UNDERSTANDING THE JOINT COMMISSION'S NEW 2022 REQUIREMENTS ON WORKPLACE VIOLENCE

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UNDERSTANDING THE JOINT COMMISSION’S NEW 2022 REQUIREMENTS ON HOSPITAL & HEALTHCARE WORKPLACE VIOLENCE PREVENTION

By: William S. Marcisz, JD CPP CHPA

December 21, 2021

INTRODUCTION:

Workplace Violence is a national epidemic. In terms of statistical data, healthcare workers are victimized by workplace violence far more than employees in any other industry.

Effective January 1, 2022, The Joint Commission (TJC) will implement new Workplace Violence Requirements to existing Standards. In so doing, TJC has taken an important step to standardize certain requirements hospitals must implement to prevent, mitigate, and respond to workplace violence. The new requirements clarify the roles of hospital staff and leaders who are responsible for administering the workplace violence prevention and response by attaching certain accountabilities.

However, there has been some confusion on what is being added to the existing workplace violence standards. Even for those who understand the new TJC requirements, you may be left with questions on how to go about meeting some of those requirements. This article seeks to explain the new Joint Commission requirements, and how to bring your organization into compliance.

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THE NEW WORKPLACE VIOLENCE REQUIREMENTS:

The Joint Commission is an independent, not-for-profit organization that provides healthcare accreditation. To this end, it establishes Standards for hospitals to meet to attain accreditation. Within the TJC’s Standards are “Elements of Performance” (EPs) that explain what a hospital must do to meet the Standard.

Before delving into the new Joint Commission requirements relating to workplace violence, it is important to clarify there are 3 new elements of performance (EPs) to existing standards, and two revised EPs. As such, there are no new standards, only additions to existing Joint Commission standards.

Standard EC.02.01.01: The hospital manages safety and security risks.

Note: The following is a new Element of Performance added to Standard EC.02.01.01.

EP 17: The hospital conducts an annual worksite analysis related to its workplace violence prevention program. The hospital takes actions to mitigate or resolve the workplace violence safety and security risks based upon findings from the analysis. A worksite analysis includes:

1.????A proactive analysis of the worksite,

2.????An investigation of the hospital’s workplace violence incidents, and

3.????An analysis of how the program’s policies and procedures, training, education, and environmental design reflect best practices and conform to applicable laws and regulations.

SSMC Analysis: This is a new Element of Performance to ensure hospitals are assessing risk and identifying gaps in security & safety as it relates to workplace violence. The purpose is to ensure hospitals continuously assess and develop plans for improvements to process and the physical environment.

Because hospital security policies, processes, and infrastructure are so inextricably entwined, SSMC suggests conducting both a Security & Workplace Violence Assessment on an annual basis. The assessment can be accomplished by a Security audit and gap analysis and by compiling various datasets that track: 1) Incidents of Workplace Violence; 2) Employee Injuries & Lost Time resulting from incidents of WPV; and 3) Threats made to hospital and staff. SSMC further recommends the datasets drill down to factors such as date, time, and location of incidents, as well as the occupation of the employee/victim.

Program Training & Education should track the number of employees trained and the education received. Different levels of training and education can be appropriate as to level of risk of exposure to workplace violence. For example, a nurse working in an Emergency Room or Behavioral Health Unit are likely to have greater exposure than a clerical worker or employee who is working remotely.

It is an industry best practice to perform an annual assessment of Security & Workplace Violence Prevention, and to have an independent consultant review the hospital’s site, plans, and programs every five years.

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Standard EC.04.01.01: The hospital collects information to monitor conditions in the environment

Note: This is only a slight revision to Element of Performance #1 of Standard EC.04.01.01.

EP 1: The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following:

-?????????Injuries to patients or others within the hospital’s facilities

-?????????Occupational illnesses and staff injuries

-?????????Incidents of damage to its property or the property of others

-?????????Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence

-?????????Hazardous materials and waste spills and exposures

-?????????Fire safety management problems, deficiencies, and failures

-?????????Medical or laboratory equipment management problems, failures, and use errors

-?????????Utility systems management problems, failures, or use errors

Note 1: All incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions. A summary of such incidents may also be shared with the person designated to coordinate safety management activities.

Note 2: Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, or services, or to prevent similar incidents, are not lost as a result of following the legal process.

SSMC Analysis: Here, there is language added to the existing Element of Performance covering reporting and documentation of Security incidents to include those concerning Workplace Violence. In essence, your hospital will want to create specialized datasets to categorize incidents of workplace violence. At a minimum, the hospital should track: 1) Incidents of Workplace Violence; 2) Employee Injuries & Lost Time resulting from incidents of WPV; and 3) Threats made to hospital and staff.

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Standard EC.04.01.01: The hospital collects information to monitor conditions in the environment

Note: The following is language added to Element of Performance #6 of Standard EC.04.01.01.

EP 6: Based on its process(es), the hospital reports and investigates the following: Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.

SSMC Analysis: This new Element of Performance may be considered a “bookend” to the added requirements in EP 1 of Standard EC.04.01.01 discussed above. There, the standard requires collection & monitoring of data related to workplace violence. IN EP# 6, the standard requires the hospital to act on the information.

As indicated, your hospital will want to create specialized datasets to categorize incidents of workplace violence. At a minimum, the hospital should track: 1) Incidents of Workplace Violence; 2) Employee Injuries & Lost Time resulting from incidents of WPV; and 3) Threats made to hospital and staff. It is suggested to catalog the type of incident (verbal or physical), where it occurs, and the team member who is the victim (EX: Nurse, PCT, Security Officer, Etc.).?

Hospital-based Workplace Violence data is typically found in three areas: Security (Incident Reports), Risk Management (Incident Reports), and Human Resources/Employee Health (Employee Injury Reports, Lost Time, Employee Assistance Referrals, and Workers’ Compensation cases). To attain a meaningful understanding of how workplace violence is impacting your hospital, it is recommended to examine data from all three areas to gain a comprehensive assessment of reported workplace violence. To date, I have not found a software or an effective single database for a hospital to use that captures all incidents, outcomes, or provides any meaningful analysis other than reporting raw data. This is because Security, Risk Management, Human Resources, and Administration capture and analyze only the data that is important to their discipline.?

Security incident reports provide good aggregate data on workplace violence in terms of where, when, who, what type of incident, and how frequently this is occurring. The downside to confining analysis solely to Security Reporting is that clinical staff does not always call security opting to manage incidents on their own or may document minor incidents of workplace violence through 1) charting patient behavior; 2) verbal reporting to the Charge Nurse; and/or 3) submit an occurrence report in a risk management database. As such, this is one reason why workplace violence is under-reported.

Risk Management incident reports on workplace violence should also be assessed because they capture many incidents that occur on nursing units and elsewhere in the hospital that Security is never called on to respond to. In many circumstances, nursing staff will not call security because there was no imminent threat of harm, or they were able to resolve the issue without the need of security. It is not uncommon for hospitals to correlate Security & Risk Management records and find the same incident was reported in both security & risk management records management systems about 15% - 20% of the time. In addition to information on actual incidents, Risk Management can also provide important records relating to litigation and claims covering how many incidents result in a lawsuit, what damages/settlements were paid, and what the litigation costs were for the organization because of incidents of workplace violence. This is information that few organizations tabulate and provide to their Administration on others tasked with workplace violence prevention.

Human Resources records provide substantive data related to employees who are injured or have filed a Workers’ Compensation claim. This is where the organization will find important information relating to business continuity and resiliency. Costs relating to employee injuries (Lost Time; Medical Expenses; Workers’ Compensation Claims; and Employee Retention Rates) caused by workplace violence are readily available through Human Resources/Employee Health. Finally, Human Resources records provide two additional key reports not found in Security or Risk Management databases. First, Employee vs. Employee incidents are seldom reported to security (or risk management) unless there is some high level of concerning behavior or threat. Second, Human Resources records do capture additional incidents of workplace violence that were not reported to security or risk management.

SSMC recommends representatives from security, risk management, and human resources compile their respective datasets and formally provide a report (monthly or quarterly) to a designated committee to ensure information is being transparently disseminated to persons in the organization who have both a clinical and/or environmental safety responsibility.

Having a complete picture on the total scope of workplace violence reporting allows the organization to make informed decisions on prioritizing resources designated for prevention and response to workplace violence. Having financial data relating to revenue losses caused by workplace violence allows for a cost-benefit analysis to determine the value of training & education, security measures, and other prevention strategies. This is the type of information hospital administrators need for strategic planning not only to provide the safest work environment possible, but also in terms of strategic planning, organizational resilience, and fiscal sustainability.

The committees who may receive information on workplace violence typically include Environment of Care, Clinical Safety, or even a Workplace Violence Committee. It is further suggested that at least one committee have specific responsibility to report information on workplace violence to Senior Leadership, and that an annual report be provided to the areas responsible for quality assurance and organizational safety, such as Quality Assurance Performance Improvement (QAPI), and/or the organization’s Board of Directors.

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Standard HR.01.05.03: Staff participate in ongoing education and training

Note: The following is a new Element of Performance added to Standard HR.01.05.03.

EP 29: As part of its workplace violence prevention program, the hospital provides training, education, and resources (at time of hire, annually, and whenever changes occur regarding the workplace violence prevention program) to leadership, staff, and licensed practitioners. The hospital determines what aspects of training are appropriate for individuals based on their roles and responsibilities.

The training, education, and resources address prevention, recognition, response, and reporting of workplace violence as follows:

-?????????What constitutes workplace violence

-?????????Education on the roles and responsibilities of leadership, clinical staff, security personnel, and external law enforcement

-?????????Training in de-escalation, nonphysical intervention skills, physical intervention techniques, and response to emergency incidents

-?????????The reporting process for workplace violence incidents

SSMC Analysis: This is a new Element of Performance added to TJC’s standards relating to human resources management. This EP is designed to ensure hospitals are providing education and training to hospital staff. There are both explicit requirements listed in the EP, as well as elements that are implied.

Explicit is that the training & education should occur upon hiring and change of position. The “upon hiring and change of position” language is added to close a gap where certain positions may require enhanced or added training in workplace violence than the previous position occupied by the employee. Also explicit in the new EP is the provision that an annual training or refresher education be completed annually.

The first thing that should be implied is that training and education requirements be formalized and monitored under the supervision of a hospital’s human relations department. Implicit is that the training be formalized and specific to job functions. A better practice may be to include and identify certain specialized workplace violence training and education in job descriptions to reinforce employee responsibilities to have situational awareness and report incidents and injuries.

The standard’s new requirements on training and education should include:

1.??????An explanation on what constitutes workplace violence. This should also be in the organization’s policy or procedure on workplace violence.

2.??????An explanation to clarify roles & responsibilities. Because leadership, clinical staff, and security are specifically mentioned, the education should identify responsibilities for all so there is no confusion as to who is accountable for elements of prevention, response, and reporting. Accountabilities should also be clearly defined in the policy covering workplace violence and within the job descriptions of staff.

3.??????As indicated above, the specific training provided to staff depends upon their roles and expectations.

a)?????De-Escalation training can (and should) be combined with “Customer-Service” skills and education. Good customer service creates employee awareness, and, in many cases, it can mitigate anxiety and frustration, which can be precursors to escalation of aggression. It is better to avoid aggressive behavior before it mushrooms into the need to advance to non-physical and physical intervention. It is recommended for all hospital staff to receive training on de-escalation and basic customer service.

b)?????Non-Physical and Physical Intervention are generally provided to staff that have frequent contact with aggressive patients and visitors. Security, Behavioral Health, Emergency Room, and clinical staff are recommended to receive Non-Physical Intervention Training.

c)?????At a minimum, Security, Behavioral Health, and Emergency Room staff should be trained in Physical Intervention with aggressive patients. In addition, all staff assigned to an Emergency Response Team (ERT) should also receive this advanced level of training.

d)?????As a best practice, Non-Physical and Physical Intervention training should consist of an independent program that certifies staff in these skills.

4.??????Training and education should also identify when it is appropriate for external law enforcement agencies to be summoned to assist, what information can or should be provided to police, who is responsible for documenting police intervention.

a)?????To reinforce and add clarity to law enforcement assistance with incidents involving workplace violence, SSMC recommends a policy & process be established to ensure roles and responsibilities are defined.

b)?????A good practice is to engage local law enforcement in the development of the policy as there may be limitations and legal aspects of police involvement. Said another way, a hospital should partner with police for both the hospital and police to gain empathy and buy in. This will effectuate seamless cooperation at the line-staff level to avoid future misunderstandings.

5.??????Training for “Emergency Incidents” is not defined. However, it implies hospitals have both an Emergency Response Team (ERT), and/or Threat Management Team (also referred to as Threat Assessment Teams). These are two different types of response teams, and we will discuss both as follows:

a)?????An Emergency Response Team (or sometimes referred to as a BERT – Behavioral Emergency Response Team), is a multidisciplinary group of designated staff who respond to an ongoing threat or act of aggressive behavior.

·????????An ERT is typically comprised of the Administrative Supervisor, Security, and other designated staff trained and certified in De-Escalation of aggressive behavior and Physical Restraints.

·????????Note: as a Best Practice, the ERT can be set up similarly to a code team, with designated responsibility for a staff member to bring an ERT cart or bag with restraints and medications that can be administered if needed. This eliminates delays and allows the team to resolve the aggressive behavior and create a safer environment.

·????????The ERT should have a designated “clinical chain of command” beginning with the Administrative Supervisor. These are persons with decision-making authority to address the clinical aspects of the incident. A clearly defined leader hastens decision-making and eliminates confusion.?

b)?????It is recommended for each hospital site to establish a Threat Management Team (TMT) consistent with ASIS/SHRM standards.

·????????Security, Risk Management, Human Resources, Administration, and Legal, generally form the core of a TMT, but the team can flex and add subject matter experts as the situation requires.

·????????SSMC recommends the core members receive Threat Management training from a certified Threat Assessment Professional, and that annual training be offered to new members and that existing staff on the TMT undergo an annual skills assessment.

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Standard LD.03.01.01: Leaders create and maintain a culture of safety and quality throughout the hospital

Note: The following is a new Element of Performance added to Standard LD.03.01.01.

EP 9: The hospital has a workplace violence prevention program led by a designated individual and developed by a multidisciplinary team that includes the following:

-?????????Policies and procedures to prevent and respond to workplace violence

-?????????A process to report incidents in order to analyze incidents and trends

-?????????A process for follow-up and support to victims and witnesses affected by workplace violence, including trauma and psychological counseling, if necessary

-?????????Reporting of workplace violence incidents to the governing body

SSMC Analysis: This is a new Element of Performance directed to hospital leadership. Without leadership buy-in and overt & active support for the workplace violence program, it will be difficult for the subordinate leaders who are expected to carry out all the above requirements of the workplace violence plan and program.

Without full leadership accountability and support, the workplace violence program will be more difficult to effectuate and function. Half-measures and inefficiencies in a workplace violence prevention program can result in needless and unnecessary physical injuries, and/or mental trauma.

The new EP expressly states hospital leadership is responsible for:

Policies & procedures concerning workplace violence prevention and response.

a)?????A process to report and analyze incidents of workplace violence and trends. As indicated above, a safety or workplace violence committee, or Environment of Care Committee could be the reporting mechanism, but a sub-committee with key stakeholders may be more effective to analyze and provide briefings to the committee with oversight of reporting. As a best practice, Quality Assurance and Performance Improvement, and Senior Leadership (the C-Suite) should be required to receive a workplace violence status briefing from committee subject matter experts no less than once a year.

b)?????Workplace violence can cause mental trauma. Most organizations already have some form of Employee Assistance Program (EAP) to assist employee victims of violence. However, it is also recommended that leaders tasked with managing the workplace violence program to also reach out to employee victims of violence (to the extent any overture is welcome). We know good Security Directors who “inconspicuously” but intentionally round on employees who have been victimized. An authentic display of compassion (and empathy) is appreciated by the employee and benefits the organization by sustaining employee engagement and at times, retention.

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CONCLUSION:

Workplace violence prevention & response is a complex program to administer in a hospital environment. It requires subject matter expertise, time, resources, commitment, and an organizational will to be effective. The new Joint Commission requirements codify several existing healthcare industry best practices and adds accountability standards designed to help a hospital’s workplace violence program attain success.

Workplace violence is difficult for a hospital to manage because it requires a thorough understanding and coordination by several key disciplines, as well as a total commitment by all staff. Even for organizations whose departments work together, it may still be hard to get everyone on the same page.

What is beginning to take shape as a best practice in managing workplace violence is several healthcare systems and large hospitals have created a “Workplace Violence Manager” position whose overarching responsibility is dedicated to administering the healthcare system’s workplace violence prevention program. The chief advantage of this position is that it takes the burden off Security Directors, Risk Managers, Human Resources, and others who have responsibility for workplace violence prevention, in addition to their own roles.

This person can gather information from the various sources in the organization, prepared datasets and reports to committees and leadership, ensure compliance with all aspects of the organizations Workplace Violence program, and in some cases oversee Threat Management response.

?On behalf of SSMC, we hope this briefing and analysis has been helpful.

?Best Regards,

William S. Marcisz, JD CPP CHPA

President & Chief Consultant

Strategic Security Management Consulting, Inc.

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The author is a Hospital and Workplace Violence Security Expert with 40 years of healthcare security & legal experience. Mr. Marcisz has assessed, developed, and implemented security and workplace violence programs in organizations ranging from small rural hospitals to large complex multi-regional healthcare systems. Bill has received peer reviewed recognition and top industry awards for distinguished service in developing Security Programs, and individual performance as a Security Director.

For any questions or additional information on security or workplace violence prevention, feel free to reach out to SSMC’s President & Chief Consultant, William S. Marcisz, JD CPP CHPA, at [email protected] or visit our website at www.SSMCSecurity.com