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New Workplace Violence Prevention Requirements Coming in 2022

08/09/2021

By Antigone E. Kokalias, MBA, MSN, RN, Clinical Project Director – Clinical, Department of Standards and Survey Methods 

A whopping 73% of nonfatal workplace injuries and illnesses causing days of missed work in health care are connected to workplace violence.

Since incidents of workplace violence tend to be underreported, the actual figure is probably much higher.

Exposure to workplace violence can lead to:

  • ineffective patient care 
  • psychological distress
  • job dissatisfaction
  • absenteeism
  • high turnover
  • higher costs

It’s apparent that the time is right to develop new requirements addressing workplace violence. After an extensive literature and public field review, we are pleased to announce that The Joint Commission is introducing new workplace violence requirements, effective January 1, 2022. They will be applicable to hospitals and critical access hospitals.

The requirements will provide a framework to guide hospitals and critical access hospitals in: 

  • developing strong workplace violence prevention systems
  • defining workplace violence 
  • establishing leadership oversight for the program
  • fine-tuning policies and procedures
  • creating easy and accessible reporting systems
  • analyzing, tracking and trending data
  • crafting post-incident strategies
  • staff training and education to decrease workplace violence

Defining Workplace Violence
One of the overarching goals of the new requirements is to actually define workplace violence. 

The accreditation manual’s glossary now defines workplace violence as “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.”

Managing Safety & Security Risks 
Performing a worksite analysis is a successful approach to evaluating the effectiveness of a workplace violence prevention program. Environmental modifications are then implemented based on findings from the analysis.

Annual worksite analysis related to a hospital’s workplace violence prevention program is required and should include:

  • investigation of workplace violence incidents
  • analysis of how the program’s policies/procedures/training/environmental design reflect best practices

Hospitals and critical access hospitals need to take actions to mitigate or resolve the workplace violence safety and security risks based upon findings from the analysis. It’s also essential that hospitals review their policies to ensure consistency with leading practices.

Environmental Monitoring
Just as hospitals must continually monitor their environment for fire safety and equipment problems, they also need to continually monitor, internally report and investigate incidents related to workplace violence.

This monitoring will allow hospitals and critical access hospitals to identify risk factors in vulnerable areas and implement:

  • environmental controls
  • education
  • other mitigation strategies

Ongoing data collection can identify:

  • trends
  • patterns
  • program gaps
  • effectiveness of the program

Incident reports should be shared with staff in quality assessment, improvement, or other functions as well as to the designated leader of the workplace violence reduction effort. A summary of such incidents may also be shared with the person designated to coordinate safety management activities.

Appropriate legal processes must be followed to ensure confidentiality but also must not impede on the opportunity to improve care, treatment and services.

Staff Education & Training
Recognition of what constitutes workplace violence begins with awareness of the different types of physical and nonphysical acts and threats of workplace violence. Additionally, education and training should focus on:

  • what constitutes workplace violence 
  • roles and responsibilities of leadership, clinical staff, security personnel, and external law enforcement 
  • de-escalation
  • nonphysical intervention skills
  • physical intervention techniques
  • response to emergency incidents 
  • reporting process for workplace violence incidents

Hospitals determine what type of training and education is appropriate for employees, based on their role. Training and education should occur at:

  • initial hire
  • annually
  • whenever changes occur to the workplace violence prevention program

Safety Culture
Leadership is responsible for creating and maintaining a culture of safety throughout the hospital. 

This may start with identifying an individual to be accountable for an organization’s workplace violence prevention program, which establishes clear lines of accountability. Per the new requirement, hospital workplace violence prevention programs must be led by a designated individual and developed by a multi-disciplinary team to include: 

  • policies and procedures to prevent and respond to workplace violence 
  • incident reporting process 
  • follow up and support to victims and witnesses affected by workplace violence, including trauma and psychological counseling, if necessary 
  • reporting of workplace violence incidents to the governing body

Having policies and a standardized process to report and follow up on events or near-misses decreases variation in the program. Data collection and simple, accessible reporting structures show commitment to providing a safe and secure work environment. Regularly reporting incidents and trends to the governing body promotes transparency and further establishes accountability for the program.

For more information on the new requirements, view the R3 Report and the Workplace Violence Prevention Compendium of Resources

Health care workers and social workers should not be five times as likely to experience workplace violence on the job and these requirements may be a first step in reversing that trend.


Antigone Kokalias, MBA, MSN, RN, is a Project Director – Clinical in the Department of Standards and Survey Methods. She has close to 20 years of nursing experience in critical care, hospital operations, project management, strategic planning and health care design.