When the going gets tough…

By Steve MacArthur, Hospital Safety Consultant

I’m thinking this might be the last “big” regulatory news story of 2022, and like so many of the big stories over the years, it’s not necessarily “new.”

Concerns relating to violence in the healthcare workplace has been with us a long time (was there ever a time when it wasn’t somewhere in the mix? I tend to think not).

And while the solutions seem pretty clear (education and training of staff, having enough staff to appropriately manage the patient environment and the patients, etc.), the practical, sustained implementation of those solutions would appear to be as elusive as they could possibly be. That’s not to say that there aren’t some places that do a good job with this, but, ultimately, the goal is to perfectly manage the risks. And perfection is typically a very tall order in our imperfect world.

In a December 2022 issue of Healthcare Facilities Today, there’s an article covering the release of an alert from CMS in which the agency outlines their commitment to enforcing the regulatory expectations that patients and staff have an environment that prioritizes their safety to ensure effective delivery of healthcare. The article in HFT concludes with a passage quoted from the alert: “CMS has cited hospitals in the past for failures to meet these obligations.”

“Examples include: a nurse in a unit without adequate staffing who was sexually assaulted by a behavioral health patient who was stopped only through intervention by other patients; a patient who died after hospital staff and law enforcement performed a takedown that resulted in a hospital custodian holding the patient down on the floor with his knee against the patient’s back, during which the patient stopped breathing and died; and a patient who was acting out and shot in his hospital room by off-duty police officers following the failure of hospital staff to perform appropriate assessment and de-escalation of the patient,” according to the alert.

I can’t imagine that there’s anyone out there in the audience that hasn’t experienced some tense moments relative to the management of at-risk patients—hopefully they ended up being near-misses, but it is clear that each and every day brings a new set of challenges.

There is one interesting (at least to me) aspect of the CMS alert ( https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/workplace-violence-hospitals ), which deals with this topic as a function of compliance with the Emergency Preparedness Condition of Participation (CoP). The alert includes a note that, under the Medicare Hospital Emergency Preparedness CoP at §482.15(a), a hospital’s emergency preparedness plan must be based on, and include, a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. It must also include strategies for addressing emergency events identified by the risk assessment as well as address the patient population, including, but not limited to, persons at-risk. The alert goes on to invoke the Emergency Preparedness CoP at §482.15(d)(1), which contains requirements for hospitals to train staff and to have policies and procedures aimed at protecting both their workforce and their patients.

As I think about Hazard Vulnerability Analyses (HVAs) that I’ve reviewed this year, I think pretty much every one has reference workplace violence to some degree, but this makes me think that:

  1. If you haven’t identified workplace violence as a specific vulnerability on your HVA, you definitely should;
  2. It may be time to go through the whole HVA list to ensure that it is representative of an “all hazards” approach (how much is “all”?);
  3. It may be time to do a “deep dive” analysis of workplace violence protective measures; this sort of dovetails with the annual workplace analysis required by TJC, so perhaps the results of that activity can “feed” back to the HVA.

I know everyone is working very diligently to get their arms around this and I’m hoping for some kind of breakthrough, but I suspect it’s not quite around the corner.

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.