Protecting Staff in Clinics and Other Outlying Healthcare Facilities - The "Forgotten Step-Children"

The Outlying Outpatient Opportunity and Challenge   A key part of today’s healthcare business model is that healthcare systems are aggressively spreading throughout their service regions by the addition of mostly outpatient facilities smaller than the traditional hospitals and medical centers. Such facilities may include clinics, medical office buildings, rehab, urgent care, small rural and suburban hospitals, stand-alone ER's, elder care, family health centers, day surgical centers, behavioral health, retail pharmacies and optical, physicians' offices, etc. These facilities could be many miles from the nearest hospital and, while they may face similar security and safety-related risks and threats, they do not enjoy the same resources, support and responders that the larger hospitals enjoy. They may have several employees and often fall under a separate Medical or Physicians Services group. Therefore, hospital-based security, safety and emergency processes and plans may not apply and support may be thin.

In recent years I am seeing more healthcare systems recognizing the needs of these smaller facilities and providing higher levels of attention and support. For example, some systems have created separate departments and staff for providing security, safety and emergency planning support to the outlying facilities. It is always much appreciated.

The Issues and Concerns   When I visit such smaller facilities and interview staff I too often hear the same sorts of issues I hear at the hospitals, including concerns over aggressive, confrontational, threatening and even violent behavior up to the active shooter.  And yet these employees often feel like the forgotten "step-children" who don't get near the attention and support that hospital staff and patients get.

The Covid pandemic has only amplified these risks and concerns. 

Further examples of issues I have encountered at such outlying healthcare facilities include:

·         When I ask to see their emergency plan or security and workplace violence policies or plans, I often receive the hospital plan and policies which don't apply in most ways

·        Security management staff and officers at the hospitals are often stretched and have little time to devote to these facilities. Usually the facilities are too far away for adequate hospital security officer response.

·         During a violence event at a clinic, distant hospital management attempted to manage response remotely and made a series of bad decisions

-          A patient’s family member was getting confrontational with a clinic receptionist who was fearful because she had no way to escape nor to communicate her duress with staff in the back.

-          A clinic employee was being stalked by an ex-boyfriend. She was fearful that he would come to her workplace or that he would confront her while she walked to her vehicle in the evening.

·        Many public do not appreciate the distinction between Urgent and Emergency care. Therefore, it is not unusual for Urgent Care Centers to face patients and families who present the same levels of acuity, disruption and threat as hospital Emergency Departments face without the resources and support the ER's may enjoy.

·        Front-line staff like receptionists, Covid screeners and registration relate incidents of persons intimidating and threatening them and even jumping over counters, and they don't know what to do and they feel exposed

·        Staff in the front usually have no way to safely communicate emergencies and other concerns to the rear areas and vice versa

·        Staff and patients at a women's health center were repeatedly threatened by current or former husbands or boyfriends. For them, just the identification and equipping of safe rooms in which they and patients could seek shelter until law enforcement arrived gave them comfort.

·        Following a significant violence event, system administrators neglected to visit to offer support causing long-term resentment and heightened turnover among clinic staff

-        When a small rural clinic called the police, police responders could not find an address for the clinic and had never visited.         

·         Following an active shooter event at the hospital, responders neglected to notify outlying facilities as to what was going on, what they should do and whether they were at risk which caused heightened resultant fear and resentment

Solutions    Security and safety considerations for outlying healthcare facilities, therefore, may include:

• Policies, procedures and plans that address the particular and realistic functions, history, culture, issues, risks, vulnerabilities, size and layouts of these facilities        
• Planning security and safety into the design of these facilities. For example, public areas such as waiting ideally should be restricted from treatment and office areas for safety and privacy reasons. If at all possible, there should not be more than one public access point and all other exterior doors restricted.
• Taking protective procedural and physical steps to protect front-line staff such as receptionists, screeners and registration by training, space and counter design, escape routes, duress communications, safe rooms and shelters, etc.
• Consideration of violence mitigation and prevention measures including identifying and equipping safe rooms/shelters, internal emergency communications, panic/duress alarms and rapid facility or suite lockdown capabilities.
• Fostering a close working relationship with local emergency responders including fire and police.
• Especially where no security staff are present, creating facility-specific Behavioral Response Teams of employees trained on threat management, the response process and conflict resolution.   
• Conducting security, safety and violence management vulnerability assessments. Some healthcare systems, for example, commissioned me to assess a representative sampling of outlying facilities along with higher risk facilities rather than have me visit what could be more than a hundred locations. An ancillary benefit of such assessments is that they help demonstrate to outlying facility staff that they are valued by their leaders.
• As part of the recent Joint Commission Workplace Violence Guideline, conducting WPV Worksite Analyses of each of these facilities and developing resultant site-specific plans.
• Planning and training on safe closing procedures. Closing, especially when only one employee is present, can be a particularly vulnerable time.
• Let us not forget our people who work in Home Health. We may feel relatively safe within the four walls, but these employees are out in the world, visiting residents that could present all sorts of risks including drugs, weapons, vicious animals, criminals, etc. Safety measures can include training, duress communications, neighborhood crime analyses, residence risk analyses, etc.
• Most incidents of violence in healthcare settings occur in less than five minutes, almost never more than ten minutes. Therefore it is critical for designated facility staff to be trained and authorized to make decisions and communicate directions as promptly as possible. Waiting for hospital leaders or AOC’s to be briefed or even to wake up will take too long.
• Where there are many such facilities within a system, some systems place a Manager or Director of Safety, Security and Emergency Preparedness dedicated to serving the outlying facilities
• Perpetrators of violence often were known earlier as somehow problematic and of concern. Instituting early identification and intervention patient (and family member) threat assessment and management processes that early identify persons with a proclivity toward violence and an inter-disciplinary team to review, assign levels of risk and, based upon the determined risk levels, plan a safe patient management and care process as the patient moves through the system.
• Consideration of placement and proper usage of security equipment such as video, electronic access control, panic/duress buttons, intrusion detection alarm systems, barriers, PA or intercom systems and exterior lighting. Note that, even where the facility is only open days, it gets dark early over the winter.
• Related to the above, some growing healthcare systems find it justifiable to place central security monitoring/dispatch centers to remotely monitor and support video, access control, alarms and staff response at all facilities.  This is another way to demonstrate the administration's concern for the safety and welfare of all staff and patients and can be a powerful force multiplier.
• It is essential to include these staff, especially the front line "gatekeepers," in security and safety training. They should at least understand the early warning signs of potential violence, how to de-escalate (and not escalate) and what to do when faced with threatening or violent behavior. Most such staff I interviewed received no such training.
• Often the clinic may be leased or within a large building with other tenants. This presents unique challenges. How does the healthcare suite’s emergency and security plans and procedures relate to the building’s plans? Protective measures may have to be pulled to the suite or floor level.  

The trend in the healthcare industry is toward more outpatient space and less inpatient, so this is our future. These outlying "step-children" should understand that they are valued and protected members of the organization's team and family.

Dick Sem, CPP President of Sem Security Management, based in Burlington,Wisconsin, has over 50 years’ security and violence management leadership experience. He serves large and small healthcare systems across North America in almost every state performing comprehensive security and violence management assessments, targeted assessments (of ED, Security Department/Program, Workplace Violence Program, Accessibility, Outlying Facilities, etc.), Workplace violence Worksite Analyses, development of related policies and plans, expert witness service and training.  

Dick Sem, CPP – Sem Security Management – [email protected]

262-862-6786

www.semsecurity.com