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With violent incidents on the rise in the hospital setting, patient access departments are taking steps to protect registration staff, such as providing de-escalation training. Other approaches include:
A man entered a hospital outpatient center by shooting down the door, then headed to the cardiac ICU.
“He committed suicide when the SWAT team arrived, but had held several nurses hostage for a few minutes before the situation was handled by police,” says Sara Smiley, who was the hospital’s patient access director at the time.
Around the same period, a patient set himself on fire at the ED registration desk.
“Patient access staff were obviously affected by these incidents,” Smiley recalls.
Since the hospital provided both adult and pediatric psychiatric services, many staff were certified to provide Critical Incident Stress Management training.
“This was vital after the gun violence incident,” Smiley says.
Understandably, patient access employees were worried about their safety. Some asked for additional protections at registration areas, such as bulletproof glass.
“Many changes were put into place immediately,” Smiley remembers. “Panic” buttons were added to phones, so registrars could alert security of a problem within seconds.
“The hardest challenge for patient access is trying to balance providing superior customer service with ensuring safety,” says Smiley, currently a process improvement consultant for Experian Health.
Many hospitals have decentralized registration, which means there are many entrances — all open to the public.
“This was the case with our facility. We had many public entry points, and not all of them were staffed with security guards,” Smiley says, noting the hospital closed several entrances after the violent incidents. “All patients and visitors now enter through one of a few doors, all of which have security staff.”
During her frequent site visits, Smiley often is surprised at the lack of security in place.
“It’s kind of surprising how many hospitals just point us in the right direction, and that’s it,” she says. “There is a huge variety in the levels of security hospitals provide. There doesn’t seem to be a standard.”
Violence in hospitals clearly is increasing nationwide.
“Registration areas are no exception. These front-line personnel often get the brunt of a patient’s, family’s, or friend’s frustration,” says Richard D. Roebuck Jr., BAAS, CHPA, MPO, captain of police for the Dallas County Hospital District Police Department, based at Parkland Health & Hospital System.
Roebuck says threats of violence and physical assaults are a concern that demand “vigilance, training, and sensitivity. Registrars are in a unique position to encounter these situations.” Already-anxious ED patients lacking proper patient identification needed for registration sometimes take out their frustration on the person in front of them.
“Often the customer lashes out in an attempt to move the process faster,” Roebuck says.
The registrar’s three-fold challenge is to stay calm while providing excellent service, always with their own safety top of mind.
“It is a good idea to train all front-line employees on how to remove themselves from a volatile situation and not allow it to escalate to threats of violence or actual violence,” Roebuck says. (See related story on de-escalation training below.)
Roebuck says de-escalation training “is always a good idea. It puts a few tools in the registrar’s tool box on how to handle unruly customers, reducing the potential for violence or assaults.”
Mary Lee DeCoster, a Phoenix-based revenue cycle consultant, offers these suggestions for patient access leaders:
Organizational development, education, security, social services, pastoral care, and compliance are good contacts.
“Training topics can be modified to fit the agenda and available time,” DeCoster says.
Some examples include safety awareness, recognizing when a patient is agitated, how to defuse a tense situation, hospital policies involving active shooters, and diversity training.
Registrars can spend a few minutes in a nearby conference room, break room, a leader’s office, or a nearby restroom, for instance.
“Co-workers can move in to partner with the affected registrar, and function as a third party to defuse rising tensions,” DeCoster suggests.
A colleague can interrupt the registration interview in several ways, based on personal observations of the ongoing or escalating conflict. Some examples: “Hello, my name is Mary, may I offer assistance?” “It sounds like I might be able to help, if you will allow me to do so?” “Would you like something to drink? I can provide you with some water.” “I work with Mary, and believe I can help resolve this issue.”
“The words used should reflect respect for the coworker, while inviting the customer to turn their attention to them for additional support,” DeCoster says.