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Briefings on Hospital Safety, June 2017


May 25, 2017

Workplace violence prevention: OSHA looks to states for input, models

Wrinkles yet-to-be ironed out include disputes over necessity, cost, and definitions

Donna Gross clocked out for a dinner break one Saturday evening in 2010, and she never clocked back in. The 54-year-old psychiatric technician, who had worked for 14 years at Napa State Hospital in California, was found dead in a courtyard at work, strangled by one of her patients. The killer, who later pleaded no contest to a murder charge, had dragged Gross over a wall and stolen jewelry and a small amount of cash.

The case prompted reforms to curb workplace violence not only at the local healthcare facility, but at the state level as well. Last fall, six years after Gross died, regulators within the California Division of Occupational Safety and Health (Cal/OSHA) approved a new rule motivated in large part by her tragic death. The standard, which took effect in April, specifies steps that employers of healthcare professionals must take to develop and enact workplace violence prevention plans. It has been hailed as the first of its kind, and the federal government is now asking whether it should follow California’s lead.

With a nod to Gross’ case, OSHA issued a request for information late last year and began collecting stakeholder feedback regarding whether and how OSHA might implement a nationwide rule. While some questioned the necessity and efficacy of enacting a California-style standard on the federal level, commenters from coast to coast greeted the idea with applause.

“Healthcare facilities are no longer safe havens, and have joined other previously sacrosanct settings such as houses of worship and schools as prime venues for acts of violence,” wrote Bryan Warren, BS, MBA, CHPA, director of corporate security for Carolinas HealthCare System based in Charlotte, North Carolina, in response to OSHA’s request. He urged the administration to call upon the expertise of healthcare security leaders and move forward with its prospective rulemaking process.

“Since the vast majority of the violent incidents and injuries to caregivers are caused by the very persons that we are trying to help, healthcare professionals must be supported in the adoption of strategies to better understand the circumstances and events leading up to these types of behaviors,” Warren said. “A good foundation is the creation of rules and standards with which to better prevent and respond to incidents of workplace violence when they occur.”

The reservations voiced by others, however, signal just how difficult it could be for federal regulators to devise a standard that works for everyone.

Existing policy, law

Although federal OSHA officials praised California’s occupational health and safety standard as trailblazing, they acknowledged that there were already laws on the books in at least nine states—California, Connecticut, Illinois, Maine, Maryland, New Jersey, New York, Oregon, and Washington—mandating some form of workplace violence prevention plan for healthcare facilities. These laws vary widely, each offering its own scope and set of requirements, along with differing definitions of workplace violence. Some point to this patchwork as evidence that a federal rule is needed.

Jeannie K. Tomlinson, MSN, RN, COHN-S, FAAOHN, president of the American Association of Occupational Health Nurses, Inc. (AAOHN), a Chicago-based group with members working in all 50 states, commented that the federal government should not leave policymaking in this area up to individual states because there is no way to guarantee that all of them will make workplace violence prevention a priority.

Available data suggest that healthcare and social assistance workers are far more likely to be injured in an incident of workplace violence than their counterparts in other sectors. In 2014, there were 8.2 injuries related to workplace violence per 10,000 full-time healthcare and social assistance workers—that’s more than quadruple the rate experienced by the private sector overall (which saw 1.7 injuries per 10,000 workers), according to an OSHA analysis of data from the U.S. Bureau of Labor Statistics. Violence rates were highest in psychiatric and substance abuse hospitals, where OSHA found 109.5 intentional injuries per 10,000 full-time workers.

Officials have long been aware of a need to proactively identify and mitigate threats, which is why OSHA published the first version of its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers more than two decades ago. (The latest version, which was updated in 2015, is available online for free: www.osha.gov/Publications/osha3148.pdf.) These voluntary guidelines include recommended policies and procedures to combat workplace violence in a variety of settings by focusing on five core “building blocks”:

  1. Management commitment and employee participation. Although the details will vary by locale, OSHA recommends establishing a joint committee involving managers and employees to address workplace violence or safety topics more generally.
  2. Work site analysis. Certain areas within a hospital will carry greater risks than others. Workers in admission areas, EDs, and behavioral health centers may need more protection than their counterparts elsewhere. A detailed analysis will enable facilities to spot local hazards.
  3. Hazard prevention and control. After identifying local risks, facilities can implement a number of controls to mitigate the threat of violence, including administrative tools (e.g., a zero-tolerance policy on violence), engineering tools (e.g., alarm systems, metal detectors, or physical barriers), PPE (e.g., gloves, sleeves, and blocking mats when caring for patients with certain developmental disabilities), and more innovative strategies.
  4. Safety and health training. Getting all staff members on the same page and keeping them up to date will maximize the efficacy and efficiency of any effort to deter violence.
  5. Recordkeeping and program evaluation. Employers are required to record certain workplace injuries and illnesses in the OSHA 300 Log. This and related documentation can be used to track risks and measure whether interventions are working.

Although federal OSHA guidelines do not specifically require employers to develop workplace violence prevention programs, the administration can issue citations under the General Duty Clause when providers fail to address known hazards. And if inspectors spot workplace violence hazards, but fewer than four of the above criteria are met, they can still issue a warning known as a “hazard alert letter” recommending that the employer voluntarily take steps to improve employee safety.

“The letters describe the specific hazardous conditions identified in an inspection, list corrective actions that can be taken to address them, and provide contact information to seek advice and consultation on addressing the hazards,” the GAO report states.

OSHA issued 48 such workplace violence–related letters from 2012 through May 2015, but the administration was reportedly unable to tell the GAO how many of those letters resulted in follow-up inspections.

James A. Tacci, MD, JD, MPH, FACOEM, FAACPM, president of the American College of Occupational and Environmental Medicine, said the time has come for OSHA to turn its voluntary guidance into an enforceable standard.

“Such a step would serve to level the playing field across the states,” Tacci wrote in a comment. “Evidence for the effectiveness of these standards is beginning to emerge.”

Defining workplace violence

Despite being widely discussed for decades, the phrase “workplace violence” can be slippery, both in its definition on paper and in the real world. That fact was evident in a public comment submitted to OSHA by Stacy Maitha, BS, RN, president of the Indiana Emergency Nurses Association. Maitha was working at IU Health in Bloomington when she stopped a patient care technician in the ED.

“What are you doing, Kelli?” Maitha recalled asking.

“I have to step away for a few minutes from the verbal assault I’m receiving back there,” the tech responded.

“Oh, you get used to it,” Maitha replied flippantly.

The dismissive comment elicited an expression of shock and disbelief from the tech, prompting Maitha to rethink her perspective. She used the story to explain that she had grown somewhat accustomed to having patients spit at, kick, curse at, and threaten her.

“Like most of the people I work with, I have come to expect this behavior from the people we serve in our community hospital,” Maitha said. “But that day, Kelli’s face reminded me that I shouldn’t expect it, and that I absolutely shouldn’t be telling my coworkers to just ‘get used to it.’ ”

Stakeholders generally agree that being intentionally kicked by a patient fits within the definition of workplace violence. But what about cursing and threats? Might a broad definition empower healthcare personnel and policymakers to better identify troubling behavior and trends before they result in injury or death?

Azita Mashayekhi, MHS, staff industrial hygienist for The International Brotherhood of Teamsters, argued in a comment that OSHA should implement a standard that defines “workplace violence” as California’s standard did, including “any act of violence or threat of violence that occurs at the work site,” excluding lawful defensive actions. OSHA’s request for information addressed only the prospect of violence from customers, clients, and patients, but Mashayekhi argued the focus should be expanded to include worker-on-worker violence, incidents stemming from personal relationships, and purely criminal acts (detached from the patient care relationship) as well.

Others, however, cautioned that defining workplace violence too broadly could quickly drown healthcare personnel in paperwork. Melinda Ward, associate CEO and director of support services for the nonprofit OHI, which serves adults with intellectual disabilities and mental illness in central Maine, said OSHA could easily find itself imposing overly burdensome rules, especially if it requires documentation not only of each injury but of every threat as well.

“Providers of services and OSHA could not possibly keep up with that amount of recording without considerable increases in administrative staff to record and follow these incidents,” Ward wrote in a comment.

Even so, proponents of a broader definition include industry heavyweights, like The Joint Commission’s CMS Policy Advisor Matthew Icenroad, who submitted a comment on behalf of the accrediting organization.

“The Joint Commission recommends OSHA include the threat of violence within their definition as these acts may predict future events and assist facilities in assessing their workplace violence prevention plans and objectives,” Icenroad wrote.

To whom should it apply?

Beyond disputes over what, specifically, should constitute workplace violence, there is potential for disagreement over whom a mandatory OSHA standard should apply to.

Andrea P. Thau, OD, president of the American Optometric Association, said it would seem appropriate for OSHA to take “a facilities-based approach” to determine which healthcare professionals must abide by which rules. An emergency room staffer in a high-volume hospital would likely face greater risk than a staffer in an eye doctor’s office, for instance, even if the two workers carry similar titles and qualifications.

“To include in a possible standard all members of a certain occupation, regardless of the unique characteristics of where they work, runs the risk of creating an unnecessary burden in many settings and the possibility of failing to protect low-risk employees in a high-risk setting,” Thau wrote in a comment.

The Joint Commission has advised healthcare employers to assess local risk factors for workplace violence in each facility. But the organization recommends also that OSHA implement standards encompassing “all employees regardless of job and facility/setting,” as Icenroad noted in his comment.

“Threats or actual violent acts may impact any type of healthcare settings, and therefore facilities should develop prevention programs regardless of their location and type of patients served,” Icenroad wrote.

Worth the cost?

South Dakota is among the states without a law mandating workplace violence prevention plans. Even so, most of the 54 hospitals, three large health systems, and 34 postacute care providers with membership in the South Dakota Association of Healthcare Organizations report already having a relevant program or policy in effect on an organizational level, according to Jen Porter, EdD, MBA, the group’s vice president of postacute care.

Association members worry that the cost of complying with a new nationwide standard (rather than continuing to rely on their own policies) could cost more than it’s worth, Porter wrote in a comment.

Michael Van Sickle, CEO of Bethany Lutheran Home, a faith-based residential facility in Council Bluffs, Iowa, argued that adding federal (or even state) regulation on workplace violence prevention would do nothing more than “penalize an employer for an uncontrollable situation.”

“We already have laws for assault that would cover family assaults on healthcare workers. We have laws about domestic violence that would cover family internal struggles. We have laws AND regulations that address patient assaults on caregivers,” Van Sickle wrote in a comment responding to OSHA’s request.


How to comply with the Cal/OSHA model

California’s workplace violence standard, as approved by the Office of Administrative Law, requires that employers establish, implement, and maintain an effective workplace violence prevention plan in writing. The plan must contain 12 things:

  1. Names or job titles of personnel responsible for implementing the plan
  2. Procedures to secure active involvement from employees and their representatives in crafting, using, and revising the plan
  3. Methods to coordinate implementation of the plan and ensure personnel understand their respective roles
  4. Procedures for contacting law enforcement during all shifts, including a policy expressly permitting employees to contact police and local emergency services on their own, without fear of reprisal, if a violent incident occurs
  5. Procedures for the employer to handle reports of workplace violence and prohibit retaliation against employees who file such reports
  6. Procedures to ensure compliance by supervisors and non-supervisors alike
  7. Procedures to communicate with employees regarding proper documentation and communication between shifts and units; ways to report violent threats, incidents, or other concerns without fear of backlash; and means by which concerns will be investigated and investigatory results delivered
  8. Procedures to develop and provide workplace violence prevention training
  9. Procedures to assess environmental risk factors, including community-based factors, for each facility, unit, service, or operation
  10. Procedures to identify risk factors specific to patients and to assess potential risks associated with other non-employers
  11. Procedures to correct workplace violence hazards in a timely manner, taking care of imminent hazards immediately and serious hazards within seven days
  12. Procedures for responding to and investigating violent incidents after the fact, including the provision of immediate medical care, subsequent trauma counseling, and a hindsight assessment of risk reduction efforts

In addition to the plan, employers subject to the California standard must maintain a log of violent incidents, with post-incident responses and investigations. The log, which includes threats of physical force and completed attacks alike, must be considered during an annual review of the plan’s effectiveness.

Incidents involving the use of physical force against an employee that “has a high likelihood of resulting in” injury or psychological trauma, or that actually results in such harm, must be reported to state authorities under the Cal/OSHA standard. The report must be made within 24 hours if the incident involves a firearm or other dangerous weapon, or if it otherwise presents “an urgent or emergent threat to the welfare, health, or safety of hospital personnel,” meaning “a realistic possibility of death or serious physical harm.” All other reports must be made within 72 hours.

The full version of California’s policy, along with other relevant documents, is available for download at www.dir.ca.gov/OSHSB/Workplace-Violence-Prevention-in-Health-Care.html.


ASHE study offers guidelines for emergency power resiliency

Monograph urges hospitals to turn to technology, study successes of other facilities to prepare for outages

Hospitals are beginning to take advantage of technological advances to prepare for utility outages in the wake of hurricanes and other disasters, as well as to meet more stringent code standards, but they still have a lot of work to do to take care of basic preparations.

That’s the consensus of a new white paper released by the American Society for Healthcare Engineering (ASHE) studying the effects, the aftermath, and most importantly, the responses of hospitals to stay operational in the wake of natural disasters such as Hurricane Katrina in New Orleans, Hurricane Sandy in the New York area, and most recently Hurricane Matthew in South Carolina.

During those three events, hospitals in the U.S. were faced with perhaps some of the greatest challenges in history to not only stay open, but also stay operational to help patients in the community. Those lessons don’t come easy, as was evidenced when Katrina hit New Orleans in 2005 with record flooding, plunging 80% of the city underwater and leaving hospitals without power and unable to evacuate even their most critical patients. Then came Sandy in October 2012, which hit the New York and New Jersey area with such fury that basement generators were flooded, knocking out emergency power and forcing hospitals to turn to evacuation plans they never thought they’d need. ASHE noted, however, that hospitals had learned some lessons from Katrina in preparing for Sandy, and carried out evacuation plans ahead of the storm.

“In many hospitals and nursing homes, emergency power systems functioned as intended, allowing facilities to remain open to care for their most critical patients, or to serve as a refuge for patients displaced from other hospitals and nursing homes,” the report said. “Greater-than-expected flooding contributed to the loss or pre-emptive shutdown of emergency power at six hospitals in New York and New Jersey; two had previously evacuated patients. For the four hospitals with patients when emergency power was lost, sizeable evacuations of patients occurred. No fatalities or serious injuries resulted from these evacuations, which is a credit to the extensive pre-planning hospitals undertook to prepare for potential evacuations.”

“Major storms and natural disasters such as Hurricane Katrina and Hurricane Sandy have intensified the national dialogue on emergency power for critical health care systems,” wrote the authors in the ASHE monograph, Roadmap to Resiliency. Check out the entire document at www.ashe.org/management_monographs/pdfs/mg2017cote_flannery.pdf.

“Health care facilities, emergency preparedness experts, and regulators have used these lessons learned to improve the resiliency of emergency power systems,” continued the monograph. “However, more needs to be done to heed the lessons learned given the loss of emergency power during Hurricane Sandy from the same threats that disabled emergency power during Hurricane Katrina seven years earlier. Hurricane Matthew in 2016 brought new potential challenges to light, requiring new solutions as different lessons were presented.”

In other words, don’t wait until the storm is heading your way to begin figuring out your backup plans for power generation; the time to start thinking about your needs when the lights go out is now.

Code changes reflect new needs

In emergency planning, most of today’s preparation is a direct result of the mistakes that were made during yesterday’s disasters. That certainly was the case during hurricanes Sandy and Matthew.

Some of the crucial lessons that monograph authors Eric Cote and Jonathan Flannery said hospitals need to learn from previous incidents of catastrophic utility failure include the following:

  • Flooding of emergency power system components is a chief culprit in emergency power system failures during hurricanes
  • Insufficient pre-disaster coordination with generator service and fuel providers can result in service delays at a time when it is most needed
  • Failure to inventory critical spare parts for emergency power systems can result in lengthy delays in the restoration of emergency power

The ASHE document references changes that accreditation agencies made to preparation standards in late 2016 as things that facilities should be paying attention to when crafting their preparations for the future.

For instance, in late 2016, CMS passed emergency preparedness requirements for 17 types of healthcare facilities that receive government benefits. Among other things, CMS now requires hospitals to plan to stay operational for 96 hours after a major event—and that requires the hospitals to prove that their backup power systems can remain operational.

Additionally, in July 2016, CMS officially adopted the 2012 edition of the National Fire Protection Association (NFPA)’s Life Safety Code® (LSC), a long-awaited move considered monumental by most hospital security and life safety experts as it brought up to date many standards that had been in place since 2003, when CMS adopted the 2000 edition. The new rule also included provisions of the NFPA’s 2012 edition of the Health Care Facilities Code.

One of the crucial things to keep in mind about the new regulations, ASHE said, is that while CMS in its new emergency preparedness rules dropped much-debated requirements that hospitals conduct a four-hour full-load generator test every three years, and another proposal that generators be located at higher and newer flood plain levels, that doesn’t mean these things shouldn’t be done. In addition, section 7.2.3 of the 2010 edition of NFPA 110 states that “the rooms, shelters, or separate buildings housing Level 1 or Level 2 emergency power supply system (EPSS) equipment shall be designed and located to minimize the damage from ?ooding, including that caused by the following:

  • Flooding resulting from firefighting
  • Sewer water backup
  • Similar disasters or occurrences”

The takeaway for facilities is that even though the regulations don’t say you need to test the generators or keep them above ground, the onus is still on you to prove that you are ready to deal with the unexpected.

“Questions have been raised as to why NFPA 110 simply doesn’t prohibit the generator and essential emergency power system components from being located anywhere in a flood-prone zone or area of the structure,” says the ASHE report. “Some buildings or properties cannot accommodate this measure without alternate risks, such as fuel storage within or above occupied areas, which may be why NFPA 110 language on this matter is a performance metric rather than a mandatory requirement. The burden is placed on a facility designer and owner to determine how to best protect the generator and related components from flooding hazards.”

In other words, assess your facility and its grounds now, especially since outdated and unexpected circumstances—and old and untested equipment—are exactly what led to knocked-out power at many of the hospitals that failed during Katrina, Sandy, and Matthew.

Consider the following experiences of hurricane-struck hospitals:

Bellevue Hospital in New York City—Routine evacuation and pre-storm plans worked fine. In addition, the hospital had a new electric power plant and emergency generator well above ground level on the 13th floor. However, emergency fuel stores and elevator electrical systems were located in the basement, and when a submarine door meant to protect the basement failed, floodwaters from Hurricane Sandy surged in and led to the failure of these systems.

“All utilities and services in the basement were lost, including electrical power, steam, communications, HVAC equipment, IT, computers, fire protection, systems, and elevators. Mechanical systems lost or damaged included pumps, electrical switchgear, and a combined domestic water and ?re pump system,” the report said.

While the hospital did need to be evacuated, fuel stores and generators above ground allowed contingency plans to go into effect. Specifically, the New York police brought a tanker truck in to provide emergency refueling, and hospital staff carried emergency fuel up 13 flights of stairs.

Hoboken (New Jersey) University Medical Center—While evacuating critical patients to nearby hospitals during Hurricane Sandy, a hastily executed emergency plan tried to keep the facility open, with staff installing plywood over doors, sandbagging walls, and covering low-level openings to keep out floodwaters. Two above-ground emergency generators consumed fuel from 2,000-gallon fuel tanks, which were also located above ground.

However, the hospital’s switchgear, meant to switch over to emergency power, was at a lower elevation and subject to flooding, so the hospital had to turn it off to minimize damage. As a result, while the fuel tanks, pumps, and generators were fine, the hospital still lost power, and two of its eight elevators were flooded. The event required hospital officials to relocate the switchgear equipment to higher levels in the hospital.

Southeastern Regional Medical Center, Lumberton, North Carolina—During Hurricane Matthew in 2016, while most hospitals evacuated in preparation for the storm, this facility suffered the failure of one of its five generators, which placed the hospital’s full emergency power requirements on the four remaining units. The local utility couldn’t provide an estimated time of restoration given the extensive damage to utility infrastructure, and the hospital was able to request deployment of temporary generators from the state of North Carolina and FEMA, underscoring the importance of establishing relationships with outside suppliers before disaster strikes.

Best practices

If you’re a facility concerned with staying on top of codes and regulations, and trying to make sure your hospital is ready to stay operational and keep the power on during an emergency, where do you start?

ASHE says you start with a good assessment of where you are now. Specifically, it suggests starting with an emergency power supply system vulnerability assessment survey available from the California Hospital Association (www.poweredforpatients.org/assessmentsurvey). Among the questions you should address are the following:

  • In addition to conducting required testing on backup generators, do you routinely test switchgear equipment?
  • Do you have a service contract for your emergency power system?
  • Who are your primary and secondary service and fuel providers?
  • Have you identified locations for temporary generator installations on your campus?
  • Does the hospital have a stock of recommended spare parts for the diesel generator or assurances from local diesel distributor to provide spare parts?
  • Have appropriate personnel been trained on manual operation of the diesel generators or emergency system?
  • Does your emergency generator system have any unique cooling or operational requirements that may require special measures during a disaster (heat exchangers, cooling towers, etc.)?
  • Do you have a protocol for detaching and reattaching to your electric utility during power outages?
  • Does your hospital plan to replace some or all of its generators within the next three to five years?
  • Are there restrictions in place with respect to which service companies are authorized to provide service to any of your generators, switchgear equipment, or automatic transfer switches?
  • Is your water system dependent on power for water pressure because of building elevation?
  • Is your wastewater system dependent on power for sewage flow away from your facility into local sewer or septic systems?
  • Are your generator and its components, including fuel tanks, above the flood plain and safe from other water surges such as dam and water tower breaks? If not, are system components encapsulated and protected from a flood?
  • Approximately how many years old are your generators?

“Opportunities are presented that would allow hospitals to island from the grid through innovative power generating technologies that provide the added benefit of covering more of a hospital’s critical functions on emergency power,” said the ASHE report. “As hospitals embrace these new technologies and innovative protocols, they can better protect patients and more fully serve the communities that depend on them during disasters.” These new technologies include co-generation, microgrids, and distributed generation.


How to minimize emergency risks

To minimize risks, ASHE recommends that hospitals consider taking the following actions:

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