Author: John Walpole
Healthcare organizations no longer need to be reminded of the value of a workplace violence program. They no longer need dramatic statistics on healthcare worker injuries, assaults and even deaths to persuade them to take action. They don't need another bulletin or article encouraging a workplace violence program. Healthcare organizations "get it" and are working toward systemic changes to manage workplace violence as an organizational process.
The unfortunate reality is that workplace violence is and has been a risk of working in the healthcare environment. Like healthcare safety, security and infection control, workplace violence has become an assumed risk with everyday exposures to healthcare workers.
In this article, we offer insight and suggestions for structuring, implementing and managing a workplace violence (WPV) program.
Taking action: Establish structure
Most organizations have established a task force, steering committee or subcommittee. Although these committees are valuable components of the program and represent a nucleus for managing WPV activity, they're just one component of the program.
If asked to present the WPV steering committee to the executive committee or an accredited organization, providing an overview of the steering committee and its minutes wouldn't reflect a program — that is, it doesn't reflect the organizational structure, processes or stakeholders.
A simple step in creating such an illustrative document is to create a WVP organizational chart illustrates the organizational structure and delegation of responsibility. It would include:
- To whom the steering committee reports. Quality/Patient safety? The executive committee?
- Who's on the steering committee
- Who the program director/manager is
- What departments are stakeholders — Security, Nursing, Behavioral Health, Facilities, Emergency Department (ED), Obstetrics (OB), etc.
An organizational chart is important because it requires the organization to define the flow of exposures and the internal champions. For example, if the steering committee is dealing with an issue in which a policy is clear and in place, and if the issue has been addressed through education or other means, yet the issue remains due to political or organizational issues, the issue must have a process to be passed or shared with the oversight committee to the WPV steering committee.
The organizational chart will also serve as a valuable tool for providing an overview of the WPV Program to leadership, accrediting organizations, management training and new employee orientation.
Establishing the workplace violence committee
WPV committees are needed in many cases, as the necessary information and program reviews require much more time than can be allotted in a typical environment of care (EOC) committee.
Fortunately, healthcare organizations have the EOC committee or safety committee as models. Stakeholders can determine the membership and provide standing reports on initiatives, program elements or incidents specific to their area. It's imperative that the committee remain a performance-based committee, with tangible products, programs, engineering controls, education, etc., resulting from the committee meetings.
Security, buildings and grounds are all areas with historical problems. However, clinical issues must be central to committee focus as well. From the onset, committees need to balance clinical discussions with employee injury/incident reviews and updates on assaults investigations. These issues include, but aren't limited to, establishing zero tolerance or similar programs, processes for managing threatening behavior, updating medical record systems behavioral flags, patient termination, managing restraining orders and guiding staff with options after an assault.
Clearly, there's no shortage of topics. Although the topics and exposures are coming fast and furious, you should rely on the stakeholder responsible for medical record training or developing a patient termination policy to concisely inform the group of updates.
Performance improvement measures
An overwhelming aspect of the WPV program and committee management process is how to measurably manage action and progress of issues within each area overseen by a stakeholder. Immediate action can take place with the "task management."
Each stakeholder represents an "expert" in their individual departments (OB, ED, Behavioral Health, Education, Security, etc.). Each stakeholder should be tasked with conducting a brief review of their individual area and developing a single issue/exposure that they submit as a performance improvement measure.
These performance measures will provide the end-of-day evidence of an on-going tangible improvement program. The identification of performance improvement measures can be needlessly complicated. The objective is to simply identify an issue that needs improvement. This improvement can be the evaluation of compliance with known established policy or an obvious issue of non-compliance.
For example, a security manager might conduct a walk-through of the facility and identify staff and/or patients who aren't complying with identification requirements. If the amount of non-compliance is determined to be significant, it can become a performance improvement measure. A simple process — such as education, memos and meetings with department heads — may be enough to move non-compliance from 70% to possibly 98%.
Partnering with performance measures
Consider a partnership to evaluate potential exposures within the stakeholders themselves. For example, security management has a clear policy on managing the admission of patients with established restraining orders. The OB/Labor and Delivery department is a common exposure risk for this issue.
If OB/Labor and Delivery is asked, "How many times in the past year have you admitted a patient who indicated they had an established restraining order against the boyfriend, father or other person?" and the answer is, "We have probably admitted eight to 10 patients," then go to Security Management and inquire, "How many times have you been notified by OB/Labor and Delivery that they admitted a patient with an established restraining order?"
If the answer is eight to 10, great! If it's one or two, we know we have the potential for serious problems. And, importantly, the answer isn't that we have a policy or a procedure, because we know we have those in place. The issue is clearly a communication issue, and it's relatively easy to measure. Improving this measure to 100% as opposed to 10% is an excellent example of performance improvement and tangible evidence of organizational improvement of a serious exposure.
Another example could be interviewing clinicians to determine their awareness and use of the medical record system's behavioral flags.
The list goes on. But most significant is that the individual stakeholders are moving forward with identifying and improving areas that need improvement while the WPV committee continues to develop organizational initiatives.
Program exposures
Once the program's structural components are in place, it will be easier to focus on specific risks. The issues are certainly more involved than can be addressed in this article. Active shooter, de-escalation, behavioral health and documentation of medical records barely scratch the surface. The point is that the needs of the program are far larger than a single person can manage.
Identify and use resources
Healthcare organizations must also consider the economics of healthcare; healthcare organizations are struggling, and resources to fund programs are limited. It's imperative to identify and use resources that provide valuable information at no cost.
Examples include:
- "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers," OSHA, 2016. PDF file.
- "About Workplace Violence," CDC. 22 Apr 2024.
- "Emergency Preparedness: Hospital Code Silver Activation — Active Shooter Planning Checklist," California Hospital Association, 2017. PDF download.
- "Nursing World," ANA Enterprise.
- "International Association for Healthcare Security & Safety," iahss.org.
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