Is your hospital prepared if a crime should occur on your campus?

Sentinel Event Alert focuses on violence in health care settings

A couple enters the emergency department — the wife with a black eye and fresh bruises on her arm. She tells registration she fell down the stairs. A man hooked on drugs comes to the emergency department with a gunshot wound; he clearly is still "under the influence" and is showing signs of aggression and paranoia. A woman delivering her baby at the hospital seems afraid that her boyfriend may visit her. Such situations could, and should, signal at least the possibility of a situation that could escalate into violence or other crime. All hospital staff should be able to spot "red flags" and alert the organization's security department. Identification is the first step in mitigating or de-escalating violence in health care settings, says Joe Bellino, CHPA, HEM, president of the International Association for Healthcare Security & Safety (IAHSS) and system executive, security at Memorial Hermann in Houston, TX.

According to The Joint Commission's latest Sentinel Event Alert, violence in hospitals is on the rise, and due to under-reporting, the only data the organization has on such occurrences may not reflect the true numbers of crimes committed. (To read the entire alert, go to http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_45.htm for the entire alert.)

The alert — "Preventing violence in the health care setting" — focuses on assault, rape, and homicide of patients and visitors at the hands of staff, visitors, other patients, and "intruders to the institution." Including those three categories of crime, The Joint Commission's Sentinel Event Database holds 256 reports since 1995, with a caveat that those numbers "are believed to be significantly below the actual number of incidents due to the belief that there is significant under-reporting of violent crimes in health care institutions."

Michael R. Parks, director of security at Mercy Medical Center in Baltimore, says he was not surprised by the issuance of the alert. "I'm not surprised at all. In fact we, those of us who are in the business of security for health care organizations, have seen an increase in the years of violent acts being committed in the hospital settings and health care settings. This is not news to us," he says.

"I don't know where [The Joint Commission has] been for so long," says Bellino, in response to the alert.

"OSHA addressed this issue with workplace violence standards back in the 90s, [which] was promulgated by health care workers in California being assaulted and killed. So they put the workplace violence standard into place and then we, for lack of better terms, jumped on the bandwagon to address it," he says.

He says he and his peers were disappointed when The Joint Commission "18 months ago merged the safety chapter and the security chapter... Many of us felt they should have never combined it, because I feel it diminished security. Although I do agree that safety and security go hand in hand."

He does fear that the alert makes the problem seem more rampant than it is. "There's always crime, don't get me wrong. But it's not as bad as other areas of industry and business; we do have competent, highly professional security people and security officers doing their jobs," he says.

He points to the data provided in the alert: "Since 2004, the Sentinel Event Database indicates significant increases in reports of assault, rape, and homicide, with the greatest number of reports in the last three years: 36 incidents in 2007, 41 in 2008, and 33 in 2009."

"I think about the millions and millions of people that are being treated every day. One could argue that one [criminal incident] is too many, and I agree with that philosophy. I never want to have any of that happen at any of my facilities or any other hospital facilities," he says. "But 36 events over a three-year period out of [about 6,000 hospitals in the United States] doesn't indicate to me a rampant, aggressive-type crime spree. It's bad; don't get me wrong. I'm not saying it's not bad. But we have to deal with it, and I think we are. I think we're doing a very good job at it."

Ken Kizer, MD, MPH, consultant, has a unique perspective. Founding president of the National Quality Forum and responsible for introducing the first "never event" in 2001, Kizer sees a parallel between the recognition of violence in the health care setting to the beginnings of the patient safety movement in the mid-1990s. Kizer, who has researched and written about serial murders committed in health care settings, says, "By and large, I think many hospital administrators — not just directors, but the whole management team — do not know and just don't understand that these events do occur, even though as we pointed out [in the articles I have written] that there's been dozens of them over recent years. When they read about them, they, or at least the response I've gotten from them and colleagues, is 'Well that's there. That couldn't happen here.'

"I think, one, there's a lot of lack of knowledge or awareness that these events occur, and I think among those who may have read about it or heard about it, there is a lot of resistance to accepting the idea that it is significant," he says.

Kizer says health care had the same response — "Those things happen, but not at our hospital" — when the patient safety movement, and issues such as medication errors and wrong-site surgeries, started about a decade ago. "The first thing is for people just to understand that these events occur, and they can occur anywhere. Just to have that mindset, being open to the possibility, as disturbing as that might be, but just to recognize that it can happen."

Joint Commission requirements

Identifying and mitigating or preventing violence from occurring is a hospital's duty; just as a hospital is responsible for treating its patients, it is responsible for keeping those patients and its staff safe.

Parks says to fulfill Joint Commission standards a hospital should:

  • "identify safety and security risks associated with the environment of care, and these are risks that are identified from internal sources such as ongoing monitoring of the environment, results of root-cause analyses, results of annual proactive risk assessments of high-risk processes, and also from credible external sources such as Sentinel Event Alerts and from law enforcement"
  • take "actions to minimize or eliminate identified safety and security risks in the physical environment"
  • identify "individuals entering its facilities... and determine which of those individuals would actually require identification"
  • control "access to and from areas it identifies as security-sensitive"
  • implement "written procedures to follow in the event of a security incident including infant abductions or pediatric abductions"
  • follow identified procedures when a security incident occurs.

"A strong and robust security management plan is absolutely paramount, and that plan needs to be an ongoing process where we keep trying to determine whether or not that plan meets the needs of the organization at that time. And if not, then we need to make adjustments. But then annually we review that plan for its effectiveness to make sure it's doing as we anticipated it to be doing," Parks says. In that plan, you want to define access control policies, workplace violence practices, and police presence in your facilities.

The first step in creating a plan and corresponding policies is identifying the crime trends in your locale, he says. Experts agree that the most notable areas for risk of criminal activity include: the emergency department; pediatric units or hospitals; labor and delivery and any units that house mother and baby; and the pharmacy. To understand local crime trends, it's crucial you build a relationship with your local police department or sheriff's office and include them in your annual risk assessment or vulnerability analysis.

Kristen Kenst, JD, MBA, manager of risk services at Community Mercy Health Partners in Springfield, OH, says one method to assess crime rates and statistics is to use the hospital's mortality and morbidity committee to review incidents that happen within the hospital. Last year, along with her manager of security, she met with the chief of police and members of the county sheriff's department "on the ways we could further the relationship we had with them." Being new to the area, she wanted to get a better sense of the trends in the community "and how we could best prepare to handle that from a hospital risk standpoint."

Following that conversation, a policeman came to the facility to hold a nonviolent crime intervention training program for staff in security, the ED, and the birthing center. After training, one hospital conducted a "code silver" drill, simulating a hostage situation to gauge the training's effectiveness.

For Community Mercy, the local police department's special operations team participated in the code silver drill. Now, almost a year later, Kenst is preparing to do another drill "to again assess the current state of our community, see what's changed over the last year, determine whether or not we need to consider new or additional resources, and then see if there's any opportunities that we can explore that will further strengthen our relationship with local law enforcement."

One trend the team uncovered from conversations with police was an uptick in drug-related crimes and break-ins resulting from the down economy. For drug-related crimes, understanding how to treat those patients became an initiative, Kenst says.

"It's about equipping the emergency department with the tools it needs — for example, the nonviolent crisis intervention training — to be able to handle those patients who come in and are coming down [from a drug] or still on a high, to work with them and create a safe environment, not only for the patient but for the other people [in the ED] as well." Drug-related crimes also present other situations that could easily escalate. For example, often a perpetrator or a victim will come into the hospital with the police who are doing an investigation. The family of the opposing side often comes into the ED to hear what is said in the conversation with police. Mitigating situations like these became priority. To address the increase in break-ins, the organization stepped up security guard rounding in the hospital and its parking lots.

Bellino recalls working at a hospital that was seeing a number of break-ins. Security ultimately caught the perpetrators. "The word on the street was, 'Don't go that hospital. They have a good security department. They have cameras everywhere. You'll get caught. You'll go to jail.'

"Our crime rate went down exponentially. You want to publicize your successes. A lot of people are afraid to do that, but I think when you can use security as a marketing tool — you have a safe and secure environment that has a great balance between customer service and the enforcement model of security — you really can use that to your advantage."

Bellino also suggests using websites that will report all the crimes committed in your area, such as www.spotcrime.com, and following guidelines, such as ones developed by IAHSS.

Engaging staff housewide

Parks says it's also essential to communicate information about trends to staff. For example, he says, crime numbers tend to increase in the winter, especially around Christmas. "You should alert your staff about the potential of becoming a victim of an assault or worse, and things that they can do to reduce their chances of becoming a victim. You alert them either through crime prevention bulletins or by becoming involved in a patient safety fair at your hospital."

Bellino suggests talking to staff about de-escalating situations that could result in violence. "Everywhere I've been where we've worked with the psychiatric staff, nursing, security, we've decreased violence."

Executive director, security and parking, at UPMC Presbyterian Shadyside and Magee-Womens Hospital of UPMC, Don Charley, says he runs an annual computer-based training session with staff, as well as alerting them through in-house newsletters about security matters they should be aware of.

At Mercy Medical, Parks says four staff employees are certified instructors in a program offered by the Crime Prevention Institute. "We're training a cross-section of security emergency room clinical staff, receptionists who deal with patients and visitors coming in, the people who work in the field of registration, and social work on how to deal with preventing and intervening in crisis situations," Parks says. The program is held at least twice a year by the Crisis Prevention Institute "to help our staff identify when someone is in crisis and then how to minimize the risk of that escalating and then it becoming an act of violence. That's been very helpful for us."

He also communicates regularly with risk managers and senior leadership because they "can make recommendations about changes to our environment" and perhaps get financial help to fund such changes. Bellino says in every institution he has worked throughout his career, he has built a strong relationship with the quality improvement directors and has sat on the quality council, where he can speak to board members. He encourages his staff to familiarize themselves with all staff members. The philosophy that security is the security department's problem is a broken one, he says. "Security is everybody's issue."

How can you work with and help your security director? Charley says his hospitals' quality improvement team has helped him understand how the patient population is changing. For example, one hospital in the multi-hospital system closed, and another facility was handling the majority of the overflow in its ED. QI, he says, "helps us understand that trending, those kinds of statistics, how things are changing."

Parks recommends networking with other hospitals in building your security management plan. "Why reinvent the wheel if there are other plans out there that will fit your needs? You just have to tweak it to your specific campus."

[For more information contact:

Michael Park, Director of Security, Mercy Medical Center, 301 Saint Paul Place, Baltimore, MD 21202-2165. Phone: (410) 332-9159. E-mail: mparks2@mdmercy.com.]