Building a Safe Workplace and Community Mitigating the Risk of Violence The American Hospital Association's Hospitals Against Violence (HAV) initiative hosted the American Society for Health Care Risk Management (ASHRM) for a facilitated dialogue to explore challenges and current strategies to mitigate the risk of violence. The discussion fostered an exchange of ideas and solutions that informed this issue brief and accompanying case studies. [:] American Hospital m OSpita Is Association™ Ag ainst Advancing Health in America ViOIen ce Introduction In 2021, HAV developed the Building a Safe Workplace and Community framework to guide health care leaders in their efforts to prevent and mitigate violence. This issue brief examines risk mitigation and marks the first in a series that expand on each domain of the framework: culture of safety, violence intervention, trauma support and risk mitigation. This issue brief is an outgrowth of a series of discussions between hospital and risk management leaders. The brief shares considerations when assessing potential risks, strategies to mitigating violence and insights on making the care environment safer. Trauma Culture of Support Safety Violence [V Ry Mitigate Risk Background Violence in health care settings is a complex issue and an ongoing public health concern. Hospitals and health systems across the country are faced with a significant increase of violence and incivility in the workplace and against the health care workforce. During the COVID-19 pandemic, health care workers reported an increase in threats and assaults, which can have a devastating impact on access and delivery of patient care.! Adding to the individual and collective trauma are the repeated violent acts plaguing our communities and overwhelming our health care system and workforce. ©2023 American Hospital Association | April 2023 Page2 | www.aha.org DEFINITIONS TO KNOW Workplace Violence ACCORDINGTO: e Occupational Safety and Health Administration (OSHA): Workplace violence is any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It can affect and involve workers, clients, customers and visitors. e CDC''s National Institute for Occupational Safety and Health: Violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty. Examples of violence include threats, which are expressions of intent to cause harm, including verbal threats, threatening body language and written threats. ¢ The Joint Commission: An act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors. Risk Assessment A part of the overarching process of risk management that identifies, analyzes and evaluates risks that may have a negative influence on health care organizations' quality and safety of care delivered. Threat Assessment A behavior-based inquiry process that helps organizations respond to a threat of targeted violence and identify those who may be moving toward an intentional harmful event; it is a multi-disciplinary approach to identifying, assessing and mitigating concerns of intentional violence.? )2 american Hospita [Elospitals Association™ Ag ainst Advancing Health in America VIO ence Enterprise risk management encompasses the entire organizational care setting (inpatient, outpatient services, outpatient offices, freestanding labs and urgent care settings, long-term care, home health and others) and administrative processes with the goal of mitigating risks, identifying types of hazard prevention and risk control measures necessary to avoid or mitigate security incidents. A role of the risk professional is to proactively and systemically identify, assess, mitigate and prevent risk to improve safety for all.2 As health care leaders consider the implementation or enhancement of existing organizational risk management practices to mitigate the risk of violence, consideration needs to be given to continuous review and updating of existing tools and interventions. For example, according to the American Society for Healthcare Risk Management (ASHRM), "Traditional risk management is no longer sufficient to sustain organizational success in an environment of transforming health care delivery and payment. Enterprise risk management provides a more comprehensive, holistic approach that can help hospitals, health systems and their boards better anticipate, recognize and address the myriad risks associated with the increased complexity of transformational change." See ASHRM ERM Quick Reference Tool. Assessing Risk Arisk assessment is based on research and data on the EVlDENCE- prevalence of violent incidents in particular populations, as well as individual factors that are associated with disruptive BASED RISK and violent behaviors. A variety of risk assessment tools exist ASSESSMENT 4,5 TOOLS to evaluate individuals and situations for potential violence, enabling the health care workforce to share a common frame of reference and understanding. e ASHRM's Facility Workplace Violence Risk Assessment Tool -=/\\\ {11 s O - Event reporting is essential to the organization's ability to mitigate the risk of violence. Leaders play a role in fostering a culture of safety and risk awareness that encourages reporting incidents of violence, intimidation or threats; promotes the use of a consolidated security/event incident reporting system and established categories; and sponsors the implementation of evidence-based safety technologies. ¢ Dynamic Appraisal of Situational Aggression Brgset Violence Checklist Triage Tool Indicator for Violent Behavior e Danger Assessment Tool Risk assessment and threat assessments are often used interchangeably, but each are significantly different. A risk assessment is evidenced-based practices based on a processes that identify the organization's historical and current risks as well as future risks. This risk identification process allows risk controls to be put in place. However, both risk and threat assessment gf::ttggies EMR flagging and behavioral health response training that reduces violence at New York health system Worked NewYork-Presbyterian leaders balance traditional security and emergency management processes with information technology infrastructure. With 11 hospitals and 47,000 employees, the New York City-based health system''s security NewYork- : : e : . . professionals are continuously identifying new and innovative strategies, includ- ing electronic medical record flagging, behavioral risk assessment and mass casualty event training, to prevent and mitigate workplace violence incidents. Preshyterian Hospital ©2023 American Hospital Association | April 2023 [EZ american tospita [ospitals Association™ Against Page 3 | WWW.aha.0rg Advancing Health in America V|° ence teams are a multidisciplinary rapid response group and part of a comprehensive workplace violence prevention program. The four key components of a risk assessment are 1) identify the risk; 2) analyze the risk; 3) control, transfer or mitigate the risk; and 4) monitor risk control measures. SECURITY STRATEGIES CONSIDERATIONS A threat .assessmgnt is the process of gathering e information to decide the potential for violence. Its use is prevalent in other industries, but its adoption is * Hospital-based police departments slow within health care organizations. In a health care « Interdisciplinary stakeholder committees and organization, a threat assessment program begins by workgroups creating an interdisciplinary team, including members _ of the clinical team, operations, safety and security, risk * Canines/K-9 management, human resources and communications. « Documenting and flagging for potential or The four key components of a threat assessment historical violent or disruptive behavior process are 1) creating the threat assessment team; 2) identification of a potential threat; 3) investigation; and 4) mitigation and management of the threat. * De-escalation training - to include simulation training ¢ Threat assessment teams Mitigating Risk e Staff duress alarms Mitigating the risk of violence begins with the » Surveillance security technology and acceptance that risks of violence exist in all health equipment, including body cameras care settings. Risk professionals and administrative leadership need to adopt a multi-pronged approach and work collaboratively with all stakeholders and outside ¢ Mass notification systems partners, including but not limited to state and local police, county agencies and others.® ¢ Metal detection systems Visitor identification policies Most important are the people working in health care facilities. All staff should be empowered to enforce policies and report any incidents of violence." Leaders can empower staff through clear and consistent communication, following up on any reported incidents and by providing trauma support for any team members affected by violence. Workplace violence prevention program procedures should be readily available and include input from leaders, staff, patients and visitors. Categories of workplace violence that may be included in trainings are interpersonal violence, active shooter and de-escalation training. Safety e T Leveraging community partnerships UG to take a stand against hospital violence Worked Bristol Health decreased workplace violence by upgrading their incident reporting system, boosting prevention education and supporting employees. Bristol leaders ' orged an organization-wide culture of safety. They meticulously track data to help (T forged i de cult f safety. Th ticulously track data to hel prevent future incidents and have gained crucial support from local stakeholders Health and policymakers, ultimately inspiring conversations about community-wide policy changes. ©2023 American Hospital Association | April 2023 [E}Z= american Hospitar [Elospitals Association™ Against Page 4 | WWW.aha.0rg Advancing Health in America V|° ence In addition, security technologies are striving to meet the demand to improve safety in our communities. Hospital and health system leaders are evaluating the various security technologies, available resources and potential impact to patient care. Improving the Environment Health care leaders strive to create a safe, trusted and healing environment for all. Efforts to mitigate the risk of workplace violence contributes to improving a team-based response in moments of crisis, encourages trust in reporting and improves the physical and psychological safety of all internal and external stakeholders. Assigning an executive sponsor(s) to champion the workplace violence organizational focus and how the organization identifies and manages violence or threats of violence is strongly encouraged for success. A place for leadership to begin this work is reinforcing that safety is a priority and commit to the short- and long-term needs of those affected by violence. A good starting point is the creation or review of a workplace violence prevention program policy and related procedures. A key stakeholder group in improving safety in hospitals and health systems are the trustees. It is important to the overall violence prevention strategy to meaningfully engage trustees by sharing data and incidents, request input on safety-related initiatives and utilize the board to connect with the community to find shared solutions.? We must all work together to make the health care environment safer. Safety e ae e gm . Srsieais Multidisciplinary teams reduce violence that at Inova Health System Worked Inova leaders formed a multidisciplinary team to evaluate current data, develop employee engagement strategies and ensure system-wide buy-in. As a result, Inova safety leaders have reduced the severity and frequency of injuries in Inova's Health emergency departments, behavioral health units and across the system. RGN ©2023 American Hospital Association | April 2023 [:]/'m';?:_pn::'sflw ngsjg%nsts Page 5 | WWW.aha.0rg Advancing Health in America ViOIence Resources AHA Resources Building a Safe Workplace and Community: A Framework for Hospital and Health System Leadership Case Studies * Bristol Health ¢ [nova Health System * NewYork-Presbyterian ASHRM Workplace Violence Toolkit American Organization for Nursing Leadership and Emergency Nurses Association Guiding Principles: Mitigating Violence in Health Care American Organization for Nursing Leadership and Emergency Nurses Association Toolkit for Mitigating Violence in the Workplace AHATrustee Services and ASHRM - Enterprise Risk Management for Health Care Boards: Leveraging the Value The CLEAR Field Guide for Emergency Preparedness Creating Safer Workplaces: A guide to mitigating violence in health care settings, a collaboration between AHA and the International Association for Health Care Security and Safety National Resources Intemational Association of Healthcare Security and Safety. Threat Assessment Strategies to Mitigate Violence in Healthcare Intemational Association of Healthcare Security and Safety and the Security Industry Association. Mitigating the Risk of Workplace Violence in Health Care Settings. August 2017 Massachusetts Hospital Association's Security Guidance: Developing Healthcare Safety & Violence Prevention Programs within Hospitals Oregon Association of Hospitals and Health Systems Public Services Health and Safety Association Workplace Violence Risk AssessmentToolkit for Acute Care ©2023 American Hospital Association | April 2023 [EZ american tospita [Hospitals Association" Against Page 6 | WWW.aha.0rg Advancing Health in America Violence Sources 1. International Committee for the Red Cross. 600 violent incidents recorded against health care providers, patients due to COVID-19. https:// www.icrc.org/en/document/icrc-600-violent-incidents-recorded-against-healthcare-providers-patients-due-covid-19 2. Marisa Randazzo & J. Kevin Cameron, From Presidential Protection to Campus Security: A Brief History of Threat Assessment in North American Schools and Colleges, (Journal of College Student Psychotherapy, 2012), 279. 3. Kaya GK, Ward JR, Clarkson PJ. A framework to support risk assessment in hospitals. Int J Qual Health Care. 2019 Jun 1;31(5):393-401. doi: 10.1093/intghc/mzy194. PMID: 30184151; PMCID: PMC6528703. 4. https://www.acep.org/globalassets/sites/acep/media/public-health/risk-assessment-violence_seltharm.pdf 5. Woods P Aimvik R. The Breset violence checklist (BVC). Acta Psychiatr Scand Suppl. 2002;(412):103-5. doi: 10.1034/].1600-0447.106.s412.22 x. PMID: 12072138. 6. The National Institute for Occupational Safety and Health (NIOSH). Violence Occupational Hazards in Hospitals. https://www.cdc.gov/niosh/ docs/2002-101/default.html 7. Shaw J. Staff perceptions of workplace violence in a pediatric emergency department. Work. 2015;51(1):39-49. doi: 10.3233/\WOR-141895. PMID: 24894692. https://jpubmed.ncbi.nim.nih.gov/24894692/ 8. Jawed, A, Thompson, BS. No excuses, no exceptions except with compassion: A narrative review of visitor aggression in pediatrics. J Healthc Risk Manag. 2022; 42: 9- 17, https://doi.org/10.1002/jhrm.21518 ©2023 American Hospital Association | April 2023 [.:-]/'a'fiz;'é?:.@'ofl?"'""' [:]R;g:::'aslts Page 7 | WWW.aha.0rg Advancing Health in America Violence In fall 2022, ASHRM met with the AHAs Hospitals Against Violence Advisory Group - comprised of clinicians and hospital leaders from across the nation, along with experts within the AHA - to develop this issue brief. Special thanks to the contributors. AHA's HAV Adyvisory Group Mary Beth Kingston, R.N., Ph.D., Co-chair, HAV's Advisory Group, EVP Chief Nursing Officer, Advocate Health Adam Apolinar, Chief Executive Officer, Uvalde Memorial Hospital Toni Ardabell, R.N., MSN, MBA, Chief of Clinical Enterprise Operations, Inova Health System Kurt Barwis, President & Chief Executive Officer, Bristol Health Kenneth Bowman, Chief Executive Officer, UW Health Rehabilitation Hospital Lindsay Caulfield, Chief Marketing & Experience Officer, Grady Health Craig Coldwell, M.D., MPH, Deputy Chief Medical Officer, Veterans Health Affairs (VHA) New England Healthcare System Cindy Kelleher, Chief Executive Officer, University of Maryland Rehabilitation Lesley Ogden, M.D., Chief Executive Officer, Samaritan North Lincoln Hospital Diego Rodriguez, Vice President of Emergency Management and Security, NewYork-Presbyterian Hospital Ann Schumacher, President, CHI Health Immanuel Monica Vavilala, M.D., Director of the Harborview Injury Prevention & Research Center, UW Medicine ASHRM Leadership: Carolyn Bailey, Director of Risk Management, Blessing Health System Katie Du Fresne, Executive Director of Clinical Risk Management, Indiana University Health Karen Garvey, DFASHRM, CPHRM, CPPS, Vice President for Safety & Clinical Risk Management, Parkland Health & Hospital System Jose Guzman, Hudson Insurance Group and Napa River Insurance Services Inc. Rodney Melton, MHA, BSN, R.N., CPHRM, Clinical Risk Manager, Baylor Scott & White All Saints Tatum O'Sullivan, R.N., BSN, MHSA, CPHRM, DFASHRM, Ambulatory Risk Management & Patient Safety Director, North Shore Physicians Group M/ - AMERICAN == American Hospital SOCIETY FOR / Association™ ASH RM HEALTH CARE -_- RISK Advancing Health in America . MANAGEMENT