Standards Related Information

Answer: The Joint Commission (TJC) does not currently have standards specific to workplace violence. However, several standards relate directly or indirectly to its prevention.

As described in the Environment of Care^® (EC) chapter in the Comprehensive Accreditation Manual for Hospitals (CAMH): Organizations are required to have processes for managing, evaluating, monitoring, analyzing and improving the safety and security of its environment. These standards include EC.01.01.01, EC.04.01.01, EC.04.01.03, EC.04.01.05, etc.

Organizations are required to comply with local, state, and federal laws, rules and regulations per LD.04.01.01 EP 2. The Occupational Safety and Health Administration (OSHA) is the federal agency that requires employers to maintain a safe working environment for their staff.

The organization should consider conducting a risk assessment, per EC.02.01.01 EP 1, specific to workplace violence risks within the organization. The risk assessment should be conducted by the most appropriate persons available to your organization. It is usually a multidisciplinary team event, often led by the head of security and including staff from human resources, medical officers, nursing, and representatives from the behavioral sciences, security/law enforcement, labor union(s), known high-risk workplaces, employee education (e.g. training), patient advocacy, and legal counsel. The risk assessment process should encompass resources for various types of workplace violence—for example, those involving patient/visitor-to-worker, disgruntled employees, staff disputes and domestic violence situations, as well as scenarios that may be common or reasonably possible (such as if multiple victims involved with a rival gang shooting go to the same trauma center). A defensible organizational policy should be generated, and the organization is expected to implement and adhere to its policy.

Per EC.04.01.01, EC.04.01.03 and EC.04.01.05: Risk assessment and implementation results are to be reported to the multi-disciplinary environment of care committee, and adjustments to the implemented plan or process are to be made as needed.

Other standards that relate to preventing workplace violence include:

PC.01.02.13 in the “Provision of Care, Treatment, and Services” (PC) chapter, which requires that patients receiving treatment for emotional or behavioral disorders receive an assessment that includes “maladaptive or other behaviors that create a risk to patients or others.”

In the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC), the “Care, Treatment, and Services” (CTS) chapter that requires organizations to have a screening procedure for the identification of risk of imminent harm to self or others (standard CTS 02.01.01) and that a preliminary plan of care, treatment, or services is developed to address safety issues (Standard CTS 01.03.01).

A standard in the “Rights and Responsibilities of the Individual” chapter (RI 01.06.03), which requires that the patient has the right to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse.

CAMH standard LD.03.01.01, which requires that leaders create and maintain a culture of safety and quality throughout the hospital. This standard includes elements of performance that require leaders to develop a code of conduct that separates acceptable behavior from those that undermine a culture of safety. This standard also requires leaders to create and implement a process for managing behaviors that undermine a culture of safety.

Answer: Life Safety Code and clinical surveyors discuss workplace violence and other security-related issues during the building tour, tracer activity and Environment of Care and Emergency Management sessions.

Under EC.01.01.01, EP 4, the organization is responsible for the security of everyone who enters the hospital. As a result, the surveyors will ask hospital representatives about the process to accomplish this goal.
Under EC.02.01.01, EP 8, the hospital is required to control access to and from security sensitive areas, and identify mitigating factors that have been implemented.

In the emergency department, surveyors may ask if organizations have conducted a risk assessment for workplace violence. Organizations may refer to externally-developed risk assessment tools, for example, the tool developed by the Emergency Nurses’ Association entitled Workplace Violence Toolkit, or the checklist developed by OSHA for full hospital workplace violence risk assessment in the Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (OSHA 3148).

Another consideration is whether the organization has developed an active shooter response plan and/or conducted an exercise with local law enforcement. Having regular meetings and implementing training with local law enforcement leadership can be very helpful. The relationship with local law enforcement is especially critical when it comes to forensic patients (patients in legal custody of law enforcement).

Other questions may relate to security staff. For example, does your state require licensure of security officers? Is your organization’s security supported by employed staff or contracted services? Membership in the International Association for Healthcare Security and Safety (IAHSS) or other professional membership groups will assist hospitals with keeping up to date with recommended guidelines to prevent workplace violence.

To address an identified risk of an active shooter, terrorist attack, or civil unrest, organizations are urged to elevate response through emergency management planning, particularly in terms of prioritizing risk (EM.01.01.01, EP 3), coordinating with community incident command (EM.01.01.01, EP 7), and ensuring security and safety precautions (EM.02.02.05, EPs 1-10).

Whether or not an event occurred, surveyors may want to know if the organization implemented its process to identify safety and security risks, took action to minimize or eliminate safety and security risks in the environment, and followed its identified procedures. For example, has the organization incorporated lessons learned from emergency management drills or actual events?

Answer: Yes! A sentinel event is a patient safety event that is not primarily related to the natural course of the patient’s illness or underlying condition, affects a patient and results in any of the following:

• Death
• Permanent harm
• Severe temporary harm*

An event is also considered sentinel if it is one of the following:

• Rape or assault leading to death, permanent harm, or severe temporary harm, or homicide of any patient receiving care, treatment, and services while on site at the hospital†
• Rape or assault leading to death, permanent harm, or severe temporary harm, or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital

Although not required, hospitals are strongly encouraged to report to The Joint Commission any patient safety event that meets the Joint Commission definition of a sentinel event—in order to partner to identify root causes, improve systems, and prevent further harm.

The Joint Commission’s Sentinel Event Policy is designed to operate in conjunction with its Patient Safety Systems Chapter and the National Patient Safety Foundation’s RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. The RCA2 provides methodologies and techniques that an organization or individuals can credibly and effectively use to prioritize the events, hazards, and vulnerabilities in their systems to understand what and why the event occurred, and how to prevent future events.

• Verbal abuse
• Threatening, intimidating or humiliating behaviors—both verbal and nonverbal
• Work interference – sabotage – which prevents work from getting done¹

A standard in the “Rights and Responsibilities of the Individual” chapter (RI.01.06.03) provides for the patient’s “right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse”.²

The Joint Commission’s 2012 publication Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation describes civility as a necessary precursor for a safety culture in which care teams and patients must be treated with respect.³

Leaders especially have a critical role in battling bullying behaviors, including:

• Establishing a safety system and culture that does not tolerate bullying behaviors
• Confronting bullies and supporting the targets of bullying¹

• Educating all team members – both physicians and non-physician staff – on appropriate professional behavior defined by the organization’s code of conduct. The code and education should emphasize respect. Include training in basic business etiquette (particularly phone skills) and people skills.
• Holding all team members accountable for modeling desirable behaviors, and enforcing the code consistently and equitably among all staff regardless of seniority or clinical discipline.
• Develop and implement policies and procedures/processes appropriate for the organization that address:
• “Zero tolerance” for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Incorporate the zero-tolerance policy into medical staff bylaws and employment agreements as well as administrative policies.
• Medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a health care organization. These should be complementary and supportive of policies present in the organization for non-physician staff.
• Reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive and other unprofessional behavior. Non-retaliation clauses should be included in all policy statements that address disruptive behaviors.
• Responding to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors. The response should include hearing and empathizing with their concerns, thanking them for sharing those concerns, and apologizing.
How and when to begin disciplinary actions (such as suspension, termination, loss of clinical privileges, reports to professional licensure bodies).

 

* Severe temporary harm is critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition. Adapted from: Throop C, Stockmeier C. The HPI SEC & SSER Patient Safety Measurement System for Healthcare. 2011 May. Accessed Aug 12, 2014. http://hpiresults.com/publications/HPI White Paper - SEC SSER Measurement System REV 2 MAY 2010.pdf. (Definition of Sentinel Event E-dition July 1, 2017, Release)

† Sexual abuse/assault (including rape) as a sentinel event is defined as nonconsensual sexual contact involving a patient and another patient, staff member, or other perpetrator while being treated or on the premises of the hospital, including oral, vaginal, or anal penetration or fondling of the patient’s sex organ(s) by another individual’s hand, sex organ, or object. One or more of the following must be present to determine that it is a sentinel event:

• Any staff-witnessed sexual contact as described above
• Admission by the perpetrator that sexual contact, as described above, occurred on the premises
• Sufficient clinical evidence obtained by the hospital to support allegations of unconsented sexual contact

1. The Joint Commission. Bullying has no place in health care. Quick Safety. Oakbrook Terrace (IL): The Joint Commission; 2016 June;24
2. The Joint Commission. 2017 Comprehensive Accreditation Manual for Hospitals, Update 1. Oak Brook (IL): Joint Commission Resources; 2017.
3. The Joint Commission. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation. Oakbrook Terrace (IL): The Joint Commission; 2012.
4. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. Oakbrook Terrace (IL) The Joint Commission; 2008 Jul 9;40.