Getting Survey-Ready in 2022: Workplace Violence

Sandy Garcia, RN, BSN, MBA, NHA, CJCP
Sandy Garcia, RN, BSN, MBA, NHA, CJCP
Associate Vice President Regulatory Affairs and Behavioral Health Services

I’m writing a series of blogs about getting survey-ready in 2022. Click here to read the first blog about 1135 blanket waivers. Stay tuned for future blogs on water management, resuscitation and performance improvement.

There has been a significant rise in healthcare workplace violence events across the country. Every regulatory body has a way to cite workplace violence, and if you are not paying attention to it, you are not doing your due diligence to make your staff feel safe.

In April 2021, the Workplace Violence Preventions for Health Care and Social Service Workers Act (H.R. 1195) was passed in the House of Representatives with a vote of 254 to 166. While this has only passed in the House and has yet to pass in the Senate, this legislation would direct the U.S. Secretary of Labor to issue an interim final standard requirement based on OSHA’s guidelines of 2015.

The proposed bill requires employers to provide annual training and education to employees, maintain detailed records of workplace violence risk, hazard assessments and violent incidents, and submit annual summaries of incidents to the Secretary of Labor.

This piece of legislation could be cumbersome for facilities in the future. It’s important that healthcare organizations start creating and implementing standards and processes now to address staff safety.

The Joint Commission manual’s glossary defines workplace violence as, “an act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression, threatening, intimidating, harassing, or humiliating words or actions bullying, sabotage sexual harassment.”

Looking at tools provided by The Joint Commission, whether your organization is surveyed by them or not, can offer suggestions to address workplace violence. If your organization is Joint Commission accredited, these standards already went into effect on January 1, 2022. Additionally, DNV and HFAP survey to those requirements, but they do not have specific prescriptive elements of performance like The Joint Commission.

Where Do You Start?

I recommend starting with a committee charter for workplace violence. This can be integrated into your Environment of Care Committee or where it makes sense for your organization. Committee leaders will need to decide who is going to take the lead and who will be members. You will want to involve security, imaging services, human resources, laboratory, emergency nursing and clinical engineering divisions. You will want to involve your medical staff in the process and include a medical staff designate – potentially your Chief of Staff or an emergency department physician.

What Are We Trying to Accomplish?

The charter itself will address what you are trying to accomplish. Designate both an individual and a team who is accountable to an organization’s workplace violence prevention program. Develop policies and standardized processes to report any of those events, including near-misses without variation. Hospitals will need to develop structures to promote safety and security of employees, patients and visitors to the hospital and to collect and analyze data to help ensure a safe and secure workplace environment. Establish a reporting mechanism to the CEO and Board of Directors, ensuring transparency. Be sure to define workplace violence, not only in your committee but in your policy as well.

The key takeaways are to:

  • Make sure to have a policy/plan in place,
  • Develop a reporting structure, and
  • Collect data.

Some organizations have decided to create a separate dashboard for workplace violence, however, that’s not necessary.* Every other regulatory body expects a policy. If you have another regulatory body and are close to being surveyed, I highly recommend that you develop a policy and plan to complete the worksite analysis and ensure your training has started.

We want to make sure leadership has oversight and they are supporting the policies and procedures for documentation and reporting. You will want to review standards relative to your policy and procedures.*

If you’re looking for a really effective tool, The Joint Commission has put out a step-by-step process that sets expectations and offers solutions to setting up your workplace violence program. It’s a great resource.

As required by The Joint Commission, start with a committee, develop a process and a policy, and conduct worksite analysis. I’ve seen language for HFAP, DNV and CMS as well.

How: A Sample Outline for Worksite Analysis

Below is a sample outline to use for worksite analysis.

The critical takeaway on this list is security site assessments. The last big piece is you will need to decide who is going to be the security lead for the assessment. Is that going to be an outside organization or do you have somebody from security on-site that can conduct and lead the site assessments? It is up to your organization to decide. As soon as possible, perform your site assessment.

You then want to create an education plan with trainings to communicate your policies to staff, have debriefs and allow critique of those as well. I suggest creating a dashboard with targeted metrics. Just as importantly, it is imperative to include workplace violence drills into your emergency management drills.

* If your organization is accredited by The Joint Commission, requirements for compliance started January 1, 2022.

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