This month in the RL Webinar Series we welcomed Carrie Arrieta, Risk Manager at North Shore Medical Center. Carrie shared NMSC's journey to developing a workplace violence prevention program. The presentation sparked so much conversation, that we didn't have time to get to all of your questions during the live webinar Q&A. Here are the answers to all of your lingering questions about how NMSC built out their workplace violence program.
How did you decide what questions to include on your workplace safety survey? What are some of the questions you chose to include?
Carrie: We carried over questions from our 2012 survey and added a couple more. We felt it was important to get a temperature reading on how people feel about their safety at work and also ask open ended questions so we could get narrative feedback.
Some of the questions we ask are: Have you been injured as a result of workplace violence? Have you been injured by a patient in the workplace? Have you reported an assault or workplace violence situation?
You mentioned using visual cues to indicate a risk of violence outside patient rooms. What do these look like? And when they're in use, how do you explain to patients what they mean?
Carrie: We're still in the process of arriving at what these visual cues will look like, but currently we're proposing a solid-colored, neon square. We want something that will stand out, but at the same time something that won't catch too much attention.
As for how we explain the use of the cues to patients, we say something along the lines of, "This is our process is to ensure a safe and respectful environment for all patients, family, members and staff. We want to be sure that you/your family member gets the care and treatment you/they need without any harm to our staff."
We find that staff in our psychiatric center don't report many episodes of assault by patients, in part because the behavior has been normalized. Have you experienced challenges with something similar?
Carrie: Very much so! It's been a challenge getting staff to report. People say that it's just part of the job, it's not the patient's fault, the patient is sick, it takes too long to report, if I reported every incident I would be reporting all day long - the list goes on.
As we've gone through this journey we've been getting more reports about disruptive behavior - which is usually a precursor to violence - and that's really what we want to see, people reporting before it becomes escalated.
Could you speak to how you have worked to ensure that notes/alerts to the EMR are appropriately placed and monitored for clinical appropriateness?
Carrie: We only have one person that can place the alert and the plans at this time. I work in collaboration with nursing, psychiatry and security, and usually nursing drafts the safety plan.
Are you only searching high risk/mental health patients or all patients?
Carrie: We search all high-risk patients where there is a suspicion that the patient may have contraband. We have seven different types of presenting concerns that trigger a request for a search:
- Suicidal ideation
- Homicidal ideation
- Alcohol or overdose
- Evidence of self-harm
- Other risk of dangerousness
Would you mind telling us more about the ED sign that promotes commitment to a safe environment?
Carrie: Of course! The sign was the product of a lot of collaborative work between our departments - risk, security, marketing, etc.
The final wording on the sign is: "At NMSC our focus is great care. We must ensure a safe environment. Abusive language and behavior will not be tolerated. Thank you."
We also incorporate two photos, one of a nurse and a child and a photo of one of our special police officers with a female security guard.
Do you just collect data about incidents between non-staff and staff? Or do you also collect data on intimidating or disruptive behavior between staff?
Carrie: We collect both, it's really anything that gets reported in the RL form or through security. However, behavior between staff tends to be reported through HR.
How many security officers do you utilize in your ED?
Carrie: We have 3-4 on each shift for the whole house, so usually that means one in the ED. This is an ongoing challenge for us, given our patient population and our status as a safety net hospital.
Do you have a process for discharging your "frequent flyers" when they are not active in their care?
Carrie: We are required to see any person that arrives to our Emergency Department for a medical screening exam per EMTALA, but once they are screened they can either be discharged or admitted.
How does your organization approach the use of force and what level is appropriate?
Carrie: Our Police and Security Department is trained in and utilizes MOAB techniques. Our SSPOs have additional training.
Do you have a protocol to respond to negative comments or threats posted on social media by patients or family?
Carrie: Yes, we have a standard response where we invite them to contact our Patient and Family Relations Department.
Is the establishment of the high-risk patient criteria done at a centralized level or at the hospital level?
Carrie: The establishment of the criteria is done at the hospital level. However, Partners is our hospital network, and if Massachusetts General Hospital (MGH) places a flag we can see it, but we can't remove their flag. Our NSMC flags will dictate the internal process, but because we can see the flags from other hospitals in the networks it provides an indicator to proceed with some level of caution.
Any final advice to other organizations on the journey to workplace violence prevention?
Carrie: Work in collaboration with the department leaders in it – risk, security, nursing. Support people and listen to them after each incident, I’ve learned so much from talking to the staff that are involved in them and that’s helped guide us along the way.