violence no longer stops outside the doors to the hospital!

Violence No Longer Stops Outside The Doors To The Hospital!

5th Annual Hospital and Healthcare Security & Safety Conference

October 26, 2012

Lisa Pryse, CHPA, CPPPresident, ODS Healthcare Security/Company Police

ASIS International Healthcare Council and President-Elect, IAHSS

ACT definition targets the impact of violence as criteria in a very broad sense:

“Workplace Violence is any action or incident which causes physical or psychological harm to another person”

ACT Definition of Workplace Violence:

Abusive language, intimidation, assault, fighting, or other violent acts displayed by employees, co-workers, management, patients, visitors, or other parties which may cause emotional or physical intimidation or harm.

US OSHA Definition of Workplace Violence:

TYPE I : The aggressor has no legitimate relationship to the workplace and the main objective is to commit a robbery (cash, drugs) or other criminal act. (“External” violence).

TYPE II : The aggressor is the recipient or the object of a service provided by the affected workplace or the victim, e. g. a client, patient. This may include also relatives or friends of the clients. (“Client initiated” violence).

TYPE III : The aggressor has an employment-related involvement in the work setting. Usually it is a another employee , a co-worker, a supervisor, a boss, a student (“internal” violence).

Guidelines on Workplace Violence in the Health Sector

Comparison of major known national guidelines and strategies: UK, Australia, Sweden, USA (OSHA and California)

Video:“Flash Point For Healthcare”

Recognizing and Preventing Violence in the Healthcare Community

By The Center of Personal Protection and Safety

The employee survey results suggest that under-reporting of aggression is a significant problem.

They also suggest that many employees do not believe management understands the aggression problems and are not committed to reducing the risks of aggression.

Heads of Workplace Safety Authorities (HWSA)Australia and New Zealand

“Aggression Management in Hospitals Intervention and Compliance Campaign – 2011”

The National OHS Strategy 2002 – 2012 required a reduction in the incidence of work related injury by 40% by June 2012.

To achieve this 10 year target, a 5% to 6% annual reduction in the rate of injury was required.

Heads of Workplace Safety Authorities (HWSA) “Aggression Management in Hospitals

Intervention and Compliance Campaign - 2011

However, data on the number of national worker’s compensation claims show that between 2001 and 2008:

- the total number of national claims in Hospitals decreased by only 6%

- the number of “assault by other person” national claims in Hospitals increased by 58%

Heads of Workplace Safety Authorities (HWSA) “Aggression Management in Hospitals

Intervention and Compliance Campaign – 2011”

More assaults (greater than 50%) occur in healthcare and social service industry than in any other industry (US Department of Labor).

Working in healthcare is considered to be the third most dangerous job in the US.

CDC and NIOSH has identified nursing as one of the most dangerous occupations in the US (Massachusetts Nursing Association Legislative Agenda 2000).

Statement of the Problem for Healthcare

Diverse Population• Can’t turn anyone away

• Ambulatory & non-Ambulatory

• Patients, Family, Friends, Vendors, Staff

• Microcosm of a City

Open Access to Public• 24/7

• Multiple Access Points

Duty to Provide Care & Protect the Vulnerable

Prescriptive Culture

Heightened Anxiety and Frustration Levels• Crisis Mentality

• Staffing Shortages

• Unpredictable

Last Place People Want to Be…

Unique Environmental Considerations for Healthcare

Persistent perception in the healthcare industry that assaults are a part of the job .

Nurses often fail to identify violent acts as actual violence and there is a tendency to minimize the severity of violence.

Statement of the Problem for Healthcare Internationally

Prevalence of various types of weapons

Increasing number of acute and chronically mentally ill patients now being released without follow up care

The availability of drugs or money in hospitals or clinics (Point of Service payment)

Public building - unrestricted movement in much of building

Risk Factors

Drug or alcohol abusers

The presence of street gangs in some locations

Trauma patients many times are victims of violence

Distraught family members

Frustrated clients due to long waits (what is the definition of a long wait?)

Risk Factors

Domestic disputes which may spill over into the work environment

Low staffing levels during periods of increased activity

Isolated work with clients

Remote work locations with little security or access to communication devices

Risk Factors

Lack of staff training in recognizing and managing escalating hostile and assaultive behavior

Poor conflict resolution and communication skills of management

Lack of feedback to employees and inconsistent implementation of policies which may lead to disgruntled employees

Risk Factors

Physical harm to staff, visitors, patients

Psychological harm

Low morale

Increased job stress

Increased staff turnover

Reduced trust

Creation of a hostile working environment

Financial implications

Legal implications

Potential Impact

“Inquiry Into Violence And Security Arrangements In Victorian Hospitals And, In Particular, Emergency Departments – December 2011”

Principles Informing The Recommendations:

1. The Committee believes that all hospital staff are entitled to a safe and secure working environment that is free of all forms of violence.

2. The Committee recognises that hospital administrations face a complex challenge in reducing violence in especially in some large emergency departments (EDs).

3. The law should support clinical and security staff in their work environments.

Parliament of VictoriaDrugs and Crime Prevention

Committee


4. The Committee believes that in addressing violence and security issues in Victorian hospitals:

a) A ‘one size fits all’ approach does not address the specific issues, needs and requirements of individual hospitals and health facilities.

b) Proactive policies based on prevention strategies are the key to addressing violence in hospitals.


Committee


4. (continued)

c) A holistic and tailored approach is required that meets the specific requirements of each hospital. Such a holistic approach should draw upon strategies including:

• strong leadership, support and encouragement by the senior management team at the hospital.


Committee


4. (4c continued)

• appropriate policies and infrastructure that promote a ‘zero tolerance’ approach to violence towards…. all persons located in the hospital premises or environment.

• accredited comprehensive education and training programs to address violent behaviour in hospitals for all.


Committee


4. (4c continued)

• approaches that recognise the specific factors that contribute to hospital violence and promotes strategies to address these.

• environmental and design strategies that address the situational factors that may exacerbate violence in the hospital setting, particularly the emergency

department.


Committee


4. (continued)

d) Strategies to prevent and address violence in hospitals are most effective when clinical staff, security staff, management and external workers work collaboratively as part of a team.


Committee


4. (continued)

e) Effective security strategies to prevent and address violence in hospitals are underpinned by a ‘patient focused’ approach that draws on interpersonal skills to defuse, minimise and manage aggressive behaviour.

f) Effectively addressing violence in the hospital setting requires uniform reporting procedures and data collection across the Victorian hospital system.


Committee


5. The Committee believes as a general principle that security staff should be licensed specialists in the area of hospital security and appointed by individual hospitals as determined by the hospital’s specific needs.

6. The Committee believes that firearms should not be used as a security measure in Victorian hospitals by security personnel.


Committee

Principles Informing The Recommendations (cont’d):

7. The Committee believes that as a general principle, capsicum spray and tasers should not be used as a security measure in Victorian hospitals, by security personnel. However, individual hospitals should have the power to decide what other forms of restraint and security mechanisms should be employed.


Committee

Discussion??


Committee

Engineering Controls

Worksite Analysis

Department designs Security measures must be considered when planning

renovation or new construction

Security Devices Access Control and other security hardware

Cameras

Program Development

Administrative Controls

Policies and Procedures

Training

Program Development

Security Management Plan

Management of Access Control

Employee Administrative Inspections

Guidelines for Management of Potentially Threatening Letters, Packages, Parcels

Protection of Patients in Custody

Security Risk Patient Protection Plan

Weapons on Property

Management of Sexual Harassment

Important Policies and Procedures

Workplace Violence Response Plan

Civil Disturbance Response Plan

Hostage Response Plan

Bomb Threat Response Plan

Threat Response Plans

High Security Alert Response Plan

Domestic Violence Response Plan

Clients and employees

Important Policies and Procedures

Provide screening and resources.

When an employee has a domestic order that lists any healthcare facility as being protected areas, the employee is to report the information to the hospital security department.

Information will be managed with sensitivity to confidentiality

Information will be used to develop a personal safety plan to protect employee and co-workers, e.g. escorts to vehicles, rotating routes of travel to work, department safety plan, etc.

Domestic Violence

All threats are to be taken seriously.

All threats are to be reported to one’s supervisor.

Threat Report Form.

Employee Injury/Illness form if an actual injury was sustained.

Multidisciplinary Threat Assessment/Management Team.

Security Risk Plan.

Management of Threats

Executive endorsement

Must be at all levels of the organization

Mandatory for high risk departments

Multiple topics

Training Programs

Violence in the Workplace Work Group (Threat Assessment Team)

Development of policies and procedures

Data analysis of events / trends

Development of action plans

Training Program Development

Crisis Intervention Team

Program Oversight

IAHSS Security Design Guidelines for Healthcare Facilities (www.iahss.org)

Additional IAHSS Guidelines for Healthcare Facilities

Violence in Healthcare

Targeted Violence

Forensic Patient Security

Security Officer Staffing & Deployment

Searching Patients and Patient Areas for Contraband

Security Response to a Critical Incident

Restricting Weapons in the Healthcare Environment

Restricted Access

Security in the Emergency Care Setting

Behavioral/Mental Health General

Director of Security should be educated and well credentialed in the field of healthcare security (IAHSS, ASIS, etc.) as well as leadership in general.

Security officers should be trained in healthcare specific security issues , non-violent crisis intervention/de escalation techniques, state laws with oversight for security officers, personal defense tactics, as an IAHSS Security Officer, etc .

Security Department should offer ongoing classes for hospital staff (Personal Defense for Women, etc.).

What Role Should the Security Department Play?

Consider an ongoing (quarterly) facilitated team meeting between the Security Department and the Emergency Department (where most of the reported acts of violence originate).

Consider specially trained security officers to staff the Emergency Department as well as any inpatient Behavioral Health Unit.

The Security Department should be held to as high a standard as any other department in the organization and thus allowed to participate in various patient care, etc. initiatives.

What Role Should the Security Department Play?

Violence Spectrum

Awareness Mindset Critical• CANNOT Ignore Behaviors of Concern

Do NOT Go Away

Escalation Likely

Recognition• Intervene Early and Appropriately

Alert supervisors to concerns

Report ALL incidents• Nothing is insignificant

Violence Spectrum

There is a balance which must be maintained between security of the facility and accessibility…..

Ultimate Workplace Violence Incident: Active Shooter Prevention and Response

Who is the Active Shooter?

An armed person who has used deadly

force on other persons and continues to do

so while having unrestricted access to

additional victims, different from hostage

situations.

Sheriff’s Office Policy and Procedure Manual. Colorado Springs, Colorado, USA: El Paso

County Sheriff's Office. 2004-01-01. http://shr2.elpasoco.com/PDF/policy/chapter_07/731_policy.pdf.

Active Shooter Definition

http://en.wikipedia.org/wiki/Colorado_Springs

http://en.wikipedia.org/wiki/Colorado

http://en.wikipedia.org/wiki/USA

http://shr2.elpasoco.com/PDF/policy/chapter_07/731_policy.pdf

The U.S. Department of Homeland Security Active Shooter Book recommends:

1. Evacuate

2. Hide out

3. Take action against the active shooter, as a last resort.


Date: October 31, 2011

Victims: 0 killed, 0 wounded

Offenders: 66 year old patient

Incident: Australian Doctor Discovers Gun In

Prosthetic Leg Of St. Vincent’s Hospital Patient

Sydney, AustraliaSt. Vincent's Hospital in Lockdown After Gun Found

With Patient on Level 9

Date: April 20, 1999


Offenders: Dylan Klebold 17, Eric Harris, 18

Incident: Active Shooter

Columbine High SchoolLittleton, CO

Dylan Klebold

Eric Harris


Victims: 32 killed, 17 injured

Offender: Seung Hui Cho


Virginia Tech, Blacksburg, VA

Seung Hui Cho

http://en.wikipedia.org/wiki/Image:Cho_Seung-hui_3.jpg

Date: February 14, 2008

Victims: 6 killed, 18 injured

Offender: Steven Kazmierczak


Northern Illinois, DeKalb, IL

Steven Kazmierczak

Date: November 5, 2009


Offender: Nidal Malik Hasan


Fort Hood, Killeen, TX

Nidal Malik Hasan

Date: March 27, 2008

Location: Columbus, GA

Shooter: Charles Johnston

Victim(s): 3 Deaths

Hospital Area : 5th

Floor

Event: A 63-year-old retired school teacher entered the

hospital at 3:30 PM with a gun, went to the 5th

floor, and

opened fire on hospital workers. His mother had died of

natural causes in 2004 on the 5th

floor. One of the victims

was a truck driver he encountered in the parking deck.

Shooter bore a grudge against a nurse over his mother’s

treatment.

Columbus Regional Medical Center Shooting (aka Doctors Hospital)

Date: November 26, 2008

Location: Soldotna, AK

Shooter: Joseph A. Marchetti

Victim(s): 2 Deaths/1 Injury

Hospital Area : Imaging Dept/ Main Corridor

Event: A former employee who lost his job as a digital imaging

technician a day earlier entered the hospital shortly before 10:00

AM armed with a .223 caliber semiautomatic rifle and a .9mm

pistol. He opened fire on his ex-supervisors, killing one and

wounding the other.

During the 40-minute shooting spree, the gunman, after

shooting his first victim, spotted him later sitting in a wheelchair

bleeding, and shot him again.

Central Peninsula General Hospital Shooting

Date: March 29, 2009

Location: Carthage, NC

Shooter: Robert Stewart

Victim(s): 8 Deaths, 3 Wounded (including shooter)

Event: A 45-year-old gunman burst into a North Carolina nursing

home and started shooting, barging into the rooms of terrified

patients, sparing some from his rampage, without explanation, while

killing seven residents and a nurse caring for them. Stewart’s ex-

wife, who was married to him for 15 years, said he had violent

tendencies. Victims ranged in age from 39 (nurse) to 98.

Pinelake Health & Rehab Center Shooting


Location: Long Beach, CA

Shooter: Mario Ramirez

Victim(s): 3 Deaths (Gunman)

Hospital Area : Rear of Hospital Pharmacy

Event: A pharmacy technician showed up for work at 11:47 AM

brandishing two handguns; killed his boss and another manager and

then fatally shot himself. All three men worked in the outpatient

pharmacy. There were layoffs the previous month, but none other

projected. A friend felt he was concerned about losing his job.

Long Beach Memorial Medical Center Shooting

Date: August 16, 2010

Location: Las Vegas, NV

Shooter: Susan Kapfer

Victim(s): 2 Deaths

Hospital Area : Patient Room

Event: Susan Kapfer, 50, shot and killed her husband Michael, 55, at

4:40 AM at Las Vegas' Valley Hospital before killing herself. She had

spent the night in his private room. Her husband suffered from

deteriorating health. She left a suicide note in her car dated three days

before. Note ended, “They (hospital) just don’t care.”

Valley Hospital Shooting

Date: September 16, 2010

Location: Baltimore, MD

Shooter: Paul Warren Pardus

(aka Warren Leo Davis)

Victim(s): 2 Deaths/1 Injury

Hospital Area : Patient Room

Event: Dr. Cohen was giving the 50-year-old man some news

about the care and condition of his mother just outside the doorway

of her room. The gunman grew "over-whelmed" when the doctor told

him about the care of his mother and pulled a small semi-automatic

handgun from his waistband.

Johns Hopkins Hospital Shooting

Date: September 29, 2010

Location: Omaha, NE

Shooter: Jeffery Layten

Victim(s): 1 Death/3 Injuries

Hospital Area : Front Lobby

Event: A 39-year-old man led police on a car chase, and then

opened fire hours later at an Omaha hospital. Police report he

was wanted for domestic assault and terroristic threats. A

friend reported he was distraught about his marital problems

and didn’t want to live anymore.

Creighton University Medical Center Shooting

Nature of violence

•Violence often results from frustration•Conflicting parties usually feel threatened and compelled to protect their positions at all costs.

• Violence, many times, results from a breakdown in communications• The key is to identify the source of the frustration and open a line

of communication

There is no profile of an Active Shooter

Nature of violence

•Not a single variable capable of predicting violence

•Best predictor of future behavior is past behavior

•Unaddressed disruptive behaviors will either continue and/or increase

There is no profile of an Active Shooter

1. Long history of frustration, failure, and a diminished

ability to cope with life’s disappointments

2. Externalizes blame

3. Lack of emotional support from family and friends

4. Suffer a precipitating event they view as catastrophic

5. Access to a weapon powerful enough to satisfy need

for revenge James Alan Fox

Northeastern University

Five Characteristics of Mass Killers

Single male shooter with more than one

firearm

Daylight hours

In a building

Well populated location

Shooting over in 2 to 3 minutes

Initially target specific people

If targeted people unavailable or killed, will

target people at random

Will likely take own life

Study of Active Shooter Incidents

Perpetrators of targeted acts of lethal violence

often engage in covert and overt pre-attack

behaviors.

Perpetrators:

Consider

Plan

Prepare

Share

Move from ideas to actions

Targeted Violence Process

Rings of Security Hot Zone – Immediate Danger

Warm Zone – Intermediate Danger

Cold Zone – Remote Danger

The Healthcare Action ACRONYM 4 A’s: Accept, Assess, Act, Alert

Equivalent of “Race and Pass”

Active Shooter Survival in a Healthcare Setting

“No Plan Leads to the Wrong Plan” Independent, proactive measures can be

dangerous

Risky self protection vs. team approach

Doubtful effectiveness in future

Moral obligation not met by organization

Dangers of Untrained Individuals

Normalized Behavior in Stressful

Situations

Plan in place

Persistence in the face of adversity

Protection of self and others

Proactive stance

Post situation recovery

Moral obligation met by organization

Benefits of Training -

Extreme Danger Gap

Onset of

ViolenceArrival of First

Responders

Immediate Responders:• Need to be Prepared

• Need to be Empowered

• Need to be Supported

1. Workplace violence is a serious threat for all

healthcare facilities (HCFs) and requires proactive

steps to be taken to prevent and mitigate risks

associated with violence. A situation involving a

person who has or is threatening to use a firearm,

and may be moving from one location to another

on campus, requires a specific response protocol

by all HCFs.

International Association of Healthcare Security and Safety (IAHSS) Active Shooter

Response Guideline

Summary of Points:

2. A multidisciplinary team should be appointed by the HCF

to designate, in writing, its plan for responding to an active

shooter on campus in coordination with local law

enforcement.

3. Communication procedures should be established that

includes the creation of a specific announcement

(emergency code or plain language) and procedure to

institute a response to an active shooter situation.


Response Guideline

Summary of Points

4. The HCF should have a timely campus-wide

notification system to alert staff to the threat of an

active shooter. The mechanisms should include

multiple modes of notification intended to reach all

persons inside the facility and on its grounds. These

may include overhead pages, text (SMS) messaging,

digital displays, e-mails, intercoms, call boxes, popup

messages, or other notification methods.


Response Guideline

Summary of Points

5. Employees and staff should be educated on their

awareness, reporting of and response to an active

shooter. Specific procedures should be

established for the initial response of staff or

anyone in the immediate vicinity of an active

shooter.


Response Guideline

Summary of Points

6. Activation of the active shooter response plan should include

immediate notification to law enforcement.

7. Activation of the active shooter response plan may include

specified actions (listed in guideline).

8. Upon conclusion of an active shooter event, the HCF should

announce an “all clear” only after law enforcement has

indicated the environment is safe.

9. Active shooter drills should be conducted periodically to

exercise the plan and the response of law enforcement.


Response Guideline

Additional dynamics exist in the healthcare environment: duty to protect the patient.


Video:“Shots Fired For Healthcare”

Guidance for Surviving an Active Shooter Situation in the Healthcare Community

By The Center for Personal Protection and Safety

The Center for Personal Protection & Safety (www.cppssite.com) has developed two videos specific for healthcare: Shots Fired: Healthcare; Flashpoint: Prevention Strategies in Healthcare.


Thank you!

[email protected]

804-389-0208

mailto:[email protected]



violence no longer stops outside the doors to the hospital!

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