News”

*ENA (2011)13

Employee Employee Violence

• Increasing number of situations involving improper conduct which cause disruptions– Inappropriate / disrespectful actions– Bullying– Verbal Threats– Violent Acts

• The healthcare setting is a tense environment due to nature of the business– Stress– Burnout

• Employees often enter into romantic relationships which can lead to violent interactions 14

Sources of Outsider Violence

• Distraught family members and friends• Gangs• Drug and alcohol abusers • Availability of drugs or money in healthcare

setting• Increasing number of acute and chronic mentally

ill patients• Long waits in ED or clinic areas leading to

frustration• Forensic patients being brought in by the police

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FBI Recommendations for Reducing Violence

• Adopt a written violence prevention program• Advise all patients/visitors of organization’s “zero

tolerance” to violence• Establish a Rapid Response Team to deal with

violence • Educate/encourage employees to report incidents• Review workplace layout to identify hazards;

maintain alarm systems/panic buttons and arrange for response system

• Utilize metal detectors as appropriate16

What Can We Do?

• Establish a Culture of Safety • Employee education/training to report promptly• “Speak up and Speak out”• Patient/family centered care• Patient advocates or ombudsman• Employee Counseling • RAT – Risk Assessment Team (dealing with employee

violence)• BAG – Behavioral Alert Group (dealing with

patients/visitors)• Violence Prevention Programs • Disruptive Behavior Group

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Action Team

• Leadership– Facilities– Nursing– VPMA– HR

• Risk Management• Security• Public Affairs/Media Relations• Local Police and Fire

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ERM – Violence is a Risk to the Entire System

• Protect the entity against exposure, legal action (including whistleblower actions) or reputational damage

– Corporate Culture of Safety – Campus wide risk evaluation– Around the clock enforcement of policies– Consistent oversight and discipline of those who

participate in violent acts– Ongoing employee safety education– Appropriate training for security staff– Speak up and Speak Out

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Our Story

• Johns Hopkins Hospital– Approximately 47,450 people

on campus during the day– Campus consists of over 20

interconnect and separate buildings spread over 1 square mile

– Over 90 entrances and exits accessible to the public

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Lessons Learned from Virginia Tech

• After the Virginia Tech tragedy in 2007 we reassessed our readiness to deal with a similar situation – Honestly assessed our vulnerabilities– Understand the environment– Met with local police and fire departments to establish

strategic plan of action– Implemented JH Emergency Alert System– Created additional policies– Initiated specialized training for security supervisors – Informed and educated staff– Table Top Exercises

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Coordination of Internal Efforts

• Specific issues to be addressed– Floor Plans– Electricity/Power– Door Keys– Television broadcast in patient rooms– How do we deal with crowd control and site safety

• Plan how to deal with patients, staff and visitors at or near source of violence

• Traffic flow• Control entrances and exits

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The Event

• September 16, 2010• Son of patient shoots attending physician on

inpatient unit in the presence of nurses/staff• Shooter immediately barricades himself in the

patient room with his mother• Shooter shoots and kills his mother (patient) and

then shoots himself

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The Hallway – Nelson 8

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View From the Front of Hospital

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Time Line of Events

11:10 am Calls to Corporate Security from staff on unit.

11:11 am All available security staff and supervisors dispatched to unit.

11:12 am Senior security staff man Communication Center. Informed that physician was shot.

11:13 am Senior security arrives at scene and informed shooter is in patient room. He takes position outside the door. Code Team arrives.

11:14 am Active Shooter Plan activated. BCP units begin to arrive.

11:15 am BCP take command of scene.

11:17 am Emergency Alert System activated, employees notified.

11:26 am Facilities on the scene, elevators stopped.

11:45 am – 12:15 pm

Decision to relocate patients from the floor. 2 patients cannot be evacuated as they would need to cross the “hot zone.”

1:40 pm BCP give the “All Clear.”

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The Role of Risk Management During Crisis

• Man the Control or Command Center• Notify and keep leadership advised of events• Contact TJC, OSHA, State• Alert Public Affairs / Media Relations• Assist in patient and staff evacuations• Assist in ensuring business continuity in the rest

of the system

KEEP CALM AND CARRY ON27

Post Event Priorities

• Establish “Crisis Teams” for patients and staff to deal with feelings of guilt and anger – “The 2nd Victims”– Social Workers– Counselors – Chaplains

• Ensure basic services are available (food and supplies)• Isolate witnesses• Prepare for interviews with police/authorities • Openly and honestly discuss the events with staff

(Town Hall Meetings)• Dealing with the Regulatory Agencies• Dealing with the press 28

The Debriefing

• Assess what happened during the incident– Emergency Management Overview

• Was the shooter contained?• Where notifications appropriate?• Was Command Center established quickly?

– Communication• Was the correct information shared with the right people in

a timely manner?

– Patient and staff safety• Did we adequately protect staff and patients who were in

the “Hot Zone”?

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Lessons Learned

• More simulations or Table Top exercises needed

• Mandatory training of all staff in how to deal with aggressive patients/visitors

• Information regarding aggressive patients/visitors must be shared when patients are transferred (in EMR)

• Establish process to deal with aggressive behavior by staff, patients or visitor

• Keep lines of communication open with Police/Fire

• Alerts Systems need to be reviewed and there may need to be multiple system in place to ensure proper communication of the events 30

Business Continuity

• Prepare in advance and know who makes the decision as to:– What business operations continue?– Evacuation decisions for

inpatients/outpatients/staff

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The 3rd Victims

Risk Managers have feelings too!

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Workplace Violence and Insurance

From 1992 to 2010, there were 13,827 homicide victims in the workplace—an average of about 14 per week.Bureau of Labor Statistics (2011)

Workplace violence is incredibly damaging to a corporation’s reputation. The unanticipated expenses that flow from these types of events can be financially devastating.

Is your institution adequately insured? 33

Workplace Violence Expenses

• Compensation claims • Insurance costs • Lost productivity • Counseling for employees • Grievances • Lawsuits • Extra security

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Workers Compensation

Workers compensation policies cover on-the-job injuries, but may exclude coverage for acts of lethal force and the threat of lethal force. Intentional acts are almost always excluded.

Consider a carrier with applicable endorsements or even purchase separate insurance to protect against the aftermath of workplace violence. 35

General Liability

There is a Common Law Duty to Provide a Safe Workplace!

A general liability policy MAY cover on-site workplace violence injuries to invited visitors.

Many traditional commercial general liability insurance policies will exclude coverage for workplace violence, likely through application of the "expected and intended" exclusion or the "assault and battery" exclusion. 36

Professional Liability

A professional liability policy could kick in if there wereallegations following a workplace violence incident thata psychiatric patient, for example, was prematurelydischarged or inadequately examined or treated andthen committed an act of workplace violence.

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Property, Health Insurance and Medicals

Property insurance would likely cover the area(s) physically affected by the workplace violence. Check your deductibles as they are often very high.

Health insurance and medical insurance will come into play if a Workers Compensation claim(s) is denied or if there is not enough funds in the policy to adequately cover the involved employee(s).

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Endorsements and Workplace Violence Business Insurance

• Various insurers including Chartis and Chubb offer workplace

violence business insurance which covers the company, the

directors and officers, the employees, including those seasonal,

temporary and leased, volunteers and guests on the company’s

premises.

• Chubb and Darwin Professional Underwriters, Inc., offer similar

versions of a “Workplace Violence Expenses Endorsement” which

is part of their insured’s directors and officers liability coverage.

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Associated Costs

Wherever workplace violence happens, employers suffer direct and indirect costs. Employers who fail to protect their employees against violence in their workplaces are subject to government citations and costly civil litigations and judgments.

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QUESTIONS?

Resources

• National Center for the Analysis of Violence Crime (NCAVC)

• National Institute for Occupational Safety and Health (NIOSH)

• U.S. Department of Justice; Special Report on “Workplace Violence, 1993-2009”

• U.S. Secret Service, U.S. Department of Education and the FBI Report: “Campus Attacks: Targeted Violence Affecting Institutions of Higher Education

• Violence Against Women Act (VAWA)

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