Mike Dunning, CEM, CHPASenior Director, Healthcare

Reducing Violence in Healthcare

2019

Lisa Terry, CHPA, CPPVice President, Vertical Markets, Healthcare

Presented by:

Lisa Terry, CHPA, CPPVice President

Vertical Markets - Healthcare

Mike Dunning, CEM, CHPASenior Director

Vertical Markets - Healthcare

Core Concept…

Violence is the precursor to Violence

Violence in Healthcare: Evaluate the Problem

The Centers for Disease Control and Prevention (CDC) National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”

The U.S. Department of Labor defines workplace violence as “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.”

Workers in healthcare settings have 20% higher chance of being victims (IAHSS)

12% of emergency department nurses experienced physical violence1

59% experienced verbal abuse—during a seven-day period1

21% of RNs and nursing students reported being physically assaulted over 12 months2

Over 50% reported being verbally abused over 12 months3

Healthcare accounts for nearly as many injuries as all other industries combined3

75% of aggravated assaults and 93% of all assaults against health care workers from patients or customers4

1 2009–2011 Emergency Nurses Association survey of 7,169 nurses.2 A 2014 American Nurses Association’s Health Risk Appraisal survey of 3,765 registered nurses and nursing students

3 Source: Bureau of Labor Statistics data for 2011–2013, covering injuries that required days away from work.42017 BLS 2. National Crime Victimization Survey (2018) 3. TJC Sentinel Event Data 2018

Violence in Healthcare: Evaluate the Problem

Point of Care Violence

In 2016, U.S. hospitals and health systems alone expended approximately$2.7 billion in respondingto violence

Consider…

48 HC Worker fatalities in 2017 due to violence (30% of HC fatalities)

31 due to homicides (compared to 458 in ALL industries) • 6 – domestic partner• 5 – co-worker or work associate • 6 – inmates• 14 – others (patients and visitors)

22 were from gunshot wounds, others include blunt force,asphyxiation or strangulation and other traumatic injuries

16 suicides

USAF.FEMA.GOV, Data.BLS.GOV

The Motivators…

Violence is motivated by… • Revenge• Anger• Ideology• Mental Illness• Desire to be famous

TJC Sentinel Event Data 2018, AHA Study on Violence in Healthcare

The most common characteristic exhibited by perpetrators of workplace violence is altered mental status associated with dementia, delirium, substance intoxication, or decompensated mental illness.

One study showed that patients in police custody within a health care setting are involved in 29% of shootings in emergency departments, with 11% occurring during escape attempts.

Contributing Factors…

TJC Sentinel Event Data 2018, AHA Study on Violence in Healthcare

• Poor lighting or other factors restricting vision in corridors, rooms, parking lots and other areas – especially in parking areas

• No access to emergency communication, such as panic alarm, cell phone or call bell

• Unrestricted public access to hospital rooms and clinics

• Stressful conditions, such as long wait times or crowding in the clinical environment or being given “bad news” related to a diagnosis or prognosis

• Staff working in isolation or in situations in which they can be trapped without an escape route

• No training/discussion on de-escalation and situational awareness

Contributing Factors…

• Lack of organizational policies and training for security and staff to recognize and de-escalate hostile and assaultive behaviors

• Domestic disputes among patients or visitors

• The presence of firearms or other weapons

• Inadequate security and mental health personnel on site

• Understaffing, especially during mealtimes and visiting hours

TJC Sentinel Event Data 2018, AHA Study on Violence in Healthcare

Culture Challenges

I want to feel safe

Protect Me!

I’m Important

I don’t want to be here!Be nice

to me!

What do I do?

I’m Angry

Compliance Challenges

• How are you protecting staff and patients: “Right to receive care insafe setting” and “Right to work in a safe setting”

• An environment where a reasonable person would consider safe• Vulnerable patients, including newborn and children• Must protect emotional health and safety as well as physical

• Physical restraints – have you defined training & competencies (in writing)• Armed accounts will be targets for CMS and TJC

• Especially Tasers and firearms• “Panel” review every incident • NO pepper SPRAY• Have a written policy• Use of Force and Review Policy/Protocol

Violence Management Program: Evaluate ROI

Healthcare workers more likely to take time off work after experiencing acute and chronic episodes of violence in the workplace (BLS)Workplace violence in healthcare causes

high turnover (BLS)Violence results in low staff morale and

lawsuits (OSHA)

Root Causes for Cracks in the Environment

Lack of Program with Processes

Lack of Training

Lack of Reporting

Lack of Specialized Response

Slow Response Time

The Advisory Board, 2017

The Solution…

… requires a change in mindset

Consider...

Mindset must get away from “Reactive” only

• Prepare• Respond• Recover

Building a Proactive Program

• Establish a Threat Assessment Team

• Build the Training Program

• Develop the Plan, Policies/Procedures

Healthcare Threat Assessment Team

• Focus on protecting patients, staff and visitors

• Proactively identify potential threats or acts of violence

• Establish proactive steps to prevent violence

• Ensure clear paths of reporting and communication

Objectives of a Threat Assessment Team

Guiding Principles based on Gene Deisinger, Ph.D1. Targeted violence can often be prevented2. Violence is a dynamic process3. Targeted violence is a function of several factors4. Corroboration is critical (identify and verify)5. Threat assessment is about behaviors, not profiles6. Cooperating systems are critical

Healthcare Threat Assessment Team

Based on Gene Deisinger, Ph.D.; The Handbook for Campus Threat Assessment & Management Teams

7. Does the person pose a threat?8. Keep victims in mind9. Early intervention and identification 10.Multiple reporting mechanisms 11.Multifaceted resources 12.Safety is a primary focusBased on Gene Deisinger, Ph.D.; The Handbook for Campus Threat Assessment & Management Teams

Healthcare Threat Assessment Team

Threat Assessment Tool

Example

Poll Question

30,000+Sites Served

Do you have a standing Threat Assessment Team in your facility?YesNo

Focus training on:

Prevention

Recognition Response

Reporting

Training

1. Identify potential issues and early awareness

2. Adhere to reporting protocols

3. Activate an Emergency Response

4. Document threats and incidents

5. Emphasize all threats should be taken seriously

6. Share learning and key findings from historical issues

7. Continuously train on plans, policies and procedures

Training

Resources

Policies, Procedures and Plans

• IAHSS Industry Guidelines01.01.09 Violence Healthcare

01.01.09.01 Targeted Violence

01.09.09.02 Management of Weapons

01.09.03 Threat Management

02.02.04 De-Escalation Training

05.03 Violent Patient Visitor Management

Resources

• OSHA 3148 & 3827 (HR

1309 still in proposal)

• CA H&SC 1257.7 and

1257.8

• TJC Sentinel Event Alert

#59

• ENA WPV Toolkit

• HASC WPV Toolkit

Resources

The Policies, Procedures and Plans must include:

• Detect

• Deter

• Delay

• Respond

• Recover

Detect…

Active Screening

Notification & Alert Systems

Access Control & Visitor

Management

Security

Situational Awareness

Active Engagement

De-escalation

Reporting

Everyone

Detect…

Active Screening

Notification & Alert Systems

Access Control & Visitor

Management

Security

Situational Awareness

Active Engagement

Reporting

Everyone

Active Presence

Physical Screening

Tools/Weapon

Security

Active Presence

De-EscalationSocial Services

Service Recovery

Reporting

Everyone

Detect… Deter…

Active Screening

Notification Systems

Access ControlVisitor

Management

Security

Situational Awareness

Active Engagement

Reporting

Everyone

Active Presence

Physical Screening

Tools/Weapon

Security

Active Presence

De-EscalationSocial Services

Service Recovery

Reporting

Everyone

Deter…

Poll Question

30,000+Sites Served

Does your facility utilize a stand-alone magnetometer to screen persons entering your Emergency Department?YesNo

Basics – Exterior/Parking Areas

• Signage posted at driveway entrances stating that video surveillance is in use

• Signage posted about “no weapons” policy for the facility• Well-lit parking areas with good visibility from the facility• Security team performing visible patrol activity in marked

vehicles- consider having vehicles with light bars activated• Designated assembly areas for evacuation are maintained

and highly visible

Basics – Access Control

• Visitor access limited to controlled entry points• Employee access points monitored to prevent “tailgating” and other

unauthorized access• Weapons screening in place for visitors• Reception areas are well marked and reception personnel are trained

to recognize potential signs of impending violence/aggression• Patrol activities are conducted regularly to ensure that no entry

points are compromised • Badge audits/key audits are conducted regularly to ensure that all

access control is accounted for

Basics – Reception/Waiting Areas

• Reception personnel are trained in recognizing signs of potential violence and making notification

• Reception personnel have drilled in RUN/HIDE/FIGHT• Reception areas are well marked • Access into interior facility areas is controlled- visitors/patients

cannot access interior spaces without interacting with a reception person

• Security personnel patrolling the area regularly• “See something-say something” is enforced

Basics – Patient Care/Treatment Areas

• Access controlled and visitor policies enforced• Department staff are trained in recognizing signs of potential

violence• Department staff are trained and have a plan for patient care in the

event of a threat – not just Run/Hide/Fight• Department staff have “safe areas” identified that they can secure

against a threat• Department staff are trained to immediately report potential issues• Department staff conduct drills, table top exercises, and “what if”

scenarios regularly

Basics – Administrative/Billing/HR Areas

• Access strictly controlled into administrative areas, except in public roles• Security is made aware of employee counseling/termination issues• Controlled space is used for sensitive conversations with security available • Billing disputes and financial issues are conducted in private areas with

video monitoring/panic alarms available• Access to senior leadership strictly controlled• Administrative/management personnel are trained and drilled in

RUN/HIDE/FIGHT• Personnel are trained and drilled in hasty exit/exterior assembly procedures• Aggressive complaints/calls/communications are reported• Facility has an emergency management plan in place• Security review/assessments are conducted regularly

Poll Question

30,000+Sites Served

Does your facility actively utilize an electronic visitor management system to screen visitors entering the property?YesNo

Problem Areas with Security Rounding

Conducted at “Random”Priorities are not placed on certain areas, all areas treated as equal

Primary Focus on “Other” issuesSecurity spends majority of time on non-security related tasks

!

!

Three Key Components of Security-Driven Rounding

Formal Check-In on Each Unit

Initiate focused check-ins with charge nurse or manager: proactively identify potential risks and develop relationships

Target Hotspots of Concern

Round on every unit but disproportionally spend time on units where staff have expressed specific concerns or a history of activity

Formal Handoff at Security Shift Change

Communicate to flag safety and security concerns each shift

Active Presence

Physical Screening

Tools/Weapon

Security

Active Presence

De-EscalationSocial Services

Service Recovery

Reporting

Everyone

Detect… Deter… Delay…

Active Screening

Notification Systems

Access ControlVisitor

Management

Security

Situational Awareness

Active Engagement

Reporting

Everyone

Emergency Protocols

Communication

Security

Access ControlPhysical BarriersAlarms

Shelter In PlaceSafe Rooms

Escape Routes

Everyone

Detect… Deter… Delay…

Emergency Protocols

Communication

Security

Access ControlPhysical BarriersAlarms

Shelter In Place

Safe RoomsEscape Routes

Everyone

Advance Planning – Shelter in Place

Poll Question

44

30,000+Sites Served

Has your department identified “safe areas” for staff to utilize in the event of an emergency?YesNo

Response…

Response Protocols

911Containment

When to call for help

Weapons & ToolsCommunication

Evacuation

Security

Response Protocols &

ExpectationsShelter in Place

Barriers & BarricadesEvacuation

Weapons & Tools

Communication

Everyone

Specialized Responses for:

Criminal Activity

Immediate Hostile Threats/Violence

Behavioral Health Patients in Crisis

Violent Situation Response Teams

Code TeamTeam of clinical and non-

clinical staff specially trained in de-escalation techniques and ready to

be dispatched 24/7 to support colleagues

dealing with a threatening, disruptive, or

violent situation

Code Team Roles

Team LeadCoordinates team huddle, develops response action plan response, assigns responsibilities.

Clinical Supervisor or Charge NurseBriefs responders on actual or potential threats contributing to escalating behavior AND any patient condition the team needs to be aware.

Frontline RespondersResponds to codes and assists with de-escalation and restraint.

SecurityProvides show of force and ensures environmental safety.

Violent Situation Response Teams

Active Shooter/Assailant - Drills

Form Committee

Invite outside contributors

Form plan and objectives

Conduct table-top

Train staff

Conduct mini drills with objectives

Critique and re-plan

Plan full drill with committee

Invite outside contributors

Inform the staff, patients, media,

public and agencies

Plan for PTSD

Critique and re-plan

Never start with a full drill

Table tops - Walk-throughs - Department Level - Full Scale

Post Response…

Is everyone OK?

Did we respond appropriately?

Did we miss an escalation trigger point?

What was the root cause of the outburst?

Recover…

Communication

Evaluate staff

Evaluate response

Improve plan

Security

Communication

Employee Assistance –

PTSD

Damage assessment

Back to normal –can take years

Everyone

You will have a crime scene…

Ongoing care

Evacuation

Business Continuity

Culture Challenges…

American workers feel safer with violence prevention programs at their companies.

WPV Survey, SHRM, March 2019

Results…

35% increase in feeling of safety by staff

45% increase in confidence of security by staff

32% increase in patient satisfaction scores

42% reduction in patient restraints

35% decrease in workplace violence injuries

69% decrease in worker compensation budget

The Advisory Board, 2017

Violence Manifests In Many Ways…..

The American College of Healthcare Executives (ACHE) Encourages Executives to Take the Following Actions:• Clearly Define Workplace Violence• Assess the Scope and Prevalence of Violence the Facility• Raise Awareness that Workplace Violence is a Public Health Issue• Identify and Remediate Risk Factors• Provide Training on How to Recognize and Mitigate Workplace

Violence• Evaluate, Measure and Report Progress

Final Recommendations…

• Have a workplace violence prevention program in place• Threat Management/

Threat Assessment Team• Threat Assessment

• Review contributing factors and plan for them

• Provide training to all employees on how to respond to incidents

• Communicate with workers about what resources are available

Reducing Violence in Healthcare

2019

Questions and Comments