VHA tackles risks of HC violence

‘It can be a very rapid progression.’

There is predictability in “unpredictable” violence. Clear warning signs emerge as a patient progresses from unhappy to agitated to aggressive, and health care workers can learn to defuse the situation before an incident turns violent.

That is the essence of the Veterans Health Administration’s extensive violence prevention program, which is the focus of increased attention and resources.

Acts of violence that plague health care don’t typically stem from a thought-out plan. They just erupt, says Lynn M. Van Male, PhD, director of the VHA’s Behavioral Threat Management Program in Portland, OR.

“It goes from grievance to ideation,” she says. “[Patients] get the idea that violence is the way to solve the problem. Then they breach, they start breaching protocol, etiquette and physical barriers. Then they attack. It can be a very rapid progression. The good news is that it can be turned around at any stage.”

Employees need training to identify the warning signs and learn how to respond, Van Male says. The VHA is revamping its tracking of sexual assaults and other violent assaults, risk assessments and security precautions to comply with the 2012 law, the Honoring America’s Veterans and Caring for Camp Lejeune Families Act.

Every VHA facility must complete a Workplace Behavior Risk Assessment tool, appoint a Disruptive Behavior Committee to respond to the risks, and report violent incidents.

GAO: Many rapes not reported

Merely having a policy isn’t enough. In 2011, a General Accounting Office (GAO) report criticized the VHA for gaps in reporting, patient screening and security. The GAO found reports of 284 sexual assaults between January 2007 and July 2010 at five VA medical facilities, including 67 allegations of rape. Two-thirds of the rape cases were not reported to the VA Office of Inspector General and most were not reported to VHA leadership, as required, the GAO said.

The GAO also found some VHA alarms that didn’t function properly, understaffing of VHA police, and inadequate information on the past legal history of patients. Of the rape allegations, 25 were patient on patient assaults, 13 were employee on patient, and one was patient on employee. There were also 83 allegations of patients inappropriately touching employees.1

Amid broader concerns about sexual assaults in the military, the report put the VHA under the spotlight.

“All veterans and employees need to be treated with the utmost respect in every facility,” Richard L. Eubank, national commander of the Veterans of Foreign Wars, a retired Marine and Vietnam combat veteran from Eugene, OR, said when the report became public. “This is a zero tolerance issue, and nothing less is acceptable to the VFW.”

Many of the groping or touching incidents involve patients who have dementia, psychosis, or other cognitive deficits, says Van Male. The VHA has streamlined its reporting to help address the incidents, she says. “VHA has required all sexual assaults, alleged or suspected, be reported immediately to the police and within two hours the police have to report that to the integrated operation center,” she says.

Task force targets high risks

The centerpiece of a violence prevention program is a multidisciplinary task force, says David Drummond, PhD, associate professor of psychiatry at Oregon Health & Sciences University in Portland, who helped design the VHA violence prevention program at the Portland VA Medical Center.

The task force is led by a senior clinician, but includes security, legal counsel, and a union representative or frontline employee. Employees who feel threatened by a particular patient can bring their concerns to the Disruptive Behavior Committee. Similarly, an Employee Threat Assessment Team looks into concerns about co-workers.

“It’s their task to decide what risk, if any, is posed by an individual and what mitigation strategies if any are appropriate to be able to manage that risk,” says Van Male.

Each VA hospital must conduct a workplace behavioral risk assessment to determine the high-risk areas. Common targets: the emergency department, mental health units, and long-term care.

“We want our policies about mandatory training to align with the need in the workplace,” she says.

Violent incidents — shouting, physical aggression, even shootings — can seem to come as suddenly as a lightning strike. A brooding patient strikes out or a visitor arrives with a score to settle. But training can help health care workers identify the warning signs. So far, the VHA has trained more than 22,000 employees in violence prevention.

The skills begin with an enhanced sense of customer service, explain Drummond and Van Male. A patient may be upset over a perceived slight, or a prolonged wait, or a visitor may become angry when their loved one’s condition deteriorates.

The goal is to deescalate the situation. “They are expressing a grievance in an unacceptable manner. Maybe they have a psychiatric disturbance. Maybe they have chronic pain. Maybe the rest of their life is falling apart,” says Drummond.

“We would be able to say, ‘We want to get you the help you need. We’ll get you a different doctor. How about I hook you up with the psychiatric department and see if we can help you with your sleep problem and your depression?’ Sometimes that’s all it needed. They’re asking for help in a really bad way,” he says.

“A lot of times they’ll say, ‘You’re the first person who ever listened to me. No one has ever listened to me before,’” he says.

Flagging records prevents harm

What if you can’t diffuse the situation with some calm conversation? With role-playing techniques, the VHA trains health care workers to handle an aggressive patient and to protect themselves from physical harm.

Meanwhile, the VHA makes use of a “flagging” system pioneered by Drummond. A flag in electronic patient records identifies those few who have multiple violent outbursts. When they arrive in an outpatient clinic or emergency department, they receive expedited treatment – accompanied by preventive measures, such as the presence of a security guard.

The new measures led to a 92% reduction in violent incidents.2 “We virtually eradicated violence in this high risk group,” Drummond says.

The VHA continues to use the flagging system, as do some private hospitals. Reporting and tracking events is critical to the prevention of future incidents — and reporting is a focus of the 2012 directive.

“People go into health care because they care,” say Van Male. “And we don’t want them to be afraid to come to their jobs and care for people.”


  1. U.S. Government Accountability Office. VA Healthcare: Actions needed to prevent sexual assaults and other safety incidents. June 2011; GAO-11-530. Available at www.gao.gov/assets/320/319342.pdf.
  2. Drummond DJ, Sparr LF, and Gordon GH. Hospital violence reduction among high-risk patients. JAMA 1989; 261:2531-2534.