OSHA released an update to its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. The publication includes industry best practices and provides some insight on how to reduce the risk of violence in various healthcare and social service settings.  To protect against violence, OSHA recommends that healthcare providers develop an effective workplace violence prevention program that includes:  (1) Management commitment and employee participation; (2) Worksite analysis/Tracking and Trending; (3) Hazard prevention and control; (4) Safety and health training; and (5) Recordkeeping and program evaluation.  In the Guidelines, OSHA provides several detailed charts to assist employers in navigating and implementing these program elements.

In the Guidelines, OSHA indicates that healthcare and social service workers face a significant risk of job-related violence.  According to the Bureau of Labor Statistics (BLS), 27 out of the 100 fatalities in the healthcare and social service industries in 2013 were due to assaults and violent acts.  In addition, 70-74% of all workplace assaults occurred in the healthcare and social service industries and assaults comprised 10-11% of workplace injuries involving days away from work for healthcare workers.

Work-related assaults and other incident of workplace violence primarily result from violent behavior from patients, clients and residents in healthcare and social service settings.  Working directly with people who have a history of violence or who have abused drugs or alcohol increase the risk that an employee can be subject to workplace violence.  Working with the public or with relatives of patients and residents also increases the risk of violence.  Other factors that employers should consider in assessing whether their employees are at risk for workplace violence include:

• Working with volatile, unstable people

• Transporting patients, residents or clients

• Working alone in a facility or in a patient’s home

• Lack of emergency communication

• Working late at night or early morning hours

• Working in poor lit corridors, rooms, parking lots and other areas

• Working in areas with high crime rates

• Availability of firearms and weapons

• Long waits for care and services

• Overcrowded or uncomfortable waiting rooms

Hospitals, Residential Treatment, Non-residential Treatment, Community Care, and Field work settings may have a number of these risk factors that would warrant the need to create a written violence prevention program with the five program elements.

Management Commitment and Worker Participation

OSHA concludes that management commitment and worker participation are essential elements of an effective violence prevention program.  OSHA recommends that employers develop procedures to ensure that management and employees are involved in the creation and operation of a workplace violence program and participate in regular meetings related to workplace violence prevention.

Some management commitment elements in the new guidance that employers may not currently have in their program include:

• Maintaining a system of accountability for involving managers, supervisors, and workers;

• Establishing a comprehensive program of medical and psychological counseling and debriefing of workers who have experienced or witnessed assaults and other violence incidents;

• Ensuring that trauma-informed care is available; and

• Establishing policies that ensure that reporting, recording and monitoring of both incidents and near misses.

OSHA believes that worker participation is critical in creating an effective program.  Employees are encouraged to participate in the development, implementation, evaluation, investigation, and modification of the program.  Employees should also provide assistance in identifying the daily activities that employees believe put them most at risk for workplace violence, as well as participate in safety and health committees, perform facility inspections and respond to recommendations for corrective strategies.

Worksite Analysis and Hazard Identification

OSHA concludes that healthcare employers should perform worksite assessments as part of an effective violence prevention program.  The worksite assessments should be used to identify the possible risk factors, the types of hazard prevention and control measures that can be implemented to reduce or eliminate a workplace violence incident, and the appropriate training that should be developed and given to employees.

According to OSHA, the worksite analysis should include a records review, a review of the procedures and operations for different jobs, a security review, and employee surveys.  As part of the worksite analysis, employers should review medical, safety, complaint, workers’ compensation and insurance records to identify patterns of workplace violence and near misses.  This information should be organized by departments, work areas, job titles, activities performed at time of occurrence, and time of day to assist in identifying trends and patters of occurrence. OSHA provides some examples of a way to track such information to help in identifying trends in the new Guidelines.

Employers are also encouraged to perform a job hazard analysis to identify specific tasks or positions that may put an employee at risk for workplace violence.  OSHA indicates that priority should be given to jobs that require administering medicine and transferring patients or residents.  In addition, employers are encouraged to conduct employee questionnaires or surveys to assist in identifying potential hazards that may lead to violent incidents.  In the new Guidance, OSHA provides some sample questions that could be asked:

• What daily activities, if any expose you to the greatest risk of violence?

• What, if any, work activities make you feel unprepared to respond to a violent action?

• Can you recommend any changes or additions to the workplace violence prevention training you received?

• Can you describe how a change in a patient’s daily routine affected the precautions you take to address the potential for workplace violence?

Hazard Prevention and Control

OSHA concludes that employers need to select and implement effective controls to eliminate or reduce any workplace violence hazards.  Employers are encouraged to follow-up to confirm that the controls are being used and maintained properly and that they are effective.   OSHA has adopted the hierarchy of controls for the healthcare and social services setting with respect to workplace violence – (1) substitution, (2) engineering controls, (3) administrative controls and (4) personal protective equipment.

While OSHA recognizes that substitution may be difficult in the therapeutic healthcare environment, it suggests that transferring a patient to a more secure facility may be appropriate if the patient has a history of violent behavior that cannot be handled at a less secure environment.

For facilities where it is appropriate, employers are encouraged to implement engineering control measures to prevent or reduce workplace violence hazards.  Such controls may include: (a) using physical barriers (such as enclosures or guards) or door locks; (b) metal detectors; (c) panic buttons or silenced alarms; (d) better or additional lighting; (e) more accessible exits; (f) closed circuit videos; (g) curved mirrors; (h) glass panels in doors/walls for better monitoring of behavior; and (i) lockable bathrooms and staff counseling and treatment rooms.

In addition, OSHA recommends that administrative and work practice controls be implemented to reduce possible violence.  Such controls may include: (a) log-in/log-out procedures; (b) determine the behavioral history of new and transferred patients and residents; (c) communicate with staff about violent history or new incidents; (d) treat and interview aggressive or agitated patients in relatively open areas; (e) use the buddy system when personal safety may be threatened; (f) provide responsive, timely information to those in waiting rooms or waiting for care; (g) implement sign-in procedures for all visitors and guests; (h) use properly trained security officers and counselors to respond to aggressive behavior; and (i) prepare contingency plans to treat clients who are “acting out” or making verbal or physical attacks or threats

In the Guidelines, OSHA provides charts of possible engineering and administrative controls that could be implemented for different healthcare and social service settings.

Post-Incident Procedures and Services

OSHA concludes that post-incident response and evaluation are important components to an effective workplace violence prevention program.  Employers are encouraged to investigate all incidents of workplace violence.  Employees who witnessed the event or work near the area where the event occurred should be involved in the incident investigation.  During the investigation, employers should identify the root cause of the incident to assist in preventing future occurrences.  OSHA recommends that employers should not stop at “worker error” or “unpredictable event” but should ask “why” the patient acted and “why” the employer responded in a certain way in order to uncover the reason behind the actions.

OSHA also recommends that employers investigate all near misses.  OSHA notes that near misses are caused by the same conditions that produce more serious outcomes and signal that some hazards are not being adequately controlled or that unidentified hazards exist.

Employers are also encouraged to provide – at no charge to the employee – prompt medical treatment along with a psychological evaluation whenever an assault takes place regardless of the severity.  Trauma-crisis counseling, critical-incident stress debriefing or employee assistance programs may also be provided to assist victims of workplace violence.

Safety and Health Training

OSHA concludes that employers need to provide appropriate education and training to ensure that all staff members are aware of potential workplace violence hazards and how to protect themselves and their coworkers.  Effective training should cover the policies and procedures for a facility, as well as hands-on de-escalation and self-defense training.

OSHA provides an extensive list of training topics that should be covered.  Some of the most interesting training topics that you may not be providing to your employees include:

• Risk factors that cause or contribute to assaults;

• Early recognition of escalating behavior or recognition of warning signs or situations that may lead to assaults;

• Ways to recognize, prevent or diffuse volatile situations or aggressive behavior, manage anger and appropriately use medications;

• Ways to deal with hostile people other than patients and residents, such as relatives and visitors; and

• Progressive behavior control methods.

Supervisors and managers should also be trained to recognize high-risk situations so they can ensure that workers are not placed in assignments that compromise their safety and can make any necessary changes to reduce or eliminate violent workplace behavior.

Finally, OSHA notes that security personnel should be trained on the psychological components of handling aggressive and abusive patients, and the ways to handle aggression and defuse hostile situations.

Recordkeeping and Program Evaluation

OSHA concludes that recordkeeping and program evaluation are essential components of an effective violence prevention program.  OSHA asserts that accurate recordkeeping can assist employers in identifying any developing trends or patterns experienced at the worksite, as well as identify any hazard controls and training needs.

Employers are encouraged to review the program routinely and re-evaluate policies and procedures to identify deficiencies and take corrective actions.  Reviews should include, among other things, the following:

• Establishing a uniform violence reporting system and regularly review reports;

• Reviewing reports and minutes from staff meetings on safety and security issues;

• Analyzing trends and rates in illnesses and injuries cause by violent episodes or threats

• Keeping abreast of new strategies available to prevent and respond to violence in the healthcare and social setting environments, and

• Requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving worker safety.

Reissuing updated guidance suggests that OSHA may devote more time and resources to investigating claims of workplace violence in the hospital, residential care and social services environments.  It may be a good time to look over your program and consider your risk.