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Violence on the rise, more attention needed
Health care facilities are being confronted with steadily increasing rates of crime, including assault, rape and murder, according to a new report from The Joint Commission (TJC) in Oakbrook Terrace, IL. Providers must devote more attention to protecting patients, visitors, and staff from violence, the report says.
The Sentinel Event Alert urges greater attention to the issue of violence and to controlling access to facilities to protect patients, staff, and visitors, noting that assault, rape, and homicide are consistently in the top 10 types of serious events reported to TJC. The alert cautions that the actual number of violent incidents is significantly under-reported and advises organizations to mandate the reporting of all real or perceived threats.
To prevent violence in health care facilities, the alert newsletter suggests that facilities take a series of 13 specific steps, including the following:
Evaluate the facility's risk for violence by examining the campus, reviewing crime rates, and surveying employees about their perceptions of risk.
Take extra security precautions in the emergency department, especially if the facility is in an area with a high crime rate or gang activity. Precautions might include uniformed security guards, scanning people entering the building for weapons, and inspecting bags.
Conduct thorough background checks of prospective employees and staff.
Report crime to law enforcement.
Standards apply to violence
In addition to the specific recommendations contained in the alert, TJC urges hospitals to comply with the requirements described in its accreditation standards to prevent violence. The standards require accredited health care facilities to have a security plan, as well as conduct violence risk assessments, develop strategies to prevent violence, and have a response plan when a violent episode occurs.
TJC standards also are clear that patients have a right to be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse. While there are many different types of crimes and instances of violence that take place in the health care setting, the alert specifically addresses assault, rape, or homicide of patients and visitors perpetrated by staff, visitors, other patients, and intruders to the institution. TJC's Sentinel Event Database includes a category of assault, rape, and homicide (combined), with 256 reports since 1995 – numbers that 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, the report says. (For the full text of the alert, go to http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_45.htm )
"While not an accurate measure of incidence, it is noteworthy that the assault, rape, and homicide category of sentinel events is consistently among the top 10 types of sentinel events reported to The Joint Commission," the report says. "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."
Top causes identified
The report says the following contributing causal factors were identified most frequently over the last five years:
Leadership Noted in 62% of the events, most notably problems in the areas of policy and procedure development and implementation.
Human resources-related factors Noted in 60% of the events, such as the increased need for staff education and competency assessment processes.
Assessment Noted in 58% of the events, particularly in the areas of flawed patient observation protocols, inadequate assessment tools, and lack of psychiatric assessment.
Communication failures Noted in 53% of the events, both among staff and with patients and family.
Physical environment Noted in 36% of the events, in terms of deficiencies in general safety of the environment and security procedures and practices.
Problems in care planning, information management, and patient education These causal factors were identified less frequently.
Must improve reporting
Hospitals have long tried to keep incidents of violence quiet, says Tim Dimoff, a former police detective and SWAT team member who founded SACS Consulting, a security services company in Akron, OH. They fear that patients will be driven to competing hospitals if word gets out about violence in the facility, Dimoff says.
"I do see hospitals recognizing that they need to be more proactive in preventing violence, rather than just hiding it," he says. "In the last five years, I've seen much more activity with hospitals conducting assessments, running drills and table-top exercises, planning for potential violence. Hospitals are finally realizing they need to have an organized system for preventing violence."
Risk managers should start by conducting an assessment of the hospital's security and vulnerability, Dimoff says. Determine the strengths and weaknesses of the facility, he says.
In addition, the hospital must train physicians, nurses, and other staff in how to deal with threats of violence, he says. Clinicians and other staff usually are the first to deal with a person who shows signs of potential violence, so they should know how to recognize those signs, how to de-escalate the situation, and how to respond if the person does get violent, he says.
Train staff to de-escalate
The hospital also must send the message to the community, and individuals in the hospital, that violence will not be tolerated, and that it will be met with swift and decisive action, he says. That doesn't mean turning the hospital into an armed camp or having guards run roughshod over people, but it does mean having trained security personnel respond quickly, he says. For instance, Dimoff says it can be a good idea for staff to call security when they are about to confront a person they suspect may get violent.
"If the nurse is about to give some bad news to someone who already seems aggressive, there's nothing wrong with having a security guard stand nearby," he says. "It's not overbearing, but it gives the message that you're ready if the person decides to get violent and that it won't be tolerated."
The assistance doesn't have to come from a security guard, Dimoff explains. Another staff person can discourage violence simply by being present, he says.
"Why, as a nurse, would you go in a room alone with a person who is very upset and encounter him one-on-one?" he says. "You can go in the room to encounter the individual, but you have another person standing [in] the doorway. That is a de-escalation move. The person sees that there is another person watching and listening, and it discourages violence."
Staff also must be trained to call for help at the first sign of aggression, rather than brushing it aside and moving on. Too often, nurses let the person act out aggressively without calling for help, and each instance becomes more serious. By the time the nurse is concerned enough to call for assistance, the person has become violent, he says.
"That's the opposite of what we want to see with de-escalation," Dimoff says. "The longer you wait, the harder it is to stop it."
Code Orange brings help
Gang-related violence has become a bigger concern in recent years for Georgene Saliba, RN, HRM, CPHRM, FASHRM, administrator for risk management and patient safety at Lehigh Valley Hospital & Health Network in Allentown, PA, and 2009 president of the American Society for Healthcare Risk Management (ASHRM) in Chicago. Lehigh Valley has recently improved its security by taking the steps outlined in the TJC alert, and she says other risk managers should take the issue seriously.
"Clearly, violence has increased," Saliba says. "The Joint Commission is trying to provide hospitals with guidance, and we should take advantage of what they're offering. They have seen the increase in violence in their own statistics, and I'm sure most facilities could look at their own data and find that you're seeing more violence than before."
Hospitals are always at risk of violence, because the doors are open to anyone who wants to come in, notes Gerald Kresge, CHS III, director of security at Lehigh Valley. And the nature of health care also means that people will be put in situations that may push them beyond their capacity for self-control, he says.
"A lot of times we think in terms of violence coming from the drug user or the gang member in the emergency room, and we build almost all of our plan around that kind of scenario. But what really happens in a hospital is that the person who was just told his child died can act out against staff, or the family member who is distraught about a loved one in surgery," Kresge says. "Remember that a person can be the most calm, level-headed, decent citizen, but if you call him at 4 a.m. and tell him his son was in an accident, that's not who shows up at the hospital. The person who shows up is scared, angry, anxious, and they can act out in unexpected ways. That is extremely dangerous if you don't handle that well."
Kresge says the current economic situation only increases the risk of violence, as many people already are stressed before their experience at the hospital.
One of Lehigh Valley's efforts is a "Code Orange" program, in which staff can call for help from other staff who are trained in de-escalation. Staff undergo a two-day program in verbal and physical de-escalation techniques. When the Code Orange call goes out, a minimum of five people respond, Kresge says.
Lehigh Valley's work in reducing violence has paid off. Kresge tracks intervention injuries, or those that occur when staff have to intervene with a violent patient, and the figures have dropped off sharply after the security assessment and training programs.
"We've gone three or four years now without a serious intervention injury," he says. "That's attributable to training and intervening early."
Must focus on prevention
Tony Kubica, a founding partner of Kubica Laforest Consulting in Warwick, RI, was vice president of hospital services, with responsibility for security, at an urban hospital in the Northeast in the early 1990s, when a rise in violence prompted concern. Violence and other crime at the hospital became known in the community, and media outlets covered the problem extensively, he says. That forced the hospital to confront the problem.
"The Joint Commission's Sentinel Event Alert raises an important issue for hospital executives one that must be taken seriously," he says. "The alert outlines actions that should be taken to reduce the level of violence within and in the vicinity of the hospital."
Kubica says he learned that violence must be addressed as a primary concern for the hospital, not merely an afterthought. In particular, he says, someone in the organization must be solely responsible for security.
"Too often, this responsibility is tacked onto someone else's job duties, and it doesn't get the attention it deserves," Kubica says. "If you want to get serious about improving security and reducing violence, you have to devote the manpower and resources necessary for achieving that goal."
For more information on violence in hospitals, contact:
Tim Dimoff, President and CEO, SACS Consulting, Akron, OH. Telephone: (330) 255-1101. E-mail: email@example.com.
Georgene Saliba, RN, HRM, CPHRM, FASHRM, Administrator for Claims and Risk Management, Lehigh Valley Hospital & Health Network, Allentown, PA. Telephone: (610) 402-3005. E-mail: firstname.lastname@example.org.
Gerald Kresge, CHS III, Director of Security, Lehigh Valley Hospital & Health Network, Allentown, PA. Telephone: (610) 402-1077. E-mail: email@example.com.
Tony Kubica, Founding Partner, Kubica Laforest Consulting, Warwick, RI. Telephone: (401) 885-2011. E-mail: firstname.lastname@example.org.