Joint Commission’s Worksite Analysis for Workplace Violence Prevention in Healthcare – A new Best Practice?

In business school, one of my professors presented us with his theory of program analysis and management. He stated, “I can’t measure something I can’t count, I can’t evaluate something I can’t measure.” This became our mantra.

After graduation, in my professional life, the reality of the business world collided with those neat and clean academic theories. While I understood the wisdom behind this statement, I also realized it was much more important to understand what I was actually counting and measuring. The real challenge for any organization conducting self-analysis is to determine the right performance metrics:

  • What are we counting?
  • What are we evaluating,?
  • How does it connect and advance the mission?
  • Are we asking the right questions?

Recently, the healthcare industry has addressed this issue. Effective January 1, 2022, the Joint Commission (the largest accreditation body for healthcare organizations) introduced new standards for workplace violence prevention. These new standards reflect a major shift in the approach to workplace violence. They are emphasizing preventive measures along with its previously published response protocols.

One of the foundational requirements contained in the new and revised standards is that each accredited organization must conduct an “Annual Worksite Analysis” with a specific focus on the prevention of workplace violence. Could this new requirement conduct an annual worksite analysis be a best practice for other business sectors to implement?

Do you have a policy or program that focuses on prevention?

Most organizations have a written workplace violence prevention policy. But the key question here is do you actually have a program based on this policy and one that conducts ongoing active measures to prevent, detect, identify, mitigate, and/or respond to incidents of workplace violence?

In our work with a wide range of organizations, we’ve had the opportunity to participate as active members and advisors and observed a number of committees and models.

We’ve found that many of these committees merely become a vehicle for reporting statistical or demographic information. As such, a typical meeting can often go something like this, “During the last month we had 27 documented assaults against staff, 32 calls for service for the local Police Department, and we confiscated 42 weapons. OK, next item on the agenda.” In such a cursory format little work is done to address root causes or come up with actual solutions to address future incidents related to workplace violence.

Worksite Analysis – A Multi-Disciplinary Approach

When we unpack the new Joint Commission standards the first key element is a requirement to conduct proactive analysis of workplace violence events. Any worksite analysis under the new Joint Commission standards must seek to “identify, address, and mitigate gaps and trends in workplace violence incidents within an organization.” If an ongoing analysis shows a spike in workplace violence incidents in one unit or location, what conclusions might be drawn?

A true worksite analysis will look at all factors surrounding a workplace violence event as a way to identify causes, and pre-incident indicators as well as evaluate the efficacy of any interventions.

Continued

Considering this further, could an issue simply be a factor of facilities design? Are there principles of Crime Prevention Through Environmental Design that can/should be employed to increase staff safety and reduce the incidence of workplace violence? Broad-spectrum, multi-disciplinary questions like these should be considered when conducting a worksite analysis.

Additionally, inherent in the worksite analysis is the requirement to conduct a full investigation of all workplace violence incidents. This begs the question, what is a proper investigation? To conduct a full investigation that will inform workplace violence prevention efforts, we must look at several other factors:

  • Who was the person that assaulted the staff member?
  • Were there any preincident indicators prior to the assault?
  • What interventions were employed to address the workplace violence incident?
  • Were those interventions effective?
  • Were there any other factors that either aggravated or mitigated the act of workplace violence? (Factors such as facility design, staffing, and other interactions with staff, family members, or visitors.)

A true investigation will focus on all these factors to develop an all-encompassing and holistic image of the events leading up to the incident, the incident itself, and the organization’s response.

Reporting/Documentation

I learned very early in my law enforcement career that “if it isn’t on paper, it didn’t happen.” The problem in assessing an organization’s true threat from workplace violence is the lack of information or, at the very least, incomplete information. Multiple studies indicate that workplace violence is significantly underreported. Our team has had access to several informal climate surveys that directly addressed this issue and the overwhelming response from staff confirms that workplace violence is vastly underreported. Many reasons are given, but a common theme that emerges is the lack of confidence by the workforce that substantive change will occur.

We’ve had the opportunity to review several common risk management and security reporting applications. The challenge is that these applications are designed solely with the interest of the data collector in mind. For example, a well-known risk management reporting tool is designed to aid risk managers. It, therefore, asks for information and collects information in a format that’s useful to risk managers. Unfortunately, this places the burden of reporting on the victimized employee.

Considering this further, could an issue simply be a factor of facilities design? Are there principles of Crime Prevention Through Environmental Design that can/should be employed to increase staff safety and reduce the incidence of workplace violence? Broad-spectrum, multi-disciplinary questions like these should be considered when conducting a worksite analysis.

Additionally, inherent in the worksite analysis is the requirement to conduct a full investigation of all workplace violence incidents. This begs the question, what is a proper investigation? To conduct a full investigation that will inform workplace violence prevention efforts, we must look at several other factors:

  • Who was the person that assaulted the staff member?
  • Were there any preincident indicators prior to the assault?
  • What interventions were employed to address the workplace violence incident?
  • Were those interventions effective?
  • Were there any other factors that either aggravated or mitigated the act of workplace violence? (Factors such as facility design, staffing, and other interactions with staff, family members, or visitors.)

A true investigation will focus on all these factors to develop an all-encompassing and holistic image of the events leading up to the incident, the incident itself, and the organization’s response.

Reporting/Documentation

I learned very early in my law enforcement career that “if it isn’t on paper, it didn’t happen.” The problem in assessing an organization’s true threat from workplace violence is the lack of information or, at the very least, incomplete information. Multiple studies indicate that workplace violence is significantly underreported. Our team has had access to several informal climate surveys that directly addressed this issue and the overwhelming response from staff confirms that workplace violence is vastly underreported. Many reasons are given, but a common theme that emerges is the lack of confidence by the workforce that substantive change will occur.

We’ve had the opportunity to review several common risk management and security reporting applications. The challenge is that these applications are designed solely with the interest of the data collector in mind. For example, a well-known risk management reporting tool is designed to aid risk managers. It, therefore, asks for information and collects information in a format that’s useful to risk managers. Unfortunately, this places the burden of reporting on the victimized employee.

Implementation

It would be a mistake to view the new requirement for an annual worksite analysis as simply another annual requirement that must be met. Organizations must view their worksite analysis as an ongoing and contemporaneous analysis of workplace violence incidents at the event level. This analysis must take a long-term prevention-centric view in detecting, identifying, and mitigating trends, gaps, and other systemic vulnerabilities.

However, it must also be responsive in making necessary mid-course corrections during the year to address emergent threats, gaps, vulnerabilities, and needs. We recommend monthly workplace violence prevention committee meetings with a portion of each agenda dedicated to a discussion of past incidents and remediation efforts, as well as ongoing prescriptive analysis of data gathered to date.

We also recommend periodic consultation with external subject matter experts. Every two-to-three years these external subject matter experts should conduct a thorough review of existing policies and procedures, crisis management, and emergency response plans, as well as review all prior annual worksite analysis documentation. This review will ensure compliance with accreditation standards, federal, state, and local regulations (as applicable), as well as conformance to current industry best practices.

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